Prognostication is a major part of what physicians do in many fields of medicine, and it is particularly relevant when a treatment or procedure is controversial or anxiety-provoking. Being able to accurately tell a prospective ECT patient how likely he or she is to respond would be helpful.
The March 27 announcement from the FDA that it is looking into a possible connection between Merck's biggest seller, Singulair (montelukast sodium) and suicidality once again raises questions about whether the agency is requiring close enough scrutiny during clinical trials of possible connections between new drugs and psychiatric effects.
Although several antimanic agents are available to treat individuals with bipolar disorder (BD), many patients have a less than satisfactory response or experience adverse effects.1 With the exception of lithium, all of the current antimanic agents are either anticonvulsant or antipsychotic drugs. It is remarkable that no drug has been developed specifically for BD, especially because this illness was conceptualized more than a century ago.
Since the discovery of dopamine as a neurotransmitter in the late 1950s, schizophrenia has been associated with changes in the dopaminergic system. However, the dopamine hypothesis of schizophrenia cannot explain all the symptoms associated with this disorder. Therefore, research has also focused on the role of other neurotransmitter systems, including glutamate, g-aminobutyric acid, serotonin, and acetylcholine (ACh) in schizophrenia.
The vesicular monoamine transporter (VMAT) is a membrane-embedded protein that transports monoamine neurotransmitter molecules into intraneuronal storage vesicles to allow subsequent release into the synapse.1,2 By accumulating both newly synthesized neurotransmitter molecules and freshly returned neurotransmitter molecules from the synapse, VMAT function plays a critical role in the signaling process between monoamine neurons. The VMAT exists in 2 distinct forms: VMAT1 and VMAT2.3
The modern era of psychopharmacology is only 60 years old, having begun with the discovery of the psychotherapeutic benefits of reserpine, lithium, monoamine oxidase inhibitors, and chlorpromazine in the late 1940s and early 1950s, which was followed a few years later by the synthesis and testing of the tricyclic antidepressants and benzodiazepines.
Suicide is a devastating, tragically frequent outcome for persons with varying psychiatric conditions, including schizophrenia. An estimated 5% to 10% of persons with schizophrenia commit suicide and 20% to 50% attempt suicide during their lifetime.1,2 Patients with schizophrenia have more than an 8-fold increased risk of completing suicide (based on the standardized mortality ratio) than the general population.3
An international team of experts recently proposed expanding the diagnostic criteria for several subtypes of bipolar disorder, adding a pediatric bipolar disorder category and eliminating the schizoaffective disorder category.
Evidence-based medicine (EBM) is rapidly becoming the norm. It is taught in medical schools and is encouraged by both government agencies and insurance plan providers. Yet, there is little proof that this model can be adapted to fit psychiatry.
In the second century ad, a brilliant physician had a powerful idea: 4 humours, in varied combinations, produced all illness. From that date until the late 19th century, Galen's theory ruled medicine. Its corollary was that the treatment of disease involved getting the humours back in order; releasing them through bloodletting was the most common procedure and was often augmented with other means of freeing bodily fluids (eg, purgatives and laxatives).
In recent years, we have learned a great deal about posttraumatic stress disorder (PTSD) and its public health implications. From 9/11 to Katrina and the present Iraq war, PTSD has been in the forefront of health concerns and public policy.
Concern about the rising number of preschool-age children receiving atypical antipsychotics, α-agonists, or other psychotherapeutic medications recently motivated pediatric mental health professionals to develop best-practice algorithms for psycho-pharmacological treatment of young children. It also prompted some states and mental health providers to initiate medication monitoring and consultation programs.
It is estimated that at least half of persons who begin antidepressant treatment will not respond to monotherapy.
The number of prescriptions for antipsychotic treatment of teenagers has increased sharply in office-based medical practice. Adolescents with psychotic symptoms frequently present for clinical evaluation, and early-onset schizophrenia spectrum disorders (onset of psychotic symptoms before the age of 18 years) represent an important consideration in the differential diagnosis in these youths
Congress substituted a 0.5% increase in Medicare fees for the first 6 months of 2008 for the 10% reduction that would otherwise have been enacted. That reduction in what is called the Medicare fee "update" was predetermined by a formula Congress itself put in place.
Reading crystal balls has always been difficult. Nevertheless, it may be a worthwhile exercise to stop and make some educated guesses about where the field of psychopharmacology will stand 10 years from now--knowing full well that insights and discoveries we cannot predict or anticipate now may pop up to dramatically change the course and direction of clinical psychopharmacology.
For many years, research on mood disorders has focused on neurotransmitters, particularly on the monoamines (serotonin, norepinephrine, and dopamine) and their action at the neuronal junction, or synapse. Although the monoamine theory helps explain the action of tricyclics, monoamine oxidase inhibitors, and SSRIs, it fails to account for many other things.
Panic disorder with or without agoraphobia is a chronic, debilitating psychiatric illness that affects about 4.7% of the general US population.
On a hypothetical morning, you've arrived early at your office to answer e-mails and respond to prescription requests without interruptions. The following voice mail, left for you much earlier that day, awaits your attention: "Doctor, I need to discuss my mother's behavior with you. The medications she's taking might be calming her down during the days, but she's not okay at night."
Both cognitive-behavioral and pharmacological treatments for panic disorder have been found to be effective over the short term. Not all patients, however, can tolerate or fully respond to these approaches, and the effectiveness of these interventions over the long term remains unclear.
When a suicidal patient in crisis calls the psychiatrist and hears the recorded message, "If you have a 'true' emergency, go to your nearest emergency room or call 911," the patient's risk of suicide may increase.
It is my great honor and pleasure as a psychiatric educator to teach many excellent medical students and residents. These young and not-so-young men and women are by and large diligent, highly professional, and caring.
A Public Health Approach to Intervening With Youth in Schools
Evidence for Use of Neurostimulating Techniques
Intensive psychosocial intervention was found to improve overall functioning in patients with bipolar depression, concluded researchers of the Systemic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial. Results were reported in the September 2007 issue of the American Journal of Psychiatry.
