Geriatric Psychiatry

This article examines the risks involved in prescribing psychotropic medication and offers suggestions for managing those risks to ensure the best possibility for a favorable outcome.

Psychiatrists who work in inpatient units are faced with daily decisions about predicting which patients will be violent, both in the hospital and after discharge. These decisions are often made using unstructured clinical judgment based on the clinician's experience and knowledge of the literature. How long such judgment stays the standard of care remains to be seen, because psychiatric researchers have produced a number of assessment and management tools to improve the accuracy and use of violence risk assessment. This article briefly outlines 3 tools: the Brøset Violence Checklist (BVC), the Classification of Violence Risk (COVR), and the Historical Clinical Risk-20 (HCR-20).

The role of no-suicide contracts is but a small tactical piece of the larger strategic approach to the assessment and prevention of suicide. Its many obvious limitations-to some degree in assessment, but primarily in suicide prevention-should have driven serious discussion of no-suicide contracts out of consideration as a practical measure in clinical practice and a legal talking point in the courtroom.

Four physicians work on the same patient for days at a time, continually returning to a white board, where they list the patient's changing symptoms and their own differential diagnoses. They think inside and outside the box. As data come in from tests and as interventions succeed or fail, they remain flexible in their way of thinking. The attending physician's main lesson to his 3 fellows is to remain unencumbered by preconceived notions and to constantly revise their thinking to fit the data. Only then, he tells his trainees, is there any chance of a correct diagnosis and medical treatment.

Delirium is characterized by an altered level of consciousness, decreased attention span, acute onset, and fluctuating course. Approximately 15% of elderly patients admitted to the hospital have delirium as a presenting or associated symptom. Delirium will develop in another 15% of elderly patients during hospitalization.

Medical school graduation usually involves taking the Hippocratic oath, in which physicians vow not to intentionally harm their patients. Keeping patients safe is another basic principle of patient care. Physicians are charged with ensuring that their patients are in a safe environment and minimizing risks to their patients by carefully selecting treatment options.

In the article by Drs Kunen and Mandry, "Should Emergency Medicine Physicians Screen for Psychiatric Disorders?" (Psychiatric Times, October 2006), no mention was made of formally assessing a patient's mental status to diagnose delirium.

Suicide is a serious public health problem that ranks as the 11th leading cause of death in the United States. Within the 15- to 24-year-old age group, it is the third leading cause of death.1 Many suicide victims have had contact with the mental health system before they died, and almost one fifth had been psychiatrically hospitalized in the year before completing suicide. A recent review found that psychiatric illness is a major contributing factor to suicide, and more than 90% of suicide victims have a DSM-IV diagnosis.

Each year, the CDC's National Center for Health Statistics creates a report on the current health status of the US. In addition to the issues usually addressed in this report, such as information on morbidity and mortality, vaccination rates, and use of health care resources, the recently released report contained a special feature on pain.

Attention-deficit/hyperactivity disorder (ADHD) is often underappreciated and inadequately treated in adults. Long thought to be a disorder of childhood, ADHD is now believed to persist into adulthood in approximately half of all cases.

Recent issues of Psychiatric Timeshad articles focusing on psychiatricpractice guidelines and algorithms. Dr Michael Fauman examinedthe extent to which they are used,how they are used, and studies that havevalidated their usefulness comparedwith usual care.

Several months ago, a new psychiatrist came from a prestigious university in the Northeast to work in the VA hospital out West where I practice. During one of our initial conversations, he expressed the emphatic view that "benzodiazepines are only useful for acute alcohol withdrawal or psychiatric emergencies and other than that they have no place in pharmacology." I juxtaposed this position with that of several of our older clinicians, who are equally strong advocates of the generous use of benzodiazepines for a variety of psychiatric symptoms.

Surveys of ECT use in the United Statesshow disparate applications, with theprincipal use in academic medical centers.While more than half the treatmentsare given to outpatients, wholepopulations are underserved.

Over the past 50 years, psychiatry has increasingly become psychiatric medicine coincident with the enormous developments in our understanding of and ability to effectively use clinical psychopharmacology to treat patients with psychiatric illnesses. There have been both increased understanding of the molecular mechanisms underlying the effects of psychiatric medications and increased numbers of psychiatric medications. The latter has occurred in tandem with a similar explosion in the availability of medications to treat a host of other medical conditions. In fact, the repertoire of available medications expands virtually every few weeks.

This is a film for psychiatrists who are concerned about women's issues and for anyone else who struggles to reconcile an enlightened humanism with the constraints of religious tradition.

According to the Centers for Disease Control and Prevention (CDC), there are approximately 50,000 violent deaths each year in the United States. Until recently, there were no comprehensive data available to the public regarding these deaths. It was with this in mind that the National Violent Death Reporting System (NVDRS) was created, not only to provide statistics of reported violent deaths, but also to educate and possibly prevent more violent deaths from occurring.

Increased plasma cortisol levels (correlated with increased hypothalamic-pituitary-adrenal axis activity) may be associated with more rapid disease progression in Alzheimer-type dementia (AD). In a study conducted at the Washington University School of Medicine in St Louis, Dr John Csernansky and colleagues assessed 33 patients with very mild or mild AD and 21 persons without AD annually for up to 4 years, using the Clinical Dementia Rating Scale and various neuropsychological tests. Plasma was obtained from each patient and assessed for cortisol level.

Panic disorder occurs in about 1 in 5 individuals who have bipolar disorder. Anxiety amplifies the distress caused by depression and mania, but pharmacological approaches are tricky and under-studied. Frequent comorbidity and evidence of a possible genetic relationship of bipolar and panic disorders are suggestive of a causal relationship between the 2. Thus, it may be fruitful to look more closely at evidence for common biological abnormalities in both disorders to find a pathophysiological mechanism that links mania, depression, and panic attacks. Mood episodes and panic attacks can both be modeled as the result of deficits in amygdala-mediated emotional conditioning. From this model, some insight may be gained for potentially helpful treatment strategies for the 2 disorders when they occur together.

Ronald Fieve and his colleagues were among the first to document milder versions of manic symptoms-hypomania-in the 1970s, observations that did not make it into DSM until 1994.This book appears mainly to be intended for families and patients; clinicians might find some parts simplistic and other parts informative.

Depression and Diet in Elderly Community-Dwelling Mexican and European Americans

Ronald Pies, MD, has been named Editor in Chief of Psychiatric Times.

Beyond demographic characteristics, risk and protective factors for suicide in older adults have been much more clearly defined in recent years by a series of methodologically rigorous, case-controlled psychological autopsy studies.

The topic of life's meaning is, of course, a primary issue in existential theory.

Despite the accepted validity of Hispanic as a distinct demographic and cultural category, we have only fragmentary evidence and scarce guidelines regarding the treatment of mentally ill Hispanic Americans. This article provides a brief review of the topics with the most clinical relevance to diagnosis and treatment of mental disorders in Hispanic Americans.

Mostly because of increased speed and decreased costs of communication and transportation, cities are growing increasingly diverse in their population. Consequently, cultural factors have taken center stage in the understanding of urban mental health. This article will focus on the main approaches to urban mental health and briefly summarize the 3 lines of research in this area. It will then discuss the main themes of a vast body of literature on the cultural aspects of urban mental health.