Schizophrenia/Psychosis

Other Hormones on Behavior - Poetry of the Times

One day after Eli Lilly and Company researchers reported finding olanzapine (Zyprexa) superior to risperidone (Risperdal) on some measures in a 28-week comparative study presented to the American College of Neuropsychopharmacology (ACNP) meeting in 1996, Janssen Pharmaceutica Inc. issued a press statement critical of the methodology and results of the study. Janssen then announced it would undertake its own comparative trial. The results of this trial's initial eight-week acute treatment phase were presented at the European College of Neuro-psychopharmacology meeting held Oct. 31, 1998, through Nov. 4, 1998, in Paris. They indicate risperidone has an advantage for positive symptoms such as hallucinations and delusions, and for anxiety/depression in patients with schizophrenia and schizo-affective disorder.

Tina, a 35-year-old legal secretary, is admitted to the hospital hearing voices that demand she gouge out her own eyes as punishment for having lived a sinful life. She was seen in the local emergency room prior to admission, both for involuntary certification and treatment for corneal damage from having attempted to harm herself. She states to the admitting psychiatrist, "If thine eye offend thee, pluck it out!"

Recent advances in the treatment of mental and addictive disorders, along with research findings in basic neuroscience, molecular genetics and molecular biology that contribute to the understanding of such disorders, were discussed at the American College of Neuropsychopharmacology's 37th annual meeting in Puerto Rico. The following are brief reports from selected presentations.

More than 80 medications are in development to treat mental illnesses, including 18 for depression, 15 for schizophrenia and 16 for anxiety disorders, according to the Pharmaceutical Researchers and Manufacturers of America (1998). Which ones will most likely come to market in the United States?

Myron Liptzin, M.D., is a respected psychiatrist who specialized in the treatment of university students. Liptzin retired last year as chief of psychiatry of student health at the University of North Carolina at Chapel Hill, where he had earned a reputation as a skillful clinician who was particularly adept at crisis intervention. If Liptzin had hoped to go on to a less hectic and stressful life, his expectations were shattered when he found himself accused of negligence in one of the most unusual cases of psychiatric malpractice of this century. A former patient went on a rampage-killing two people-and then blamed Liptzin. The verdict against the psychiatrist was front-page news, and CBS's "60 Minutes" went to North Carolina to do a story that aired mid-November 1998. Like a bolt out of the blue, Liptzin had gotten his 15 minutes of unwanted fame.

It is more cost-effective for psychiatrists to provide medication and psychotherapy to depressed patients than it is to split treatment between medical doctors and other mental health care providers

Aware that there is a "rush to hold all providers delivering mental health and chemical dependency services accountable for the accessibility, quality and satisfaction of such services," the American Managed Behavioral Healthcare Association (AMBHA) recently released the second version of its Performance Measures for Managed Behavioral Healthcare Programs (PERMS 2.0).

In Western psychiatry, depression is considered a major cause of suicide. But research from China calls that assumption into question. More than 300,000 suicides occur annually in China, nearly 10 times the number of suicides in the United States.

Verdicts in separate malpractice cases have heightened apprehension over the erosion of patient-physician confidentiality and the increase in malpractice liability exposure. Psychiatrists now face the more serious prospect that they could end up, in essence, having to guarantee society that their patients won't act dangerously.

Insufficient intake of essential fatty acids (EFAs) may contribute to the pathogenesis of mental diseases, while their supplementation may relieve some symptoms, according to researchers who attended the National Institutes of Health (NIH) Workshop on Omega-3 Essential Fatty Acids and Psychiatric Disorders held in Bethesda, Md., in September 1998.

The passage of the Mental Health Parity Act of 1996, which took effect Jan. 1, 1998, came amid dire warnings from edgy business groups that it would cause exorbitant cost increases in health insurance premiums or prompt a dramatic reduction of medical and surgical benefits. But a recently released report emphasized the affordability of mental health insurance coverage.

This month establishes a milestone for CME LLC Not only is it the company's 11th annual U.S. Psychiatric & Mental Health Congress, it also marks the 20th anniversary of the company's first conference. CME LLC grew out of a desire to reach and educate more people regarding psychiatric issues. One way to do this was by developing high-quality continuing education opportunities.

Atypical antipsychotic treatment for borderline personality disorder (BPD) and augmentation therapy with olanzapine (Zyprexa) or estrogen replacement therapy (ERT) for patients with mood disorders were among the research questions addressed at the American Psychiatric Association's annual meeting in Toronto. Following are some brief reports of selected presentations.

The diagnostic criteria for sexual addiction are derived from the behaviorally nonspecific criteria for addictive disorder that were presented in Part 1 (Goodman, 1998b), by replacing "behavior" with "sexual behavior".

Explaining the Realities of Mental Illnesses. The ongoing campaign against stigma and discrimination attempts to promote an attitudinal shift from misunderstanding and fear to knowledge and compassion. Unfortunately, mental illnesses only grab the public's attention when high-profile tragedies become front-page news.

In more than two dozen programs throughout the United States, telepsychiatry is ushering in a new way of bringing mental health services to thousands of individuals who, in the past, may have gone without. More often than not, however, they are pilot projects or grant-supported endeavors, meaning that these prototypes of the psychiatrist's office of the future have yet to prove themselves in the medical marketplace.

Despite threatening skies on a Sunday afternoon in late May, about 2,000 people gathered in New York City's Bryant Park for the fourth annual picnic given by National Picnic for Parity, a broad-based coalition of mental health providers, consumer groups, legislators and other advocates interested in achieving parity for mental illness.

While there is broad-ranging support for increased resources for the mentally ill, the degree to which innovations should include mandated care has re-ignited a long-standing debate over whose civil rights are actually being trampled-those individuals who are forced to receive care, or those who are denied care even though they desperately need it.

This is the fourth in a series of five articles regarding obsessive-compulsive spectrum disorders. The first three articles ran in the March 1997, June 1997 and January 1998 issues of Psychiatric Times. The first article gave an overview of spectrum disorders, the second discussed obsessive-compulsive disorder and the third examined body dysmorphic disorder.

A leader of a key mental illness patient advocacy group indirectly but pointedly criticized psychiatrists for the care they give schizophrenics. Laurie Flynn, the executive director of the National Alliance for the Mentally Ill (NAMI), said she was "appalled" by the results of face-to-face interviews with over 700 schizophrenics during a 16-month period. The interviews turned up evidence of under- and overdosing of patients and a failure to get patients into effective community treatment plans.

The concept of a barrier between the blood and the brain arose in the late 19th century when the German bacteriologist Paul Ehrlich observed that certain dyes administered intravenously to small animals stained all of the organs except the brain. Ehrlich interpreted this to mean that the brain had a lower affinity for the dye than the other tissues. In subsequent experiments, one of Ehrlich's students injected a blue dye directly into the cerebrospinal fluid of rabbits and dogs. The dye readily stained the entire brain, but did not enter the bloodstream to stain the other internal organs.

Bestowed in gratitude in recognition of (his) superb, invigorating leadership of the American Psychiatric Association, his dedication to the principle that the highest quality patient care rests firmly on a true integration of the latest advances in psychodynamic and psychobiological thinking, and his strong advocacy for the scientific validation of what we do--all accomplished with his own consummate grace and elegance.

"Can we talk?" asks a recovering patient who chastises psychiatry for too readily dismissing patients with her diagnosis as unable to benefit from talking therapy (A Recovering Patient, 1986). With managed care administrators quick to seize upon a lack of outcome data as a pretext for limiting treatment and a public mental health system pressed to handle caseloads as high as 200 to 300 patients per clinician, psychiatry's regrettable answer has often been: "No, we're too busy." Recent research findings, however, convincingly demonstrate that a flexible form of individual psychotherapy, when combined with appropriate neuroleptic medication, can yield improvements in social and vocational functioning unobtainable with "treatments as usual."

The explosion of neuroscience developments in this "Decade of the Brain" now provides people with schizophrenia a new generation of antipsychotic therapies. For many, these medications (e.g., clozapine [Clozaril], olanzapine [Zyprexa], risperidone [Risperdal], and quetiapine [Seroquel]) produce an improvement over their "old" antipsychotics in terms of side effects and, for some, clinical response. For a select few, however, these medications can produce dramatic improvement, akin to what Sacks (1990) termed an "awakening." These medications create exciting opportunities to use psychotherapy, group work and rehabilitation with a population historically relegated to back wards or triaged to "case management."

After a teenager's suicide attempt, her desperate and bewildered parents dragged her to a mental health clinic. The 16-year-old admitted to drinking nearly every day and using an assortment of other illicit drugs. Only after a month in treatment did the clinician learn that the teenager had been molested when she was 8 years old by an uncle and threatened with death if she ever told her parents.

There is a substantial constituency for alternative medicine. Worldwide, 70% to 90% of all health care "ranges from self-care according to folk principles, to care given in an organized health care system based on an alternative tradition or practice." As many as one-third of all Americans are reported to have some belief in alternative medicine or to be actively using nonmainstream remedies.

For 17 years, claim federal prosecutors, Theodore Kaczynski terrorized the nation with a string of 16 bombings that killed three people and injured 23 more. On trial now for his life, the alleged Unabomber's case will most likely hinge on the expert testimony proffered by a covey of psychiatrists and psychologists scheduled to be called as witnesses as the case unfolds in U.S. District Court in Sacramento, Calif. this month.

Nelson Kull, executive director of Pathways, sees an additional benefit to consumer employment: it provides patients with a first-hand look inside the system, and this can help defuse the sometimes antagonistic relationship between consumers and caregivers. "Some people criticize doctors and pharmaceutical companies for making a lot of money," says Kull, "but they gave me back my life. I once told meeting [attendees] that yes, psychiatry and medical care cost a lot, but your car costs a lot. I can't drive my car without my medications, so which comes first?"

The goals of National Coalition for Mental Health Professionals and Consumers are to educate the public about the problems of managed mental health care and to develop alternative health delivery models. I think greater media coverage has spawned greater awareness of the difficulties with managed care and has provided legislators with vital information. Certainly sharing their stories has made many people feel less alone and isolated within a system they find frustrating and depriving. I think media advocacy has helped doctors find support for their right to stand up to these abuses and band together in greater numbers to fight for integrity and quality in mental health care delivery.