Benzodiazepines Remain Important Therapeutic Options in Psychiatric Practice

Benzodiazepines and medications acting on benzodiazepine receptors that do not have a benzodiazepine structure (z-drugs) have been viewed by some experts and regulatory bodies as having limited benefit and significant risks. Data presented in this article support the use of these medications as treatments of choice for acute situational anxiety, chronic anxiety disorders, insomnia, alcohol withdrawal syndromes, and catatonia. They may also be useful adjuncts in the treatment of anxious depression and mania, and for medically ill patients. Tolerance develops to sedation and possibly psychomotor impairment, but not to the anxiolytic effect of benzodiazepines. Sedation can impair cognitive function in some patients, but assertions that benzodiazepines increase the risk of dementia are not supported by recent data. Contrary to popular opinion, benzodiazepines are not frequently misused or conduits to misuse of other substances in patients without substance use disorders who are prescribed these medications for appropriate indications; most benzodiazepine misuse involves medications that are obtained from other people. Benzodiazepines are usually not lethal in overdose except when ingested with other substances, especially alcohol and opioids. Benzodiazepines comprise one of the few classes of psychotropic medication the mechanisms of action of which are clearly delineated, allowing for greater precision in their clinical use. These medications, therefore, belong in the therapeutic armamentarium of the knowledgeable clinician.

Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment

Psychotic depression was initially considered to be at one end of a continuum of severity of major depression. Subsequent experience demonstrated that psychosis is an independent trait that may accompany mood disorders of varying severity. While much has been learned about the impact of severe mood congruent delusions and hallucinations on the course and treatment response of depression, less is known about fleeting or mild psychosis, mood incongruent features, or psychotic symptoms that reflect traumatic experiences. Acute treatment of psychotic unipolar depression generally involves the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy. There is inadequate information about maintenance treatment of unipolar psychotic depression and acute and chronic treatment of psychotic bipolar disorder. Decision-making therefore still must rely in part on clinical experience.

Preliminary Assessment of a Novel Continuum-of-Care Model for Young People With Autism Spectrum Disorders

Because of limited intermediate-care services, patients with autism spectrum disorders (ASDs) are increasingly being treated in emergency departments (EDs) and psychiatric hospitals. To address this growing problem, the authors developed a mobile outreach program, called Access to Psychiatry through Intermediate Care (APIC), for young (≤26 years) patients with ASD at risk for involvement with emergency medical services or the legal system. In its initial year, the average program duration per patient was 264.5 days. Clinical and Family Distress Scale scores indicated significant improvements for participating patients and caretakers. In the first year, among 40 patients with sufficient data for comparison, 13 (33%) went to the ED, and lengths of stay decreased up to 77% from pre- to postintervention. Given a cost per APIC-enrolled patient of $1,700, the net saving for the cost of ED treatment was $2,260-$2,559 per patient. The feasibility and cost-effectiveness of the APIC model has attracted additional state and county funding.

Selective serotonin reuptake inhibitors and benzodiazepines in panic disorder: A meta-analysis of common side effects in acute treatment

BACKGROUND

Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.

AIM

The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.

METHODS

We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.

RESULTS

Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.

CONCLUSION

Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

Applications of calcium channel blockers in psychiatry: pharmacokinetic and pharmacodynamic aspects of treatment of bipolar disorder

Introduction: Calcium channel blockers (CCBs) comprise a heterogeneous group of medications that reduce calcium influx and attenuate cellular hyperactivity. Evidence of hyperactive intracellular calcium ion signaling in multiple peripheral cells of patients with bipolar disorder, calcium antagonist actions of established mood stabilizers, and a relative dearth of treatments have prompted research into potential uses of CCBs for this common and disabling condition. Areas covered: This review provides a comprehensive overview of intracellular calcium signaling in bipolar disorder, structure and function of calcium channels, pharmacology of CCBs, evidence of efficacy of CCBs in bipolar disorder, clinical applications, and directions for future research. Expert opinion: Despite mixed evidence of efficacy, CCBs are a promising novel approach to a demonstrated cellular abnormality in both poles of bipolar disorder. Potential advantages include low potential for sedation and weight gain, and possible usefulness for pregnant and neurologically impaired patients. Further research should focus on markers of a preferential response, studies in specific bipolar subtypes, development of CCBs acting preferentially in the central nervous system and on calcium channels that are primarily involved in neuronal signaling and plasticity.

A preliminary study of a novel emergency department nursing triage simulation for research applications

Background

Studying the effect on functioning of the emergency department of disasters with a potential impact on staff members themselves usually involves table top and simulated patient exercises. Computerized virtual reality simulations have the potential to configure a variety of scenarios to determine likely staff responses and how to address them without intensive utilization of resources. To decide whether such studies are justified, we determined whether a novel computer simulation has the potential to serve as a valid and reliable model of on essential function in a busy ED.

Methods

Ten experienced female ED triage nurses (mean age 51) mastered navigating a virtual reality model of triage of 4 patients in an ED with which they were familiar, after which they were presented in a testing session with triage of 6 patients whose cases were developed using the Emergency Severity Index to represent a range of severity and complexity. Attitudes toward the simulation, and perceived workload in the simulation and on the job, were assessed with questionnaires and the NASA task load index. Z-scores were calculated for data points reflecting subject actions, the time to perform them, patient prioritization according to severity, and the importance of the tasks. Data from questionnaires and scales were analyzed with descriptive statistics and paired t tests using SPSS v. 21. Microsoft Excel was used to compute a correlation matrix for all standardized variables and all simulation data.

Results

Nurses perceived their work on the simulation task to be equivalent to their workload on the job in all aspects except for physical exertion. Although they were able to work with written communications with the patients, verbal communication would have been preferable. Consistent with the workplace, variability in performance during triage reflected subject skill and experience and was correlated with comfort with the task. Time to perform triage corresponded to the time required in the ED and virtual patients were prioritized appropriately according to severity.

Conclusions

This computerized simulation appears to be a reasonable accurate proxy for ED triage. If future studies of this kind of simulation with a broader range of subjects that includes verbal communication between virtual patients and subjects and interactions of multiple subjects, supports the initial impressions, the virtual ED could be used to study the impact of disaster scenarios on staff functioning.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-2337-3) contains supplementary material, which is available to authorized users.

Mania

PURPOSE OF REVIEW

Primary mania and hypomania in full or subsyndromal forms are the defining features of bipolar disorder and are common in neurologic patients, as are manic syndromes precipitated by medications used to treat neurologic disorders. This article addresses the diagnosis, pathophysiology, treatment, and course of bipolar disorder after a manic episode as well as mania as a manifestation of neurologic disease.

RECENT FINDINGS

Mania can be a primary psychiatric disorder but can also be a symptom of a neurologic disorder, especially right-sided cerebrovascular disease. Treatments (such as corticosteroids and dopaminergic agents) for neurologic illnesses regularly induce mania. The neurobiology of primary mania and bipolar disorder involves alterations in intracellular signaling, changes in gene expression, neural network interactions, and apoptosis. Except when induced by time-limited treatment with a provoking agent, mania tends to be highly recurrent and to alternate or be exhibited alongside depression. Symptoms of mania become more complex and treatment refractory with time, although effective treatment improves the long-term outcome.

SUMMARY

Behavioral manifestations of mania may be more obvious than affective symptoms, especially in patients with aprosodia. Atypical antipsychotic drugs are often first-line acute treatments, but the evidence supporting their long-term prophylactic efficacy is questionable. In addition to being an established mood stabilizer, lithium has putative neuroprotective properties, although a side effect can be impaired memory.

The usefulness of genotyping cytochrome P450 enzymes in the treatment of depression

INTRODUCTION

Pharmacogenomics, which is derived from genome-wide association studies (GWAS), and pharmacogenetics, which involves candidate gene association studies (CGASs), are proving increasingly useful in personalized cancer care. Research in psychiatric applications has primarily involved genetic polymorphisms of P450 CYP enzymes, which mediate oxidative metabolism, particularly CYP2D6, which is involved in the metabolism of at least 30 psychotropic medications. This work has been supplemented by genotyping of proteins for the drug efflux pump P-glycoprotein (P-gp), serotonin receptors, and the serotonin reuptake pump.

AREAS COVERED

This review covers principles of pharmacogenetics and pharmacogenomics, previous analyses of pharmacokinetic and pharmacodynamics studies, newer studies of the predictive value of genetic testing in the treatment of depression, obstacles to implementation of genetic testing in predicting treatment response and side effects, and suggestions for future research.

EXPERT OPINION

Studies of multiple genes have produced some positive results in groups of patients, but genetic testing does not yet seem to be applicable to choosing medications for a specific patient.

Increased platelet intracellular calcium ion concentration is specific to bipolar disorder

BACKGROUND

Increased baseline ([Ca(2+)]B) and agonist-stimulated ([Ca(2+)]s) free intracellular calcium ion concentrations ([Ca(2+)]i) are well-replicated findings in bipolar disorder, but whether this finding is specific to that condition and if so, whether it is a marker of the mood disorder or a feature seen in other disorders such as psychosis has remained unclear.

METHODS

Platelet [Ca(2+)]i was assessed in 15 inpatients with psychotic and nonpsychotic mania, 17 schizophrenia inpatients, and 17 matched controls.

RESULTS

Platelet [Ca(2+)]B and [Ca(2+)]s were significantly higher than controls in bipolar disorder but not schizophrenia. Variability of [Ca(2+)]B was significantly increased in bipolar disorder regardless of the presence of psychosis, but not in schizophrenia.

LIMITATIONS

Use of antipsychotic drugs by the majority of both patient groups may have obscured elevated [Ca(2+)]i in schizophrenia, or may have masked a difference between psychotic and nonpsychotic bipolar disorder. Measurement of [Ca(2+)]i is too labor intensive to become a routine test for diagnosis or prediction of treatment response.

CONCLUSIONS

Elevated intracellular Ca(2+) signaling may be a marker of primary cellular hyperactivity that could contribute to comorbid conditions such as hypertension and neuronal apoptosis. Since lithium and carbamazepine attenuate increased [Ca(2+)]i, further research may demonstrate a correlation between normalization of [Ca(2+)]i and response to one of these medications, and further research may clarify whether a subgroup of patients may respond well to calcium channel antagonists.

Pharmacokinetic evaluation of vortioxetine for the treatment of major depressive disorder

INTRODUCTION

Major depressive disorder (MDD), one of the most common disorders in medical practice and one of the leading causes of disability worldwide, is frequently comorbid with anxiety disorders. Vortioxetine (Lu AA21004) is a new antidepressant that combines a number of neurotransmitter reuptake and receptor effects that have been thought to predict efficacy as a treatment for depressive and anxiety disorders.

AREAS COVERED

This review summarizes the pharmacology and neurobiology of vortioxetine. Studies of its efficacy and tolerability in major depression and generalized anxiety disorder are critically reviewed.

EXPERT OPINION

Despite the fact that industry-sponsored studies are more likely than other clinical trials to support efficacy of the experimental drug, results have been mixed. Some studies supported that vortioxetine is superior to placebo in the treatment of MDD and some do not. Two studies supported the efficacy of vortioxetine in the treatment of generalized anxiety disorder and two do not. The incidence of sexual dysfunction has varied considerably in different studies, but cardiac effects and psychomotor impairment seem to be minimal. Advantages of vortioxetine over existing antidepressants are not yet clear.

Predictors of later bipolar disorder in patients with subthreshold symptoms

INTRODUCTION

The clinical significance of subthreshold bipolar disorder (SBD), which is characterized by an insufficient number or severity of hypomanic symptoms to qualify for a formal bipolar disorder diagnosis, remains to be determined.

METHODS

We examined the outcomes three years later (2004-2005; Wave 2) of 40,512 civilian, non-institutionalized subjects who endorsed elation and/or irritability but did not meet full criteria for lifetime mania or hypomania in 2001-2002 (Wave 1).

RESULTS

The likelihood of developing a clear episode of mania or hypomania by Wave 2 was significantly increased in subjects with elation or only irritability at Wave 1 compared with subjects who did not endorse either (OR 2.8, p<0.01 for each). Endorsement of both symptoms at Wave 1 increased the likelihood of a new episode of mania or hypomania 4.6 times, which was significantly higher than for those with only elation or irritability (p<.05 for each).

LIMITATIONS

SBD was not limited to depression, reducing comparability to previous studies. Despite the large sample size, there were not enough subjects to determine the impact of different numbers and types of additional symptoms on bipolar outcome. Although the majority of subjects were followed between the two Waves, the total duration of follow-up was probably too short to determine the long-term conversion rate to mania or hypomania.

CONCLUSIONS

Elation and/or irritability, especially if accompanied by trouble concentrating, racing thoughts or hyperactivity, may represent a prodrome of formal bipolar disorder that indicate close follow-up and cautious use of antidepressants.

Pharmacokinetic evaluation of olanzapine + fluoxetine for the treatment of bipolar depression

INTRODUCTION

A proprietary combination of the atypical antipsychotic drug olanzapine and the serotonin reuptake inhibitor fluoxetine (OFC, Symbyax) was approved for the treatment of bipolar depression based on a double-blind, placebo-controlled comparison of olanzapine, OFC, and placebo.

AREAS COVERED

This review considers published controlled and uncontrolled studies of the efficacy, pharmacodynamics, pharmacokinetics, interactions, and adverse effects of OFC. Beyond previously reviewed efficacy studies, an open-label 7-week study of 161 bipolar depressed patients (93% bipolar I), and an 8-week double-blind study of 833 bipolar I depressed patients with an open-label extension were identified. The structure and limitations of clinical trials of OFC are critically addressed.

EXPERT OPINION

OFC trades simplicity of administration for loss of flexibility of dosing and lack of a generic preparation, both of which are available for olanzapine and fluoxetine separately. Clinical trials are limited by short-term follow-up, exclusive use of symptom rating scale scores, limitation of subjects to those with depression that is not overly complex or comorbid, lack of consideration of subsyndromal hypomania and mood cycling, and high dropout rates. In the absence of comparisons to mood stabilizers combined with each other and/or antidepressants, the role of OFC in the treatment of bipolar depression remains unclear.

New approaches for the management of bipolar disorder: role of sublingual asenapine in the treatment of mania

Bipolar disorder is a prevalent disorder that tends to become progressive without treatment and with inadequate treatment. Second generation (atypical) antipsychotic drugs have increasingly been used as adjunctive treatment or monotherapy for mania, but they have the potential for significant adverse effects and their role in maintenance treatment remains unclear. Asenapine is a new atypical antipsychotic medication formulated in a sublingual preparation that has been studied for mania but not maintenance therapy. Evidence indicating efficacy, adverse effects, and potential benefits and drawbacks of using asenapine in the treatment of bipolar disorder based on currently available published data are summarized.

RNA-Seq analysis implicates dysregulation of the immune system in schizophrenia

BACKGROUND

While genome-wide association studies identified some promising candidates for schizophrenia, the majority of risk genes remained unknown. We were interested in testing whether integration gene expression and other functional information could facilitate the identification of susceptibility genes and related biological pathways.

RESULTS

We conducted high throughput sequencing analyses to evaluate mRNA expression in blood samples isolated from 3 schizophrenia patients and 3 healthy controls. We also conducted pooled sequencing of 10 schizophrenic patients and matched controls. Differentially expressed genes were identified by t-test. In the individually sequenced dataset, we identified 198 genes differentially expressed between cases and controls, of them 19 had been verified by the pooled sequencing dataset and 21 reached nominal significance in gene-based association analyses of a genome wide association dataset. Pathway analysis of these differentially expressed genes revealed that they were highly enriched in the immune related pathways. Two genes, S100A8 and TYROBP, had consistent changes in expression in both individual and pooled sequencing datasets and were nominally significant in gene-based association analysis.

CONCLUSIONS

Integration of gene expression and pathway analyses with genome-wide association may be an efficient approach to identify risk genes for schizophrenia.

Short-term safety and pharmacokinetic profile of asenapine in older patients with psychosis

OBJECTIVES

The aim of this study was to assess the short-term tolerability of two titration schedules of sublingual asenapine in older patients with psychosis, not associated with organic brain disease, and to compare asenapine pharmacokinetics in older patients versus younger adults with schizophrenia.

METHODS

Patients ≥ 65 years with psychosis without dementia were randomized for 6 weeks to two dose-escalation regimens: 2 days at 2 mg twice daily (BID), 2 days at 5 mg BID, and 10 mg BID thereafter (slow escalation); or 4 days at 5 mg BID and 10 mg BID thereafter (rapid escalation). Clinical and pharmacokinetic assessments were performed in each group.

RESULTS

Of 122 randomized patients, 76 (62.3%) completed the trial. The incidence of treatment-emergent adverse events (AEs) was comparable (72.1%) with both regimens. The most frequently reported AEs were hypertension, headache, and somnolence; incidence of extrapyramidal symptom-related AEs was 5.7%. Mean end point weight change was 0.4 kg. For asenapine 5 and 10 mg BID, median times to maximum concentration were 1.00 and 1.06 h, respectively; maximum concentrations (C(max) ) were 4.73 and 7.93 ng/mL; areas under the concentration versus time curve (0-12 h; AUC(0-12) ) were 32.1 and 56.3 ng∙h/mL.

CONCLUSIONS

Despite 12-30% increases in asenapine C(max) and AUC(0-12) in older patients compared with previously published findings in younger schizophrenia patients, possibly as a result of slower drug clearance, asenapine was generally well tolerated during both dose-escalation schedules. No dose adjustment appears to be necessary in older patients.

Self-prescribed and other informal care provided by physicians: scope, correlations and implications

BACKGROUND

While it is generally acknowledged that self-prescribing among physicians poses some risk, research finds such behaviour to be common and in certain cases accepted by the medical community. Largely absent from the literature is knowledge about other activities doctors perform for their own medical care or for the informal treatment of family and friends. This study examined the variety, frequency and association of behaviours doctors report providing informally. Informal care included prescriptions, as well as any other type of personal medical treatment (eg, monitoring chronic or serious conditions).

METHOD

A survey was sent to 2500 randomly-selected physicians in Colorado, 600 individuals returned questionnaires with usable data. The authors hypothesised: (1) physicians would prescribe the same types of treatment at home as they prescribed professionally; and (2) physicians who informally prescribed addictive medications would be more likely to engage in other types of informal medical care.

RESULTS

Physicians who wrote prescriptions for antibiotics, psychotropics and opioids at work were more likely to prescribe these medications at home. Those prescribing addictive drugs outside of the office treated more serious illnesses in emergency situations, more chronic conditions and more major medical/surgical conditions informally than did those not routinely prescribing addictive medications. Physicians reported a variety of informal care behaviour and high frequency of informal care to family and friends.

DISCUSSION

The frequency and variety of informal care reported in this study strongly argues for profession-wide discussion about ethical and guideline considerations for such behaviour. These areas are discussed in the paper.

Maintenance Treatment of Bipolar Disorder with Ziprasidone in Adjunctive Use with Lithium or Valproate

Ziprasidone is a second generation (“atypical”) antipsychotic drug that has been used alone and as an adjunct to standard mood stabilizers to reduce recurrence rates in bipolar disorder. Approval of ziprasidone as an adjunct to lithium or valproate in 2009 was based on an industry sponsored study of 584 outpatients with a current or recent manic episode; 240 of these subjects were randomized to adjunctive ziprasidone or placebo and 138 completed a six month trial. Patients enrolled in maintenance studies did not have refractory mood disorders, comorbid conditions or risk of dangerousness. Maintenance ziprasidone augmentation is an option for patients who do not respond to a single mood stabilizer rapidly, and possibly for those with residual psychotic symptoms, but there are insufficient data to prefer this approach to combinations of mood stabilizers or augmentation with other agents. Ziprasidone is generally well tolerated, with less sedation and weight gain than many other antipsychotic drugs; it should be taken with food. Primary interactions of concern are with other serotonergic medications, MAO inhibitors, and other medications that prolong the QT interval.

Can academic departments maintain industry relationships while promoting physician professionalism?

The authors describe the development of a comprehensive policy for relationships of full-time and volunteer faculty and residents with industry. The underlying philosophy was that an academic approach to relations with industry that emphasizes objective outcomes and internal change will be more effective than rote restrictions on behavior that assume that physicians cannot learn new behaviors and that are impossible to enforce. The policy, developed through much discussion and debate with stakeholders, involves elimination of industry-supplied meals, gifts, and favors; integration of industry-sponsored and academic research; education of faculty and residents about the ways in which industry marketing influences clinical decision making; and comprehensive disclosure by faculty, including to patients, of financial interests in industry. At occasional points in the psychopharmacology curriculum and at a departmental "pharma symposium," industry representatives or industry-sponsored guest speakers are allowed to present peer-reviewed articles followed by comments by a faculty member with relevant expertise about aspects of the presentation that are accurate or misleading and by a general discussion of research and clinical implications of the research and the manner in which it is presented. Adherence to new protocols has been high because faculty and residents participated in developing them and are involved in their implementation. Acceptance by industry representatives has been variable. Experience with this approach suggests that it is possible to develop a collaborative relationship with industry that maintains appropriate boundaries between industry and academia.

Agomelatine, a melatonin agonist with antidepressant properties

Agomelatine (beta-methyl-6-chloromelatonin), which is structurally homologous to melatonin, is a potent agonist of melatonin MT1 and MT2 receptors as well as an antagonist of serotonin 5-HT(2C) receptors. Agomelatine appears to improve sleep without causing daytime sedation. It has not been found to be associated with sexual side effects and discontinuation symptoms. Three placebo-controlled trials, one of them a dose finding study and two of them pivotal trials, suggest that agomelatine is an antidepressant at doses of 25 - 50 mg/day. Agomelatine appears to be well tolerated, without sexual or cardiac adverse effects, weight gain or discontinuation syndromes. Animal studies suggest a possible neuroprotective action of agomelatine, although there are more data in favor of an anxiolytic effect. Substantially more research is needed to establish its role in the treatment of mood and circadian rhythm disorders.

Psychopharmacology for neurologists

Psychiatric disorders are common in neurological patients, and psychopharmacological agents are frequently used to treat agitation and other problems in neurological practice. Antidepressants are effective for depression caused by neurological illness, but they can interact with other medications. Antianxiety drugs can aggravate cognitive disorders and should be used cautiously in this context. Antipsychotic drugs can be useful for acute agitation, but they are being found to be neither effective nor safe for chronic nonpsychotic agitation. Other agents such as beta blockers and serotonergic agents are being found to be more useful. Uses, doses, adverse effects, and interactions of psychiatric medications in neurology are summarized in this article, and suggestions are provided for the practical application of these treatments.

Mood disorders and the outcome of suicidal thoughts and attempts

Suicidal ideation and attempts are common reasons for visits to the emergency department and critical care hospitalizations and a common public health problem. Most patients who make a suicide attempt have a psychiatric disorder, most frequently a mood, psychotic, substance use, or personality disorder. Patients who are at high risk of another attempt and cannot be transferred promptly to a psychiatric service should be managed jointly by the psychiatric and critical care teams with an emphasis on protection of the patient, identification of substance intoxication and withdrawal, making the environment safe, and instituting treatment of the psychiatric disorder. Antidepressants reduce suicide risk but their slow onset of action may make electroconvulsive therapy a desirable alternative for severely depressed patients. Parenteral treatment is possible with benzodiazepines and antipsychotic drugs but not antidepressants.

Can admissions interviews predict performance in residency?

OBJECTIVE

The authors aim to determine whether admission interviews predict performance in residency.

METHODS

The authors determined whether interview and other admission data were correlated with performance during postgraduate years 2-4 and with remaining in the residency in 544 residents enrolled in a single psychiatry residency program between 1963 and 2004.

RESULTS

Considered together, admissions data predicted 13% of the variance in performance ratings in postgraduate year 2 (PGY-2) and 5% in PGY-4. Interview scores were moderately correlated with performance ratings in PGY-2, modestly correlated with performance in PGY-3, and not correlated with performance ratings in PGY-4. Letters of reference were moderately correlated with performance ratings in PGY-2 and modestly correlated with performance in PGY-3 and PGY-4. In PGY-2, interview scores differentiated between the top quartile of performance and the other three quartiles, while letters of reference differentiated performance in the top and bottom quartiles from the middle quartiles. Numerical differences among groups were not great enough to be practically useful, and no variables predicted which residents would leave the program before completing it.

CONCLUSION

As they are currently conducted, application interviews do not have sufficient power to predict performance during residency. Letters of reference may be useful to the extent that they reflect personal experience with the applicant, but differences in ratings of these letters are not great enough to base admission decisions on them. As it is currently performed, the interview process may be more useful as a means of interesting applicants in the program than of evaluating their potential for success in the residency.

The mental health clinic: a new model

The role of psychiatrists into public mental health clinics has been hampered by a perceived restriction of the psychiatrist's role to prescribing and sign-ing forms, limiting opportunities to engage in the kind of integrated care that attracted many physicians to this specialty. We propose a revision of the current model in a direction that maximizes the expertise of this specialist as well as other clinicians in the health care team. The basic unit would consist of a psychiatrist (with adequate background both in psychopharmacology and psychotherapy), an internist and four clinical psychotherapists, who may provide evidence-based treatment after the initial evaluation of the psychiatrist. Its functioning would emphasize repeated assessments, sequential combination of treatments, and close coordination of team members. Re-invigorating the role of the psychiatrist in the context of a team in which role assignments are clear could result in better outcomes and enhanced recruitment of psychiatrists into the public sector.

Do data obtained from admissions interviews and resident evaluations predict later personal and practice problems?

OBJECTIVE

The authors assessed whether current methods of evaluating residency applicants and residents identify psychiatrists who later develop evidence of impairment.

METHOD

Residency admissions and performance data for all physicians who were enrolled in a psychiatry residency between 1965 and 1994 and who were referred to an impaired physician program up to 35 years later were matched for age and gender with a nonreferred physician from the same class.

RESULTS

There were no significant differences between groups in admission interview assessments, performance ratings, or narrative observations by faculty during residency.

CONCLUSIONS

Standard approaches do not identify physicians at risk of later impairment.

Treatment of bipolar depression

This article discusses current practices in the treatment of bipolar depression. In the absence of more definitive research, the treatment of bipolar depression is guided by clinical experience and expert opinion, and sometimes by marketing and popular trends, as much as it is by hard data. Considering the limitations of current knowledge is an essential component of the scientific practice of psychiatry.

Massive graviton as a testable cold-dark-matter candidate

We construct a consistent model of gravity where the tensor graviton mode is massive, while linearized equations for scalar and vector metric perturbations are not modified. The Friedmann equation acquires an extra dark-energy component leading to accelerated expansion. The mass of the graviton can be as large as approximately (10(15) cm)(-1), being constrained by the pulsar timing measurements. We argue that nonrelativistic gravitational waves can comprise the cold dark matter and may be detected by the future gravitational wave searches.

Who is teaching psychopharmacology? Who should be teaching psychopharmacology?

OBJECTIVE

To review the current status of psychopharmacology education for medical students, residents, and practitioners in psychiatry and other specialties.

METHODS

A search of the MEDLINE and PsychInfo data bases was conducted using four keywords: pharmacology, psychopharmacology, teaching, and student. Additional references were obtained from citations in these articles. Published material was supplemented with the experience of the author and others involved in psychopharmacology teaching.

RESULTS

The majority of psychopharmacology education is provided by faculty from disciplines that include psychiatry, primary care medicine, basic science, and pharmacy. The pharmaceutical industry supports a substantial amount of continuing medical education (CME) by psychiatrists, pharmacists, and other medical practitioners, while much of the information that office practitioners receive and an increasing amount of material provided to residents comes from pharmaceutical representatives. The most important attributes of the effective psychopharmacology educator are knowledge, enthusiasm, honesty, an ability to encourage critical thinking, and genuine interest in the student. However, the primary criteria for participation in psychopharmacology education are faculty who are most available and willing in the academic medical center and those who engage in paid CME activities.

CONCLUSIONS

Educators with clinical experience should play a core role in helping students to integrate research with actual clinical practice and should be able to teach students how to evaluate new research in psychopharmacology, especially if it is industry sponsored.

Rapid cycling bipolar disease: new concepts and treatments

Having been recognized by Kraeplin at the beginning of the 20th century, rapid cycling was first described as a specific entity by Dunner et al. in 1974. The prevalence of rapid cycling ranges from 12% to 20% in patients with bipolar disorder who are not selected for a high rate of cycling.

Nicardipine improves the antidepressant action of ECT but does not improve cognition

INTRODUCTION

Cognitive impairment, the most important adverse effect of electroconvulsive therapy (ECT), may involve elevated intracellular calcium ion signaling. Animal research suggests that calcium channel-blocking agents, which attenuate excessive intracellular calcium activity, may reduce cognitive dysfunction caused by ECT.

METHOD

The lipid-soluble calcium channel-blocking drug nicardipine or matching placebo were randomly assigned to 26 patients with major depressive disorder receiving ECT. A rater blind to the experimental condition administered the Hamilton Depression Rating Scale, the Montgomery-Asberg Depression Rating Scale, the Beck Depression Inventory, the Mini-Mental State Examination and a comprehensive battery of neuropsychological tests prior to ECT, at the completion of ECT, and 6 months after ECT completion.

RESULTS

Compared with patients receiving placebo, patients taking nicardipine had significantly lower scores on the Hamilton and Montgomery-Asberg but not the Beck Depression rating scale scores at the completion of ECT. There were no differences between placebo and nicardipine groups in depression scores 6 months after ECT. Cognitive function declined over the course of ECT and improved over the next 6 months in both groups, but changes were statistically significant for only two subtests on the neuropsychological battery. Changes in Mini-Mental State Examination scores were small and were not significant at any point. There were no significant differences between nicardipine and placebo treated groups in any assessment of cognition.

DISCUSSION

Standard approaches to ECT in younger patients without preexisting neurological impairment do not produce cognitive side effects of sufficient severity for calcium channel-blocking agents to reduce these side effects demonstrably. Studies of treatments for cognitive impairment should be conducted in patients with risk factors for more severe cognitive impairment such as geriatric patients or patients with a history of interictal delirium during previous treatment with ECT. A possible effect of nicardipine in enhancing the antidepressant action of ECT requires further investigation in a study designed to test this action.

Treatment resistance in anxiety disorders

As primary care physicians become more comfortable prescribing treatments for anxiety disorders, mental health specialists increasingly are encountering patients with refractory anxiety. In this article, the authors briefly review causes of treatment resistance and approaches to failure to respond to treatment of specific anxiety disorders.

Statistics of clustering of ultrahigh energy cosmic rays and the number of their sources

Observation of clustering of ultrahigh energy cosmic rays (UHECR) suggests that they are emitted by compact sources. Assuming small ( <3 degrees ) deflection of UHECR during the propagation, the statistical analysis of clustering allows an estimate of the spatial density of the sources h(*), including those not yet observed. When applied to astrophysical models involving extragalactic sources, the estimate based on 14 events with energy E>10(20) eV gives h(*) approximately 6x10(-3) Mpc(-3). With increasing statistics, this estimate may lead to exclusion of some models.

Use of clozapine in 10 mentally retarded adults

The cost, side effect profile, and required weekly blood draws associated with clozapine may dissuade some clinicians from prescribing this atypical neuroleptic to mentally retarded patients. All publications on clozapine use in mentally retarded patients are reviewed and the treatment of 10 such patients is described, bringing the total number of published cases to 84. Clozapine is efficacious and well tolerated in this population and should be considered for those patients with psychosis or bipolar illness who are intolerant of or unresponsive to other agents.

The impact of a history of childhood abuse on hospital outcome of affective episodes

OBJECTIVE

Despite increased awareness of the prevalence of a history of childhood abuse among adults with psychiatric disorders, the implications for treatment and outcome are generally unknown. This study examined the impact of childhood sexual abuse (in some cases combined with physical abuse) on the hospital treatment of severe mood disorders.

METHODS

A chart review was conducted of 110 cases of consecutively admitted adult inpatients with affective disorders. The abused and nonabused groups were compared in terms of demographic variables, severity of illness, treatment history, duration of hospitalization, and outcome of the hospital treatment episode.

RESULTS

A history of childhood abuse was associated with younger age, comorbid personality disorders, and shorter duration of hospitalization. Other measures, such as level of functioning at discharge and recidivism, were not related to abuse status.

CONCLUSIONS

The results suggest that childhood abuse may be associated with earlier onset of affective episodes and personality disorders but is not strongly associated with other clinical and outcome measures in the acute treatment setting.