Focus CLINICAL SYNTHESIS

Psychiatric Aspects of HIV Spectrum Disease [CLINICAL SYNTHESIS]

Goodkin, K. — 2009-08-28

The HIV/AIDS epidemic is not considered "under control" in the United States. An unacceptably high incident case rate has been sustained over the past decade. CDC now advocates for routine HIV antibody testing to be offered in all health care settings. The psychiatrist can play an important role in identifying HIV high risk behaviors, in presenting the option for HIV antibody testing, and in providing follow-up with counseling. The high risk for HIV infection among the severely mentally ill also directly involves the psychiatrist today in HIV/AIDS care. Anxiety, depressive spectrum, neurocognitive, and psychotic disorders present with symptom profiles and in settings that are specific to HIV infection and require the need for individually tailored psychiatric care. Guidelines for the psychiatrist treating HIV infected patients are available. It is incumbent upon the practicing psychiatrist to maintain familiarity with these guidelines and offer the capacity to treat the psychiatric disorders that occur in this patient population.

Psychiatric Involvement in Obesity Treatment [CLINICAL SYNTHESIS]

Ruelaz, A. R. — 2009-08-28

Obesity is a growing concern among all areas of medicine. Psychiatric patients in particular are more likely than the general population to be overweight and suffer from obesity-related comorbidities. Psychiatrists need to be aware of the risks inherent to psychiatric patients, as well as the weight-related side effects associated with many psychiatric medications. However, awareness alone is not sufficient. Psychiatrists are being asked to take on a greater role in weight management because psychiatric patents frequently do not receive such assistance from other physicians. Another role that psychiatrists may become involved in is the evaluation of bariatric surgery candidates. There are several key areas that must be reviewed to identify patients at risk of poor surgical outcomes and sufficiently address those risk factors.

Psycho-Oncology: A Review for the General Psychiatrist [CLINICAL SYNTHESIS]

Meyer, F., Ehrlich, M., Peteet, J. — 2009-08-28

This article provides an overview of psycho-oncology, including epidemiology of common psychiatric conditions in cancer, effects of cancer and chemotherapy on the brain, and effects of coping styles and other psychosocial factors on cancer treatment. It describes the assessment, differential diagnosis, and treatment of adjustment disorders, anxiety, depression, delirium, chemotherapy- and radiotherapy-induced cognitive dysfunction, character disorders, substance disorders, and major mental illness in oncology patients. Survivorship and bereavement are addressed, as are future directions for this growing field.

Ask the Expert: Psychosomatic Medicine/Transplant Assessment [CLINICAL SYNTHESIS]

Maldonado, J. R. — 2009-08-28

Ask the Expert: Psychosomatic Medicine/Delirium [CLINICAL SYNTHESIS]

Maldonado, J. R. — 2009-08-28

Patient Management Exercise for Psychosomatic Medicine [CLINICAL SYNTHESIS]

Cook, I. A. — 2009-08-28

This exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, making your decisions as you would with a real-life patient.

Questions are presented at "decision points" that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.

The management of psychiatric conditions in patients hospitalized for medical or surgical treatment poses special concerns. In addition to the classic issues posed by managing the biological and psychosocial aspects of a psychiatric condition in a patient with multiple other problems, the current system of care of inpatient hospitalization can unexpectedly add complicating factors.

Quick Reference Psychosomatic Medicine: Med-Psych Drug-Drug Interactions Update An Overview of Psychotropic Drug-Drug Interactions [CLINICAL SYNTHESIS]

2009-08-28

Source: Sandson NB, Armstrong SC, Cozza KL: Med-Psych Drug-Drug Interactions Update An Overview of Psychotropic Drug-Drug Interactions. Psychosomatics 2005;46:464–494. Reprinted with permission. Please refer to the full article for specific citations of each interaction.

The psychotropic drug-drug interactions most likely to be relevant to psychiatrists' practices are examined. The metabolism and the enzymatic and P-glycoprotein inhibition/induction profiles of all antidepressants, antipsychotics, and mood stabilizers are described; all clinically meaningful drug-drug interactions between agents in these psychotropic classes, as well as with frequently encountered nonpsychotropic agents, are detailed; and information on the pharmacokinetic/pharmacodynamic results, mechanisms, and clinical consequences of these interactions is presented. Although the range of drug-drug interactions involving psychotropic agents is large, it is a finite and manageable subset of the much larger domain of all possible drug-drug interactions. Sophisticated computer programs will ultimately provide the best means of avoiding drug-drug interactions. Until these programs are developed, the best defense against drug-drug interactions is awareness and focused attention to this issue.

Adult Disaster Psychiatry [CLINICAL SYNTHESIS]

Pandya, A. — 2009-05-11

Although most individuals are resilient, individuals who are exposed to trauma in mass casualty events have an increased rate of Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), other anxiety disorders such as Panic Disorder and Generalized Anxiety Disorder, and medically unexplained somatic symptoms. Risk factors for psychopathology include female gender, minority ethnic status, prior psychopathology, prior traumas, duration and severity of exposure as well as physical proximity to the disaster. Immediate interventions after a disaster should include attending to basic needs such as physical health, housing and reuniting families. The role of debriefings as an early intervention remains controversial. Later interventions include cognitive and behavioral therapy (CBT) and the use of selective serotonin reuptake inhibitors for those who meet criteria for PTSD. Further research is required to determine whether Eye Movement Desensitization and Reprocessing offers any additional benefits beyond those offered by CBT.

Posttraumatic Stress Disorder: From Phenomenology to Clinical Practice [CLINICAL SYNTHESIS]

Benedek, D. M., Ursano, R. J. — 2009-05-11

The psychological and behavioral consequences of exposure to traumatic events—particularly combat—have been recognized throughout the ages. Since its 1982 introduction in the Diagnostic and Statistical Manual of Mental Disorders, 3^rd edition much has been learned about the pathophysiology of PTSD. Current theories focus on brain regions and neurobiological systems regulating stress and fear response, fear memory formation and retrieval. Effective pharmacologic and psychotherapeutic interventions target these systems. New treatments must prove more effective in specific subpopulations of patients with PTSD. These will include combinations of pharmacologic agents and psychotherapy, and treatments targeting different regions, receptors, or mechanisms involved in the traumatic stress response.

Clinical Importance of Sleep Disturbance as a Treatment Target in PTSD [CLINICAL SYNTHESIS]

Lydiard, R. B., Hamner, M. H. — 2009-05-11

In this review, evidence for the importance of sleep-related disturbances in PTSD as a target for treatment is presented. Examination of efficacy studies of the first-line treatments for posttraumatic stress disorder (PTSD)—selective serotonin reuptake inhibitors and cognitive behavior therapy—indicates that neither adequately treats PTSD nightmares and insomnia. The published guidelines that recommend these treatments do not provide advice on treating posttraumatic sleep disturbance, suggesting a possible lack of awareness of the problem. Based on clinical reports, imaging, and polysomnographic studies, a theoretical model in which REM dysregulation in PTSD plays a key role in the development and persistence of PTSD will be presented. Finally, evidence regarding the beneficial effects of prazosin and other agents in the treatment of PTSD-related sleep disturbance will be highlighted.

Ask the Expert: Acute Management of Sexual Assault [CLINICAL SYNTHESIS]

Vigod, S., Stewart, D. — 2009-05-11

Performance in Practice: Clinical Tools to Improve the Care of Patients with Posttraumatic Stress Disorder [CLINICAL SYNTHESIS]

Duffy, F. F., Craig, T., Moscicki, E. K., West, J. C., Fochtmann, L. J. — 2009-05-11

To facilitate continued clinical competence, the American Board of Medical Specialties and the American Board of Psychiatry and Neurology are implementing multifaceted Maintenance of Certification programs, which include requirements for self-assessments of practice. Because psychiatrists may want to gain experience with self-assessment, two sample performance-in-practice tools are presented that are based on recommendations of the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder and the US Departments of Veterans Affairs and Defense (VA/DoD) Clinical Practice Guideline for the Management of Post-Traumatic Stress. One of these sample tools provides a traditional chart review approach to assessing care (Appendix A); the other sample tool presents an approach that permits a real-time evaluation of practice (Appendix B). Both tools focus on treatment of posttraumatic stress disorder (PTSD) among adults age 18 or older, and both can be used as a foundation for subsequent performance improvement initiatives with the aim of enhancing outcomes for patients with PTSD.

Psychiatric Assessment and Diagnosis in Older Adults [CLINICAL SYNTHESIS]

Meeks, T. W., Lanouette, N., Vahia, I., Dawes, S., Jeste, D. V., Lebowitz, B. — 2009-02-25

To provide optimal care, the approach to psychiatric evaluation and diagnosis in older adults requires special attention to several issues. There are important biological, psychological, and social changes associated with either aging itself or with generational differences. In this review, we will address some of the most important aspects of assessment and diagnosis that make geriatric psychiatry a unique subspecialty, including age-related variability in the clinical presentation of common psychiatric disorders, assessment and diagnosis of cognitive disorders and medical comorbidity, and common psychosocial challenges faced by older adults. Although geriatric psychiatrists are uniquely positioned to address the complexities of psychiatric illness in older adults, the fact remains that the majority of older adults who seek psychiatric care will see general adult psychiatrists without subspecialty training. However, with continued vigilance to the issues outlined below, psychiatrists from a variety of training backgrounds can skillfully assess and diagnose psychiatric illnesses in older adults.

Depression, Pain, and Aging [CLINICAL SYNTHESIS]

Karp, J. F., Reynolds, C. F. — 2009-02-25

The prevalence of persistent pain increases with age. Painful conditions such as fibromyalgia, chronic low back pain, osteoarthritis, and neuropathic pain are frequently comorbid with depression. When comorbid, these conditions slow the treatment of each other, worsen physical and psychological disability, and increase caregiving burden. Anatomic, neurochemical, and psychological similarities lead to high rates of comorbidity. Anxiety, disordered sleep, fatigue, and cognitive impairment are frequent "cotravelers" with depression and pain in late life; these conditions require vigilant screening and treatment. Psychiatrists should be familiar with current analgesic prescribing patterns and be able to effectively collaborate with primary care physicians and physical therapists to optimize treatment outcomes for patients with these complex problems. In this article we provide a review of the literature, an update on some of our own research in this area, and relevant clinical perspectives.

The Role of the Immune System in Alzheimer's Disease [CLINICAL SYNTHESIS]

Cohen, R. M. — 2009-02-25

The accumulation of toxic products (TP) of the processing of the amyloid precursor protein is the likely initial event in a "cascade of events" that leads to Alzheimer's disease (AD). The immune system is, however, attracting the increasing attention of researchers working in this area. First, as a responder to and possible contributor to the pathological events that occur in AD, second as a modifier of the production of and clearance of TP, third as part of a system of neuroprotection, and fourth as a suitable target in designing AD treatment strategies. While still at an early stage of understanding these complex, multidimensional, and at times, conflicting roles of the immune system in AD it is likely that successful AD treatment strategies will need to carefully consider and account for the immune network within the overall design.

Ask the Expert: Geriatric Psychiatry [CLINICAL SYNTHESIS]

Cheong, J. A. — 2009-02-25

Update on the Assessment, Diagnosis, and Treatment of Individuals with Social Anxiety Disorder [CLINICAL SYNTHESIS]

Delong, H., Pollack, M. H. — 2008-11-18

Social anxiety disorder, also called social phobia, is a disorder characterized by extreme fear and/or avoidance of social or performance situations that involve evaluation or possible scrutiny by others. This disorder encompasses both isolated performance anxiety and generalized fears of many social encounters, leading to significant impairment and dysfunction in social, family, educational, and occupational functioning. It is often complicated by the presence of comorbid mood disorders, such as depression, and alcohol and substance use disorders. This article reviews the epidemiology, associated impairment, comorbidity, and treatment of social anxiety disorder, including pharmacotherapy and psychosocial therapies.

Assessment of Panic Disorder Across the Life Span [CLINICAL SYNTHESIS]

Madaan, V. — 2008-11-18

Panic disorder is a relatively common anxiety disorder that is often disabling. It may or may not be associated with agoraphobia. Panic disorder can be imitated by various medical illnesses, which, even when treated, can get cued with panic symptoms. It is also frequently comorbid with other psychiatric disorders including depression, generalized anxiety disorder, and substance use disorders. Although often initially seen in early adulthood, panic disorder can also present in childhood or in the geriatric population. Clinicians should thus be aware of the variability in clinical presentations that may be associated with both the pediatric and geriatric age groups. This article provides a broad overview of various screening and assessment tools used to evaluate panic disorder across the lifespan. The article also highlights some of the developmental differences and variability in the clinical presentation of pediatric and geriatric panic disorder.

Ask the Expert: Treatments for Panic Disorder [CLINICAL SYNTHESIS]

Roy-Byrne, P. P. — 2008-11-18

Quick Reference Panic And Social Anxiety Disorder: Applications of Individual Cognitive-Behavioral Therapy to Specific Disorders Efficacy and Indications [CLINICAL SYNTHESIS]

2008-11-18

Source: Epp AM, Dobson KS, Cottraux J: Applications of Individual Cognitive-Behavioral Therapy to Specific Disorders in Textbook of Psychotherapeutic Treatments. Edited by Gabbard GO, Washington DC, American Psychiatric Publishing Inc. 2009 p239–247 Excerpted and Reprinted with permission.