Western Psychiatric Institute Research Articles

Understanding Community Mental Health Administrators' Perspectives on Dialectical Behavior Therapy Implementation

In this study, key informant interviews were conducted with 13 administrators from nine community-based mental health agencies implementing dialectical behavior therapy in order to assess their perspectives on implementation. Four major themes were identified. They include opinions about dialectical behavior therapy and its fit with existing practices, resource concerns (for example, reimbursement issues, time commitment, and staff training), staff selection for training and staff turnover, and ongoing client referrals. Understanding agency administrators' unique perspectives and addressing their concerns is critical to treatment implementation given administrators' role in determining whether and how a treatment will be implemented. Better understanding of the fit between dialectical behavior therapy and existing service structures, the impact of staff turnover on implementation, and the resources required for implementation are all needed to ensure successful implementation and sustainability.

The Conceptual Development of DSM-V

The Conceptual Development of DSM-V

Transient Complex Visual Hallucinations With Venlafaxine Treatment

Sir: Antidepressants have been noted to cause hallucinations, often with drug overdose, but also in rare instances as a side effect at therapeutic dose.1 Bupropion, tricyclics, and selective serotonin reuptake inhibitors (SSRIs) have most often been cited as the causative agents.1 We present a case of transient complex visual hallucinations following the initiation of venlafaxine for major depressive disorder. Case report. Mr. A was a 44-year-old man recovering from alcohol dependence in an outpatient partial hospitalization program. He had been recently hospitalized for delirium tremens and was discharged 3 days before admission to our outpatient program in December 2007. He began venlafaxine treatment, 75 mg daily, for depression 2 weeks after his last drink. Before initiation of treatment, he had had no auditory or visual hallucinations for 10 days and no history of psychotic disorders or manic symptoms. He was diagnosed according to DSM-IV-TR with alcohol dependence and recurrent major depressive disorder without psychosis. Mr. A had been 3 weeks' sober when, after 1 week of venlafaxine treatment, he reported having visual hallucinations during daytime group sessions: seeing an acetylene torch in his hand and trying to strike it against his desk to light it as well as nodding his head to drop a welding shield over his face, as he did when he worked as a welder. He had insight that these were hallucinations. He had no delusions or hallucinations in other modalities, no manic symptoms, and no altered mental status. The only other side effect noted was increased vividness to his dreams. The only other medication changes were the addition of lactulose for mildly elevated ammonia, 41 μmol/L at the onset of hallucinations. After 1 week, his hallucinations resolved, and he had no repeat episodes. The venlafaxine dose was maintained throughout his treatment. He completed the outpatient program and was discharged without further incidents 3 weeks later, and at 2 monthly follow-up appointments he reported no additional hallucinations. Antidepressants have been cited as inducing hallucinations in rare cases. There have been 2 reports of venlafaxine-induced hallucinations, in an adolescent patient and an adult patient.2,3 Given that Mr. A's dose was low (75 mg daily), the assumed mechanism of action for hallucinosis is serotonergic, not norepinephrinergic. Some studies have suggested that SSRIs may induce psychotic symptoms by 5-HT2– and 5-HT3–mediated dopamine release in the ventral striatum.4 Venlafaxine may have produced visual hallucinations via dopamine release in the mesolimbic pathway by stimulation of 5-HT2 and 5-HT3 receptors. A possible interaction could have been reactivation of alcoholic hallucinosis with venlafaxine, which was reported with sertraline in 1 case by Hermann et al.5 However, the causative mechanism in that case was felt to be due to increased dopamine availability. Sertraline shows the greatest amount of dopamine reuptake inhibition of all SSRIs, while venlafaxine shows no inhibition of the dopamine reuptake transporter. Lastly, our patient's ammonia was mildly elevated, and treatment could have exacerbated a subclinical hepatic encephalopathy, although no altered mental status or other signs of delirium were observed during his partial hospitalization. Adam C. Tripp, M.D., Ph.D. Western Psychiatric Institute & Clinic, University of Pittsburgh Medical Center Scott A. Golden, M.D. Behavioral Health Division, Veterans Hospital at Highland Drive, Pittsburgh, Pennsylvania

Several Factors Predict Response to Treatment in Depressed Teens

Back to table of contents Next article Clinical & Research NewsFull AccessSeveral Factors Predict Response to Treatment in Depressed TeensJun YanJun YanSearch for more papers by this authorPublished Online:3 Apr 2009https://doi.org/10.1176/pn.44.7.0001aTeenagers who suffer from antidepressant-resistant depression and have a concurrent history of family conflict, nonsuicidal self injury, or more severe symptoms of depression will likely have a poorer response to a new course of treatment, according to a study published in the March Journal of the American Academy of Child and Adolescent Psychiatry.The study also found that adding cognitive-behavioral therapy (CBT) to antidepressant medications produces the most benefit for patients who have comorbidities such as anxiety disorders.The study's findings can help clinicians individualize treatment plans for adolescents with more chronic and complicated forms of depression. Analyzing the data from the Treatment-Resistant Depression in Adolescents (TORDIA) study, Joan Asarnow, Ph.D., a professor of psychiatry and behavioral sciences at the University of California at Los Angeles (UCLA) and the principal investigator of TORDIA at UCLA, and coauthors identified a number of patient characteristics that are associated with the likelihood of response to treatment and the benefit of medication—CBT combination therapy versus medication alone in this hard-to-treat population.In the TORDIA study, 334 adolescents with moderate to severe depression who had failed to respond to a course of a selective serotonin-reuptake inhibitor (SSRI) were randomized to one of four treatments for 12 weeks: a different SSRI, a different SSRI plus CBT, venlafaxine, or venlafaxine plus CBT.Because only 40 percent to 55 percent of these SSRI-resistant patients achieved response after the study treatment, knowing the predictors and moderators of clinical response can be valuable for clinicians in devising the most effective strategy as early as possible for patients who have already gone through a course of unsuccessful treatment.A higher percentage of patients who received the medication and CBT combination reached clinical response than patients who received medication alone (Psychiatric News, March 21, 2008). The authors pointed out, however, that the response rate to the combination therapy was 54.8 percent, statistically significantly but not vastly higher than the 40.5 percent response to medication alone. In addition, they noted that high-quality CBT can be too expensive and inaccessible for many patients to take advantage of combination therapy.Similar to previous research on first-step treatment response, depressed teens with a greater severity of depression symptoms, functional impairment, suicidal ideation, hopelessness, and youth-reported family conflict at baseline were more likely to have a poor response to the second-step treatment, the authors found. In addition, the analyses revealed a new link between a history of nonsuicidal self-injury, such as cutting, scratching, and burning, and poor treatment response.“One of the predictors for poor response was high [level of] family conflict—this is a replication of previous studies,” David Brent, M.D., a professor of psychiatry at the University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic and the senior author of the study, told Psychiatric News. “For clinicians, [the message is that a] high level of family conflict will affect the efficacy of treatment and needs to be addressed and managed up front.” Brent was principal investigator of the TORDIA study at the Pittsburgh site.The added benefit of CBT was particularly evident in patients with comorbid disorders, especially attention-deficit/hyperactivity disorder and anxiety disorders. “The combination therapy really pulled away from medication alone in these patients,” Brent commented. “Many patients in the community setting have these comorbidities. The combination therapy can be very cost-effective for this group.”However, the addition of CBT to medication made no significant difference in patients with a history of being abused and a higher level of hopelessness. Treating depressed teens with a history of abuse and with nonsuicidal self-injurious behaviors is particularly challenging for psychiatrists, Brent acknowledged.“A history of maltreatment predicted less response to CBT,” he said. “We don't quite understand the mechanism yet. Clinicians should take patients' history of maltreatment into consideration.... They may need more individualized treatment.”Meanwhile, adolescents with nonsuicidal self-injurious behaviors“ have more difficulty with emotional regulation and [have] a lower stress tolerance,” according to Brent. He suggested that, although the addition of standard CBT did not provide substantial benefit for these patients in the study, psychotherapy with specific focus on addressing these deficits might be useful.An abstract of “Treatment of Selective Reuptake Inhibitor–Resistant Depression in Adolescents: Predictors and Moderators of Treatment Response” is posted at<journals.lww.com/jaacap/Abstract/2009/03000/Treatment_of_Selective_Serotonin_Reuptake.13.aspx>.▪ ISSUES NewArchived

Best Practices: An Intervention to Promote Evidence-Based Prescribing at a Large Psychiatric Hospital

Best Practices: An Intervention to Promote Evidence-Based Prescribing at a Large Psychiatric Hospital

Primary Nursing in Psychiatry

Perspectives in Psychiatric CareVolume 20, Issue 2 p. 73-78 Primary Nursing in Psychiatry An Effective and Functional Model Vivian Romoff R.N., M.S.N., Vivian Romoff R.N., M.S.N. An Assistant Director at Western Psychiatric Institute and Clinic, Director of Nursing, Assistant Professor of Clinical Psychiatry, University of Pittsburgh, Pittsburgh, Pa.Search for more papers by this authorIrene Kane R.N., M.S.N., Irene Kane R.N., M.S.N. An Assistant Director at Western Psychiatric Institute and Clinic.Search for more papers by this author Vivian Romoff R.N., M.S.N., Vivian Romoff R.N., M.S.N. An Assistant Director at Western Psychiatric Institute and Clinic, Director of Nursing, Assistant Professor of Clinical Psychiatry, University of Pittsburgh, Pittsburgh, Pa.Search for more papers by this authorIrene Kane R.N., M.S.N., Irene Kane R.N., M.S.N. An Assistant Director at Western Psychiatric Institute and Clinic.Search for more papers by this author First published: April 1982 https://doi.org/10.1111/j.1744-6163.1982.tb00154.xCitations: 3AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume20, Issue2April 1982Pages 73-78 RelatedInformation

Diagnostic and Treatment Considerations: Bipolar Patients with Comorbid Substance Use Disorders

&lt;p&gt;Diagnostic and Treatment Considerations: Bipolar Patients with Comorbid Substance Use Disorders &lt;/p&gt; &lt;p&gt;Comorbidity of bipolar disorder (BD) and alcoholism and substance use disorders (SUDs) represents a serious public health problem and a major challenge to treatment systems. Bipolar disorder is among the top causes of disabilities worldwide, and reportedly the fourth leading mental illness as a source of disease burden in established market economies. Large epidemiologic surveys in the United States have consistently confirmed a high association between bipolar disorder and SUDs. The Epidemiological Catchments Area Study reported bipolar I and bipolar II disorders as having the highest association with SUDs when compared with any other major psychiatric disorder. The prevalence of lifetime alcohol abuse or dependence in persons with bipolar I disorder and bipolar II disorders were found to be 46%, and 39.2% respectively. Similarly, the National Comorbidity Survey reported respondents with mania to be 8 to 9 times more likely to have an additional lifetime disorder of drug or alcohol dependence compared with the general population. The most recent and largest epidemiologic survey of more than 42,000 respondents in the United States, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), reported that mania and hypomania were associated with very high rates of SUDs. Those with mania were 6 times more likely to have alcohol dependence and 14 times more likely to have drug dependence over the past 12 months. &lt;/p&gt; &lt;h4&gt;ABOUT THE AUTHORS&lt;/h4&gt; &lt;p&gt;Ihsan Salloum, MD, MPH; and Lauren Williams, MD, are with the Department of Psychiatry and Behavioral Science, University of Miami Miller School of Medicine. Antoine Douaihy, MD, is with the Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine.&lt;/p&gt;&lt;p&gt; Address correspondence to: Ihsan M. Salloum, MD, MPH, 1120 NW 14th Street, Miami, FL 33136; fax 305-243-1682; or e-mail &lt;a href="mailto:isalloum@med.miami.edu"&gt;isalloum@med.miami.edu&lt;/a&gt;.&lt;/p&gt;&lt;p&gt; Dr. Salloum and Dr. Williams have disclosed no relevant financial relationships. Dr. Douaihy has disclosed the following relevant financial relationship: AstraZeneca: Research grant recipient.&lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt;&lt;li&gt;Develop knowledge about the frequency and clinical significance of bipolar disorder and substance use disorders comorbidity. &lt;/li&gt; &lt;li&gt;Demonstrate the diagnostic considerations in patients with co-occurring bipolar disorder and substance use disorder &lt;/li&gt; &lt;li&gt;Identify the latest research-based psychotherapy and pharmacotherapy treatments for this comorbidity. &lt;/li&gt; &lt;/ol&gt;

Sleep Disturbance in Bereavement.

&lt;p&gt;Bereavement is a ubiquitous part of the human condition. Almost no person makes it through his or her life without having to cope with the loss of a loved one several different times. The loss of a parent, child, or grandparent can be very distressing. For many, the most devastating loss is that of their spouse or partner, which usually occurs during later life. More than 800,000 older Americans are widowed every year. Apart from the severe emotional strain of the loss of a loved one, there are profound changes in lifestyle and status, often accompanied by reductions in financial security, perceived personal safety, and freedom of action. Thus, late-life spousal bereavement (LLSB) comprises one of the major impacts of bereavement on society. &lt;/p&gt; &lt;h4&gt;ABOUT THE AUTHORS&lt;/h4&gt; &lt;p&gt;Timothy H. Monk, PhD, DSc, is Professor of Psychiatry, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Anne Germain, PhD, is Assistant Professor of Psychiatry, University of Pittsburgh School of Medicine. Charles F. Reynolds III, MD, is the Professor of Geriatric Psychiatry and Professor of Neurology and Neuroscience, University of Pittsburgh Medical Center.&lt;/p&gt; &lt;p&gt;Address correspondence to Timothy H. Monk, DSc, Western Psychiatric Institute and Clinic, Room E1123, 3811 O’Hara Street, Pittsburgh PA 15213; fax 412-246-5300; or e-mail &lt;a href="mailto:monkth@upmc.edu"&gt;monkth@upmc.edu&lt;/a&gt;.&lt;/p&gt; &lt;p&gt;Dr. Monk, Dr. Germain, and Dr. Reynolds have disclosed no relevant financial relationships.&lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt;&lt;li&gt;Recognize the importance of sleep disruption in bereavement. &lt;/li&gt; &lt;li&gt;Explain the possible role of insomnia treatment for bereaved individuals. &lt;/li&gt; &lt;li&gt;Discuss the etiology of sleep disorders in bereavement. &lt;/li&gt; &lt;/ol&gt;

The Relationship Between the University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center—A Profile in Synergy

In the synergistic evolution of their research, educational, and clinical programs, the University of Pittsburgh (Pitt) School of Medicine (SOM) and the University of Pittsburgh Medical Center (UPMC) have followed one core principle: What is good for one is good for both. The collaboration is underpinned by UPMC's commitment to its community mission, including support for the academic and research objectives of the SOM. UPMC's conceptual origin was fostered by its experience with Western Psychiatric Institute and Clinic in the 1970s. Over time, UPMC acquired other hospitals through merger and negotiation and, by 2008, had grown into a $7 billion global health enterprise. From the outset, the senior leaders of both UPMC and Pitt committed to collaborative decision making on all key issues. Under this coordinated decision-making model, UPMC oversees all clinical activity, including that from a consolidated physicians' practice plan. Pitt remains the guardian of all academic priorities, particularly faculty-based research. UPMC's steady financial success underpins the model. A series of interrelated agreements formally defines the relationship between Pitt and UPMC, including shared board seats and UPMC's committed ongoing financial support of the SOM. In addition, the two institutions have jointly made research growth a priority. The payoff from this dynamic has been a steadily growing Pitt research portfolio; enhanced growth, visibility, and stature for UPMC, the SOM, and Pitt as a whole; and the sustained success of UPMC's clinical enterprise, which now has an international scope. Given the current stagnation in the National Institutes of Health budget, the Pitt-UPMC experience may be instructive to other academic health centers.

Pharmacotherapy for Psychotropic Drug-Related Weight Gain

Weight gain is a significant problem for many patients taking various psychotropic medications. The U.S. Food and Drug Administration (FDA) has approved certain medications for the treatment of obesity. Other medications known to be associated with weight loss could be used for treating obesity, although they are not FDA approved for this indication. This article briefly describes the sympathomimetic, antidepressant, anticonvulsant, histamine-modulating, antidiabetic, and gastrointestinal drugs that have been found to cause weight loss and might be considered for adjunctive use in the overall management of psychotropic drug-related weight gain. However, even if such drugs are effective, all patients should receive ongoing dietary and physical activity counseling.

American Association of Community Psychiatrists' Views on General Features of DSM-IV

American Association of Community Psychiatrists' Views on General Features of DSM-IV

Medication Adherence

&lt;p&gt;The modern era of psychopharmacology began in the 1950s with the discovery of the antipsychotic drug chlorpromazine (Thorazine). Since then, many drugs have been developed, investigated, and marketed for the treatment of all forms of mental illness. Although medications are not completely effective for all patients, most individuals will generally derive some satisfactory benefit from an appropriately prescribed medication. However, even the best medications do not work in patients who do not take them. Although not taking medication reliably is well recognized as a common problem, surprisingly, patients and their prescribers can grossly overestimate medication adherence. For this reason, the concept of medication adherence is a more practically important pharmacotherapy issue than is expert knowledge in clinical psychopharmacology. In this article, the importance of medication adherence, the factors associated with poor adherence, and some approaches for improving adherence is discussed. &lt;/p&gt;&lt;h4&gt;ABOUT THE AUTHOR&lt;/h4&gt; &lt;p&gt;Robert H. Howland, MD, is Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.&lt;/p&gt; &lt;p&gt;Address correspondence to Robert H. Howland, MD, Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213; e-mail: &lt;a href="mailto:HowlandRH@upmc.edu"&gt;HowlandRH@upmc.edu&lt;/a&gt;.&lt;/p&gt; &lt;p&gt;Dr. Howland has disclosed no relevant financial relationships.&lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt;&lt;li&gt; Review why medication adherence is important.&lt;/li&gt; &lt;li&gt;Describe some of the factors associated with poor medication adherence.&lt;/li&gt; &lt;li&gt;Discuss some approaches to improving medication adherence.&lt;/li&gt; &lt;/ol&gt;

Limitations of Evidence in the Practice of Evidence-based Medicine

&lt;p&gt;Evidence-based medicine is a concept that has become widely described, discussed, criticized, and studied in the medical literature. The broad goal of evidence-based medicine is to address two main kinds of decisions — population-based policies and individual medical decisions — that serve to improve health outcomes through the use of the most proven effective treatments. As a result, there have been increased efforts to apply evidence-based medicine concepts to develop treatment guidelines, support medical education, inform individual decision making, and justify insurance coverage policies. The essence of evidence-based medicine is to use evidence (typically research data) related to the effectiveness of medical interventions to guide decisions about whether to use those interventions in clinical practice. In other words, the principles of evidence-based medicine suggest that good policies and clinical practice are based on using evidence that treatment X is helpful for treating disease Y in patient Z. Therefore, the quality of evidence is the critical component in understanding and using evidence-based medicine. &lt;/p&gt; &lt;h4&gt;ABOUT THE AUTHOR&lt;/h4&gt; &lt;p&gt;Robert H. Howland, MD, is Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.&lt;/p&gt; &lt;p&gt;Address correspondence to Robert H. Howland, MD, Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213; e-mail: &lt;a href="mailto:HowlandRH@upmc.edu"&gt;HowlandRH@upmc.edu&lt;/a&gt;.&lt;/p&gt; &lt;p&gt;Dr. Howland has disclosed no relevant financial relationships.&lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt;&lt;li&gt; Assess the concept of evidence-based medicine.&lt;/li&gt; &lt;li&gt;Describe the kinds of evidence used in the practice of evidence-based medicine. &lt;/li&gt; &lt;li&gt;Discuss some limitations of evidence used in the practice of evidence-based medicine. &lt;/li&gt; &lt;/ol&gt;

Commentary: The Need to Guard Against Pharmaceutical Industry Influence

Back to table of contents Previous article Next article Brief ReportFull AccessCommentary: The Need to Guard Against Pharmaceutical Industry InfluenceRobert H. Howland M.D.Robert H. Howland M.D.Search for more papers by this authorPublished Online:1 May 2008AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Recently, an outpatient whom I have known a long time came for a routine medication visit. He has schizophrenia and has been clinically stable for many years on a well-tolerated dosage of fluphenazine. Unexpectedly, he asked me why I was giving him an "archaic" drug. He had just seen his primary care physician, Dr. R, for a routine medical visit. Dr. R had referred to fluphenazine as an "archaic 19th century drug" and thought that it was "time for a change." My patient did not understand what the problem was with his medication and was quite disturbed by these comments. We talked about his long-term experience with fluphenazine and discussed newer alternatives. Ultimately, we agreed that there was no need to make a change. In this issue of Psychiatric Services, Arbuckle and colleagues ( 1 ) report on a survey of psychiatrists regarding their opinion of second-generation antipsychotics. This topic is timely, given increasing concerns about the costs, efficacy, and safety of these agents compared with first-generation antipsychotics. The survey findings are predictable. Only 3% of respondents preferred first-generation agents. If psychiatrists do not prefer these drugs, and perhaps are not as familiar with them, why would they choose to use them or feel optimistic about their use? The vast majority (88%) was optimistic about the benefits of second-generation agents. If psychiatrists were not optimistic about these medications, would they still predict that they would be effective for patients who do not respond to first-generation antipsychotics? Moreover, why would a psychiatrist choose to not use a medication that he or she optimistically believes will offer an improvement? Even though less than a quarter of respondents (22%) cited drug representatives or advertisements as being an influential source of information, it is notable that having weekly visits from drug representatives was one of two factors significantly associated with optimism about second-generation antipsychotics (the other factor being familiarity with practice guidelines). This finding is not necessarily surprising. Would many psychiatrists admit to prescribing drugs on the basis of marketing influences rather than for strict clinical or scientific reasons? What occurs during these office visits? Brand-name drug samples are given. Branded pens, notepads, and educational materials are left behind. Copies of published studies about the product are presented, sometimes with published treatment guidelines if they are favorable or are not unfavorable to the product. By contrast, use of first-generation antipsychotics is not promoted through office visits, drug samples, educational materials, or other advertising efforts.The small number and narrow focus of the survey questions in this study, as well as the small unrepresentative sample of psychiatrists surveyed, limit the overall value and interpretation of the results. Despite these limitations, the authors know more about this group of psychiatrists than I know about Dr. R. I know nothing about Dr. R, except that he is not a psychiatrist and that he apparently believes that my prescribing fluphenazine is behind the times. Second-generation antipsychotics have been actively investigated for conditions other than schizophrenia, and some have gained approval for treatment of mood disorders. Consequently, they are being marketed more widely to the general public as well as to nonpsychiatrists. Although I do not know what sources of information influence Dr. R's opinion about antipsychotics for schizophrenia, it would surprise me if he, as a primary care physician, reads relevant research reports or practice guidelines. However, I think it is likely that drug representatives visit his office. If they do visit Dr. R, is he less likely to be optimistic toward the second-generation antipsychotics than the psychiatrists surveyed by Arbuckle and colleagues?With the advent of the second-generation agents, are patients with schizophrenia better off than they were 15 years ago? Schizophrenia is a devastating and difficult-to-treat illness, and it is always good to have treatment options. But the choice of drug treatment for an individual patient should be based as much as possible on the best unbiased clinical and scientific information available, together with sensitivity to practical cost considerations.Dr. Howland is affiliated with the Department of Psychiatry, Western Psychiatric Institute and Clinic, 3811 O'Hara St., Pittsburgh, PA 15213 (e-mail: [email protected]).Reference1. Arbuckle MR, Gameroff MJ, Marcus SC, et al: Psychiatric opinion and antipsychotic selection in the management of schizophrenia. Psychiatric Services 59:561–565, 2008Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 59Issue 5 May, 2008Pages 566-566PSYCHIATRIC SERVICES May 2008 Volume 59 Number 5 Metrics PDF download History Published online 1 May 2008 Published in print 1 May 2008

Antidepressants and Suicide: Putting the Risk in Perspective

&lt;P&gt;According to the Centers for Disease Control and Prevention (CDC) (2007), more than 30,000 people in the United States died by suicide in 2001, more than 116,000 people were treated and released from emergency rooms after suicide attempts in 2002, and more than 130,000 people were hospitalized following suicide attempts in 2002. Although suicidal thoughts are a symptom of depression, and completed suicide is a tragic complication of depressive illness, in October 2004, the U.S. Food and Drug Administration (FDA) ordered that all antidepressant medications carry a warning indicating that they are associated with an increased risk of suicidal thinking, feeling, and behavior in children and adolescents. In May 2007, the FDA expanded this warning to include information about an increased risk of suicidal symptoms in young adults ages 18 to 24. &lt;/P&gt; &lt;H4&gt;ABOUT THE AUTHOR&lt;/H4&gt; &lt;P&gt;Dr. Howland is Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania. &lt;/P&gt; &lt;P&gt;Address correspondence to Robert H. Howland, MD, Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213; e-mail: &lt;A HREF="mailto:HowlandRH@upmc.edu"&gt;HowlandRH@upmc.edu&lt;/A&gt;. &lt;/P&gt; &lt;P&gt;Dr. Howland has disclosed no relevant financial relationships.&lt;/P&gt; &lt;H4&gt;EDUCATIONAL OBJECTIVES&lt;/H4&gt; &lt;OL&gt; &lt;LI&gt;Assess the rationale for the current Food and Drug Administration warning that antidepressant medications are associated with an increased risk of suicidal symptoms in children, adolescents, and young adults.&lt;/LI&gt; &lt;LI&gt;Describe some of the problems with assessing suicide risk from randomized placebo-controlled antidepressant medication trials.&lt;/LI&gt; &lt;LI&gt;Discuss relevant findings from larger population-based studies on antidepressant usage and the relative risks of suicide in real-world settings.&lt;/LI&gt; &lt;/OL&gt;

Med Check

Med Check

Agomelatine: A Novel Atypical Antidepressant

This article reviews the novel atypical antidepressant drug agomelatine (Valdoxan), which is currently being actively investigated in the United States for the treatment of depression but is not yet approved by the U.S. Food and Drug Administration. Agomelatine is a synthetic analog of the hormone melatonin and has unique pharmacological properties that distinguish it from other currently available antidepressant drugs. Agomelatine is efficacious, safe, and well tolerated but does not appear to have major efficacy advantages compared with other antidepressant drugs. Because of its unique pharmacology and relatively benign tolerability profile, however, it may be a more effective alternative for patients who do not respond to or cannot tolerate currently available antidepressant drugs.

Brain Mechanisms of Borderline Personality Disorder at the Intersection of Cognition, Emotion, and the Clinic

Brain Mechanisms of Borderline Personality Disorder at the Intersection of Cognition, Emotion, and the Clinic

SAVE CHILDREN FROM A LIFE OF CRIME

Criminology & Public PolicyVolume 6, Issue 4 p. 871-879 SAVE CHILDREN FROM A LIFE OF CRIME BRANDON C. WELSH, BRANDON C. WELSH Associate Professor in the Department of Criminal Justice and Criminology at the University of Massachusetts Lowell. He received his Ph.D. degree in criminology from Cambridge University.Search for more papers by this authorDAVID P. FARRINGTON, DAVID P. FARRINGTON Professor of Psychological Criminology at the Institute of Criminology, Cambridge University, and an adjunct professor of psychiatry at Western Psychiatric Institute and Clinic, University of Pittsburgh.Search for more papers by this author BRANDON C. WELSH, BRANDON C. WELSH Associate Professor in the Department of Criminal Justice and Criminology at the University of Massachusetts Lowell. He received his Ph.D. degree in criminology from Cambridge University.Search for more papers by this authorDAVID P. FARRINGTON, DAVID P. FARRINGTON Professor of Psychological Criminology at the Institute of Criminology, Cambridge University, and an adjunct professor of psychiatry at Western Psychiatric Institute and Clinic, University of Pittsburgh.Search for more papers by this author First published: 29 November 2007 https://doi.org/10.1111/j.1745-9133.2007.00465.xCitations: 11AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume6, Issue4November 2007Pages 871-879 RelatedInformation

Lithium: Underappreciated and Underused?

&lt;p&gt;At the universe&amp;#146;s origin, the only chemical elements created with the &amp;#147;Big Bang&amp;#148; were hydrogen, helium, and lithium. Lithium, the third element of the periodic table, is ubiquitous throughout our environment, and trace amounts are present in our diet. Although lithium batteries power many electronic gadgets, lithium compounds dampen the energetic highs of patients experiencing bipolar disorder. Yet, how a naturally occurring chemical element such as lithium is an effective treatment for bipolar disorder remains a mystery. Many trace elements are known to influence various biological processes and are essential for human health. Although it has been hypothesized that lithium may be an essential trace element for humans, and studies in rats and goats suggest it may be an essential dietary nutrient, the natural or essential role of lithium in human beings remains uncertain. In this article, the history of lithium and some important aspects of its clinical use are reviewed.&lt;/p&gt; &lt;h4&gt;ABOUT THE AUTHOR&lt;/h4&gt; &lt;p&gt;Robert H. Howland, MD, is Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.&lt;/p&gt; &lt;p&gt;Address correspondence to: Robert H. Howland, MD, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O&amp;#146;Hara Street, Pittsburgh, PA 15213; e-mail: &lt;a href="mailto:HowlandRH@upmc.edu"&gt;HowlandRH@upmc.edu&lt;/a&gt;.&lt;/p&gt; &lt;p&gt;Dr. Howland has disclosed no relevant financial relationships.&lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt; &lt;li&gt;Discuss the history of lithium&amp;#146;s therapeutic use in psychiatry.&lt;/li&gt; &lt;li&gt;Describe some of the therapeutic uses of lithium in psychiatry.&lt;/li&gt; &lt;li&gt;Explain the biological effects of lithium on the central nervous system.&lt;/li&gt; &lt;/ol&gt;