Polypharmacy in Maintenance of Bipolar Disorder.

Objectives: To track the outcomes of bipolar patients who had remitted from an acute manic episode on single- and multiple-drug regimens including lithium (LI), valproate (VPA), and carbamazepine (CBZ), in order to compare relapse rates on 1, 2, or 3 medications.

Methods: Following treatment of an acute manic episode and a 1-month period of no signs of mood episodes, patients were evaluated at 1- to 2-month intervals as to the kind of regimen required to maintain their stability while continuing on this regimen for 2 years. Medication regimens included 1, 2, or 3 of the following drugs: LI, VPA, and/or CBZ.

Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder: a naturalistic study.

Mood stabilizers are used clinically for the management of bipolar disorder. Prophylactic therapy with mood stabilizers is the primary treatment for preventing depressive and manic relapses in bipolar patients once they are stabilized. In this study, we examined the relative efficacy of the three most commonly used mood-stabilizing agents: lithium (Li), valproic acid (VPA), and carbamazepine (CBZ), in preventing relapse episodes.

Maintenance treatment for obsessive-compulsive disorder: findings from a naturalistic setting.

Background: Although the utility of medication in the acute treatment of adult obsessive-compulsive disorder (OCD) is well-established, the role of maintenance therapy is not as well-studied. This study examines the efficacy of long-term treatment for, and predictors of, stability in medicated patients with adult OCD.

Methods: Using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), we retrospectively evaluated 84 OCD patients who responded to a 10- to 12-week, open-label, acute treatment in a naturalistic clinic setting.

Prophylactic efficacy of fluoxetine, escitalopram, sertraline, paroxetine, and concomitant psychotherapy in major depressive disorder: outcome after long-term follow-up.

The acute efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of major depressive disorder (MDD) is well established; however their role in longer-term prevention of recurrence remains unconfirmed. This study aims at examining: the prophylactic efficacy of four commonly used SSRIs in MDD in a naturalistic setting with long-term follow-up, the effect of concomitant cognitive behavioral therapy (CBT), and the predictors of outcome. In a prospective cohort study, 387 patients who either remitted or responded following treatment with four different SSRIs-fluoxetine, escitalopram, sertraline and paroxetine-were followed up over several years.

Patient-reported outcomes before and after treatment of major depressive disorder.

Patient reported outcomes (PROs) of quality of life (QoL), functioning, and depressive symptom severity are important in assessing the burden of illness of major depressive disorder (MDD) and to evaluate the impact of treatment. We sought to provide a detailed analysis of PROs before and after treatment of MDD from the large Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. This analysis examines PROs before and after treatment in the second level of STAR*D.

The impact of spirituality before and after treatment of major depressive disorder.

Objective: The authors sought to assess spirituality in depressed patients and evaluate whether the degree of initial depressive symptoms and response to pharmacotherapy treatment has a correlation with degree of spirituality and belief in God.

Methods: Our participants included 84 patients who presented to a depression/anxiety clinic for naturalistic treatment of their depressive illness over the course of two years. All patients met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for major depression, as confirmed by structured interviews using the Structured Clinical Interview for DSM-IV, and were treated with selective serotonin reuptake inhibitors for eight weeks.

The discrepancy between patients and informants on clinician-rated measures in major depressive disorder: implications for clinical trials and clinical practice.

Clinician-rated measures are used in clinical trials and measurement-based clinical care settings to assess baseline symptoms and treatment outcomes of major depressive disorder (MDD), with a widely held dictum that they are sufficient in assessing the patient's clinical status. In this study, we examined clinician-rated measures of depressive and global symptom severity, obtained by interviewing patients as well as informants in an attempt to examine the potential difference or similarity between these two sources of information. The sample consisted of 89 treatment seeking, DSM-IV diagnosed MDD outpatients treated between 1995 and 2004.

Patient-reported outcomes of quality of life, functioning, and depressive symptom severity in major depressive disorder comorbid with panic disorder before and after SSRI treatment in the star*d trial.

Background: Panic disorder (PD) is highly comorbid with major depressive disorder (MDD) with potential impact on patient-reported outcomes of quality of life (QOL), functioning, and depressive symptom severity.

Methods: Using data from the sequenced treatment alternatives to relieve depression (STAR*D) trial, we compared entry and post-SSRI-treatment QOL, functioning, and depressive symptom severity scores in MDD patients with comorbid PD (MDD+PD) to MDD patients without PD (MDDnoPD). We also compared pre- and posttreatment proportions of patients with severe impairments in quality of life and functioning.

Long-acting injectable antipsychotics and the development of postinjection delirium/sedation syndrome (PDSS).

Objectives: Five long-acting injectable (LAI) antipsychotics are currently available in the United States for the treatment of schizophrenia: fluphenazine decanoate, haloperidol decanoate, risperidone microspheres, paliperidone palmitate, and olanzapine pamoate. Additionally, aripiprazole LAI is currently under FDA review. However, research into the safety and tolerability of these LAIs, with particular regard to the development of postinjection delirium/sedation syndrome (PDSS), is limited and has been focused mainly on olanzapine pamoate.

Scopolamine as an antidepressant: a systematic review.

Objectives: The cholinergic-adrenergic hypothesis of mania and depression states that depression is characterized by an increase in central cholinergic activity relative to noradrenergic tone. Scopolamine is a centrally acting competitive inhibitor of the muscarinic cholinergic receptor site. This review seeks to find all available data investigating scopolamine as an antidepressant.

Co-occurring psychotic and addictive disorders: neurobiology and diagnosis.

Psychosis and substance abuse are intimately related. Psychotic spectrum illnesses commonly co-occur with substance use disorders (SUDs), and many substances of abuse can cause or exacerbate psychotic symptoms along a temporal spectrum from acute to chronic presentations. Despite the common co-occurrence between psychotic spectrum illnesses and SUDs, they are often under-recognized and undertreated, leading to poor treatment outcomes.

Pharmacotherapy of addictive disorders.

Substance use disorders are highly prevalent in the United States and cause considerable damage to our society. They are underrecognized and undertreated despite a vast body of literature demonstrating the efficacy of treatment using both psychosocial and psychopharmacological modalities. For the last decade, research and progress into the biological basis of the addictive process has led to a rapidly growing number of pharmacological agents used to interrupt the addictive process at its various stages such as the initiation of substance abuse, the transition from abuse to dependence, and the prevention of drug reinstatement or relapse.

The neurobiology of addictive disorders.

Addiction is increasingly understood as a neurobiological illness where repetitive substance abuse corrupts the normal circuitry of rewarding and adaptive behaviors causing drug-induced neuroplastic changes. The addictive process can be examined by looking at the biological basis of substance initiation to the progression of substance abuse to dependence to the enduring risk of relapse. Critical neurotransmitters and neurocircuits underlie the pathological changes at each of these stages.

Discontinuation of maintenance selective serotonin reuptake inhibitor monotherapy after 5 years of stable response: a naturalistic study.

Objective: Selective serotonin reuptake inhibitors (SSRIs) are effective treatments of major depressive disorder (MDD), but data to guide the duration of maintenance therapy in community settings are limited. We assessed whether extending maintenance beyond 5 years provided additional benefit and identified other predictors of outcome.

Method: All patients treated at an urban community outpatient clinic between June 1993 and September 2005 were considered for inclusion in this study.

Schizoaffective disorder: diagnostic issues and future recommendations.

Objective: Difficulties surrounding the classification of mixed psychotic and affective syndromes continue to plague psychiatric nosology. This paper addresses the controversy regarding the diagnostic validity of schizoaffective disorder (SAD), a diagnosis that is used in both DSM-IV and ICD-10 and one that encroaches on both schizophrenia (SCZ) and bipolar disorder (BD).

Methods: A systematic synthesis of clinical and empirical literature, including evidence from cognitive, neurobiological, genetic, and epidemiological research, was undertaken with the aim of evaluating the utility of the SAD classification.

Teaching psychopharmacology: what works and what doesn't.

How do we best teach clinical psychopharmacology to trainees and clinicians, so they not only increase their knowledge base, but even more importantly also learn to practice the most informed, evidence-based practice possible? This article attempts to answer this elusive question by compiling the individual and combined wisdom of 5 expert psychopharmacology teachers, each of whom draws on years of their own experiences as master educators. The topics covered include teaching clinical psychopharmacological competence in adult psychiatry residency training and in issues specific to both pediatric and geriatric populations, teaching physicians to improve clinical outcomes through continuing medical education, and new developments in adult-centered pedagogy and assessment. Although the focus of this article is on practical pearls found useful in teaching psychiatric residents and practicing physicians, the lessons learned are applicable to other groups of learners such as medical students, other trainees, and nonmedical clinicians.

Three-year medication prophylaxis in panic disorder: to continue or discontinue? A naturalistic study.

Objective: Little is known about maintenance treatment for panic disorder. The purpose of this naturalistic study is to compare outcomes of remitted panic disorder patients continued on versus those successfully discontinued from maintenance medication.

Methods: After 3 years of sustained remission with medication in a naturalistic setting, 168 patients were continued on, whereas 37 successfully discontinued from medication.

Continuation versus discontinuation of lithium in recurrent bipolar illness: a naturalistic study.

Objectives: Lithium's efficacy in prophylaxis of mood episodes in bipolar disorder (BD) is well established in the clinical trial setting, but may be less robust in routine clinical practice. We compared illness recurrence in bipolar patients naturalistically continued on or discontinued from lithium after an extended period of clinical stability on lithium monotherapy, and evaluated other potential risk factors for relapse.

Methods: We followed 213 patients who were stable for 2 years on lithium monotherapy following resolution of acute symptoms marking their last manic episode.

Effects of D-cycloserine on negative symptoms in schizophrenia.

Introduction: The negative and cognitive symptoms of schizophrenia are poorly responsive to neuroleptic treatment. Glutamatergic dysfunction may mediate some of these symptoms. Low dose D-cycloserine (DCS) is a partial agonist at the glycine site of the NMDA-associated receptor complex, noncompetitively enhancing NMDA neurotransmission.

Prepulse inhibition of acoustic startle in subjects with schizophrenia treated with olanzapine or haloperidol.

Studies of the acoustic startle response and of its inhibition by the presentation of a non-startling preliminary stimulus (prepulse inhibition, PPI) have revealed deficits in PPI in schizophrenic subjects compared to healthy controls. Animal studies indicate that atypical antipsychotics improve PPI deficits induced by NMDA antagonists more consistently than typical antipsychotics. The effect of medication status on PPI in schizophrenia is unresolved in the literature.