Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Alcohol-Related Disorders

Key Points Incidence Alcohol misuse is one of the leading causes of morbidity and mortality in the US. Epidemiology The highest rates of alcohol use, heavy binge use, and alcohol use disorders occur between the ages of 18 and 29 years. Pathophysiology Alcohol causes harm through three distinct, but related pathways: intoxication, toxicity, and alcohol use disorder. Clinical Findings Alcohol use disorders are heterogeneous disorders that…

Dementia

Key Points Clinical Findings In the DSM-IV, dementia was defined as a syndrome with multiple etiologies and characterized by a disabling decline in memory as well as an impairment in at least one other higher cortical activity (e.g., with aphasia, apraxia, agnosia, or executive dysfunction). In the DSM-5, cognitive disorders are classified as “neurocognitive disorders” and exist on a spectrum of cognitive and functional impairment: delirium,…

Natural Medications in Psychiatry

Key Points Complementary and alternative medical therapies are made up of a diverse spectrum of practices (including natural medications) that often overlap with more traditional medical practice. The use of natural medications is growing considerably in the US and around the world, and patients often do not report use of natural medications to their physicians. Historical lack of scientific research in this area has contributed to…

Side Effects of Psychotropic Medications

Key Points Background A systematic approach to side effects of medications should include consideration of the nature, severity, and timing of symptoms to facilitate optimal management of such side effects. History Many medications (e.g., nefazodone) previously used in psychiatric disorders, but shown to have serious adverse side effects, have been removed from the market over the years. Clinical and Research Challenges Rates of medication side effects…

Drug–Drug Interactions in Psychopharmacology

Key Points Drug–drug interactions refer to alterations in drug levels or drug effects (or both) related to the administration of two or more prescribed, recreational, or over-the-counter agents in close temporal proximity. Although some drug–drug interactions involving psychotropic medications are life-threatening, most interactions manifest in more subtle ways through increased side-effect burden, aberrant drug levels, or diminished efficacy. Pharmacokinetic drug–drug interactions involve a change in the…

Stimulants and Other Medications for ADHD

Key Points Attention-deficit/hyperactivity disorder (ADHD) is a common disorder in children, adolescents, and adults. While the phenotype of ADHD changes across the life span, ADHD persists in many children, adolescents, and adults. Formulations of stimulant and non-stimulant medications are Food and Drug Administration-approved as pharmacological treatments for ADHD in children, adolescents, and adults. Co-morbid psychiatric and learning disorders are common in patients with ADHD across the…

The Use of Antiepileptic Drugs in Psychiatry

Key Points A “kindling hypothesis” of mood instability led to the search for anticonvulsant medications that might improve the course of illness in bipolar disorder (BPD). Divalproex sodium (valproate) and carbamazepine (in extended-release form) are effective in the treatment of acute mania. Lamotrigine is effective in the prevention of relapse to a new mood state in BPD, especially to major depression. The risk of the development…

Lithium and Its Role in Psychiatry

Key Points Lithium remains a first-line treatment for all phases of bipolar disorder, including mania, depression, and prevention of recurrence. While not examined in a controlled trial, abundant evidence supports a role for lithium in decreasing the risk of suicide. Lithium has a narrow therapeutic window, necessitating careful titration and close monitoring of plasma levels. Lithium toxicity may cause confusion and ataxia. Drugs that affect lithium…

Antipsychotic Drugs

Key Points All antipsychotics share dopamine 2 blockade as the presumed main mechanism of action. Primary symptom targets of antipsychotics are positive symptoms (disorganization, delusions, and hallucinations) and agitation; their efficacy for negative symptoms and cognitive deficits of schizophrenia is questionable. Increasingly, antipsychotics are used for treatment of mood disorders. Historically, antipsychotics have been grouped into first-generation antipsychotics (typical or conventional antipsychotics, which are all characterized…

The Pharmacotherapy of Anxiety Disorders

Key Points A variety of pharmacological agents are effective for the treatment of anxiety disorders. The SSRIs and SNRIs are first-line pharmacological agents for the treatment of anxiety disorders. Benzodiazepines are effective, rapidly acting and well-tolerated, but are associated with the risk of abuse and dependence, and lack efficacy for co-morbid depression. Anticonvulsants, atypical antipsychotics, adrenergic antagonists, and other agents also play role in the treatment…

Bipolar Disorder

Key Points Incidence The lifetime prevalence of bipolar disorders is approximately 2%. Epidemiology Bipolar disorder is associated with significant morbidity, including functional impairment, as well as significant risk for suicide. Clinical Findings Diagnosis of bipolar disorder rests on establishing current or prior manic, hypomanic, mixed, or depressive episodes. Treatment Options Treatments with evidence of efficacy for prevention of recurrence of mood episodes in bipolar disorder include…

Pharmacological Approaches to Treatment-Resistant Depression

Key Points Background Treatment-resistant depression (TRD) refers to an inadequate response to at least one antidepressant given in sufficient doses and for an appropriate duration. History Despite the recent advances in treatment of depression, only 30%–40% of patients achieve remission following initial treatment. Clinical and Research Challenges Inadequate response usually means failure to achieve remission. However, the, importance of functional recovery in treatment has also been…

Antidepressants

Key Points The immediate mechanism of action of modern antidepressants (“immediate effects”) involves influencing the function of one or more monoamine neurotransmitter systems (serotonin, norepinephrine [noradrenaline], or dopamine). Influencing monoaminergic function has been shown to result in several changes in second-messenger systems and gene expression/regulation (“downstream effects”). “Downstream effects” may explain the delayed onset of antidepressant response seen with all contemporary agents (most patients improve following…

Treatment Adherence

Key Points Background Among patients with a psychiatric illness, treatment adherence is associated with better treatment outcomes, a lower risk of relapse and hospitalization, and better adherence to treatments for co-morbid medical illnesses. However, barriers to adherence are common and rates of suboptimal adherence remain critically high. History Over the past several decades, approaches have evolved to help patients continue treatment for chronic health problems. The…

Psychiatric Neuroscience: Incorporating Pathophysiology into Clinical Case Formulation

Key Points One can approach the study of the brain and its pathophysiology from various perspectives with different levels of resolution: molecular, genetic, cellular, synaptic, systems, and behavioral. Pathological processes and therapeutic interventions can target one or more of these levels, leading to a cascade of events that changes each of them. Affect, behavior, and cognition are processed in specific brain circuits, and their altered function…

Management of a Psychiatric Consultation Service

Overview The purpose of this chapter is to give psychiatric providers of consultation-liaison (C-L) services an understanding of the complex business aspects of their work. Understanding that appropriately adhering to the often-confusing guidelines for reimbursement can be stressful to clinicians and expose them to time-consuming and stressful audits and substantial penalties, both personally and for their institutions. In this atmosphere, providing ethical, legal, and clinically astute…

Physician Well-Being and Coping With the Rigors of Psychiatric Practice

Overview The practice of medicine is focused on disease, not health, and on treatment, not primary prevention. Therefore, it is not surprising that physicians have difficulty maintaining their own health, minimizing stress, and preventing burnout in their own lives. The very same character traits that make physicians successful (e.g., perfectionism, an exaggerated sense of responsibility, selflessness) also make physicians vulnerable to chronic stress. Stress can be…

Approaches to Collaborative Care and Behavioral Health Integration

Overview Historical trends in psychiatry over the last century mirrored developments in the U.S. healthcare system more broadly that promoted system re-design to provide safer and more personalized, cost-effective, and high-quality health care. Care re-design in the treatment of psychiatric disorders included innovative approaches to providing psychiatric care in the general medical setting, which is commonly the first site of presentation of mental illness, and is…

Legal Aspects of Consultation

Overview Legal issues are common and acknowledged, although rarely welcomed, aspects of modern medicine. Physicians respond to these issues in various ways, ranging from denial of their existence, to resentment at the perceived intrusion into the patient care they create, to obsessive concern that can ultimately interfere with good clinical care. Although it is true that legal issues are ever-present, and at times are the dominant…

Culture and Psychiatry

Overview Race, ethnicity, and culture may all exert a tremendous impact on medical diagnosis, treatment, and outcomes. This is especially true in psychiatry, given the prominent role that culture plays in patients' interpretation and management of symptoms that fall within the affective, behavioral, and cognitive domains. Behaviors that appear bizarre in one cultural context may be perfectly acceptable in another. Although an in-depth understanding of every…