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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…

Psychiatric Illness During Pregnancy and the Postpartum Period

Overview Psychiatric consultation to obstetric patients typically involves evaluating and treating an array of psychopathology. Once thought to be a time of emotional well-being for women, studies now suggest that pregnancy does not protect women from the emergence or persistence of psychiatric disorders. Because many psychiatric conditions are chronic or recurrent and have high prevalence rates in women during the reproductive years, many women will become…

Care of the Geriatric Patient

Overview The United States population over the age of 65 years has been increasing dramatically, reflecting improvements in health, nutrition, and medical care for the elderly. Illness (both medical and psychiatric) increases with advancing age in part due to stressful life events, the burden of co-morbid conditions, and combinations of medications used. Roughly 40% to 60% of those hospitalized with medical and surgical illnesses are over…

Pediatric Consultation

Overview Pediatric psychiatry consults are requested to address a diverse set of issues and needs. Similar to the work involving adult psychiatric consultations, the child psychiatrist evaluates the patient, acts as a liaison to the medical and nursing staff, manages the psychiatric needs and demands of patients and their families, and helps treatment teams unite around common goals of quality care. Additionally, the pediatric consultant incorporates…

Care at the End of Life

With more than 2.6 million deaths each year in the United States, providing both competent and compassionate care for patients at the end of life is a crucial task for physicians. The Institute of Medicine identified end-of-life care as one of the priority areas for improvement of quality of care, and it specifically identified pain control in advanced cancer and care of patients with advanced organ…

Emergency Psychiatry

Introduction Over the past 20 years, emergency psychiatry has developed into an independent subspecialty practice within psychiatry. Although formal board certification requirements are lacking, all accredited US psychiatric residency-training programs follow minimum training guidelines for emergency psychiatry. The emergence of emergency psychiatry as a specialized practice parallels the recent dramatic increase in patient volume in emergency care settings. In 2001, there were over 2 million visits…