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Organ Transplantation: Pre-transplant Assessment and Post-transplant Management

Key Points Solid organ transplantation is a viable treatment option for patients with end-organ failure. Psychiatrists are integral members of multi-disciplinary transplant teams, involved in both pre-operative and post-operative assessment and care. The emotional well-being of the transplant patient can influence outcome. Neuropsychiatric sequelae attend both the complications of end-organ failure and the medications used to treat the rejection and infection that follows transplantation. Ethical issues…

Psychiatric Aspects of HIV Infection and AIDS

Key Points Highly active antiretroviral therapy (HAART) has transformed infection with the human immunodeficiency virus (HIV) from a terminal illness to a chronic, treatable condition. Psychiatric and substance use disorders are frequent concomitants of HIV infection and complicate its diagnosis and treatment. Evaluation of affective, behavioral, and cognitive symptoms must be broad and include primary psychiatric disorders and secondary conditions related to HIV infection, opportunistic infections,…

Psycho-oncology: Psychiatric Co-morbidities and Complications of Cancer and Cancer Treatment

Key Points By exploring the patient's capacity to consider choices, psychiatrists convey respect and enhance the patient's conviction of influence on the world. The sense of purpose adds value to life regardless of time frame. Additional psychosocial interventions combine education, relaxation skills, and social support. So that treatable psychiatric syndromes do not interfere with quality cancer care, psychiatrists diagnose and plan specific treatment. They also may…

Life-threatening Conditions in Psychiatry: Catatonia, Neuroleptic Malignant Syndrome, and Serotonin Syndrome

Key Points Background Catatonia, neuroleptic malignant syndrome (NMS), and serotonin syndrome are neuropsychiatric conditions with prominent motor, behavioral, and systemic manifestations. Catatonia is a syndrome with multiple medical, neurological, and psychiatric etiologies that requires a systematic approach for diagnosis. NMS is a form of malignant catatonia. Serotonin syndrome (SS), caused by an excess of serotonin, shares many features in common with catatonia and NMS. History Catatonia…

Psychiatric Consultation to Medical and Surgical Patients

Key Points Consultation psychiatry encompasses the evaluation and management of affective, behavioral, and cognitive symptoms in medical and surgical patients in general hospitals. Effective psychiatric consultation requires clear communication with the referring physician to hone the consultation question, to provide a useful response, and to facilitate optimal patient care. A temporal orientation to history-taking and a hierarchical approach to neuropsychological screening are keys to effective patient…

The Suicidal Patient

Key Points Suicide, or intentional self-harm with the intent of causing death, is one of the most common causes of death in the US. For every completed suicide, between 8 and 25 attempts are made. Psychiatric illness is the most powerful risk factor for both completed and attempted suicide; mood disorders are responsible for a majority of suicides. Medical illness, especially of a severe or chronic…

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…

Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder across the Life Span

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…

Neurotherapeutics

Key Points Somatic therapies are a group of device-based techniques that modulate disease-relevant structures of the nervous system via surgical ablation or electrical stimulation with the goal of therapeutically modifying pathological patterns of brain activity and circuit connectivity. Ablative limbic system surgical procedures, such as anterior cingulotomy, sub-caudate tractotomy, limbic leucotomy, and anterior capsulotomy are viable treatment options for patients with treatment-refractory major depressive disorder (MDD)…

Electroconvulsive Therapy

Key Points Remission rates of 70%–90% have been reported in clinical trials of electroconvulsive therapy (ECT) and ECT is currently the most promising prospect for addressing the unmet worldwide need for effective treatment of individuals suffering from depression. The symptoms that predict a good response to ECT are those of major depression (e.g., anorexia, weight loss, early morning awakening, impaired concentration, pessimistic mood, motor restlessness, increased…

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…

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…

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…

Personality and Personality Disorders

Key Points Epidemiology Personality has evolved to guide both social and interpersonal function. Use of dimensional diagnostic systems improves reliability and descriptive breadth. Clinical Findings Normal personality traits and DSM-5 personality disorders share many features. Treatment Options Empirical findings indicate that personality disorders respond positively to a wide range of psychotherapies. Targeted pharmacotherapy for personality disorders can be implemented in a rational fashion. Overview The last…