Alan Stoudemire

The economic burden of depression

This article provides estimates of direct treatment costs and indirect costs from lost productivity associated with the morbidity and mortality of depression. Data are based on epidemiologic estimates of the prevalence of major depressive illness and on the number of suicides assumed to be secondary to depression. The number of hospitalizations, hospital days, physician and mental health provider visits, home/nursing home costs, and pharmaceutical costs are estimated. The direct and indirect costs are estimated to be approximately

Medication noncompliance: Systematic approaches to evaluation and intervention

16.3 billion per year. These economic figures provide a lower-bound estimate of the full economic burden of major depression and further emphasize the need for timely recognition and treatment to potentially minimize the negative impact of the illness on society.

Psychopharmacologic Treatment of Depression in the Medically Ill

Medication noncompliance is a significant problem in medical practice, but many intervention strategies developed for noncompliant patients (such as tangible rewards, contingency contracting) are not practical for the large numbers of patients seen by private practitioners on an ongoing basis. Based upon a review of the literature concerning the key determinants affecting compliance, the authors have developed a practical, rational, and systematic approach to assessing medication compliance that may serve as a guide for psychiatrists in formulating consultation recommendations, in liaison teaching activities, and in clinical psychiatric practice. Special emphasis is placed upon the identification of psychiatric syndromes that may negatively affect compliance. Implications for compliance-related research in consultation-liaison psychiatry are also discussed.

The Academy of Psychosomatic Medicine Practice Guidelines for Psychiatric Consultation in the General Medical Setting

Appropriate selection of an antidepressant agent in medically ill patients requires a careful risk-benefit assessment matching the pharmacokinetic and pharmacodynamic properties of the drug being considered against the patients physiological vulnerabilities, potential for drug interactions, and primary symptoms of the patients depression. While in the past antidepressant drug selection was limited by the almost sole availability of the tricyclic antidepressants, newer drugs such as selective serotonin reuptake inhibitors, bupropion, and venlafaxine have vastly simplified treating depression in the medically ill. In refractory cases of depression in patients with medical illness, electroconvulsive therapy can be used with appropriate anesthetic management.

Neuropsychiatric Toxicity Associated With Cytokine Therapies

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the field, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and revised prior to final approval. Some of the topics discussed include qualifications of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations.

OBRA regulations and the use of psychotropic drugs in long-term care facilities: Impact and implications for geropsychiatric care

The cytokines interleukin-2 and interferon-alpha are potent biological agents used to treat malignancy, infectious diseases, and neurodegenerative disorders. While these medications show substantial therapeutic promise, the neuropsychiatric toxicity associated with these agents is often treatment-limiting. The pathophysiology of this toxicity is not well delineated, and adverse effects to the central nervous system are often misdiagnosed by clinicians. This report reviews the preclinical and clinical literature describing the morbidity associated with these agents and suggests appropriate clinical management strategies and future directions for research.

Organization and development of combined medical-psychiatric units: Part 1

This article reviews governmental guidelines regulating the use of psychotropic drugs in long-term care facilities as established by the Omnibus Budget Reconciliation Act (OBRA) of 1987 and their impact on the use of psychotropic agents in these settings. A major component of these guidelines is to regulate the clinical indications for psychoactive drugs (neuroleptics, benzodiazepines, and sedative hypnotics) in residents of long-term care facilities. Responsibilities of the prescribing physician, facility medical director, and consulting pharmacist--as well as quality assurance procedures-in complying with OBRA regulations are examined. Evidence that OBRA regulations have reduced the use of psychotropic drugs and physical restraints in long-term nursing facilities is reviewed. Implications of the OBRA regulations for the training and clinical practice of psychiatrists and primary care clinicians are discussed as well as recommendations for increasing the availability of mental health services for this patient population via multidisciplinary geropsychiatric consultation-liaison teams.

Corticosteroid-induced delirium and dependency

Abstract Key issues examined in this first of a two-part series on the organization and development of combined medical-psychiatric units include definition of the intended patient populations, features of the physical environment for both patients and staff, diagnostic and therapeutic capabilities, kinds of psychiatric therapy in relation to this particular therapeutic milieu, and the roles of other mental health practitioners. This evaluation, along with the subsequent discussion of associated features in Part 2, is intended to provide a comprehensive guide for assessing the feasibility of successfully operating a combined unit within a general hospital setting.

Expanding Psychopharmacologic Treatment Options for the Depressed Medical Patient

A case of a patient with chronic lung disease who developed an addiction pattern of corticosteroid dependency is described in which steroid-induced delirium also developed. The rare phenomenon of corticosteroid dependency is discussed as well as the phenomenology and possible mechanisms of steroid-induced delirium.

The role of ciprofloxacin in a patient with delirium due to multiple etiologies

Psychopharmacologic treatment of depression in medically ill patients is greatly enhanced by the availability of new antidepressant medications that have low or no anticholinergic, anti-alpha-adrenergic, antihistaminic, and quinidine-like properties. This article discusses the important pharmacodynamic and pharmacokinetic properties of the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, and sertraline), bupropion, venlafaxine, and nefazodone--with an emphasis on their side effects relevant to medical patients as well as important drug interactions. In addition, the safety of these newer medications is compared with that of tricyclics; the role for continued tricyclic use in the medical-psychiatric population is examined; the use of electroconvulsive therapy in medically ill patients who are refractory to antidepressants is also briefly discussed.