Chaya G. Bhuvaneswar

Adverse endocrine and metabolic effects of psychotropic drugs: selective clinical review.

The article critically reviews selected, clinically significant, adverse endocrine and metabolic effects associated with psychotropic drug treatments, including hyperprolactinaemia, hyponatraemia, diabetes insipidus, hypothyroidism, hyperparathyroidism, sexual dysfunction and virilization, weight loss, weight gain and metabolic syndrome (type 2 diabetes mellitus, dyslipidaemia and hypertension). Such effects are prevalent and complex, but can be managed clinically when recognized. They encourage continued critical assessment of benefits versus risks of psychotropic drugs and underscore the importance of close coordination of psychiatric and general medical care to improve long-term health of psychiatric patients. Options for management of hyperprolactinaemia include lowering doses, switching to agents such as aripiprazole, clozapine or quetiapine, managing associated osteoporosis, carefully considering the use of dopamine receptor agonists and ruling out stress, oral contraceptive use and hypothyroidism as contributing factors. Disorders of water homeostasis may include syndrome of inappropriate antidiuretic hormone (SIADH), managed by water restriction or slow replacement by hypertonic saline along with drug discontinuation. Safe management of diabetes insipidus, commonly associated with lithium, involves switching mood stabilizer and consideration of potassium-sparing diuretics. Clinical hypothyroidism may be a more useful marker than absolute cut-offs of hormone values, and may be associated with quetiapine, antidepressant and lithium use, and managed by thyroxine replacement. Hyper-parathyroidism requires comprehensive medical evaluation for occult tumours. Hypocalcaemia, along with multiple other psychiatric and medical causes, may result in decreased bone density and require evaluation and management. Strategies for reducing sexual dysfunction with psychotropics remain largely unsatisfactory. Finally, management strategies for obesity and metabolic syndrome are reviewed in light of the recent expert guidelines, including risk assessment and treatments, such as monoamine transport inhibitors, anticonvulsants and cannabinoid receptor antagonists, as well as lifestyle changes.

Predicting response to leuprolide of women with premenstrual dysphoric disorder by daily mood rating dynamics.

Approximately 60-70 percent of women with premenstrual dysphoric disorder (PMDD) show symptomatic improvement in response to the GnRH agonist leuprolide acetate, which suppresses ovarian function. However, it has been very difficult to either predict or understand why some women respond, while others do not. We applied several complementary statistical methods to the dynamics of pre-treatment mood rating data to determine possible predictors of response for women with PMDD. We compared responders (n = 33) to nonresponders (n = 12) in clinical trials of leuprolide (three months in duration) as a treatment for PMDD, on the basis of pre-trial daily self-ratings of sadness, anxiety, and irritability. We analyzed both sequential irregularity (approximate entropy, ApEn) and a quantification of spikiness of these series, as well as a composite measure that equally weighted these two statistics. Both ApEn and Spikiness were significantly smaller for responders than nonresponders (P ≤ 0.005); the composite measure was smaller for responders compared with nonresponders (P ≤ 0.002) and discriminated between the subgroups with high sensitivity and specificity. In contrast, mean symptom levels were indistinct between the subgroups. Relatively regular and non-spiky pre-trial dynamics of mood ratings predict a positive response to leuprolide by women with PMDD with high probability, moreover based on typically less than 3 months of daily records. The statistical measures may have broad and direct applicability to behavioral studies for many psychiatric disorders, facilitating both accurate diagnosis and the prediction of response to treatment.

Cycloid Psychoses Revisited: Case Reports, Literature Review, and Commentary

&NA; Emil Kraepelin proposed to separate psychiatric disorders with psychotic features into two major categories, dementia præcox (later schizophrenia) and manic‐depressive insanity (later bipolar disorder and major depression). Over the past century, there have been many efforts to categorize conditions that do not fit readily in either group. These conditions include many cases of acute psychotic illnesses of limited duration, with recovery between recurrences. For some of these conditions, Karl Kleist proposed the term cycloid psychosis: acute features were psychotic, as in schizophrenia, but the course was episodic, as in manic‐depression. His concept was later elaborated by Karl Leonhard and Carlo Perris, and validated by modern studies. Leonhard described three overlapping cycloid subtypes (anxiety‐beatific, excited‐inhibited confusional, and hyperkinetic‐akinetic motility dysfunction forms); Perris proposed a more unitary syndrome with operational diagnostic criteria; and recent investigators have considered relatively affective versus thought‐disordered subtypes. The cycloid concept is not explicitly included in standard international diagnostic schemes, but both DSM‐IV and ICD‐10 have broad categories for acute, recurrent psychotic disorders, whose validity remains insecure. We present two cases of probable cycloid psychosis, review the history of the concept, and propose that it be reconsidered as a clinically useful category whose validity and utility for prognosis and treatment can be further tested.(HARV REV PSYCHIATRY 2008;16:167–180.)

Pilot study of the effect of lipophilic vs. hydrophilic beta-adrenergic blockers being taken at time of intracardiac defibrillator discharge on subsequent PTSD symptoms.

A pathophysiological model of posttraumatic stress disorder (PTSD) posits that an overly strong stress response at the time of the traumatic event leads to overconsolidation of the events memory in part through a central β-adrenergic mechanism. We hypothesized that the presence of a β-blocker in the patients brain at the time of the traumatic event would reduce the PTSD outcome by blocking this effect. The unpredictable, uncontrollable discharge of an implantable intracardiac defibrillator (ICD) is experienced by most patients as highly stressful, and it has previously been shown to be capable of causing PTSD symptoms. The present pilot study evaluated a convenience sample of 18 male cardiac patients who had been taking either a lipophilic β-blocker (which penetrates the blood-brain barrier) or a hydrophilic β-blocker (which does not) at the time of a discharge of their ICD. The self- report PTSD Checklist-Specific Version quantified 17 PTSD symptoms pertaining to the ICD discharge during the month preceding the evaluation. There was a statistical trend for patients who had been taking a lipophilic β-blocker at the time of the ICD discharge to have (35%) less severe PTSD symptoms than patients who had been taking a hydrophilic β-blocker (one-tailed p=0.07, g=0.64). Further, prospective, randomized, controlled studies are suggested.

Multiple Neurologic, Psychiatric, and Endocrine Complaints in a Young Woman: A Case Discussion and Review of the Clinical Features and Management of Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Stroke

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their thrice-weekly rounds, Dr. Stern and other members of the Psychiatric Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Using the Technique of Journal Writing to Learn Emergency Psychiatry.

ObjectiveThe authors discuss journal writing in learning emergency psychiatry.MethodsThe journal of a psychiatry intern rotating through an emergency department is used as sample material for analysis that could take place in supervision or a resident support group. A range of articles are reviewed that illuminate the relevance of journal writing for the learning process, including articles about resident resilience, “autognosis,” the learning process in psychiatry, and “limbic music.”ResultsJournal writing is a useful tool in consolidating knowledge, and can be used along with traditional exercises for learning psychiatry such as writing chart notes, process notes, and completing required studies for examinations.ConclusionPsychiatry training should continue to explore the use of journals as residents continue to write them.

Psychiatric Care of Deaf Patients in the General Hospital: An Overview

BACKGROUND While the number of Deaf and hard-of-hearing patients worldwide is estimated at six hundred million, few specialized psychiatric services or training resources exist to support the provision of mental health care to this population. This presents a particularly acute problem in the general hospital, where the consultant psychiatrist is likely to be confronted with the challenges of providing comprehensive psychiatric evaluation, diagnosis and treatment to patients with whom he or she may have limited experience or confidence. METHOD We review critical considerations in the work-up, differential diagnosis, and management of commonly-presenting psychiatric disorders among Deaf patients in the general hospital setting.

Multiple Neurologic, Psychiatric, and Endocrine Complaints in a Young Woman: A Case Discussion and Review of the Clinical Features and Management of Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Stroke: (Rounds in the General Hospital)

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their thrice-weekly rounds, Dr. Stern and other members of the Psychiatric Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.