Jack W. Barber

Practical guidelines for the use of new generation antipsychotic drugs (except clozapine) in adult individuals with intellectual disabilities.

New generation antipsychotic (NGA) drugs introduced to the US market after clozapine (aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone) are frequently used in individuals with intellectual disabilities (ID). However, there is very limited research to fully establish evidence-based or personalized medicine approaches for their use in this population. These guidelines take a pragmatic approach to establishing frameworks for their use by utilizing the prescribing information and reviewing the available literature on other relevant neuropsychiatric disorders. In the absence of expert consensus guidance and well-controlled comparison trials, we present a set of guidelines to inform initiation, dosing and monitoring of use in adults. Further, in these guidelines we provide practical information on drug-drug interactions and adverse drug reactions, and a brief review of discontinuation syndromes, potential for abuse, use during pregnancy and cost considerations. We also provide drug utilization review forms for each NGA to facilitate implementation of these guidelines, these guidelines provide a practical and necessary resource for practitioners treating psychiatric disorders and challenging behaviors in adult individuals with ID.

Abnormal diurnal weight gain among long-term patients with schizophrenic disorders

We found diurnal weight gain to be abnormal among 65 long-term patients with schizophrenic disorders. Patients were weighed at 7 a.m. and 4 p.m. serially and diurnal weight gain was normalized (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.2 +/- 1.5% for 47 male patients compared (P = 0.001) with 0.6 +/- 0.4% for 11 male controls. NDWG was 1.7 +/- 0.7% for 18 female patients compared (P less than 0.0001) with 0.5 +/- 0.3% for 14 female controls. We hypothesize that NDWG may be an index of both the severity and duration of the schizophrenic disorder.

The link between fluid intake and weight gain in psychosis

Diurnal weight gain was found to be abnormal among 44 of 77 institutionalized chronically psychotic patients. All patients were weighed and urine samples obtained weekly for 3 weeks at 7 A.M. and 4 P.M. Diurnal weight gain was normalized as a percentage by subtracting the 7 A.M. weight from the 4 P.M. weight, multiplying the difference by 100, and then dividing the result by the 7 A.M. weight. Normalized diurnal weight gain (NDWG) was 2.504 +/- 1.266% for the 44 study patients with abnormal findings, .631 +/- .405% for the 16 acutely psychotic controls, and .511 +/- .351% for 29 normals. Urine excretion was related (r = .476, p = .001) to NDWG in the subgroup of study patients with abnormal NDWG, consistent with the observation that their fluid intake exceeded fluid excretion in the afternoon.

Change and Systems Transformation

People with mental illness have been advocating for their own recovery and increasingly demanding recovery-oriented services from their caregivers. Inpatient psychiatry has been one of the last bastions of traditional medical model care and, in many ways, intractable to change. But, as Victor Hugo said, there is no stopping an idea whose time has come, and it is high time that inpatient psychiatry embraces recovery-oriented services. In this chapter, we consider the difference between recovery and recovery-oriented care, the impetus for moving to recovery-oriented services, and what the basic principles of such care would entail. Then, we outline eight common errors that are evident in organization change and could be avoided when behavioral health service entities begin transforming their services to align with recovery-oriented services. These pitfalls can doom the transformation process, but adherence to proven strategies should enable an entity to fully embrace recovery-oriented services in reality and not just in name. This would require the entity to make fundamental changes in mission statements, policies, procedures, record keeping, quality assurance, and employee selection, training and supervision. Finally, we provide examples of how such changes have been implemented by service agencies, and the available resources that may make the process of change a less onerous one.

State-university collaboration: Role of the psychiatric hospital medical director

Medical directors are clinician-executives who provide leadership to advance state-university collaboration programs, and to facilitate recruiting and empowering a professional staff in the public sector. This article examines the medical directors role and tasks from the perspective of a “social systems clinician” who interacts with medical staff, hospitals, agencies, and university systems to meet oversight responsibilities and promote organizational development.