Jacqueline Maus Feldman

Clozapine: A Clinical Review of Adverse Effects and Management

Clozapine (Clozaril®) is a novel and unique prototype atypical, tricyclic, dibenzodiazepine-derivative, antipsychotic agent. It has been proven effective and significantly superior to placebo, as well as to conventional neuroleptics, in several placebo-controlled, double-blind studies in treatment-resistant schizophrenia. It has also been found to produce an incidence of extrapyramidal symptoms (EPS) as low as that found with placebo. Approximately 30–60% of all schizophrenic patients who fail to respond to typical antipsychotics may respond to clozapine. It was the first major advance that marked a turning point in the treatment of schizophrenia and other psychotic disorders since the introduction of the typical antipsychotic agents, i.e., chlorpromazine and haloperidol in the 1950s and 1960s, respectively. After its introduction in clinical studies in the United States in the early 1970s, it was withdrawn in 1974, and was not approved for clinical use in the United States until February 1990, because of the risk of agranulocytosis. Its novel pharmacological profile, lack of propensity to cause EPS in both short- and long-term uses, lack of effects on serum prolactin, and ameliorative effects on tardive dyskinesia have resulted in the expansion of its use from refractory schizophrenia to schizoaffective disorders, affective disorders, some neurological disorders, aggression, as well as psychosis in patients with dementia and parkinsonism. This review covers the history, pharmacology, management of side effects, and fetal and neonatal effects of clozapine.

Efficacy of Add-On Topiramate Therapy in Psychiatric Patients with Weight Gain

BACKGROUND: Weight gain is a common adverse effect of many psychotropic medications including antipsychotics, antidepressants, and mood stabilizers. There is a growing body of evidence that topiramate may be useful as an add-on therapy to induce weight loss in patients who have experienced psychotropic-induced weight gain. OBJECTIVE: To determine the efficacy and tolerability of topiramate for treatment of weight gain in a naturalistic mental health clinic setting. METHODS: A retrospective chart review was conducted at a community mental health clinic. Subjects were non-elderly adults who received topiramate therapy beginning in 2002–2005 for documented weight gain during treatment with psychotropic drugs. Primary outcome measures included response rate (based on weight loss of any magnitude) and mean changes in weight and body mass index (BMI). RESULTS: Forty-one patients were included in the study. There was a 58.5% (n = 24) response rate. Mean reductions in weight and BMI were approximately 2.2 kg and 0.5 points, respectively. Responders lost an average of 7.2 kg, whereas nonresponders gained an average of 5.0 kg. Patients with a baseline weight of at least 91 kg and those receiving a greater number of psychotropic medications were more likely to experience success with topiramate therapy. Of the 24 patients who responded to therapy, 22 experienced onset of weight reduction by the next clinic visit (1–4 mo) following either initiation of therapy or titration to the eventual therapeutic dose, and the usual rate of weight loss was 0.45–1.4 kg per month. Therapy was typically initiated at 50 mg/day. The mean maximum dose was 93.9 mg/day and the median maximum dose was 100 mg/day. Seven (17.1%) patients had documented adverse effects to topiramate therapy. CONCLUSIONS: Topiramate therapy resulted in overall modest (ie, <2%) decreases in weight and BMI, but many patients experienced more impressive weight loss. Therapy was generally well tolerated.

Introduction to the Special Issue of Community Mental Health Journal Commemorating the 40th Anniversary of The Community Mental Health Centers Act of 1963.

We are pleased to introduce this special issue of Community Mental Health Journal commemorating the 40th anniversary of the Community Mental Health Centers Act of 1963. That event was a turning point in the history of mental health policy and services in the United States. It resulted from and fostered sustained proactive thinking and planning for the mental health needs throughout this country. Up until then, most care was provided in long-term institutions, in spite of the fact that Clifford Beers and others had urged the development of community based care in less restrictive environments more than 50 years earlier. This anniversary provides us an opportunity to mark time and review how far we have come, and to honor those dedicated to enhancing services. It also allows us to identify how much more work we have left to do. This watershed event in 1963 spawned the modern community mental health movement. It led eventually to much more organized and comprehensive care delivery systems, increased attention to prevention and earlier intervention, recognition of the psychosocial rehabilitative and recovery needs of our patients, the importance of working more effectively with families, and the value of integrating care for mental health, chemical dependency and primary care conditions. These service system

History of Community Psychiatry

Since antiquity, mental illnesses have proven challenging for individuals suffering with them, for families who wish to support them, and for communities in which they live. Evolution in the development of community services and supports has been predicated on the understanding or interpretation of mental illness, aided by acceptance and innovation, but often anchored in ignorance, stigma, and short-sightedness. Regardless of how one defines community psychiatry (by provider, by setting, by duration of care, by diagnosis, by set of principles, by finances/payer of services), multiple facets are important in the evolutions of the field. A historical review of community psychiatry is imperative to comprehending the variables that impact the lives of those touched by mental illness, and may suggest how systems of care should be organized to enhance recovery.

Medication options for treatment-resistant schizophrenia: implications for global mental health financing

Treatment resistance in schizophrenia creates a persistent public health problem and leads to repeated hospitalization. In search for a treatment for such patients, psychiatrists have co-prescribed multiple psychotropic medications simultaneously. Such practice is based mostly on clinical experience, rather than research derived evidence. Such combinations may not be fully “effective” if the cost, adverse effect profile and the potential for noncompliance by patients secondary to regimen complexity are considered. Is it really wise to try these various combinations of costly medicines in the mental health system, which is already struggling with its limited resources and funding worldwide? However, if mental health policy makers restrict reimbursement for such “unproven” combinations, patients might not receive the benefits of some of these combinations, which are showing some promise for the treatment of resistant schizophrenia.

CMHJ Editorial Comments for November 2015 Issue

In this issue we have included several articles that reflect some components of Narrative Medicine. Part of the mission statement of the Columbia Program of Narrative Medicine (http://narrativemedicine.org) notes ‘‘Narrative Medicine fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness.’’ Often in academic medical scholarly writings, research findings are reported in graphs and figures. The prose, while enlightening and instructive, may feel barren and bereft of any emotional content. We are trained to be objective, to report and receive findings in a structured, clinical, and/or scientific fashion. However, at times the inclusion of actual patient or provider comments can elucidate the meaning and impact of illness and treatment in a far more instructive fashion. Let us know if articles are helped or hindered by the inclusion of these narratives. Please be aware that the Board of the American Association of Community Psychiatrists continues to move forward with strategizing how to meet the needs of our constituencies, including you, our readers. As such, revised mission and vision statements have been developed, are posted on our website, and are as follows:

Context-Specific Assessment

To appropriately evaluate people in their communities requires careful consideration of a panoply of contextual parameters. These are composed of a welcoming and safe ambience; physical plant characteristics; the clinical setting (e.g., inpatient, outpatient, emergency room, homeless shelter or under a bridge, correctional setting); whether the assessment is routine, urgent, emergent, or investigatory; the nature of the evaluation’s expected product; and the cultural attributes of people, their communities, and the evaluator. Consideration of all these contextual issues will expand the evaluator’s capacity to establish a therapeutic alliance, and to engage the patient in the assessment, and possibly treatment. Awareness of and responses to these contextual concerns will improve both the evaluative process and the evaluation product.

The Present and Future of Community Psychiatry: An Introduction

This book aims to be a practical guide to twenty-first century community psychiatry. While academics have well traversed the territory of community mental health over the past decade, the most recent comprehensive book specifically focusing on American-based community psychiatry was published in 1996 (Vaccaro and Clark 1996). A long time coming, our volume owes tribute to and builds on the important contributions of many other works characterizing the principles and practices of community psychiatry. But in addition to an ever expanding fund of technical knowledge, because psychiatry, and especially community psychiatry, is so sensitive to social mores and economic flux, a comprehensive reevaluation of community psychiatry is appropriate at this time.

Exercising Effective Leadership

In order to exercise effective leadership in community psychiatry, one must be and do a variety of things: enjoy interfacing with people, be motivated and passionate about working in systems of care; be creative and innovative; be ready and willing to be an advocate for one’s self, one’s staff, and one’s patients in terms of providing quality care; practice a specific skills set; be willing to undergo training in a wide variety of topics; and be open to receiving, and changing from feedback. This chapter reviews the extant literature which describes the desired attributes of an effective leader, suggests venues of training necessary to support skills acquisition, and identifies system of care requirements to facilitate growth in leaders who understand and embrace community-based recovery-oriented systems of care.

Special Section for Contributions on International Community Psychiatry

For the last 2 years, increasing numbers of manuscripts have been submitted by our international colleagues, offering considerable research on the efficacies of a wide variety of programs, interventions, and treatment modalities, as well as observations on populations facing unique challenges. The Board of the American Association of Community Psychiatrists has committed to a more ‘‘global’’ embrace of community psychiatrists; one step in this process is ensuring that authors from beyond our shores have ample opportunity to have their findings published in the literature. As such, I am using dedicated space in the CMHJ to highlight findings by international authors, knowing we will all profit from better understanding the salient mental health issues that affect the world’s population; I predict we will find both similarities and contrasts in our thinking, our approaches, and our philosophies regarding mental health. I know expanding our understanding can do nothing but enhance our global community.