James M. Ellison

Neuropsychiatric correlates of white matter hyperintensities in Alzheimer's disease†

To investigate the association of behavioral and psychological symptoms of dementia (BPSD) in Alzheimers disease (AD) and magnetic resonance imaging (MRI) measures of brain atrophy and white matter hyperintensities (WMH).

Depression in later life: an overview with treatment recommendations.

We have already entered a new, more exciting, and hopeful era in the treatment of late-life depression. The increasing numbers of older adults who are surviving to more advanced ages and the greater recognition of late-life depression’s prevalence and impact on quality of life emphasize how important it is to detect and treat this disorder. Our increasing repertoire of evidence-based psychotherapeutic, pharmacologic, and neurotherapeutic treatment interventions offers many treatment alternatives, allowing substantial individualization of treatment approach. Demonstration of the effectiveness of depression treatment in primary care suggests the feasibility of increasing our patients’ access to care. Growing appreciation of the pathophysiology of depression and its interrelationships with cognitive impairment may increase our ability to limit or delay certain aspects of cognitive impairment through more aggressive treatment of depression. Improved recognition and treatment of late-life depression holds great potential for improving physical and mental health in later life, reducing disability in later years, and improving quality of life.

Safety and Efficacy of Electroconvulsive Therapy for the Treatment of Agitation and Aggression in Patients With Dementia

OBJECTIVES Noncognitive behavioral disturbances including agitation and aggression frequently accompany the cognitive symptoms of dementia accounting for much of dementias morbidity, yet treatment options are currently limited. The authors examine the safety and efficacy of Electroconvulsive Therapy (ECT) for agitation and aggression in dementia patients. DESIGN Retrospective systematic chart review. SETTING McLean Hospitals geriatric neuropsychiatry unit. PARTICIPANTS Sixteen patients with a diagnosis of dementia treated with ECT for agitation/aggression during 2004-2007. MEASUREMENTS Clinical charts were rated on the Pittsburgh Agitation Scale as the primary outcome, the Clinical Global Impression scale and the Global Assessment of Functioning pre- and post-ECT. RESULTS 16 patients of mean age 66.6 ± 8.3 years were studied. Their average overall and pre-ECT lengths of stay were 59.7 ± 39.7 days and 23 ± 15.7 days, respectively. Patients received a mean of 9 ECT treatments, mostly bilateral. Patients showed significant reductions in their total Pittsburgh Agitation Scale scores from baseline after ECT (from 11.0 ± 5.0 to 3.9 ± 4.3 [F = 30.33, df = 1, 15, p < 0.001]). Clinical Global Impression scale decreased significantly (from 6.0 ± 0.6 pre-ECT to 2.1 ± 1.6 post-ECT [F = 112.97, df = 1, 15, p < 0.001]). Global Assessment of Functioning change was not significant (from 23.0 ± 4.9 to 26.9 ± 6.9 [F = 5.73, df = 1, 13, p = 0.32]). Only one patient, in whom ECT was discontinued following 11 bilateral treatments, showed no improvement. Eight patients showed transient postictal confusion, which typically resolved within 48 hours. Two patients showed more severe postictal confusion that required modification of treatment. CONCLUSIONS These results suggest that ECT is an effective and safe treatment for agitation and aggression in dementia. Further prospective studies are warranted.

A 60-Year-Old Woman With Mild Memory Impairment Review of Mild Cognitive Impairment

Many older individuals experience or demonstrate cognitive impairment that is significantly abnormal for their age and education yet beneath the threshold for a diagnosis of dementia. This mild cognitive impairment causes minimal functional impairment and is often overlooked in clinical settings, yet affected individuals are at heightened risk for a range of adverse outcomes including conversion to dementia. The case of Ms E, a 60-year-old woman with mild memory impairment and white matter lesions on magnetic resonance imaging, provides an opportunity to consider the questions that face patient, family, and clinicians when mild cognitive symptoms prompt a search for diagnosis and management options. Discussion of her case reviews mild cognitive impairment with emphasis on an evidence-based approach to evaluation and treatment, including management of comorbid medical conditions, lifestyle changes, and pharmacotherapy.

Schizophrenia and the life cycle.

We reframe the longitudinal treatment of persons with schizophrenia from the perspective of phases in adult development. This approach articulates the need for different interventions of varying intensities over the persons lifetime. The paper discusses the implications of an adult developmental perspective in managing pharmacologic treatment and psychosocial interventions, and in reallocating financial resources for improved long-term outcomes. This perspective is especially useful in the context of a comprehensive community mental health program permitting access to a continuum of services throughout the lifecycle.

Antidepressant-induced sexual dysfunction: review, classification, and suggestions for treatment.

&NA; Sexual function, an important component of quality of life, is often affected by antidepressant treatment. Reports associate antidepressant medications with a wide range of sexual disorders of desire, arousal, and orgasm, and with the occurrence of sexual pain. Fewer sexual dysfunctions have been reported with bupropion, nefazodone, and mirtazapine than with the monoamine‐oxidase inhibitors, tricyclic antidepressants, selective serotonin‐reuptake inhibitors, and venlafaxine. Sexual dysfunctions may occur in more than half of patients treated with selective serotonin‐reuptake inhibitors, but patients may not readily divulge sexual information unless a clinician is knowledgeable and proactive in assessment. Once an antidepressant‐induced sexual dysfunction is detected and its nature is characterized, an appropriate treatment intervention can be chosen in order to alleviate the sexual disorder and enhance treatment compliance. This review classifies antidepressant‐induced sexual dysfunctions, discusses assessment and differential diagnosis, and describes currently reported treatment approaches.

Description of antipanic therapy in a prospective longitudinal study

The authors present a summary scale for assessing the percentage of patients in a large longitudinal study of panic disorder who received proven effective psychopharmacologic treatment. Such a scale provides a means for assessing and comparing somatic treatments of panic disorder across medication classes. The antipanic therapy levels were applied to data on medication treatment received by 492 patients participating in a naturalistic study and reflect psychopharmacologic treatment prescribed in 11 academic centers. Results show that among patients treated by psychiatrists at major teaching hospitals only 54% of the most symptomatic groups received optimal pharmacologic treatment. Among less symptomatic patients, who nonetheless met full criteria for panic disorder with or without agoraphobia, only 43% received maximal therapy.

Mood Disorders in Later Life

about the book... Formatted as a stand-alone text, Mood Disorders in Later Life examines the varied spectrum of mood disorders encountered in older adults, including minor depressive disorders, unipolar and bipolar disorders, bereavement, vascular depression, depression with comorbid medical disorders, and depression with psychotic features. Highlighting diagnostic assessment and state of the art treatment interventions that can improve clinical outcomes, this hands-on resource explores the range of current therapeutic interventions for mood disorders in later life.

Psychopharmacologic approaches to borderline syndromes

Abstract Psychopharmacologic approaches to the treatment of patients with “borderline personality” have been aided by increasing refinement of the diagnostic term. The broadly conceived category of borderline personality organization includes numerous clinical syndromes with specific patterns of symptoms and response to medications. This paper reviews these syndromes in relationship to four psychopathologic “borders” of borderline personality disorder : schizophrenia, affective disorders, organic mental disorders, and personality disorders. Current psychopharmacologic approaches to the treatment of these syndromes are reviewed, and medication choice is discussed with respect to target symptoms. Compliance with treatment, often a problem with borderline patients, is discussed with respect to medication use.

Methamphetamine abuse presenting as dysuria following urethral insertion of tablets

Foreign bodies are inserted into the male urogenital tract for a variety of motives, and patients may present with symptoms of dysuria, urinary retention, hematuria, discharge, or priapism. Concomitant psychopathology is seen frequently, necessitating a thorough psychiatric assessment with attention to other acts of self-mutilation, suicide attempts, psychosis, or substance abuse. We report the case of an abuser of methamphetamine who inserted a sustained-release form of medication into his urethra, with resulting mechanical and pharmacological trauma.