Julie B. Penzner

Type and duration of subsyndromal symptoms in youth with bipolar I disorder prior to their first manic episode

The aim of the present study was to systematically evaluate the prodrome to mania in youth.

Lack of Effect of Stimulant Combination with Second-Generation Antipsychotics on Weight Gain, Metabolic Changes, Prolactin Levels, and Sedation in Youth with Clinically Relevant Aggression or Oppositionality

BACKGROUND Second-generation antipsychotics (SGAs) are associated with weight gain, metabolic abnormalities, sedation/sleep disturbance, and prolactin abnormalities, especially in youths. Although stimulants have opposing dopamine receptor and adverse effects, it is unclear whether stimulant co-treatment counteracts the therapeutic or side effects of antipsychotics. METHODS This was a naturalistic cohort study including 153 antipsychotic trials in youths aged 4-19 (mean, 11.3 +/- 3.0) years, started on an SGA for clinically significant aggression or oppositionality associated with oppositional defiant disorder, conduct disorder, disruptive behavior disorder not otherwise specified (NOS), impulse control disorder NOS, intermittent explosive disorder, Tourettes disorder, autistic disorder, and pervasive developmental disorder NOS. Patients underwent fasting assessments of body composition, lipids, glucose, insulin, prolactin, sedation, and general efficacy at baseline, weeks 4, 8, and 12, comparing patients co-prescribed stimulants (n = 71) with those not co-prescribed stimulants (n = 82). RESULTS Patients received risperidone (33.3%), aripiprazole (29.4%), quetiapine (18.4%), olanzapine (11.8%), ziprasidone (5.9%), or clozapine (0.7%). With and without adjustment for differences in baseline variables (sex, prior stimulant use, primary Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition [DSM-IV] disorders, co-morbid attention-deficit/hyperactivity disorder [ADHD], present in 46.3% of youths not receiving stimulants, and some body composition parameters), patients on versus off stimulants did not differ on any of the assessed outcomes (all p values > or = 0.1). CONCLUSIONS In contrast to guidelines, stimulant use did not precede or accompany antipsychotic use during the current episode of aggression/oppositionality in almost half of those youths who had aggressive/oppositional behavior and a DSM-IV diagnosis of ADHD. At the clinically prescribed doses, stimulant co-treatment of SGAs did not seem to significantly reduce antipsychotic effects on body composition, metabolic parameters, prolactin, sedation, and broad efficacy.

Mania Induced by Garcinia cambogia: A Case Series.

To the Editor: Despite that the putative mechanism of action of the weight loss supplement Garcinia cambogia is considered to be serotonergic, literature about its psychiatric effects is limited.1,2 We report 3 stable, euthymic adults whose mania emerged when they began taking G.cambogia. Case 1. Mr A, a 50-year-old man with bipolar I disorder, had been stable off medications for 6 years before presenting to the emergency department with mania. Two months prior, Mr A had begun dieting and taking 2 pills of G. cambogia daily. One month later, he developed grandiosity, irritability, pressured speech, excessive spending, increased social activity, and decreased need for sleep. He was admitted to the psychiatric unit and diagnosed with bipolar I disorder, manic, severe (DSM-5). After a 16-day hospitalization, he was discharged on olanzapine and valproic acid treatment and counseled to avoid G. cambogia. Case 2. Mr B, a 25-year-old man without a psychiatric history, presented to the emergency department with mania. He had begun dieting, exercising, and consuming G. cambogia 1–2 pills daily for 2 months prior to presentation. Within weeks of starting this regimen, he developed inflated self-esteem, grandiosity, decreased need for sleep, increased activities, excessive spending, and pressured speech. Later symptoms included paranoia and religious delusions. He was admitted to the psychiatric unit with bipolar I disorder, manic, severe, with psychosis (DSM-5). He was discharged 8 days later on olanzapine and valproic acid treatment and counseled about cessation of G. cambogia. Case 3. Ms C, a 34-year-old woman with bipolar II disorder and past selective serotonin reuptake inhibitor (SSRI)–induced hypomania, had begun dieting, exercising, and taking G. cambogia for 4–6 weeks prior to onset of symptoms, which included irritability, pressured speech, decreased need for sleep, and agitation. She saw her psychiatrist 1 month after symptom onset and was diagnosed with a recurrence of bipolar II disorder, hypomanic, moderate (DSM-5). Her symptoms remitted with low-dose lorazepam, cessation of G. cambogia, and continuation of preexisting medications (aripiprazole, bupropion, topiramate). This case series describes 3 stable patients whose manias emerged during use of Garcinia cambogia, an over-the-counter weight loss supplement. The putative mediator of G. cambogia’s weight loss effect is hydroxycitric acid (HCA), a substance with demonstrated serotonergic activity in animals and humans.2,3 HCA is thought to promote release and synaptic availability of serotonin, influencing appetite. There are 2 known case reports4,5 that suggest HCA-containing weight loss supplements may contain psychoactive serotonergic properties. One involved mania that emerged on Hydroxycut (Iovate Health Sciences International, Inc), an HCA-containing supplement.4 The other involved a patient who developed serotonin syndrome when an SSRI was combined with G. cambogia.5 Antidepressants have been theorized to promote a switch to mania through action on neurotransmitters.6 Other medical conditions and substances have also been implicated in generating symptoms and in altering the course of bipolar disorder.7–14 Our case series suggests that G. cambogia may induce mania or hypomania in predisposed euthymic individuals. Our patients were euthymic, and manic symptoms developed after G. cambogia was started. Two patients had previously diagnosed bipolar illness; the third did not. Given the multifactorial mechanisms of mania, it is impossible to establish G. cambogia as causative. Furthermore, supplements have inherent variability in dosages and ingredients. However, identifying G. cambogia as a risk is important. For the 2 patients with known bipolar disorder, it seems that G. cambogia altered the course of their disorder by precipitating episodes during stable phases. In Mr B’s case, G. cambogia either unmasked primary bipolar illness or created a substance-induced disorder. In all 3 cases, recovery included cessation of G. cambogia and usual clinical treatment. We remind clinicians of the importance of inventorying all medications, vitamins, and supplements during a patient’s psychiatric evaluation and suggest further research is needed to clarify the psychiatric effects or side effects of Garcinia cambogia.

Use of Electronic Resources for Psychiatry Clerkship Learning: A Medical Student Survey

ObjectiveThe primary aim of this study is to examine medical students’ use patterns, preferences, and perceptions of electronic educational resources available for psychiatry clerkship learning.MethodsEligible participants included medical students who had completed the psychiatry clerkship during a 24-month period. An internet-based questionnaire was used to collect information regarding the outcomes described above.ResultsA total of 68 medical students responded to the survey. Most respondents reported high utilization of electronic resources on an array of devices for psychiatry clerkship learning and indicated a preference for electronic over print resources. The most commonly endorsed barriers to the use of electronic resources were that the source contained irrelevant and non-specific content, access was associated with a financial cost, and faculty guidance on recommended resources was insufficient. Respondents indicated a wish for more psychiatry-specific electronic learning resources.ConclusionThe authors’ results suggest that a demand exists for high-quality electronic and portable learning tools that are relevant to medical student education in psychiatry. Psychiatry educators are usefully positioned to be involved in the development of such resources.

Electroconvulsive therapy for the treatment of refractory mania.

We present the case of a patient with treatment-refractory mania. The patient had been tried on numerous medications, to which she either did not respond well or on which she developed severe side effects, However, the patient improved rapidly when treated with unilateral electropercussive therapy (ECT) following a court order. We outline the legal barriers that have been raised against the use of ECT in patients with mania, who often refuse treatment, and the irony that ECT can be safer than medications for some patients. ECT is underutilized in mania but deserves more frequent consideration. (Journal of Psychiatric Practice. 2011;17:61-66).

Religious Conversion in a Psychotic Individual

The authors describe the case of a man who appeared to have psychotic symptoms, including self-injurious behavior, but who understood his own experience as a religious conversion. The symptoms, clinical course, and treatment response are described with reference to the works of Kurt Schneider and William James. Empirical studies of the attitudes of psychiatrists, psychiatric patients, and clergypersons about the relationship between religious belief and psychiatric illness are described, and various theoretical models used to understand this relationship are articulated.

Mutism in non-catatonic schizophrenia: Psychotic symptom and adaptive behavioral strategy.

Abstract Mutism in adults has a wide differential, and can be difficult to evaluate. Defined as an absence or reduction of speech, either voluntary or avolitional, mutism is typically associated with catatonia, usually in schizophrenia, but also depression, bipolar disorder, intoxication, and neurological conditions. Mutism in non-catatonic schizophrenia was common before anti-psychotic use, correlating with untreated illness. Case reports continue to appear in developing nations, but accounts of mutism in patients with advanced treatment are scarce. Here we present an unusual case of mutism in non-catatonic schizophrenia, in which it appears as both psychotic symptom and adaptive behavioral strategy.

An Ounce of Prevention: A Public Health Approach to Improving Physician Well-Being

The physician workforce is facing a crisis, with increasing numbers of physicians reporting distress, career dissatisfaction, burnout, and depression [1, 2]. Impaired well-being is a pressing issue for physicians at all career stages, ranging from medical students to practicing physicians [3, 4]. However, residents are at particularly high risk, enduring long hours, and high stress, with little control over their lives [4]. Improving physician well-being has been identified as an urgent national priority within the medical community [5]. Numerous interventions to improve physician well-being have been proposed and described in the literature. However, many interventions have not been rigorously studied, and those that have, often report only small benefits [6]. It remains unclear how effective any single intervention will be in improving physician well-being on a large scale [7]. Furthermore, educators and administrators who seek to implement well-being interventions in their own institutions may be faced with a long list of potential options, with little guidance about how to choose. Should one implement mindfulness training or burnout screening? Balint groups or increased ancillary staff? Reducedfee mental health treatment or a coaching program? As with any complex public health issue, a comprehensive and integrated approach is needed in order to make a significant impact. To our knowledge, no clear conceptual model has yet been proposed in the literature to help better describe, categorize, and organize the myriad potential interventions available to promote physician well-being.

A Woman With Major Depression With Psychotic Features Requesting a Termination of Pregnancy

Case Presentation Ms. A, a married, pregnant 31-year-old woman with a history of major depressive disorder, was admitted to an inpatient psychiatric unit with dysphoria, ruminative worries about her work performance, difficulty sleeping,doubtsaboutherpotentialtobeagoodmother, and suicidal impulses to jump out of her apartment window. On the day before admission, she impulsively punched herself in the abdomen with the hope of inducing a miscarriage. Acti ng on the advice of her out

A Multi-tiered Model for Clinical Scholarship

The Accreditation Council for Graduate Medical Education (ACGME) stipulates that all psychiatric residents need familiarity with scholarship and research [1]. However, clinical scholarship in academic settings is under pressure, with demands of quick treatment and few resources. The tension between clinical demands and academic models grows as the necessary focus on outcome and cost swells. As National Institutes of Health (NIH) support shifts towards basic science research, clinical faculty struggle to function simultaneously as funded investigators. A mentorship and infrastructure deficit ensues for psychiatric residents, making the ACGME mandate harder to fulfill [2]. We propose a coordinated model for scholarship beginning withmedical students and offering programming for residents, early career, and senior faculty, to facilitate academic scholarship. A continuum model encourages idea sharing, creates accountability, and fosters community.