Sexual activity declines in late life but the cause has as much to do with illness and social circumstances as with the physiology of aging. Older patients welcome counsel on sexual health but because of the delicacy of the matter, physicians need to initiate the conversation and be aware of opportunities for sexual expression as well as limitations. When the focus is on intimacy and affection rather than intercourse and orgasm, older adults need not retire from sex simply because of advanced age or infirmity.
Objective: To study the tone, content, and structure of in-office discussions between psychiatrists and adults with depression and possible comorbid attention-deficitlhyperactivity disorder (ADHD). Methods: Patients with a pre-existing diagnosis of depression, but not ADHD, and screening results indicating the possible presence of ADHD, were selected. Office visits were videotaped and analyzed for tone, content, and structure, using sociolinguistic techniques. Separate post-visit interviews were conducted with patients and psychiatrists. Results: The study sample comprised 14 patients and eight psychiatrists, although data on the possibility of ADHD were available for only 13 patients. The possibility of an ADHD diagnosis was not discussed in any office visit. Psychiatrist- or patient-driven language suggesting possible ADHD symptoms occurred during five (36%) visits. In post-visit interviews of 13 patients, nine (69%) felt they had or might ha ve ADHD. In contrast, psychiatrists felt that 12 patients (92%) did not have ADHD. Nine psychiatrist-patient pairs (69%) disagreed about the possibility of ADHD. Conclusion: Psychiatrists and their patients diagnosed with depression showed low levels of agreement regarding the possibility of comorbid ADHD. Psychiatrists frequently missed or misinterpreted patient cues regarding potential ADHD symptoms, suggesting psychiatrists may need to be more vigilant in screening for ADHD in this at-risk population.
The identification ofgenetic risk factors for the familial dementias has been a productive area of scientific study, but the clinical impact for the far more common sporadic dementias has been modest at best. As a result, interest in the characterization of biomedical and psychosocial protective factors is intense as evidenced by the April 2010 National Institutes of Health (NIH) consensus conference on Preventing Alzheimer's Disease and Cognitive Decline. If genetic polymorphisms associated with exceptional longevity are associated with lessened incidence of dementia, their characterization may suggest novel pharmacologic interventions to prevent Alzheimer's disease.
I'll sleep when I die, is the attitude of millions of people who get to bed too late and get up too early, leaving insufficient time in between for adequate sleep. Getting sufficient sleep is important for the mental and physical health of all people— whether healthcare providers or patients. Unfortunately, cultural values tend to neglect the importance of sleep and society under- mines opportunities to achieve an optimum amount of sleep. Both lifestyle choices and schedules for work and school challenge the natural biological drive to sleep ∼8 hours most nights. The result is varying degrees of chronic sleep deprivation resulting in daytime sleepiness and cognitive impairment, dependence on caffeine, and an increased risk for assorted health problems. 1 .
Objective: The objective of this article is to describe the characteristics of patients with panic disorder from an emergency department by comparing them to patients with panic disorder from psychiatric settings on panic symptoms, psychiatric comorbidity, and psychological correlates of panic disorder. Methods: Eighty-four consecutive patients consulting an emergency department with noncardiac chest pain and diagnosed as having panic disorder, and 126 patients with panic disorder seen in two specialized clinics for anxiety disorders, were assessed with validated clinical interview and questionnaires. Results: Panic disorder patients recruited in the emergency department were older and reported fewer panic symptoms than their psychiatric settings counterparts. They also had less severe agoraphobic cognitions and less sensitivity to anxiety. The two samples displayed similar rates of psychiatric comorbidities and similar rates of suicidal ideation, with 24.3% to 31.3% of panic disorder patients overall having had thoughts of killing themselves. Discussion: Panic disorder patients encountered in the emergency department tend to report physical, rather than psychological, symptoms of panic. This finding could explain the extremely low rates of panic disorder recognition in the emergency department. Conclusion: Despite showing less severe panic symptoms, and sometimes no emotional orcognitive signs of fear at all, emergency department patients with panic disorder have elevated rates of psychiatric comorbidities and suicidal ideation and need adequate clinical attention.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 1 is scheduled for release in May 2013. In February2010, The preliminary draft revisions to the current diagnostic criteria became available for review and comment. Although diagnostic biomarkers and neuropsychologic criteria for dementia have yet to emerge, there are conceptual advances evident in the proposed criteria which have substantial implications for treatment. What follows is a discussion of the proposed revisions to help readers who may want to submit comments during the review period.
In 1998, the American Medical Association Scientific Counsel wrote that attention-deficit/hyperactivity disorder (ADHD) is one of the best researched disorders in medicine. Since then, rapidly emerging research coupled with increased interest by clinicians and the public have advanced the identification, diagnosis, and treatment of ADHD in patients of all ages. In treating patients with ADHD and their families, we hope that symptoms are reduced throughout the day leading to improved functioning, enhanced self-confidence, and better quality of life for all involved. Because of the volume of information, there is a need for clinicians to have rapid access to up to date reviews of clinically relevant information to assist in the accurate diagnosis and effective treatment of ADHD and associated psychiatric comorbidities. For the clinician, satisfaction comes from playing an instrumental role in facilitating this optimal outcome. This educational review presents information in brief text and tables for quick reference for the busy practitioner.
Tobacco dependence is common among people with psychotic disorders and is associated with significant morbidity and mortality. Illness, socio-demographic, lifestyle, institutional, and tobacco industry influences are all associated with this high prevalence. While many smokers with psychotic disorders are willing to quit or reduce smoking, they are often provided with limited support within the healthcare system. Numerous randomized controlled trials among smokers with psychotic disorders have demonstrated that smoking cessation interventions can be effective in the short-term, with smoking reduction a common finding. Support for smoking cessation can be offered within primary health settings, and should include adequate and longer-term pharmacotherapies combined with psychosocial counseling. Psychosocial strategies that can readily be incorporated into primary care settings include brief motivational interventions, the encouragement of social support, behavioral strategies such as avoidance of high risk situations and activity scheduling, cognitive strategies to cope with cravings and negative moods and to improve lifestyle, and relapse prevention. As smoking is a chronic and relapsing condition, numerous change attempts should be encouraged and normalized, with flexible combinations of pharmacotherapies and counseling employed.
Objective: To conduct a literature review of patient- and populationbased research on depression literacy and determine the implications of the findings for patient psycho-education. Method: The authors searched PubMed for articles published between January 1995 and January 2007; they chose English-language articles of studies based on samples drawn from the general population as well as clinical studies conducted in North America, Australia, and European countries. Results: A total of 48 published papers in referred journals (two review articles and 46 original research papers) met the inclusion criteria. Most studies examined the public’s knowledge and attitudes towards treatment of depression. To examine the ability of participants to recognize clinical depressive symptoms and attitudes towards depression and its treatment, researchers commonly used vignettes involving survey methods based on community samples. Depression literacy is generally poor among the general public and patients alike. Public opinion clearly favors the lay support system of all healthcare professionals; family physicians were identified as the preferred point of first contact. The authors found that poor knowledge of and negative attitudes towards depression influence negatively the choice of treatments and help-seeking behavior. Conclusion: There is widespread misunderstanding of the nature of depression and its causes; attitudes towards treatment are negative. More research is needed to investigate those of high-risk patient groups as well as the need for psycho-education campaigns.
he National Institutes of Health (NIH)-State-of-the-Science Conference on “Preventing Alzheimer’s Disease and Cognitive Decline” sought to review the available evidence and provide carefully reasoned recommendations. The preliminary draft statement of the conference panel found insufficient evidence to support any definitive recommendations to prevent Alzheimer’s disease or the cognitive impairment related to advancing age. Equally disappointing was the conclusion that present diagnostic criteria for both Alzheimer’s disease and cognitive decline lack the consensus necessary for uniform application and risk identification. Nonetheless, a number of promising predictors of both increased and decreased risk emerged. In addition, they overlap substantially with recommendations for the prevention of heart disease and stroke. As a result, the tentative prevention recommendations put forth by the Alzheimer’s Association remain not only the best available but the most promising as well.
Patients with advanced illness and their caregivers are intimately familiar with the experience of grief and loss. Being diagnosed with a serious illness is often the beginning of emotional and physical losses that may end with the patient's death. Along the difficult journey through illness, patients and caregivers may develop varying degrees and types of emotional distress. Depression, severe grief reactions, and demoralization are common types of disorders experienced by patients and caregivers in the palliative care setting. While commonly recognized as separate diagnostic entities, these disorders share many symptoms, making their differentiation challenging. Accurate diagnosis is crucial because of its treatment implications. This article reviews the characteristic features of these disorders in the context of palliative and end-of-life care. Assessment and non-pharmacologic treatment modalities are presented.
World health experts encourage women to breastfeed, but many primary care physicians, obstetricians, and psychiatrists are hesitant to encourage new mothers who are taking psychiatric medications to do so. Unfortunately, there are only a few casecontrolled studies on the safety of psychotropics in breastfeeding. This article outlines the benefits of breastfeeding, both for the infant and for the mother; postpartum illness and its effect on the mother and infant; and the existing data on the most commonly used psychotropics. The effect of psychotropics on the nursing infant is examined and summarized.
Attention-deficit/hyperactivity disorder (ADHD) is a common childhoodonset neuropsychiatric disorder characterized by cardinal features of inattention, locomotor hyperactivity, and poor impulse control. Research indicates that ADHD is associated with alterations in the higher cortical circuits that mediate attention and behavioral control. Given the prominent role of the prefrontal association cortex in regulating cognition and behavior through its extensive connections to sensory and motor cortices as well as subcortical structures, impairments in prefrontal function are believed to underlie many of the behavioral features of ADHD. Prefrontal cortex is sensitively modulated by numerous neurotransmitters including catecholamines, and changes in levels of dopamine-1 and norepinephrine α2A-adrenoceptor stimulation are associated with prominent effects on prefrontal function. Effective treatments for ADHD (including stimulants, atomoxetine, and guanfacine) influence catecholamine signaling in the prefrontal cortex and are believed to ameliorate ADHD symptoms via their effects on improved prefrontal cortical regulation of attention and impulse control.
arkinson's disease affects as many as 1 million Americans and with advanced age is complicated by dementia in a majority of cases. However, the recognition of cognitive impairment in Parkinson's disease is made complicated by the predominance of motor symptoms and a neuropsychiatric profile that differs from the more common dementia of the Alzheimer's type. Differentiating the decline in personal and social activities due to cognitive impairment rather than preexisting movement disorder is difficult. Several expert bodies have addressed the use of cholinesterase inhibitors for the dementia of Parkinson's disease, but the evidence base is far less substantial than that which exists for Alzheimer's disease. Although most patients with Parkinson's disease dementia should be offered a trial of anti-cholinesterase therapy, particularly those experiencing hallucinations, dramatic benefits are not common. Temporary symptomatic relief rather than disease modification is the most that can be expected. As a result, treatment should be presented as an option rather than an imperative.
Epidemiologic studies indicate that co-occurring substance use disorders and psychiatric disorders are frequently found in clinical practice. From a neurobiologic perspective, what do these two seemingly different groups of disorders have in common? Currently, several hypotheses are postulated to explain the high rates of comorbidity. Chronic alcohol and drug use may lead to neuroadaptation in the biologic systems mediating psychiatric disorders. Conversely, co-occurring psychiatric and substance use disorders (SUDs) may represent phenotypic expressions of common premorbid neurobiologic abnormalities. Similar alterations in the dopamine-mediated reward system and various neurotransmitter systems including glutamate, γ-aminobutyric acid, and serotonin are found in both SUDs and numerous psychiatric disorders. Stress and chronic distress with the resultant activation of the hypothalamic-pituitary-adrenal axis and stress system has also been implicated in the pathophysiology of both psychiatric disorders and SUDs. Better understanding the commonalities between the two groups of disorders should lead to more efficacious treatments and targeted prevention strategies.
Forgetfulness is a common complaint of people who do not get enough sleep, whether it is due to sleep deprivation from an overly busy schedule or the result of insomnia. People often find that it is more difficult both to learn and remember things when they are unable to achieve sufficient sleep on a regular basis. Although recorded observations about the benefits of sleep on memory date back to ancient Rome, recent research has provided exciting evidence related to different types of memory and the role sleep can perform in learning and memory consolidation. Research findings now suggest that different types of sleep can affect different types of memory It appears that sleep also can influence emotional aspects of our memory Some studies 1 even suggest that certain types of memory can be enhanced during sleep with instrumentation capable of promoting greater slow wave activity.
