CP/AACP Psychiatry Update 2021




Highlights from Past Events

2017 Current Psychiatry/AACP Conference Wrap Up

Psychiatry Update: Solving Clinical Challenges, Improving Patient Care
Hilton Chicago
March 30 - April 1, 2017

2016 Current Psychiatry/AACP Conference Wrap Up

Psychiatry Update: Solving Clinical Challenges, Improving Patient Care
Hilton Chicago
March 10-12, 2016

2015 Current Psychiatry/AACP Conference Wrap Up

Psychiatry Update: Solving Clinical Challenges, Improving Patient Care
Hilton Chicago
April 16-18, 2015

2014 Current Psychiatry/AACP Conference Wrap Up

Psychiatry Update: Solving Clinical Challenges, Improving Patient Care
Hilton Chicago
March 27-29, 2014

2013 Current Psychiatry/AACP Conference Wrap Up

Psychiatry Update: Solving Clinical Challenges, Improving Patient Care
April 4-6, 2013

2012 Current Psychiatry/AACP Conference Wrap Up

Psychiatry Update: Solving Clinical Challenges, Improving Patient Care
March 29-31, 2012

2011 Current Psychiatry/AACP Conference Wrap Up

Psychotic and Cognitive Disorders: Solving Clinical Challenges, Improving Patient Care
April 15 - 17, 2011

2010 Current Psychiatry/AACP Conference Wrap Up

Mood and Anxiety Disorders: Solving Clinical Challenges, Improving Patient Care
Sheraton Chicago
April 8 - 10, 2010

2009 Current Psychiatry/AACP Conference Wrap Up

Bipolar Disorder and ADHD: Solving Clinical Challenges, Improving Patient Care
Westin Chicago River North
April 2-4, 2009


Thursday, March 30, 2017

Essentials of Malingering Assessment
Douglas Mossman, MD, University of Cincinnati

Malingering is intentional lying with an external incentive, such as avoiding work or obtaining drugs. Dr. Mossman gave 2 examples of malingered posttraumatic stress disorder and psychosis. Although lying cannot be detected by careful examination of facial expressions or gestures, a detailed evaluation can reveal malingering. An individual who is malingering psychosis may describe symptoms, such as “I talk to voices all the time,” but clinicians never observe such behavior. Signs of malingering include using “textbook” terms for symptoms; inconsistencies in their history or symptoms; sudden onset of delusions; exaggerating; and being unpleasant, dishonest, or demanding.

Beyond Efficacy and Effectiveness: Neurotoxicity vs Neuroprotection are the REAL Differences Between Typical and Atypical Antipsychotics
Henry A. Nasrallah, MD, Saint Louis University School of Medicine

Dr. Nasrallah discussed the difference between typical vs atypical antipsychotics—the former is neurotoxic, the latter is neuroprotective. Because patients with schizophrenia experience a loss of brain volume and cerebral grey matter and increased lateral ventricle volume, consider atypical antipsychotics for their neuroprotective properties.

In several studies typical antipsychotics, such as haloperidol, have been found to be neurotoxic, causing apoptosis and decreased cell viability. Atypical antipsychotics may be beneficial for patients with schizophrenia because they:

  • stimulate production of new brain cells and increase neurotropic factors
  • reverse PCP-induced changes in gene expression and loss of dendritic spines in the frontal cortex
  • are neuroprotective against ischemic stroke damage
  • prevent oligodendrocyte damage caused by interferon gamma-stimulated microglia.

Medicolegal Hazards in the Information Age: Malpractice and More
Douglas Mossman, MD, University of Cincinnati

Dr. Mossman began by answering the question, “What should I do if a patient ‘friended’ me on Facebook?” Such online relationships can blur boundaries or risk breaching confidentiality, therefore medical organizations recommend ignoring a friend request. Telemedicine via Skype is cost effective and enhances outreach to patients in rural areas or who cannot travel to the office, but online clinical encounters lack multidimensional aspects of the interpersonal encounter and might not be HIPAA compliant. E-mail carries some of the same concerns, such as confidentially of personal information, although the practice—when employed appropriately—is supported by some medical associations, including the American Psychiatric Association.

Friday, March 31, 2017

Treatment-Resistance and Suicidality in Schizophrenia: 2 Major Management Challenges

Henry A. Nasrallah, MD, Saint Louis University School of Medicine

Patients can seem treatment-resistant because of inadequate antipsychotic dosing, smoking, substance-induced relapse, nonadherence, or a general medical condition. Dr. Nasrallah discussed how to recognize true treatment-resistant schizophrenia and rule of spurious treatment resistance. If your patient is truly treatment-resistant, what do you do when everything else fails?

Risk factors for suicide include male sex, depressed mood, substance use, and social isolation. Clozapine, the only drug FDA-approved for refractory schizophrenia and suicidality, is underutilized for such patients. Dr. Nasrallah also presented evidence for the use of adjunctive modalities, such as lamotrigine, steroids, omega-3 fatty acids, NSAIDs, antidepressants, glutamatergic agents, and rTMS, as well as psychotherapy.

New and Old Treatments for Opioid Abuse and Dependence
Mark S. Gold, MD, Washington University

Each day more than 1,000 people are treated in emergency departments for improper use of prescription opioids. But is naloxone saving lives or is overdose reversal nothing more than CPR? Dr. Gold spoke about the need for psychiatric assessment after a patient has been revived. Historically, treatment has stopped at abstinence or overdose treatment, but patients need ongoing treatment. Family therapy, vocational assistance, and psychotherapy are essential.

Dr. Gold reviewed established and newer treatments, including naloxone and naltrexone. Methadone and buprenorphine-naloxone can be effective for adherent patients who abuse only one drug. Naltrexone gives patients time to get their lives on track. Probuphine has comparable efficacy with buprenorphine-naloxone and methadone.

Impact of a Personality Disorder in Management of Comorbid Disorder
Donald W. Black, MD, University of Iowa

Personality disorder (PD) indicates patterns of long-term functioning and are not limited to episodes of illness. Abnormal personality traits are common among the general population, but are not considered a personality disorder unless they are inflexible, maladaptive, persisting, and cause distress either for the patient or the family. There are few cases of “pure” PDs without a comorbid psychiatric disorder. Personality disorders are not as stable as once understood; they wax and wane in response to stressors or depressed mood or anxiety. When a PD is comorbid with another disorder, patients are less likely to respond to medication and to experience remission from the comorbid psychiatric disorder.

Evaluation and Treatment of Patients Who Abuse Methamphetamine or Cocaine

Mark S. Gold, MD, Washington University

There are no FDA-approved medications or advancement in treatment for cocaine overdose—primary treatment is still ice baths. When assessing cocaine use, consider the route of ingestion and duration of use, which influence severity. Stimulants, whether methamphetamine or cocaine, cause changes in dopamine that are difficult to reverse. Substitute stimulants, such as modafinil, or vaccines have been proposed for cocaine abuse, but the evidence is not robust. Methamphetamine produces a schizophrenia-like illness, but antipsychotics are not effective. Naltrexone and bupropion showed some efficacy but was not statistically significant. There are no effective treatments for overdose or relapse prevention other than traditional group and residential treatment approaches.

Risks in Using Cannabis
Kevin Hill, MD, MHS, McLean Hospital

Although only 9% of Cannabis users become dependent, Dr. Hill recommended talking to all patients who use Cannabis about the risks, such as problems with work, school, and relationships. When treating patients with Cannabis use disorder, explore reasons that the individual would want to stop using Cannabis, take a careful history, and most importantly, build a good therapeutic alliance.

The most robust data for medical Cannabis is for chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis; however, there are more than 70 indications among the 28 states that allow its use. Dr. Hill suggests having a written policy, engage in conversation about why the patient wants medical Cannabis, be open to evaluating such a patient, and consider treating the patient’s symptoms with traditional modalities.

How Providers can Help Women During Pregnancy
Marlene P. Freeman, MD, Massachusetts General Hospital

Dr. Freeman discussed the important role mental health providers play in helping women during pregnancy decrease medical and obstetrical risks, such as nutrition and maintaining a healthy weight. Because one-half of pregnancies in the United States are unplanned, consider medications that are compatible with pregnancy, and recommend omega-3 fatty acids and lifestyle changes such as diet.

To diagnose premenstrual dysphoric disorder, Dr. Freeman recommends asking your patient to document and rate daily moods using a mobile app or calendar. In perimenopause, the risk of depression increases because estrogen has antidepressant effects. Although, there are no guidelines for treating depression in women in perimenopause, consider serotonergic antidepressants, supplements such as omega-3 fatty acids, isoflavones, and black cohosh, and sleep aids for patients with insomnia—a common feature of menopause.

ADHD, Bipolar Disorder, and Depression in Children
Jeffrey R. Strawn, MD, FAACP, University of Cincinnati

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) may share an underlying biological etiology, Dr. Strawn explained. Shared risk factors include in utero events, dietary factors, and genetics. Differentiating ADHD from BD depends on the developmental stage of the patient. Symptoms overlap, which could lead to overdiagnosis of ADHD in youths with BD.

Dr. Strawn discussed how children with depression might display mood lability and irritability, rather than verbalizing feelings because they do not use language effectively until age 7. Children may have somatic symptoms early and irritability might decrease into adolescence. Anxiety disorder in children emerges early—usually as a phobia—around age 12 to 14, with an increase in onset of depressive disorders. Dr. Strawn reviewed screening tools to diagnose and track anxiety symptoms, as well as the pros and cons of pharmacological treatments.

Find Underyling Problems in Patients with Psychotic Disorders
George T. Grossberg, MD, Saint Louis University

Psychotic symptoms could be common in older adults; therefore it is important to evaluate whether these symptoms cause emotional suffering or impairment in daily function. Dr. Grossberg recommended that when treating psychotic disorders in geriatric patients to first evaluate and treat underlying medical problems and identify offending medications or environmental or psychosocial triggers, then consider psychosocial or environmental interventions. Consider antipsychotics for patients who are experiencing severe emotional distress or those who pose a high safety risk. If antipsychotics are necessary, pick an agent based on side effects, “start low, go slow,” and discuss the risks and benefits with the family.

Role of Psychiatrists in Long-term Care Facilities
George T. Grossberg, MD, Saint Louis University

In his presentation on the role of psychiatrists in long-term care facilities, Dr. Grossberg described common disorders including the behavioral and psychiatric symptoms of dementia, as well as risk for depression. Overprescribing is common in long-term care facilities; therefore when considering a patient’s medication regimen, often less is more. Dr. Grossberg also discussed common undertreated or undercorrected physical health problems, including hearing or vision deficits, obstructive sleep apnea, and malnutrition.

Saturday, April 1, 2017

Treating Somatizing Patients
Alexander W. Thompson, MD, MBA, MPH, University of Iowa Carver College of Medicine

Somatizing patients experience symptoms all of the time, whether a headache or nausea, but most symptoms do not have an organic cause, and they might seek treatment for any or all symptoms. The goal of treating somatizing patients is to not harm them with unneeded workup and treatment. Dr. Thomspon recommends providing a letter to the patient’s primary care physician with your recommendations, which can reduce medical costs and improve physical function. Although there are no clear pharmacotherapies, cognitive-behavioral therapy focused on health and anxiety can help.

Alexander W. Thompson, MD, MBA, MPH, University of Iowa Carver College of Medicine
Fatigue experienced by patients with chronic fatigue syndrome is unrelenting, is not the result of ongoing exertion, and is unrelieved by rest. When approaching a patient with extreme fatigue, start with a thorough evaluation in collaboration with a primary care physician, Dr. Thompson said. Establish a rapport with the patient, limit iatrogenic harm, and treat chronic fatigue as you would any chronic condition. Rintatolimod and valganciclovir have showed some evidence of benefit, and graded exercise therapy has shown success.


Thursday, March 10, 2016

Successful Aging
George T. Grossberg, MD, Saint Louis University

Dementia is the result of many underlying pathological processes, some that can be changed, others that cannot. Research indicates that interventions that are good for cardiovascular health, such as addressing hyperlipidemia, blood pressure, and diabetes, also are beneficial for the brain, possibly by increasing blood flow and oxygen to the brain. Moderate use of alcohol and caffeine could be beneficial for cognitive function. Vitamins, such as D, B complex, E, and C, might slow cognitive decline, but won’t stop it. Recommend adherence to a Mediterranean diet, physical activity, and mental exercises such as learning a new language or playing games. Ask patients about head injuries, specifically if they have ever experienced a concussion and lost consciousness. Non-modifiable risk factors include genetics and adverse early life experiences.

Psychopharmacology and Pregnancy: The New Labeling Changes and Implications for Clinical Practice
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-half of pregnancies in the United States are unplanned and many women have experienced psychiatric illness before pregnancy. Therefore, clinicians need to consider the reproductive safety profile of psychotropics when treating women of reproductive age. The FDA letter categories for pregnancy risk often were based on animal, not human, data, and didn’t address the risk of untreated psychiatric illness or the context in which psychotropics are clinically necessary. New FDA labeling changes that were rolled out in 2015 are focused on human data, includes information about background rates of adverse events during pregnancy, and will be updated as new information becomes available in postmarketing studies (older letter-based categories will be phased out).

Anxiety Disorders in Women Across the Lifecycle
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-third of women will meet criteria for an anxiety disorder during their lifetime, and symptoms can become worse during pregnancy and the postpartum period. Postpartum obsessions and psychosis can be difficult to distinguish, but the key is insight. Psychotherapy is first-line treatment for mild to moderate anxiety during pregnancy, but medication plus psychotherapy is indicated for severe cases. Antidepressants are considered compatible with breast-feeding, although the long half-life of fluoxetine means higher concentrations in breast milk. During menopause, women with preexisting anxiety may be more susceptible to the development of anxiety disorders. Serotonergic antidepressants, as well as gabapentin, have evidence of efficacy for hot flashes. A diagnosis of premenstrual dysphoric disorder (PMDD) indicates significant psychiatric morbidity that interferes with function, not an underlying psychiatric disorder that gets worse premenstrually. Ask patients to track their moods, especially while they are trying different treatments. Treating PMDD with serotonergic antidepressants has been well researched.

Mild Cognitive Impairment: “Senior Moments” and DSM-5
George T. Grossberg, MD, Saint Louis University

Subjective cognitive impairment (SCI) is a prodrome to mild cognitive impairment (MCI), which is a prodrome to Alzheimer’s disease (AD), although not all patients with MCI convert to AD. Taking a thorough history with the patient and family is the most important part of the dementia workup, which also includes a thorough physical and neurologic exam and neuropsychological assessment. Earliest recognition is possible with biomarkers, but their use is not practical in clinical practice. Depression and anxiety can mimic SCI, which points to the importance of assessing for psychiatric illness. There are no FDA-approved treatments for SCI or MCI, but diet and lifestyle modifications can slow progression.

Innovative Treatments of Anxiety, Part 1 (Use of Benzodiazepines)
Mark H. Pollack, MD, Rush University Medical Center

Benzodiazepines are effective, well-tolerated, have a rapid onset of action, and can be used as needed for situational anxiety, although they are associated with sedation, psychomotor impairment, physical dependence, and adverse interactions with alcohol. All benzodiazepines are effective for generalized anxiety disorder, but for maintenance treatment, consider a longer-acting agent. Consider combining benzodiazepines with antidepressants for rapid relief of anxiety while antidepressants begin to work, to treat residual anxiety, or to decrease early anxiety associated with antidepressant treatment. Reported increase in overdose mortality likely is conflation with other drugs of abuse, particularly opioids. Dr. Pollack ended his presentation by reviewing the use of tricyclic antidepressants, monoamine oxidase inhibitors, and other antidepressants for anxiety disorders.

Innovative Treatments of Anxiety, Part 2 (Other Standard and Novel Therapeutic Approaches)
Mark H. Pollack, MD, Rush University Medical Center

Antipsychotics are used off-label as monotherapy and as an adjunct to selective serotonin reuptake inhibitors for anxiety, although the evidence of efficacy is mixed and these agents are associated with weight gain. Anticonvulsants have shown some efficacy for anxiety, especially posttraumatic stress disorder (PTSD). Gabapentin has been used for social anxiety; lamotrigine for PTSD. Prazosin, an antihypertensive, can improve sleep and decrease nightmares in PTSD. Using hypnotics to treat sleep disturbances after a traumatic event could reduce the likelihood of developing PTSD. Propranolol has been studied, but is not considered effective for preventing PTSD. Cognitive-behavioral therapy (CBT) is effective for anxiety, may have a lower relapse rate than pharmacotherapy, and has few adverse effects; however, it is more difficult to administer than medication and may not be widely available or affordable. Dr. Pollack recommends integrating CBT with pharmacotherapy. Researchers are examining augmenting CBT or exposure therapy with d-cycloserine.

Treatment of Chronic Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital

Dr. Nierenberg presented a model of thought patterns often seen in chronically depressed patients, to help them end the cycle of negative rumination and increase cognitive flexibility. He described rumination as a deficit in switching from internal to external stimuli and a failure of stopping and forgetting negative experiences and feelings. In this model, cognitive rigidity and inability to switch cognitive networks is the basis of depressive thoughts.

Friday, March 11, 2016 

Subtypes of Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital, Alexian Brothers Behavioral Health Hospital for Violence Prevention Clinic/Program and ADHD Clinic

Depression, with its highly variable presentation and “wide network” of psychological, behavioral, and somatic symptoms, always presents a diagnostic and therapeutic challenge. Dr. Nierenberg reviewed symptoms and subtypes of depression across demographic groups and the key contributory role of stress. Depression is highly comorbid, making it complicated to manage. Duration of depressive episodes also is highly variable, with some patients experiencing episodes that last as long as 14 weeks. Stress, in combination with genetic factors, affects the brain by increasing neuronal atrophy and suppressing neurogenesis and the expression of brain-derived neurotrophic factor (BDNF)—potentially putting patients into a “ruminative loop” that resists attempts to “move forward” toward recovery. Antidepressants exert their therapeutic influence in part by blocking suppression of BDNF.

Overview of Autism Spectrum Disorder
Robert L. Hendren, DO, University of California, San Francisco

Prevalence of autism has been increasing and is more common in males than females; various theories about the increased prevalence including better recognition and diagnosis, environmental toxins, and epigenetic processes. Up to 25% of autism cases can be attributed to genetics, but researchers have not pinpointed a single gene. To attempt to prevent autism, ask expectant mothers about environmental toxins in their homes and workplaces; encourage extended breastfeeding; and limit antibiotics and acetaminophen. Most programs for individuals with autism focus on early interventions (18 to 24 months) when brains are more plastic, but later interventions during adolescence can be valuable as brains continue to grow and change and patients learn new skills.

Comorbidity of Schizophrenia and Substance Abuse
Henry A. Nasrallah, MD, Saint Louis University

Approximately one-half of patients with schizophrenia have comorbid substance abuse, including nicotine, alcohol, Cannabis, and other substances, a rate that is approximately 3 times higher than in the general population. Drugs of abuse that directly increase dopamine transmission in the nucleus accumbens produce a “high” as well as psychotic symptoms. Clozapine, although usually used only for refractory patients, might be helpful in reducing substance abuse; case reports include alcohol, cocaine, nicotine, and polydrug use. Risperidone may be helpful, but only 12% of drug abusing patients taking risperidone achieved abstinence compared with 54% with clozapine. Naltrexone has evidence of efficacy for alcohol abuse. Evidence is mixed or insufficient for olanzapine, ziprasidone, aripiprazole, and anticonvulsants.

Overview of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

Posttraumatic stress disorder (PTSD) is a conditional diagnosis because trauma exposure is required. Dr. North described the DSM-5 criteria for PTSD and pointed out that distress does not necessarily mean a patient has PTSD. Avoidance and numbing symptoms are indicators of PTSD; intrusion and hyperarousal symptoms are common among those who have experienced a trauma, but are not a strong indicator of illness in the absence of avoidance/numbing symptoms. Comorbid MDD or substance use is associated with PTSD but not with trauma exposure, therefore PTSD, not trauma, might be a causal risk for other disorders. Substance use disorders often are present before the trauma exposure, meaning that individuals might use PTSD as a way to rationalize their substance use.

Neuroinflammation and Oxidative Stress in Schizophrenia and Mood Disorders: Biomarkers and Therapeutic Targets
Henry A. Nasrallah, MD, Saint Louis University

Evidence suggests that inflammation is one of the earliest stages of the schizophrenia syndrome and could be through infections during pregnancy, head injury, stress response, or autoimmune disorders. Stress will activate microglia, which are the resident macrophages of the brain and players in innate immunity, and prompt these cells them to release cytokines and free radicals, which lead to neurodegeneration, decreased neurogenesis, and white matter abnormalities. Schizophrenia is associated with increased microglia activation. Clozapine protects neurons from inflammation by inhibiting microglial overactivation. Adjunctive anti-inflammatory drugs or omega-3 fatty acids could enhance the efficacy of antipsychotics or prevent conversion to psychosis in individuals at risk.

Clinical Management of Autism Spectrum Disorders: What Happens Over Time/Borderline Intellectual Functioning
Robert L. Hendren, DO, University of California, San Francisco

Combine types of treatments, such as behavioral interventions, speech and language therapy, and pharmacotherapy, to best serve patients with autism. Evidence of effectiveness of stimulants for patients with autism is mixed; fluvoxamine and sertraline have shown improvement in aggression and social relations. Alpha-adrenergic agonists could help relieve anxiety, but studies are limited. Risperidone and aripiprazole have FDA indications for autism, but are associated with adverse effects. Several biomedical treatments, such as omega-3 fatty acids, melatonin, probiotics, vitamin D3, methyl B12, oxytocin, restrictive diets, digestive enzymes, and choline, have evidence for use in patients with autism.

Management of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

The pathology of PTSD is thought to be related to abnormal neurobiological processing of acquired fear responses. Psychotherapy and pharmacotherapy have demonstrated effectiveness in PTSD, but it is unclear if either modality alone or combined is better; treatment choice should be guided by patient preference. Sertraline and paroxetine have FDA indications for PTSD, but all selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are considered first-line agents. Prazosin is effective for nightmares and sleep disturbances. Sedative-hypnotics and benzodiazepines can relieve specific symptoms, such as anxiety or insomnia, but do not address all PTSD symptomatology. Cognitive processing therapy and prolonged exposure therapy have the best evidence of efficacy.

Saturday, March 12, 2016

Managing the Difficult Child
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain reviewed diagnostic criteria for oppositional defiant disorder (ODD), conduct disorder (CD), and disruptive mood dysregulation disorder, which is new in DSM-5. Disruptive behavior disorders often are comorbid with other psychiatric disorders, and there is symptomatic overlap between attention-deficit/hyperactivity disorder (ADHD) and ODD. Assessment of aggressive behaviors begins with a thorough history that includes a description of the aggression; responses by parents, caregivers, teachers, and school staff; and quantifying the aggression using a rating scale. Pharmacotherapy of aggression includes atypical and typical antipsychotics, stimulants, anticonvulsants, lithium, alpha-2 agonists, and beta blockers. Treatment should be individualized and guided by underlying psychiatric illness.

General Overview of Sleep Disorders
Thomas Roth, PhD, Henry Ford Hospital

Many people who experience excessive daytime sleepiness often are seen for a depression workup. Narcolepsy with cataplexy (loss of muscle tone) is associated with a hypocretin deficiency, and is an autoimmune disease. Obstructive sleep apnea is more common in men than women, and is associated with older age and obesity; treatment is continuous positive airway pressure device. Restless leg syndrome is characterized by an irresistible urge to move, often during the evening, which can interfere with sleep and is treated with dopaminergic medications, benzodiazepines, opioids, and anticonvulsants. Periodic leg movements of sleep are characteristic leg movements that occur during sleep. Patients with REM behavior disorder act out their dreams while sleeping; treatment often is clonazepam.

Comorbid ADHD with Substance Abuse
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain explored the strong connection/predictability between ADHD and lifetime nicotine, marijuana, cocaine, and other substance use, although this connection can’t be shown definitively for alcohol use because alcohol is so widely used across all demographic groups. ADHD can be seen as a reward deficiency syndrome, which is the breakdown of the reward “cascade”—the patient is not getting rewarded by typically rewarding activities, which leads to impulsivity, other clinical correlates, and addictive behaviors. Neurobiology of ADHD and substance use disorder (SUD) (sustaining attention, motivation) is similar; genetic influences in common have been identified in studies. Dr. Rostain described the significant problem of illicit—ie, nonmedical, no Rx—stimulant use in school settings, and how such illicit stimulant use also correlates with abuse of alcohol and use of Cannabis and other substances. As for treatment, he emphasized that options for the combined disorders are limited and not fully effective. Methylphenidate plus cognitive-behavioral therapy combo is not very effective for treating comorbid ADHD and SUD, although some improvement in ADHD symptoms has been shown.

How to Treat Patients with Insomnia
Thomas Roth, PhD, Henry Ford Hospital

Insomnia can be considered a disorder of hyperarousal; patients “can’t shut their brain off.” An important criterion for insomnia is that sleeplessness occurs despite adequate opportunity and circumstances for sleep; otherwise, the problem is just considered poor sleep. Dr. Roth recommends performing a thorough sleep hygiene assessment using the mnemonic LEARNS (Light, Environment, Activity, Routine, Napping, Substances). Behavioral interventions include stimulus control therapy, sleep-restriction therapy, relaxation therapy, and cognitive therapy for insomnia. All FDA-approved benzodiazepine receptor agonists work on GABAA receptors; therefore, the difference among them is half-life. Suvorexant, an orexin agonist, targets the brain’s arousal system and improves sleep onset and sleep maintenance.


Thursday, April 16, 2015

Recognition and Diagnosis of Adult ADHD
Anthony L. Rostain, MD, MA, University of Pennsylvania
Perelman School of Medicine

Attention-deficit/hyperactivity disorder (ADHD) is a lifespan disorder that is "everywhere," Dr. Rostain beganâ€"including in adults and even "seniors." This means that the disorder "is not a diagnosis of exclusion," and that "comorbidity is the rule," including learning difficulties. Among adults, the focus of symptoms and management is on executive dysfunction and its characteristics: difficulty multitasking, problems keeping commitments, and excessive reliance on help from others. Inattention and disorganization are hallmarks of adult ADHD, and become worse as environmental demands (work, home) increase; hyperactivity decreases with age. Dr. Rostain recommends ruling out other causes of a patient's symptoms when an adult self-reports ADHD, including transient stressors, medical conditions, psychiatric disorders, and malingering.

Management of Borderline Personality Disorder
Donald W. Black, MD, University of Iowa

Dr. Black reviewed DSM-5 criteria for borderline personality disorder (BPD) and offered tips for avoiding misdiagnosis, including obtaining collateral information and using rating scales. Co-occuring disorders, such as depression and substance abuse, are common. Treatment for BPD patients includes psychotherapy (individual or group), medication, and lifestyle changes. Psychotropics treat symptoms of depression, anxiety, hostility, and impulsivity of BPD but not the fundamental nature of the disorder. When establishing a patient's treatment plan, consider the stage of illness, evaluate for any co-occurring disorders, and ask the patient what he (she) wants from treatment.

Pharmacological Treatment of Adult ADHD
Anthony L. Rostain, MD, MA, University of Pennsylvania Perelman School of Medicine

Dr. Rostain began by discussing the neurobiological basis of ADHD, which guides pharmacotherapy. He reviewed the response rate of FDA-approved agents for ADHD, including stimulants, atomoxetine, and alpha-adrenergic agonists. Best response is seen with stimulants, but some patients improve with bupropion and tricyclic antidepressants (TCAs). Employ a multimodal treatment approach, Dr. Rostain recommended, which should include psychoeducation and environmental restructuring, because, as he says, "Pills don't teach skills." He also reviewed strategies for treating ADHD in patients who have a comorbid disorder, such as bipolar disorder, major depressive disorder, or substance abuse.

Advances in the Diagnosis and Treatment of Psychotic Depression
Anthony J. Rothschild, MD, University of Massachusetts Medical School

Patients with psychotic depression meet criteria for major depressive disorder but also have delusions or hallucinations. Diagnostic issues include increased guilt, cognitive impairment, paranoia, and increased hopelessness. Dr. Rothschild reviewed methods for differentiating psychotic depression from schizophrenia, posttraumatic stress disorder, obsessive-compulsive disorder, and body dysmorphic disorder. There are no FDA-approved medications for psychotic depression, Dr. Rothschild explained; however, evidence shows that the combination of an antidepressant and an antipsychotic is superior to monotherapy with an agent from either class. In addition, he noted, studies show a high response rate with electroconvulsive therapy (ECT).

How to Address Treatment-Resistant Depression and Residual Symptoms in Depression
Anthony J. Rothschild, MD, University of Massachusetts Medical School

Return of symptoms after initial remissionâ€"while the patient is still taking an antidepressantâ€"is considered tachyphylaxis, or "poop out." Residual symptoms, when a patient meets criteria for remission but still has troubling symptoms, is a different phenomenon, although symptoms can overlap. First, Dr. Rothschild advised, ensure that patients are given an adequate trial of an antidepressant. Options are similar when tachyphylaxis or residual symptoms are present: switch drugs or add augmentation therapy, such as lithium, thyroid hormone, or an atypical antipsychotic. Data on the efficacy for bupropion and buspirone are not strong. For treatment-resistant depression when a patient does not respond to 3 adequate antidepressant trialsâ€"consider ECT or rTMS, if available, or a monoamine oxidase inhibitor or a TCA.

Treatment of Antisocial Personality Disorder
Donald W. Black, MD, University of Iowa

Dr. Black defines antisocial personality disorder (ASPD) as a disorder of lifelong, serial misbehavior, one characterized by impaired relationships, aggressive behavior, non-aggressive delinquent behavior, manipulation, and a disturbing lack of conscience. There is no standard treatment for ASPD, and no FDA-approved medications; however, potential treatments have not been adequately studied, he pointed out. Cognitive-behavioral therapy might be appropriate in mild cases; some patients benefit from specific programsâ€"for example, ones that address drug or alcohol addiction or anger, although evidence is limited. When treating ASPD patients, Dr. Black concluded, be mindful of high attrition, possible misuse of prescribed medications, and drug-drug or drug-alcohol interactions.

Bipolar Disorder and Suicide
Philip G. Janicak, MD, Northwestern University Feinberg School of Medicine

Bipolar disorder is associated with the highest risk of suicide and increased lethality among all psychiatric disorders. Lithium has evidence of an anti-suicidality effect and may reduce suicide by decreasing relapse, aggression, and impulsivity. An FDA advisory on increased risk of suicidality with anticonvulsants was based on data about patients with epilepsy, not bipolar disorder. Second-generation antipsychotics, including olanzapine, quetiapine, and lurasidone, have been shown to be effective for bipolar depression. Avoid antidepressants if possible; if you must prescribe one, reassess the need for the drug often. Several psychotherapy modalities have evidence supporting their use in bipolar disorder.

Friday, April 17, 2015

Paradigm Shifts in the Treatment of Schizophrenia
Henry A. Nasrallah, MD, Saint Louis School of Medicine

Dr. Nasrallah offered enlightening historical touch-points on how psychiatry's understanding of, and its approach to, schizophrenia have changed in the past 50 years. His goal? To challenge practitioners to rethink ideas about the disorder and how they care for affected patients. From a laundry list of comparative shifts, here are a few of Dr. Nasrallah's "then" and "now" observations:

  • The old paradigm was: Clinical and functional deterioration are inevitable in schizophrenia. The new paradigm is: Complete remission and restoration of function are feasible in many patients when they are fully adherent to the treatment plan.
  • The old: Long-acting injectable (LAI) antipsychotics are a last-resort treatment, to be prescribed after a patient is stabilized. The new: Use LAI antipsychotics early in the course.
  • Old: Begin treatment when psychosis appears. New: Work to prevent conversion to psychosis.
  • Old: The disorder is considered a consequence of neurochemical dysregulation. New: Impaired neuroplasticity is to blame.
  • Old: Treatment is a matter of trial and error. New: We can apply pharmacogenomics to predict a patient's response to various drugs and thus increase the likelihood of therapeutic success.

Psychosis Spectrum Disordersâ€"Including a Live Patient Interview
Henry A. Nasrallah, MD, Saint Louis School of Medicine

There are many pathways to psychosis and several psychotic disorders other than schizophrenia, including schizoaffective, delusional disorder, and psychotic disorder caused by a general medical condition. Dr. Nasrallah listed symptom clusters in psychosis beyond positive and negative symptoms, including neuromotor symptoms, mood symptoms, and neurocognitive deficits. Development of schizophrenia is multifactorial and involves risk genes and environmental factors seen before conception, during birth, and in early childhood; good prenatal care is the best way to prevent schizophrenia, Dr. Nasrallah noted. Several general medical conditions can produce schizophrenia-like psychosis, including some CNS disorders, toxins, autoimmune diseases, infectious diseases, and chromosomal abnormalities. The session concluded with a live interview with one of Dr. Nasrallah's patients, whose schizophrenia is in remission with clozapine.

Bipolar Disorder and Substance Abuse
Philip G. Janicak, MD, Northwestern University Feinberg School of Medicine

Drug abuse can mask signs and symptoms of bipolar disorder, which can delay diagnosis. Commonly abused substances are nicotine, alcohol, Cannabis, and cocaine; polysubstance abuse is the rule. Bipolar disorder and substance abuse share common mechanisms: impulsivity, poor modulation of motivation and response to reward, and behavioral sensitization. Treatment approaches should be flexible. Dr. Janicak reviewed the evidence for using anticonvulsants, antipsychotics, and bupropion for alcohol, Cannabis, and cocaine abuse; there are no data on treating opioid abuse. He also discussed the evidence for using naltrexone, acamprosate, disulfram, and varencline, as well as psychotherapeutic options, to treat substance abuse. Dr. Janicak encouraged clinicians in the audience to treat substance abuse in bipolar disorder patients themselves, instead of referring them to a subspecialist.

Mood Disorders in Pregnancy
Marlene P. Freeman, MD, Massachusetts General Hospital

Untreated psychiatric disorders increase obstetrical complications, possibly through decreased self-care or increased stress. For mild or moderate depression, psychotherapy might be sufficient treatment; but for severe cases, medication is the first-line approach. Dr. Freeman advises that clinicians select medications based on known safety information, patient preference, and the previous course of illness. Results of studies that lasted 4 to 5 years do not show major long-term adverse effects of antidepressant exposure on neurodevelopment or neurobehavior. When treating patients for bipolar disorder, valproate is associated with an increased risk of adverse cognitive and neurodevelopmental effects in infants compared with other anticonvulsants; evidence suggests that lamotrigine is a safer option. The research does not show an increased risk of major malformations with second-generation antipsychotics.

Bipolar Depression: Presentation, Diagnosis, and Treatment in the Outpatient Psychiatric Practice Setting
Gustavo Alva, MD, ATP Clinical Research, Costa Mesa, California
Gregory Mattingly, MD, St. Charles Psychiatric Associates, St. Charles, Missouri

Bipolar depression often is misdiagnosed as major depressive disorder, perhaps because depression, not mania or hypomania, is the primary mood symptom. In a luncheon symposium sponsored by Sunovion Pharmaceuticals, Inc., Drs. Alva and Mattingly reviewed the efficacy, safety, and tolerability for lurasidone for bipolar depression.

Menopausal Depression and Premenstrual Dysphoric Disorder
Marlene P. Freeman, MD, Massachusetts General Hospital

Most women have premenstrual symptoms; a minority have a full-blown syndrome, now known as premenstrual dysphoric disorder (PMDD). This is not an existing mood disorder that becomes worse premenstrually. Clinician and patients should track the temporal relationship of symptoms on a calendar for a few months. Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine have been well studied and are effective compared with placebo, but don't help all patients with PMDD. Consider flexible dosing strategies with SSRIsâ€"perhaps daily use, a higher dosage premenstrually, and as-needed administration. Start with an oral contraceptive or SSRI; if symptoms don't respond, add the other. Serotonergic antidepressants have been shown helpful for hot flashes and depressive symptoms in perimenopause. Dr. Freeman reviewed the evidence for using complementary and alternative therapies for menopausal symptoms and hot flushes.

Tobacco Cessation in the Seriously Mentally Ill Patient
Robert M. Anthenelli, MD, University of California, San Diego

Smoking contributes to excess mortality in seriously mentally ill patients as a result of such tobacco-related illnesses as heart disease, lung disease, and cancer. Overall improvement in mental health as well as physical health is seen when a patient stops smoking. All nicotine replacement products are effective, but patients often don't use them long enough or correctly. Begin sustained-release bupropion 1 or 2 weeks before quit date; maintain the dosage for 1 to 12 weeks after quit date and consider maintenance therapy for as long as 6 months. Varenicline is superior to placebo and bupropion, but is known to have gastrointestinal and sleep disturbance adverse effects. Quitting smoking can increase the blood level of some psychotropics, meaning that you might need to reduce their dosage. It is best to begin smoking cessation when patients are mentally stable, when motivated, and stable on their medications.

Current Trends in Substance Abuse
Robert M. Anthenelli, MD, University of California, San Diego

Drug misuse is faddish. Fentanyl and fentanyl analogues are 100 times more powerful than morphine; ingestion of even a minuscule dose can be fatal. Synthetic cannabinoids primarily are a problem among adolescents; they are more dangerous than marijuana and are associated with aggressive and suicidal behaviors. A standard toxicology screen will not detect synthetic cannabinoids. E-cigarettes are considered by users to be safer than tobacco cigarettesâ€"and probably areâ€"but they still put patients at risk of nicotine addiction. There are no safety data on e-cigarettes; the devices might contain potentially harmful chemicals and potentially toxic nicotine levels. There also are insufficient data on whether e-cigarettes are an effective smoking cessation aid. Dr. Anthenelli reported that topiramate is "the best medication I've used" for alcohol abuse disorder. The drug is not FDA-approved for this use, but has been used in a number of studies with positive outcomes.

Saturday, April 18, 2015

Helping Patients with Mental Illness Lose Weight
Robert M. McCarron, DO, University of California, Davis

Psychiatrists are well positioned to help patients lose weight because of their psychotherapeutic background. Best treatment strategy is diet plus exercise plus behavioral modification. Dr. McCarron recommends keeping it simple and telling patients to only consider calories of foods, and not to worry about sodium or fat content. Ask patients "How many minutes a day of exercise can you do?" but recommend that patients walk for 30 minutes a day at 4 mph, 5 days per week, which will help patients lose 1% to 3% of body weight. For treatment-refractory obese patients, consider medications such as bupropion, orlistat, lorcaserin, topiramate, or metformin; for those with a BMI 40, recommend bariatric surgery.

Advanced Topics in Bipolar Depression: Differential Diagnosis, Breakthrough Depression, and Partial Response
Andrew J. Cutler, MD, Florida Clinical Research Center, Bradenton, Florida
Joseph F. Goldberg, MD, Icahn School of Medicine at Mount Sinai
Martha Sajatovic, MD, University Hospitals Case Medical Center

Prominent depression differentiates bipolar depression from unipolar depression with comorbid attention-deficit/hyperactivity disorder, which have overlapping symptoms. The panelists discussed strategies for managing a patient with breakthrough bipolar depression and optimizing outcomes in patients with partial response, in a symposium supported by an educational grant from Sunovion Pharmaceuticals, Inc.

Primer on Late-Life Anxiety Disorders
George T. Grossberg, MD, Saint Louis University

Dr. Grossberg reviewed the evidence for generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and posttraumatic stress disorder. Older patients with cardiovascular disease, cancer, Parkinson's disease, diabetes, GI disorders, or chronic obstructive pulmonary disease are at high risk of anxiety symptoms. In a study of centenarians, predictors of anxiety are worse health perception, financial concerns related to medical expenses, higher number of medical conditions, and loneliness. Secondary anxiety is prevalent in Alzheimer's disease; the condition can present as fidgeting, pacing, anger, or agitation, and can be prompted by a change in routine. Acute, new-onset anxiety symptoms should trigger a complete medical evaluation, including a review of medications, supplements, and substance use. In geriatric patients, minimize use of benzodiazepines and avoid anticholinergics.

The Growing Problem of Substance Abuse in Geriatric Patients
George T. Grossberg, MD, Saint Louis University

Some older patients who abuse substances took drugs as young adults and never gave them up; others have rediscovered drugs in later life. Potential indicators of alcohol abuse in older patients are changes in cognition, mood, memory, hygiene, or sleep. Substance abuse in older adults frequently is comorbid with depression or bereavement, anxiety, and adjustment disorders. Dr. Grossberg recommends addressing the topic directly with patients. Although there are few data to guide treatment, prompt detection and appropriate treatment can improve the quality of life of older adults and their family.

Managing Cardiovascular Problems in the Mentally Ill
Robert M. McCarron, DO, University of California, Davis

Overall, psychiatry patients do not receive optimal preventive and primary medical care, leading to decreased life expectancy. Psychiatric patients have a high rate of dyslipidemia, hypertension, smoking, and obesity. Psychiatrists often don't treat these conditions, but they need to be aware of changing standard practices in preventive medicine; be able to recognize a potential problem; and make referrals when appropriate. Dr. McCarron reviewed age-based screening recommendations for hypertension, dyslipidemia, and diabetes from the book Preventive Medical Care in Psychiatry, which he co-edited. He recommends using online cardiovascular risk calculators to determine which patients need to be screened.




Obsessive-compulsive disorder can be misdiagnosed as psychosis, anxiety, or a sexual disorder. In addition to contamination, patients can present with pathologic doubt, somatic obsessions, or obsessions about taboo or symmetry. Among FDA-approved medications, clomipramine might be more effective than selective serotonin reuptake inhibitors (SSRIs). Exposure response prevention therapy shows better response than pharmacotherapy, but best outcomes are seen with combination therapy. Jon E. Grant, JD, MD, MPH, University of Chicago, also discussed obsessive-compulsive personality disorder, body dysmorphic disorder, hoarding, trichotillomania, and excoriation disorder—as well as changes in DSM-5 that cover this group of disorders.

Patients with schizophrenia are at higher risk of death from cardiac and pulmonary disease than the general population. The quality of care of patients with psychosis generally is poor, because of lack of recognition, time, and resources, as well as systematic barriers to accessing health care. Questions about weight gain, lethargy, infections, and sexual functioning can help the practitioner assess a patient’s general health. When appropriate, Henry A. Nasrallah, MD, St. Louis University School of Medicine, recommends, consider switching antipsychotics, which might reverse adverse metabolic events.

Nonpharmacologic treatment goals include improving sleep, educating patients, providing them with tools for improving sleep, and creating an opportunity for patient-practitioner discussion. Stimulus control and sleep restriction are primary therapeutic techniques to improve sleep quality and reduce non-sleeping time in bed. Thomas Roth, PhD, Henry Ford Hospital, also discussed how to modify sleep hygiene techniques for pediatric, adolescent, and geriatric patients.

Donald W. Black, MD, University of Iowa, says that work groups for DSM-5 were asked to consider dimensionality and culture and gender issues. New diagnostic categories include obsessive-compulsive and related disorders and trauma and stressor-related disorders. Some diagnoses were reformulated or introduced, including autism spectrum disorder and disruptive mood dysregulation disorder. The multi-axial system was discontinued in DSM-5. He also reviewed coding issues.

In a sponsored symposium, Prakash S. Masand, MD, Global Medical Education, Inc., looked at the clinical challenges of addressing all 3 symptom domains that characterize depression (emotional, physical, and cognitive) as an introduction to reviewing the efficacy, mechanism of action, and side effects of vortioxetine (Brintellix), a new serotonergic agent for treating major depressive disorder (MDD). In all studies submitted to the FDA, vortioxetine was found to be superior to placebo, in at least 1 dosage group, for alleviating depressive symptoms and for reducing the risk of depressive recurrence.


Oppositional defiant disorder is more common in boys (onset at age 6 to 10) and is associated with inconsistent and neglectful parenting. Treatment modalities, including educational training, anticonvulsants, and lithium, do not have a strong evidence base. Intermittent explosive disorder is characterized by short-lived but frequent behavioral outbursts and often begins in adolescence.

Dr. Grant also reviewed the evidence on conduct disorder, pyromania, and kleptomania.

Cognitive symptoms of schizophrenia often appear before psychotic symptoms and remain stable across the lifespan. There are no pharmacologic treatments for cognitive deficits in schizophrenia; however, Dr. Nasrallah listed tactics to improve cognitive function, including regular aerobic exercise. These cognitive deficits can be categorized as neurocognitive (memory, learning, executive function) and social (social skills, theory of mind, social cues) and contribute to functional decline and often prevent patients from working and going to school. Dr. Nasrallah described how bipolar disorder (BD) overlaps with schizophrenia in terms of cognitive dysfunction.

Psychiatric disorders exhibit specific sleep/wake impairments. Sleep disorders can mimic psychiatric symptoms, such as fatigue, cognitive problems, and depression. Sleep disturbances, including insomnia, obstructive sleep apnea, and decreased need for sleep, often coexist with depression, generalized anxiety disorder, posttraumatic stress disorder, and BD, and insomnia is associated with a greater risk of suicide. With antidepressant treatment, sleep in depressed patients improves but does not normalize. Dr. Roth also reviewed pharmacotherapeutic options and non-drug modalities to improve patients’ sleep.

Antidepressants have no efficacy in treating acute episodes of bipolar depression, and using such agents might yield a poor long-term outcome in BD, according to Robert M. Post, MD, George Washington University School of Medicine, Michael J. Ostacher, MD, MPH, MMSc, Stanford University, and Vivek Singh, MD, University of Texas Health Science Center at San Antonio, in an interactive faculty discussion. For patients with bipolar I disorder, lithium monotherapy or the combination of lithium and valproate is more effective than valproate alone; evidence does not support valproate as a maintenance treatment. When a patient with BD shows partial response, attendees at this sponsored symposium were advised, consider adding psychotherapy and psycho-education. Combining a mood stabilizer and an antipsychotic might be more effective than monotherapy and safer, by allowing lower dosages. The only 3 treatments FDA-approved for bipolar depression are the olanzapine-fluoxetine combination, quetiapine, and lurasidone.

FRIDAY, MARCH 28, 2014


Carmen Pinto, MD, at a sponsored symposium, reviewed the utility and safety of long-acting injectable (LAI) antipsychotics for treating schizophrenia, with a focus on LAI aripiprazole, a partial HT-receptor agonist/partial HT-receptor antagonist. Four monthly injections (400 mg/injection) of the drug are needed to reach steady state; each injection reaches peak level in 5 to 7 days. LAI aripiprazole has been shown to delay time to relapse due to nonadherence and onset of nonresponse to the drug, and has high patient acceptance—even in those who already stable. Safety and side effects with LAI aripiprazole are the same as seen with the oral formulation.

In multimodal therapy for chronic pain, psychiatrists have a role in assessing psychiatric comorbidities, coping ability, social functioning, and other life functions, including work and personal relationships. Cognitive-behavioral therapy can be particularly useful for chronic pain by helping patients reframe their pain experiences. Raphael J. Leo, MA, MD, FAPM, University at Buffalo, reviewed non-opioid co-analgesics that can be used for patients with comorbid pain and a substance use disorder. If opioids are necessary, consider "weak" or long-acting opioids. Monitor patients for aberrant, drug-seeking behavior.

In the second part of his overview, Dr. Black highlighted specific changes to DSM-5 of particular concern to clinicians. New chapters were created and disorders were consolidated, he explained, such as autism spectrum disorder, somatic symptom disorder, and major neurocognitive disorder. New diagnoses include hoarding disorder and binge eating disorder. Subtypes of schizophrenia were dropped. Pathologic gambling was renamed gambling disorder and gender dysphoria is now called gender identity disorder. The bereavement exclusion of a major depressive episode was dropped.

Antidepressants are effective in mitigating pain in neuropathy, headache, fibromyalgia, and chronic musculoskeletal pain, and have been advocated for other pain syndromes. Selection of an antidepressant depends on the type of pain condition, comorbid depression or anxiety, tolerability, and medical comorbidities. Dr. Leo presented prescribing strategies for tricyclics, serotonin-norepinephrine reuptake inhibitors, SSRIs, and other antidepressants.

Treating of BD in geriatric patients becomes complicated because therapeutic choices are narrowed and response to therapy is less successful with age, according to George T. Grossberg, MD, St. Louis University. Rapid cycling tends to be the norm in geriatric BD patients. Look for agitation and irritability, rather than full-blown mania; grandiose delusions; psychiatric comorbidity, especially anxiety disorder; and sexually inappropriate behavior. Pharmacotherapeutic options include: mood stabilizers, atypical antipsychotics, and antidepressants (specifically, bupropion and SSRIs—not TCAs, venlafaxine, or duloxetine—and over the short term only). Consider divalproex for mania and hypomania, used cautiously because of its adverse side-effect potential.


Often, BD is misdiagnosed as unipolar depression, or the correct diagnosis of BD is delayed, according to Gustavo Alva, MD, ATP Clinical Research. Comorbid substance use disorder or an anxiety disorder is common. Comorbid cardiovascular disease brings a greater risk of mortality in patients with BD than suicide. Approximately two-thirds of patients with BD are taking adjunctive medications; however, antidepressants are no more effective than placebo in treating bipolar depression. At this sponsored symposium, Vladimir Maletic, MD, University of South Carolina, described a 6-week trial in which lurasidone plus lithium or divalporex was more effective in reducing depression, as measured by MADRS, than placebo plus lithium or divalporex. Adverse effects included nausea, akathisia, somnolence, and extrapyramidal symptoms.

When assessing an older patient with psychosis, first establish the cause of the symptoms, such as Alzheimer’s disease, affective disorder, substance use, or hallucinations associated with grief. Older patients with schizophrenia who have been taking typical antipsychotics for years might benefit from a switch to an atypical or a dosage reduction. Dr. Grossberg recommends considering antipsychotics for older patients when symptoms cause severe emotional distress that does not respond to other interventions or an acute episode that poses a safety risk for patients or others. Choose an antipsychotic based on side effects, and "start low and go slow," when possible. The goal is to reduce agitation and distress—not necessarily to resolve psychotic symptoms.

Anita H. Clayton, MD, University of Virginia Health System, provided a review of sexual function from puberty through midlife and older years. Social factors play a role in sexual satisfaction, such as gender expectations, religious beliefs, and the influence of reporting in the media. Sexual dysfunction becomes worse in men after age 29; in women, the rate of sexual dysfunction appears to be consistent across the lifespan. Cardiovascular disease is a significant risk factor for sexual dysfunction in men, but not in women. Sexual function and depression have a bidirectional relationship; sexual dysfunction may be a symptom or cause of depression and antidepressants may affect desire and function. Medications, including psychotropics, oral contraceptives, and opioids, can cause sexual dysfunction.

Providers often are reluctant to bring up sexual issues with their patients, Dr. Clayton says, but patients often want to talk about their sexual problems. In reproductive-age women, look for hypoactive sexual desire disorder and pain. In men, assess for erectile dysfunction or premature ejaculation. Inquire about every phase of the sexual response cycle. When managing sexual dysfunction, aim to minimize contributing factors such as illness or medication, consider FDA-approved medications, encourage a healthy lifestyle, and employ psychological interventions when appropriate. In patients with antidepressant-associated sexual dysfunction, consider switching medications or adding an antidote, such as bupropion, buspirone, or sildenafil.



Because of the lack of double-blind, placebo-controlled trials, the risks of untreated depression vs the risks of antidepressant use in pregnancy are unclear. Marlene P. Freeman, MD, Massachusetts General Hospital, described the limited, long-term data on tricyclics and fluoxetine. Some studies have shown a small risk of birth defects with SSRIs; others did not find an association. For moderate or severe depression, use antidepressants at the lowest dosage and try non-medication options, such as psychotherapy and complementary and alternative medicine. During the third trimester, women may need a higher dosage to maintain therapeutic drug levels. Data indicates that folic acid use during pregnancy is associated with a decreased risk of autism and schizophrenia.

James W. Jefferson, MD, University of Wisconsin School of Medicine and Public Health, recommends ruling out medical conditions, such as cancer, that might be causing your patients’ fatigue or depression. Many medications, including over-the-counter agents and supplements, can cause fatigue. Bupropion was more effective than placebo and SSRIs in treating depressed patients with sleepiness and fatigue. Adding a psychostimulant to an SSRI does not have a significantly better effect than placebo on depressive symptoms. Adjunctive modafanil may improve depression and fatigue. Data for dopamine agonists are limited.

Lithium should be used with caution in pregnant women because of the risk of congenital malformations. Dr. Freeman also discussed the potential risks to the fetus with the mother’s use of valproate and lamotrigine (with the latter, a small increase in oral clefting). High-potency typical antipsychotics are considered safe; low-potency drugs have a higher risk of major malformations. For atypicals, the risk of malformations appears minimal; newborns might display extrapyramidal effects and withdrawal symptoms. Infants exposed to psychostimulants may have lower birth weight, but are not at increased risk of birth defects.

Dr. Jefferson reviewed the efficacy, pharmacokinetics, and adverse effects of vilazodone, levomilnacipran, and vortioxetine, which are antidepressants new to the market. Dr. Jefferson recommends reading package inserts to become familiar with new drugs. He also described studies of medications that were not FDA-approved, including edivoxetine, quetiapine XR monotherapy for MDD, and agomelatine. Agents under investigation include onabotulinumtoxin A injections, ketamine, and lanicemine.

Katherine E. Burdick, PhD, Mount Sinai School of Medicine, defined cognitive domains. First-episode MDD patients perform worse in psychomotor speed and attention than healthy controls. Late-onset depression (after age 60) is associated with worse performance on processing speed and verbal memory. Cognitive deficits in depressed patients range from mild to moderate and are influenced by symptom status and duration of illness. Treating cognitive deficits begins with prevention. Cholinesterase inhibitors are not effective for improving cognition in MDD. Antidepressants, including SSRIs, do not adequately treat cognitive deficits, Roger S. McIntyre, MD, FRCPC, University of Toronto, explained.



CURRENT PSYCHIATRY and the American Academy of Clinical Psychiatrists were pleased to host more than 550 psychiatric practitioners for this conference, led by Meeting Chair Richard Balon, MD, and Meeting Co-Chairs Donald W. Black, MD, and Nagy Youssef, MD, April 4-6, 2013 at the Swissôtel in Chicago, IL. Attendees could earn up to 18 AMA PRA Category 1 Credits.



Evidence-based medicine and treatment guidelines may not address complex patients with treatment-resistant depression (TRD). Andrew A. Nierenberg, MD, Massachusetts General Hospital, reviewed newer medications for TRD, including olanzapine-fluoxetine combination, ketamine, riluzole, and L-methylfolate; however, use of these medications requires careful consideration of risks and benefits.

Many FDA-approved drugs have a "black-box" warning, but still are widely used. Henry A. Nasrallah, MD, University of Cincinnati, reviewed black-box warnings for antipsychotics, antidepressants, mood stabilizers, benzodiazepines, stimulants, opiates, and hypnotics and offered strategies on how to incorporate these warnings into clinical practice.

Dr. Nierenberg discussed the outcomes of 3 published medication effectiveness studies for bipolar disorder (BD)—STEP—BD, BALANCE, and LiTMUS—and one currently underway, CHOICE. These studies examined monotherapy and combination therapy with antidepressants, anticonvulsants, antipsychotics, and psychosocial interventions.

Although there is an association between psychosis and violence, most psychotic patients are not violent. Rajiv Tandon, MD, University of Florida, reviewed modifiable and nonmodifiable risk factors for violence, key clinical questions to consider, and scales to use when assessing a patient's risk of violence.


Measuring biomarkers can augment other clinical methods to help identify metabolic, structural, and functional brain changes associated with preclinical stages of cognitive disorders. James Ellison, MD, MPH, McLean Hospital, Harvard Medical School, explained how biomarkers can improve the differential diagnosis of memory impairments and aid in identifying different types of dementia.

Case-control studies have found a strong association between schizophrenia and type II diabetes, which contributes to higher mortality among schizophrenia patients. Along with vigilant metabolic monitoring, Dr. Tandon recommended a therapeutic approach that includes changing antipsychotics, prescribing metformin, suggesting lifestyle interventions, and treating comorbid conditions.

Depressed older adults may report anxiety, hopelessness, anhedonia, or somatic symptoms, rather than sadness. Depressive symptoms may be associated with vascular disease or cognitive impairment. Dr. Ellison reviewed psychotherapeutic and pharmacologic treatments for older depressed patients.



Many strategies exist for treating patients with TRD; adding an atypical antipsychotic has the best evidence, but there are tolerability considerations. Dr. Nierenberg suggested using a combination of treatments.

Pregnancy is inherently risky for women who take antipsychotics. In all patients of childbearing potential, take a thorough reproductive history and ask about contraception use. Marlene P. Freeman, MD, Massachusetts General Hospital, explained that psychotropics with unfavorable FDA pregnancy ratings may be among first-line choices.

Clinical symptoms, cognitive deficits, psychiatric comorbidities, genetic factors, neuroimaging features, and pharmacotherapy may overlap considerably between schizophrenia and BD. Dr. Nasrallah described clinical features that differentiate the 2 disorders.

Cognitive enhancers can improve activities of daily living, behavior, and cognition in patients with Alzheimer’s disease. George T. Grossberg, MD, St. Louis University, reviewed the evidence for acetylcholinesterase inhibitors, the NMDA receptor antagonist memantine, combination therapy, and atypical antipsychotics.

Dietary consultation for older patients might help delay or decrease their risk of dementia. Patients should consume omega-3 fatty acids, whole grains, fresh fruits and vegetables, beans, legumes, and certain spices. Dr. Grossberg also suggested patients engage in physical and mental exercises, social and spiritual activities, and stress reduction, and control cardiovascular risk factors.


Many women experience anxiety during pregnancy, and the risk is highest during the first trimester. Dr. Freeman reviewed prevalence, diagnosis, and treatment of panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder during pregnancy and postpartum.

Kathleen Brady, MD, PhD, Medical University of South Carolina, explained how methylenedioxypyrovalerone, also known as bath salts, and other designer drugs are not detectable on standard urine drug screens. Agitation, tachycardia, combative behavior, hyperthermia, and hallucinations have been reported.

Alcohol abuse and depression are highly comorbid and are associated with higher suicidality, more severe symptoms, and poorer treatment response than either disorder alone. Depressive symptoms often are seen during alcohol withdrawal, and may resolve with abstinence. Dr. Brady reviewed the evidence for treating depressed alcoholics with antidepressants, medications targeting alcohol dependence such as disulfiram and naltrexone, and psychotherapy.

Ralph Aquila, MD, Columbia College of Physicians and Surgeons, discussed risk factors for and consequences of treatment nonadherence in patients with schizophrenia. Leslie L. Citrome, MD, MPH, New York Medical College, covered strategies to improve adherence, including identifying and addressing barriers to adherence for individual patients, improving the therapeutic alliance, and considering long-acting injectable antipsychotics.



Forty-six percent of depressed patients will stop pharmacotherapy before they have a chance to respond. To minimize short-term side effects, Andrew J. Cutler, MD, Florida Clinical Research Center, suggested educating patients and slowly titrating medications; options for reducing long-term side effects or residual symptoms include switching or augmenting pharmacotherapy.

When treating patients addicted to opioids, outcome measures go beyond general health to obtaining employment and reducing criminal activity. Pharmacotherapy options include methadone maintenance therapy, oral and injectable naltrexone, and oral, sublingual, and implantable buprenorphine. Walter Ling, MD, David Geffen School of Medicine at UCLA, described factors that may improve patient outcomes.

Geriatric BD is relatively common in clinical settings, but there is a lack of evidence-based clinical practice guidelines. James W. Jefferson, MD, University of Wisconsin School of Medicine and Public Health, recommended choosing a treatment based on the illness phase and balancing the benefit of certain pharmacotherapies against short- and long-term risks.

Most medications for treating alcohol dependence work by modulating functions of opioids, glutamate, GABA, and serotonin. Dr. Ling reviewed the evidence base, dosing guidelines, and clinical recommendations for disulfiram, oral and injectable naltrexone, and acamprosate, which are FDA-approved for treating alcohol dependence. He also recommended combining medications with nonpharmacologic treatments, such as 12-step programs.

Most people who die by suicide deny suicide ideation at their last mental health visit. Risk factors for suicide include family history of suicide, childhood or adult trauma, substance abuse, stressful life events, chronic illness, and psychiatric disorders. Dr. Jefferson described suicide rating and tracking scales and encouraged clinicians to document suicide risk evaluations.


Robert M.A. Hirschfeld, MD, University of Texas Medical Branch, discussed how the concept of allostatic load—bodily "wear and tear" that emerges with sustained allostatic states—may help explain cognitive and physical decline associated with BD. Roger S. McIntyre, MD, FRCPC, University of Toronto, emphasized that BD is a progressive disorder and comorbidities such as metabolic problems may promote this progression. Terence A. Ketter, MD, Stanford School of Medicine, covered new developments in BD treatment, including certain second-generation antipsychotics, dopaminergic neurotransmission enhancers, mood stabilizers, adjunctive antidepressants, and adjunctive psychotherapy.

2012 Conference Wrap-up

The Current Psychiatry/American Academy of Clinical Psychiatrists 2012 Psychiatry Update: Solving Clinical Challenges, Improving Patient Care, took place March 29-31, at the Chicago Marriott Downtown Magnificent Mile, with more than 500 psychiatrists and psychiatric clinicians in attendance. Participants of this highly interactive, learning-focused meeting had the opportunity to earn up to 18 AMA PRA Category 1 Credits.

Below is a summary of the sessions.


TMS and Other Forms of Neuromodulation
Philip G. Janicak, MD, Rush Medical College

Dr. Janicak summarized the latest data on electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), and deep brain stimulation (DBS), all of which are used for treatment-resistant depression. ECT remains the most effective neuromodulation modality. Patients who receive VNS often improve with long-term use, but lack of insurance reimbursement may limit its use. TMS is less invasive than ECT, VNS, and DBS and has reduced depressive symptoms in clinical trials.

Diagnosing and Treating PTSD
James W. Jefferson, MD, University of Wisconsin School of Medicine and Public Health

Dr. Jefferson pointed out that posttraumatic stress disorder (PTSD) is highly comorbid with depression, substance abuse, anxiety, and borderline personality disorder. Cognitive-behavioral therapy is a first-line treatment for PTSD. Paroxetine and sertraline are FDA-approved for PTSD; data for other pharmacotherapies, including atypical antipsychotics, venlafaxine, propranolol, and prazosin, are insufficient. Combining CBT and pharmacotherapy may help treatment-resistant patients.

New Pharmacologic Therapies for Depression and Anxiety
Philip G. Janicak, MD, Rush Medical College

Dr. Janicak reviewed novel treatments for depression, generalized anxiety disorder, obsessive- compulsive disorder, posttraumatic stress disorder, and sleep disorders. Atypical antipsychotics are the only FDA-approved augmentation strategies for depression. Alternate therapies that target the monoamine, glutamate, acetylcholine, and melatonin systems are under investigation but adequate data are lacking.

Treatment-Resistant Anxiety
James W. Jefferson, MD, University of Wisconsin School of Medicine and Public Health

Dr. Jefferson discussed evidenced-based approaches to treatment-resistant anxiety, including panic disorder, social anxiety disorder, and generalized anxiety disorder. Cognitive-behavioral therapy often is effective. If first-line pharmacotherapies fail, options include augmenting or switching medications; however, there is little data on these approaches.

Challenges and Opportunities in Schizophrenia
Henry A. Nasrallah, MD, University of Cincinnati

In a promotional symposium sponsored by Sunovion Pharmaceuticals, Inc., Dr. Nasrallah reviewed recent data for the atypical antipsychotic lurasidone. Randomized controlled trials have shown that lurasidone, 40 mg/d and 80 mg/d, is superior to placebo in reducing schizophrenia symptoms in adults as assessed by the Positive and Negative Syndrome Scale and the Brief Psychiatric Rating Scale. Common adverse effects include somnolence, akathisia, nausea, parkinsonism, and agitation.

Sleep Disturbances in Patients with Dementia
George T. Grossberg, MD, St. Louis University

Dr. Grossberg described how patients with Alzheimer's disease (AD) experience sleep disturbances such as insomnia, obstructive sleep apnea, and restless legs syndrome. Some of these difficulties may worsen AD. Behavioral interventions, including bright light therapy, cause fewer side effects than pharmacotherapy; however, results are mixed. Nonbenzodiazepine hypnotics are preferred to benzodiazepines because they are less likely to cause memory loss or disorientation.

Similarities and Differences Between 1st, 2nd, and 3rd Generation Antipsychotics
Henry A. Nasrallah, MD, University of Cincinnati

Dr. Nasrallah discussed the benefits and adverse effects of several pharmacologic options for treating schizophrenia, including first-generation antipsychotics and the newest agents lurasidone, asenapine, paliperidone, and iloperidone. Injectable antipsychotics, such as paliperidone and olanzapine, may improve adherence and prevent relapse.

Sleep Disturbances in the Elderly
George T. Grossberg, MD, St. Louis University

Dr. Grossberg reviewed common factors that can affect sleep among older adults, including medical and psychiatric illnesses, medications, and disrupted circadian rhythms. For insomnia, start with nonpharmacologic strategies, such as increasing physical activity, teaching sleep hygiene, and cognitive-behavioral therapy. When prescribing nonbenzodiazepine hypnotics, use the lowest effective dose for the shortest duration.

Treatment Strategies for Patients with Inadequate Response to First-Line Antidepressants
Andrew J. Cutler, MD, University of Florida

Dr. Cutler outlined treatment strategies for patients with depression who don't fully respond to first-line antidepressants, including combining antidepressants or augmenting them with atypical antipsychotics, stimulants, other medications, or natural products. For switching antidepressants, no evidence supports preference for one agent or class over another; tricyclic antidepressants and monoamine inhibitors maybe underused options.

FRIDAY, MARCH 30, 2012

Chronic Insomnia
Thomas Roth, PhD, Henry Ford Health System

Dr. Roth discussed understanding insomnia as a disorder that merits treatment, and not merely as a symptom of other disorders. In addition to sleep difficulties, patients with insomnia experience daytime symptoms such as cognitive or mood symptoms and distress/impairment. Insomnia increases the risk of depression and other psychiatric illnesses, falls, and cardiovascular disorders.

Treatment-Resistant Schizophrenia
Henry A. Nasrallah, MD, University of Cincinnati

Dr. Nasrallah reviewed the definition of treatment resistance and refractoriness in schizophrenia, which often does not consider negative or cognitive symptoms. When first-line antipsychotics or clozapine monotherapy don't work, evidence supports adding lamotrigine, an antidepressant, a glutamate receptor agent, neurosteroids, and hormones. He also reviewed the data for electroconvulsive therapy and repetitive transcranial magnetic stimulation.

How to Stabilize Acutely Psychotic Patients
Rajiv Tandon, MD, University of Florida

Dr. Tandon explained that the objectives when treating an acutely psychotic patient are to reduce acute symptoms as quickly as possible, provide interventions for the specific cause of their psychosis, and maintain safety. Treatment for extreme agitation can include behavioral approaches, such as de-escalation and seclusion, and pharmacotherapy with oral and injectable antipsychotics or benzodiazepines.

New Treatments for Sleep Disorders
Thomas Roth, PhD, Henry Ford Health System

Dr. Roth reviewed nonpharmacologic treatments for insomnia, including stimulus control therapy and sleep restriction therapy, and pharmacologic interventions, primarily benzodiazepine receptor agonists. Considering how neurotransmitter systems are affected by sleep and how medications affect these systems can help researchers develop new therapeutic targets for insomnia treatment.

Unraveling the Complexities of Schizophrenia: New Targets, New Opportunities
Henry A. Nasrallah, MD, University of Cincinnati
Daniel C. Javitt, MD, PhD, Columbia University
Andrew J. Cutler, MD, University of Florida

Dr. Nasrallah described multiple clinical features of schizophrenia and related genetic and environmental factors. Although no single gene appears to be necessary or sufficient for developing schizophrenia, many â€Å"susceptibility genes” contribute to liability for the illness.

Dr. Javitt discussed emerging perspectives and treatment opportunities in schizophrenia based on glutamate pathophysiology and models. New treatment opportunities may focus on glycine/D-serine, glycine transport inhibitors, and metabotropic receptors.

Dr. Cutler outlined how glutamate receptor dysfunction upstream of dopamine could explain schizophrenia symptoms. Various glutamate agonists, including glycine transporter inhibitors, may treat residual symptoms, particularly negative and cognitive symptoms.

Managing Schizophrenia's Medical Comorbidities
Rajiv Tandon, MD, University of Florida

Dr. Tandon discussed how medical comorbidities, particularly cardiovascular disease, are a primary cause of increased mortality in patients with schizophrenia. Switching antipsychotics and lifestyle interventions may help address weight gain and insulin resistance.

Use of Antidepressants in Bipolar Disorder
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine

Dr. Ghaemi examined evidence that indicates in bipolar disorder (BD), antidepressants do not alleviate depression and can lead to mania. He recommended using mood stabilizers without antidepressants initially in depressed BD patients, except for those with marked suicidality or severe melancholia. If antidepressants are used, consider serotonin reuptake inhibitors.

Complementary and Alternative Medicine and Nutrition in Psychiatry: Part I
Marlene P. Freeman, MD, Massachusetts General Hospital

Dr. Freeman reviewed evidence on several forms of commonly used complementary and alternative medicine (CAM), including omega-3 fatty acids, St. John's wort, s-adenosyl-L-methionine (SAMe), and vitamin D. She recommended directly asking patients about their use of CAM and discussing the evidence.


EMSAM (selegiline transdermal system) for the Treatment of Major Depressive Disorder
Neil S. Kaye, MD, DFAPA

In a promotional symposium sponsored by Dey Pharma, L.P., Dr. Kaye reviewed efficacy, safety, and tolerability data on selegiline transdermal system, which is FDA-approved for major depressive disorder in adults. He discussed clinically meaningful differences between oral and transdermal formulations of selegiline. Compared with oral formulations, the transdermal delivery system results in higher exposure to the drug.

Differential Diagnosis and Management of Comorbid Bipolar Disorder and ADHD
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine

Dr. Ghaemi suggested that the high comorbidity of attention-deficit/hyperactivity disorder with mood and anxiety disorders may indicate that these patients may have a single distinct disorder. Amphetamines, including methylphenidate, could worsen manic symptoms in patients with bipolar disorder (BD). Lithium is neuroprotective, and could be a good choice for BD patients with cognitive impairment.

Complementary and Alternative Medicine and Nutrition in Psychiatry: Part II
Marlene P. Freeman, MD, Massachusetts General Hospital

Dr. Freeman focused on the evidence-based use of select complementary and alternative medicine modalities in women across the reproductive lifespan. Omega-3 fatty acids, exercise, and folate have known benefits for pregnancy health and may play a role in the treatment of depression. Some evidence suggests that premenstrual symptoms may respond to calcium; omega-3 fatty acids may reduce hot flashes and depressive menopausal symptoms. Large studies show a relationship between nutritional quality and risk of depressive disorders.

Use of Antipsychotics for Treating Phases of Bipolar Disorder
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine

Dr. Ghaemi discussed evidence on the use of neuroleptics for treating bipolar disorder patients during acute mania, acute bipolar depression, mixed states, and maintenance. He suggested that generally, neuroleptics could be used as adjuncts to mood stabilizers for these patients.

Managing Suicidal Behavior in Patients with Bipolar Disorder
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine

Dr. Ghaemi outlined factors to consider when assessing suicide risk.

Suicide ideation is not a useful predictor of suicide. Bipolar patients are at high risk for suicide when in a depression or mixed state. Focus treatment on symptom clusters that increase acute risk, including anxiety/panic, insomnia, impulsivity, mixed states, rapid cycling, and substance abuse. Lithium is the only mood stabilizer shown to reduce suicide.

View Video testimonials from attendees of the 2012 Current Psychiatry/AACP Psychiatry Update

  • 2012 Attendee Video #1
  • 2012 Attendee Video #2

2011 Conference Wrap-up

FRIDAY, APRIL 15, 2011


Rajiv Tandon, MD, University of Florida, spoke about identifying psychotic symptoms in patients in the years before they experience their first psychotic episode. He said recognizing prodromal symptoms may allow early interventions to prevent deterioration.

John Lauriello, MD, University of Missouri, discussed monitoring all patients taking antipsychotics for weight gain, elevated triglyceride levels, and other metabolic side effects. He recommended that clinicians not sacrifice therapeutic efficacy to reduce side effects.

S. Charles Schulz, MD, University of Minnesota, spoke about how techniques to reduce aggression and violence among patients with schizophrenia differ in inpatient and outpatient settings. He emphasized recognizing antecedent behaviors to aggression, such as pacing, angry expressions, raised voice, and threatening behaviors.

Henry A. Nasrallah, MD, University of Cincinnati, examined the unique properties and side effect profiles of and differences among several new antipsychotics, including the oral agents asenapine, iloperidone, and lurasidone and injectable formulations of paliperidone and olanzapine.

In a luncheon symposium titled Challenges and Opportunities in the Treatment of Schizophrenia: An Interactive Case-Based Update, Greg Mattingly, MD, Washington University, discussed brain findings in schizophrenia, including functional abnormalities such as hypofrontality and structural abnormalities such as enlarged ventricles and loss of grey matter. Dr. Nasrallah explored several clinical issues in treating patients with schizophrenia, such as high burden of cardiovascular risk factors and medical illnesses, difficulty predicting individual treatment response, and challenges in maximizing adherence and minimizing side effects. Peter Weiden, MD, University of Illinois at Chicago, examined how nonadherence can influence schizophrenia treatment outcomes.


Dr. Lauriello, discussed extrapyramidal side effects of antipsychotics, which include parkinsonism, akathisia, tardive dyskinesia, and neuroleptic malignant syndrome. Dr. Nasrallah and Dr. Tandon ended the day by leading a lively point/counterpoint discussion of the pros and cons of emphasizing efficacy over tolerability when treating patients with antipsychotics. They debated the merits of typical vs atypical antipsychotics, the role of evidence-based medicine in schizophrenia treatment, and the impact of different types of adverse effects.



Dr. Schulz explained that although clozapine is associated with serious adverse effects, the drug may help many patients who don’t respond to other antipsychotics. He examined evidence for add-on medications for treatment-resistant schizophrenia, such as lithium or anticonvulsants.

George T. Grossberg, MD, St. Louis University, discussed the role of neuroimaging, genetic considerations, and neuropsychological testing in assessing cognitive deficits, and suggested that we are moving toward combining biomarkers with clinical symptoms for earlier, more accurate diagnosis of Alzheimer's disease and other dementias.

Marlene P. Freeman, MD, Massachusetts General Hospital, described treatment approaches for women who develop psychiatric symptoms during infertility treatment and those with a psychiatric history who are experiencing infertility. She also explored evidence for psychotropic use during pregnancy.

Dr. Grossberg emphasized that the first step of treating delirium in older adults is to determine if a medical problem or medication is the cause. He suggested addressing the underlying condition, then trying psychosocial and environmental interventions, such as reorientation or quiet environments.

In a luncheon symposium titled A Bridge to the Future: Redefining the Scientific Paradigm in the Treatment of Schizophrenia, Dr. Nasrallah discussed the historical evolution of schizophrenia, introducing the dopamine and glutamate hypofunction models of the disease. Leslie Citrome, MD, MPH, New York University, examined how glutamate receptor dysfunction upstream of dopamine could explain schizophrenia symptoms, and mentioned that several novel therapeutic targets involving glutamate receptors are being investigated. Diana O. Perkins, MD, MPH, University of North Carolina at Chapel Hill, discussed "next generation" strategies for schizophrenia treatment, including psychotherapeutic interventions and glycine reuptake inhibitors.


Dr. Freeman outlined approaches for treating psychosis, schizophrenia, and bipolar disorder during pregnancy and postpartum. She recommended that when treating a pregnant woman who has schizophrenia, a careful risk/benefit analysis should take into account that untreated psychosis likely carries a risk to the fetus.

Dr. Weiden discussed the importance of the interview approach and establishing a strong therapeutic alliance to improve medication adherence among patients with schizophrenia. He described pharmacologic strategies, such as switching to a long-acting injectable antipsychotic, and psychosocial interventions. D. P. Devanand, MD, Columbia University, described evidence on the use of antipsychotics for treating agitation and psychosis in patients with dementia. He said studies of depression treatment in dementia patients found limited evidence of efficacy for selective serotonin reuptake inhibitors.

SUNDAY, APRIL 17, 2011

Dr. Weiden recommended that when considering adding medications to an antipsychotic for a schizophrenia patient with persistent symptoms, first give full trials of a single drug at the high end of the therapeutic dose and establish well-defined target symptoms before adding a new medication. Dr. Devanand described several early markers of Alzheimer's disease, including apolipoprotein E genotyping, mild cognitive impairment (MCI), hippocampal volume, olfactory deficits, and amyloid imaging tracers.

Susan K. Schultz, MD, University of Iowa, said that although diagnosis of MCI is well understood, prevention and treatment options are less well-defined. She discussed depression in MCI, and described evidence for using cholinesterase inhibitors (not routinely indicated), nutraceuticals, and exercise.

Dr. Schultz concluded the conference by describing pharmacologic and nonpharmacologic strategies for addressing behavioral disturbances in dementia. She said evidence supports modest symptom improvements with some antipsychotics.

2010 Conference Wrap-up

Mood And Anxiety Disorders: Solving Clinical Challenges, Improving Patient Care

CURRENT PSYCHIATRY and the American Academy of Clinical Psychiatrists were pleased to host 450 psychiatric practitioners in Chicago, IL for this 3- day conference, led by Richard Balon, MD, Meeting Chair and Donald W. Black, MD, Meeting Co-Chair. Attendees were able to earn up to 18 AMA PRA Category 1 Credits.


Andrew Nierenberg, MD, Massachusetts General Hospital, discussed managing residual depressive symptoms after a first-line treatment trial. He highlighted how to use pharmacotherapy and psychotherapy to target residual symptoms such as insomnia, fatigue, and cognitive decline.

Murray B. Stein, MD, MPH, University of California, San Diego, reviewed the latest evidence on the diagnosis and pharmacotherapy of posttraumatic stress disorder. He pointed out that pharmacotherapy alone usually is inadequate to obtain optimum clinical outcomes.

Frederick K. Goodwin, MD, George Washington University, described unipolar vs bipolar depression and how to prevent misdiagnoses. He discussed subtle clinical clues that might suggest a depressed patient is bipolar.

Dr. Stein explained that although co-occurring panic disorder, social anxiety disorder, or other anxiety disorders with mood disorders generally predicts poorer outcomes, a solid evidence base supports effective treatments, including cognitive-behavioral therapy and antidepressants.

Philip R. Muskin, MD, Columbia University, chaired a luncheon symposium titled Effective Strategies for Patients with Complex Depression in Psychiatric Practice: A Case-Based Approach, and covered major depressive disorder (MDD) and medical illness. Other speakers were Dr. Nierenberg, who described results from the STAR*D trials, and George I. Papakostas, MD, Massachusetts General Hospital, who focused on augmentation and combination strategies for MDD treatment.
Audio commentary from Dr. Muskin.

Natalie Rasgon, MD, PhD, Stanford University School of Medicine, spoke on the risks and benefits of prescribing psychotropics during pregnancy, covering epidemiology, risk factors, clinical course, and controversies regarding treatment of women with perinatal mood disorders.
Audio commentary from Dr. Rasgon.

Dr. Goodwin presented strategies for monitoring and mitigating suicide risk in patients with mood and anxiety disorders.
Audio commentary from Dr. Goodwin.

Dr. Nierenberg described assessing and managing sexual dysfunction and other side effects of depression and anxiety treatment.


Dr. Rasgon focused on treating postpartum depression and anxiety, including treatment strategies for breast-feeding women.

Kiki D. Chang, MD, Stanford University School of Medicine, discussed suicidality in children, adolescents, and young adults and the possible role of antidepressants.

George T. Grossberg, MD, St. Louis University, described medical and psychosocial factors to consider in the workup of late-life depression and anxiety. He covered the latest non-pharmacologic and pharmacologic therapies for geriatric depression.

Dr. Chang reported on comorbidities in children and adolescents with bipolar disorder. He described treatment guidelines for bipolar youths who have co-occurring anxiety disorders, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders.

At a luncheon symposium, Lawrence Ginsburg, MD,discussed the role of L-methylfolate as an adjunct to antidepressants for treating depression.

Dr. Grossberg described how to avoid drug interactions and adverse effects when prescribing for older patients, focusing on herbal/drug interactions.
Audio commentary from Dr. Grossberg

Donald W. Black, MD, University of Iowa, spoke on how to treat depression and anxiety in patients with borderline personality disorder.

James W. Jefferson, MD, Madison Institute of Medicine, discussed pharmacotherapy of comorbid mood, anxiety, and substance use disorders. He emphasized methods of improving diagnostic accuracy and treatment considerations.


Dr. Jefferson described the latest evidence on obsessive-compulsive disorder in patients with psychiatric comorbidities, including major depression, bipolar disorder, and substance use disorders.

Marlene P. Freeman, MD, Massachusetts General Hospital, spoke on premenstrual mood disorders and the menopausal transition and considerations for treatment.

Dr. Black discussed how to correctly diagnose borderline personality disorder or a mood disorder. He described how the 2 disorders have overlapping symptoms that could lead to diagnostic confusion.

Dr. Freeman concluded the meeting by discussing complementary and alternative medicine and psychiatry: what the psychopharmacologist needs to know.

2009 Conference Wrap-up

A windy Chicago welcomed 314 psychiatrists and advance practice psychiatric practitioners to "Bipolar Disorder and ADHD: Solving Clinical Challenges, Improving Patient Care," April 2-4, 2009, at the Westin Chicago River North. Presented by CURRENT PSYCHIATRY and the American Academy of Clinical Psychiatrists (AACP), the interactive continuing medical education conference offered attendees up to 19.5 CME credits.


Moderator: Richard Balon, MD, Program Chair

Kiki Chang, MD, Associate Professor of Psychiatry at the Stanford University School of Medicine, kicked off the meeting with a discussion of diagnosis and treatment of ADHD in children and adolescents. Dr. Chang presented data on comorbidity and symptom overlap between ADHD and bipolar disorder and discussed stimulant and nonstimulant pharmacotherapy of ADHD.

Click here for video of Dr .Chang speaking about the importance of obtaining a baseline EKG in children before starting psychostimulants; how to distinguish between ADHD and bipolar disorder; and "ADHD Plus."

Anthony L. Rostain, MD, director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania School of Medicine, discussed the challenges in diagnosing ADHD in adults and outlined how ADHD symptoms manifest differently in adults than in children. He also offered tips for making an accurate diagnosis of adult ADHD and listed screening scales that can be used in clinical practice.

After a short networking break, Dr. Rostain continued the discussion of adult ADHD with a presentation on treatment strategies. He outlined stimulant and nonstimulant options and how to manage pharmacotherapy for adults with comorbid psychiatric disorders such as anxiety, substance abuse, or depression. Dr. Rostain also addressed concerns about adverse cardiac side effects with psychostimulant treatment and how to adjust medications to maximize treatment response.

Click here for video of Dr. Rostain as he discusses getting adult patients with ADHD ready for treatment.

Kevin Murphy, PhD, president of the Adult ADHD Clinic of Central Massachusetts, presented data showing why psychotherapy and other psychosocial interventions play a vital role in adult ADHD treatment. He recommended that clinicians help patients accept that negative symptoms are caused by a neurobiological disorder-not a character flaw or willful misconduct—that requires ongoing maintenance. Adult patients often need ongoing education and support to develop compensatory skills and strategies, avoid substance abuse, and address challenges with work, school, and family.

Click here for video of Dr. Murphy discussing the importance of instilling hope during treatment of adults with ADHD

In his second presentation, Dr. Murphy emphasized that serving as a partner/advocate for the adult with ADHD is key to continued treatment over time. To convince someone who is skeptical about starting treatment, he recommends that clinicians "take the powerplay" out of the conversation. Demystify the diagnosis, and explain why the patient meets criteria for ADHD, he said. Explain how the medication works and why treatment is important-without "jamming it down their throats," he said. Emphasize the patient's attributes, such as intelligence, creativity, high energy, "feistiness," or sense of humor.

S. Nassir Ghaemi, MD, Director of the Mood Disorders and Psychopharmacology Programs and professor of psychiatry at Tufts, University, described the "hierarchy of diagnosis" implicit in DSM-IV-TR in his discussion of comorbid adult ADHD and bipolar disorder. Because of overlapping symptoms, mood disorders (bipolar and unipolar) should be ruled out before a clinician considers a psychotic or anxiety disorder. Similarly, he cautioned against diagnosing ADHD while a patient is experiencing a mood episode or psychotic illness.

Early onset of bipolar disorder is common, according to Dr. Chang. One-half of adults with bipolar disorder experience onset as children (14%) or adolescents (36%). In children, the bipolar spectrum includes severe mood dysregulation, â€Å"full” bipolar disorder (types I and II), and possible prodromal states (such as ADHD or depression with a family history of bipolar disorder and bipolar disorder not otherwise specified). Children with bipolar disorder often show irritability, but this symptom is not specific to bipolar disorder. Randomized controlled trials have shown lithium and atypical antipsychotics to be effective for mood stabilization in pediatric bipolar disorder.


Moderator: Sanjay Gupta, MD, AACP President

Anticipate unplanned pregnancies when choosing medications for women of reproductive age with bipolar disorder, advised Marlene P. Freeman, MD, Massachusetts General Hospital perinatal and reproductive psychiatry program. A patient may deny plans to become pregnant, but two-thirds of U.S. women have at least one unintended pregnancy, and 50% to 60% of pregnancies are unintended or mistimed. Because relapse rates for bipolar women who discontinue medication during pregnancy are high, it is recommended that patients consider the serious risks of untreated bipolar disorder as well as medication exposure. Valproate appears to be the mood stabilizer associated with the greatest teratogenic potential. Among the anticonvulsants, lamotrigine appears to have the most favorable reproductive safety profile, and lithium appears to have a much lower risk of teratogenicity than was thought years ago, with a very low absolute risk of malformations with first- trimester exposure. More data are needed to inform the use of atypical antipsychotics across pregnancy and breastfeeding.

Click here for video of Dr. Freeman discussing why it is important to consider unplanned pregnancy when prescribing medication to women of reproductive age.

In his second presentation at the conference, Dr. Ghaemi reviewed the use of stimulants in bipolar disorder treatment and the risk of mood destabilization. Because patients with bipolar disorder often also experience cognitive dysfunction, he reviewed nonstimulant strategies for preserving brain function and enhancing cognition.

Click here for video of Dr. Ghaemi discussing how to preserve brain function in patients with bipolar disorder; how to identify early signs of brain dysfunction; and if it is appropriate to use stimulants in patients with bipolar disorder.

Next, Dr. Freeman returned to the podium to summarize of the latest evidence on subsyndromal depression in bipolar I disorder. She discussed the functional toll of subsyndromal depression, the risk of switching to mania with antidepressant therapy, effective use of mood stabilizers, and evidence supporting other therapies. These include psychotherapy, complementary and alternative medicine, omega-3 fatty acids, exercise, and light therapy.

Suicidal behavior in patients with bipolar disorder was the topic of the session presented by Frederick Goodwin, MD, Research Professor of Psychiatry at George Washington University Medical Center. Dr. Goodwin covered suicide risk factors, mood stabilizers' efficacy in reducing suicide risk, and the importance of ongoing communication with patients and families about suicide and the underlying bipolar disorder.

Dr. Ghaemi served as moderator at a luncheon symposium on "Maintaining wellness in patients with bipolar disorder." Claudia Baldassano, MD, assistant professor of psychiatry at the University of Pennsylvania, discussed how to promote wellness in patients with bipolar disorder. Robert Hirschfeld, MD, professor and chairperson, cepartment of psychiatry and behavioral sciences, University of Texas Medical Branch, spoke on integrating pharmacotherapy and nonpharmacologic treatments for bipolar disorder.

Friday afternoon's sessions began with a presentation of the evidence on rapid and ultradian cycling in bipolar disorder patients by Steven Dubovsky, MD, professor and chair, department of psychiatry, University at Buffalo. Dr. Goodwin then described how to use lithium in the acute treatment of mania, treatment of bipolar depression, and maintenance treatment bipolar disorder.

Click here for video of Dr. Baldassano discussing how she handles polypharmacy and her approach to simplifying regimens.

In a "Psychopharmacology Jam Session," audience members stepped to the microphones to comment on clinical case reports presented by AACP members Sanjay Gupta, MD, president; Gregory Teas, MD, and Nagy Youssef, MD.

The day ended with a session by Dr. Chang, who discussed strategies for promoting treatment adherence in patients with bipolar disorder. Dr. Chang's presentation covered patient, clinician, and system factors that contribution to nonadherence and included video from a patient interview that helped illustrate these issues.

Follow Us