What is the best way to provide early interventions for psychiatric disorders after trauma? The terrorist attacks of September 11, 2001, have raised urgent concerns about the evidence for early treatments after trauma that can prevent psychiatric disorders. This review outlines the expected course of posttraumatic stress reactions and discusses the current means of identifying people who are at risk of developing disorders. A critique of psychological debriefing and an analysis of evidence for cognitive-behavioral therapy as an early intervention is provided. The major challenges for early intervention are discussed, including increasing treatment effectiveness, delivering therapy when it is required by thousands of people, and developing early interventions for a wide array of psychiatric disorders in addition to posttraumatic stress disorder that can develop following trauma.

Depression and anxiety disorders are very common in the elderly. Data accumulated over the past 2 decades have shown that most older patients can tolerate and respond to acute treatment with serotonergic antidepressants, other psychotropic agents, or manual-based psychotherapy. However, outcomes under usual-care conditions remain poor. This review proposes that clinicians may significantly improve the long-term outcomes of their older patients with depression and anxiety by focusing on four key factors: (1) identification and treatment of comorbid conditions; (2) full remission of acute symptoms; (3) education of patients, families, and professional colleagues about the need for long-term treatment; and (4) prevention and management of medication side-effects.

The presentations and clinical courses of patients with bipolar disorder differ greatly by gender. In addition, medical therapy must be tailored differently for men and women because of emerging safety concerns unique to the female reproductive system. In November 2005, these topics were explored by a panel of experts in psychiatry, neurology, and reproductive health at a closed roundtable meeting in Dallas, Texas. This clinical information monograph summarizes the highlights of that meeting.

Compared to men with bipolar disorder, women have more pervasive depressive symptoms and experience more major depressive episodes. They are also at higher risk for obesity and certain other medical and psychiatric comorbidities. Mood changes across the menstrual cycle are common, although the severity, timing, and type of changes are variable. Bipolar disorder is frequently associated with menstrual abnormalities and ovarian dysfunction, including polycystic ovarian syndrome. Although some cases of menstrual disturbance precede the treatment of bipolar disorder, it is possible thatvalproate and/or antipsychotic treatment may play a contributory role in young women.

Pregnancy does not protect against mood episodes in untreated women. Maintenance of euthymia during pregnancy is critical because relapse during this period strongly predicts a difficult postpartum course. Suspending therapy in the first months of pregnancy may be an option for some women with mild-to-moderate illness, or those with a long history of euthymia during pre-pregnancy treatment. However, a mood stabilizer should be reintroduced either in the later stages of pregnancy or in the immediate postpartum period. Preliminary data suggest that fetal exposure to some mood stabilizers may raise the risk of major congenital malformations and neurodevelopmental delays. For women planning to become pregnant, clinicians may consider switching to other drugs before conception. The value and drawbacks of breastfeeding during treatment must be considered in partnership with the patient, with close monitoring of nursing infants thereafter. The risks and benefits of medical treatment for women with bipolar disorder should be carefully reconsidered at each stage of their reproductive lives, with a flexible approach that is responsive to the changing needs of patients and their families.

ISSUE:Although many patients with schizophrenia fail to respond adequately to trials of 2 or more antipsychotics, utilization of clozapine for these patients remains low, despite recommendations for its use by accepted treatment guidelines. Some experts estimate that 5–10 times more patients could benefit from clozapine than who are now receiving it. Learning how to manage the unique side effect profile of clozapine can potentially remove barriers to prescribing this agent and thus unlock its unique therapeutic efficacy for more patients.

The treatment of patients with unexplained medical symptoms is difficult because there is neither a clear etiology for the symptoms, nor a useful paradigm with which to understand and treat them. Patients with such symptoms are often referred to psychiatry with vague diagnoses of “somatization” or “hypochondriasis.” Rather than considering somatoform diagnoses based on the number or diversity of physical symptoms, evolving research suggests an emphasis on the type of physical symptom as an indicator of Axis I pathology. This article links specific symptomatic complaints, such as chronic pain, chest pain, and dizziness, to the respective Axis I disorders associated with them, such as depression, panic disorder, and anxiety disorders.

This article proposes that a recent shift in our understanding of dopamine function may support translational research to target deficits in positive emotions and reward processing in individuals with major depressive disorder (MDD). We review how dopamine functions to modulate approach behaviors in response to positive incentives, and we describe the incentive salience hypothesis, which posits that dopamine primarily modulates “wanting,” or anticipatory reward, rather than “liking,” or subjective pleasure. Although the incentive salience hypothesis was first proposed to help explain how drugs of abuse may reinforce harmful behaviors in the absence of continued pleasure or “liking,” it may also provide a basis for understanding and developing new treatment approaches for MDD. Specifically, it provides a rationale for combining behaviorally activating psychotherapies and pro-dopaminergic agents to target impaired reward processing in MDD.

Efforts to identify clinical risk factors for complete suicide through the follow-up of depressed patients have yielded relatively few robust predictors. Those identified by at least three studies are (in order of decreasing frequency) suicidal plans/attempts, male sex, being single or living alone, inpatient status, and hopelessness. Because the best established of these predictors has only modest sensitivity and specificity, the need for other robust tools is clear. A rich body of research has identified two biological risk factors for suicide in depressive disorder: hypothalamicpituitary-adrenal axis hyperactivity and deficits in serotonin function. Moreover, there is now considerable evidence that the dexamethasone suppression test and measures of serum cholesterol concentrations, respectively, may provide a clinically useful reflection of these two mechanisms. Observations that these measures appear to be additive, both with each other and with other clinical risk factors, indicate that a substantial improvement in the clinician's ability to assess suicide risk is possible.

This article provides an overview of cognitive-behavioral therapy (CBT) for panic disorder. CBT is currently considered a first-line treatment for panic disorder. It offers benefit after short-term intervention, typically consisting of 12–15 sessions conducted in either an individual or a group format. The treatment focuses on the elimination of the patterns that underlie and perpetuate the disorder. Through CBT, patients learn about the nature of the disorder and acquire a set of strategies that counter the fears of panic attacks themselves, and break the recurring cycle of anticipatory anxiety, panic, and agoraphobic avoidance. The collaborative format of treatment, and a focus on elimination of core fears may be factors in enhancing longer-term outcome. In this article, we review the efficacy of CBT as a first-line treatment, a strategy for medication nonresponders, a replacement strategy for patients who wish to discontinue pharmacotherapy, and a potential preventive strategy for at-risk individuals. We also discuss some of the complex issues involved with combination-treatment strategies.

Introduction: The clinical and self-report versions of the Quick Inventory of Depressive Symptomatology (QIDS-C16 and QIDS-SR16) have been well studied in patients with major depressive disorder and in one recent study using patients with bipolar disorder. This article examines these measures in a second sample of 141 outpatients with bipolar disorder in different phases of the illness.

Methods: At baseline, 61 patients were depressed and 30 were euthymic; at exit, 50 were depressed and 52 were euthymic. The remaining patients (at baseline or exit) were in either a manic or mixed phase and were pooled for statistical reasons.

Results: Similar results were found for the QIDS-C16 and QIDS-SR16. Scores were reasonably reliable to the extent that variability within groups permitted. As expected, euthymic patients showed less depressive symptomatology than depressed patients. Sad mood and general interest were tne most discriminating symptoms between depressed and euthymic phases. Changes in illness phase (baseline to exit) were associated with substantial changes in scores. The relation of individual depressive symptoms to the overall level of depression was consistent across phases.

Conclusion: Both the QIDS-SR16 and QIDS-C16 are suitable measures of depressive symptoms in patients with bipolar disorder.

Chirality has become an increasingly important consideration in the development of psychoactive drugs because enantiomers often show major differences in their pharmacokinetic and pharmacologic properties. This review illustrates the implications of stereochemistry in clinical psychopharmacology using the antidepressant class of drugs as a focus. In many cases, a better understanding of stereochemistry can improve therapeutic outcomes. For example, with citalopram, the racemic formulation is effective for depression as well as panic and obsessive-compulsive disorders. However, the S-enantiomer, escitalopram, is at least twice as potent as racemic citalopram as an inhibitor of serotonin reuptake, implying that it can be used at lower doses, while offering an improved therapeutic index as well as an improved safety profile and reduced drug interaction liability. Clinical trial data support these advantages. Continuing research on the stereochemical properties of psychoactive drugs should simplify the characterization of dose-response relationships, and clarify the effects of disease states, genetic polymorphisms, pregnancy, age, and gender on stereoselective pharmacokinetics and pharmacodynamics. Better understanding of the fate of chiral psychotropic agents and the factors that influence their stereoselective disposition and actions will provide a rational basis for their expanded use in various patient populations.

Antipsychotics are the mainstay of treatment for patients with schizophrenia. However, these medications only work if they are taken and perhaps work best if they are taken for longer periods of time than seen in typical research trials. Here we explore the idea of “time as a drug” by reviewing the data showing the potential benefits of long-term antipsychotic use. We also discuss the utility of depot antipsychotic formulations for improving the chances of attaining long-term therapeutic results.

Wake-up stroke (WUS) or ischemic stroke occurring during sleep accounts for 14%–29.6% of all ischemic strokes. Management of WUS is complicated by its narrow therapeutic time window and attributable risk factors, which can affect the safety and efficacy of administering intravenous (IV) tissue plasminogen activator (t-PA). This manuscript will review risk factors of WUS, with a focus on obstructive sleep apnea, potential mechanisms of WUS, and evaluate studies assessing safety and efficacy of IV t-PA treatment in WUS patients guided by neuroimaging to estimate time of symptom onset. The authors used PubMed (1966 to March 2018) to search for the term “Wake-Up Stroke” cross-referenced with “pathophysiology,” ‘‘pathogenesis,” “pathology,” “magnetic resonance imaging,” “obstructive sleep apnea,” or “treatment.” English language Papers were reviewed. Also reviewed were pertinent papers from the reference list of the above-matched manuscripts. Studies that focused only on acute Strokes with known-onset of symptoms were not reviewed. Literature showed several potential risk factors associated with increased risk of WUS. Although the onset of WUS is unknown, a few studies investigated the potential benefit of magnetic resonance imaging (MRI) in estimating the age of onset which encouraged conducting clinical trials assessing the efficacy of MRI-guided thrombolytic therapy in WUS.

The present paper examines the role of cognitive-behavioral therapy (CBT) in the treatment of social anxiety disorder (SAD). A cognitive-behavioral model of SAD is first presented. Different modalities of CBT for SAD are then described, including exposure, cognitive restructuring, relaxation training, and social skills training, and evidence supporting their efficacy is reviewed. The comparative and combined impact of CBT and pharmacotherapeutic interventions is also explored. CBT appears to be an efficacious treatment for SAD. However, the overall efficacy CBT may be increased by closer examination of the active ingredients of treatment. Such analyses may also enable more successful integration of the different CBT techniques and of CBT and pharmacotherapy in the treatment of SAD.

In treating and managing acute psychosis in patients with schizophrenia, early intervention may be valuable. The need to quickly control severe symptoms, however, must be balanced with a treatment algorithm that is both safe and effective. The present management of acute psychotic agitation varies among clinicians. Key treatment goals have been to calm the agitated, assaultive, violent, or disruptive patient, minimize the danger to self and others, and achieve a smooth transition from intramuscular to oral maintenance. For many years, intramuscular treatment with benzodiazepines and/or conventional antipsychotics, such as haloperidol, has been the mainstay of treatment for acute psychosis. Unfortunately, the poor tolerability of conventional antipsychotics compromises their usefulness for both short- and long-term treatment. Although new antipsychotics have a more favorable side-effect profile, the transition from an intramuscular formulation has been problematic. Fortunately, the development of intramuscular formulations of olanzapine and ziprasidone offer new treatment options for patients experiencing acute psychotic episodes. This article will review the use of intramuscular agents, standard antipsychotics, and new antipsychotics in the emergency room setting. The strengths and limitations of each will be discussed.

The association between obsessive-compulsive (OC) symptoms and schizophrenia has been discussed in the literature for many decades. Recent studies, which have been more systematic than earlier reports and benefited from more rigorous diagnostic criteria, have generated results that contradict earlier findings. The current consensus is that OC symptoms are seen in a significant number of patients with schizophrenia, and indicate a poor prognosis. These recent studies also suggest that OC symptoms are more than just expressions of persistent schizophrenic psychosis, and that they share characteristics with obsessive-compulsive disorder (OCD). This article discusses the arguments supporting the possibility that OC symptoms are either manifestations of comorbid OCD, or are characteristics of a distinct subtype of schizophrenia.