Neuropsychiatry has had different meanings at different times in the history of clinical neuroscience. In this article, the origins of what has become today’s neuropsychiatry are briefly explored, hopefully revealing a number of pioneers of the discipline, some of the names being familiar to many readers, others however being less recognized or even unknown to those who today would wish to carry the moniker of a neuropsychiatrist. It explores the rise of what I refer to as modern or today’s neuropsychiatry, and empathizes a phenomenological approach to clinical understanding, and the fact that neuropsychiatry it is a discipline in its own right and not just a wing of psychiatry or a bridge between neurology and psychiatry.

Patients with schizophrenia have a 20% shorter lifespan than people without the disorder. An increased risk of cardiovascular morbidity and mortality is also associated with schizophrenia. Atypical antipsychotics may contribute to the prevalence of cardiovascular disease by causing weight gain and increased adiposity, risk of insulin resistance, hyperglycemia, diabetes, and hyperlipidemia. Atypical antipsychotics that produce the greatest degree of weight gain also appear to impose the greatest risk of diabetes and hyperlipidemia. Recent evidence suggests that atypical antipsychotics may even affect glucose and lipid metabolism independent of weight gain. Among the currently marketed antipsychotics, clozapine and olanzapine appear to produce the greatest degree of weight gain. Moderate increases in weight are also observed with quetiapine and risperidone. Only ziprasidone and aripiprazole appear to be weight neutral. Atypical antipsychotics that produce the greatest degree of weight gain also appear to carry the greatest risk of diabetes and hyperlipidemia. Because of the potential for atypical antipsychotics to cause weight gain and adversely affect glucose and lipid metabolism, clinical monitoring of these parameters is critical. Dietary modification and exercise may be critical to addressing antipsychotic-induced weight gain and its consequences. In patients with persistent weight gain, evaluation of the risks and benefits of ongoing medications and consideration of switching to an antipsychotic with lower weight-gain liability may improve health outcomes.

Objectives: To investigate the current and lifetime frequency and severity of obsessive-compulsive (OC) symptom dimensions in Tourette syndrome (TS) patients, and how these dimensions affect clinical characteristics.

Methods: Forty TS outpatients (29 males, 11 females) were interviewed with the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS), the Yale Global Tic Severity Scale (YGTSS), the Shapiro Tourette Syndrome Severity Scale, and the Global Assessment of Functioning (GAF).

Results: OC symptoms were present in 80% of the total sample. The miscellaneous and the symmetry dimensions were the most frequent at the “current” and “lifetime” surveys, respectively. The aggression dimension had the smallest difference between “worst ever” and current ratings among the all OC symptom dimensions. TS patients with the aggression dimension (n=7) had significantly lower scores in the GAF scale and higher frequencies of coprolalia. There were significant correlations between the YGTSS severity scores and specific DY-BOCS dimensions.

Conclusion: OC symptoms are frequent in TS subjects and there were differences in the frequency, severity, and course of the OC symptom dimensions. These results emphasize the need for future longitudinal studies using a dimensional approach for the evaluation of OC symptoms in tic disorders.

Psychosocial interventions are part of the complex understanding and treatment of violent behavior in our state mental health hospitals. A comprehensive assessment of violence and aggression includes attention to all 3 domains of prevention and assessment (primary-institutional, secondary-structural, and tertiary-direct). Trauma experiences and their consequences may include behavioral violence and aggression. The authors’ premise is that trauma is a universal component in the individual assessment of violent behavior. Therapeutic interventions must include a trauma-informed formulation to be effective. Organizational commitment to trauma-informed, person-centered, recovery-oriented (TPR) care is crucial to the efficacy of any of the interventions discussed. Thus, the dynamic nature of the individual, interpersonal, environmental, and cultural factors associated with the daily operations of the inpatient unit need to be assessed through the lens of primary and secondary violence prevention, building on the recognition that the majority of persons served and staff have significant trauma histories. Once a compassionate, respectful, empathic, and empowering approach is embraced by leadership and staff, the work with individuals can proceed more effectively. Interventions used include a variety of cognitive-behavioral, interpersonal, and somatosensory therapies. These interventions, when effectively applied, result in more self-esteem, self-mastery, self-control for the person served, and diminished behavioral violence.

Parasomnias are involuntary behaviors or subjective experiences during sleep. Our objective was to review existing information on the presence of parasomnias in patients with addictions or during treatment for addictions. Information about parasomnias related to rapid-eye-movement (REM) and non-REM sleep in patients with addictions, while using substances or in abstinence, was reviewed. A systematic search of published articles reporting parasomnias as a consequence of drug use or abuse was conducted in the PubMed and SciELO databases. The search for the studies was performed in three phases: (1) by title, (2) by abstract, and (3) by complete text. The search was performed independently by two researchers, who then compared their results from each screening phase. Seventeen articles were found. The consumption of alcohol was reported in association with arousal disorders, such as sexsomnia and sleep-related eating disorder; and REM sleep behavior disorder was reported during alcohol withdrawal. Cocaine abuse was associated with REM sleep behavior disorder with drug consumption dream content. Overall, we found that several types of parasomnias were very frequent in patients with addictions. To avoid accidents in bedroom, legal problems, and improve evolution and prognosis; must be mandatory to include security measures related to sleep period; avoid pharmacological therapy described as potential trigger factor; improve sleep hygiene; and give pharmacological and behavioral treatments for patients with these comorbid sleep disorders.

The advent of the newer “atypical” antipsychotics has revolutionized pharmacologic treatment of schizophrenia (SZ) and other psychotic disorders. In contrast to the first-generation conventional neuroleptics, these second-generation antipsychotic agents possess a broader spectrum of efficacy and cause fewer motor side effects such as extrapyramidal symptoms and tardive dyskinesia. Despite their substantial advantages, however, these second-generation agents also have significant limitations in terms of both efficacy and adverse effects. Several strategies to address these shortcomings are currently under study and some of these are likely to become part of our therapeutic armamentarium in the future. Current shortcomings in the pharmacologic treatment of SZ and strategies under investigation to address each of these deficiencies are reviewed. New formulations of existing medications and new antipsychotics under development are discussed. Developing adjunctive treatment strategies to address each of the major psychopathologic domains in SZ are summarized. The potential application of genetic information to treatment-matching in SZ is reviewed and likely refinements in the practice of evidence-based medicine in the pharmacotherapy of SZ are considered.

Depression is one of the world's great public health problems. As there are no perfect or uniformly effective treatments for depression, it is not surprising that treatment-resistant depression (TRD) is likewise an important public health problem. Although the potential benefits of antidepressants are now well documented, no widely used antidepressant can be expected to be effective in more than half the patients who begin to take it. Even under optimal circumstances (ie, a patient who is fully adherent to 12 weeks of treatment), there is only a 60% to 70% chance that the first choice of medication will be effective. The need for effective alternate strategies for TRD, as well as the need for innovations in service delivery systems to ensure those strategies are implemented in a timely manner, are foremost to fully realizing the potential benefits of antidepressant therapies.

Over the years, hierarchies of treatment strategies for TRD have been based on the widespread use of particular treatments, their ease of use, and their safety or complexity. One of the strategies consistently used since its introduction 20 years ago has been augmentation of the ineffective antidepressant by a second medication. The second agent may or may not have antidepressant effects of its own, but when used in combination with a primary antidepressant the agent reliably increases a patient's likelihood of response and symptom remission.

Complementary and alternative medicine (CAM) is very popular in the United States, Canada and other Western societies, and the number of patients seeking treatment by CAM practitioners is increasing. This trend also affects treatment-seeking patients with affective disorders. Many patients and mental health providers update their information and formulate opinions and decisions based on second-hand digested summaries and scientific reviews of the literature. This results in the proliferation of review articles and journals that are exclusively dedicated to reviews. Since most medical schools do not teach CAM and most continuing medical education programs still ignore these subjects, it is of interest to examine the reliability of reviews that claim to be “systematic” and not to take their procedures and conclusions for granted.

Atypical antipsychotics—clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole—differ from conventional antipsychotics primarily by virtue of their actions at multiple central receptor sites. Each agent has its own unique receptor profile. The discovery of dopaminergic receptor-blocking capabilities of conventionblockingal antipsychotic drugs led to the dopamine hypothesis of schizophrenia. More recently, the role of serotonergic and other receptors in the pathophysiology and symptomology of schizophrenia and schizoaffective disorder has been identified, and the receptor actions of atypical antipsychotics have been linked to both antipsychotic efficacy and the propensity for extrapyramidal symptoms and other adverse effects. Receptor occupancy is directly related to antipsychotic dose, and the nature of the relationship between clinical utility and receptor occupancy is beginning to emerge. As our understanding of this relationship becomes more clear, the mechanism underlying clinical distinctions between agents will be understood.

From the perspective of efficacy, the main advantages of the group of new antipsychotic drugs, including ziprasidone, clozapine, quetiapine, olanzapine, and risperidone, are their ability to improve cognitive function. Other advantages are more selective, eg, clozapine in treatment-resistant schizophrenia, while the advantages for positive and negative symptoms in neuroleptic responsive patients are modest and sometimes difficult to demonstrate. The advantage for cognitive function is important because of abundant evidence that cognitive function is a key predictor of work and social function acquisition. The drug-induced cognitive improvement can synergize with typical rehabilitation programs and more experimental cognitive retraining programs to optimize these areas of improvement. Improved cognition also has implications for better compliance and decreased caretaker burden. It is also important to consider the efficacy of antipsychotics to improve mood and negative symptoms and to provide a biological framework for their ability to achieve these advantages over typical neuroleptic drugs. This article will provide new data on efficacy of this class of drugs relative to each other and to typical neuroleptics. Current theories linking efficacy in cognition to unique effects on cortical dopaminergic and cholinergic function and improved patterns of connectivity in the brain during cognitive task performance will be discussed. Finally, pharmacologic strategies to augment affect and cognitive improvements due to the new antipsychotic drug therapies will be discussed.

The long-term management of schizophrenia with a goal of functional rehabilitation remains an enormous challenge to clinicians despite improvements in drug therapy, psychosocial treatments, and family and community interventions. The goals of long-term therapy are to preserve the gains made during acute treatment, prevent symptom exacerbation, enhance psychosocial functioning, and improve quality of life. Schizophrenia is an illness that disrupts broad areas of mental function, including thought, cognition, affect, and motor performance. The new antipsychotics should aid physicians in meeting higher treatment goals for persons with schizophrenia. These agents combine high efficacy with improved tolerability, mainly through a low liability for extrapyramidal symptoms and probably improve cognitive affect. Recent studies have demonstrated efficacy of these new antipsychotics in improving psychopathology and symptoms and in preventing relapse during long-term use. These drugs are likely to provide physicians with an increasingly viable option in the long-term treatment and rehabilitation of patients with schizophrenia.

Objective: To identify characteristics of patients diagnosed with unipolar depression who may have undiagnosed bipolar disorder.

Methods: Patients diagnosed with unipolar depression by a healthcare provider were identified through the Consumer Health Sciences National Health and Wellness Survey. Manic symptoms, comorbid conditions, psychiatric symptomatology, use of healthcare resources, and patient demographics were identified through Internet-based questionnaires. A self-report adapted version of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision criteria identified symptoms consistent with a manic episode. Psychological well-being was measured by the Psychological General Well-Being Index.

Results: Of the 1,602 respondents who met inclusion criteria, 219 (14% or ~1 out of 7) reported symptoms consistent with a manic episode and were considered at risk for undiagnosed bipolar disorder. These respondents were younger and had a lower socioeconomic status. At-risk patients rated their depression as more severe and experienced greater impairment of psychological well-being. More than 70% of those at risk reported speaking with a healthcare provider about their mania symptoms. Comorbid mental disorders, especially anxiety-related conditions, were common in these patients.

Conclusion: These findings underscore the importance of evaluating unipolar patients for bipolar disorder and may help clinicians identify symptoms and comorbidities associated with patients with unipolar depression at risk for undiagnosed bipolar disorder.