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Many physicians who work in the emergency department (ED) consider the agitated patient the bane of their existence. These patients are frequently difficult to deal with, are uncooperative, and can bring an already busy ED to its knees. Although it is easy to understand why severely agitated patients are commonly placed in restraints or seclusion, it is essential that cooler minds prevail when an agitated patient presents to the ED. The patient should be treated with dignity, respect, and understanding. Because these patients often cannot express their feelings adequately, many who work in the ED do not realize that these patients do not like the feeling of being out of control.

Articles on psychiatric emergency services (PESs) published between 1983 and 2003 were reviewed to evaluate research on providers, clients, and services; access, use, evaluation, treatment, and continuity of care; and outcomes of the use of PESs. Eighty-five articles were selected as representative of the literature on variation in PES arrangement and effectiveness. The Donabedian model (structures, processes, and outcomes) was used to evaluate health care services.

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Restraints and seclusion have been used for many years in emergency departments (EDs) and psychiatric emergency services (PESs), but anecdotal case reports and newspaper investigations as well as clinical advances have led to restrictions in their use.

Dr Zun has done an excellent job of reviewing the many controversies and complexities that surround the use of mechanical and chemical restraint as well as seclusion. He also shows us how many unanswered questions there are about such interventions. For example, an insightful psychiatric resident once raised the question of which intervention was more restrictive and stigmatizing: seclusion or restraint?

The use of restraint and seclusion remains a controversial issue, and emergency care providers must remain absolutely current on it. We can come under criticism both for using too much coercion and for not using enough. Restraint and seclusion exist at an intersection of science, government policy, and public perception. These seemingly straightforward forms of medical coercion are still, in actuality, far from straightforward.

"Chemobrain," a term coined by patients in breast cancer support groups to describe cognitive impairment associated with chemotherapy, is becoming a subject of research.

Sensitivity and specificity of a new bipolar spectrum diagnostic scale.

Recent research has shown environmental factors may increase the risk of schizophrenia in persons who may already have a genetic predisposition toward the illness.

In an attempt to reframe the either-or debate over the impact of genetics versus environment on emotional makeup, a panel convened at the American Psychoanalytic Association’s Winter 2005 Meeting in New York City. This article highlights studies presented at the meeting.

Irritable Bowel Syndrome: Psychiatric Factors and Therapies

Obsessive-compulsive disorder is a prevalent, disabling and chronic illness. Serotonin reuptake inhibitors are the first-line of treatment; however a large proportion of patients will have either a partial or nonresponse. This review outlines the strategies for treatment-resistant OCD, including augmentation agents, alternative monotherapies, intravenous strategies and newer nonpharmacologic somatic treatments under development.

After the apparent failures of the U.S. Food and Drug Administration to discern cardiovascular effects of COX-2 inhibitors and suicidality in children receiving antidepressants, critics of the FDA say that the agency has failed to protect public health. Read what advocacy groups are saying and Congress is doing to change the FDA.

Impulsive behaviors play an important role in both bipolar and substance abuse disorders. However, results of studies investigating this link are often ambiguous, in part, due to the multidimensional nature of the impulsivity construct and the fact that many studies use a single measurement technique. We describe a model of impulsivity characterized by three components: response initiation, response inhibition and consequence sensitivity. How these components differ from one another in terms of their use, behavioral theory and biological function is discussed, along with measurement techniques.

Proposed changes in the conceptualization of compulsivity and impulsivity in the DSM-V will have important implications in the way clinicians recognize and treat these disabling conditions.

One of this year’s recipients of the National Medal of Science sits down to talk with Psychiatric Times about his research, accomplishments and music.

If I Were a Painter

Marijuana is the number one illegal drug of abuse in the United States; in second place is the nonmedical use of prescription medications such as pain relievers, tranquilizers, stimulants and sedatives. The National Institute on Drug Abuse is intensifying its research in understanding mechanisms that underlie the reinforcing, addictive and toxic properties of prescription medications, and developing medications with less abuse potential.

Comparative data are emerging on the metabolic effects of the second-generation antipsychotics on adolescents and children. Data presented at national meetings is discussed. When using these medications, the risks and benefits need to be carefully weighed until more definitive information is available.

Subspecialization within the practice of neurology is now reality with the recent approvals of subspecialty designations for neuromuscular pathology, headache medicine, and neuro-oncology. The American Academy of Neurology (AAN) Committee on Neuromuscular Pathology sponsored the neuromuscular pathology membership application. Two associations--the AAN Headache and Facial Pain Section and the American Headache Society--sponsored the headache medicine application.

The Workforce Task Force of the American Academy of Neurology projects that the number of pediatric neurologists will be 20% below demand, at least through the year 2020

Animal models enable researchers to track amyotrophic lateral sclerosis (ALS) pathogenesis. Erik Storkebaum, MSc, and colleagues at the Center for Transgene Technology and Gene Therapy at Flanders Interuniversity, Leuven, Belgium, took several approaches to increase supply of the neuroprotective protein vascular endothelial growth factor (VEGF) in an animal model. "When administered to rats at 60 days, which is 1 month before symptoms, it delayed onset and prolonged survival by 22 days. When we gave VEGF at the age of disease onset, which more closely mimics the human situation, the treatment still prolonged life by an average of 10 days," Storkebaum reported at the Society for Neuroscience annual meeting in October 2004

All clinical trial sponsors will be required to register all publicly and privately sponsored clinical trials with the existing government clinical trials registry, www.clinicaltrials.gov, before the first patient is enrolled in the trial.

Until recently, physicians assumed that any recovery from spinal cord injury (SCI) was limited to the first few months to a year after the injury occurred. In children, this window of opportunity for recovery could last about 2 years. Certainly, no one expected any significant recovery in any person with a chronic SCI or other condition that causes SCIs, such as a stroke, blood clots, or arteriovenous malformation affecting the spinal cord.

An estimated 18,500 cases of primary cancer of the brain and CNS will be diagnosed this year, according to the American Cancer Society (Cancer Facts and Figures 2005;

Clinical trials--and how they are conducted--have been getting a lot of attention lately, as discussed in our article, "Clinical Trials Appear Headed for More Openness," beginning on page 13. We had already finished editing the article, however, when I got a notice on June 22 about a survey commissioned by the Michael J. Fox Foundation for Parkinson's Research. According to the results, of the surveyed US physicians who treat people with Parkinson disease (PD), 96% agreed that clinical trials are necessary to develop better treatments.

On physical examination, the patient appeared well, except for the obvious diffuse rash. Erythematous macules, papules, and patches covered his extremities, face, trunk, palms, and soles. His conjunctivae, mucous membranes, and joints were normal, as were the results of cardiac, pulmonary, abdominal, and neurologic examinations. Several anterior and posterior cervical lymph nodes (0.5 to 1 cm) were present bilaterally.

The FDA approved on June 21 the prescribing of levetiracetam (Keppra, UCB Pharma) as an add-on treatment for partial-onset seizures in children 4 years or older who have epilepsy. The approval follows a randomized, double-blind, placebo-controlled trial conducted at 60 sites and involving 198 children aged 4 to 16 years