Bipolar Disorder

Eastern philosophy and religion have always had what the philosopher Hajime Nakamura2 called “a preference for the negative.” This stands in stark contrast to our Western penchant for the positive, and our proclivity for defining and intervening is most pronounced in the overactivist mode of modern American medicine."

Anger is an emotion that is familiar to everyone. An episode of anger may dissipate quickly and harmlessly or evolve into a murderous rage. Between the benign and malignant end points in this spectrum, a seething, chronic anger may come to dominate a person’s thinking, feeling, and behavior.

To improve validity, we proposed extending the current MDD bereavement exclusion-which excludes “uncomplicated” (relatively brief, lacking certain severe symptoms) depressive bereavement from diagnosis-to also exclude uncomplicated reactions to other major stressors, such as romantic breakups, job loss, and serious medical diagnoses.

For many antidepressants, the issue of brand-name versus generic has no practical significance. Elavil was first marketed almost a half century ago, and its patent has long expired. It lives on, however, but as generic amitriptyline. Today, only a few antidepressants are still fully protected by patents, namely, Cymbalta (2010), Lexapro (2012), and Pristiq (2022) for major depressive disorder (MDD); and Seroquel (2011) and Symbyax (2017) for bipolar depression.

Several classes of hypnotic medication are available: the older barbiturates and their derivatives; benzodiazepines; chemically distinct “z-compounds”; antihistamines and antihistaminic antidepressants; and melatoninergic compounds. The use of hypnotic medications continues at a high rate. However, some switching to the shorter-acting benzodiazepines has occurred. The z-compounds-eszopiclone, zolpidem, and zaleplon-have become popular; they seem to have fewer residual effects than the benzodiazepines. Even so, care is needed in prescribing such hypnotics for the elderly.

This Special Report presents an important set of articles that considers controversial issues relevant to the practice of psychiatry. These articles demonstrate that what we do as practitio­ners is often based on incomplete evidence and/or reliance on experience and the art of psychopharmacology. There are considerable limitations to “evidence-based medicine” as applied to the issues considered and also to what can be said officially about “off-label” uses of medications. All that said, these articles represent a very interesting set of perspectives on important and, to date, unresolved problems for which our science falls quite short of giving us definitive answers.

For Allen, that film was the measure of Bergman’s genius, and it reached aesthetic heights that he conceded his own films would never attain. Bergman, like his Knight, Allen observed, could not put off the ultimate checkmate nor would his great art secure for him a personal afterlife as intellectuals wanted to believe. Allen was sure that Bergman would barter each great film he had made for another year of life so he could go on making films.

Psychotropic treatment can often prevent the relapse of psychotic and mood symptoms. However, many patients take medication intermittently or not at all; or the symptoms may be only partially responsive to medication. Therefore, there is a need for interventions that can supplement the effect of medication and improve treatment outcomes.

The assessment and treatment of psychiatric symptoms in persons with cognitive dysfunction are becoming increasingly important. Prevalence estimates of dementia in the United States range from 5% in those aged 71 to 79 years to 25% to 50% in those 90 or older.

Autism spectrum disorders (ASDs) are a group of 5 neuro developmental conditions (autism, Asperger syndrome, pervasive developmental disorder not otherwise specified [PDD-NOS], Rett syndrome, and disintegrative childhood disorder).1 Once thought to be rare, the incidence of these disorders is now estimated to be 1 in 150 children in the general population.2 Furthermore, the number of recognized cases has increased markedly in recent years.

Optimal management of bipolar disorder (BD) includes the careful selection and regular ingestion of appropriate medication to stabilize mood. Unfortunately, between 40% and 50% of patients with BD in routine clinical settings take breaks or forget to take their medication or even discontinue the drug altogether.1-3 Treatment nonadherence is associated with mood relapse, hospitalization, and suicide.4,5

What exactly is a “mental disorder”? For that matter, what criteria should determine whether any condition is a “disease” or a “disorder”?

Medications cannot be marketed in the United States without an FDA determination that they are safe and effective for their intended use. To obtain such certification, pharmaceutical companies submit their products to rigorous scrutiny (eg, in vitro studies, animal studies, human clinical trials) and present the subsequent data to the FDA, which determines whether the medication in question is safe and effective for a specific purpose.

Patients with bipolar depression who exhibit even minimal manic symptoms are at heightened risk for switching into mania if they receive antidepressant medication, according to a new report from the Bipolar Collaborative Network.

The central tenet of clinical comorbidity, the occurrence of 2 syndromes in the same patient, presupposes that they are distinct categorical entities.

Subjective complaints of impaired concentration, memory, and attention are common in people with major depressive disorder (MDD), and research shows that a variety of structural brain abnormalities are associated with MDD.1 These findings have intensified the interest in quantitative assessment of cognitive and neuropsychological performance in patients with mood disorders. Many studies that used standardized cognitive tests have found that mild cognitive abnormalities are associated with MDD and that these abnormalities are more pronounced in persons who have MDD with melancholic or psychotic features

Many people assume that it is the emotional and psychotic symptoms that make it difficult for a person with schizophrenia to function in everyday life. In fact, research indicates that cognitive impairment is a major reason why functional outcome is so poor.1

The FDA Pediatric Advisory Committee met in November to review drug trials and safety data for several medications under consideration for pediatric-specific labeling. Drugs included the antipsychotics olanzapine (Zyprexa) and risperidone (Risperdal). Although not yet finding sufficient evidence of safety and efficacy in this population, the committee specified additional information that could be submitted for the applications to be reconsidered.

I have a neuromuscular disorder. This problem presented itself at birth, and I took much longer than other children to crawl, walk, and reach other physical developmental milestones. My sister is also affected, and although we have had extensive workups twice, the diagnosis is unclear. I had physical therapy up until my early teens, at which point I could do everything I needed to do in day-to-day life.

Two prominent psychiatrists have agreed to curtail their research activities following revelations about sizable consulting fees from pharmaceutical manufacturers.

Eli Lilly and Company pleaded guilty on January 30 to one misdemeanor violation of misbranding Zyprexa (olanzapine) by promoting it for dementia. However, a question raised by bloggers and others remains: did the drug benefit the elderly despite the fact it was not approved by the FDA for such purposes?

The rationale for the use of anticonvulsants in anxiety disorders is supported by neurobiological underpinnings that make these compounds a likely alternative for short-term treatment.

My first job after residency involved working at a large Veterans Affairs hospital in an outpatient dual diagnosis treatment program that focused on the comorbidity of schizophrenia and cocaine dependence. Having recently completed a chief resident position at the same hospital’s inpatient unit that focused on schizophrenia without substance abuse, I was struck by how “unschizophrenic” my new patients were. They were organized and social. Their psychotic symptoms were usually limited to claims of “hearing voices,” for which insight was intact and pharmacotherapy was readily requested.

The words attributed to Socrates resonate with the perspectives of many contemporary parents and clinicians.1 The endurance of the concern suggests something fundamental about the psychopathology of deviant, disruptive behavior of youth. Yet clinicians struggle to understand its origins, to help parents control their children, and to help the children control themselves. Clinically, this manifests in failed pharmacological treatments, incompleted courses of individual therapy, problems in engaging families in treatment, and controversies over which therapy is most effective.

Because numerous diseases- infectious, endocrinological, metabolic, and neurological, as well as connective-tissue disease-can induce psychiatric and/or behavioral symptoms, clinicians need to distinguish these neuropsychiatric masquerades from primary psychiatric disorders, warned José Maldonado, MD, the director of Stanford University’s Psychosomatic Medicine Service.

The FDA is forcing manufacturers of all antiepileptic drugs to include new warnings of possible suicide ideation in the prescribing information and also to prepare a new Medication Guide to be distributed by pharmacies to consumers. In addition, the companies will have to produce a Risk Evaluation and Mitigation Strategy for each drug, which the FDA only requires for drugs with possible adverse effects it considers especially dangerous.

In a resolution that has been expected since October 2008, pharmaceutical company Eli Lilly pled guilty to a criminal charge and has agreed to pay $1.42 billion in a settlement for what federal prosecutors called the illegal promotion of the antipsychotic drug Zyprexa (olanzapine). The drug was found to increase the risk of severe adverse effects, including sudden cardiac death, heart failure, and life-threatening infections, in certain populations.

Suicide risk assessment is a core competency that all psychiatrists must have.1 A competent suicide assessment identifies modifiable and treatable protective factors that inform patient treatment and safety management.2 Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Patient suicide is an occupational hazard. A clinical axiom holds that there are 2 kinds of psychiatrists: those who have had patients commit suicide-and those who will.

The insanity defense represents a prominent symbol of the relationship between law and psychiatry. Despite the fact that it is infrequently raised and seldom successful, the insanity defense is the subject of intense legal and public scrutiny.

The development of new, more effective antipsychotics with fewer adverse effects (eg, extrapyramidal symptoms, tardive dyskin­esia, metabolic syndrome) is paramount.