Faculty Bibliography

Two studies published in the February issue of the Archives of General Psychiatry suggest that taking a careful psychiatric history and performing a timely, routine blood test can predict the likelihood of developing postpartum depression (PPD) and of needing hospitalization. In each article, the authors described some of their findings as being 'remarkable.' Given that the focus of this issue Primary Psychiatry is women's mental health, I thought it useful to share the published information with you.

Presents a session with Marlene Freeman, MD in which the interviewer gathers her views on the use of omega-3 fatty acids in complementary alternative medicine in psychiatry. Dr. Freeman is a lecturer at Harvard Medical School and staff psychiatrist at Massachusetts General Hospital in Boston. Her research and clinical interests focus on mood disorders in women. Her particular interest is in treatment research that takes into account patient preferences and safety for the perinatal period. This has led her to focus on integrative medicine strategies. Dr. Freeman also focuses on the accurate and broad dissemination of evidence-based information to healthcare providers and the public.

Nicotine is an alkaloid found in tobacco. It has long been known that use of tobacco, mainly in the form of cigarettes, is much more prevalent among patients with depression and schizophrenia. From the perspective of both healthcare providers and patients, this is often one of the most difficult aspects of psychiatric hospitalization. It is standard policy in most hospitals to forbid smoking on inpatient units, a situation that adds to the discomfort of patients admitted to psychiatric hospitals. By being forced to quit smoking, not only do they experience nicotine withdrawal, but, emerging evidence suggests, their psychiatric symptoms may get worse and they may become more prone to agitation. As a result, nicotine withdrawal can increase aggressive behavior.

Presents an interview with Jerome M. Siegel. Jerome M. Siegel, PhD, is professor of psychiatry at the University of California, Los Angeles, former president of the Sleep Research Society, and the recipient of Merit and Javits awards from the National Institutes of Health and the Distinguished Scientist award from the Sleep Research Society. His laboratory has made discoveries concerning the role of hypocretin in human narcolepsy and Parkinson\'s disease. He has studied the phytogeny of sleep as a clue to sleep function, discovering that the primitive mammal platypus has rapid eye movement sleep and that marine mammals can go without extended periods of sleep for long periods without ill effects.

Presents an interview with Wayne K. Goodman. Dr. Goodman is chairman in the Department of Psychiatry at Mount Sinai School of Medicine in New York City. He previously served as director of the Division of Adult Translational Research and Treatment Development at the National Institute of Mental Health in Bethesda, Maryland. Dr. Goodman is a member of the American College of Neuropsychopharmacology a distinguished fellow of the American Psychiatric Association, and member and past chair of the Food and Drug Administration's Psychopharmacologic Drug-Advisory Committee. A pioneering researcher in the field of obsessive-compulsive disorder (OCD), Dr. Goodman is the principal developer of the Yale-Brown Obsessive Compulsive Scale, the gold standard for assessing OCD. In this interview, Goodman discusses the role of deep brain stimulation in the treatment of psychiatric disorders.

Psychiatric literature abounds with research reports that purport to find some biochemical, anatomic, or genetic marker that correlates significantly with a major psychiatric syndrome. These findings typically receive widespread publicity in the general press and become incorporated in academic presentations. For example, early in my career reports appeared that cited the 'pink spot' which was said to represent abnormal transmethylation in schizophrenic patients. There were studies of bufotenine, which was supposedly found in the urine of patients with schizophrenia. In the early 1880s, an abnormal dexamethasone suppression test was widely accepted as a diagnostic tool for major depressive disorder (MDD). Most recently, it has become almost universally accepted that a single gene (the gene responsible for expression of the serotonin transporter) modulates the effect of life stressors and the development of MDD. The source of the latter belief was a study published by Caspi and colleagues in 2003. They cited a polymorphism in the serotonin transporter (5-HTT)-linked polymorphic region (5-HTTLPR), a 44-base pair insertion/deletion polymorphism in the promoter region of the gene coding for the 5-HTT that results in two common alleles, termed ''short''(s) and ''long''(l). The s allele was found to be associated with increased risk for depression, especially when exposed to loss or environmental stress.

In last month's issue, I commented on recent research that the gene responsible for expression of the serotonin transporter (5-HTT) modulates the effect of life stressors and the development of major depressive disorder. Caspi and colleagues cited a polymorphism in the 5-HTT-linked polymorphic region (5-HTTLPR), that results in two common alleles, termed 'short'(s) and 'long'(l). The 's' allele was found to be associated with increased risk for depression, especially when exposed to loss or environmental stress. I also pointed out that a new study found that the 5-HTTLPR gene may not be as critical as believed, since the original finding had not been consistently replicated. The authors found no evidence that the serotonin transporter genotype alone or in interaction with stressful life events is associated with an elevated risk of depression in men alone, women alone, or in both sexes combined. Yet, here we are a month later and two new articles published in the July issue of British Journal of Psychiatry brings us back to 5-HTTLPR as a focal point of research on the prediction of who will develop depression and the prediction of antidepressant response.

Presents an interview with Sarah H. Lisanby on transcranial magnetic stimulation therapy (TMS). Topics discussed include the development of TMS, FDA appoval of TMS, the difference betwen TMS and magnetic resonance imaging, and how TMS works as psychiatric treatment.

The contributions to this month's issue of Primary Psychiatry cover a range of topics: dementia, attention-deficit/hyperactivity disorder (ADHD), secondary mania, and complications resulting from off-label use of medication. To the extent that there is a theme to this issue, it is that we ultimately are better clinicians if we are both well informed about the diagnostic and therapeutic literature and are flexible in applying this information when evaluating patients and developing a treatment plan. For example, the sudden onset of psychosis in an adult should lead us to look for possible underlying medical disease as a cause. Treating the symptoms without a full workup can prevent more timely diagnosis and treatment of the real cause of the presenting symptoms. Similarly ADHD remains a controversial diagnosis, and there are many clinicians who overlook this diagnosis or are reluctant to treat patients with this condition. Those who are skeptical about the validity of ADHD and that it persists into adulthood should review the recent literature about the risks and benefits of treatment before denying effective interventions to these patients. Part of what patients and their families expect is that, at best, we clinicians find that there is nothing seriously wrong. If we find a potentially life-altering or life-threatening condition, then patients want to hear that it can be effectively treated.

This issue of Primary Psychiatry presents the 2010 Guide to Psychiatric Drug Interaction's, a regular feature of this publication. Authored by Sheldon H. Preskorn, MD, and David A. Flockhart, MD, PhD--both respected authorities on the subject of psychotropic pharmacodynamics and pharmacokinetics--it is invaluable to any clinician, even those who do not specialize in the treatment of mental illness. Underscoring the public health implications of this topic, the authors note that a recent Health and Human Services report noted that 7% of Americans >18 years of age and >20% of Americans >65 years of age had taken >=5 prescription medications in the week and patients with psychiatric disorders are at increased risk relative to other age-matched patients for being on multiple medications and complex regimens, which makes-them particularly vulnerable to drug interactions. Prescribers should appreciate that psychiatric medications do not interact principally on the basis of their therapeutic use but instead on the basis of their pharmacokinetic and pharmacodynamic properties. A rational and informed approach to drug interactions, based on pharmacokinetic and pharmacodynamic knowledge, can reduce the chance of adverse effects and improve patient outcomes. What makes this educational review so useful is that it contains so many clear and concise tables and figures that accompany the text. I encourage all those who read this review to refer to it throughout the year.