Faculty Bibliography

Considerable advances have been made since the mid-20th century in understanding and treating the suicidal patient. Self-inflicted death is the fourth leading cause of death in adults 18-65 years of age. Approximately 25,000-30,000 individuals kill themselves annually. The most outstanding advances in care of suicidal patients are due to both the better understanding of the neurochemistry of impulsive violence and to the development of psychopharmacotherapy and psychotherapies that target disorders associated with increased risk. (journal abstract)

Though considerable progress has been made in the treatment of anxiety and depressive disorders over the last 2 decades, many patients either fail to achieve remission or struggle with burdensome residual symptoms and personal conflicts. This article describes the application of short-term, psychoanalytically based, dynamic psychotherapy for the treatment of these prevalent psychiatric disorders. The article describes the psychodynamic views of anxiety and depression, the criteria for the selection of patients for these treatments, and the delineation of the spectrum psychotherapeutic techniques that are used to foster the resolution of the unconscious dynamic conflicts which generate, or maintain, anxiety or depressive experiences. In addition, recent meta-analysis of the application of short-term dynamic psychotherapies for the treatment of anxiety and depressive disorders have demonstrated efficacy comparable to psychopharmacology and cognitive-behavioral trials. Case examples and descriptions of the clinical process of therapy are provided. (journal abstract)

Cocaine-dependent subjects were treated by psychiatric residents in a 24-week sequence of Network Therapy. This approach, developed for practitioners in solo practice, employs a cognitive-behavioral orientation in sessions with family and peers as well as in individual sessions. Of 47 subjects, 73% of all observed weekly urines were negative for cocaine, and 20 (45%) of the subjects had negative toxicologies in the last 3 scheduled samples. A positive outcome was associated with the number of network (but not individual) sessions attended and completion of the full treatment sequence. Results suggest the utility of Network Therapy, even in the hands of relatively naive therapists

In this study, the authors examined the relationship between steady-state haloperidol blood levels and clinical response in patients with acute psychotic mania. Fifty-four inpatients with acute mania were randomly assigned to receive either haloperidol 25 mg/day or haloperidol 5 mg/day. Each subject also received a concomitant medication: lorazepam 4 mg/day, lithium, or placebo. The relationship between steady-state haloperidol blood levels and clinical improvement was studied using analysis of covariance. There was wide interindividual variation in the haloperidol blood level-dose ratio. Haloperidol blood levels (log-transformed) were found to significantly correlate with clinical response in acute mania. Low-dose haloperidol with concomitant lithium may produce an optimal response in acute mania. Haloperidol blood levels may be clinically useful in identifying patients who are nonresponsive because of low drug levels and, hence, in enhancing optimal haloperidol dosing for acute mania with psychosis

Health care systems of the 21st century confront the confluence of two important forces that conform their policies regarding culture. On the one hand, population demographics announce increasing diversity; on the other, a rising knowledge base regarding the impact of culture on mental health awaits to be incorporated into actual clinical practices nationwide. As regulators and payors incorporate this knowledge into their practices, standards and guidelines, the dream of mental health cultural parity will come somewhat closer to fulfillment. In this article, we have aimed to review how the integration of developing knowledge and evolving standards may contribute to such fulfillment

Antipsychotic dosing for acute mania has not been well studied. Combined treatment with lithium and an antipsychotic is the most common treatment, but additional antimanic efficacy of a lithium-antipsychotic combination beyond that of an antipsychotic alone has not been well demonstrated. Furthermore, the possibility that lithium could affect antipsychotic dose requirement is believed to have never been studied. In this study, 63 acutely psychotic bipolar manic inpatients were randomly assigned to receive double-blind treatment with 1 of 2 haloperidol doses, 25 mg/day or 5 mg/day, for 21 days. In addition to haloperidol, subjects were randomly assigned to receive concomitant treatment with placebo, standard lithium, or lorazepam 4 mg/day. The high haloperidol dose produced greater improvement and more side effects than did the low dose. Lithium added to the low dose produced a markedly greater clinical response than did the low dose alone. Lorazepam did not improve the outcome for the patients receiving low-dose haloperidol. The clinical response produced by high-dose haloperidol was not enhanced by adding either lithium or lorazepam. All treatment effects emerged by the fourth day of treatment and persisted. Used alone, a haloperidol dose of 5 mg/day is too low for most manic patients, but concomitant lithium produces a dose-dependent enhancement of haloperidol response. Lorazepam 4 mg/day was insufficient to produce an advantage when added to low-dose haloperidol

A subgroup of adults in private treatment for cocaine dependence in remission reported a therapeutic effect from cocaine during the initial phases of cocaine addiction and, also, met DSM-IV criteria for ADHD. We report evidence that study subjects probably medicated their ADHD symptoms with cocaine and describe a 1-year treatment algorithm featuring long-acting stimulants that was effective in the management of their ADHD and cocaine dependence. Nineteen stable patients in full remission from all substance dependence were entered into an open label, prospective, treatment trial for ADHD. The treatment schedule consisted of the progressive introduction-and discontinuation of ineffective medication-of each of several medications in the following order: fluoxetine, bupropion, pemoline, sustained-release methylphenidate, dextroamphetamine spansules, and methamphetamine gradumets. Treatment of ADHD was successful. Several treatment regimens, especially those including long-acting stimulants, alone or in combination with other agents, were highly effective. All but 1 of the 19 subjects had a fully effective response for at least 1 full year. Mean UTAH scale scores were 7.4 before any medications were administered and 1.6 at the end of the study. Treatment proved successful in suppressing ADHD symptoms, with minimal cocaine slips or side effects