The challenges of clinical psychopharmacological management

Collaboration among health care providers in the treatment of mental health patients with comorbid medical and neurological conditions can be very challenging, especially with pharmacotherapy management where medications are prescribed by multiple providers. An individual example of a patient with a number of comorbid conditions taking multiple concurrent medical and psychotropic medications is described to highlight how challenging such situations can be. Medical conditions or medical medications might trigger or exacerbate symptoms of mental disorders. Psychotropic drugs may cause adverse effects that come to the attention of medical providers. Accurate communication among providers-and between the patient and providers-is important to avoid misinformation or misunderstandings in the care of patients with complicated problems.     

What's a medication group?

For therapists interested in a didactic model, a Medication Group can be an ideal vehicle for patient education. Our patients are remarkably well informed on dopamine, tardive dyskinesia, side effects, types and levels of drugs, early symptoms, individual stressors and coping mechanisms. They request and titrate drug levels according to their own identification of symptom distress. There is no question that the ability to control their symptoms and medications is a positive and important experience for them. The focus for this paper, however, has been an exploration of a group therapeutic strategy which deals with the phenomenological needs of chronic schizophrenics to address the residual or negative symptoms of schizophrenia, and not their educational needs.     

Obsessive-compulsive disorder: suffering in silence

Obsessions and compulsions vary in frequency and intensity. Many individuals have habits that cause minimal or no disruption of their lives. OCD, however, causes significant distress and interference with daily life. The problem may go unnoticed by anyone except the involved individual, or it may involve family, friends, and acquaintances. The disorder can be disabling, adversely affecting a student personally, socially, and occupationally. Those who are significantly affected by OC symptoms are encouraged to seek treatment. Behavior therapy and medications are extremely beneficial in helping to relieve symptoms of OCD. Clomipramine and fluoxetine (Prozac) are new drugs available in the US that appear to be effective for OCD symptoms. Several other anti-OCD medications may be available in the US within the next few years. It is important that students and others on campus be made aware that OCD is more common than previously recognized, that more persons with OCD are seeking help, and that effective treatment is available. This "secretive," often disabling disorder is more open now, and it is to be hoped that more individuals will take advantage of current, effective evaluation and treatment modalities.     

The hunt for a cure for Parkinson's disease

Several exciting new scientific advances have been made in the past decade toward both understanding the causes of and finding a cure for Parkinson's disease. Heartened by an acceleration in research findings in the past several years, the government has recently called for an infusion of funds from both the National Institutes of Health and private foundations into this burgeoning area of biomedical research. Most currently available conventional treatments for the disease only temporarily delay symptom presentation while doing nothing to halt disease progression. However, the rapidly accelerating pace of research in this field has left researchers hopeful that Parkinson's will be the first major age-related neurodegenerative disease for which we have a viable cure. In this article, advances in various areas of Parkinson's disease research are reviewed.     

Parkinson's disease

In this case study, we describe the symptoms, neurological examination, test results, and brain pathology of a man with Parkinson's disease (PD). PD commonly presents with tremor or changes in one's ability to walk or move. Other major difficulties caused by this disease include rigidity of the body, slowness of movement, and postural imbalance. The disease symptoms principally result from the degeneration of a specific population of neuronal cells in the brain stem, in a region called the pars compacta of the substantia nigra. Pathology shows the loss of these cells and the appearance of characteristic neuronal cytoplasmic inclusions called Lewy bodies, which are composed principally of aggregated alpha-synuclein protein.     

Systemic lupus erythematosus and hormone replacement therapy

The indications for hormone replacement therapy (HRT) in postmenopausal women is the treatment of climacteric symptoms and the prevention of osteoporosis. Women with systemic lupus erythematosus (SLE) are more likely to have a premature menopause, osteoporosis and cardiovascular disease. HRT can induce SLE flares and cardiovascular or venous thromboembolic events. Therefore it should not be used in women with active disease or those with antiphospholipid (aPL) antibodies. In general, it should be used only for patients without active disease, a history of thrombosis or aPL antibodies. Non-oral administration of estrogen is recommended because of its lesser effect on coagulation. With regard to the progestogen, progesterone or pregnane derivatives are preferred. Otherwise, non-estrogen-based strategies should be used.     

Management of Parkinson's disease in older women

Elderly women with Parkinson's disease (PD) represent a specific patient population that may benefit from individualized treatment strategies. PD has been shown to occur approximately twice as often in men than in women, resulting in theories regarding estrogen being protective against the disease and as a potential treatment strategy. Given women's longer life expectancy, they are more likely to reach an age where antiparkinsonian medications are associated with side-effects. This paper will review medical and surgical treatments as well as the relationship of gender and age with respect to the management of PD.     

Mitochondrial abnormalities and oxidative imbalance in neurodegenerative disease

An increasing body of evidence now suggests the involvement of mitochondrial abnormalities in the etiology of neurodegenerative diseases, such as Parkinson's disease (PD) and Alzheimer disease. In this Perspective, we describe a recent study that shows that treatment of human patients with the antioxidant coenzyme Q(10'), which functions in concert with certain mitochondrial enzymes, reduced the worsening of symptoms associated with PD. These findings are consistent with the hypothesis that mitochondrial dysfunction plays a role in the pathogenesis of PD and that treatments that target mitochondrial biochemistry might ameliorate the functional decline observed in patients suffering from PD.     

Neurodegeneration in normal brain aging and disease

Normal "healthy" aging is defined as aging without disease. Many aged people do not exhibit symptoms of disease and lead normal lives, but nonetheless display pathological changes that are characteristic of Alzheimer's disease (AD), Parkinson's disease (PD), dementia with Lewy bodies (DLB), and/or cerebrovascular disease (CVD). These changes are restricted to distinct brain regions and might represent preclinical stages of these disorders. This Perspective discusses arguments in favor of and against the hypothesis that pathological changes related to AD, PD, DLB, and CVD in the brains of nondemented elderly people represent early stages of these diseases rather than healthy aging. We conclude that early pathological disease-related changes do indeed constitute the beginning of AD, PD, DLB, and CVD rather than normal concomitants of aging, even in the absence of any clinical symptoms. Aging is, therefore, a major risk factor for these diseases but does not necessarily lead to age-related diseases.     

Zyban: a new aid to smoking cessation treatment--will it work for psychiatric patients?

1. Psychiatric patients who smoke are more highly dependent on nicotine and are less likely to be successful at quitting. When they attempt to quit, depression is more likely to be a part of the withdrawal process. 2. Careful monitoring is required when psychiatric patients abruptly start or stop smoking. Clinicians must be aware that changes in smoking status will affect the actions and side effects of neuroleptic medications. Prescribing clinicians should ask about their patients' smoking patterns on a regular basis. 3. Psychiatric nurses have an ethical responsibility to identify individuals at risk of smoking-related disease, to inform current and future smokers about the risks of cigarette smoking, and to provide counseling and education for those who wish to quit.     

Akathisia. When treatment creates a problem

1. Akathisia is a state of restlessness and motor agitation, which includes subjective feelings of inner tension, emotional unease, anxiety, a constant need to move, restless motor activity, and an inability to tolerate inactivity or rest. 2. Akathisia is often unrecognized or misdiagnosed as agitation or anxiety of psychiatric origin; this often leads to inappropriate increases in the antipsychotic dosage, which then potentiates its severity, or to the misuse of antianxiety agents, which masks symptoms. 3. Akathisia can be easy to recognize by simple clinical observation of the patient's behaviors, especially if the symptoms worsen after increases in antipsychotic dosages or the frequent use of as needed medications. Assessment must also include the patient's own report.     

PMS and PMDD in the domain of mental health nursing

Premenstrual syndrome (PMS) is a complex cluster of symptoms that occurs 7 to 14 days prior to menses and ends 1 to 2 days after menses. Premenstrual syndrome symptoms can create severe, debilitating psychological and physical problems. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) provides criteria for premenstrual dysphoric disorder (PMDD), which can be considered the most severe presentation on the PMS continuum. A critical part of determining the diagnosis is evaluating the timing of symptoms. True PMS only occurs during the luteal phase of the menstrual cycle, with a symptom-free period during the follicular phase. After identifying a diagnosis of PMS or PMDD, the first-line treatment of these symptom clusters continues to be lifestyle changes, including stress management, healthy diet, regular aerobic exercise, cognitive-behavioral therapy, and fortified coping strategies. Women whose symptoms are not controlled adequately with lifestyle modifications may benefit from medications. Possible medication recommendations include selective serotonin re-uptake inhibitors (SSRIs), diuretics, gonadotropin-releasing hormone (GnRH) agonists, and vitamin and mineral supplements.     

Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of "atypical symptoms"

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians' interpretations of patient sex-gender affect diagnostic certainty and, in turn, decision making for coronary heart disease. Data are from a factorial experiment of 256 physicians who viewed 1 of 16 video vignettes with different patient-actors presenting the same symptoms of coronary heart disease. Physician participants completed a structured interview and provided a narrative about their decision-making processes. Quantitative analysis showed that diagnostic uncertainty reduces the likelihood that physicians will order tests and medications appropriate for an urgent cardiac condition in particular. Qualitative analysis revealed that a subset of physicians applied knowledge that women have "atypical symptoms" as a generalization, which engendered uncertainty for some. Findings are discussed in relation to social-psychological processes that underlie clinical decision making and the social framing of medical knowledge.     

Pharmacotherapy for psychotropic drug-related weight gain

Weight gain is a significant problem for many patients taking various psychotropic medications. The U.S. Food and Drug Administration (FDA) has approved certain medications for the treatment of obesity. Other medications known to be associated with weight loss could be used for treating obesity, although they are not FDA approved for this indication. This article briefly describes the sympathomimetic, antidepressant, anticonvulsant, histamine-modulating, antidiabetic, and gastrointestinal drugs that have been found to cause weight loss and might be considered for adjunctive use in the overall management of psychotropic drug-related weight gain. However, even if such drugs are effective, all patients should receive ongoing dietary and physical activity counseling.     

Huntington's disease

In this case study, we describe the symptoms, neurological exam, neuropsychological test results, and brain pathology of a man who died with Huntington's disease (HD). HD is a rare neurodegenerative disease. Like other movement disorders involving the basal ganglia, HD affects motor, cognitive, and psychiatric functioning. The disease follows an autosomal dominant pattern of inheritance, with onset of symptoms most commonly occurring in the late 30s or early 40s, as in this patient. HD is caused by an unstable expansion of the trinucleotide CAG, coding for glutamine, on chromosome 4. Despite knowledge of the gene mutation responsible for HD, no definitive treatment is currently available to slow or halt progression of the disease. However, symptomatic treatment can significantly improve the quality of life for patients with HD.     

Vocational implications of post-polio syndrome

Of more than 1,000,000 survivors of poliomyelitis living in the United States, about 80% experience symptoms associated with post-polio syndrome (PPS). New weakness, fatigue, and pain are the most common symptoms that may appear years after acute polio. PPS is reported to be the most prevalent progressive neuromuscular disease in North America. The physical symptoms of PPS can be severe enough to decrease an individual's quality of life, significantly alter work function, and impose lifestyle changes. The psychological implications of battling once again with a disease that had stabilized decades ago can be devastating. Rehabilitation physicians and counselors knowledgeable of post-polio syndrome and its possible impact on employment can have a positive influence on persons with PPS.     

Progressive supranuclear palsy

In this case study, we describe the symptoms, neurological examination, clinical course, and neuropathology of a patient with progressive supranuclear palsy (PSP). PSP is a relatively uncommon neurodegenerative disorder with many features similar to those of Parkinson's disease. It is characterized by slow motor function, ocular movement abnormalities, dystonia, and cognitive disabilities. PSP is largely a sporadic disorder caused by accumulation of the protein tau in diverse regions of the central nervous system. It is thus classified as one of several tauopathies. The exact cause of the disease remains unknown, and treatment is often limited. The following case provides a framework to explore the manifestations of PSP, as well as the progress made in understanding the nature of this challenging disorder.     

PRN medication use in inpatient psychiatry

1. Administration of p.r.n. medications occurs frequently for staff nurses in inpatient psychiatry. 2. The appropriate use of p.r.n. medications is not well addressed in nursing textbooks or hospital policies and procedures. 3. Thorough assessment of patients is an essential step in the safe administration of p.r.n. medications. 4. Concise, accurate clinical evaluations may be the most successful way to determine the best dose of medication for each patient.     

More from Louis Baxter on doctors taking MAT

The question of whether or not doctors and other health care professionals on medication‐assisted treatment (MAT) are safe to practice medicine has been debated for the last few years since the advent of Food and Drug Administration (FDA)–approved MAT for opioid use disorder (OUD). The newly approved medications have been primarily buprenorphine formulations for OUD, naltrexone formulations for OUD and alcohol use disorder (AUD), and, most recently, an alpha 2‐adrenergic medication that specifically targets amelioration of opioid‐withdrawal symptoms from OUD (lofexidine). Quite frankly, the question of safety about medications to treat substance use disorder (SUD) has been asked since the development of methadone for OUD treatment more than 30 years ago.