Dopamine hypothesis of schizophrenia: Making sense of it all

The dopamine (DA) hypothesis of schizophrenia has evolved over the last decade from the stage of circumstantial evidence related to clinical observations and empirical validation from antipsychotic treatment to finally reach more direct testing and validation from imaging studies. These have provided much information that allows us at this point to assemble all the pieces and attempt to synthesize them and integrate them with the other neurotransmitter alterations observed in this illness. Although clearly not sufficient to explain the complexity of this disorder, the DA dysregulation offers a direct relationship to symptoms and to their treatment. We will review here its history, validation, and implications for treatment.     

Making it better: building evaluation capacity in community mental health

This paper describes a province-wide initiative aimed at building the capacity of community mental health programs to participate in program evaluation and development by transferring knowledge, promoting discussion and developing resources. Active involvement of stakeholders and evaluation of the current capacity of the field informed the ongoing development of the initiative. Recovery served as a guiding framework for formulating and understanding community mental health outcomes. Despite the interest of the field in evaluation activities, programs were constrained by limited resources and accountability structures. Sustainability of the project would be enhanced by direct work with programs to facilitate application of Continuous Improvement.     

Making sense of ADHD in practice: a stakeholder review

The study aimed to explore and synthesize stakeholders' conceptualizations and solutions concerning ADHD in the context of CAMHS. The participants were 28 stakeholders consisting of seven mental heath professionals, two teachers, seven parents/carers, five children referred for an ADHD assessment, two siblings and five peers. Individual, semi-structured interviews were held with all professionals and parents/carers. The children's interviews used methods tailored for junior age children and were semi-structured, individual and in a group format for the peers. All interviews were transcribed verbatim and the children's pictures were analysed. A thematic analysis was undertaken with ADHD thematically emerging as a confusing mess with conflicts reverberating across all levels of analysis from the intra-psychic world of the child to wider social contexts. Professionals attempt to make sense of this mess, parents experience the emotional impact of the mess and children's identities are shaped by it. A reflective space where complexity, uncertainty and hidden feelings are thought about is postulated to reduce confusion and dissonance, and which in turn would enable the system to become more self aware and less na?ve.     

Translating monotherapy trials into clinical practice: a look into the abyss

To be approved for monotherapy by regulatory authorities, new antiepileptic drugs (AEDs) must first be tested in well-controlled studies in refractory patients (conversion to monotherapy trials) or in patients with newly diagnosed epilepsy. However, the applicability of the information obtained in these trials to day-to-day clinical practice is limited. Clinical trials in newly diagnosed patients, particularly those allowing dose flexibility, offer more useful information, but a close scrutiny of methodological details is required to avoid misinterpretation of the findings. In many instances, the neurologist has a drug with a label, but lacks critical information on optimal titration rates, optimal target and maintenance dosages, response rates in populations with different epilepsy syndromes, different age ranges and comorbidities, and long-term safety data. Such information becomes available only through general clinical experience, well-designed phase IV studies, and postmarketing surveillance.     

Translating research into clinical practice: integrating robotics into neurorehabilitation for stroke survivors

Technological advances continue to infuse the field of neurorehabilitation with both excitement and apprehension. A challenge for clinicians is to determine which of the growing number of devices or interventions available should be incorporated into their clinical practice, and when and with whom they should be offered, in order to best assist their patients in attaining the highest level of function and quality of life. Robotics is one area of technology that has seen robust growth in rehabilitation applications, so much so that the presence of robotic devices in rehabilitation centers has become an expectation among patients, their caregivers, and therapists. Although rehabilitation robotic devices afford the opportunity to provide high doses of repetitive movement in a reliable and controllable manner, the role they play in the continuum of clinical care remains uncertain. The focus of this article is on translating the empirical evidence related to the application of rehabilitation robotics for improving lower limb and walking function in a manner that the clinician, or any stakeholder, will be able to incorporate relevant findings into clinical practice. A process is outlined and applied to a recent review of the literature related to the use of robotics for the treatment of lower limb and walking function in persons with stroke. This process provides the reader with a tool that can be applied to the translation and implementation of evidence related to any intervention for any client with neurological injury or disease.     

Ethics and forensic psychiatry: translating principles into practice

Twenty-five years ago, Alan Stone expressed his skepticism that forensic psychiatry could be practiced ethically. His remarks have proven a useful goad to the field, focusing attention on the importance of an ethics framework for forensic practice. But Stone remains dubious that any system of ethics--including the "Standard Position" on which he focuses his critique--could be of much value in practice. In contrast, I suggest that Stone's pessimism is not well founded. Immanent in forensic practice itself is a reasonable set of ethics principles, based on truth-telling and respect for persons. Psychiatrists can offer reliable and valid testimony, while resisting seduction into an advocacy role. Indeed, with new structured approaches to assessment, the potential utility of forensic testimony is probably greater than ever. Though problematic behavior still exists, forensic psychiatry offers the factual background and interpretive context to allow legal decision-makers to make better choices than they otherwise would.     

Psychiatric rehabilitation programs: Putting concepts into practice?

Mental health settings serving the severely psychiatrically disabled or the long-term chronic client have begun developing a rehabilitation orientation in an attempt to increase their effectiveness with this group. The authors have, in an earlier work, described basic elements of a rehabilitation program. These elements have been refined. Forty rehabilitation-oriented community and hospital agencies were assessed in terms of the presence or absence of these elements of a rehabilitation approach. Results indicate that the programs in the agencies clearly value client involvement and a program focus on improving skill and resource utilization. These concepts, however, are only beginning to be systematically implemented in practice.     

Pharmacogenetics in psychiatry: translating research into clinical practice

Pharmacogenetic/pharmacogenomic (PGx) approaches to psychopharmacology aim to identify clinically meaningful predictors of drug efficacy and/or side-effect burden. To date, however, PGx studies in psychiatry have not yielded compelling results, and clinical utilization of PGx testing in psychiatry is extremely limited. In this review, the authors provide a brief overview on the status of PGx studies in psychiatry, review the commercialization process for PGx tests and then discuss methodological considerations that may enhance the potential for clinically applicable PGx tests in psychiatry. The authors focus on design considerations that include increased ascertainment of subjects in the earliest phases of illness, discuss the advantages of drug-induced adverse events as phenotypes for examination and emphasize the importance of maximizing adherence to treatment in pharmacogenetic studies. Finally, the authors discuss unique aspects of pharmacogenetic studies that may distinguish them from studies of other complex traits. Taken together, these data provide insights into the design and methodological considerations that may enhance the potential for clinical utility of PGx studies.     

Clinical utility of the Trail Making Test practice time

The Trail Making Test (TMT) is one of the most frequently used measures in clinical neuropsychology. Data obtained from the TMT practice times were analyzed to determine their utility in predicting success and failure on the full version of the test and to allow establishment of criteria by which to judge administration or discontinuation of the full test. Results indicated that TMT practice times were useful in predicting successful completion of Part A and B of the TMT. Tables are provided which describe the classification accuracy of various TMT practice times. These tables allow clinicians to select a practice-time cutoff and then use the cutoff as a heuristic to assist in the decision to administer the remainder of that particular part of the TMT or discontinue the test. A 20-s cutoff resulted in optimal prediction of successful completion (< 180 s) of TMT Part A. A cutoff of 30 s optimally predicted successful completion (< 300 s) of TMT Part B.     

Treatments for borderline personality disorder: integrating evidence into practice

There has been a spate of new developments in the treatment of borderline personality disorder (BPD) in the past few years. Improved diagnostic methods and clarification of the nosological status have led to progress in recognition and management of this condition. In particular, uses of low dose neuroleptics and selective serotonin reuptake inhibitors, partial hospitalization and cognitive behaviour therapy have helped to reduce the nihilism associated with treating these patients. The emphasis is now on providing integrated as well as targeted treatment packages The trends in treatment are reviewed with a stress on needs for more randomized controlled studies of effective pharmacologic agents as well as psychological treatments.     

Outcome measures in neurological physical therapy practice: part I. Making sound decisions

Standardized outcome measures (OMs) are a vital part of evidence-based practice. Despite the recognition of the importance of OMs, recent evidence suggests that the use of OMs in clinical practice is limited. Selecting the most appropriate OM enhances clinical practice by (1) identifying and quantifying body function and structure limitations; (2) formulating the evaluation, diagnosis, and prognosis; (3) informing the plan of care; and (4) helping to evaluate the success of physical therapy interventions. This article (Part I) is the first of a 2-part series on the process of selecting OMs in neurological clinical practice. We introduce a decision-making framework to guide the selection of OMs and discuss 6 main factors-what to measure, the purpose of the measure, the type of measure, patient and clinic factors, psychometric factors, and feasibility-that should be considered when selecting OMs for clinical use. The framework will then be applied to a patient case in Part II of the series (see the article "Outcome Measures in Neurological Physical Therapy Practice: Part II. A Patient-Centered Process" in this issue).