Neurotic disorders and the receipt of psychiatric treatment

Access to psychiatric treatment by people with neurotic disorders in the general population is likely to be affected both by the severity of disorder and by sociodemographic differences. In the household component of the National Surveys of Psychiatric Morbidity >10,000 subjects in Great Britain with psychiatric symptoms were interviewed using the CIS-R. They were also asked about difficulties experienced in performing seven types of everyday activity. All subjects classed as having an ICD-10 disorder were questioned about their experience of treatment with antidepressants, hypnotics, and counselling or psychotherapy. Less than 14% of people with current neurotic disorders were receiving treatment for them. Within the previous year, only a third had made contact with their primary care physician for their mental problem: of these <30% were receiving treatment. Overall, 9% of people with disorders were given medication and 8% counselling or psychotherapy. A diagnosis of depressive episode was that most associated with antidepressant medication. Treatment access was affected by employment status, marital status, and age, but the major determinant was symptom severity. Neither sex nor social class influenced which people received treatment. People with psychiatric disorders seldom receive treatment, even when they have consulted their primary care physician about them. In many cases, this must represent unmet needs with a strong claim on health resources. There are also inequalities in the receipt of treatment, although the major influence is the severity of disorder.     

Neurotic disorders and the receipt of psychiatric treatment

Access to psychiatric treatment by people with neurotic disorders in the general population is likely to be affected both by the severity of disorder and by sociodemographic differences. In the household component of the National Surveys of Psychiatric Morbidity >10,000 subjects in Great Britain with psychiatric symptoms were interviewed using the CIS-R. They were also asked about difficulties experienced in performing seven types of everyday activity. All subjects classed as having an ICD-10 disorder were questioned about their experience of treatment with antidepressants, hypnotics, and counselling or psychotherapy. Less than 14% of people with current neurotic disorders were receiving treatment for them. Within the previous year, only a third had made contact with their primary care physician for their mental problem: of these <30% were receiving treatment. Overall, 9% of people with disorders were given medication and 8% counselling or psychotherapy. A diagnosis of depressive episode was that most associated with antidepressant medication. Treatment access was affected by employment status, marital status, and age, but the major determinant was symptom severity. Neither sex nor social class influenced which people received treatment. People with psychiatric disorders seldom receive treatment, even when they have consulted their primary care physician about them. In many cases, this must represent unmet needs with a strong claim on health resources. There are also inequalities in the receipt of treatment, although the major influence is the severity of disorder.     

Mortality of patients with organ-induced psychiatric disorders during inpatient psychiatric treatment

In this paper data from seven psychiatric hospitals in Baden-Württemberg, which can be regarded as representative for this region, are analysed. All patients with organic mental disorders of the ICD-9 categories 290, 293, 294 and 310 were included, while patients with alcohol- or psychoactive drug-induced psychoses were excluded. During the period from 01.01.1984 to 30.06.1986, 1821 episodes of treatment were recorded. 41% of all patients were male, the mean age of the population was 72.4 +/- 15.1 years. During their stay in hospital 137 patients died from natural causes, which is to compare with an expected number of deaths of 18.3, calculated according to the age- and sex-adjusted mortality rates of the German population. With a ratio of 7.5 the mortality of the whole study population was significantly raised. In all diagnostic subgroups a correlation with raised mortality was found, the risk being highest in patients with acute organic psychosis. An inverse relationship between age and mortality could be established. The main causes of death were cardiovascular disorders and pneumonias. The data of this investigation indicate an unequivocally increased mortality risk of patients with organic mental disorder during their stay in acute psychiatric units. The causes for this phenomenon are discussed, as well as potential consequences for hospital care of patients with organic mental disorder.     

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.     

Psychiatriform disorders: psychiatric analogues of somatoform disorders

BACKGROUND: Somatoform disorders can be understood to mimic supposedly more 'legitimate' physical disorders. To the extent that mental disorders are now also often considered legitimate, might clinicians expect to encounter the psychiatric equivalent of somatoform disorders, 'psychiatriform disorders'? METHOD: The relevant literature on somatoform disorders is reviewed in light of the tendency for mental and physical symptoms to co-occur. DISCUSSION: Illness attribution and behaviour may explain some of the recent rise in the prevalence of mental disorder. Hypotheses regarding the cause and nature of somatoform disorders are applied to their proposed psychiatric equivalent. Despite lack of current recognition, there is a strong theoretical basis for the existence of psychiatriform disorders. Psychiatriform disorders can be expected to have similar causes, comorbidity, and response to treatment, as somatoform disorders. A variety of cultural forces may be contributing to a rise in prevalence. CONCLUSION: As with somatoform disorders, psychiatriform disorders present problems in their distinction from conscious fabrication and from the ;legitimate' disorders they mimic. Given their likely prevalence and associated impairments, psychiatriform disorders warrant further examination, despite the methodological difficulties this presents.     

Home treatment for children and adolescents with psychiatric disorders

The study examines the effectiveness of home treatment in 70 children and adolescents (aged 6-17 years) with heterogeneous psychiatric disorders. Home treatment was offered to parents/children as an alternative to inpatient treatment (no randomized group assignment). Interventions were carried out by psychiatric nurses (n = 38) and medical students (n = 32) under the supervision of experienced child psychiatrists. Assessment of treatment effects was based on a structured parent interview and parents', children's and therapists' ratings of various aspects of psychosocial functioning. Pre- or post-treatment comparisons indicate significant improvement of psychiatric symptoms, severity of the disorder, and psychosocial adjustment after three months of home-based interventions. Outcome of behavioral interventions carried out by experienced nurses was superior, compared to treatment effects achieved by advanced medical students. Post-treatment comparison of home-based (n = 70) and inpatient-based (n = 35) treatment effects suggests that inpatient treatment all in all was more effective. At one-year follow-up, however, the effects of home treatment were maintained in a higher number of patients, compared to the stability of effects seen after psychiatric hospitalization. Thus, home treatment appears to be an effective treatment setting. Motivation and compliance of patient and parents, and high skills of the therapists are key ingredients for the success of a home-based treatment program.     

Diagnosis and treatment of psychiatric disorders in medically ill inpatients

Medical and surgical inpatients with coexisting psychiatric disorders pose several challenges to the consulting mental health professional in the general hospital. A major challenge is determining whether presenting signs and symptoms have a medical or psychiatric basis. Making such a determination requires a careful history, a mental status examination, and the utilization of bedside screening and diagnostic instruments. Recommended treatments include psychotherapy, psycho-education, and pharmacotherapy. However, psychotropic drugs must be used with caution because of potential interactions with drugs prescribed for medical conditions. Studies indicate that timely psychosocial interventions can improve the medical patient's mental health and have the potential to reduce length of hospital stay and utilization of health services.     

Duloxetine in the treatment of major psychiatric and neuropathic disorders

Major depressive disorder (MDD) is one of the most disabling disorders. Antidepressant pharmacotherapy is currently effective in approximately 70% of all treated cases; the potential superiority of a dual mechanism of pharmacological action (e.g., inhibiting the reuptake of serotonin and norepinephrine) is widely known. Duloxetine, a novel dual acting, selective serotonin and norepinephrine reuptake inhibitor, has demonstrated clinical efficacy in the treatment of MDD and general anxiety disorder (GAD). Duloxetine has been found to be safe and well tolerated, with mild-to-moderate adverse events, a favorable cardiovascular and sexual dysfunction profile, and minor influence on weight gain. The efficacy of duloxetine in the treatment of MDD has been established in randomized, double-blind, placebo-controlled studies. In addition to improving classical emotional symptoms of MDD, duloxetine has in particular beneficial effects on somatic symptoms of depression including pain. The superiority of duloxetine was shown over placebo, while comparison studies with other antidepressants showed only partial superiority. Randomized clinical trials in GAD also provide evidence for beneficial effects compared with placebo and improvement in quality of life, wellbeing and general health. Moreover, duloxetine is effective and well tolerated in the treatment of diabetic peripheral neuropathic pain and stress urinary incontinence. First results indicate that duloxetine might also be effective in the treatment of children with depression and pain. Overall, duloxetine is an interesting novel treatment option in the management of major depression and has shown efficacy in a broad range of diseases. It therefore may provide additional benefit to current therapeutic options in the treatment of psychiatric, internal, as well as urological disorders such as spinal dysfunctions. Due to duloxetine's properties, a wide range of use will be encountered in the mid-to-long term.     

The role of peptides in treatment of psychiatric disorders

About 25 years ago the observation that neuropeptides serve as signalling molecules in the nervous system generated great expectations for drug industry. In this article the progress made since then in exploiting neuropeptide systems pharmacologically in psychiatry is highlighted. In affective disorders a number of neuropeptides seem to be causally involved in development and course of illness, especially corticotropin releasing hormone (CRH), vasopressin (AVP) and substance P, whose receptors are now targeted with small molecules designed to reduce depressive and anxiety symptoms. Although not exactly neuropeptides, also neurotrophins, may have a distinct role in antidepressant action and possibly also in causation of depression. Schizophrenia-like symptoms are caused by neurotensin (NT), supporting the notion that drugs interfering with NT systems are potential antipsychotics. Finally, sleep disorders, currently treated with hypnotics, that have serious adverse effects can be targeted with neuropeptides. According to the work by Axel Steiger several neuropeptides even if peripherally administered produce improvements of quality of sleep. All these observations call for intensified application of novel research tools necessary to exploit the potential of neuropeptide systems as psychopharmaceutical targets.     

Transcranial magnetic stimulation in the treatment of psychiatric disorders

Transcranial magnetic stimulation (TMS) is a new technology that applies the principles of electromagnetism to deliver an electrical field to the cerebral cortices. Well established in diagnostic electrophysiology, TMS is now being studied as a treatment for psychiatric disorders. Evidence suggests this technique is safe and acceptable to patients. The future may see the application of TMS in obsessive-compulsive disorder, post-traumatic stress disorder and mania. There is strong evidence that it will become an accepted treatment of depression.     

L-tryptophan in the treatment of levodopa induced psychiatric disorders

Nine patients with levodopa induced psychiatric side effects were treated with L-Tryptophan in a single blind controlled study. In all patients levodopa therapy was continued and no sedative agents were given. In 8 patients all psychiatric side effects cleared within 48 hours, and without reoccurrence of these symptoms on an 8 month follow up. Only one patient did not respond to the treatment, but this patient proved to have a psychotic depression which was unrelated to levodopa therapy. Six patients with levodopa induced psychiatric disorders were used as control subjects and were not treated with L-Tryptophan. In these patients mental changes subsided only after levodopa had been discontinued for a period of 2 to 8 weeks. The rationale for treatment with L-Tryptophan is based on the findings of decreased serotonin content of the brain after levodopa treatment. This was documented by animal studies and reflected by changes in the spinal fluid concentration of 5-hydroxyindolacetic acid before and after L-Tryptophan treatment. This study confirms the results described by Dr. Birkmayer who treated levodopa induced psychosis first in 1972 in this manner.