Evidence-based medicine and geriatric psychiatry

The vast amount of clinical information available today and the difficulties that clinicians have in applying this information have given rise to interest in evidence-based medicine. An additional impetus for the development of the evidencebased medicine movement has been the increasing recognition that much of medical practice is not evidence-based. This article presents a brief overview of the principles of evidence-based medicine and its historical development, discusses some common criticisms of evidence-based practice, and illustrates its application to address a clinical problem. Suggestions are also provided for clinicians interested in developing evidence-based medicine skills.     

Evidence-based ethics for neurology and psychiatry research

American bioethics, historically arising out of theology and philosophy, has been dominated by the method of normative analysis. Ethics as policy, however, requires in addition a solid evidence base. This paper discusses the background conditions that make neurotherapeutics research particularly challenging. Three key ethical issues are discussed within an evidence-based ethics framework: the ethical challenges arising from changes in the financial incentive structures for academic researchers and their institutions, the challenges of risk—benefit analysis for neurotherapeutics protocols testing innovative interventions, and the evolving issues surrounding impaired decision-making capacity and surrogate consent for research. For each of these issues, selected empirical data are reviewed, areas for further inquiry are noted, and the need for development of novel methods for bioethics policy research is discussed.     

Evidence-based treatments in child and adolescent psychiatry: an inventory

OBJECTIVE: To provide a list of evidence-based psychopharmacology and psychotherapy treatments for child psychiatry. METHOD: Published reviews and Medline searches were examined to generate a list of treatments supported by randomized controlled trials. RESULTS: For psychopharmacology, the best evidence to date supports the use of stimulant medications for attention-deficit/hyperactivity disorder and selective serotonin reuptake inhibitors (SSRIs) for obsessive-compulsive disorder. There is also reasonable evidence addressing SSRIs for anxiety disorders and moderate to severe major depressive disorder, and risperidone for autism. The psychosocial interventions best supported by well-designed studies are cognitive-behavioral and behavioral interventions, especially for mood, anxiety, and behavioral disorders. Family-based and systems of care interventions also have been found effective. CONCLUSIONS: Although the number of evidence-based treatments for child psychiatry is growing, much of clinical practice remains based on the adult literature and traditional models of care. Challenges toward adopting evidence-based practices are discussed.     

Epilogue: Conversations between a psychoanalyst and a psychiatry resident

The authors discuss the importance of psychoanalytic training from the perspectives of a psychiatry resident about to begin psychoanalytic training and a psychiatrist who is a training and supervising psychoanalyst. Drs. Hyun and Alfonso discuss psychoanalytic motivations and engage in a dialogue reflecting on the relevance of psychoanalytic training in current psychiatric practice and the profession’s need for more dynamically trained psychiatrists. In doing so this article provides further insight from their firsthand experiences as to why young psychiatrists today still choose to engage in psychoanalytic training and its positive impact on their clinical practices.     

Kleine-Levin syndrome: interface between neurology and psychiatry

We report the first episode of Kleine-Levin (KLS) syndrome in a 17-year-old male. The illness onset, clinical features, neuropsychological evaluation and polysomnographic recording are described. Typical symptoms hypersomnia, hyperphagia and sexual disinhibition were observed besides behavioral disturbances, polysomnographic and neuropsychological alterations. Behavioral disturbances similar to a manic episode including psychotic symptoms were relevant. The pharmacologic treatment included lithium, methylphenidate and risperidone. The introduction of risperidone aimed the control of psychotic symptoms and the persistent manifestations of hypersexuality after sleepiness control and to the best of our knowledge there are no other reports regarding risperidone use for KLS in the literature.     

Evidence-based strategies for achieving treatment goals in bipolar disorder: A review and synthesis of contemporary treatment guidelines

The fundamental goals of treatment in bipolar disorder are full remission of acute mood episodes and prevention of future episodes. Contemporary treatment guidelines recommend a number of intermediate goals to facilitate remission and maintenance of bipolar disorder. These goals vary somewhat between guidelines, and the rationale behind them and strategies for achieving them often receive little discussion. We therefore reviewed published guidelines to derive a core set of treatment goals in bipolar disorder. During acute episodes, these goals include rapidly assuring safety for patients and those around them, and limiting the length and consequences of illness. Goals are more varied during maintenance phase treatment, and in addition to preventing recurrence include targeting residual symptoms, ensuring medication adherence, identifying and planning for sentinel symptoms, reducing risk of harm, minimizing possible precipitants of relapse, and maximizing psychosocial functioning. We review the rationale for selecting each of these, and suggest strategies for achieving them.     

Geriatric Treatment Center: a contemporary model for collaboration between psychiatry and neurology

The diagnosis and treatment of individuals with problems involving both psychiatry and neurology have become more sophisticated in recent years, but these advances may be difficult to implement in the modern health care environment. For 16 years, an inpatient Geriatric Treatment Center within a state mental hospital has been used to diagnose and treat older persons with complex neuropsychiatric disorders. Eight illustrative cases are presented of patients with major behavioral dysfunction that could not be managed effectively in other health care facilities. After neuropsychiatric evaluation and behavioral neurology consultation, all had neurologic diagnoses established as the cause of their presentation. Seven improved with appropriate treatment, of whom one could return to independent living, and the eighth died and had an autopsy diagnosis of his disease at a nearby academic medical center. This series highlights the value of collaboration between psychiatry and neurology for evaluation and treatment of older patients with neuropsychiatric problems not easily accommodated by many existing health care settings.     

The impossible dialogue between psychiatry and the judicial system: a language problem

The interface between psychiatry and law is complex and has the potential for gross misunderstanding. Each discipline has its own concerns with regard to the psychiatric patient, and there is a significant language gap between the two disciplines. The language of the medical discipline describes the patient's state on a continuum that ranges from extremely ill to completely healthy. The judicial language, on the other hand, is a binary language: the patient is either competent or incompetent, either dangerous or not dangerous. This article describes three potential areas for discourse in the Israeli context: involuntary hospitalization, criminal responsibility and legal representation of involuntarily hospitalized patients. The two systems can be complementary only if both sides make a serious effort to communicate and respect each other's principles and language.     

Cytokine interactions and cytokine balance in the brain: relevance to neurology and psychiatry.

Cytokine-cytokine and cytokine-neurotransmitter-neuropeptide interactions are pivotal for the magnitude of neurological and psychiatric manifestations, neuroimmunological and neuroinflammatory responses, and neurological complications of disorders associated with increased cytokine production.     

Chronic dizziness: the interface between psychiatry and neuro-otology

PURPOSE OF REVIEW: This paper reviews the often-enigmatic relationships between dizziness and psychiatric symptoms. Psychiatric causes of dizziness, neuro-otologic causes of anxiety, underrecognized co-morbid conditions, and medical illnesses that masquerade as 'psychogenic' dizziness are examined. Key clinical features and data from recent treatment trials are presented with potential pathophysiologic mechanisms. RECENT FINDINGS: Investigations at the interface between psychiatry and neuro-otology have identified the distinguishing features of several clinical conditions that present with non-vertiginous dizziness, subjective imbalance, and psychiatric symptoms. The most common condition is chronic subjective dizziness; a refinement of earlier concepts of psychogenic dizziness, phobic postural vertigo, and space-motion phobia. Chronic subjective dizziness is consistent with advancing research on anxiety and somatoform disorders and offers greater insights into the relationships between neuro-otologic illnesses and anxiety. Migraine, post-concussional syndrome, and dysautonomias also cause persistent dizziness and may be misdiagnosed or malingering or psychogenic dizziness because they often present with comorbid psychiatric symptoms in the absence of identifiable vestibular deficits. SUMMARY: Recent research has defined the key features of several medical-psychiatric conditions that cause chronic dizziness, permitting greater diagnostic precision and insight into underlying pathophysiologic processes. Treatment studies have identified potentially effective interventions, which must be evaluated in controlled clinical trials.