L-tryptophan in neuropsychiatric disorders: a review.

Animal data indicate that serotonin (5-HT) is a major neurotransmitter involved in the control of numerous central nervous system functions including mood, aggression, pain, anxiety, sleep, memory, eating behavior, addictive behavior, temperature control, endocrine regulation, and motor behavior. Moreover, there is evidence that abnormalities of 5-HT functions are related to the pathophysiology of diverse neurological conditions including Parkinson's disease, tardive dyskinesia, akathisia, dystonia, Huntington's disease, familial tremor, restless legs syndrome, myoclonus, Gilles de la Tourette's syndrome, multiple sclerosis, sleep disorders, and dementia. The psychiatric disorders of schizophrenia, mania, depression, aggressive and self-injurious behavior, obsessive compulsive disorder, seasonal affective disorder, substance abuse, hypersexuality, anxiety disorders, bulimia, childhood hyperactivity, and behavioral disorders in geriatric patients have been linked to impaired central 5-HT functions. Tryptophan, the natural amino acid precursor in 5-HT biosynthesis, increases 5-HT synthesis in the brain and, therefore, may stimulate 5-HT release and function. Since it is a natural constituent of the diet, tryptophan should have low toxicity and produce few side effects. Based on these advantages, dietary tryptophan supplementation has been used in the management of neuropsychiatric disorders with variable success. This review summarizes current clinical use of tryptophan supplementation in neuropsychiatric disorders.     

Clonidine in neuropsychiatric disorders: a review

We describe the basic pharmacological principles underlying the activity of the alpha 2-adrenergic receptor agonist clonidine, including its interactions with the cholinergic, histaminergic, serotoninergic, endorphinergic and possibly dopaminergic systems. The use of clonidine for the therapy of various neuropsychiatric indications in which it appears to be beneficial is described. These conditions include migraine, Korsakoff's psychosis, Tourette's syndrome, withdrawal states, tardive dyskinesia, essential tremor, neuroleptic-induced akathisia, neurogenic bladder, idiopathic orthostatic hypotension, paroxysmal localised hyperhydrosis, diabetic neuropathy and stiff-man syndrome. The need for long term evaluation of this agent in some of these diseases is stressed.     

Age of onset of mental disorders: a review of recent literature

PURPOSE OF REVIEW: The aim of this article is to review recent epidemiological research on age-of-onset of mental disorders, focusing on the WHO World Mental Health surveys. RECENT FINDINGS: Median and inter-quartile range (IQR; 25th-75th percentiles) of age-of-onset is much earlier for phobias (7-14, IQR 4-20) and impulse-control disorders (7-15; IQR 4-35) than other anxiety disorders (25-53, IQR 15-75), mood disorders (25-45, IQR 17-65), and substance disorders (18-29, IQR 16-43). Although less data exist for nonaffective psychosis, available evidence suggests that median age-of-onset is in the range late teens through early 20s. Roughly half of all lifetime mental disorders in most studies start by the mid-teens and three quarters by the mid-20s. Later onsets are mostly secondary conditions. Severe disorders are typically preceded by less severe disorders that are seldom brought to clinical attention. SUMMARY: First onset of mental disorders usually occur in childhood or adolescence, although treatment typically does not occur until a number of years later. Although interventions with early incipient disorders might help reduce severity-persistence of primary disorders and prevent secondary disorders, additional research is needed on appropriate treatments for early incipient cases and on long-term evaluation of the effects of early intervention on secondary prevention.     

Seclusion and restraint: a review of recent literature

An October 1998 Hartford Courant investigative series highlighted alleged cases of brutality and death suffered by involuntarily secluded, restrained, and/or emergently medicated patients. The resulting public and professional furor prompted a spate of new federal regulations and legislative initiatives setting national standards for reporting and clinical oversight. These events provide stimulus for this literature review. Rates, duration, and methods of seclusion and restraint still vary widely. Little evidence is available to guide clinical practice regarding relative benefits and risks of various methods to control acute adult patient aggression; even less evidence exists in child and adolescent populations. Further efficacy and effectiveness studies are needed to address this issue. Various programmatic efforts successfully reduce seclusion and restraint-at times dramatically-and can be used as examples of systematic quality improvement so "best practices" may evolve and spread throughout psychiatric inpatient settings.     

Partial hospitalization: a review of recent literature

The author reviews recent studies on the evaluation of partial hospitalization programs in North America and Europe. The lack of a clear definition of partial hospitalization is one of the factors leading to its underutilization, many authorities believe. After discussing the nomenclature and emphasizing the importance of classifying programs by function--day hospitals, day treatment programs, and day care centers--the author reviews the recent literature and makes recommendations in the framework of this nomenclature.     

Obsessive-compulsive disorders: a review of the literature

The authors reviewed the studies on obsessive-compulsive disorders published from 1953 to 1978. They report on various theories of the etiology of the disorders and provide an overview of the studies based on these theories. The treatment modalities covered include behavioral modification, drug therapy psychotherapy, surgery, and experimental therapies. the authors conclude that, although the obsessive-compulsive disorders are widely present, there is a paucity of new data concerning their treatment. The evidence to date, however, suggests that psychotherapy is an essential ingredient in the treatment process. They recommended that further clinical studies be done to elucidate the etiology and treatment of these disorders.     

Co-occurring severe mental illness and substance use disorders: a review of recent research.

OBJECTIVE: Understanding the complex diagnostic and treatment issues posed by the co-occurrence of severe mental illness and substance use disorders has become a necessary exercise in current psychiatric practice. The authors reviewed research studies from the past six years that have contributed to our knowledge about effective assessment, diagnosis, course of illness, and treatment approaches. Research on special populations, including women, persons infected with HIV, and violent patients, is highlighted. METHODS: PsycINFO, Silver Platter, and MEDLINE were used to search for English-language studies published in the United States and other countries. To augment the search, selected bibliographies were reviewed with a focus on clinical standards. Information was sought on epidemiology, screening and assessment strategies, course of illness, models of treatment delivery, and cost of care. RESULTS AND CONCLUSIONS: Although estimates of the prevalence of substance use disorders vary by population, a higher prevalence among persons with severe mental illness has been confirmed. Routine screening for and assessment of substance use disorders among persons with severe mental illness has become the accepted standard of care. The course of severe mental illness is negatively influenced by a substance use disorder, and an integrated approach to the treatment of both disorders is generally accepted to be the most promising treatment strategy. Components of this strategy include harm reduction, treatment in stages, motivational interviewing, cognitive-behavioral interventions, and modified 12-step self-help groups.     

Prevalence studies of substance-related disorders: a systematic review of the literature.

OBJECTIVE: To present the results of a systematic review of literature published between January 1, 1980, and December 31, 2000, that reports epidemiologic estimates of substance-related disorders. METHOD: We conducted a literature search of substance-related epidemiologic studies, using medline and HealthSTAR databases and applying a set of predetermined inclusion and exclusion criteria to identify relevant studies. We extracted and analyzed prevalence and incidence data for heterogeneity. RESULTS: A total of 19 prevalence studies of substance-related disorders met inclusion criteria for this review. Heterogeneity analyses revealed significant variability across 1-year and lifetime prevalence of both alcohol and other substance use disorders. The corresponding 1-year and lifetime pooled rates were 6.6 per 100 and 13.2 per 100, respectively, for alcohol use disorders and 2.4 per 100 and 2.4 per 100, respectively, for other substance use disorders. We observed variability among countries and also among regions within the same country. In contrast to other drug problems, alcohol use disorders were substantially more common, were more likely to occur among male subjects, and were more likely to be associated with abuse symptoms. For other drugs, dependence was consistently more prevalent than abuse. CONCLUSIONS: Studies using rigorous and comparable methodologies report significant variability in rates of alcohol and other substance use disorders. These data suggest that different policies and regional practices are associated with variability in rates of disorders. Policy-makers and health planners require regular, regionally sensitive estimates of prevalence rates to respond effectively to unique patterns of need in their constituencies.     

Levodopa responsiveness in disorders with parkinsonism: a review of the literature.

A literature review was conducted to investigate whether or not levodopa (LD) responsiveness (LR) is a useful criterion in the diagnosis of parkinsonian disorders. Although LR does appear to differ among the parkinsonian disorders, there is considerable confusion in the literature. While most patients with Parkinson's disease (PD) have a sustained benefit from LD, a small minority of patients with documented PD do not respond. The literature suggests that the LR rate is higher for multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and corticobasal degeneration (CBD) than based on published diagnostic criteria. Magnitude and duration of response to LD and tolerability (time course, type and distribution of dyskinesias, mental effects and motor worsening) may be useful features in distinguishing PD, MSA, PSP, and CBD. Efforts should be directed toward better defining LR when used for diagnostic purposes and in scientific publications.     

Calcium channel blockers in psychiatric disorders: a review of the literature.

OBJECTIVES: To review the published literature of the past 15 years regarding use of calcium channel blockers (CCBs) in psychiatric practice. These drugs, especially verapamil, have been recommended as possible treatments for mania and other disorders. METHODS: The Cumulative Medical Index and other databases were searched and back-tracked to locate relevant articles. Sixty-one such articles were uncovered: 37 anecdotal reports, 7 partially controlled reports, and 17 controlled trials. RESULTS: Most studies involved treatment of mania using verapamil. Although anecdotal reports were generally favourable, results from partially controlled reports or controlled clinical trials were mixed. Generally, verapamil was less effective than was lithium or placebo. Treatment of depression with CCBs was not very successful, regardless of the type of trial; the best trial was negative. The same was true for the treatment of schizophrenia, although the cases studied were extremely chronic and treatment-resistant. Evidence for efficacy in other illnesses, such as Alzheimer's disease or tardive dyskinesia was scanty but suggested that further trials might be in order. CONCLUSIONS: CCBs do not at present have an established place in psychiatric treatment. Nonetheless, clinicians faced with a manic patient not responsive to other antimanic drugs, either alone or in combination, might consider adding verapamil as an adjunct. A study bearing on this specific issue is needed to determine whether or not such off-label use would really be justified.     

Substance P and neuropsychiatric disorders: an overview.

Substance P (SP) is a naturally-occurring tachykinin peptide isolated from brain tissues and gastrointestinal tract. In the brain, substantia nigra and basal ganglia contain relatively high amounts of substance P. There is evidence suggesting that substance P functions as a neurotransmitter. It has been implicated in the pathophysiology of several neuropsychiatric disorders. Substance P may also serve as a useful tool in studying the effects of antidepressant drugs and electroconvulsive therapy. However, the contribution of substance P to the understanding of neuropsychiatric disorders is far from clear. Future studies should focus on the interactions and coexistence of substance P with other neurotransmitters and neuropeptides.     

Infant botulism: two recent cases and literature review

Infant botulism is a cause for significant pediatric morbidity in the United States, though early recognition and supportive care can greatly improve clinical outcomes. Since the approval of human botulism immune globulin by the United States Food and Drug Administration (FDA) for the treatment of infant botulism in 2003, the importance of prompt initiation of therapy has been emphasized, with clinical suspicion remaining the mainstay of diagnosis. In this report, 2 cases of infant botulism are described. Each presented to the Pediatric Neurology service at our institution in Upstate New York in the spring and summer months of 2007 and were felt to be related to markedly dusty environmental conditions and the probable ingestion of C. botulinum organisms present in soil. Following this, a comprehensive review of the literature regarding infant botulism in the United States is presented, wherein the pathophysiology, clinical features, epidemiology, and treatment are discussed.     

Depression and conduct disorders in children and adolescents: a review of the literature.

The psychological literature presents three explanatory models of the relationship between childhood or adolescent depression and conduct disorders: (1) a direct causal relationship; (2) an indirect causal relationship, involving a third set of variables (i.e., personality disorders and developmental deficits); and (3) the "final common pathway" hypothesis, which derives a relationship ex post facto. Each of these models has dominated the literature at a different period, each was affected by different research purposes, and each in turn influenced further research. The author describes and critiques the three models and concludes with suggestions for further exploration in the areas of theory and etiology, research, diagnosis, and treatment.     

The role of the cerebellum in the pathophysiology and treatment of neuropsychiatric disorders: a review

The cerebellum has traditionally been looked upon as a brain area primarily involved in motor behaviour. The last decade has however heralded the cerebellum as a brain region of renewed interest for neuropsychiatric disorders. This renewed interest is fuelled by new insights obtained from neuroanatomical research, modern functional neuroimaging and transcranial magnetic stimulation studies. In this review, evidence in support of cerebellar involvement in neuropsychiatric disorders will be presented. In addition, transcranial magnetic stimulation will be introduced as a novel way to study cerebellar contributions to the pathophysiology of psychiatric disorders. In conclusion, a new functional concept of the cerebellum as more than simply a brain area regulating motor control appears mandatory and the involvement of the cerebellum should be considered when studying the neurological basis of neuropsychiatric disorders.     

Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature.

OBJECTIVE: To present the results of a systematic review of the literature published between January 1, 1980, and December 31, 2000, that reports findings on the prevalence and incidence of schizophrenia and related disorders. METHOD: We conducted a literature search of schizophrenia-related epidemiological studies, using Medline and HealthSTAR databases and canvassing English-language publications. We used a set of predetermined inclusion-exclusion criteria to identify relevant studies. Eligible publications were restricted to age ranges of 18 years and over for prevalence studies and 15 years and over for incidence studies. Prevalence and incidence data were extracted and analyzed for heterogeneity. RESULTS: A total of 18 prevalence and 8 incidence studies met eligibility criteria for the review. Heterogeneity analysis revealed significant differences across 1-year and lifetime prevalence and 1-year incidence of schizophrenia. The corresponding pooled rates were: 0.34 per 100, 0.55 per 100, and 11.1 per 100,000, respectively; the variation in rates between studies was generally between 2- and 5-fold. CONCLUSIONS: Although we restricted this review to studies using rigorous and relatively homogeneous methods, there remains significant heterogeneity of prevalence and incidence rates. This strengthens support for the hypothesis that there is real variation in the distribution of schizophrenia around the world. Health planners need to have local data on schizophrenia rates to improve the accuracy of their interventions, while clinicians and researchers need to continue to investigate the etiology of this variation.