Solving clinical challenges, improving patient care.
THURSDAY, MARCH 10, 2016
Dementia is the result of many underlying pathological processes, some that can be changed, others that cannot, such as genetics and adverse early life experiences, explained George T. Grossberg, MD, Saint Louis University. Research indicates that interventions that are good for cardiovascular health, such as addressing hyperlipidemia, elevated blood pressure, and diabetes, are beneficial for the aging brain, possibly by increasing blood flow and oxygen. Vitamins, such as D, B complex, E, and C, might stow cognitive decline, but won't stop it.
Subjective cognitive impairment (SCI)is a prodrome to mild cognitive impairment (MCI), which is a prodrome to Alzheimer's disease (AD), although not all patients with MCI convert to AD, Dr. Grossberg explained. Taking a thorough history with the patient and family is the most important part of the dementia workup, which also includes thorough physical and neurologic exams and neuropsychological assessment. Depression and anxiety can mimic SCI, which points to the importance of assessing for psychiatric illness. There are no FDA-approved treatments for SCI or MCI, but diet and lifestyle modifications can slow progression.
Because many women have experienced psychiatric illness before pregnancy, clinicians need to consider the safety profile of psychotropics when treating women of reproductive age. The FDA letter categories for pregnancy risk often were based on animal, not human, data, and didn't address the risk of untreated psychiatric illness or the context in which psychotropics are clinically necessary. Marlene P. Freeman, MD, Massachusetts General Hospital, explained that new FDA pregnancy labeling changes that were rolled out in 2015 are focused on human data; include information about background rates of adverse events during pregnancy; and will be updated as new information becomes available in post-marketing studies. Older letter-based categories will be phased out.
Almost one-third of women will meet criteria for an anxiety disorder during their lifetime, and symptoms can become worse during pregnancy and postpartum, according to Dr. Freeman. Psychotherapy is first-line treatment for mild and moderate anxiety during pregnancy, but medication plus psychotherapy is indicated for severe cases. Antidepressants are considered compatible with breast-feeding, although the long half-life of fluoxetine means a higher concentration in breast milk. During menopause, women with preexisting anxiety may be more susceptible to the development of anxiety disorders. A diagnosis of premenstrual dysphoric disorder indicates significant psychiatric morbidity that interferes with function, not an underlying psychiatric disorder that gets worse premenstrually.
Benzodiazepines are effective, well-tolerated, have a rapid onset of action, and can be used as needed for situational anxiety, although they are associated with sedation, psychomotor impairment, physical dependence, and adverse interactions with alcohol. All benzodiazepines are effective for generalized anxiety disorder; for maintenance treatment, however, consider a longer-acting agent. Mark H. Pollack, MD, Rush University Medical Center, ended his presentation by reviewing the use of tricyclic antidepressants, monoamine oxidase inhibitors, and other antidepressants for anxiety disorders.
Antipsychotics are used off-label as monotherapy for anxiety and as an adjunct to selective serotonin reuptake inhibitors (SSRIs), although the evidence of efficacy is mixed and these agents are associated with weight gain. Anticonvulsants have shown some efficacy for anxiety, especially posttraumatic stress disorder (PTSD). Gabapentin has been used for social anxiety; lamotrigine for PTSD. Cognitive-behavioral therapy (CBT) is effective, may have a lower relapse rate than pharmacotherapy, and has few adverse effects; however, it is more difficult to administer and may not be widely available or affordable. Dr. Pollack recommends integrating CBT with pharmacotherapy.
Andrew A. Nierenberg, MD, Massachusetts General Hospital, presented a model of thought patterns often seen in chronically depressed patients, to help them end the cycle of negative rumination and increase cognitive flexibility. He described rumination as a deficit in switching from internal to external stimuli and a failure of stopping and forgetting negative experiences and feelings. In this model, cognitive rigidity and inability to switch cognitive networks are the basis of depressive thoughts.
FRIDAY, MARCH 11, 2016
Depression, with its highly variable presentation and "wide network" of psychological, behavioral, and somatic symptoms, always presents a diagnostic and therapeutic challenge. Dr. Nierenberg reviewed symptoms and subtypes of depression across demographic groups and the key contributory role of stress. Stress, in combination with genetic factors, affects the brain by increasing neuronal atrophy and suppressing neurogenesis and the expression of brain-derived neurotrophic factor (BDNF)--potentially putting patients into a "ruminative loop" that resists attempts to "move forward" toward recovery. Antidepressants exert their therapeutic influence in part by blocking suppression of BDNF.
Prevalence of autism spectrum disorder has been increasing and is more common in males than females; various theories about the increased prevalence include better recognition and diagnosis, environmental toxins, and epigenetic processes. Robert L. Hendren, DO, University of California, San Francisco, advises that, when aiming to prevent autism, ask expectant mothers about environmental toxins in their homes and workplaces; encourage extended breastfeeding; and limit antibiotics and acetaminophen. Most programs for people with autism focus on early intervention (18 to 24 months) when brains are more plastic, but later interventions during adolescence can be valuable as brains continue to grow and patients learn new skills.
Combine types of treatments, such as behavioral interventions, speech and language therapy, and pharmacotherapy, to best manage patients with autism spectrum disorder. Evidence of the effectiveness of stimulants for patients with autism is mixed; fluvoxamine and sertraline have shown improvement in aggression and social relations, according to Dr. Hendren. Risperidone and aripiprazole have an FDA indication for autism, but are associated with adverse effects. Several biomedical treatments, such as omega-3 fatty acids, melatonin, probiotics, vitamin D3, methyl B12, oxytocin, restrictive diets, digestive enzymes, and choline, have evidence for use in patients with autism.
Approximately one-half of patients with schizophrenia have comorbid substance abuse, including nicotine, alcohol, Cannabis, and other substances, according to Henry A. Nasrallah, MD, Saint Louis University. Drugs of abuse that directly increase dopamine transmission in the nucleus accumbens produce a "high" as well as psychotic symptoms. Clozapine, although usually used only for refractory patients, might be helpful in reducing substance abuse. Risperidone may be helpful, but only 12% of drug abusing patients taking risperidone achieved abstinence, compared with 54% with clozapine. Evidence is mixed or insufficient for olanzapine, ziprasidone, aripiprazole, and anticonvulsants.
Dr. Nasrallah described evidence that suggests that inflammation is one of the earliest stages of the schizophrenia syndrome, and could develop through infection during pregnancy, head injury, stress response, or an autoimmune disorder. Stress activates microglia, which are the resident macrophages of the brain and players in innate immunity, and prompt these cells to release cytokines and free radicals, which lead to neurodegeneration, decreased neurogenesis, and white matter abnormalities. Schizophrenia is associated with increased microglia activation. Adjunctive anti-inflammatory drugs and omega-3 fatty acids could enhance the efficacy of antipsychotics or prevent conversion to psychosis in at-risk patients.
PTSD is a conditional diagnosis because trauma exposure is required. Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center, described the DSM-5 criteria for PTSD and pointed out that distress does not necessarily mean that a patient has PTSD. Avoidance and numbing symptoms are indicators of PTSD; intrusion and hyperarousal symptoms are common among those who have experienced a trauma, but are not a strong indicator of illness in the absence of avoidance and numbing symptoms.
Psychotherapy and pharmacotherapy have demonstrated effectiveness in PTSD, but it is unclear if either modality alone or combined is better; treatment choice should be guided by patient preference. Sertraline and paroxetine have FDA indications for PTSD, Dr. North said, but all SSRIs and serotonin-norepinephrine reuptake inhibitors are considered first-line agents. Prazosin is effective for nightmares and sleep disturbances. Sedative-hypnotics and benzodiazepines can relieve specific symptoms, such as anxiety or insomnia, but do not address all PTSD symptoms. Cognitive processing therapy and prolonged exposure therapy have the best evidence of efficacy.
SATURDAY, MARCH 12, 2016
Anthony L. Rostain, MD, MA, University of Pennsylvania, reviewed diagnostic criteria for oppositional defiant disorder, conduct disorder, and disruptive mood dysregulation disorder, which is new in DSM-5. Assessment of aggressive behaviors in so-called "difficult" children begins with a thorough history that includes a description of the aggression; responses by parents, caregivers, teachers, and school staff; and quantifying the aggression using a rating scale. Pharmacotherapy of aggression includes atypical and typical antipsychotics, stimulants, anticonvulsants, lithium, alpha-2 agonists, and beta blockers. Treatment should be individualized and guided by underlying psychiatric illness.
Dr. Rostain explored the strong connection, predictability between attention-deficit/ hyperactivity disorder (ADHD) and lifetime nicotine, marijuana, cocaine, and other substance use. ADHD can be seen as a reward deficiency syndrome, which is the breakdown of the reward "cascade"-the patient is not getting rewarded by typically rewarding activities, which leads to impulsivity, other clinical correlates, and addictive behaviors. As for treatment of comorbid ADHD and substance abuse, he emphasized that options for the combined disorders are limited and not fully effective. Methylphenidate plus CBT is not very effective, although some improvement in ADHD symptoms has been shown.
Narcolepsy with cataplexy (loss of muscle tone) is associated with a hypocretin deficiency, and is an autoimmune disease, explained Thomas Roth, PhD, Henry Ford Hospital, in his overview of sleep disorders. Obstructive sleep apnea is more common in men than women, and is associated with older age and obesity; treatment is a continuous positive airway pressure device. Restless leg syndrome is characterized by an irresistible urge to move, often during the evening, which can interfere with sleep and is treated with dopaminergic medications, benzodiazepines, opioids, and anticonvulsants. Periodic leg movements of sleep are characteristic leg movements that occur during sleep. Patients with REM behavior disorder act out their dreams while sleeping; treatment often is clonazepam.
Insomnia can be considered a disorder of hyperarousal; patients "can't shut their brain off." Dr, Roth recommends performing a thorough sleep hygiene assessment using the mnemonic LEARNS (Light, Environment, Activity, Routine, Napping, Substances). Behavioral interventions include stimulus control therapy, sleep-restriction therapy, relaxation therapy, and cognitive therapy for insomnia. All FDA-approved benzodiazepine receptor agonists work on GABAA receptors; therefore, the difference among them is half-life. Suvorexant, an orexin agonist, targets the brain's arousal system and improves sleep onset and sleep maintenance.
SPONSORS AND SUPPORTERS
* American Professional Agency
* American Psychiatric Publishing
* Arbor Pharmaceuticals, LLC
* Arcadian Telepsychiatry, LLC
* Assurex Health
* Bassett Medical Center
* Correct Care Solutions
* Group Health Physicians
* Insight Behavioral Health Centers
* Kaiser Permanente-Southern California
* LWW-Wolters Kluwer
* Millennium Health
* Ministry Health Care
* Professional Risk Management Services, Inc.
* Rhodes Pharmaceuticals
* Sunovion Pharmaceuticals, Inc.
* Takeda Pharmaceuticals USA, Inc./Lundbeck
* Wexford Health Sources
* Yellowbrick Consultation and Treatment Center
The meeting organizers acknowledge support provided by the sponsors. Determination of educational content for this program and the selection of speakers are responsibilities of the program director and co-directors. Sponsors and supporters did not have input in these areas.
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|Title Annotation:||PSYCHIATRY UPDATE 2016|
|Date:||Jun 1, 2016|
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