PSYCHIATRY UPDATE 2016

Current Psychiatry welcomed more than 650 psychiatric practitioners from across the United States and abroad to this annual conference, which was headed by Meeting Co-chairs Richard Balon, MD, and Donald W. Black, MD, March 10-12, 2016, at the Marriott Chicago Magnificent Mile in Chicago, Illinois. Attendees earned as many as 18 AMA PRA Category 1 Credits™. We welcome you to join us next year in Chicago, March 30 to April 1, 2017.

View summaries from the event on the following pages.

 

 

Thursday, March 10, 2016

Make Way for Possibilities of an Adjunctive Treatment for Major Depressive Disorder
Roueen Rafeyan, MD, Feinberg School of Medicine at Northwestern University

In an industry-sponsored symposium, Dr. Rafeyan explained that many depressed patients do not fully respond to an initial antidepressant, making the next step in treatment either switching to a different antidepressant or adding an adjunctive agent. In pivotal trials, brexpiprazole (Rexulti) added to an antidepressant reduced depressive symptoms, as measured by Montgomery-Åsburg Depression Rating Scale (MADRS) total score, more than an antidepressant plus placebo. Akathisia and weight gain were the most common adverse events and occurred in ≥5% of patients in these studies. The mechanism of action of brexpiprazole in major depressive disorder is unknown, but the efficacy of this drug might be mediated through a combination of partial agonist activity at serotonin 5-HT1A and dopamine D2 receptors and antagonist activity at serotonin 5-HT2A receptors. 

 

Successful Aging
George T. Grossberg, MD, Saint Louis University 

Dementia is the result of many underlying pathological processes, some that can be changed, others that cannot. Research indicates that interventions that are good for cardiovascular health, such as addressing hyperlipidemia, blood pressure, and diabetes, also are beneficial for the brain, possibly by increasing blood flow and oxygen to the brain. Moderate use of alcohol and caffeine could be beneficial for cognitive function. Vitamins, such as D, B complex, E, and C, might slow cognitive decline, but won’t stop it. Recommend adherence to a Mediterranean diet, physical activity, and mental exercises such as learning a new language or playing games. Ask patients about head injuries, specifically if they have ever experienced a concussion and lost consciousness. Non-modifiable risk factors include genetics and adverse early life experiences.

 

Psychopharmacology and Pregnancy: The New Labeling Changes and Implications for Clinical Practice
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-half of pregnancies in the United States are unplanned and many women have experienced psychiatric illness before pregnancy. Therefore, clinicians need to consider the reproductive 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. New FDA labeling changes that were rolled out in 2015 are focused on human data, includes information about background rates of adverse events during pregnancy, and will be updated as new information becomes available in postmarketing studies (older letter-based categories will be phased out).

 

Anxiety Disorders in Women Across the Lifecycle
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-third of women will meet criteria for an anxiety disorder during their lifetime, and symptoms can become worse during pregnancy and the postpartum period. Postpartum obsessions and psychosis can be difficult to distinguish, but the key is insight. Psychotherapy is first-line treatment for mild to 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 higher concentrations in breast milk. During menopause, women with preexisting anxiety may be more susceptible to the development of anxiety disorders. Serotonergic antidepressants, as well as gabapentin, have evidence of efficacy for hot flashes. A diagnosis of premenstrual dysphoric disorder (PMDD) indicates significant psychiatric morbidity that interferes with function, not an underlying psychiatric disorder that gets worse premenstrually. Ask patients to track their moods, especially while they are trying different treatments. Treating PMDD with serotonergic antidepressants has been well researched.

 

Mild Cognitive Impairment: “Senior Moments” and DSM-5
George T. Grossberg, MD, Saint Louis University

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. Taking a thorough history with the patient and family is the most important part of the dementia workup, which also includes a thorough physical and neurologic exam and neuropsychological assessment. Earliest recognition is possible with biomarkers, but their use is not practical in clinical practice. 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.

 

Assessing major depressive disorder and an option for treatment
Jay D. Fawver, MD, Indiana University School of Medicine

Depression is multifactorial, including difficulty with cognition and focus because of dysregulation of multiple regions of the brain and neurotransmission symptoms, says Dr. Fawver in an industry-sponsored symposium. Vortioxetine (Brintellix) is an FDA-approved medication for depression that some describe as energizing or enhancing. The drug has a unique mechanism of action and is thought to be related to enhancement of serotonergic activity in the CNS through inhibition of reuptake of 5-HT. In double-blind, placebo-controlled trials, 5 to 20 mg/d of vortioxetine was superior to placebo in improving depressive symptoms as measured by mean change in MADRS or HAM-D₂₄ total score. Among adverse effects, vomiting and nausea are common, but could be mitigated if it is taken with food. Vortioxetine is weight neutral. 

 

Innovative Treatments of Anxiety, Part 1 (Use of Benzodiazepines)
Mark H. Pollack, MD, Rush University Medical Center

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, but for maintenance treatment, consider a longer-acting agent. Consider combining benzodiazepines with antidepressants for rapid relief of anxiety while antidepressants begin to work, to treat residual anxiety, or to decrease early anxiety associated with antidepressant treatment. Reported increase in overdose mortality likely is conflation with other drugs of abuse, particularly opioids. Dr. Pollack ended his presentation by reviewing the use of tricyclic antidepressants, monoamine oxidase inhibitors, and other antidepressants for anxiety disorders.

 

Innovative Treatments of Anxiety, Part 2 (Other Standard and Novel Therapeutic Approaches)
Mark H. Pollack, MD, Rush University Medical Center

Antipsychotics are used off-label as monotherapy and as an adjunct to selective serotonin reuptake inhibitors for anxiety, 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. Prazosin, an antihypertensive, can improve sleep and decrease nightmares in PTSD. Using hypnotics to treat sleep disturbances after a traumatic event could reduce the likelihood of developing PTSD. Propranolol has been studied, but is not considered effective for preventing PTSD. Cognitive-behavioral therapy (CBT) is effective for anxiety, may have a lower relapse rate than pharmacotherapy, and has few adverse effects; however, it is more difficult to administer than medication and may not be widely available or affordable. Dr. Pollack recommends integrating CBT with pharmacotherapy. Researchers are examining augmenting CBT or exposure therapy with d-cycloserine.

 

Treatment of Chronic Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital

Dr. Nierenberg 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 is the basis of depressive thoughts.

 

 

 

Friday, March 11, 2016

Subtypes of Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital, Alexian Brothers Behavioral Health Hospital for Violence Prevention Clinic/Program and ADHD Clinic

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. Depression is highly comorbid, making it complicated to manage. Duration of depressive episodes also is highly variable, with some patients experiencing episodes that last as long as 14 weeks. 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.

 

Managing ADHD: What Matters Most When Selecting a Treatment Option
Michael Feld, MD, Alexian Brothers Behavioral Health Hospital for Violence Prevention Clinic/Program and ADHD Clinic

In an industry-sponsored symposium, Dr. Feld began his review of therapeutic strategies by noting that stimulant medications have long been recommended first-line therapy for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). Nonstimulant ADHD agents, such as atomoxetine, are a second-line option; antidepressants are third. Today, newer formulations of stimulants give clinicians an additional option to test and adjust at the start of therapy.

Dr. Feld discussed the utility of the brand-name extended-release (ER) methylphenidate HCl (Aptensio) for its value in children—specifically, its ability to “extend the day” without additional dosing of a short-action medication. The design of Aptensio—a multilayered beaded delivery system in which every bead is both an immediate- and an extended-release vehicle—allows an early peak serum drug level and later peak level (at 8 hours). Aptensio is administered by sprinkling the contents of a capsule on applesauce; it is is safe practice, Dr. Feld explained, to augment the ER drug delivery with an immediate-release agent when deemed necessary, by observing how difficult it is for the patient to make it through the day at home, school, or work.

 

Overview of Autism Spectrum Disorder
Robert L. Hendren, DO, University of California, San Francisco

Prevalence of autism has been increasing and is more common in males than females; various theories about the increased prevalence including better recognition and diagnosis, environmental toxins, and epigenetic processes. Up to 25% of autism cases can be attributed to genetics, but researchers have not pinpointed a single gene. To attempt 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 individuals with autism focus on early interventions (18 to 24 months) when brains are more plastic, but later interventions during adolescence can be valuable as brains continue to grow and change and patients learn new skills.

 

Comorbidity of Schizophrenia and Substance Abuse
Henry A. Nasrallah, MD, Saint Louis University

Approximately one-half of patients with schizophrenia have comorbid substance abuse, including nicotine, alcohol, Cannabis, and other substances, a rate that is approximately 3 times higher than in the general population. 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; case reports include alcohol, cocaine, nicotine, and polydrug use. Risperidone may be helpful, but only 12% of drug abusing patients taking risperidone achieved abstinence compared with 54% with clozapine. Naltrexone has evidence of efficacy for alcohol abuse. Evidence is mixed or insufficient for olanzapine, ziprasidone, aripiprazole, and anticonvulsants.

 

Overview of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

Posttraumatic stress disorder (PTSD) is a conditional diagnosis because trauma exposure is required. Dr. North described the DSM-5 criteria for PTSD and pointed out that distress does not necessarily mean 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/numbing symptoms. Comorbid MDD or substance use is associated with PTSD but not with trauma exposure, therefore PTSD, not trauma, might be a causal risk for other disorders. Substance use disorders often are present before the trauma exposure, meaning that individuals might use PTSD as a way to rationalize their substance use.

 

Bipolar Depression: Presentation, Diagnosis, and Treatment in the Outpatient Psychiatry Practice Setting
Peter J. Weiden, MD, University of Illinois at Chicago

Bipolar depression can overlap with major depressive disorder (MDD), but treatments for the 2 disorders diverge, Dr. Weiden explained in an industry-sponsored symposium. Adding an antidepressant to a mood stabilizer is no more effective than a mood stabilizer plus placebo for treating bipolar depression. Lurasidone (Latuda) is indicated for treating a depressive episode in a patient with a diagnosis of bipolar I disorder as monotherapy or adjunctive therapy with lithium or valproate. As monotherapy and adjunctive therapy, lurasidone reduced Montgomery-Åsburg Depression Rating Scale scores score over 6 weeks compared with placebo. Nausea and vomiting are most common adverse effects, then akathisia and sedation.

 

Neuroinflammation and Oxidative Stress in Schizophrenia and Mood Disorders: Biomarkers and Therapeutic Targets
Henry A. Nasrallah, MD, Saint Louis University

Evidence suggests that inflammation is one of the earliest stages of the schizophrenia syndrome and could be through infections during pregnancy, head injury, stress response, or autoimmune disorders. Stress will activate microglia, which are the resident macrophages of the brain and players in innate immunity, and prompt these cells them to release cytokines and free radicals, which lead to neurodegeneration, decreased neurogenesis, and white matter abnormalities. Schizophrenia is associated with increased microglia activation. Clozapine protects neurons from inflammation by inhibiting microglial overactivation. Adjunctive anti-inflammatory drugs or omega-3 fatty acids could enhance the efficacy of antipsychotics or prevent conversion to psychosis in individuals at risk.

 

Clinical Management of Autism Spectrum Disorders: What Happens Over Time/Borderline Intellectual Functioning
Robert L. Hendren, DO, University of California, San Francisco

Combine types of treatments, such as behavioral interventions, speech and language therapy, and pharmacotherapy, to best serve patients with autism. Evidence of effectiveness of stimulants for patients with autism is mixed; fluvoxamine and sertraline have shown improvement in aggression and social relations. Alpha-adrenergic agonists could help relieve anxiety, but studies are limited. Risperidone and aripiprazole have FDA indications 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.

 

Management of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

The pathology of PTSD is thought to be related to abnormal neurobiological processing of acquired fear responses. 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, but all selective serotonin reuptake inhibitors 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 symptomatology. Cognitive processing therapy and prolonged exposure therapy have the best evidence of efficacy.

 

 

 

Saturday, March 12, 2015

Managing the Difficult Child
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain reviewed diagnostic criteria for oppositional defiant disorder (ODD), conduct disorder (CD), and disruptive mood dysregulation disorder, which is new in DSM-5. Disruptive behavior disorders often are comorbid with other psychiatric disorders, and there is symptomatic overlap between attention-deficit/hyperactivity disorder (ADHD) and ODD. Assessment of aggressive behaviors 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.

 

Major Depression With Subsyndromal Mania/Hypomania: Implications for Diagnosis and Management
Trisha Suppes, MD, PhD, Stanford University School of Medicine, Roger S. McIntyre, MD, FRCPC, University of Toronto, and J. Craig Nelson, MD, University of California, San Francisco

In an industry-sponsored symposium, Dr. Suppes described the history and DSM-5 diagnostic features of the mixed features specifier for major depressive disorder and bipolar disorder. Dr. Nelson explained that because mixed states is a new specifier, there are few studies examining treatment, but studies of bipolar depression are informative. Specific anticonvulsants and atypical antipsychotics have been approved to treat bipolar depression. In a randomized, double-blind, placebo-controlled trial, flexibly dosed lurasidone was more effective in the primary outcome, which was mean change in Montgomery-Åsburg Depression Rating Scale score from baseline, and response and remission rates. Dr. McIntyre reviewed medical comorbidities found in mixed states, including obesity, cardiovascular disease, and metabolic syndrome. Inflammatory processes may play a role in medical issues seen in patients with a mood disorder.

 

General Overview of Sleep Disorders
Thomas Roth, PhD, Henry Ford Hospital

Many people who experience excessive daytime sleepiness often are seen for a depression workup. Narcolepsy with cataplexy (loss of muscle tone) is associated with a hypocretin deficiency, and is an autoimmune disease. Obstructive sleep apnea is more common in men than women, and is associated with older age and obesity; treatment is 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.

 

Comorbid ADHD with Substance Abuse 
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain explored the strong connection/predictability between ADHD and lifetime nicotine, marijuana, cocaine, and other substance use, although this connection can’t be shown definitively for alcohol use because alcohol is so widely used across all demographic groups. 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. Neurobiology of ADHD and substance use disorder (SUD) (sustaining attention, motivation) is similar; genetic influences in common have been identified in studies. Dr. Rostain described the significant problem of illicit—ie, nonmedical, no Rx—stimulant use in school settings, and how such illicit stimulant use also correlates with abuse of alcohol and use of Cannabis and other substances. As for treatment, he emphasized that options for the combined disorders are limited and not fully effective. Methylphenidate plus cognitive-behavioral therapy combo is not very effective for treating comorbid ADHD and SUD, although some improvement in ADHD symptoms has been shown.

 

How to Treat Patients with Insomnia
Thomas Roth, PhD, Henry Ford Hospital

Insomnia can be considered a disorder of hyperarousal; patients “can’t shut their brain off.” An important criterion for insomnia is that sleeplessness occurs despite adequate opportunity and circumstances for sleep; otherwise, the problem is just considered poor sleep. 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 GABA_A 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.

 

Current Psychiatry welcomed more than 650 psychiatric practitioners from across the United States and abroad to this annual conference, which was headed by Meeting Co-chairs Richard Balon, MD, and Donald W. Black, MD, March 10-12, 2016, at the Marriott Chicago Magnificent Mile in Chicago, Illinois. Attendees earned as many as 18 AMA PRA Category 1 Credits™. We welcome you to join us next year in Chicago, March 30 to April 1, 2017.

View summaries from the event on the following pages.

 

 

Thursday, March 10, 2016

Make Way for Possibilities of an Adjunctive Treatment for Major Depressive Disorder
Roueen Rafeyan, MD, Feinberg School of Medicine at Northwestern University

In an industry-sponsored symposium, Dr. Rafeyan explained that many depressed patients do not fully respond to an initial antidepressant, making the next step in treatment either switching to a different antidepressant or adding an adjunctive agent. In pivotal trials, brexpiprazole (Rexulti) added to an antidepressant reduced depressive symptoms, as measured by Montgomery-Åsburg Depression Rating Scale (MADRS) total score, more than an antidepressant plus placebo. Akathisia and weight gain were the most common adverse events and occurred in ≥5% of patients in these studies. The mechanism of action of brexpiprazole in major depressive disorder is unknown, but the efficacy of this drug might be mediated through a combination of partial agonist activity at serotonin 5-HT1A and dopamine D2 receptors and antagonist activity at serotonin 5-HT2A receptors. 

 

Successful Aging
George T. Grossberg, MD, Saint Louis University 

Dementia is the result of many underlying pathological processes, some that can be changed, others that cannot. Research indicates that interventions that are good for cardiovascular health, such as addressing hyperlipidemia, blood pressure, and diabetes, also are beneficial for the brain, possibly by increasing blood flow and oxygen to the brain. Moderate use of alcohol and caffeine could be beneficial for cognitive function. Vitamins, such as D, B complex, E, and C, might slow cognitive decline, but won’t stop it. Recommend adherence to a Mediterranean diet, physical activity, and mental exercises such as learning a new language or playing games. Ask patients about head injuries, specifically if they have ever experienced a concussion and lost consciousness. Non-modifiable risk factors include genetics and adverse early life experiences.

 

Psychopharmacology and Pregnancy: The New Labeling Changes and Implications for Clinical Practice
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-half of pregnancies in the United States are unplanned and many women have experienced psychiatric illness before pregnancy. Therefore, clinicians need to consider the reproductive 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. New FDA labeling changes that were rolled out in 2015 are focused on human data, includes information about background rates of adverse events during pregnancy, and will be updated as new information becomes available in postmarketing studies (older letter-based categories will be phased out).

 

Anxiety Disorders in Women Across the Lifecycle
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-third of women will meet criteria for an anxiety disorder during their lifetime, and symptoms can become worse during pregnancy and the postpartum period. Postpartum obsessions and psychosis can be difficult to distinguish, but the key is insight. Psychotherapy is first-line treatment for mild to 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 higher concentrations in breast milk. During menopause, women with preexisting anxiety may be more susceptible to the development of anxiety disorders. Serotonergic antidepressants, as well as gabapentin, have evidence of efficacy for hot flashes. A diagnosis of premenstrual dysphoric disorder (PMDD) indicates significant psychiatric morbidity that interferes with function, not an underlying psychiatric disorder that gets worse premenstrually. Ask patients to track their moods, especially while they are trying different treatments. Treating PMDD with serotonergic antidepressants has been well researched.

 

Mild Cognitive Impairment: “Senior Moments” and DSM-5
George T. Grossberg, MD, Saint Louis University

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. Taking a thorough history with the patient and family is the most important part of the dementia workup, which also includes a thorough physical and neurologic exam and neuropsychological assessment. Earliest recognition is possible with biomarkers, but their use is not practical in clinical practice. 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.

 

Assessing major depressive disorder and an option for treatment
Jay D. Fawver, MD, Indiana University School of Medicine

Depression is multifactorial, including difficulty with cognition and focus because of dysregulation of multiple regions of the brain and neurotransmission symptoms, says Dr. Fawver in an industry-sponsored symposium. Vortioxetine (Brintellix) is an FDA-approved medication for depression that some describe as energizing or enhancing. The drug has a unique mechanism of action and is thought to be related to enhancement of serotonergic activity in the CNS through inhibition of reuptake of 5-HT. In double-blind, placebo-controlled trials, 5 to 20 mg/d of vortioxetine was superior to placebo in improving depressive symptoms as measured by mean change in MADRS or HAM-D₂₄ total score. Among adverse effects, vomiting and nausea are common, but could be mitigated if it is taken with food. Vortioxetine is weight neutral. 

 

Innovative Treatments of Anxiety, Part 1 (Use of Benzodiazepines)
Mark H. Pollack, MD, Rush University Medical Center

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, but for maintenance treatment, consider a longer-acting agent. Consider combining benzodiazepines with antidepressants for rapid relief of anxiety while antidepressants begin to work, to treat residual anxiety, or to decrease early anxiety associated with antidepressant treatment. Reported increase in overdose mortality likely is conflation with other drugs of abuse, particularly opioids. Dr. Pollack ended his presentation by reviewing the use of tricyclic antidepressants, monoamine oxidase inhibitors, and other antidepressants for anxiety disorders.

 

Innovative Treatments of Anxiety, Part 2 (Other Standard and Novel Therapeutic Approaches)
Mark H. Pollack, MD, Rush University Medical Center

Antipsychotics are used off-label as monotherapy and as an adjunct to selective serotonin reuptake inhibitors for anxiety, 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. Prazosin, an antihypertensive, can improve sleep and decrease nightmares in PTSD. Using hypnotics to treat sleep disturbances after a traumatic event could reduce the likelihood of developing PTSD. Propranolol has been studied, but is not considered effective for preventing PTSD. Cognitive-behavioral therapy (CBT) is effective for anxiety, may have a lower relapse rate than pharmacotherapy, and has few adverse effects; however, it is more difficult to administer than medication and may not be widely available or affordable. Dr. Pollack recommends integrating CBT with pharmacotherapy. Researchers are examining augmenting CBT or exposure therapy with d-cycloserine.

 

Treatment of Chronic Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital

Dr. Nierenberg 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 is the basis of depressive thoughts.

 

 

 

Friday, March 11, 2016

Subtypes of Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital, Alexian Brothers Behavioral Health Hospital for Violence Prevention Clinic/Program and ADHD Clinic

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. Depression is highly comorbid, making it complicated to manage. Duration of depressive episodes also is highly variable, with some patients experiencing episodes that last as long as 14 weeks. 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.

 

Managing ADHD: What Matters Most When Selecting a Treatment Option
Michael Feld, MD, Alexian Brothers Behavioral Health Hospital for Violence Prevention Clinic/Program and ADHD Clinic

In an industry-sponsored symposium, Dr. Feld began his review of therapeutic strategies by noting that stimulant medications have long been recommended first-line therapy for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). Nonstimulant ADHD agents, such as atomoxetine, are a second-line option; antidepressants are third. Today, newer formulations of stimulants give clinicians an additional option to test and adjust at the start of therapy.

Dr. Feld discussed the utility of the brand-name extended-release (ER) methylphenidate HCl (Aptensio) for its value in children—specifically, its ability to “extend the day” without additional dosing of a short-action medication. The design of Aptensio—a multilayered beaded delivery system in which every bead is both an immediate- and an extended-release vehicle—allows an early peak serum drug level and later peak level (at 8 hours). Aptensio is administered by sprinkling the contents of a capsule on applesauce; it is is safe practice, Dr. Feld explained, to augment the ER drug delivery with an immediate-release agent when deemed necessary, by observing how difficult it is for the patient to make it through the day at home, school, or work.

 

Overview of Autism Spectrum Disorder
Robert L. Hendren, DO, University of California, San Francisco

Prevalence of autism has been increasing and is more common in males than females; various theories about the increased prevalence including better recognition and diagnosis, environmental toxins, and epigenetic processes. Up to 25% of autism cases can be attributed to genetics, but researchers have not pinpointed a single gene. To attempt 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 individuals with autism focus on early interventions (18 to 24 months) when brains are more plastic, but later interventions during adolescence can be valuable as brains continue to grow and change and patients learn new skills.

 

Comorbidity of Schizophrenia and Substance Abuse
Henry A. Nasrallah, MD, Saint Louis University

Approximately one-half of patients with schizophrenia have comorbid substance abuse, including nicotine, alcohol, Cannabis, and other substances, a rate that is approximately 3 times higher than in the general population. 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; case reports include alcohol, cocaine, nicotine, and polydrug use. Risperidone may be helpful, but only 12% of drug abusing patients taking risperidone achieved abstinence compared with 54% with clozapine. Naltrexone has evidence of efficacy for alcohol abuse. Evidence is mixed or insufficient for olanzapine, ziprasidone, aripiprazole, and anticonvulsants.

 

Overview of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

Posttraumatic stress disorder (PTSD) is a conditional diagnosis because trauma exposure is required. Dr. North described the DSM-5 criteria for PTSD and pointed out that distress does not necessarily mean 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/numbing symptoms. Comorbid MDD or substance use is associated with PTSD but not with trauma exposure, therefore PTSD, not trauma, might be a causal risk for other disorders. Substance use disorders often are present before the trauma exposure, meaning that individuals might use PTSD as a way to rationalize their substance use.

 

Bipolar Depression: Presentation, Diagnosis, and Treatment in the Outpatient Psychiatry Practice Setting
Peter J. Weiden, MD, University of Illinois at Chicago

Bipolar depression can overlap with major depressive disorder (MDD), but treatments for the 2 disorders diverge, Dr. Weiden explained in an industry-sponsored symposium. Adding an antidepressant to a mood stabilizer is no more effective than a mood stabilizer plus placebo for treating bipolar depression. Lurasidone (Latuda) is indicated for treating a depressive episode in a patient with a diagnosis of bipolar I disorder as monotherapy or adjunctive therapy with lithium or valproate. As monotherapy and adjunctive therapy, lurasidone reduced Montgomery-Åsburg Depression Rating Scale scores score over 6 weeks compared with placebo. Nausea and vomiting are most common adverse effects, then akathisia and sedation.

 

Neuroinflammation and Oxidative Stress in Schizophrenia and Mood Disorders: Biomarkers and Therapeutic Targets
Henry A. Nasrallah, MD, Saint Louis University

Evidence suggests that inflammation is one of the earliest stages of the schizophrenia syndrome and could be through infections during pregnancy, head injury, stress response, or autoimmune disorders. Stress will activate microglia, which are the resident macrophages of the brain and players in innate immunity, and prompt these cells them to release cytokines and free radicals, which lead to neurodegeneration, decreased neurogenesis, and white matter abnormalities. Schizophrenia is associated with increased microglia activation. Clozapine protects neurons from inflammation by inhibiting microglial overactivation. Adjunctive anti-inflammatory drugs or omega-3 fatty acids could enhance the efficacy of antipsychotics or prevent conversion to psychosis in individuals at risk.

 

Clinical Management of Autism Spectrum Disorders: What Happens Over Time/Borderline Intellectual Functioning
Robert L. Hendren, DO, University of California, San Francisco

Combine types of treatments, such as behavioral interventions, speech and language therapy, and pharmacotherapy, to best serve patients with autism. Evidence of effectiveness of stimulants for patients with autism is mixed; fluvoxamine and sertraline have shown improvement in aggression and social relations. Alpha-adrenergic agonists could help relieve anxiety, but studies are limited. Risperidone and aripiprazole have FDA indications 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.

 

Management of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

The pathology of PTSD is thought to be related to abnormal neurobiological processing of acquired fear responses. 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, but all selective serotonin reuptake inhibitors 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 symptomatology. Cognitive processing therapy and prolonged exposure therapy have the best evidence of efficacy.

 

 

 

Saturday, March 12, 2015

Managing the Difficult Child
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain reviewed diagnostic criteria for oppositional defiant disorder (ODD), conduct disorder (CD), and disruptive mood dysregulation disorder, which is new in DSM-5. Disruptive behavior disorders often are comorbid with other psychiatric disorders, and there is symptomatic overlap between attention-deficit/hyperactivity disorder (ADHD) and ODD. Assessment of aggressive behaviors 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.

 

Major Depression With Subsyndromal Mania/Hypomania: Implications for Diagnosis and Management
Trisha Suppes, MD, PhD, Stanford University School of Medicine, Roger S. McIntyre, MD, FRCPC, University of Toronto, and J. Craig Nelson, MD, University of California, San Francisco

In an industry-sponsored symposium, Dr. Suppes described the history and DSM-5 diagnostic features of the mixed features specifier for major depressive disorder and bipolar disorder. Dr. Nelson explained that because mixed states is a new specifier, there are few studies examining treatment, but studies of bipolar depression are informative. Specific anticonvulsants and atypical antipsychotics have been approved to treat bipolar depression. In a randomized, double-blind, placebo-controlled trial, flexibly dosed lurasidone was more effective in the primary outcome, which was mean change in Montgomery-Åsburg Depression Rating Scale score from baseline, and response and remission rates. Dr. McIntyre reviewed medical comorbidities found in mixed states, including obesity, cardiovascular disease, and metabolic syndrome. Inflammatory processes may play a role in medical issues seen in patients with a mood disorder.

 

General Overview of Sleep Disorders
Thomas Roth, PhD, Henry Ford Hospital

Many people who experience excessive daytime sleepiness often are seen for a depression workup. Narcolepsy with cataplexy (loss of muscle tone) is associated with a hypocretin deficiency, and is an autoimmune disease. Obstructive sleep apnea is more common in men than women, and is associated with older age and obesity; treatment is 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.

 

Comorbid ADHD with Substance Abuse 
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain explored the strong connection/predictability between ADHD and lifetime nicotine, marijuana, cocaine, and other substance use, although this connection can’t be shown definitively for alcohol use because alcohol is so widely used across all demographic groups. 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. Neurobiology of ADHD and substance use disorder (SUD) (sustaining attention, motivation) is similar; genetic influences in common have been identified in studies. Dr. Rostain described the significant problem of illicit—ie, nonmedical, no Rx—stimulant use in school settings, and how such illicit stimulant use also correlates with abuse of alcohol and use of Cannabis and other substances. As for treatment, he emphasized that options for the combined disorders are limited and not fully effective. Methylphenidate plus cognitive-behavioral therapy combo is not very effective for treating comorbid ADHD and SUD, although some improvement in ADHD symptoms has been shown.

 

How to Treat Patients with Insomnia
Thomas Roth, PhD, Henry Ford Hospital

Insomnia can be considered a disorder of hyperarousal; patients “can’t shut their brain off.” An important criterion for insomnia is that sleeplessness occurs despite adequate opportunity and circumstances for sleep; otherwise, the problem is just considered poor sleep. 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 GABA_A 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.

 

Current Psychiatry welcomed more than 650 psychiatric practitioners from across the United States and abroad to this annual conference, which was headed by Meeting Co-chairs Richard Balon, MD, and Donald W. Black, MD, March 10-12, 2016, at the Marriott Chicago Magnificent Mile in Chicago, Illinois. Attendees earned as many as 18 AMA PRA Category 1 Credits™. We welcome you to join us next year in Chicago, March 30 to April 1, 2017.

View summaries from the event on the following pages.

 

 

Thursday, March 10, 2016

Make Way for Possibilities of an Adjunctive Treatment for Major Depressive Disorder
Roueen Rafeyan, MD, Feinberg School of Medicine at Northwestern University

In an industry-sponsored symposium, Dr. Rafeyan explained that many depressed patients do not fully respond to an initial antidepressant, making the next step in treatment either switching to a different antidepressant or adding an adjunctive agent. In pivotal trials, brexpiprazole (Rexulti) added to an antidepressant reduced depressive symptoms, as measured by Montgomery-Åsburg Depression Rating Scale (MADRS) total score, more than an antidepressant plus placebo. Akathisia and weight gain were the most common adverse events and occurred in ≥5% of patients in these studies. The mechanism of action of brexpiprazole in major depressive disorder is unknown, but the efficacy of this drug might be mediated through a combination of partial agonist activity at serotonin 5-HT1A and dopamine D2 receptors and antagonist activity at serotonin 5-HT2A receptors. 

 

Successful Aging
George T. Grossberg, MD, Saint Louis University 

Dementia is the result of many underlying pathological processes, some that can be changed, others that cannot. Research indicates that interventions that are good for cardiovascular health, such as addressing hyperlipidemia, blood pressure, and diabetes, also are beneficial for the brain, possibly by increasing blood flow and oxygen to the brain. Moderate use of alcohol and caffeine could be beneficial for cognitive function. Vitamins, such as D, B complex, E, and C, might slow cognitive decline, but won’t stop it. Recommend adherence to a Mediterranean diet, physical activity, and mental exercises such as learning a new language or playing games. Ask patients about head injuries, specifically if they have ever experienced a concussion and lost consciousness. Non-modifiable risk factors include genetics and adverse early life experiences.

 

Psychopharmacology and Pregnancy: The New Labeling Changes and Implications for Clinical Practice
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-half of pregnancies in the United States are unplanned and many women have experienced psychiatric illness before pregnancy. Therefore, clinicians need to consider the reproductive 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. New FDA labeling changes that were rolled out in 2015 are focused on human data, includes information about background rates of adverse events during pregnancy, and will be updated as new information becomes available in postmarketing studies (older letter-based categories will be phased out).

 

Anxiety Disorders in Women Across the Lifecycle
Marlene P. Freeman, MD, Massachusetts General Hospital

Almost one-third of women will meet criteria for an anxiety disorder during their lifetime, and symptoms can become worse during pregnancy and the postpartum period. Postpartum obsessions and psychosis can be difficult to distinguish, but the key is insight. Psychotherapy is first-line treatment for mild to 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 higher concentrations in breast milk. During menopause, women with preexisting anxiety may be more susceptible to the development of anxiety disorders. Serotonergic antidepressants, as well as gabapentin, have evidence of efficacy for hot flashes. A diagnosis of premenstrual dysphoric disorder (PMDD) indicates significant psychiatric morbidity that interferes with function, not an underlying psychiatric disorder that gets worse premenstrually. Ask patients to track their moods, especially while they are trying different treatments. Treating PMDD with serotonergic antidepressants has been well researched.

 

Mild Cognitive Impairment: “Senior Moments” and DSM-5
George T. Grossberg, MD, Saint Louis University

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. Taking a thorough history with the patient and family is the most important part of the dementia workup, which also includes a thorough physical and neurologic exam and neuropsychological assessment. Earliest recognition is possible with biomarkers, but their use is not practical in clinical practice. 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.

 

Assessing major depressive disorder and an option for treatment
Jay D. Fawver, MD, Indiana University School of Medicine

Depression is multifactorial, including difficulty with cognition and focus because of dysregulation of multiple regions of the brain and neurotransmission symptoms, says Dr. Fawver in an industry-sponsored symposium. Vortioxetine (Brintellix) is an FDA-approved medication for depression that some describe as energizing or enhancing. The drug has a unique mechanism of action and is thought to be related to enhancement of serotonergic activity in the CNS through inhibition of reuptake of 5-HT. In double-blind, placebo-controlled trials, 5 to 20 mg/d of vortioxetine was superior to placebo in improving depressive symptoms as measured by mean change in MADRS or HAM-D₂₄ total score. Among adverse effects, vomiting and nausea are common, but could be mitigated if it is taken with food. Vortioxetine is weight neutral. 

 

Innovative Treatments of Anxiety, Part 1 (Use of Benzodiazepines)
Mark H. Pollack, MD, Rush University Medical Center

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, but for maintenance treatment, consider a longer-acting agent. Consider combining benzodiazepines with antidepressants for rapid relief of anxiety while antidepressants begin to work, to treat residual anxiety, or to decrease early anxiety associated with antidepressant treatment. Reported increase in overdose mortality likely is conflation with other drugs of abuse, particularly opioids. Dr. Pollack ended his presentation by reviewing the use of tricyclic antidepressants, monoamine oxidase inhibitors, and other antidepressants for anxiety disorders.

 

Innovative Treatments of Anxiety, Part 2 (Other Standard and Novel Therapeutic Approaches)
Mark H. Pollack, MD, Rush University Medical Center

Antipsychotics are used off-label as monotherapy and as an adjunct to selective serotonin reuptake inhibitors for anxiety, 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. Prazosin, an antihypertensive, can improve sleep and decrease nightmares in PTSD. Using hypnotics to treat sleep disturbances after a traumatic event could reduce the likelihood of developing PTSD. Propranolol has been studied, but is not considered effective for preventing PTSD. Cognitive-behavioral therapy (CBT) is effective for anxiety, may have a lower relapse rate than pharmacotherapy, and has few adverse effects; however, it is more difficult to administer than medication and may not be widely available or affordable. Dr. Pollack recommends integrating CBT with pharmacotherapy. Researchers are examining augmenting CBT or exposure therapy with d-cycloserine.

 

Treatment of Chronic Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital

Dr. Nierenberg 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 is the basis of depressive thoughts.

 

 

 

Friday, March 11, 2016

Subtypes of Depression
Andrew A. Nierenberg, MD, Massachusetts General Hospital, Alexian Brothers Behavioral Health Hospital for Violence Prevention Clinic/Program and ADHD Clinic

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. Depression is highly comorbid, making it complicated to manage. Duration of depressive episodes also is highly variable, with some patients experiencing episodes that last as long as 14 weeks. 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.

 

Managing ADHD: What Matters Most When Selecting a Treatment Option
Michael Feld, MD, Alexian Brothers Behavioral Health Hospital for Violence Prevention Clinic/Program and ADHD Clinic

In an industry-sponsored symposium, Dr. Feld began his review of therapeutic strategies by noting that stimulant medications have long been recommended first-line therapy for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). Nonstimulant ADHD agents, such as atomoxetine, are a second-line option; antidepressants are third. Today, newer formulations of stimulants give clinicians an additional option to test and adjust at the start of therapy.

Dr. Feld discussed the utility of the brand-name extended-release (ER) methylphenidate HCl (Aptensio) for its value in children—specifically, its ability to “extend the day” without additional dosing of a short-action medication. The design of Aptensio—a multilayered beaded delivery system in which every bead is both an immediate- and an extended-release vehicle—allows an early peak serum drug level and later peak level (at 8 hours). Aptensio is administered by sprinkling the contents of a capsule on applesauce; it is is safe practice, Dr. Feld explained, to augment the ER drug delivery with an immediate-release agent when deemed necessary, by observing how difficult it is for the patient to make it through the day at home, school, or work.

 

Overview of Autism Spectrum Disorder
Robert L. Hendren, DO, University of California, San Francisco

Prevalence of autism has been increasing and is more common in males than females; various theories about the increased prevalence including better recognition and diagnosis, environmental toxins, and epigenetic processes. Up to 25% of autism cases can be attributed to genetics, but researchers have not pinpointed a single gene. To attempt 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 individuals with autism focus on early interventions (18 to 24 months) when brains are more plastic, but later interventions during adolescence can be valuable as brains continue to grow and change and patients learn new skills.

 

Comorbidity of Schizophrenia and Substance Abuse
Henry A. Nasrallah, MD, Saint Louis University

Approximately one-half of patients with schizophrenia have comorbid substance abuse, including nicotine, alcohol, Cannabis, and other substances, a rate that is approximately 3 times higher than in the general population. 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; case reports include alcohol, cocaine, nicotine, and polydrug use. Risperidone may be helpful, but only 12% of drug abusing patients taking risperidone achieved abstinence compared with 54% with clozapine. Naltrexone has evidence of efficacy for alcohol abuse. Evidence is mixed or insufficient for olanzapine, ziprasidone, aripiprazole, and anticonvulsants.

 

Overview of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

Posttraumatic stress disorder (PTSD) is a conditional diagnosis because trauma exposure is required. Dr. North described the DSM-5 criteria for PTSD and pointed out that distress does not necessarily mean 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/numbing symptoms. Comorbid MDD or substance use is associated with PTSD but not with trauma exposure, therefore PTSD, not trauma, might be a causal risk for other disorders. Substance use disorders often are present before the trauma exposure, meaning that individuals might use PTSD as a way to rationalize their substance use.

 

Bipolar Depression: Presentation, Diagnosis, and Treatment in the Outpatient Psychiatry Practice Setting
Peter J. Weiden, MD, University of Illinois at Chicago

Bipolar depression can overlap with major depressive disorder (MDD), but treatments for the 2 disorders diverge, Dr. Weiden explained in an industry-sponsored symposium. Adding an antidepressant to a mood stabilizer is no more effective than a mood stabilizer plus placebo for treating bipolar depression. Lurasidone (Latuda) is indicated for treating a depressive episode in a patient with a diagnosis of bipolar I disorder as monotherapy or adjunctive therapy with lithium or valproate. As monotherapy and adjunctive therapy, lurasidone reduced Montgomery-Åsburg Depression Rating Scale scores score over 6 weeks compared with placebo. Nausea and vomiting are most common adverse effects, then akathisia and sedation.

 

Neuroinflammation and Oxidative Stress in Schizophrenia and Mood Disorders: Biomarkers and Therapeutic Targets
Henry A. Nasrallah, MD, Saint Louis University

Evidence suggests that inflammation is one of the earliest stages of the schizophrenia syndrome and could be through infections during pregnancy, head injury, stress response, or autoimmune disorders. Stress will activate microglia, which are the resident macrophages of the brain and players in innate immunity, and prompt these cells them to release cytokines and free radicals, which lead to neurodegeneration, decreased neurogenesis, and white matter abnormalities. Schizophrenia is associated with increased microglia activation. Clozapine protects neurons from inflammation by inhibiting microglial overactivation. Adjunctive anti-inflammatory drugs or omega-3 fatty acids could enhance the efficacy of antipsychotics or prevent conversion to psychosis in individuals at risk.

 

Clinical Management of Autism Spectrum Disorders: What Happens Over Time/Borderline Intellectual Functioning
Robert L. Hendren, DO, University of California, San Francisco

Combine types of treatments, such as behavioral interventions, speech and language therapy, and pharmacotherapy, to best serve patients with autism. Evidence of effectiveness of stimulants for patients with autism is mixed; fluvoxamine and sertraline have shown improvement in aggression and social relations. Alpha-adrenergic agonists could help relieve anxiety, but studies are limited. Risperidone and aripiprazole have FDA indications 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.

 

Management of PTSD
Carol S. North, MD, MPE, DFAPA, University of Texas Southwestern Medical Center

The pathology of PTSD is thought to be related to abnormal neurobiological processing of acquired fear responses. 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, but all selective serotonin reuptake inhibitors 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 symptomatology. Cognitive processing therapy and prolonged exposure therapy have the best evidence of efficacy.

 

 

 

Saturday, March 12, 2015

Managing the Difficult Child
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain reviewed diagnostic criteria for oppositional defiant disorder (ODD), conduct disorder (CD), and disruptive mood dysregulation disorder, which is new in DSM-5. Disruptive behavior disorders often are comorbid with other psychiatric disorders, and there is symptomatic overlap between attention-deficit/hyperactivity disorder (ADHD) and ODD. Assessment of aggressive behaviors 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.

 

Major Depression With Subsyndromal Mania/Hypomania: Implications for Diagnosis and Management
Trisha Suppes, MD, PhD, Stanford University School of Medicine, Roger S. McIntyre, MD, FRCPC, University of Toronto, and J. Craig Nelson, MD, University of California, San Francisco

In an industry-sponsored symposium, Dr. Suppes described the history and DSM-5 diagnostic features of the mixed features specifier for major depressive disorder and bipolar disorder. Dr. Nelson explained that because mixed states is a new specifier, there are few studies examining treatment, but studies of bipolar depression are informative. Specific anticonvulsants and atypical antipsychotics have been approved to treat bipolar depression. In a randomized, double-blind, placebo-controlled trial, flexibly dosed lurasidone was more effective in the primary outcome, which was mean change in Montgomery-Åsburg Depression Rating Scale score from baseline, and response and remission rates. Dr. McIntyre reviewed medical comorbidities found in mixed states, including obesity, cardiovascular disease, and metabolic syndrome. Inflammatory processes may play a role in medical issues seen in patients with a mood disorder.

 

General Overview of Sleep Disorders
Thomas Roth, PhD, Henry Ford Hospital

Many people who experience excessive daytime sleepiness often are seen for a depression workup. Narcolepsy with cataplexy (loss of muscle tone) is associated with a hypocretin deficiency, and is an autoimmune disease. Obstructive sleep apnea is more common in men than women, and is associated with older age and obesity; treatment is 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.

 

Comorbid ADHD with Substance Abuse 
Anthony L. Rostain, MD, MA, University of Pennsylvania

Dr. Rostain explored the strong connection/predictability between ADHD and lifetime nicotine, marijuana, cocaine, and other substance use, although this connection can’t be shown definitively for alcohol use because alcohol is so widely used across all demographic groups. 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. Neurobiology of ADHD and substance use disorder (SUD) (sustaining attention, motivation) is similar; genetic influences in common have been identified in studies. Dr. Rostain described the significant problem of illicit—ie, nonmedical, no Rx—stimulant use in school settings, and how such illicit stimulant use also correlates with abuse of alcohol and use of Cannabis and other substances. As for treatment, he emphasized that options for the combined disorders are limited and not fully effective. Methylphenidate plus cognitive-behavioral therapy combo is not very effective for treating comorbid ADHD and SUD, although some improvement in ADHD symptoms has been shown.

 

How to Treat Patients with Insomnia
Thomas Roth, PhD, Henry Ford Hospital

Insomnia can be considered a disorder of hyperarousal; patients “can’t shut their brain off.” An important criterion for insomnia is that sleeplessness occurs despite adequate opportunity and circumstances for sleep; otherwise, the problem is just considered poor sleep. 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 GABA_A 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.