ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Traditionally, psychiatric medications were withheld during pregnancy because of fear of teratogenic and other effects. The emergence of evidence of the safety of most commonly used psychiatric medications, the availability of this information in the form of online databases, and the documentation of the adverse effects of untreated maternal mental illness have all increased the comfort of physicians and patients with respect to the use of psychiatric medications during pregnancy. The tricyclic antidepressants and fluoxetine (Prozac) appear to be free of teratogenic effects, and emerging data support similar safety profiles for the other selective serotonin reuptake inhibitors. The mood stabilizers appear to be teratogenic. With the exception of the known risk for depression to worsen in the postpartum period, there is little consistent evidence of the effects of pregnancy on the natural history of mental illness. Decisions regarding the use of psychiatric medications should be individualized, and the most important factor is usually the patient's level of functioning in the past when she was not taking medications.
Delirium - Article
ABSTRACT: Delirium is characterized by an acute change in cognition and a disturbance of consciousness, usually resulting from an underlying medical condition or from medication or drug withdrawal. Delirium affects 10 to 30 percent of hospitalized patients with medical illness; more than 50 percent of persons in certain high-risk populations are affected. The associated morbidity and mortality make diagnosis of this condition extremely important. Patients with delirium can present with agitation, somnolence, withdrawal, and psychosis. This variation in presentation can lead to diagnostic confusion and, in some cases, incorrect attribution of symptoms to a primary psychiatric disorder. To make the distinction, it is important to obtain the history of the onset and course of the condition from family members or caregivers. Primary care physicians must be able to recognize delirium so that the underlying etiology can be ascertained and addressed. The management of delirium involves identifying and correcting the underlying problem, and symptomatically managing any behavioral or psychiatric symptoms. Low doses of antipsychotic drugs can help to control agitation. The use of benzodiazepines should be avoided except in cases of alcohol or sedative-hypnotic withdrawal. Environmental interventions, including frequent reorientation of patients by nursing staff and education of patients and families, should be employed in all cases.
ABSTRACT: Increasingly, atypical antipsychotic drugs are prescribed for elderly patients with symptoms of psychosis and behavioral disturbances. These symptoms often occur in patients with Alzheimer's disease, other dementias, or Parkinson's disease. As the average age of Americans increases, the prevalence of Alzheimer's disease and Parkinson's disease will rise accordingly. Although nonpharmacologic treatments for behavioral disturbances should be tried first, medications often are needed to enable the patient to be adequately cared for. Current guidelines recommend using risperidone and olanzapine to treat psychosis in patients with Alzheimer's dementia. Quetiapine and clozapine are recommended for treatment of psychosis in patients with Parkinson's disease. Additional research is needed for a recently approved agent, ziprasidone. To minimize side effects, these medications should be started at low dosages that are increased incrementally. Drug interactions, especially those involving the cytochrome P450 system, must be considered. Clozapine's potentially lethal side effects limit its use in the primary care setting. Informed use of atypical antipsychotic drugs allows family physicians to greatly improve quality of life in elderly patients with dementia and behavior disturbances.
ABSTRACT: Psychosis may pose a greater challenge than cognitive decline for patients with dementia and their caregivers. The nature and frequency of psychotic symptoms varies over the course of illness, but in most patients, these symptoms occur more often in the later stages of disease. Management of psychosis requires a comprehensive nonpharmacologic and pharmacologic approach, including an accurate assessment of symptoms, awareness of the environment in which they occur, and identification of precipitants and how they affect patients and their caregivers. Nonpharmacologic interventions include counseling the caregiver about the nonintentional nature of the psychotic features and offering coping strategies. Approaches for the patient involve behavior modification; appropriate use of sensory intervention; environmental safety; and maintenance of routines such as providing meals, exercise, and sleep on a consistent basis. Pharmacologic treatments should be governed by a "start low, go slow" philosophy; a monosequential approach is recommended, in which a single agent is titrated until the targeted behavior is reduced, side effects become intolerable, or the maximal dosage is achieved. Atypical antipsychotics have the greatest effectiveness and are best tolerated. Second-line medications include typical antipsychotics for short-term therapy; and, less often, anticonvulsants, acetylcholinesterase inhibitors, antidepressants, and anxiolytics. Goals of treatment should include symptom reduction and preservation of quality of life.
Schizophrenia: A Review - Article
ABSTRACT: Schizophrenia is a debilitating mental illness that affects 1 percent of the population in all cultures. It affects equal numbers of men and women, but the onset is often later in women than in men. Schizophrenia is characterized by positive and negative symptoms. Positive symptoms include hallucinations, voices that converse with or about the patient, and delusions that are often paranoid. Negative symptoms include flattened affect, loss of a sense of pleasure, loss of will or drive, and social withdrawal. Both types of symptoms affect patients' families; therefore, it is important for physicians to provide guidance to all persons affected by the disease. Psychosocial and family interventions can improve outcomes. Medications can control symptoms, but virtually all antipsychotics have neurologic or physical side effects (e.g., weight gain, hypercholesterolemia, diabetes). There is a 10 percent lifetime risk of suicide in patients with schizophrenia.
ABSTRACT: Family physicians commonly care for patients with serious mental illness. Patients with psychotic and bipolar disorders have more comorbid medical conditions and higher mortality rates than patients without serious mental illness. Many medications prescribed for serious mental illness have significant metabolic and cardiovascular adverse effects. Patients treated with second-generation antipsychotics should receive preventive counseling and treatment for obesity, hyperglycemia, diabetes, and hyperlipidemia. First- and second-generation antipsychotics have been associated with QT prolongation. Many common medications can interact with antipsychotics, increasing the risk of cardiac arrhythmias and sudden death. Drug interactions can also lead to increased adverse effects, increased or decreased drug levels, toxicity, or treatment failure. Physicians should carefully consider the risks and benefits of second-generation antipsychotic medications, and patient care should be coordinated between primary care physicians and mental health professionals to prevent serious adverse effects.
ABSTRACT: Delirium is common in hospitalized older patients and may be a symptom of a medical emergency, such as hypoxia or hypoglycemia. It is characterized by an acute change in cognition and attention, although the symptoms may be subtle and usually fluctuate throughout the day. This heterogeneous syndrome requires prompt recognition and evaluation, because the underlying medical condition may be life threatening. Risk factors for delirium include visual impairment, previous cognitive impairment, severe illness, and an elevated blood urea nitrogen/serum creatinine ratio. Interventions that have been shown to reduce the incidence of delirium in at-risk hospitalized patients include repeated reorientation of the patient to person and place, promotion of good sleep hygiene, early mobilization, correction of dehydration, and the minimization of unnecessary noise and stimuli. The treatment of delirium centers on the identification and management of the medical condition that triggered the delirious state. Nonpharmacologic interventions may be beneficial, but antipsychotic agents may be needed when the cause is nonspecific and other interventions do not sufficiently control symptoms such as severe agitation or psychosis. Although delirium is a temporary condition, it may persist for several months in the most vulnerable patients. Patient outcomes at one year include a higher mortality rate and a lower level of functioning compared with age-matched control patients.
Combative Delirium - Curbside Consultation
ABSTRACT: The use of antipsychotic medications entails a difficult trade-off between the benefit of alleviating psychotic symptoms and the risk of troubling, sometimes life-shortening adverse effects. There is more variability among specific antipsychotic medications than there is between the first- and second-generation antipsychotic classes. The newer second-generation antipsychotics, especially clozapine and olanzapine, generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus. Also, as a class, the older first-generation antipsychotics are more likely to be associated with movement disorders, but this is primarily true of medications that bind tightly to dopaminergic neuroreceptors, such as haloperidol, and less true of medications that bind weakly, such as chlorpromazine. Anticholinergic effects are especially prominent with weaker-binding first-generation antipsychotics, as well as with the second-generation antipsychotic clozapine. All antipsychotic medications are associated with an increased likelihood of sedation, sexual dysfunction, postural hypotension, cardiac arrhythmia, and sudden cardiac death. Primary care physicians should understand the individual adverse effect profiles of these medications. They should be vigilant for the occurrence of adverse effects, be willing to adjust or change medications as needed (or work with psychiatric colleagues to do so), and be prepared to treat any resulting medical sequelae.
When the Side Effect Is Really the Symptom - Curbside Consultation