RESUMO
Borderline personality disorder is estimated to be present in approximately 6% of outpatient primary care settings. However, the time and energy spent on this population can greatly exceed what primary care doctors are able to spend. This article gives an overview of borderline personality disorder, including the clinical characteristics, epidemiology, and comorbidities, as well as pharmacologic and most important behavioral management. It is our hope that, with improved understanding of the disorder and skills for managing this population, caring for patients with the disorder can be more satisfying and less taxing for both primary care doctors and their patients.
Assuntos
Transtorno da Personalidade Borderline/diagnóstico , Transtorno da Personalidade Borderline/terapia , Atenção Primária à Saúde , Antipsicóticos/uso terapêutico , Transtorno da Personalidade Borderline/epidemiologia , Encéfalo/patologia , Comorbidade , Predisposição Genética para Doença , Humanos , Imageamento por Ressonância Magnética , Neuropeptídeos/metabolismo , Prevalência , Psicoterapia/métodos , Indução de Remissão , Comportamento Autodestrutivo/psicologia , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Meio Social , Ideação SuicidaRESUMO
BACKGROUND: Glucocorticoids are widely prescribed for a variety of diseases and are known to cause neuropsychiatric as well as somatic side effects. OBJECTIVE: This article will review the incidence, clinical characteristics, course, and treatment of neuropsychiatric effects of glucocorticoids. METHODS: We performed a literature review of the neuropsychiatric complications of glucocorticoids using the PubMed database. RESULTS: The neuropsychiatric effects of glucocorticoids involve affective, behavioral, and cognitive manifestations. Serious neuropsychiatric effects occur in about 6% of patients who receive steroids. Although the effects of glucocorticoids are unpredictable, the administered dose is the most significant risk factor for the development of neuropsychiatric symptoms. Dosage reduction typically results in clinical recovery. Although evidence from controlled trials is sparse, administration of antipsychotics or mood stabilizers may be beneficial in the prevention and treatment of neuropsychiatric effects of steroids. CONCLUSION: The neuropsychiatric effects of glucocorticoids are more diverse than the often-misleading term "steroid psychosis" suggests. This label should be limited to those patients who are truly psychotic, and specific designations applied to patients with other effects. The adverse neuropsychiatric effects of glucocorticoids remain poorly characterized in the literature (which consists largely of case reports and case series). Reliable risk factors (other than dose) that identify individuals at risk are lacking; guidelines for the prevention of neuropsychiatric effects are not evidence-based. Further controlled clinical studies are needed to elucidate the optimal management of glucocorticoid-induced neuropsychiatric symptoms.
Assuntos
Sintomas Afetivos/epidemiologia , Glucocorticoides/efeitos adversos , Psicoses Induzidas por Substâncias/psicologia , Tranquilizantes/uso terapêutico , Sintomas Afetivos/induzido quimicamente , Fatores Etários , Encéfalo/efeitos dos fármacos , Transtornos Cognitivos/induzido quimicamente , Relação Dose-Resposta a Droga , Glucocorticoides/administração & dosagem , Glucocorticoides/farmacologia , Humanos , Psicoses Induzidas por Substâncias/epidemiologia , Psicoses Induzidas por Substâncias/prevenção & controle , PubMed , Fatores de Risco , Índice de Gravidade de Doença , Distribuição por Sexo , Síndrome de Abstinência a Substâncias/prevenção & controleRESUMO
OBJECTIVE: To examine the prevalence and treatment of typical and subsyndromal bipolar disorder (BD) in depressed primary care patients. METHODS: Patients with a diagnosis of a mood disorder being treated with antidepressants in 2 academic family practice clinics underwent a structured diagnostic interview (Mini International Neuropsychiatric Inventory) for manic and hypomanic symptoms. RESULTS: Of 58 patients evaluated, 19% met full criteria for bipolar I disorder and 8.6% for bipolar II disorder; 31% had subsyndromal BD (ie, persistent elation or irritability accompanied by additional symptoms of hypomania but not enough symptoms to meet full criteria for bipolar I or II disorder). Only 5 patients with BD were receiving mood stabilizers, which had not been instituted in any patient by the primary care physician. CONCLUSIONS: The high prevalence of patients meeting full criteria for BD and the low rate of identification of BD in primary care patients are consistent with estimates using self-administered questionnaires, but the interview revealed a substantial additional population that could be considered to have subsyndromal BD. Because subsyndromal forms of BD are associated with significant impairment and comorbidity as well as progression to frank BD, recognition of both full and subthreshold BD in primary care practice should be improved.
Assuntos
Transtorno Bipolar/epidemiologia , Depressão/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antidepressivos/uso terapêutico , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/tratamento farmacológico , Depressão/tratamento farmacológico , Humanos , Entrevista Psicológica , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Prevalência , Atenção Primária à Saúde/estatística & dados numéricos , Escalas de Graduação Psiquiátrica , Adulto JovemRESUMO
INTRODUCTION: Antipsychotic drugs are increasingly used in the maintenance treatment of bipolar disorder. This review addresses the evidence supporting the use of one of these medications for this indication in order to place available data in perspective for the clinician. AREAS COVERED: The approval of ziprasidone for maintenance treatment of bipolar I disorder was based on two open-label extensions of industry-sponsored 3-week monotherapy trials in mania, involving a total of 189 patients and an industry-sponsored study using sample enrichment of 584 outpatients who had either ziprasidone or a placebo added to lithium or valproate. Patients enrolled in maintenance studies did not have refractory mood disorders or comorbid conditions or risk of dangerousness, and they were able to give sustained consent. Ziprasidone is generally well tolerated, but should be taken with food. Primary interactions of concern are those with other serotonergic medications and other medications that prolong the QT interval. EXPERT OPINION: Although antipsychotic drugs are used frequently for maintenance treatment, current guidelines recommend that an attempt be made to withdraw them after acute treatment. The use of these medications as part of a maintenance regimen is most appropriate in cases of persistent psychosis or failure to respond to standard mood stabilizer combinations.
Assuntos
Antipsicóticos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Piperazinas/uso terapêutico , Tiazóis/uso terapêutico , Adulto , Antipsicóticos/efeitos adversos , Método Duplo-Cego , Humanos , Piperazinas/efeitos adversos , Placebos , Ensaios Clínicos Controlados Aleatórios como Assunto , Tiazóis/efeitos adversosRESUMO
Psychiatric disorders are common in neurological patients, and psychopharmacological agents are frequently used to treat agitation and other problems in neurological practice. Antidepressants are effective for depression caused by neurological illness, but they can interact with other medications. Antianxiety drugs can aggravate cognitive disorders and should be used cautiously in this context. Antipsychotic drugs can be useful for acute agitation, but they are being found to be neither effective nor safe for chronic nonpsychotic agitation. Other agents such as beta blockers and serotonergic agents are being found to be more useful. Uses, doses, adverse effects, and interactions of psychiatric medications in neurology are summarized in this article, and suggestions are provided for the practical application of these treatments.
Assuntos
Antipsicóticos/uso terapêutico , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/etiologia , Doenças do Sistema Nervoso/complicações , Psicofarmacologia/métodos , Eletroconvulsoterapia/métodos , Humanos , Doenças do Sistema Nervoso/tratamento farmacológicoRESUMO
Suicidal ideation and attempts are common reasons for visits to the emergency department and critical care hospitalizations and a common public health problem. Most patients who make a suicide attempt have a psychiatric disorder, most frequently a mood, psychotic, substance use, or personality disorder. Patients who are at high risk of another attempt and cannot be transferred promptly to a psychiatric service should be managed jointly by the psychiatric and critical care teams with an emphasis on protection of the patient, identification of substance intoxication and withdrawal, making the environment safe, and instituting treatment of the psychiatric disorder. Antidepressants reduce suicide risk but their slow onset of action may make electroconvulsive therapy a desirable alternative for severely depressed patients. Parenteral treatment is possible with benzodiazepines and antipsychotic drugs but not antidepressants.
Assuntos
Transtornos Psicóticos Afetivos , Antidepressivos/uso terapêutico , Cuidados Críticos/métodos , Eletrochoque , Fatores de Risco , Tentativa de Suicídio/psicologia , Suicídio/estatística & dados numéricos , Adolescente , Adulto , Transtornos Psicóticos Afetivos/complicações , Transtornos Psicóticos Afetivos/tratamento farmacológico , Transtornos Psicóticos Afetivos/psicologia , Criança , Feminino , Humanos , Masculino , Prevalência , Suicídio/psicologia , Estados Unidos/epidemiologia , Adulto Jovem , Prevenção do SuicídioRESUMO
OBJECTIVE: The authors aim to determine whether admission interviews predict performance in residency. METHODS: The authors determined whether interview and other admission data were correlated with performance during postgraduate years 2-4 and with remaining in the residency in 544 residents enrolled in a single psychiatry residency program between 1963 and 2004. RESULTS: Considered together, admissions data predicted 13% of the variance in performance ratings in postgraduate year 2 (PGY-2) and 5% in PGY-4. Interview scores were moderately correlated with performance ratings in PGY-2, modestly correlated with performance in PGY-3, and not correlated with performance ratings in PGY-4. Letters of reference were moderately correlated with performance ratings in PGY-2 and modestly correlated with performance in PGY-3 and PGY-4. In PGY-2, interview scores differentiated between the top quartile of performance and the other three quartiles, while letters of reference differentiated performance in the top and bottom quartiles from the middle quartiles. Numerical differences among groups were not great enough to be practically useful, and no variables predicted which residents would leave the program before completing it. CONCLUSION: As they are currently conducted, application interviews do not have sufficient power to predict performance during residency. Letters of reference may be useful to the extent that they reflect personal experience with the applicant, but differences in ratings of these letters are not great enough to base admission decisions on them. As it is currently performed, the interview process may be more useful as a means of interesting applicants in the program than of evaluating their potential for success in the residency.
Assuntos
Logro , Internato e Residência , Entrevistas como Assunto , Psiquiatria/educação , Adulto , Feminino , Humanos , Masculino , Estudantes de MedicinaRESUMO
OBJECTIVE: The authors assessed whether current methods of evaluating residency applicants and residents identify psychiatrists who later develop evidence of impairment. METHOD: Residency admissions and performance data for all physicians who were enrolled in a psychiatry residency between 1965 and 1994 and who were referred to an impaired physician program up to 35 years later were matched for age and gender with a nonreferred physician from the same class. RESULTS: There were no significant differences between groups in admission interview assessments, performance ratings, or narrative observations by faculty during residency. CONCLUSIONS: Standard approaches do not identify physicians at risk of later impairment.
Assuntos
Competência Clínica , Internato e Residência , Entrevistas como Assunto/normas , Padrões de Prática Médica/normas , Papel Profissional , Critérios de Admissão Escolar , Humanos , Transtornos Mentais/epidemiologia , Inabilitação do Médico/estatística & dados numéricos , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: There is increasing interest in the use of propofol, an ultrashort-acting hypnotic agent, for sedation during endoscopic examinations. A protocol was developed for administration of propofol, combined with small doses of midazolam and meperidine, for endoscopic sedation under the direction of a gastroenterologist. Initial experience with using this protocol is described. METHODS: A total of 819 consecutive endoscopic examinations under sedation with propofol, midazolam, and meperidine (or fentanyl), in adherence with the sedation protocol, were reviewed retrospectively. RESULTS: There were 638 colonoscopies and 181 EGDs; 89% of patients were classified as American Society of Anesthesiologists (ASA) class I or II. Mean dosages of medications were: propofol 63 (33.5) mg, meperidine 48 (7.2) mg, and midazolam 1 (0.12) mg. The dose of propofol was inversely correlated with age and ASA class, and positively correlated with patient weight and duration of examination. Hypotension (>20 mm Hg decline in either systolic or diastolic blood pressure) developed in 218 (27%) patients, and hypoxemia (oxygen saturation <90%) developed in 75 (9%). All episodes of hypotension and hypoxemia were transient, and no patient required administration of a pharmacologic antagonist or assisted ventilation. The average time for recovery after colonoscopy and after EGD was, respectively, 25 minutes and 28 minutes. All EGDs and 98% of colonoscopies were completed successfully. CONCLUSIONS: On the basis of this initial experience, it is believed that propofol, potentiated by small doses of midazolam and meperidine, can be safely and effectively administered under the direction of a gastroenterologist. Additional research will be necessary to determine whether propofol is superior to the current methods of sedation.