Mirtazapine: a newer antidepressant.

Mirtazapine is a newer antidepressant that exhibits both noradrenergic and serotonergic activity. It is at least as effective as the older antidepressants for treating mild to severe depression. Sedation is the most common side effect. Although agranulocytosis is the most serious side effect, it is rare (approximately one in 1,000) and usually reversible when the medication is stopped. Mirtazapine is relatively safe in overdose. Many clinicians consider mirtazapine a second-line or even third-line antidepressant to be used when older antidepressants are not tolerated or are ineffective. Physicians who are concerned about the risks of elevated lipid levels and agranulocytosis may choose to reserve mirtazapine as a third-line choice. It is particularly useful in patients who experience sexual side effects from other antidepressants. Mirtazapine is also a good choice in depressed patients with significant anxiety or insomnia. Although mirtazapine has been used successfully in Europe for a number of years, its place in the care of patients with depression in the United States has not yet been established.

Naltrexone in alcohol dependence.

Naltrexone is a narcotic antagonist that has been shown to reduce alcohol craving and alcohol use in patients with alcohol dependence. It should not be used as exclusive treatment but only as an adjunct to a comprehensive program that includes psychologic and social treatment approaches such as those in Alcoholics Anonymous or professional programs. The two most serious complications of naltrexone therapy are the precipitation of narcotic withdrawal in patients taking narcotics, and hepatotoxicity. The latter complication occurs only at dosages much higher than the 50 mg per day recommended for treatment of alcohol dependence. Alcohol is known to enhance opioid receptors. Evidently, naltrexone blockade of these receptors results in reduced craving for alcohol, less of a "high" while drinking and less alcohol use.

Strategies for managing depression complicated by bipolar disorder, suicidal ideation, or psychotic features.

BACKGROUND: Major depression, a common clinical problem that, if recognized early and treated vigorously, is often highly responsive to antidepressants and can be complicated by such features as mania, suicidal thoughts and actions, and psychosis. Suicide is one of the most serious complications of major depression. METHODS: An online search of the medical literature was used to select English-language articles addressing depression using, but not limited to, the following specific terms: "primary care," "depressive disorders," "bipolar disorder," "suicide," "psychosis," and "antidepressants." RESULTS AND CONCLUSIONS: Treatment of the manic phases of bipolar disorder includes lithium or anticonvulsants. Breakthrough depression can be particularly resistant to treatment in bipolar patients, and the tricyclic antidepressants can cause patients to cycle more rapidly into the manic phase. The selective serotonin reuptake inhibitors (SSRIs) and bupropion are less likely to cause rapid cycling in bipolar disorder. Depressed patients with suicidal tendencies should be closely monitored and given full doses of antidepressant medications. The SSRIs lessen suicidal tendencies and, importantly, are markedly safer than the tricyclic antidepressants when taken in an overdose. Depressed patients can also become psychotic, exhibiting mood-congruent delusions. Combination therapy with antidepressant and antipsychotic medications is often necessary. Some physicians prefer to hospitalize patients with psychotic depression. Depression can be a complex and multifaceted disorder that requires careful diagnosis and treatment plans.

Drug treatment of insomnia: indications and newer agents.

Insomnia is a symptom that should be treated according to the underlying etiology. It is more common in elderly individuals and in women. Common causes of insomnia include acute situational factors, psychiatric disorders, use of various medications and illicit drugs, and medical disorders that cause pain, dyspnea or nausea. Pharmacotherapy should be generally restricted to use of the benzodiazepines, imidazopyridines (zolpidem) and occasionally tricyclic antidepressants. As a rule, hypnotic drugs should be used for less than two weeks to one month.

Hospital-based professional assistance committees: literature review and guidelines.

This paper presents a review of the current literature on hospital professional assistance committees, a discussion of key issues, and a set of guidelines for the design and operation of these committees. The employee assistance program is suggested as a resource to these committees.

A pilot study of a modified Balint group using cognitive approaches to physician attitudes about somatoform disorder patients.

This is a pilot study of the use of cognitive therapy theories and techniques in a time-limited Balint group of family physicians with a focus on the care of the somatoform disorders. Family physicians often find these patients difficult and unpleasant to treat. Physicians in the group were compared with other family physicians in a pre and post test of attitudes towards patients with somatoform disorders. In addition, the beliefs of the physicians were elicited. After the 13 session Balint group was completed, attitudes of the family physicians in the group improved so that they were less likely to feel that somatizing patients take up too much of their time (p less than 0.05). Underlying beliefs about somatoform disorder patients were identified in the group and subsequently modified. This study suggests that a time-limited cognitive therapy Balint group, focusing on somatoform disorder patients, results in improved attitudes toward the care of these patients.

HIV testing: issues for the family physician.

Human immunodeficiency virus (HIV) infection affects all communities. To provide optimal patient care, physicians must understand the ramifications of HIV-antibody testing and provide appropriate counseling before and after testing. The seropositive patient requires knowledgeable surveillance. In addition, the family physician must be prepared for the psychologic and social stresses that HIV infection imposes on the patient and the family.