Current Psychiatry Reviews - Volume 7, Issue 3, 2011

Clozapine has a lower incidence of neurologic side effects, in particular extrapyramidal symptoms and is associated with a decreased mortality, largely due to a significant reduction in the risk of suicide, in comparison to firstgeneration antipsychotics. Favourable clinical results however are faced with a not negligible risk of serious adverse effects in particular agranulocytosis, weight gain or metabolic syndrome. Dilated cardiomyopathy, myocarditis, pericarditis and sudden death are less frequent but potentially fatal cardiac adverse effects related to clozapine treatment. The diagnosis of cardiac toxicity is usually made only when severe clinical symptoms occurs and impairment of left ventricular function is often irreversible At present no prospective studies on cardiac toxicity are reported in literature and clozapine related cardiac toxicity may be actually underestimated. In the present review we tried to up to date cardiovascular risk associated with clozapine treatment.

Eating disorders frequently have their onset in adolescence. This is problematic as Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS) often present with serious psychiatric and medical sequelae that can affect an adolescent's physical and emotional development. It is well documented that complications from eating disorders in adolescence can result in long-term health consequences, rendering effective psychiatric and medical treatments a necessity. To combat the medical consequences associated with eating disorders in adolescents, pediatricians must identify, treat, and monitor medical complications. Pediatricians are also responsible for assessing the need for hospitalization due to medical instability. Some advances have been made regarding psychopharmacological treatments for eating disorders. For example, antidepressant medications, such as SSRIs, have demonstrated efficacy in the treatment of adults with BN. The true effectiveness of these medications in adolescent populations remains unknown. A multidisciplinary team approach is a common treatment model in outpatient practice, but further research is required to investigate how to facilitate the collaboration of psychiatric and medical professionals. The majority of psychiatric and medical trials for eating disorder patients have involved adult participants, and most studies have investigated either psychiatric or medical treatments for eating disorders. In this review, we will add to the current literature by focusing on both psychiatric and medical treatments for eating disorders, with particular emphasis on studies conducted with adolescents.

Anti-NMDA receptor encephalitis is an autoimmune disorder in which antibodies attack NMDA (N-methyl-Daspartate)-type glutamate receptors at central neuronal synapses. Symptoms include a highly characteristic set of neurologic deficits, but also prominent psychiatric manifestations that often bring mental health professionals into the course of care. Distinct phases of illness have become increasingly appreciated, and include a range of psychotic symptoms early in the course of the disease followed by more severe fluctuations in consciousness with neurologic involvement, and ultimately protracted cognitive and behavioral deficits. Young women are most commonly impacted and an ovarian teratoma is sometimes associated with the syndrome. Patients respond well to immunotherapy, but psychiatric symptoms can be challenging to manage. We provide an up to date review of this disorder and highlight the role of psychiatry in diagnosis, symptomatology, and treatment.

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric condition that arises from exposure to a traumatic event such as combat exposure, a vehicular accident, or an act of violence. The symptom clusters of PTSD include hyperarousal and re-experiencing of the traumatic event when exposed to trauma reminders, as well as avoidance of such reminders. The fear-and anxiety-related symptoms of PTSD can be conceptualized, and subsequently modeled, as the result of fear conditioning such that the traumatic event serves as an unconditioned stimulus and the environmental cues present at the time of the trauma serve as conditioned stimuli that can ultimately elicit conditioned fear responses (i.e., clinical symptoms) long after the trauma has occurred. Many of the most successful treatments for anxiety disorders such as PTSD are based on the principles of fear extinction in which the repeated presentation of a conditioned stimulus, without noxious consequences, reduces the frequency and intensity of a conditioned response. In the current review, we discuss the most widely employed psychophysiological protocols that have been used to study fear processing in human populations, both psychiatrically healthy and with PTSD. Special emphasis is placed on how translational clinical research can inform clinical practices and vice versa.

Background: Understanding the course of schizophrenia is essential to improve prophylaxis, early diagnosis, diagnostic validity, and prognosis. Method: We completed a comprehensive literature search for longitudinal, prospective and retrospective studies of schizophrenia. As studies span over almost a century and use different diagnostic criteria to decrease the effect of studies heterogeneity we reviewed the data organized according to historical periods (institutionalization and deinstitutionalization, pre and post neuroleptic periods) Results: The majority of the longitudinal studies of schizophrenia report that up to 30-50% of patients present with a stable or favorable course. Interestingly, this moderately positive outcome is de-emphasized in the literature, which most times focuses on the bleaker outcome of the rest of the patients (50-70%). A number of putative course predictors at the time of the initial diagnosis have been proposed. However, the current level of evidence about risk and protective factor is putative rather than clear and convincing.

Objective: Depression is a very common disorder in patients with an acute coronary syndrome (ACS). Evaluating depression in patients with ACS in clinical settings is complicated by the lack of uniform criteria in choosing the appropriate instruments and the appropriate time of assessment of depressive symptoms. The aim of this review is to examine the performance of the instruments utilized to assess depression in patients with an ACS in a primary care setting. Methods: We identified studies published between 1990 and 2010 that used standardized validated questionnaires to assess depression. Results: Of the studies reviewed, 85% assessed depression within a week of hospitalization for ACS. Sensitivity ranged from 75% in the Hospital Anxiety Depression Scale to 88% in the Beck Depression Inventory (BDI) and Patient Health Questionnaire (PHQ-9). Specificity ranged from 62% for the Geriatric Depression Scale to 88% for the PHQ-9. Conclusions: This review suggests that the PHQ-9 is the most effective instrument for primary care settings due to its high sensitivity (88%) and specificity (89%). In a screening process, a scale with high sensitivity but low specificity will yield more false positives, whereas a scale with low sensitivity high specificity will yield a higher number of false negatives. In the case of choosing a screening tool to assess depression in patients with ACS, advantages and disadvantages should be considered, especially the trade-off between sensitivity (true positives) and specificity (false positives).

Objective: Weight loss surgery has been heralded as a treatment alternative for patients with morbid obesity. Psychiatric disorders are highly prevalent in bariatric surgery candidates and a myriad of psychosocial variables has been explored to identify mediators of post-surgery weight loss. The following review aims to elucidate psychosocial predictors of weight loss outcomes specific to Roux-en-Y gastric bypass surgery (RYGBS). Methods: We searched PubMed for prospective trials evaluating psychosocial predictors for weight loss with RYGBS published between 2000 and 2010. Manual searches of references listed in review articles, case series and anecdotal reports supplemented our literature search. Additional literature on post-bariatric surgery psychosocial outcomes and management of psychiatric sequelae in bariatric surgery patients are discussed in this review. Results: A total of 20 prospective studies were identified. Our review found that few psychosocial factors have been studied and results were predominantly inconclusive. We observed heterogeneity amongst studies with respect to study duration and assessment methods. Binge eating disorder, mood disorders, and anxiety disorders have not reliably predicted weight loss in identified studies. Preliminary results suggest that psychosocial support is an important predictor of postoperative weight loss and highlight a likely role for pre- and post-surgery support groups. Conclusion: Social support, current or lifetime Axis I disorder, and post-operative loss of control over eating have been identified as important predictors of weight loss post-RYGBS. Larger, long-term studies are needed to further elucidate psychosocial risk factors for weight loss post-RYGBS

Transforming western technology to Eastern populations, including Malaysia, presents important implications in understanding the development, maintenance, and treatment of depression. The present paper aims to review the literature on the prevalence of depression studies in Malaysia. PsycINFO, Medline databases, local journals, and 13 published articles, were included in the current review. Findings were presented in three categories i.e., ‘prevalence of depression in primary care’, ‘general community’, and ‘among clinical population’. Major limitations of previous studies were noted, and thus, problems associated with the implementation and future direction of clinical and research on depression in Malaysia, was provided. In short, the contribution of empirical research on the prevalence of depression has remained inconsistent and fragmented and it is therefore, a time to venture modification.

Objective: The term “schizophrenia” concerns heterogeneous psychopathological syndromes that are often associated with neurocognitive impairment and poor functional outcome. Research over the past 20 years or so has revealed that many symptoms associated with schizophrenia can be interpreted as a result of poor “metacognition”, first defined as the ability to think about one's mental operations, which in our understanding more specifically refers to the ability to reflect upon mental states of oneself and others, and to flexibly entertain this knowledge in social interaction and problemsolving (termed “mastery”). The latter aspect implies that metacognitive dysfunction is putatively critical to explain social impairment. Method: The present article reviews the evidence for a link between metacognitive deficits in schizophrenia and poor social functioning. Results: Metacognition including its subcomponents such as self-reflectivity, empathetic perspective-taking and mastery are profoundly linked with awareness of illness and social functioning in schizophrenia. The impact of metacognition on awareness of illness and social functioning seems to be partially independent of neurocognitive functioning. Conclusion: Research into metacognitive abilities in schizophrenia have revealed new insights into the understanding of individual symptoms and outcome measures, with potentially important implications for psychotherapy and (meta-) cognitive remediation in schizophrenia.