Current Psychiatry Reviews - Volume 4, Issue 3, 2008

Evidence is reviewed here which suggests that antiepileptic drugs (AEDs) may be effective for the treatment of impulsivity across a range of psychiatric disorders and for impulse control and cluster B personality disorders in particular. AEDs may be effective for the treatment of the brain circuitry related to impulsivity, by modulating GABA, glutamate, serotonin, and norepinephrine. It is suggested that interventions should be directed at the brain circuitry which modulates core symptoms like impulsivity that may be shared across disorders, rather than the disorder itself. In addition to these core symptom domains, clinicians should identify comorbid conditions and associated symptoms related to brain systems as they can also influence overall treatment response. The increasing experience of psychiatrists in treating impulse control disorders, cluster B personality disorders, and impulsivity across disorders should complement the knowledge obtained from research. This will lead to a better understanding of the brain mechanisms underlying impulsive symptom domains within disorders and to more targeted treatments with improved outcomes.

Psychiatric Advance Directives (PADs) are legal documents designed to allow individuals with serious mental illnesses (SMI) to continue to exercise choice in care during crises. PADs allow individuals with SMI to express their wishes for mental health care and to communicate relevant information regarding their condition at a future time when, because of SMI relapse, they may lack capacity and no longer be able to do so. PADs allow competent individuals to state preferences for mental health care through two mechanisms: advance instructions and health care power of attorney. Though medical advance directive legislation has existed since the 1980s, PAD legislation is newer, starting in the early 1990s. This review explores the literature addressing PADs, including the history and posited benefits of these documents. It examines the empirical literature on clinician attitudes towards PADs, the demand for PADs among individuals with SMI, the content of PADs that are developed, and their effectiveness during times of crisis. The review includes a discussion of the actions needed if PADs are to fulfill their promise as an effective tool to increase autonomy and decrease crises in persons with SMI. It concludes with recommendations on next steps for research in this field.

Objectives: Depressive episodes and symptoms are common in bipolar disorder and are often treated with medication. The aim of this literature review is to critically examine the empirical evidence supporting the pharmacological treatment options in bipolar depression. Methods: Randomized controlled trials (RCTs) with parallel-group design of medications for bipolar depression were identified using PubMed. Reference sections were searched for publications of additional RCTs. The quality of the trials was rated. Results: We identified 35 studies. Most trials are of moderately good quality, underpowered and use active comparators of uncertain merit. Large and replicated clinical trials support the efficacy of quetiapine and the combination of olanzapine and fluoxetine. One very large trial found olanzapine alone to be efficacious. One study found lamotrigine to be superior to placebo on some outcome measures, but several negative lamotrigine trials have remained unpublished. The efficacy of lithium is supported by small trials in mixed samples. There is no convincing evidence that antidepressants are effective in bipolar depression, with the possible exception of tranylcypromine. Conclusion: Quetiapine, and olanzapine alone or in combination with fluoxetine, are well documented treatments for bipolar depression. The evidence in favour of lithium and lamotrigine is weaker. Commonly prescribed antidepressants are probably unhelpful.

The autosomal dominant spinocerebellar ataxias (SCA) are a heterogeneous group of disorders associated with progressive degeneration of the cerebellum and other brain regions to varying degrees. Neuropsychiatric and cognitive symptoms are now considered to be well established clinical features of the SCA's, and one central area of research is to examine clinical differences in neuropsychiatric and cognitive symptoms between SCA subtypes and their relationship to underlying neuropathological features. Among the most common SCA subtypes (SCA 1,2,3 and 6), memory impairment and depression occur most frequently in patients with SCA3, possibly related to relatively greater dysfunction of frontalsubcortical circuits through degeneration of the basal ganglia. In contrast, patients with SCA6 are less frequently depressed and demonstrate normal performance on measures of intelligence, attention, verbal and non-verbal memory, and executive functions. This implies that non-motor cognitive functions are less commonly affected in SCA6 possibly due to the more restricted expression pattern of the mutated calcium channel gene in this disorder. Patients with SCA2 demonstrate impairment in multiple cognitive domains including verbal memory and frontal lobe functions suggesting a more generalized process. These findings highlight the importance of evaluating all patients presenting with progressive ataxia for neuropsychiatric and cognitive symptoms.

Parents who have a child with anorexia nervosa often experience difficulties and distress as a result of their child's illness. Recent work has hypothesized carers' illness models based on qualitative and quantitative analyses of caregiving experiences. One relevant area that has received little attention in this modeling is grief and loss theory. We propose a revised theoretical model that incorporates this theory through a psychoeducational parent program, described here in detail. We suggest our model may augment outcomes of both parent caretakers and youth with anorexia nervosa by reducing factors of grief and loss associated with having a chronically ill child. However, extensive clinical studies are still needed.

Suicide remains a significant public issue. Several concordant information exists suggesting that patients diagnosed with severe and persistent psychiatric disorder (SPPD) show relatively higher rates of deaths by suicide compared with patients suffering from other mental illness. In particular, recent researches have demonstrated that, in pregnant women with history of SPPD, a percentage ranging from 13.1% to 33.0% of mothers may have suicidal ideation. Both psychopathological and social specificities of women with SPPD must force clinicians to consider any suicidal expression shown by these mothers as a signal of possible high-lethality suicide attempts. Because of the vast majority of maternal suicidal deaths due to psychiatric disorder usually occur before week 20 of gestation, the necessity exists to analyze and summarize published literature information on the teratogenic risk of antisuicidal drugs and somatic treatments also associated with the property to reduce the rate of self-aggressive behaviors, in order to identify the safest option to treat suicidal risk during early pregnancy. Further, the difficulties of managing the suicidal risk during the last stages of pregnancy are briefly summarized.