Current Psychiatry Reviews - Volume 6, Issue 4, 2010

Since 1982 isotretinoin has been implicated in numerous reports that describe depression, behavioral change and suicidality in patients. Several epidemiological studies have investigated the association suggested by these reports. Results have varied. Other research has attempted to establish a plausible biological mechanism associating isotretinoin with these behavioral changes. Current research has focused on the hippocampus. It is possible that individuals that experience these side effects have a predisposition to these outcomes. There is need for additional prospective studies and randomized clinical trials that consider both the presence of a potential mechanism as well as the methodological weaknesses in the current literature. Additional basic science research also needs to further evaluate this potential mechanism.

Cognitive impairment is present in neurodegenerative disease, usually as part of a spectrum of symptoms that includes different domains of cognitive function. While the nature of the cognitive impairment tends to be diseasespecific, the aspects of cognitive impairment seen in different disease entities overlap considerably. This overlap makes distinctions among them difficult and, when considered with accumulating insights from molecular genetic and neuropathological analyses, increasingly suggests that different neurodegenerative diseases share not only aspects of their symptomatology but also their pathogenesis. This realization has prompted a reconsideration of the classification of these diseases. Reexamination of the clinical phenotypes of different neurodegenerative diseases has revealed that cognitive impairment is more commonly present than previously thought. Thus, the comparison of the patterns of cognitive impairment in different neurodegenerative diseases, when combined with molecular genetic, neuropathological, and imaging analyses, has considerable heuristic value. This review focuses on cognitive impairment in Alzheimer's disease (AD), Parkinson's disease (PD), and amyotrophic lateral sclerosis (ALS), which can be considered “pure neurodegenerative diseases”, and in multiple sclerosis (MS), whose pathogenesis includes both neurodegenerative and autoimmune processes. Rather than presenting an exhaustive description of studies addressing cognitive impairment in these diseases, it attempts to highlight the emerging patterns of cognitive impairment associated with the temporal and spatial context of their neurodegenerative processes.

At present, there is no consensus in the literature regarding the appropriate medical evaluation of the patient with a psychiatric chief complaint in the emergency department (ED). There is agreement in the literature that the evaluation should include obtaining a history, performing an appropriate physical and mental status examination, and performing medical tests as needed. However, controversy exists as to the components of the evaluation, the proper documentation of the process, and the need to perform tests on patients presenting with behavioral or psychiatric chief complaints. There are no clear established guidelines or standards to guide the clinician in the emergency room in determining how extensive an evaluation is needed. Some patients may be receiving an unnecessary workup while others may not be receiving adequate medical clearance. The lack of clear evidence-based standards often leads to disagreement between ED clinicians and psychiatrists about the “medical clearance” of a patient. The purpose of this paper is to review the available literature on the topic and to suggest guidelines to help structure the medical clearance of a psychiatric patient in the emergency room.

Fragile X syndrome (FXS) (OMIM#300624) is the leading inherited form of mental retardation. Fragile X syndrome is caused by large methylated trinucleotide expansions of a CGG repeat (> 200) upstream of the fragile X mental retardation 1 gene (FMR1), that lead to subsequent transcriptional silencing of the FMR1 gene and lack of the fragile X mental retardation protein (FMRP) synthesis, resulting in fragile X syndrome. The specific function of FMRP is not yet fully understood. The protein is known to be very important for normal brain development. The behavioral phenotype of FXS includes hyperarousal, social anxiety and withdrawal, abnormalities in communication, unusual responses to sensory stimuli, stereotypic behavior. Until recently, it was believed that premutation carriers of fragile X syndrome (55-200 CGG repeats) have no neurobiological abnormalities. Quantitative studies of brain structure and metabolism showed that premutation female carriers have abnormalities in brain anatomy and metabolism. Women with more than 100 CGG repeats reported higher rates of depression and interpersonal sensitivity than those with less than 100 repeats. The recent documentation of abnormal elevation of FMR1 mRNA, discovery of fragile X-associated tremor/ataxia syndrome, and reports of psychiatric disorders in carriers of premutation have suggested a pathogenic gene-brain-behavior mechanism. Increased psychological symptoms in premutation female subjects would be most strongly associated with abnormal elevation of FMR1 mRNA.

Recent advances in pediatric therapeutic technology have led to a significant increase in the number of children receiving treatment in pediatric intensive care units (PICU). Similarly, preterm births, which now represent 12-13% of all live births in the United States and which have increased by 31% since 1981, have resulted in increased numbers of hospitalizations in neonatal intensive care units (NICU). While sophisticated use of technology has been a major factor in improving survival rates in the pediatric population, the admission of a child to an intensive care unit is often a stressful event in the lives of their parents. Recently, researchers have identified post traumatic stress disorder (PTSD) as a model to describe and explain the psychological reaction of parents to their PICU and NICU experiences. This model is useful in helping interpret parental reactions and in informing potential preventative and treatment interventions. The current review presents a comprehensive overview of parental traumatic stress reactions and intervention studies in the ICU setting.

Background: Adolescent pregnancy and parenting is a concerning and relevant issue for child and adolescent psychiatrists. This article reviews the most recent English literature on psychosocial factors, intervention, prevention, and policy relating to pregnant and parenting teens in developed nations. Methods: Preference was given to longitudinal studies with large samples published after 2000. In cases where no such study exists, other older cross-sectional or retrospective studies were included with an emphasis on literature published in the past 5 years. Results: Risk for teenage pregnancy is associated with psychiatric distress, arrest, substance abuse, lack of social support, and economic disadvantage. Predictors of improved outcome for the adolescent parent include support from a cohesive family, attainment of educational goals, and decreased social isolation. Depression in the adolescent mother is associated with decreased maternal confidence in ability to parent, decreased perceived social support, and discord with family members. Effective pharmacologic treatment of depression and careful consideration of complicating psychosocial factors is required when evaluating and treating a pregnant or parenting teen. Conclusions: Future research and intervention strategies for this unique population should utilize evidenced based strategies, address cultural disparities, utilize family members and partners, and incorporate HIV/STI testing. Interventions utilizing novel media and technology, such as virtual reality and social networking, are an exciting area of future study.

Purpose: To determine whether cognitive remediation therapy improves social cognition in patients with schizophrenia. Method: We reviewed the studies assessing the effect of cognitive remediation therapy on social cognition deficits in patients with schizophrenia. Results: To date, a small number of reports on cognitive remediation therapies to improve social cognition in these patients have been published. These programs targeted either broad social cognition, or more specific processes, such as emotion recognition and theory of mind. The results demonstrated improved performance on social cognition tasks in patients who received cognitive remediation therapies. However, when their performance was compared to that of a control group, significant differences were not always observed. The impact of cognitive remediation therapies on clinical symptoms is unclear. Conclusions: Definite conclusions cannot be drawn based on these studies. We discuss these results and propose avenues for future research. In particular, we address some aspects of the therapies, such as their duration, their format and the exercises that could be tested. Moreover, we suggest alternative indices to cognitive measures that would estimate the impact of cognitive remediation therapies on deficits observed in patients with schizophrenia.