Free Articles

Expert Q&A

Decisional Capacity

Topics: Aid to capacity evaluation (ACE) | Capacity | Collaborative care | Decisional Capacity | Dispositional capacity | Free Articles | Medical incapacity hold | Surrogate decision-maker

CHPR: Can you start by telling us what criteria you use to assess capacity? Dr. Cheung: We generally look for evidence of capacity in four domains. These have become the standard criteria for assessing capacity, based on Dr. Paul Appelbaum’s work from many years ago (Appelbaum PS and Grisso T, N Engl J Med 1988;319(25):1635–1638). The domains are:

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Clinical Update

Approaches to Autism Intervention

Topics: ABA | Applied Behavioral Analysis | Autism | Developmental Relationship Based Intervention | DRBI | Free Articles | Naturalistic Developmental-Behavioral Intervention | NDBI | treatment

Your patient is a young child who has recently been diagnosed with autism. Her parents are asking about the available treatments, and in particular, they want to know whether they should pursue the 40-hour-per-week program recommended by the local autism society. As clinicians, we are often faced with questions from families about the “best” pr

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Clinical Update

Intranasal Esketamine: New Hope for Suicidal Patients?

Topics: Depression | Esketamine | Fast-acting | Free Articles | Intra-nasal | Ketamine | Management | Psychopharmacology | Suicidality

It’s likely your patients have asked you about esketamine. The buzz is that it’s a rapid-acting miracle cure for suicidal depression. Dr. Thomas Insel, former director of NIMH, declared that ketamine “might be the most important breakthrough in antidepressant treatment in decades” (www.nimh.nih.gov/about/directors/thomas-insel/blog/2014/ketamine

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Expert Q&A

Serotonin Syndrome Versus NMS

Topics: Free Articles | Serotonin

CHPR: Can you start by telling us about yourself? Dr. Tormoehlen: Sure. I am a neurologist and have completed a medical toxicology fellowship. I am an attending physician for the neurology service at Indiana University Health Methodist Hospital, as well as for the toxicology service at Methodist, University, Riley, and Eskenazi Hospitals. I also run th

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Clinical Update

Deliberate Foreign Body Ingestion

Topics: Borderline Personality Disorder | Deliberate foreign body ingestion | DFBI | Free Articles | Gastroenterology | Malingering | Management | Obsessive compulsive disorder/OCD | Personality Disorders | Pica | Psychosis | Self-injury | Swallowing

During morning rounds at your inpatient unit, you are informed by staff that your patient M, a 32-year-old woman with bipolar disorder and borderline personality disorder, has swallowed a small pencil. This is her fourth swallowing episode since her admission to the unit 2 weeks ago. Even though you had restricted her access to sharp objects, she has ma

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Expert Q&A

Combination Treatment for Schizophrenia

Topics: Adjunct treatment | Antidepressant | Antipsychotic | Benzodiazepine | CATIE | Combination treatment | Free Articles | Mood stabilizer | Outcomes | Psychopharmacology | Schizoaffective disorder | Schizophrenia | Substance Use Disorder

CHPR: You recently published a study on the use of adjunctive medications in patients with schizophrenia (Stroup TS et al, JAMA Psychiatry 2019;76(5):508–515). Your findings were provocative as you found that adjunctive medications often help improve patients’ outcomes, yet many clinicians avoid polypharmacy because of concern that patients will exp

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Research Update

Antipsychotic Dosing: How High?

Topics: Antipsychotics | Free Articles | Research Update

Review of: Leucht S et al, Am J Psychiatry 2020;177(4):342–353 (published correction appears in Am J Psychiatry 2020;177(3):272) How high should we go when dosing antipsychotics in schizophrenia? Surprisingly little is known about optimal doses. During drug development, dosing is estimated from animal studies, but more detailed studies in humans ar

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Clinical Update

Managing Video Gaming in Children and Teens

Topics: Computer addiction | electronic use | Free Articles | videogaming addiction

CCPR: We are here to talk about managing video gaming in children and adolescents, which is a ubiquitous habit that might be even more pronounced given that we’re in the middle of a pandemic. Dr. Dilley, can you start with the relationship between mood disorders and gaming? Dr. Dilley: There is a complex relationship between mood disorders and gaming

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Article

Transcranial Magnetic Stimulation (TMS) for Depression in Children and Adolescents

Topics: adolescents | Brain Devices | children | Depression | Free Articles | pediatric | safety | teens | TMS | Transcranial Magnetic Stimulation

Editor’s note: This article is about the “usual” TMS that we have been hearing about for many years. We are covering trigeminal nerve stimulation (eTNS) separately in this issue in a News of Note as it is far newer with far less clarity about its utility. The search for safer treatment With concerns about both safety and efficacy surrounding a

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Research Update

Steroid-Induced Psychosis in the ­Pediatric Population

Topics: adolescents | Child Psychiatry | children | Free Articles | pediatric | Psychosis | Research Update | steroids | teens

Review of: Hodgins GE et al, J Child Adolesc Psychopharmacol 2018;28(5):354–359 Childhood psychosis is a rare disorder, and accurate diagnosis is crucial. Recently, clinicians at the University of Miami Miller School of Medicine reported a case of steroid-induced psychosis in a pediatric patient. In the case report, a 12-year-old Haitian girl wa

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Research Update

Risk of Psychosis With Stimulants in ADHD Patients

Topics: ADHD | adolescents | amphetamine | Child Psychiatry | children | Free Articles | Medication | methylphenidate | pediatric | Psychosis | Research Update | stimulant | teens

Review of: Moran LV et al, N Engl J Med 2019;380(12):1128–1138 In 2007, the FDA required stimulant manufacturers to warn of possible psychosis with stimulants. But what is the real incidence? This study set out to find and discern if there is a difference between methylphenidate and amphetamine classes of medications. Drawing from two large comm

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Article

Cognitive Behavioral Therapy for Substance Use Disorders

Topics: Cognitive Behavioral Therapy | Free Articles | Substance Use Disorder

Cognitive behavioral therapy (CBT) is one of the most widely used psychotherapies. It was developed in the 1960s by Aaron Beck specifically for the treatment of depression, but its core principles were quickly adapted and applied to a variety of diagnoses. We now have evidence-based CBT interventions not only for depression but also for anxiety, PTSD, b

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Clinical Update

Reducing the Stigma of Addiction Through Language and Terminology

Topics: Disparities | Engagement | Free Articles | Opioid Use Disorder | Stigma

The words we use in discussing addiction shape the way our patients, fellow clinicians, and communities think about substance use disorders. Addiction has long been viewed as a moral failing, and the terminology of addiction has reinforced this belief. Here, we review the evidence that documents how terminology can perpetuate—or reduce—the stigma as

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Clinical Update

Breastfeeding and Addiction

Topics: Breastfeeding | childcare | Free Articles | infant | lactation | newborn

Addiction providers typically treat one patient at a time. But once we start working with a patient who is breastfeeding, that number jumps to two (or more in the case of twins, triplets, etc). Although breastfeeding has a host of infant health benefits, many providers do not feel confident managing patients who are nursing. In order to deliver the best

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Clinical Update

An Unexpected Opioid: Loperamide Misuse

Topics: Free Articles | Opioids | Over the counter medication | safety | Side Effects

Loperamide, a common antidiarrheal available at pharmacies across the country, has unexpectedly become one of the latest in a growing trend of over-the-counter medications being repurposed for recreational use. Over the past 10 years, the broader public has discovered that supratherapeutic doses of loperamide can result in opioid-like euphoric effects.

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Clinical Update

Perioperative Pain Management in Opioid Use Disorder

Topics: Buprenorphine | Collaborative care | Free Articles | Methadone | Opioid Use Disorder | Opioids | Pain

When your patients with opioid use disorder (OUD) develop pain due to medical illness or trauma, pain management can get tricky. When they seek pain control, they may be perceived as “drug seeking” in medical settings. Studies have shown that providing adequate pain management for these patients is a particular challenge (Department of Veterans Affa

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Clinical Update

The “Z-Drugs”: Safety Issues and Misuse Potential

Topics: Anxiety | Clinical practice | Deprescribing | Free Articles | Pharmacology | polypharmacy | prescribing patterns | Risk Management | Sleep | Sleep Disorders

Originally marketed as safer alternatives to benzodiazepines, the Z-drugs—eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien)—were considered devoid of misuse potential. But recent data and FDA warnings suggest we’ve been hitting the snooze on them for too long. Here, we review their risks and discuss safe prescribing. Medical risks

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Clinical Update

Harm Reduction Strategies—A Primer

Topics: Free Articles | Hepatitis | HIV | Opioid epidemic | Overdose | Prevention

As is frequently the case with chronic diseases, cure is often neither possible nor an appropriate goal in addiction treatment. That’s where the concept of “harm reduction” comes in. Such strategies can help prevent death, serious injury, or other negative consequences of substance use in patients who are continuing to use drugs or struggle with a

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Expert Q&A

Getting Uncomfortable with Esketamine

Topics: Antidepressant Augmentation | Antidepressants | Brain Devices | Depression | Depressive Disorder | ECT | Esketamine | Free Articles | Ketamine | Neurotoxicity | Novel Medications | rTMS | Suicidality | TMS | Transcranial Magnetic Stimulation | Treatment-Resistant Depression

Esketamine (Spravato) was approved for treatment-resistant depression in 2019. In this interview, Dr. Williams (who has no relationship with Janssen Pharmaceuticals, Inc) addresses some lingering doubts that have been raised about the medicine. TCPR: Where does esketamine fit in the list of interventional therapies for depression, like repetitive tra

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Clinical Update

A Potentially Lethal Side Effect You Probably Never Heard Of

Topics: Clozapine | FDA Warnings | Free Articles | Management | Psychosis | Schizophrenia

In January 2020, the FDA issued a strong warning about constipation on clozapine. With a fatality rate of 1 in 1000, this is not just a nuisance side effect, and it can happen with other antipsychotics and psychotropics as well. This type of constipation is caused by slowing of the gut, or gastric hypomotility, and it requires a unique approach. Fiber s

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