Routine treatment duration for clients attending a community based anxiety disorders clinic.

OBJECTIVE: To determine the average duration of treatment at a community-based anxiety disorders clinic. METHOD: Data were collected on primary disorder, the presence of co-occurring disorders and treatment length (both in terms of number of sessions and weeks of therapy) for 248 consecutive clients. RESULTS: The mean number of sessions was 13, and average treatment length was 29 weeks. There was substantial variation in treatment duration (range for number of sessions = 1-128, range for treatment duration = 0-186 weeks). CONCLUSION: Clients with anxiety disorders were often treated in relatively few sessions, in line with randomised controlled trials (RCTs). However, a number of clients required many more sessions and were treated for a longer period of time than clients in RCTs. Health services should be cautious in mandating limits to therapy duration for anxiety disorders given the wide range in the duration of treatment for clients in our sample.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part II: OCD and PTSD.

AIM: This is the third version of the guideline of the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Posttraumatic Stress Disorders which was published in 2002 and revised in 2008. METHOD: A consensus panel of 34 international experts representing 22 countries developed recommendations based on efficacy and acceptability of the treatments. In this version, not only medications but also psychotherapies and other non-pharmacological interventions were evaluated, applying the same rigorous methods that are standard for the assessment of medication treatments. RESULT: The present paper (Part II) contains recommendations based on published randomised controlled trials (RCTs) for the treatment of OCD (n = 291) and PTSD (n = 234) in children, adolescents, and adults. The accompanying paper (Part I) contains the recommendations for the treatment of anxiety disorders.For OCD, first-line treatments are selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT). Internet-CBT was also superior to active controls. Several second-line medications are available, including clomipramine. For treatment-resistant cases, several options are available, including augmentation of SSRI treatment with antipsychotics and other drugs.Other non-pharmacological treatments, including repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS) and others were also evaluated.For PTSD, SSRIs and the SNRI venlafaxine are first-line treatments. CBT is the psychotherapy modality with the best body of evidence. For treatment-unresponsive patients, augmentation of SSRI treatment with antipsychotics may be an option. CONCLUSION: OCD and PTSD can be effectively treated with CBT and medications.

Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page.

OBJECTIVE: To explore the clinical reasoning processes underpinning diagnostic and management decision-making in treating patients presenting with psychological distress in general practice. METHOD: Practising GPs were invited to attend small-group workshops in which two case histories were presented. Discussion was GP-facilitated and recorded for thematic analysis. GPs provided demographic data, completed personality and attitudinal questionnaires, and answered a series of multiple-choice questions embedded in the cases. RESULTS: GPs recognize the possibility of psychiatric disorders early in the clinical reasoning process, but are cautious about applying definitive diagnoses. GPs perceive that patients may be resistant to a psychiatric diagnosis and instead emphasize the need to build rapport and explore and exclude physical comorbidities. GPs see patients with a broad spectrum of distress, illness and impairment, in whom the initial presentation of psychological symptoms is often poorly differentiated and somatically focused, requiring elucidation over time. GPs therefore adopt a longitudinal strategy for diagnosis rather than investing heavily in cross-sectional assessment. CONCLUSION: GPs appear cognizant of possible psychiatric disorders and management strategies, but employ diagnostic strategies and decision-making processes that, in addition to experience and expertise, likely reflect key differences between the primary care and specialist practice settings.

Pharmacotherapy of borderline personality disorder: replacing confusion with prudent pragmatism.

PURPOSE OF REVIEW: The article aims to examine trends in the pharmacological treatment of borderline personality disorder (BPD) and shed more light on the attendant controversies. RECENT FINDINGS: Although specialized, BPD-centred psychotherapy is considered first-line treatment for BPD and no psychotropic drug has been licensed for BPD, medications are frequently prescribed in the management of this condition. Various classes of psychopharmacological agents are used for BPD and there is a prominent polypharmacy. Use of antidepressants for BPD has been decreasing somewhat and use of mood stabilizers and second-generation antipsychotics has been increasing. Although there is a general agreement that little evidence of efficacy of medications exists for BPD, clinicians are either advised to almost completely avoid pharmacotherapy for BPD or use a 'targeted' approach, administering specific medications for the specific symptoms of BPD. This has created some confusion in clinical practice and contributed to a variety of prescribing practices for BPD. SUMMARY: Well designed studies of the efficacy of pharmacological agents in BPD are needed. Clinicians should use medications for BPD with caution, usually short term and mainly for symptom relief. They should frequently review a need for ongoing pharmacotherapy and make every effort to avoid polypharmacy.

Cyberbullying: Review of an Old Problem Gone Viral.

PURPOSE: Despite being relatively new, cyberbullying is now well recognized as a serious public health problem affecting children and adolescents. Scientific exploration has lagged media attention, but a synthesis of studies across several disciplines permits an understanding of its epidemiology, phenomenology, mental health dimensions, and management tools. METHODS: To assess current knowledge of cyberbullying, we searched the MEDLINE, PubMed and PsycINFO databases for articles on "cyberbullying" and related designations. The Google search engine was used to capture otherwise unpublished legislative, governmental, and community response data and to help identify relevant books and book chapters. RESULTS: A significant proportion of children and adolescents (20%-40%) have been victims of cyberbullying, with females and sexual minorities seemingly at higher risk. Perpetrators are more likely to be male. By nature of the electronic platform, there seems to be an easier path to the bully-victim phenomenon (victims who become bullies or vice versa) than that in traditional bullying. A nonlinear relationship with age is suggested, but demographic data overall are preliminary. Accompanying psychopathology, including an increasingly well-established link to suicidality, is common. Several prevention and management approaches have been proposed to help prevent cyberbullying or mitigate its effects. DISCUSSION: Cyberbullying's seeming ubiquity, its disproportionate toll on vulnerable populations (e.g., children and sexual minorities), the link with suicidality, and the expected continued rise in Internet penetrance and connectivity make confronting it an urgent matter. A multipronged approach is most likely to succeed and would include: educational media campaigns; school-based programs; parental oversight and involvement; legislative action; and screening and evidence-based interventions by health care providers, especially pediatricians and mental health professionals. CONCLUSIONS: More research is needed into cyberbullying, but available data suggest a serious problem whose consequences are real and should not be dismissed as a "virtual" by-product of an increasingly digitalized childhood and adolescence.