Variability in the efficacy of psychopharmaceuticals: contributions from pharmacogenomics, ethnopsychopharmacology, and psychological and psychiatric anthropologies.

Psychological and psychiatric anthropology have long questioned the universality of psychiatric diagnoses, bringing to light the fluidity of mental disorder, and recognizing that the experience and expression of psychopathology is influenced by complex and interacting genetic, environmental, and cultural factors. The majority of our discussions, however, have remained centered around the role of culture in shaping mental illness: drawing attention to subjective experiences of mental illness and culturally patterned modes of symptom presentation, and interrogating the cogency of universal diagnostic rubrics. Psychological and psychiatric anthropology have yet to robustly engage the broadly assumed universal validity of psychiatric medications and the ways in which they are prescribed and experienced. This article provides an introduction into the fields of pharmacogenomics and ethnopsychopharmacology, areas of inquiry seeking to understand the ways in which genetic variability occurring between, and within, large population groups influences individual ability to metabolize psychotropic medications. This piece further addresses the complex issue of psychopharmaceutical efficacy, stressing the ways in which, just as with psychopathology, medications and their outcomes are likewise influenced by the complex interactions of genes, environment, and culture. Lastly, ways in which anthropology can and should engage with the growing fields of pharmacogenomics and ethnopsychopharmacology are suggested.

Behavior within fortuitous environments: The entwined history of Division 28 and the fields of behavioral pharmacology and toxicology.

Behavioral pharmacology emerged in the early to mid-20th century as an experimental and observational science, helping to consolidate an empirically based psychological science of behavior. Behavioral psychologists came to play significant roles in toxicology, neuropharmacology, and psychopharmacology. This article traces the first 3 decades of American Psychological Association Division 28. Sources include the Division 28 Oral History Project; formal interviews conducted by the author in the early 2000s with behavioral, experimental, and clinical pharmacologists; and the archived newsletters of Division 28. (PsycINFO Database Record

Establishing a collaborative psychopharmacology practice: practical considerations.

Prescriptive authority for the advanced practice psychiatric nurse (APPN) is accompanied by the following advantages: expanded treatment repertoire, increased marketability due to the practicality of having one provider for psychotherapy and pharmacotherapy, and increased collaboration with colleagues. The disadvantages associated with prescriptive authority include: increased professional responsibility and associated liability, labor intensity due to continuing educational demands, medical record documentation, and time-consuming dialogues with referring clinicians. A preexisting relationship between the APPN and the psychiatrist that is based on mutual respect and similarities in treatment philosophies and ethical issues positively influence outcomes.

Efectos de un programa de eliminación de sujeciones físicas sobre personas mayores con demencia en residencias / Effects of a physical restraint removal program on older people with dementia in residential care

Objetivo. Analizar los resultados de eliminar las sujeciones físicas en mayores con demencia que viven en residencias. Este objetivo se enmarca en un proceso más amplio de modificación del modelo de atención residencial. Método. Estudio cuasi experimental en dos residencias desde mayo de 2010 hasta mayo de 2012. Se recoge información en 7 momentos temporales y se efectúa un análisis longitudinal. Tras formar al personal se retiraron progresivamente las sujeciones físicas en el centro El Puig, mientras que en el centro Conarda se mantuvieron las sujeciones. Las variables principales medidas fueron: caídas, psicofármacos administrados, así como diversos indicadores de estado mental y funcional (Norton, NPI, Minimental, Tinetti, Barthel). Resultados. En el centro en el que se eliminan todas las sujeciones físicas (El Puig), se observa una ligera mejoría en el número de caídas y sus consecuencias mejoran levemente, aunque no son estadísticamente significativas. Los ANOVA mostraron mejoras significativas en el centro que ha eliminado las sujeciones respecto a la prescripción de psicofármacos, al deterioro cognitivo y a las alteraciones de conducta. Discusión. Se constata que retirar sujeciones físicas no repercute negativamente en las caídas y sin embargo mejora ciertos aspectos del bienestar y la autonomía de los mayores (alteraciones de conducta y deterioro mental). Además, se evidencia que este programa debe ser complementado con un programa de desatar químico (retirada de psicofármacos) (AU)

Objective. To analyse the results of removing physical restraints from elderly patients with dementia living in nursing homes. This objective is part of a wider process of change in residential care. Methods. Quasi-experimental study conducted in two residences from May 2010 to May 2012. Information was collected at 7 time points and longitudinal analyses were performed. After training staff, the physical restraints in El Puig centre were phased out, while in the Conarda centre, restraints were still applied to elderly people. The main variables studied were: falls, psychotropic medication prescriptions, different indicators of mental impairment, and degree of dependence (Norton, NPI, Mini-mental, Tinetti, Barthel). Results. In the El Puig centre all the physical restraints were removed. A slight improvement was seen in the number of falls, and their consequences. The ANOVA showed significant improvements in the centre that removed restraints in prescribing psychotropic medications, cognitive impairment, and behavioural changes. Discussion. It is shown that removing physical restraints do not cause negative effects as regards the number of falls, and also positively affects the welfare and independence of elderly people (through changes in behaviour and mental impairment). Furthermore, it is demonstrated that this program must be accompanied by the reduction and control of medicines (withdrawal of the number of psychotropic prescriptions) (AU)

Capacidad de detección de patología psiquiátrica por el médico de familia / Ability to detect psychiatric disorders by the family physician

OBJETIVO: Conocer la capacidad de detección de patología psiquiátrica por el médico de familia, comparando la presencia de patología psiquiátrica detectada mediante test validados y la referida por su médico de familia. DISEÑO: Estudio transversal de doble fase. Emplazamiento: Centros de Salud de un área urbana de Madrid. PARTICIPANTES: Pacientes entre 18 y 65 años que acuden a consulta por motivos no administrativos. MEDICIONES PRINCIPALES: Para la detección de posible patología psiquiátrica, en la sala de espera se utilizaron instrumentos de cribado, el GHQ-28 (punto de corte 6 o superior) y el MULTICAGE CAD-4 (punto de corte 2 o superior).como instrumento de identificación de «caso» en la segunda fase se utilizó la entrevista MINI en los pacientes con puntuación positiva en uno de los instrumentos de cribado y un 20% de los negativos. Por otro lado, cuando los pacientes entraban en la consulta entregaban a su médico una tarjeta con un número de identificación para que, de manera ciega, registrase: presencia de patología psiquiátrica actual según su criterio y existencia, o no, de tratamiento actual con psicofármacos. RESULTADOS: Participaron 628 sujetos. La prevalencia de patología psiquiátrica corregida por metodología de doble fase fue del 31,7% (IC95%: 27,9-35,5). De 185 pacientes con patología psiquiátrica detectada, el 44,2% (IC 95%: 36,7-51,7) fueron identificados como pacientes con patología psiquiátrica por su médico de familia. Las patologías mejor identificadas fueron: hipomanía, trastorno distímico, episodio depresivo con síntomas melancólicos y trastorno por angustia. CONCLUSIONES: Un porcentaje importante de pacientes con patología psiquiátrica detectada con test validados no han sido identificados por su médico de familia

OBJECTIVE: To determine the ability of family physicians to detect psychiatric disorders, comparing the presence of psychiatric disorders detected using validated tests and referrals by family physicians. DESIGN: Cross-sectional, two-phase study. LOCATION: Primary healthcare centres in an urban area of Madrid. PARTICIPANTS: Patients between 18 and 65 years attending primary healthcare centres for non-administrative purposes. MAIN MEASUREMENTS: To detect psychiatric disorders in the waiting room, an interview was performed using GHQ-28 and MULTICAGE CAD-4 in the screening phase (considered positive: score of 6 or higher on the GHQ-28 or a score 2 or higher on MULTICAGE CAD-4). Patients with a positive score and 20% with negative were recruited for the second phase (case identification) using MINI interview. During family physician consultation, the patient gave his doctor a card with an identification number to record the presence of psychiatric illness in his/her opinion and whether there was treatment with psychotropic drugs. RESULTS: A total of 628 subjects participated. The prevalence of psychiatric disorders corrected by two phase methodology was 31.7% (95%CI: 27.9 to 35.5). Of the 185 patients with a psychiatric disorder detected, 44.2% (95%CI: 36.7 to 51.7) were identified as patients with psychiatric disorders by their family physician. Disorders best detected were: hypomania, dysthymic disorder, depressive episode with melancholic symptoms, and panic disorder. CONCLUSIONS: A significant percentage of patients with possible psychiatric disorders detected with validated test have not been identified by their family physician

Demystifying federal nursing home regulations to improve the effectiveness of psychopharmacological care.

PURPOSE: This paper attempts to demystify the federal regulations that govern the administration of medications to nursing home residents, describing the intent and correct implementation of F329 Unnecessary Drugs of the Omnibus Budget Reconciliation Act of 1987, most recently revised in 2006. DESIGN AND METHODS: Methods included a comprehensive review of the literature and cases from clinical practice. FINDINGS AND PRACTICE IMPLICATIONS: Although the regulatory language is complex, less so with each subsequent revision, its requirements nevertheless parallel good clinical practice and insure that vulnerable older adults have a quality of life that includes freedom from unnecessary medication--defined as any medication prescribed in a nursing home without adequate indication, in an excessive dose, for excessive duration, as duplicate therapy, without adequate monitoring of efficacy and tolerance, or in the presence of adverse consequences.

Child and adolescent psychiatry leadership in public mental health, child welfare, and developmental disabilities agencies.

Child and adolescent psychiatrists are in a unique position to provide administrative and clinical leadership to public agencies. In mental health, services for children and adolescents in early childhood, school, child welfare, and juvenile justice settings, transition-aged youth programs, workforce development, family and youth leadership programs, and use of Medicaid waivers for home- and community-based service system development are described. In child welfare, collaboration between an academic child psychiatry department and a state child welfare department is described. In developmental disabilities, the role of the child and adolescent psychiatrist administrator is described providing administrative leadership, clinical consultation, quality review, and oversight of health and behavioral health plans for persons with developmental disabilities.

El Hospital de Día-Centro Educativo Terapéutico Pradera de San Isidro. Un dispositivo para el tratamiento intensivo de trastornos mentales graves en niños y adolescentes / The Mental Health Day Care Hospital-Educational Therapeutic Centre Pradera de San Isidro. An institution for the acute treatment of severe mental disorders in children and adolescents

Los problemas de salud mental en niños y adolescentes son motivos de consulta frecuentes en Atención Primaria (AP). En la mayor parte de los casos, un tratamiento ambulatorio desde AP o desde su Centro de Salud Mental (CSM) es suficiente para una mejora significativa. Sin embargo, en ocasiones la sintomatología puede ser la manifestación de una estructuración psíquica seriamente dañada. En esos casos, donde existe un trastorno mental grave (TMG), es posible que dichos tratamientos ambulatorios no sean suficientes. En el presente artículo se presenta el Hospital de Día-Centro Educativo Terapéutico (HD-CET) Pradera de San Isidro. Un dispositivo de hospitalización parcial que forma parte de la red de Salud Mental de la Comunidad de Madrid, en el que se atiende a menores con TMG mediante un tratamiento ambulatorio intensivo. EL HD-CET consta de dos unidades: la de infantil (de 6 a 11 años) y la de adolescentes (de 12 a 17 años). Ambas cuentan con un equipo multidisciplinar de profesionales de Salud Mental, así como con un equipo docente encargado del aspecto académico de los pacientes. Se trabaja desde el modelo de comunidad terapéutica, procurando proporcionar al paciente experiencias emocionales correctoras que logren una mejora significativa y profunda del TMG (AU)

Child and adolescence mental health conditions are common in Primary Care (PC). In most cases, Mental Health Services (MHS) will achieve a good response in an outpatient basis. However, certain symptoms may indicate seriously damaged psychic structures, as found in Severe Mental Disorders (SMD), whose ambulatory care in PC and MHS may not be sufficient. Pradera de San Isidro Mental Health Day Care Hospital-Educational Therapeutic Centre (DCH-ETC) is part of Madrid Regional Mental Health Care Services, attending children and adolescents with SMD in a outpatient intensive program. DCH-ETC comprises a Children Unit attending patients of 6 to 11 years and an Adolescents Unit for patients from 12 to 17 years. A team of teachers is responsible for the continuing academic education of patients. With a Therapeutic Community model, the program aims to provide corrective emotional experiences leading to a deep and significant improvement in SMD (AU)

Seguimiento de las recomendaciones sobre psicofarmacología y su repercusión conductual en la discapacidad intelectual / Expert psychopharmacologic recommendations follow-up and its behavioral impact on intellectual disability patients

En la población con discapacidad intelectual (DI) hay una elevada morbilidad psiquiátricaconductual. Se estima que por este motivo entre 1/3 y 3/4 de estas personas reciben antipsicóticos. Existe un consenso de expertos para guiar la toma de decisiones farmacoterapéuticas en estos casos. Su aplicación conseguiría una mayor eficacia del tratamiento, reduciendo los problemas conductuales, mejorando las habilidades adaptativas. El “Inventory for client and agency planning” (ICAP) es un instrumento para valoración y evaluación de servicios para personas con DI, que incluye escalas para puntuación de problemas conductuales y de conductas adaptativas. Para determinar la asociación entre el seguimiento de las recomendaciones farmacoterapeuticas de los expertos y las puntuaciones de los problemas conductuales y las habilidades adaptativas en un grupo de sujetos con DI, se realizó un estudio observación transversal. El tratamiento farmacológico recibido por cada sujeto de un colectivo de sujetos diagnosticados de DI (CIE-10) se clasificó como conforme o no con las recomendaciones de la guía en lo referente a los criterios de indicación, dosis, duración y polifarmacia. Se compararon las puntuaciones de conducta adaptativa y de problemas de conducta del ICAP en función de la conformidad del tratamiento con los criterios. El cumplimiento del criterio de dosis se asoció con mejor conducta adaptativa (p<0,05), el cumplimiento de los criterios de duración y polifarmacia se asociahubo asociación entre cumplimiento del criterio de indicación con la puntuación de problemas de conducta, ni de las habilidades adaptativas (AU)

Subjects with Intellectual Disability (ID) are frequently affected by behavioral and psychiatric co-mobility. As a consequence between 1/3 and ¾ are under antipsychotic treatment. It is available an expert consensus guideline with the purpose of guiding pharmacological treatment decisions. The achievement of expert recommendations may optimize drug therapy efficacy and reduce behavioral problems as well as enhance adaptive abilities. The “Inventory for client and agency planning” (ICAP) is a psychometric tool designed to assess health care to ID patients, and includes items that grade behavioral and adaptive problems. We designed a transversal study in order to determine the association between the follow-up of expert recommendations and the scores achieved on behavioral and adaptive problems items. Drug therapy been prescribed to patients diagnosed of ID (CIE-10) was analyzed and classified into a dichotomous “Do” or “Do not” achieve guideline recommendations in regard of several pharmaceutical aspects such as drug therapy indication, dosage, treatment duration and poly-pharmacy. Scores from ICAP tool as compared to guideline compliance. Follow-up of dose criteria was associated to a better adaptive behavior (p<0,05) and follow-up of poly-pharmacy criteria and duration treatment criteria was associated better behavioral outcomes (p<0,05). We found no association between follow-up of indication criteria and behavioral or adaptive problems (AU)

Monitorización de niveles plasma de antipsicóticos atípicos / Atypical antipsychotics plasma level monitoring

Introducción: El estudio de la concentración de psicofármaco en sangre o en suero permite individualizar el perfil farmacocinético del sujeto tratado. Esto se conoce como monitorización de fármacos. Actualmente se pueden analizar antidepresivos, antipsicóticos, estabilizadores del ánimo, fármacos sustitutivos de los opioides, ansiolíticos e hipnóticos. Objetivos: Revisar el estado actual del conocimiento sobre monitorización de antipsicóticos, de utilidad tanto para evaluar la adherencia terapéutica como para conocer la concentración del fármaco en plasma. Metodología: Se revisaron los trabajos publicados sobre monitorización de antipsicóticos desde 1975 hasta 2010. Como fuente de información se empleó:Embase, Medline y Pubmed. Conclusiones: La monitorización de antipsicóticos, así como de otros psicofármacos, es una práctica establecida que debe conocerse y ser objeto de actualización por parte del psiquiatra interesado en un ejercicio terapéutico basado en datos objetivos(AU)

Introduction: Analysis of psychotropic drug concentration in blood or serum is a mean to ascertain the pharmacokinetic profile of the treated subject. This is known as drug monitoring. Currently plasma antidepressants, antipsychotics, mood stabilizers, drugs substitutes for opioids, anxiolytics and hypnotics can be monitorized. Methodology: We reviewed all published articles on monitoring of psychotropic drugs in general from 1975 to 2010. As a source of information used: Embase, Medline and Pubmed. Objetive: To review the current state of science in relation to the monitoring of atypical antipsychotics. Antipsychotic plasma level monitoring is crucial both to assess adherence and to determine the plasma drug concentration. Conclusions: The monitoring of antipsychotics and other psychotropic drugs, is an established practice must be known and be maintained by a psychiatrist, like other aspects of psychopharmacology, for a therapeutic exercise based on the current state of science(AU)

Iatrogenia y prevención cuaternaria en salud mental / Iatrogenesis and quaternary prevention on mental health

La prevención cuaternaria evita o atenúa las consecuencias de la actividad innecesaria o excesiva del sistema sanitario. La iatrogenia producida por la actividad sanitaria es un grave problema de salud pública que en salud mental está poco estudiado. El perjuicio que se puede infligir a los pacientes abarca todo el episodio de atención, desde la prevención hasta el tratamiento pasando por el proceso diagnóstico. Se revisan los perjuicios que causan las actividades preventivas como el abordaje del duelo o el debriefing, los tratamientos farmacológicos y psicoterapéuticos, la iatrogenia del diagnostico y del sistema de atención relacionado especialmente con el estigma. Tomar conciencia de la gravedad de la iatrogenia que nuestras intervenciones "bien hechas" pueden producir permite poner en primer plano la relevancia de la prevención cuaternaria y la necesidad de trabajar con el modelo de decisiones compartidas considerando siempre alternativas y extremando las medidas que garanticen la seguridad y derechos de los pacientes(AU)

Quaternary prevention avoids or mitigates the consequences of unnecessary or excessive activity of the health system. Iatrogenia produced by care systems activity is a serious public health problem and in mental health is poorly understood. The damage that can be inflicted to patients covers the entire episode of care, from prevention to treatment through the diagnostic process. We review the damage caused by preventive activities as the approach of mourning or debriefing, pharmacological and psychotherapeutic treatments, the iatrogenia produced in diagnosis and the deleterious effects of being under care in the psychiatric system especially related to stigma. Become aware of the seriousness of iatrogenic effects of our "well done" interventions allows foregrounding the importance of quaternary prevention and the need to work with the shared decision making model always considering alternatives and measures to ensure safety and rights of patients(AU)

Design and reporting modifications in industry-sponsored comparative psychopharmacology trials.

This review of recently published pharmaceutical industry-sponsored comparative psychotropic drug trials aims to classify apparent design and reporting modifications that favor the sponsor's product. The modifications have been grouped into 13 discrete categories, and representative examples of each are presented. Strong circumstantial evidence suggests that marketing goals led to these adjustments. The consequences of marketing influences on comparative psychopharmacology trials are discussed in terms of conflicts of interest, the integrity of the scientific literature, and costs to consumers, as well as their impact on physician practice.

Análisis de las intoxicaciones por litio ingresadas en un servicio de medicina interna / Analysis of the poisoning by lithium in a department of internal medicine

Introducción: El litio, utilizado principalmente en el tratamiento de los trastornos bipolares, presenta un estrecho margen terapéutico, que junto a sus múltiples interacciones y farmacocinética obliga a una monitorización estrecha de concentraciones plasmáticas para evitar intoxicaciones. Objetivo: Describir características clínicas y toxicológicas de los pacientes ingresados en la Unidad Toxicología Clínica (2003-2006). Material y métodos: Estudio descriptivo y retrospectivo de 16 intoxicaciones por litio, de 150 pacientes ingresados entre los años 2003-2006. Se han utilizado dos escalas: según la clínica y los valores séricos de litio. Resultados: Dieciséis pacientes incluidos (58,3 mujeres y 43,8% hombres, 49,19 ± 18,49 años). Trastorno psiquiátrico más frecuente asociado bipolar (87,5%). Causa más frecuente de intoxicación, intento autolisis (56,3%). Según escala neurológica, 50% intoxicación moderada, 25% leve y grave o muy grave el 25% restante. En relación a los niveles de litemia, 31,35% muy grave, 25% graves, 43.7 % leve-moderado.Tratamiento más utilizado en un 50% conservador, hemodiálisis 37,5%, estancia media 4,8 días en intoxicaciones aguda, y 11,2 días en crónicas. Secuelas sólo en dos pacientes (ataxia), sin ninguna muerte. Conclusiones: Las intoxicaciones por litio conllevan gravedad clínica, complicaciones y graves secuelas, incluso la muerte. Se recomienda vigilancia estrecha en pacientes polimedicados, edad avanzada o en tratamiento concomitante de antidepresivos y neurolépticos

Introduction: Lithium salts have been mainly used in the treatment of bipolar disorder. Because of its narrow therapeutic range, and several well characterised adverse effects, serum lithium levels must be monitored regularly in patients given lithium treatment in order to prevent intoxication. Objetive: To describe the clinic and toxic characteristics in inpatients at our Clinic Toxicologic Unit. Material and methods: Descriptive and retrospective study of lithium intoxications in 150 inpatients between 2003 and 2006. Patients were classified based on their neuropsychiathric symptom profile and serum lithium levels. Results: Sixteen of 150 inpatients had lithium intoxication: 58.3% women and 43.8% men; 49.19% ± 18.49% years old. Lithium was used as treatment of bipolar disorder in 87.5% of cases. The most frequent cause of intoxication was attempted suicide. Using neuropsychiatric parametres, intoxication was moderate in 50% of cases, and mild in 25% and severe or very severe in 25%. Using serum lithium levels, intoxication was very severe in 31.35%, severe in 25%, and slight-moderate in 43.7%. Conservative measures were used as the most frequent treatment (50%), and haemodial filtration was needed in 37.5%. Mean stay was 4,8 days in acute intoxication, and 11.2 days in chronic. Sequelaes were found in two patients (ataxia). Death was not present. Conclusions: Lithium intoxications can involve severe complications, even death. Narrow control is encouraged in polymedicated and elderly patients, and in concommitant treatment with antidepressant and neuroleptics