Improving the quality of substance dependency treatment with pharmacotherapy.

This article provides an overview of current pharmacological treatments for alcohol, opioid, cocaine, and nicotine use disorders. Guidelines for a "patient-treatment" matching framework to physicians working with various "substance-abusing" patients are presented, as well as recommendations regarding when to initiate and discontinue pharmacotherapy. Standard and newer pharmacological treatments for substance dependence are reviewed, as well as therapies that may be especially useful when treating the patient with comorbid substance dependency and psychiatric disorders. To maximize the therapeutic benefits of substance dependency treatment, patients should be individually assessed and provided adjunctive medications as clinically indicated. Specific areas for future laboratory and/or clinical research are recommended.

Malignant catatonia-induced respiratory failure with response to ECT.

A 47-year-old acutely psychotic schizophrenic man was diagnosed with malignant catatonia. Because of a history of neuroleptic malignant syndrome (NMS), traditional neuroleptics were avoided, and the patient had been treated with reserpine for a period of 10 years. Symptomatically, severe agitation alternated with severe retardation. The syndrome progressed, despite early termination of any neuroleptic medications, to marked catatonic rigidity and dehydration. Worsening was associated with transfer to a medical intensive care unit, intubation, and subsequently a tracheostomy. Dantrolene and bromocriptine were unhelpful. Lorazepam produced muscular relaxation and resulting decreases in creatine phosphokinase levels but elicited no other improvement. Eleven bilateral electroconvulsive treatments, however, resolved the respiratory impairment and catatonia and improved the psychosis. This report highlights the efficacy of ECT in lethal catatonia despite respiratory impairment and tracheostomy.

Sexual functioning in depressed outpatients taking mirtazapine.

OBJECTIVES: One-third of patients with untreated depression have sexual difficulties manifested by decreased libido, erectile dysfunction or delayed ejaculation. This dysfunction may be exacerbated by stimulation of post-synaptic serotonin 5HT2 receptors, a side-effect of most widely-used antidepressant medications, especially the selective serotonin reuptake inhibitors (SSRIs). Mirtazapine is an atypical antidepressant with alpha 2 adrenergic antagonist and serotonin 5-HT2 and 5-HT3 receptor-blocking activity. In theory, it should not worsen and perhaps may improve sexual function. This pilot study investigated sexual functioning and antidepressant activity in depressed patients taking mirtazapine. EXPERIMENTAL DESIGN: Twenty-five (F = 18, M = 7) sexually active adult outpatients with a DSM-IV-diagnosis of major depressive episode entered a 12-week, flexible-dosing, open-label pilot study. The Arizona Sexual Experiences Scale (ASEX) assessed sexual functioning and the Hamilton Depression Rating Scale (HAM-D) assessed depressive symptoms on a bimonthly basis. PRINCIPAL OBSERVATIONS: Desire, arousal/lubrication, and ease/satisfaction of orgasm improved (by 41%, 52%, and 48%, respectively) in the depressed women. In men, desire, arousal/erection, and ease/satisfaction of orgasm also improved (by 10%, 23% and 14%, respectively) but much more modestly. HAM-D, Clinical Global Impression (CGI) Sheehan Disability Scale (SDS), and Symptom Checklist-90 (SCL-90) scores improved in both groups. There was a 50% dropout rate among women before six weeks of treatment. However, the ASEX and HAM-D scores of the groups terminating before and after six weeks of treatment showed similar rates of improvement. CONCLUSIONS: Mirtazapine has a beneficial effect on sexual functioning in both depressed women and men. Longer-term double-blind research assessing sexual function during the administration of mirtazapine as well as other antidepressants is recommended.

Current treatment approaches to obsessive-compulsive disorder.

The two most useful treatments in obsessive-compulsive disorder are pharmacotherapy with potent serotonin reuptake-blocking agents and behavioral techniques, such as exposure and response prevention. Based on the authors' cumulative clinical experience, it is suggested that patient education, cognitive therapy, and psychodynamic psychotherapy are helpful adjuncts during various treatment stages of obsessive-compulsive disorder. The patient's strengths and knowledge of the illness can be used by the nurse-therapist to determine the implementation and timing of these therapeutic measures. Specific behavioral and cognitive techniques that may be useful in treating specific symptoms of obsessive-compulsive disorder are highlighted. Suggestions for future nursing research are outlined.

Obsessive-compulsive disorder with and without a chronic tic disorder. A comparison of symptoms in 70 patients.

The phenomenological features of 35 obsessive-compulsive disorder (OCD) patients with a lifetime history of tics were compared to 35 age- and sex-matched OCD patients without tics. Seven categories of obsessions and nine categories of compulsions were determined using the symptom checklist of the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Discriminant function analysis revealed that, compared to their counterparts without tics, OCD patients with tics had more touching, tapping, rubbing, blinking and staring rituals, and fewer cleaning rituals, but did not differ on obsessions. These preliminary findings suggest that the types of compulsions present may help to discriminate between two putative subgroups of OCD, i.e. those with and without tics.