Dopamine blocking activity of clomipramine in patients with obsessive-compulsive disorder.

While many data suggest that Obsessive-Compulsive Disorder (OCD) is an illness accompanied by dysregulation of the serotonergic system, interesting clinical evidence and animal studies also suggest possible dysregulation of the dopaminergic (DA) system. In order to determine whether clomipramine (CMI), an antiobsessional agent, is capable of altering DA function, we performed a neuroleptic radioreceptor assay (NRRA) on plasma samples from OCD patients before and after treatment in a double-blind, placebo controlled trial of CMI. CMI produced mild but significant DA D-2 receptor binding activity in an in vitro assay. The degree of dopamine binding activity did not correlate with clinical response to clomipramine. Because it has been suggested that another drug with antiobsessional efficacy, fluoxetine, may also have dopamine blocking properties, it may be speculated that antidopaminergic activity in combination with serotonergic effects is involved in antiobsessional activity of effective agents for some patients.

A community-based public-academic liaison program.

OBJECTIVE: The authors discuss obstacles and incentives associated with successful community-based public-academic liaison activities and illustrate their conclusions by describing their public-academic liaison program, which received the American College of Psychiatrists' first annual Award for Creativity in Psychiatric Education. METHOD: The first 8 years of a state/university collaboration are described in which the parties involved first developed a variety of innovative services designed to fill specific gaps in the public service delivery system and subsequently integrated academic research and training components. RESULTS: The carefully planned and monitored process resulted in the exponential growth of interest in public sector work, the realization of the university's primary goals of developing high quality training and research sites, a substantial increase in the number of graduates accepting positions in the public sector, several projects funded by the National Institute of Mental Health, and two national awards. CONCLUSIONS: These collaborations illustrate the highly complementary relationship of public-academic liaison activities and their potential capacity to improve access to services, substantially improve the quality of these services, generate extramural support for services research, and increase the number of well-trained professionals in the public sector.

Panic and phobic disorders in patients with obsessive compulsive disorder.

Obsessive compulsive disorder shares numerous clinical features with other anxiety disorders. To study the relationship between OCD and other anxiety disorders, the authors administered the Structured Clinical Interview for DSM-III to 36 OCD patients. Thirty-nine percent (14) of patients reported a lifetime history of panic attacks, and 14% (5) met DSM-III-R criteria for panic disorder at the time of interview. Fourteen percent (5) met criteria for social phobias, and 19% (7) met criteria for simple phobias. Eighteen patients were treated with clomipramine in doses of at least 100 mg/day for 3 months. Patients with a history of other anxiety disorders responded significantly better to clomipramine.

Home-based multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis: clinical outcomes.

OBJECTIVE: The primary purpose of this study was to determine whether multisystemic therapy (MST), modified for use with youths presenting psychiatric emergencies, can serve as a clinically viable alternative to inpatient psychiatric hospitalization. METHOD: One hundred sixteen children and adolescents approved for emergency psychiatric hospitalization were randomly assigned to home-based MST or inpatient hospitalization. Assessments examining symptomatology, antisocial behavior, self-esteem, family relations, peer relations, school attendance, and consumer satisfaction were conducted at 3 times: within 24 hours of recruitment into the project, shortly after the hospitalized youth was released from the hospital (1-2 weeks after recruitment), and at the completion of MST home-based services (average of 4 months postrecruitment). RESULTS: MST was more effective than emergency hospitalization at decreasing youths' externalizing symptoms and improving their family functioning and school attendance. Hospitalization was more effective than MST at improving youths' self-esteem. Consumer satisfaction scores were higher in the MST condition. CONCLUSIONS: The findings support the view that an intensive, well-specified, and empirically supported treatment model, with judicious access to placement, can effectively serve as a family- and community-based alternative to the emergency psychiatric hospitalization of children and adolescents.

Substance abuse and emergency psychiatry.

Given the high rates of comorbidity, patients commonly present with multiple diagnoses to PESs or crisis services. Clinicians must be well versed in the evaluation, differential diagnosis, and treatment of patients with substance-abuse disorders or other Axis I, II, or III conditions if they are to provide state-of-the-art treatment of patients in need of emergency care.

A patient with mental retardation and possible panic disorder.

The limited communication skills and varying behavior patterns of people with mental retardation make the diagnosis of psychiatric disorders a challenging task. The authors present the case of a patient with mild mental retardation and possible panic disorder whose panic symptoms were missed by clinicians until a structured questionnaire to screen for those symptoms was administered. In assessing people with mental retardation for psychiatric disorder, clinicians should be alert to the possibility of panic disorder if patients show avoidant behaviors and report vague somatic complaints. A simplified structured format for assessment may lead to more accurate diagnosis.

Mobile crisis: moving emergency psychiatry out of the hospital setting.

Mobile crisis teams constitute a growing force in emergency psychiatric service provision in the community. The implications of the for-profit, private teams that are joining the long-standing public teams are discussed.

A mobile crisis program: collaboration between emergency psychiatric services and police.

An emergency psychiatry-mobile crisis program was established in 1987 in Charleston, South Carolina, linking professionals from the mental health center, the university, and the local police department. The program has two goals: to provide emergency psychiatric services to persons in the community and to train psychiatric residents in crisis intervention. Mental health staff act as consultants to the police in some situations, and in others the police provide security. The authors describe the development of the collaboration with police and important features of the program. Three cases illustrate how such collaboration can be of mutual benefit and can save lives.

From the benches to the trenches : training residents to provide emergency outreach services-a public/academic project.

The Charleston Area Mental Health Center and the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina have collaborated to form a comprehensive emergency service with mobile capacity. The service is staffed by an interdisciplinary team of professionals from public and academic psychiatry. Psychiatric residents are fully integrated into the service. A description of the program demonstrates how such liaisons can promote improved access to high-quality services, while enriching the training of psychiatrists through outreach experiences.

Preliminary report: placebo-controlled, double-blind study of the clinical and metabolic effects of desipramine in panic disorder.

Fifty-six males and females with panic disorder with or without agoraphobia participated in a 12-week, placebo-controlled treatment study of the efficacy of desipramine (DMI). Twenty-six of 28 patients receiving DMI completed the study; 17 of 28 placebo (PBO) recipients completed 12 weeks. Patients receiving DMI responded significantly better than did PBO recipients as measured by Hamilton Anxiety Scale (HAM-A) and global phobia ratings, with a trend toward greater global improvement, but no between-group differences on panic attack frequency were discerned. By Week 12, 22 of 26 (85%) DMI patients were panic-free; 13 of 17 (76%) PBO patients were panic-free. Resting metabolic rate (RMR) was tested on a subset of the patients. Patients receiving DMI showed no effects on RMR or thyroid indices but lost a significant amount of weight; the PBO recipients exhibited no weight loss or RMR effects. In this study, the high PBO response rate obscured treatment group differences on some measures. This study underscores the need for placebo comparisons in treatment studies. In summary, DMI appears to be an effective treatment for panic disorder. DMI appears to have little effect on RMR; a slight but significant weight loss was observed in the DMI but not PBO group.