A UK consensus on the administration of aripiprazole for the treatment of mania.

Aripiprazole has recently received approval for the treatment of moderate to severe manic episodes in bipolar I disorder and prevention of new manic episodes in aripiprazole-responsive patients. Aripiprazole differs from other antipsychotics in its pharmacology, and the need for prescribing guidance in the UK was recently identified. A UK multidisciplinary panel was convened in November 2007. This report describes the consensus agreed during the meeting on the optimal approach to prescribing aripiprazole: how best to approach initiation of, and switching to, treatment with aripiprazole and management strategies for side effects. A literature review of the randomised controlled clinical trials of aripiprazole in mania supports these recommendations. Aripiprazole should be initiated at 15 mg/day (range 5-20 mg/day). If necessary, adjunctive medication should be used in early treatment to manage side effects or assist in management of symptoms such as agitation. When switching to aripiprazole, the therapeutic dose of current treatment should be maintained while adding aripiprazole 15 (5-20) mg/day. Only once an effective dose of aripiprazole is reached should previous medication be reduced. Nausea, insomnia and agitation typically resolve within days. Some principles for dosing and switching are provided to assist with a successful treatment outcome with aripiprazole in mania.

The pharmacotherapy of post traumatic stress disorder. A literature review and case report of treatment with nefazodone.

Post traumatic stress disorder (PTSD) is a common and serious debilitating condition with a host of co-morbid disorders. Research has uncovered a number of structural and neurochemical abnormalities that provide exciting insights into the mind-body continuum under stress. Increasing efforts are being addressed to tailor medication according to a model based on the dysregulation of neurotransmitters. Controlled trials of treatment, whilst offering hope, are inadequate to permit the development of evidence-based protocols for the treatment of PTSD. Further psychopharmacological research is urgently required.

Family therapy with the elderly mentally ill. Some strategies and techniques.

Over a six month period, 142 consecutive referrals of patients over 65 to a community-orientated psycho-geriatric service in North London were studied. The psycho-social factors determining referral were quantified and their relationship to diagnosis analysed. Therapeutic strategies are described, devised to deal with the presenting psycho-social problems. It is suggested that a family-centred approach is of some value in the management of the elderly mentally ill.

The long term effects of childhood sexual abuse: rationale for and experience of pharmacotherapy with nefazodone.

Studies estimate that 1 in 6 women and 1 in 10 men experience childhood sexual abuse (CSA). Whilst ill-health is not an inevitable consequence, approximately 20% of victims go on to have serious long-term pathology. This is reflected in an excess incidence of CSA survivors in problem populations, be they medical, forensic or psychiatric. Four groups of research studies suggest that PTSD-related mechanisms might be a major mediating factor in the development of symptoms: 1. There is high incidence of PTSD following sexual trauma; 2. Psychometric studies show evidence of impaired limbic functions; 3. There is evidence of neuroendocrine disturbances similar to those seen in war veterans with PTSD; 4. MRI studies show evidence of hippocampal atrophy. There is a growing database of studies showing that drugs that act as seroionergic modulators are effective in the treatment of PTSD. Drugs such as nefazodone which block 5HT2 receptors and inhibit the uptake of serotonin may be of particular value. Studies suggest that trauma-related issues are not always addressed in patients with a history of abuse. Given the problems posed, there is a need to review their treatment in the light of emergent knowledge. Further research is needed to validate these findings.