Achieving Mental Health Equity: Community Psychiatry.

There are historical predicates for the inequities noted in present-day community mental health. Stigma has led to discrimination for those living with mental illness. It is more difficult for research to occur, and to access care (prevention, early identification, evidence-based treatment services) because funding is limited and workforce development curtailed. Strategies to decrease stigma are suggested, means to enhance funding are offered, and models for workforce development are noted. Different treatment delivery systems are suggested to recruit and retain sufficient numbers of culturally competent and trauma-informed providers, so as to maximize access to necessary services.

Metabolic consequences of using low-dose quetiapine for insomnia in psychiatric patients.

Quetiapine is frequently prescribed for insomnia that is comorbid with psychiatric disorders, but there has been no documentation of metabolic adverse effects associated with this practice. The objective of this study was to document changes in weight, body mass index, and waist circumference that occurred when low-dose quetiapine was used at bedtime for insomnia. The study was a retrospective chart review conducted at a community mental health center. Patients were non-elderly (19-65 years old) psychiatric patients who received quetiapine at < or =200 mg at bedtime for the explicit indication of insomnia. Forty-three patients were included in the study. Weight and BMI increased by an average of 4.9 lb. (P = 0.037) and 0.8 points (P = 0.048), respectively. Males experienced statistically significant increases in weight and BMI, and Caucasians experienced a statistically significant increase in BMI. There were no significant differences between baseline and endpoint metabolic parameters when examined by baseline BMI, age category, psychiatric diagnosis, or concomitant psychotropic medication. Despite the low doses typically used when quetiapine is prescribed for insomnia, metabolic adverse effects can occur and should be considered in the overall benefit to risk analysis.

Sexual risk behaviors and sexually transmitted infection prevalence in an outpatient psychiatry clinic.

BACKGROUND: Nearly 3% of Americans experience severe and persistent mental illness (SPMI) and behaviors that place affected individuals at risk for sexually transmitted infections (STIs) are common. Few data describe the prevalence of risk behaviors or STI among persons with SPMI. We aim to quantitate STI/human immunodeficiency virus risk and determine the STI prevalence amongst outpatient psychiatric clinic attendees. METHODS: Psychiatric outpatients were approached to participate in an interviewer-administered survey collecting data on their sexual history, psychiatric history, and risk behaviors. Females submitted self-collected vaginal swabs, whereas males submitted urine to be tested for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis (women only). RESULTS: The prevalence of N. gonorrhoeae was 1%, C. trachomatis 3.3% and T. vaginalis 15.7%. Exchanging sex for drugs was the only behavior independently associated with having an STI in this population. CONCLUSIONS: Taking a sexual history in persons with SPMI is important. Those engaging in high-risk behavior should be routinely screened for STI/human immunodeficiency virus allowing for detection, treatment, and preventive education.

Efficacy of add-on topiramate therapy in psychiatric patients with weight gain.

BACKGROUND: Weight gain is a common adverse effect of many psychotropic medications including antipsychotics, antidepressants, and mood stabilizers. There is a growing body of evidence that topiramate may be useful as an add-on therapy to induce weight loss in patients who have experienced psychotropic-induced weight gain. OBJECTIVE: To determine the efficacy and tolerability of topiramate for treatment of weight gain in a naturalistic mental health clinic setting. METHODS: A retrospective chart review was conducted at a community mental health clinic. Subjects were non-elderly adults who received topiramate therapy beginning in 2002-2005 for documented weight gain during treatment with psychotropic drugs. Primary outcome measures included response rate (based on weight loss of any magnitude) and mean changes in weight and body mass index (BMI). RESULTS: Forty-one patients were included in the study. There was a 58.5% (n = 24) response rate. Mean reductions in weight and BMI were approximately 2.2 kg and 0.5 points, respectively. Responders lost an average of 7.2 kg, whereas nonresponders gained an average of 5.0 kg. Patients with a baseline weight of at least 91 kg and those receiving a greater number of psychotropic medications were more likely to experience success with topiramate therapy. Of the 24 patients who responded to therapy, 22 experienced onset of weight reduction by the next clinic visit (1-4 mo) following either initiation of therapy or titration to the eventual therapeutic dose, and the usual rate of weight loss was 0.45-1.4 kg per month. Therapy was typically initiated at 50 mg/day. The mean maximum dose was 93.9 mg/day and the median maximum dose was 100 mg/day. Seven (17.1%) patients had documented adverse effects to topiramate therapy. CONCLUSIONS: Topiramate therapy resulted in overall modest (ie, <2%) decreases in weight and BMI, but many patients experienced more impressive weight loss. Therapy was generally well tolerated.

Efficacy of risperidone versus olanzapine in patients with schizophrenia previously on chronic conventional antipsychotic therapy: a switch study.

The objective of the study was to examine whether patients with schizophrenia who were judged to be stable on long-term treatment with conventional antipsychotic medications would further benefit from a switch to an atypical antipsychotic drug. Thirty-six subjects with schizophrenia spectrum disorder, on conventional antipsychotic medication therapy for at least 2 years, were randomized in double-blind fashion to risperidone versus olanzapine. Patients were titrated up to 6 mg risperidone or 15 mg olanzapine as tolerated, followed by tapering and discontinuation of conventional antipsychotic medication. Atypical antipsychotic agents were then administered alone (monotherapy) for 12 weeks. Efficacy and tolerability were assessed using the Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale, and Simpson Angus Scale. Body weight was measured at each visit. Both treatment groups exhibited marked and similar improvement in the total PANSS score from baseline to study endpoint (22 weeks) [risperidone: baseline=59.3 (SE 3.1), 22 weeks=44.3 (SE 2.3) (p<0.001); olanzapine: baseline=55.9 (SE 3.3), 22 weeks=46.9 (SE 3.2) (p<0.001). Both groups also exhibited significant reductions in PANSS factor scores for positive and negative symptoms and disorganized thoughts. Only risperidone-treated patients exhibited significant decreases in uncontrolled hostility/excitement and anxiety and depression. Of note, while positive factor scores exhibited the majority of change within the first 10 weeks, negative factor scores continued to decline significantly in both treatment groups throughout the study. Tolerability assessments did not differ between groups. The results indicate that both atypical antipsychotic medications provided significant additional improvement in symptom severity in patients with schizophrenia previously on conventional antipsychotic agents.

Medication options for treatment-resistant schizophrenia: implications for global mental health financing.

Treatment resistance in schizophrenia creates a persistent public health problem and leads to repeated hospitalization. In search for a treatment for such patients, psychiatrists have co-prescribed multiple psychotropic medications simultaneously. Such practice is based mostly on clinical experience, rather than research derived evidence. Such combinations may not be fully "effective" if the cost, adverse effect profile and the potential for noncompliance by patients secondary to regimen complexity are considered. Is it really wise to try these various combinations of costly medicines in the mental health system, which is already struggling with its limited resources and funding worldwide? However, if mental health policy makers restrict reimbursement for such "unproven" combinations, patients might not receive the benefits of some of these combinations, which are showing some promise for the treatment of resistant schizophrenia.

Residency training in public psychiatry: a review of literature.

BACKGROUND: Training of psychiatry residents in a conmmunity setting has been emerging as a more rational and reasonable choice for psychiatry residency training, considering the shift of reliance in the recent years for psychiatric services from inpatient care in hospitals to outpatient care in the community. METHODS: A literature review regarding residency training in community psychiatry was performed using the Medline databases. Seven residency training programs' curricula were included in this review. The curriculum of each of these seven programs was also obtained from their respective Internet home pages. The authors describe the community psychiatry training curriculum of their affiliated program, the University of Alabama at Birmingham. RESULTS: A brief description of community training curricula of these eight programs is provided. These curricula, especially their unique characteristics, are then compared in a table. DISCUSSION: The psychiatry training programs differ in many noteworthy ways while providing their residents with "community psychiatry experience." The table provides a quick comparison and highlights the differences of these programs. The authors emphasize the need for a "model curriculum," taking into consideration various factors including the local resources available where the residents could rotate for their community psychiatry experience. CONCLUSION: The authors concluded that psychiatry residency training programs need to publish their curricula, so that other programs can modify their own curricula, if needed, and hence provide an excellent experience in community psychiatry to their residents and future psychiatrists.

Clozapine: a clinical review of adverse effects and management.

Clozapine (Clozaril) is a novel and unique prototype atypical, tricyclic, dibenzodiazepine-derivative, antipsychotic agent. It has been proven effective and significantly superior to placebo, as well as to conventional neuroleptics, in several placebo-controlled, double-blind studies in treatment-resistant schizophrenia. It has also been found to produce an incidence of extrapyramidal symptoms (EPS) as low as that found with placebo. Approximately 30-60% of all schizophrenic patients who fail to respond to typical antipsychotics may respond to clozapine. It was the first major advance that marked a turning point in the treatment of schizophrenia and other psychotic disorders since the introduction of the typical antipsychotic agents, i.e., chlorpromazine and haloperidol in the 1950s and 1960s, respectively. After its introduction in clinical studies in the United States in the early 1970s, it was withdrawn in 1974, and was not approved for clinical use in the United States until February 1990, because of the risk of agranulocytosis. Its novel pharmacological profile, lack of propensity to cause EPS in both short- and long-term uses, lack of effects on serum prolactin, and ameliorative effects on tardive dyskinesia have resulted in the expansion of its use from refractory schizophrenia to schizoaffective disorders, affective disorders, some neurological disorders, aggression, as well as psychosis in patients with dementia and parkinsonism. This review covers the history, pharmacology, management of side effects, and fetal and neonatal effects of clozapine.

Electroconvulsive Therapy in a Depressed Patient with an Intracranial Arachnoid Cyst: A Brain Magnetic Resonance Imaging Study.

We describe a depressed man with an asymptomatic arachnoid cyst of the left sylvian fissure who was successfully treated with ECT. Magnetic resonance imaging of the brain before and after the course of therapy revealed no change in the cyst nor any injury to the surrounding brain parenchyma.