Failed efficacy of ziprasidone in the treatment of post-traumatic stress disorder.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a chronic anxiety disorder that is often difficult to treat. Patients suffering from PTSD often fail to respond to antidepressants and may have a high incidence of positive symptoms of psychosis, though antipsychotic medications have been minimally studied in this population. The aim of this study was to assess the impact of the atypical antipsychotic ziprasidone (Geodon) on PTSD symptom clusters, as well as comorbid major depressive disorder. To our knowledge, this is the first completed randomized controlled trial investigating the potential efficacy and tolerability of ziprasidone in patients with chronic PTSD. METHODS: We conducted a 9-week prospective, randomized, double-blind, placebo-controlled trial of ziprasidone in 30 patients diagnosed with PTSD and comorbid depression. After screening and randomization, patients completed nine weekly study visits at which treatment safety and efficacy were evaluated. Primary measures of efficacy included total and subscale scores from the Clinician-Administered PTSD Scale (CAPS), while the Hamilton Rating Scale for Depression (HAM-D), Hamilton Anxiety Scale (HAM-A), Clinical Global Impression (CGI), and Treatment Outcome PTSD Scale (TOP-8) were implemented as secondary efficacy measures. RESULTS: We observed no significant effect of treatment on reduction of PTSD or depression symptoms from pre- to post-treatment. CONCLUSIONS: Our findings suggest that ziprasidone treatment may not significantly improve symptoms of PTSD or comorbid depression, though further study is needed.

A Comparison of Homeless Male Veterans in Metropolitan and Micropolitan Areas in Nebraska: A Methodological Caveat.

This study explored differences between homeless male veterans in metropolitan and micropolitan cities in Nebraska on sociodemographic, housing, clinical, and psychosocial characteristics as well as health service use. A convenience sample of 151 homeless male veterans (112 metropolitan, 39 micropolitan) were recruited from Veterans Affairs facilities and area shelters in Omaha, Lincoln, Grand Island, and Hastings in Nebraska. Research staff conducted structured interviews with homeless veterans. Results showed that compared to homeless veterans in metropolitans, those in micropolitans were more likely to be White, unmarried, living in transitional settings, and were far more transient but reported greater social support and housing satisfaction. Veterans in micropolitans also reported more medical problems, diagnoses of anxiety and personality disorders, and unexpectedly, were more likely to report using various health services and less travel time for services. Together, these findings suggest access to homeless and health services for veterans in micropolitan areas may be facilitated through Veterans Affairs facilities and community providers that work in close proximity to one another. Many homeless veterans in these areas are transient, making them a difficult population to study and serve. Innovative ways to provide outreach to homeless veterans in micropolitan and more rural areas are needed.

Effects of Escitalopram on Autonomic Function in Posttraumatic Stress Disorder Among Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF).

OBJECTIVE: Posttraumatic stress disorder is a chronic, debilitating condition that has become a growing concern among combat veterans. Previous research suggests that posttraumatic stress disorder disrupts normal autonomic responding and may increase the risk of cardiovascular disease and mortality. Measures of heart rate variability and QT interval variability have been used extensively to characterize sympathetic and parasympathetic influences on heart rate in a variety of psychiatric populations. The objective of this study was to better understand the effects of pharmacological treatment on autonomic reactivity in posttraumatic stress disorder. DESIGN: A 12-week, Phase IV, prospective, open-label trial of escitalopram in veterans with combat-related posttraumatic stress disorder and comorbid depression. SETTING: An outpatient mental health clinic at a Veterans Affairs Medical Center. PARTICIPANTS: Eleven male veterans of Operations Enduring Freedom and Iraqi Freedom diagnosed with posttraumatic stress disorder and comorbid depression. MEASUREMENTS: Autonomic reactivity was measured by examining heart rate variability and QT interval variability. Treatment safety and efficacy were also evaluated pre- and post-treatment. RESULTS: We observed a reduction in posttraumatic stress disorder and depression symptoms from pre- to post-treatment, and escitalopram was generally well tolerated in our sample. In addition, we observed a decrease in high frequency heart rate variability and an increase in QT variability, indicating a reduction in cardiac vagal function and heightened sympathetic activation. CONCLUSION: These findings suggest that escitalopram treatment in patients with posttraumatic stress disorder and depression can trigger changes in autonomic reactivity that may adversely impact cardiovascular health.

An Open-Label Trial of Memantine for Cognitive Impairment in Patients with Posttraumatic Stress Disorder.

Background. Studies using standard neuropsychological instruments have demonstrated memory deficits in patients with PTSD. We evaluated the efficacy and safety of the N-methyl-D-aspartate antagonist memantine in veterans with PTSD and cognitive impairment. Methods. Twenty-six veterans with PTSD and cognitive impairment received 16 weeks of memantine in an open-label fashion. Cognition was assessed using the Spatial Span, Logical Memory I, and Letter-Number Sequencing subtests of the Wechsler Memory Scale III and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). RBANS measures attention, language, visuospatial skills, and immediate and delayed memories. The Clinician Administered PTSD Scale (CAPS), Hamilton Depression Scale (HAM-D), Hamilton Anxiety Scale (HAM-A), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and Sheehan Disability Scale (SDS) were secondary outcome measures. Results. There was a significant improvement in RBANS, both total and subscale scores (P < 0.05), over time. There was a reduction in total CAPS scores, avoidance/numbing symptoms (CAPS-C) and hyperarousal symptoms (CAPS-D), HAM-D, Q-LES-Q, and SDS scores. However, there was no reduction in reexperiencing (CAPS-B) and HAM-A scores. Memantine was well tolerated. Conclusions. Memantine improved cognitive symptoms, PTSD symptoms, and mood in veterans with PTSD. Randomized double-blind studies are needed to validate these preliminary observations.

The Bhagavad Gita and contemporary psychotherapies.

The Bhagavad Gita is based on a discourse between Lord Krishna and Arjuna at the inception of the Kurukshetra war and elucidates many psychotherapeutic principles. In this article, we discuss some of the parallels between the Gita and contemporary psychotherapies. We initially discuss similarities between psychodynamic theories of drives and psychic structures, and the concept of three gunas. Arjuna under duress exhibits elements of distorted thinking. Lord Krishna helps remedy this through a process akin to Cognitive Behavioral Therapy (CBT). We ascertain the analogies between the principles of Gita and CBT, grief emancipation, role transition, self-esteem, and motivation enhancement, as well as interpersonal and supportive psychotherapies. We advocate the pragmatic application of age old wisdom of the Gita to enhance the efficacy of psychotherapeutic interventions for patients from Indian subcontinent and to add value to the art of western psychotherapies.

Methylphenidate for apathy and functional status in dementia of the Alzheimer type.

OBJECTIVE: Apathy is the most common behavioral problem in persons with dementia of the Alzheimer type (DAT). Treatment of apathy in DAT is not systematically studied. The purpose of this study was to evaluate the response of apathy to methylphenidate treatment and to examine whether functional status improved. METHODS: The authors conducted a 12-week open-labeled study with immediate release formulation of methylphenidate. Twenty-three patients with DAT scoring >40 on the Apathy Evaluation Scale (AES) were recruited. Repeated measures analysis of variance and correlation analysis were performed. RESULTS: None of the patients dropped out of the study because of adverse events. Significant improvement in apathy was noted during 12 weeks. Significant improvement was also noted in depression, Mini-Mental State Examination score, and functional status. There was no correlation between changes in the AES and depression scores. CONCLUSIONS: Methylphenidate was well tolerated in these patients with DAT. Apathy improved with the use of methylphenidate.

Quality outcomes management: Veterans Affairs case study.

During the last decade, the Department of Veterans Affairs (VA) has made major strides in enhancing quality of medical, surgical, and mental health care for veterans. These improvements have been achieved through the will and commitment of VA leadership and by changes in the administrative structure, such as through the creation of Veteran Integrated Service Networks and patient care service lines, the use of state-of-the-art technology for electronic health records, implementation of high-value preventative and chronic disease management performance measures, and the ability to track their effectiveness. Parallel with these changes, the quality of mental heath care in the VA has also improved, as have mental health education and research.

Modafinil therapy for apathy in an elderly patient.

OBJECTIVE: To present a case of successful treatment of apathy syndrome with modafinil. CASE SUMMARY: A 78-year-old man with dementia and depression was also experiencing apathy that did not respond to antidepressants including escitalopram, a selective serotonin-reuptake inhibitor (SSRI). Escitalopram was discontinued and modafinil, a novel vigilance-promoting agent pharmacologically distinct from stimulants, was used to successfully treat the apathy. The dosage regimen was initiated at 50 mg and titrated to 200 mg/day over 4 weeks. Apathy was assessed using the Apathy Evaluation Scale developed specifically to identify apathy and also to differentiate this from depression. DISCUSSION: Apathy, a common behavioral problem, is often mistaken for depression; however, apathy differs from depression in symptomatology, clinical presentation, and treatment options. SSRIs, a common treatment for depression, are known to cause or increase apathy. Deficits in the dopamine receptor system are involved in the etiology of apathy; modafinil's increased dopaminergic transmission is thought to help alleviate apathy. Due to its relative lack of drug interactions, modafinil is a good alternative for elderly patients, who often receive multiple medications. Apathy improved significantly after treatment with modafinil in this patient. To the best of our knowledge, as of January 22, 2007, this is the first report of modafinil treatment of apathy syndrome. CONCLUSIONS: Modafinil may be useful in treating apathy syndrome. Its role in the treatment of apathy requires further testing in clinical trials.

Treatment of apathy with methylphenidate.

Apathy is a common condition that transcends psychiatric diagnoses. Its treatment is not well studied. The authors present four cases of apathy treated with a regimen of methylphenidate. Significant improvement in apathy and its sub-domains (motivation, novelty, and persistence) were noted.

Childhood and adolescent depression.

Major depression affects 3 to 5 percent of children and adolescents. Depression negatively impacts growth and development, school performance, and peer or family relationships and may lead to suicide. Biomedical and psychosocial risk factors include a family history of depression, female sex, childhood abuse or neglect, stressful life events, and chronic illness. Diagnostic criteria for depression in children and adolescents are essentially the same as those for adults; however, symptom expression may vary with developmental stage, and some children and adolescents may have difficulty identifying and describing internal mood states. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies. Current literature supports use of cognitive behavior therapy for mild to moderate childhood depression. If cognitive behavior therapy is unavailable, an antidepressant may be considered. Antidepressants, preferably in conjunction with cognitive behavior therapy, may be considered for severe depression. Tricyclic antidepressants generally are ineffective and may have serious adverse effects. Evidence for the effectiveness of selective serotonin reuptake inhibitors is limited. Fluoxetine is approved for the treatment of depression in children eight to 17 years of age. All antidepressants have a black box warning because of the risk of suicidal behavior. If an antidepressant is warranted, the risk/benefit ratio should be evaluated, the parent or guardian should be educated about the risks, and the patient should be monitored closely (i.e., weekly for the first month and every other week during the second month) for treatment-emergent suicidality. Before an antidepressant is initiated, a safety plan should be in place. This includes an agreement with the patient and the family that the patient will be kept safe and will contact a responsible adult if suicidal urges are too strong, and assurance of the availability of the treating physician or proxy 24 hours a day to manage emergencies.

Use of alcoholic beverages in VA medical centers.

BACKGROUND: Benzodiazepines are the first-line choice for the treatment of alcohol withdrawal syndrome. However, several hospitals continue to provide alcoholic beverages through their formulary for the treatment of alcohol withdrawal. While there are data on the prevalence of this practice in academic medical centers, there are no data on the availability of alcoholic beverages at the formularies of the hospitals operated by the department of Veteran's Affairs. METHODS: In this study, we surveyed the Pharmacy managers at 112 Veterans' Affairs Medical Centers (VAMCs) to ascertain the availability of alcohol on the VAMC formularies, and presence or lack of a policy on the use of alcoholic beverages in their VA Medical Center. RESULTS: Of the pharmacy directors contacted, 81 responded. 8 did not allow their use, while 20 allowed their use. There was a lack of a consistent policy across the VA medical centers on availability and use of alcoholic beverages for the treatment of alcohol withdrawal syndrome. CONCLUSION: There is lack of uniform policy on the availability of alcoholic beverages across the VAMCs, which may create potential problems with difference in the standards of care.

Ziprasidone therapy for post-traumatic stress disorder.

We describe the cases of 2 men with chronic combat-induced post-traumatic stress disorder (PTSD) who benefited from therapy with ziprasidone. They did not have active psychotic symptoms. Both the patients had a history of inadequate response to previous trials of different psychotropic agents. Ziprasidone was considered because of its broad-spectrum actions on various neurotransmitters. To our knowledge, this is the first published report of the usefulness of ziprasidone in the pharmacotherapy of PTSD, although atypical antipsychotic agents (e.g., olanzapine, quetiapine and risperidone) have been reported to be beneficial in the treatment of this condition.

Methylphenidate may treat apathy independent of depression.

OBJECTIVE: To report a case of apathy treated with methylphenidate in which improvement in apathy was independent of improvement of depression. CASE SUMMARY: A 47-year-old woman with a 20-year history of recurrent major depression was diagnosed as having significant apathy with lack of initiative and motivation. Over the course of a 4-week treatment regimen with methylphenidate, her apathy, as measured by the Apathy Evaluation Scale, improved, with her score decreasing from 57 to 31. During this period, her depression, as assessed by the 21-item Hamilton Rating Scale for Depression, remained unchanged. DISCUSSION: Our report of improvement of apathy with methylphenidate is consistent with other reports in the literature, although previous studies have not specifically used the rating scales to assess apathy. Even though this patient had experienced apathy for a long time, it had not been detected due to lack of direct questioning. In this case, as noted, the improvement of apathy was independent of improvement in depression. CONCLUSIONS: A high degree of suspicion and specific inquiry is required for identification of apathy. Once detected, methylphenidate may be beneficial in its treatment, a strategy that may work independently of augmentation of antidepressants.

Preparing for a successful psychiatry residency review committee site visit: a guide for new training directors.

OBJECTIVE: New residency training directors are often faced with multiple competing tasks such as meeting Accreditation Council for Graduate Medical Education (ACGME) Psychiatry Program Requirements and achieving successful completion of residency review committee (RRC) site visits. For many years, the authors have presented workshops on this subject at the American Association of Directors of Psychiatry Residency Training (AADPRT) annual meetings, and many attendees have suggested publishing this information in detail. The authors provide new residency training directors with a model of comprehensive resident, faculty, and training program records and accurate documentation of compliance with psychiatry program requirements for a successful RRC site visit. METHODS: The authors carefully reviewed the ACGME Psychiatry Program Requirements, the Program Director's Reference Guide, and literature and incorporated many comments of AADPRT workshop attendees. This is in addition to 25 years combined experience of the authors as training directors. CONCLUSIONS: The proposed working guide designed to meet program requirements for full program accreditation may be of particular use to new residency training directors.

New ACGME work-hour guidelines and their impact on current residency training practices.

OBJECTIVE: Accreditation Council for Graduate Medical Education (ACGME) has introduced new work-hour guidelines for residents in ACGME accredited programs that were implemented in July 2003. The new ACGME policies impact several practices in various psychiatry residency programs across the U.S., even though psychiatry has not been at the forefront of the debate regarding work hours. METHODS: The authors surveyed all psychiatry residency programs in the U.S. and identified several current practices that may infringe on the new ACGME work-hour guidelines. CONCLUSION: Further interpretation of the new guidelines is needed.

Electroconvulsive therapy after repair of cerebral aneurysm.

There are cases in the literature describing the use of electroconvulsive therapy (ECT) in patients with intracerebral aneurysms. We report the clinical course of a 60-year-old woman with a history of a recently ruptured intracerebral aneurysm and placement of a ventriculoperitoneal shunt that was successfully treated with ECT for major depressive disorder. Beta blockade with esmolol 20-50 mg was used to maintain her blood pressure, which ranged from 100/63 to 170/94 mm Hg. Propofol was used for anesthesia. There were no vascular complications secondary to the ECT procedure.