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2.
Artigo em Inglês | MEDLINE | ID: mdl-31634515

RESUMO

STUDY OBJECTIVES: Sleep disruption is a significant symptom of major depressive disorder (MDD). To our knowledge, no prior work has examined the impact of repetitive transcranial magnetic stimulation (rTMS) on sleep disturbances in adolescents with MDD. METHODS: Seventeen adolescents with treatment-resistant depression received 30 daily sessions of 10-Hz rTMS applied to the left dorsolateral prefrontal cortex (L-DLPFC). Clinical symptoms were assessed at baseline; after 10, 20, and 30 treatments; and at a 6-month follow-up visit. Insomnia was measured with a 3-item subscale of the Quick Inventory of Depressive Symptomatology-Adolescent (17 Item)-Self Report (QIDS-A17-SR). Hypersomnia was measured with a single QIDS-A17-SR item. Depression severity was rated with the Children's Depression Rating Scale, Revised (CDRS-R). The effect of rTMS on sleep was examined via linear mixed model analyses, with fixed effects of time (as a proxy of treatment), depression severity, age, and hypnotic medication use. RESULTS: No significant main effect of time was observed on the insomnia subscale (F4,43.442 = 1.078, p = 0 .379). However, there was a significant main effect of time on the QIDS-A17-SR hypersomnia score (F4,46.124 = 2.733, p = 0 .040), with significant improvement from baseline to treatment 10 (padj = 0.019) and from baseline to 6-month follow-up (padj = 0.044). In exploratory sensitivity analyses, response/nonresponse to rTMS for overall depressive symptoms had no significant effect on sleep outcomes. CONCLUSIONS: rTMS may have intrinsic effects on hypersomnia apart from its antidepressant effects in depressed adolescents. Future work should utilize sham controls and objective, quantitative measurements of sleep architecture to assess effects of rTMS in depressed adolescents. CLINICAL TRIAL REGISTRY: Clinicaltrials.gov identifiers are NCT00587639, NCT01502033, NCT01804270.

4.
J Pers Disord ; : 1-14, 2019 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-30742548

RESUMO

This study aimed to understand prescribing practices during acute psychiatric hospitalization in a large cohort of patients (N = 569) with borderline personality disorder (BPD) at a tertiary care psychiatry unit from January 1, 2013, through January 1, 2015. The mean number of hospitalizations per patient was 1.5 (range, 1-7). The odds of being prescribed antidepressants, antipsychotics, mood stabilizers, hypnotics, or anxiolytics were higher at discharge than at admission. The rate of psychotropic prescriptions was also higher at discharge than at admission (incidence rate ratio, 1.9). This pattern was true for the combined psychotropic and nonpsychotropic ("medical") prescriptions. Further guidelines are needed regarding optimal psychosocial, medical, and psychopharmacological care of patients with BPD during acute psychiatric hospitalizations.

5.
Artigo em Inglês | MEDLINE | ID: mdl-30651753

RESUMO

Background: Between 2009 and 2014, nearly 3% of US children (age ≤ 17 years) lived in households with at least 1 parent with substance use disorder. The present systematic review aimed to evaluate effects of parental opioid use disorder on the parent-child relationship and child developmental and behavioral outcomes. Methods: Several databases were comprehensively searched for studies published from January 1980 through February 2018 that reviewed effects of parental opioid addiction on parent-child relationships and outcomes of children (age, 0-16 years). Results: Of 304 unique studies, 12 evaluated effects of parental opioid addiction on the parent-child relationship as the primary outcome and on children's outcomes, including behaviors and development. Observation of mother-child interaction showed that mothers with opioid use disorders are more irritable, ambivalent, and disinterested while showing greater difficulty interpreting children's cues compared with the control group. Children of parents with opioid use disorders showed greater disorganized attachment; they were less likely to seek contact and more avoidant than children in the control group. The children also had increased risk of emotional and behavioral issues, poor academic performance, and poor social skills. Younger children had increased risk of abuse or neglect, or both, that later in life may lead to such difficulties as unemployment, legal issues, and substance abuse. Conclusions: Current evidence shows association between parental opioid addiction and poorer mother-child attachment and suboptimal child developmental and behavioral outcomes. Further research and treatment targeting children and families with parental opioid use are needed to prevent difficulties later in life.

6.
J Child Adolesc Psychopharmacol ; 28(9): 615-619, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30358422

RESUMO

OBJECTIVES: Clozapine is the drug of choice for treatment-resistant schizophrenia. While pediatric clozapine use is not contraindicated, the literature describing its clinical application is limited. The primary objective of this study was to assess the use of clozapine in a child and adolescent population by characterizing the documented safety and clinical benefits of the medication. METHODS: A multicenter retrospective study at sites in the United States and Australia included children and adolescents admitted to a psychiatric unit who were administered at least one dose of clozapine. Information related to demographics, patient history, past treatments, clozapine, and adverse events was collected. RESULTS: Eighty-two patients from eight sites were included in this study. Patients were predominantly clozapine naive (76.8%), and most had a discharge diagnosis of a primary psychotic disorder (61%) or bipolar disorder (25.6%). Four clozapine discontinuations occurred during hospitalization due to severe neutropenia, ileus, need for diagnostic clarification, and significant psychomotor retardation. The remainder (n = 78) were discharged on a mean clozapine dose of 218.1 ± 142.2 mg. Sedation (26.8%) and sialorrhea (17.1%) were the most common documented adverse events. The mean number of previously trialed antipsychotics before clozapine was 3.5 ± 1.4 (range 1-10). Improvement with clozapine was documented as significant (31.7%), moderate (32.9%), minimal (12.2%), no improvement (2.4%), and not described (20.7%). CONCLUSIONS: In this cohort, 95% of pediatric patients admitted with or started on clozapine during an acute psychiatric hospitalization were discharged on the medication. The high incidence of adverse events should reinforce to clinicians the need for vigilant monitoring. Pediatric guidelines recommend clozapine for refractory schizophrenia but stress the critical need to ensure an accurate diagnosis. Limited data exist for the use of clozapine in pediatric patients with other diagnoses.


Assuntos
Antipsicóticos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Clozapina/uso terapêutico , Unidade Hospitalar de Psiquiatria , Transtornos Psicóticos/tratamento farmacológico , Adolescente , Austrália , Criança , Clozapina/efeitos adversos , Feminino , Humanos , Masculino , Neutropenia/induzido quimicamente , Estudos Retrospectivos , Sialorreia/induzido quimicamente
7.
Gen Hosp Psychiatry ; 55: 10-14, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30193205

RESUMO

OBJECTIVE: Psychiatric rehospitalizations results in a significant burden to patients, families, and health care systems. Understanding psychiatric rehospitalizations offers an opportunity to identify weaknesses in current systems of care. The objective of this study was to test the hypothesis that a history of trauma or ongoing bullying increases the risk of psychiatric rehospitalization. METHOD: Retrospective cohort study of 366 individual patients (71% female) admitted to a pediatric psychiatry unit between 1/1/2015 and 12/31/2015. The primary outcome measure was rehospitalization to the same psychiatric hospital unit within one year of first discharge. Trauma was defined as having a history of Post-Traumatic Stress Disorder, Reactive Attachment Disorder, or a filed Suspected Abuse and Neglect of a Child report by the end of first hospitalization. Ongoing bullying was identified by medical record review. RESULTS: History of trauma (Odds Ratio (OR) = 3.2, 95% Confidence Interval (CI) = 1.8-5.6, p < 0.0001) and ongoing bullying (OR = 2.2, CI = 1.2-3.9, p = 0.009) were significantly associated with increased rates of rehospitalizations. We controlled for the following covariates: Patient Health Questionnaire-9 Modified (PHQ-9M) score, gender, age, relative age, initial length of stay, disrupted family system, and sexual orientation/identity. CONCLUSION: History of trauma or ongoing bullying are important risk factors for pediatric psychiatric rehospitalization.


Assuntos
Bullying/estatística & dados numéricos , Vítimas de Crime/estatística & dados numéricos , Hospitais Psiquiátricos/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Trauma Psicológico/epidemiologia , Trauma Psicológico/terapia , Adolescente , Criança , Feminino , Humanos , Masculino , Minnesota , Estudos Retrospectivos
8.
Am J Addict ; 27(7): 574-577, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30152572

RESUMO

BACKGROUND AND OBJECTIVES: A high proportion of persons in institutionalized settings such as the criminal justice system and psychiatric hospitals have substance use disorders (SUDs). We explored the association between substance use, demographics, and criminal justice involvement in a population of patients placed on involuntary 72-h holds in a psychiatric facility. METHODS: We retrospectively identified patients aged 18 through 57 years who had been placed on 72-h holds during an acute psychiatric hospitalization during a 1-year period. Data were analyzed with standard descriptive statistics, and data collection was reviewed by 2 randomly assigned psychiatrists. RESULTS: We identified 336 patients placed on 72-h holds during an acute psychiatric stay. Of these, more than two-thirds (68.5%; n = 230) had an SUD. Compared with patients not using substances, those with SUDs were significantly more likely to be younger (p = .003), male (p = .005), and unmarried (p < .001) and to have criminal justice involvement before (p < .001) and after hospitalization (p < .001). The rate of unemployment was similarly high in both users (67.4%) and nonusers (69.2%). DISCUSSION AND CONCLUSIONS: Most patients on involuntary psychiatric holds have comorbid SUDs. These patients are more likely to have interacted with the criminal justice system and less likely to have social support in the form of marriage. Unemployment was common among all patients. SCIENTIFIC SIGNIFICANCE: When SUDs are not treated by the criminal justice or mental health system, rehospitalization and criminal recidivism may result. (Am J Addict 2018;27:574-577).


Assuntos
Direito Penal/métodos , Hospitais Psiquiátricos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias , Adulto , Criminosos/psicologia , Criminosos/estatística & dados numéricos , Demografia , Feminino , Psiquiatria Legal/métodos , Psiquiatria Legal/estatística & dados numéricos , Humanos , Institucionalização/estatística & dados numéricos , Tratamento Involuntário/métodos , Tratamento Involuntário/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados Unidos/epidemiologia
9.
J Affect Disord ; 239: 282-290, 2018 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-30031247

RESUMO

BACKGROUND: This exploratory study sought to examine the effect of an acute course of high-frequency repetitive TMS on suicidal ideation in adolescents. METHODS: Data were pooled from 3 prior protocols providing a 30-session course of open-label TMS treatment for adolescents with treatment-resistant depression. All participants (n = 19) were outpatients taking antidepressant medication, with TMS provided as adjunctive treatment. Suicidality was assessed at baseline, after 10 treatments, after 20 treatments, and after 30 treatments. Outcome measures of suicidal ideation included the Columbia Suicide Severity Rating Scale (C-SSRS) "Intensity of Ideation" subscale and Item 13 "Suicidality" on the Children's Depression Rating Scale, Revised (CDRS-R). RESULTS: The predicted odds of suicidal ideation (CDRS-R Item 13 and C-SSRS Intensity of Ideation subscale) significantly decreased over 6 weeks of acute TMS treatment without adjustments for illness (depression) severity. However, the magnitude of the decrease in the predicted odds of suicidal ideation across 6 weeks of treatment was attenuated and rendered non-significant in subsequent analyses that adjusted for illness (depression) severity. LIMITATIONS: This was an exploratory study with a small sample size and no sham control. Regulatory and ethical barriers constrained enrollment of adolescents with severe suicidality. CONCLUSIONS: The present findings suggest that open-label TMS mitigated suicidal ideation in adolescents through the treatment and improvement of depressive symptom severity. Although caution is warranted in the interpretation of these results, the findings can inform the design and execution of future interventional trials targeting suicidal ideation in adolescents.


Assuntos
Depressão/patologia , Transtorno Depressivo Resistente a Tratamento/diagnóstico por imagem , Ideação Suicida , Estimulação Magnética Transcraniana/métodos , Adolescente , Transtorno Depressivo Resistente a Tratamento/tratamento farmacológico , Feminino , Humanos , Masculino
10.
Schizophr Res ; 199: 17-30, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29548760

RESUMO

The use of clozapine requires monitoring the absolute neutrophil count because of the risk of agranulocytosis, but other potentially fatal adverse events associated with clozapine (specifically, myocarditis and cardiomyopathy) do not have mandatory procedures. We performed a systematic review of English-language articles to synthesize an evidence-based approach for myocarditis and cardiomyopathy monitoring. Articles published from January 1988 through February 2017 were identified through a search of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Google Scholar. Selected articles were required to relate to myocarditis or cardiomyopathy in humans from exposure to clozapine. A total of 144 articles were included. Recommendations varied widely. Some authors recommended baseline laboratory monitoring, with or without follow-up testing, for C-reactive protein, creatine kinase MB, and troponin. Electrocardiography was commonly recommended, and echocardiography was less commonly recommended. The expense of monitoring was a consideration. A unanimous recommendation was to stop the use of clozapine and seek a cardiovascular consultation if myocarditis or cardiomyopathy is suspected. Although there is general agreement on which tests to perform for confirming myocarditis and cardiomyopathy, preemptive screening for these clozapine-induced conditions is controversial, and cost and barriers for the use of clozapine are concerns. For asymptomatic patients receiving clozapine, testing could include baseline electrocardiography, echocardiography as part of a cardiac consultation if patients have cardiac disease or risk factors, and monitoring of C-reactive protein and troponin as indicated.


Assuntos
Antipsicóticos/efeitos adversos , Cardiomiopatias/induzido quimicamente , Cardiomiopatias/diagnóstico , Clozapina/efeitos adversos , Miocardite/induzido quimicamente , Miocardite/diagnóstico , Antipsicóticos/uso terapêutico , Clozapina/uso terapêutico , Humanos , Monitorização Fisiológica , Esquizofrenia/tratamento farmacológico
13.
J Genet Couns ; 26(2): 272-275, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27744538

RESUMO

A diagnosis of Huntington's disease has broad social, vocational, reproductive and psychological implications. The ability to accurately diagnose the illness via genetic testing is not new. However, given a persistent lack of robustly effective interventions, it remains an area of ethical concern. The difficulty is compounded in cases of intellectual disability. This paper presents a case of genetic testing for Huntington's disease conducted on a patient with intellectual disability with guardian consent, but without the patient's direct knowledge and how the family illness narrative and psychiatric care were employed in the eventual disclosure of the patient's diagnosis and subsequent management.


Assuntos
Revelação , Aconselhamento Genético , Doença de Huntington/psicologia , Deficiência Intelectual/psicologia , Pacientes/psicologia , Adulto , Testes Genéticos , Humanos , Doença de Huntington/complicações , Doença de Huntington/genética , Deficiência Intelectual/complicações , Tutores Legais , Masculino
14.
J Affect Disord ; 206: 300-304, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27656788

RESUMO

BACKGROUND: Little is known about the antidepressive effects of repeated intravenous ketamine infusions beyond the acute phase of treatment in patients with refractory depression. METHODS: Twelve subjects with treatment-resistant non-psychotic unipolar or bipolar major depression and suicidal ideation were given repeated (up to 6) thrice-weekly acute-phase intravenous infusions of ketamine (0.5mg/kg, administered over 100min). Those who remitted during acute-phase treatment received continuation-phase treatment that consisted of 4 weekly ketamine infusions, followed by 4 weeks of post-continuation phase follow-up (during which no further ketamine infusions were administered). Clinical measures were assessed at baseline, at 24h following each infusion, at the last acute-phase observation, and during continuation and post-continuation follow-up (acute phase remitters only). RESULTS: Of the 12 enrollees, 5 (41.7%) remitted and 7 (58.3%) responded to ketamine treatment during the acute-phase. All five subjects who remitted during the acute-phase experienced further depressive symptom improvement during continuation-phase treatment. Four subjects lost remission status during the post-continuation phase, but all were still classified as positive treatment responders at the end of the post-continuation phase. Adverse effects were generally mild and transient during acute- and continuation-phase treatment; however, one subject developed behavioral outbursts and suicide threats during follow-up while hospitalized, and one subject died by suicide several weeks after the end of follow-up. LIMITATIONS: This was an uncontrolled feasibility study with a small sample size. CONCLUSIONS: The continuation-phase administration of ketamine at weekly intervals to patients with treatment-resistant depression who remitted during acute-phase ketamine treatment can extend the duration of depressive symptom remission. The antidepressive effect of ketamine persisted for several weeks after the end of continuation-phase treatment. Our results highlight the need for close monitoring of subjects who are at high baseline risk for suicide but do not respond clinically to ketamine. CLINICALTRIALS. GOV IDENTIFIER: NCT02094898.


Assuntos
Antidepressivos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Resistente a Tratamento/tratamento farmacológico , Ketamina/uso terapêutico , Adulto , Relação Dose-Resposta a Droga , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Indução de Remissão , Tamanho da Amostra , Ideação Suicida , Adulto Jovem
16.
Child Psychiatry Hum Dev ; 47(3): 494-502, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26323583

RESUMO

To better understand the types and quantity of mental health services and medication usage for youth diagnosed with bipolar disorder (BD) within an integrated healthcare system, medical records were reviewed from 2000 to 2011. Eighty-five youth diagnosed with BD were identified and healthcare services (medication and psychotherapy follow-up appointments, emergency room (ER) visits, admissions, phone contacts) and visit-related details (medication usage) were abstracted for 2 years after initial BD diagnosis. Despite complex medication regimens (91.7 and 81.2 % received mood stabilizers and antipsychotic agents, respectively), medication appointments were infrequent, averaging 1 visit every 2 months. Only 36 (42 %) of 85 youth were noted to receive psychotherapy services following BD diagnosis, also averaging 1 visit every 2 months. Most (58.8 %) patients needed one or more hospitalizations during the follow-up period; nearly half (48.2 %) had psychiatric ER visits. The relative lack of psychotherapy and infrequent follow-up visits suggests need for improvement to optimize healthcare delivery.


Assuntos
Antipsicóticos/uso terapêutico , Transtorno Bipolar/terapia , Serviços de Saúde Mental , Psicoterapia , Adolescente , Serviços de Saúde do Adolescente , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/tratamento farmacológico , Transtorno Bipolar/psicologia , Criança , Serviços de Saúde da Criança , Terapia Combinada , Feminino , Hospitalização , Humanos , Masculino
18.
Int J Bipolar Disord ; 3(1): 30, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26105627

RESUMO

BACKGROUND: We aimed to establish a bipolar disorder biobank to serve as a resource for clinical and biomarker studies of disease risk and treatment response. Here, we describe the aims, design, infrastructure, and research uses of the biobank, along with demographics and clinical features of the first participants enrolled. METHODS: Patients were recruited for the Mayo Clinic Bipolar Biobank beginning in July 2009. The Structured Clinical Interview for DSM-IV was used to confirm bipolar diagnosis. The Bipolar Biobank Clinical Questionnaire and Participant Questionnaire were designed to collect detailed demographic and clinical data, including clinical course of illness measures that would delineate differential phenotypes for subsequent analyses. Blood specimens were obtained from participants, and various aliquots were stored for future research. RESULTS: As of September 2014, 1363 participants have been enrolled in the bipolar biobank. Among these first participants, 69.0 % had a diagnosis of bipolar disorder type I. The group was 60.2 % women and predominantly white (90.6 %), with a mean (SD) age of 42.6 (14.9) years. Clinical phenotypes of the group included history of psychosis (42.3 %), suicide attempt (32.5 %), addiction to alcohol (39.1 %), addiction to nicotine (39.8 %), obesity (42.9 %), antidepressant-induced mania (31.7 %), tardive dyskinesia (3.2 %), and history of drug-related serious rash (5.7 %). CONCLUSIONS: Quantifying phenotypic patterns of illness beyond bipolar subtype can provide more detailed clinical disease characteristics for biomarker research, including genomic-risk studies. Future research can harness clinically useful biomarkers using state-of-the-art research technology to help stage disease burden and better individualize treatment selection for patients with bipolar disorder.

19.
Ann Pharmacother ; 49(8): 897-906, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25969570

RESUMO

OBJECTIVE: To review the literature evaluating gabapentin for alcohol withdrawal and dependence. DATA SOURCES: A literature search of MEDLINE (1966 to end of March 2015) and PubMed was performed using the terms alcohol, gabapentin, withdrawal, and dependence. Additional references were identified from a review of literature citations. STUDY SELECTION AND DATA EXTRACTION: English-language prospective studies evaluating gabapentin for alcohol withdrawal and dependence were evaluated. DATA SYNTHESIS: A total of 10 publications utilizing gabapentin in alcohol withdrawal (n = 5) and alcohol dependence (n = 5) were included in this review. Limited data suggest that gabapentin can provide benefit in managing mild alcohol withdrawal syndrome. There were 5 reported or suspected seizures in the withdrawal studies, suggesting that additional safety data are necessary before gabapentin monotherapy can be routinely considered. Sleep and mood/anxiety-related outcomes were positively influenced by gabapentin, which may result in long-term benefits if continued beyond the withdrawal period for the treatment of alcohol dependence. Studies evaluating gabapentin for alcohol dependence demonstrated dose-dependent benefits for complete abstinence, rates of no heavy drinking, and cravings. Gabapentin used to treat alcohol dependence was well tolerated with no severe adverse reactions reported in the extant literature. CONCLUSION: Gabapentin may have a role in the treatment of mild alcohol withdrawal, but future studies should focus on adequate dosing strategies. Gabapentin should be considered for the treatment of alcohol dependence when barriers prevent the use of traditional agents. Additional studies should be conducted to further validate findings from the research conducted to date, but the current literature is promising for gabapentin in the treatment of alcohol dependence.


Assuntos
Alcoolismo/tratamento farmacológico , Aminas/uso terapêutico , Ácidos Cicloexanocarboxílicos/uso terapêutico , Síndrome de Abstinência a Substâncias/tratamento farmacológico , Ácido gama-Aminobutírico/uso terapêutico , Gerenciamento Clínico , Etanol/efeitos adversos , Gabapentina , Humanos , Estudos Prospectivos
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