Psychiatry Update Solving clinical challenges, improving patient Current Psychiatry and the American Academy of Clinical Psychiatrists welcomed more than 550 psychiatric practitioners from across the United States and abroad to this annual conference, which was headed by Meeting Chair Richard Balon, MD, and Co-chairs Donald W. Black, MD, and Nagy Youssef, MD, March 27-29, 2014 at the Hilton Chicago in Chicago, Illinois. Attendees earned as many as 10 AMA PRA Category 1 Credits™.

switching , which might physical, and cognitive) as an introduction to reverse adverse metabolic events. reviewing the efficacy, mechanism of action, Nonpharmacologic treatment goals and side effects of (Brintellix), include improving sleep, educating a new serotonergic agent for treating major patients, providing them with tools depressive disorder (MDD). In all studies for improving sleep, and creating an submitted to the FDA, vortioxetine was opportunity for patient-practitioner found to be superior to placebo, in at least discussion. Stimulus control and sleep 1 dosage group, for alleviating depressive restriction are primary therapeutic symptoms and for reducing the risk of techniques to improve sleep quality depressive recurrence. and reduce non-sleeping time in bed. Thomas Roth, PhD, Henry Ford AFTERNOON SESSION Hospital, also discussed how to modify Oppositional defiant disorder is more sleep hygiene techniques for pediatric, common in boys (onset at age 6 to 10) and is adolescent, and geriatric patients. associated with inconsistent and neglectful Donald W. Black, MD, University parenting. Treatment modalities, including educational training, anticonvulsants, and Thursday, March 27, 2014 of Iowa, says that work groups for DSM-5 were asked to consider dimensionality , do not have a strong evidence base. Intermittent explosive disorder is characterized MORNING SESSION and culture and gender issues. New diagnostic categories include obsessive-compulsive and by short-lived but frequent behavioral Obsessive-compulsive disorder can be related disorders and trauma and stressor- outbursts and often begins in adolescence. misdiagnosed as psychosis, anxiety, or a related disorders. Some diagnoses were Dr. Grant also reviewed the evidence on sexual disorder. In addition to contamination, reformulated or introduced, including autism conduct disorder, pyromania, and kleptomania. patients can present with pathologic spectrum disorder and disruptive mood Cognitive symptoms of schizophrenia doubt, somatic obsessions, or obsessions dysregulation disorder. The multi-axial system often appear before psychotic symptoms and about taboo or symmetry. Among FDA- was discontinued in DSM-5. He also reviewed remain stable across the lifespan. There are no approved medications, might coding issues. pharmacologic treatments for cognitive deficits be more effective than selective in schizophrenia; however, Dr. Nasrallah listed reuptake inhibitors (SSRIs). Exposure In a sponsored symposium, Prakash S. tactics to improve cognitive function, including response prevention therapy shows better Masand, MD, Global Medical Education, regular aerobic exercise. These cognitive response than pharmacotherapy, but Inc., looked at the clinical challenges of deficits can be categorized as neurocognitive best outcomes are seen with combination addressing all 3 symptom domains that (memory, learning, executive function) and therapy. Jon E. Grant, JD, MD, MPH, characterize depression (emotional, social (social skills, theory of mind, social cues) University of Chicago, also discussed and contribute to functional decline and often obsessive-compulsive personality disorder, prevent patients from working and going to body dysmorphic disorder, hoarding, school. Dr. Nasrallah described how bipolar trichotillomania, and excoriation disorder—as disorder (BD) overlaps with schizophrenia in well as changes in DSM-5 that cover this terms of cognitive dysfunction. group of disorders. Psychiatric disorders exhibit specific sleep/ Patients with schizophrenia are at higher wake impairments. Sleep disorders can risk of death from cardiac and pulmonary mimic psychiatric symptoms, such as disease than the general population. The fatigue, cognitive problems, and depression. quality of care of patients with psychosis Sleep disturbances, including insomnia, generally is poor, because of lack of obstructive sleep apnea, and decreased recognition, time, and resources, as well need for sleep, often coexist with depression, as systematic barriers to accessing health generalized anxiety disorder, posttraumatic care. Questions about weight gain, lethargy, stress disorder, and BD, and insomnia is infections, and sexual functioning can associated with a greater risk of suicide. With help the practitioner assess a patient’s treatment, sleep in depressed general health. When appropriate, Henry patients improves but does not normalize. A. Nasrallah, MD, St. Louis University Dr. Roth also reviewed pharmacotherapeutic School of Medicine, recommends, consider ▲ Henry A. Nasrallah, MD options and non- modalities to improve ◀ Boaz Levy, PhD, (left) receives the patients’ sleep. 2014 George Winokur Research Award have no efficacy in treating from Carol S. North, MD, for his article acute episodes of bipolar depression, and on recovery of cognitive function in using such agents might yield a poor long- patients with co-occuring bipolar term outcome in BD, according to Robert M. disorder and alcohol dependence. Post, MD, George Washington University School of Medicine, Michael J. Ostacher, MD, MPH, MMSc, Stanford University, T. Grossberg, MD, St. Louis University. and Vivek Singh, MD, University of Texas Rapid cycling tends to be the norm in Health Science Center at San Antonio, in geriatric BD patients. Look for agitation an interactive faculty discussion. For patients and irritability, rather than full-blown mania; with bipolar I disorder, lithium monotherapy grandiose delusions; psychiatric comorbidity, or the combination of lithium and valproate especially anxiety disorder; and sexually is more effective than valproate alone; inappropriate behavior. Pharmacotherapeutic evidence does not support valproate as a options include: mood stabilizers, atypical maintenance treatment. When a patient with consolidated, he explained, such as autism antipsychotics, and antidepressants BD shows partial response, attendees at spectrum disorder, somatic symptom (specifically, and SSRIs—not TCAs, this sponsored symposium were advised, disorder, and major neurocognitive disorder. , or —and over the short consider adding psychotherapy and psycho- New diagnoses include hoarding disorder term only). Consider divalproex for mania and education. Combining a mood stabilizer and and binge eating disorder. Subtypes of hypomania, used cautiously because of its an might be more effective schizophrenia were dropped. Pathologic adverse side-effect potential. than monotherapy and safer, by allowing gambling was renamed gambling disorder lower dosages. The only 3 treatments and gender dysphoria is now called gender AFTERNOON SESSION FDA-approved for bipolar depression are identity disorder. The bereavement exclusion of a major depressive episode was dropped. Often, BD is misdiagnosed as unipolar the - combination, depression, or the correct diagnosis of BD , and . Antidepressants are effective in mitigating is delayed, according to Gustavo Alva, pain in neuropathy, headache, fibromyalgia, MD, ATP Clinical Research. Comorbid Friday, March 28, 2014 and chronic musculoskeletal pain, and have substance use disorder or an anxiety disorder been advocated for other pain syndromes. is common. Comorbid cardiovascular disease MORNING SESSION Selection of an antidepressant depends brings a greater risk of mortality in patients on the type of pain condition, comorbid with BD than suicide. Approximately two- Carmen Pinto, MD, at a sponsored depression or anxiety, tolerability, and symposium, reviewed the utility and safety of thirds of patients with BD are taking adjunctive medical comorbidities. Dr. Leo presented medications; however, antidepressants are no long-acting injectable (LAI) antipsychotics prescribing strategies for , serotonin- for treating schizophrenia, with a focus more effective than placebo in treating bipolar reuptake inhibitors, SSRIs, and depression. At this sponsored symposium, on LAI , a partial HT-receptor other antidepressants. agonist/partial HT-receptor antagonist. Four Vladimir Maletic, MD, University of South monthly injections (400 mg/injection) of the Treating of BD in geriatric patients becomes Carolina, described a 6-week trial in which drug are needed to reach steady state; each complicated because therapeutic choices lurasidone plus lithium or divalporex was more injection reaches peak level in 5 to 7 days. are narrowed and response to therapy is less effective in reducing depression, as measured LAI aripiprazole has been shown to delay successful with age, according to George by MADRS, than placebo plus lithium or time to relapse due to nonadherence and onset of nonresponse to the drug, and has high patient acceptance—even in those who already stable. Safety and side effects with LAI aripiprazole are the same as seen with the oral formulation. In multimodal therapy for chronic pain, psychiatrists have a role in assessing psychiatric comorbidities, coping ability, social functioning, and other life functions, including work and personal relationships. Cognitive- behavioral therapy can be particularly useful for chronic pain by helping patients reframe their pain experiences. Raphael J. Leo, MA, MD, FAPM, University at Buffalo, reviewed non- co-analgesics that can be used for patients with comorbid pain and a substance use disorder. If are necessary, consider “weak” or long-acting opioids. Monitor patients for aberrant, drug-seeking behavior. In the second part of his overview, Dr. Black Couldn’t attend? highlighted specific changes toDSM-5 of particular concern to clinicians. New Visit CPAACP-CME.com for more details chapters were created and disorders were ◀ George T. Grossberg, MD

divalporex. Adverse effects included nausea, might display extrapyramidal effects and akathisia, somnolence, and extrapyramidal withdrawal symptoms. Infants exposed to symptoms. psychostimulants may have lower birth weight, When assessing an older patient with but are not at increased risk of birth defects. psychosis, first establish the cause of the Dr. Jefferson reviewed the efficacy, symptoms, such as Alzheimer’s disease, pharmacokinetics, and adverse effects of affective disorder, substance use, or , , and vortioxetine, hallucinations associated with grief. Older which are antidepressants new to the patients with schizophrenia who have been market. Dr. Jefferson recommends reading taking typical antipsychotics for years package inserts to become familiar with might benefit from a switch to an atypical new . He also described studies of or a dosage reduction. Dr. Grossberg medications that were not FDA-approved, recommends considering antipsychotics and employ psychological interventions when including edivoxetine, quetiapine XR for older patients when symptoms cause appropriate. In patients with antidepressant- monotherapy for MDD, and . severe emotional distress that does not associated sexual dysfunction, consider Agents under investigation include respond to other interventions or an acute switching medications or adding an antidote, onabotulinumtoxin A injections, , episode that poses a safety risk for patients such as bupropion, , or sildenafil. and lanicemine. or others. Choose an antipsychotic based on Katherine E. Burdick, PhD, Mount Sinai side effects, and “start low and go slow,” when Saturday, March 29, 2014 School of Medicine, defined cognitive possible. The goal is to reduce agitation and domains. First-episode MDD patients perform distress—not necessarily to resolve psychotic MORNING SESSION worse in psychomotor speed and attention symptoms. than healthy controls. Late-onset depression Because of the lack of double-blind, placebo- Anita H. Clayton, MD, University of (after age 60) is associated with worse controlled trials, the risks of untreated Virginia Health System, provided a review performance on processing speed and verbal depression vs the risks of of sexual function from puberty through antidepressant memory. Cognitive deficits in depressed are unclear. midlife and older years. Social factors use in pregnancy Marlene P. patients range from mild to moderate and Freeman, MD, Massachusetts General play a role in sexual satisfaction, such as are influenced by symptom status and Hospital, described the limited, long-term gender expectations, religious beliefs, and duration of illness. Treating cognitive deficits data on tricyclics and fluoxetine. Some the influence of reporting in the media. Sexual begins with prevention. Cholinesterase studies have shown a small risk of birth dysfunction becomes worse in men after age inhibitors are not effective for improving defects with SSRIs; others did not find 29; in women, the rate of sexual dysfunction cognition in MDD. Antidepressants, including an association. For moderate or severe appears to be consistent across the lifespan. SSRIs, do not adequately treat cognitive depression, use antidepressants at the lowest Cardiovascular disease is a significant risk deficits,Roger S. McIntyre, MD, FRCPC, dosage and try non-medication options, factor for sexual dysfunction in men, but not University of Toronto, explained. in women. Sexual function and depression such as psychotherapy and complementary have a bidirectional relationship; sexual and alternative medicine. During the third dysfunction may be a symptom or cause of trimester, women may need a higher dosage Sponsors and supporters depression and antidepressants may affect to maintain therapeutic drug levels. Data desire and function. Medications, including indicates that folic acid use during pregnancy • American Professional Agency, Inc. psychotropics, oral contraceptives, and is associated with a decreased risk of autism • AstraZeneca and schizophrenia. opioids, can cause sexual dysfunction. • Banner Health James W. Jefferson, MD, University of Providers often are reluctant to bring up • Bassett Healthcare Network Wisconsin School of Medicine and Public sexual issues with their patients, Dr. Clayton • Civilian Corps U.S. Army Medical Health, recommends ruling out medical says, but patients often want to talk about Command conditions, such as cancer, that might be their sexual problems. In reproductive-age causing your patients’ fatigue or depression. • Global Medical Education/ women, look for hypoactive sexual desire Many medications, including over-the- HealthmattersCME disorder and pain. In men, assess for erectile counter agents and supplements, can cause • LLW-Wolters Kluwer dysfunction or premature ejaculation. Inquire fatigue. Bupropion was more effective than • Mercy Memorial Hospital System about every phase of the sexual response placebo and SSRIs in treating depressed cycle. When managing sexual dysfunction, • Otsuka patients with sleepiness and fatigue. Adding aim to minimize contributing factors such as • Professional Risk Management a psychostimulant to an SSRI does not have illness or medication, consider FDA-approved Services, Inc. (PRMS) a significantly better effect than placebo on medications, encourage a healthy lifestyle, • Sparrow Health System depressive symptoms. Adjunctive modafanil may improve depression and fatigue. Data for • Sunovion Pharmaceuticals Inc. agonists are limited. • Takeda Pharmaceuticals USA, Inc. & Lundbeck Lithium should be used with caution in pregnant women because of the risk of • Valant Medical Solutions congenital malformations. Dr. Freeman also discussed the potential risks to the The meeting organizers acknowledge fetus with the mother’s use of valproate the support provided by the sponsors. and lamotrigine (with the latter, a small Determination of educational content for increase in oral clefting). High-potency typical this program and the selection of speakers antipsychotics are considered safe; low- are responsibilities of the program director potency drugs have a higher risk of major and co-directors. Sponsors and supporters malformations. For atypicals, the risk of did not have input in these areas. malformations appears minimal; newborns