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PTSD: Suppressing unwanted memories reduces their unconscious influence on behavior

3/30/2014

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SOURCE: Medical News Today 
March 19, 2014 | University of Cambridge

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Researchers part-funded by the Medical Research Council (MRC) have shown that, contrary to what was previously assumed, suppressing unwanted memories reduces their unconscious influences on subsequent behaviour, and have shed light on how this process happens in the brain.

The study, published online in PNAS, challenges the idea that suppressed memories remain fully preserved in the brain's unconscious, allowing them to be inadvertently expressed in someone's behaviour. The results of the study suggest instead that the act of suppressing intrusive memories helps to disrupt traces of the memories in the parts of the brain responsible for sensory processing.

The team at the MRC Cognition and Brain Sciences Unit and the University of Cambridge's Behavioural and Clinical Neuroscience Institute (BCNI) have examined how suppression affects a memory's unconscious influences in an experiment that focused on suppression of visual memories, as intrusive unwanted memories are often visual in nature.

After a trauma, most people report intrusive memories or images, and people will often try to push these intrusions from their mind, as a way to cope. Importantly, the frequency of intrusive memories decreases over time for most people. It is critical to understand how the healthy brain reduces these intrusions and prevents unwanted images from entering consciousness, so that researchers can better understand how these mechanisms may go awry in conditions such as post-traumatic stress disorder.

Participants were asked to learn a set of word-picture pairs so that, when presented with the word as a reminder, an image of the object would spring to mind. After learning these pairs, brain activity was recorded using functional magnetic resonance imaging (fMRI) while participants either thought of the object image when given its reminder word, or instead tried to stop the memory of the picture from entering their mind.

The researchers studied whether suppressing visual memories had altered people's ability to see the content of those memories when they re-encountered it again in their visual worlds. Without asking participants to consciously remember, they simply asked people to identify very briefly displayed objects that were made difficult to see by visual distortion. In general, under these conditions, people are better at identifying objects they have seen recently, even if they do not remember seeing the object before - an unconscious influence of memory. Strikingly, they found that suppressing visual memories made it harder for people to later see the suppressed object compared to other recently seen objects.

Brain imaging showed that people's difficulty seeing the suppressed object arose because suppressing the memory from conscious awareness in the earlier memory suppression phase had inhibited activity in visual areas of the brain, disrupting visual memories that usually help people to see better. In essence, suppressing something from the mind's eye had made it harder to see in the world, because visual memories and seeing rely on the same brain areas: out of mind, out of sight.

Over the last decade, research has shown that suppressing unwanted memories reduces people's ability to consciously remember the experiences. The researchers' studies on memory suppression have been inspired, in part, by trying to understand how people adapt memory after psychological trauma. Although this may work as a coping mechanism to help people adapt to the trauma, there is the possibility that if the memory traces were able to exert an influence on unconscious behavior, they could potentially exacerbate mental health problems. The idea that suppression leaves unconscious memories that undermine mental health has been influential for over a century, beginning with Sigmund Freud.

These findings challenge the assumption that, even when supressed, a memory remains fully intact, which can then be expressed unconsciously. Moreover, this discovery pinpoints the neurobiological mechanisms underlying how this suppression process happens, and could inform further research on uncontrolled 'intrusive memories', a classic characteristic of post-traumatic stress disorder.

Dr Michael Anderson, at the MRC Cognition and Brain Sciences Unit said: "While there has been a lot of research looking at how suppression affects conscious memory, few studies have examined the influence this process might have on unconscious expressions of memory in behaviour and thought. Surprisingly, the effects of suppression are not limited to conscious memory. Indeed, it is now clear, that the influence of suppression extends beyond areas of the brain associated with conscious memory, affecting perceptual traces that can influence us unconsciously. This may contribute to making unwanted visual memories less intrusive over time, and perhaps less vivid and detailed."

Dr Pierre Gagnepain, lead author at INSERM in France said: "Our memories can be slippery and hard to pin down. Out of hand and uncontrolled, their remembrance can haunt us and cause psychological troubles, as we see in PTSD. We were interested whether the brain can genuinely suppress memories in healthy participants, even at the most unconscious level, and how it might achieve this. The answer is that it can, though not all people were equally good at this. The better understanding of the neural mechanisms underlying this process arising from this study may help to better explain differences in how well people adapt to intrusive memories after a trauma."

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Beyond the Brain is now on Google+

3/29/2014

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Follow the Beyond the Brain Blog from the comfort of your own Google+ page. 

>> Check out the BTB page HERE
>> Share the page with our button on the side of the page (next to our "like" button)
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CME/CE: Recent Advances in the Management of Binge Eating Disorder

3/29/2014

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Source: MedScape Education
Authors: Cynthia M. Bulik, PhD; Paul E. Keck Jr, MD; Susan L. McElroy, MD; Charles P. Vega, MD, FAAFP
Release Date: March 26, 2014
Expiration Date: March 26, 2015
CME/CE Credit: 1 Credit

>> Go HERE for the activity

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A SNAPSHOT...

The American Psychiatric Association (APA) recognized binge eating disorder (BED) as a distinct eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

The hallmark clinical feature of BED is recurrent binge eating. First recognized in 1959 by Stunkard in a subset of obese individuals, binge eating is defined as "eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances."What distinguishes binge eating from regular overeating is the sense of lack of control during the episode, which can manifest as feeling that one cannot stop eating once one has started or cannot control how much one is eating. BED is distinct from bulimia nervosa insofar as individuals diagnosed with BED do not experience recurrent inappropriate compensatory behaviors such as self-induced vomiting, laxative abuse, or excessive exercise.

In the DSM-5 BED criteria, binge eating must occur, on average, once a week for 3 months. This is a significant departure from the DSM-IV criteria, which required an average of 2 episodes of binge eating per week for 6 months, and brings the frequency and duration criteria for BED in line with those for bulimia nervosa.

In addition to the core behavioral feature of binge eating, to meet diagnostic criteria for BED the binge eating must lead to marked distress and be characterized by 3 or more of the following features: rapid eating, eating until uncomfortably full, binge eating when not hungry, eating alone due to embarrassment, and feeling disgusted, depressed, or guilty after eating. It is noteworthy that these additional features are not required for the diagnosis of bulimia nervosa.

Unlike anorexia nervosa and bulimia nervosa, there are no diagnostic criteria for BED related to body image or the influence of weight and shape on self-evaluation. Although many individuals with BED suffer from poor body image, it is not required for a diagnosis. Moreover, there is no body mass index (BMI) criterion for BED. It is important to note that BED can occur in individuals of any BMI but is commonly associated with overweight or obesity.

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Eating disorders continue to carry considerable shame and stigma. Many individuals suffer with BED for decades without divulging their symptoms to their health care providers, and many remain unaware that their dysregulated eating is a recognized, treatable syndrome. Two important challenges are spreading awareness of the nature and treatability of the disorder and reducing the stigma and shame related to it. Individuals who are overweight or obese are stigmatized throughout the world, even within the medical profession, and overweight or obese individuals with a diagnosis of BED bear a double stigma. Understanding that the causes of BED are multifold and include both genetic and environmental factors may assist in the recognition that BED is an illness, not a choice.


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Stress Can Quickly Harm Kids' Health: Study

3/28/2014

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SOURCE: HealthDay News
March 14th, 2014 | Robert Preidt

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Stressful events can have an almost immediate impact on children's health and well-being, a new study finds.

Previous research has shown that stressful events in childhood increase an adult's risk of health problems, but this study shows that these consequences may occur much sooner.

University of Florida researchers analyzed data from nearly 96,000 children across the United States who took part in the National Survey for Child Health. The survey collected information about the children's health and stressful situations they faced, such as their parents divorcing, domestic and neighborhood violence, being poor, a parent with mental health problems, exposure to drug abuse, and a parent in jail.

Children who experienced three or more stressful events were six times more likely to have physical or mental health problems or a learning disorder than those who had no stressful experiences, the investigators found.

"The kids who have the highest number of adverse experiences have the highest likelihood of having multiple conditions. It is not one poor health outcome; it is a whole slew of poor outcomes across the board," study author Melissa Bright, a research coordinator at the University of Florida's Institute of Child Health Policy, said in a university news release.

She presented her findings this week at the annual meeting of the American Psychosomatic Society, in San Francisco.

Chronic stress can trigger changes in a child's developing neuroendocrine and immune systems that lead to poor control of the stress response and a reduced ability to resist disease, the researchers said.

If this is the case, it may be possible to identify these changes early on and treat them, in order to reduce the risk of health problems, Bright suggested.

"It is also possible that having a child with multiple health conditions puts serious financial and emotional strains on families, making them more susceptible to adverse experiences such as caregiver mental illness and divorce," Bright said. "We are currently collecting data for a new study in which we plan to examine this possibility."

Research presented at medical meetings should be considered preliminary until it has been published in a peer-reviewed journal.

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First LSD Study In 40 Years Shows Promising Medical Uses

3/23/2014

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SOURCE: Huffington Post
March 6, 2014 | Emily Thomas

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After a decades-long pause on LSD medical research, the results of the first LSD study approved by the U.S. Food and Drug Administration in 40 years have put the drug's potential medical benefits back in the spotlight.

Picking up where the medical community left off in the '60s, scientists recently investigated the effects of LSD-assisted therapy on 12 terminally ill patients approaching death. The findings of this controlled study, published Tuesday in the peer-reviewed Journal of Nervous and Mental Disease, showed that LSD paired with psychotherapy alleviated end-of-life anxiety in patients suffering from terminal illnesses.

Conducted in Switzerland, where scientist Albert Hoffman first synthesized LSD in 1938, the study separated the 12 patients into two groups that underwent two preparatory therapy sessions before being administered LSD. For the trial, patients stopped taking any anti-anxiety or antidepressant medications and avoided alcohol for 24 hours prior to the study. One group was administered 200 micrograms of LSD and the other group 20 micrograms (a barely noticeable dosing). Each individual underwent two dosing sessions separated by a few weeks and were assisted by therapists, who walked them through their experiences with the psychedelic's effects. No prolonged negative effects of the drug were reported.

The low-dosage group reported that their anxiety got worse, while the higher-dosage group said their drug-therapy sessions had profound positive effects on their anxiety -- a clinical indication that psychedelic therapy may have potential as a medical treatment. In follow-up sessions, patients reported their reduced anxiety levels were maintained.

“People are more scared of dying than they are of using drugs. That’s why we were able to start LSD research with people who were anxious about dying, that and the combination of Albert Hoffman and good contacts with the Swiss equivalent of the FDA,” Rick Doblin, founder of the Multidisciplinary Association for Psychedelic Studies, which largely funded the study, told The Huffington Post over the phone.


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Over Half of Veterans Given Opioids Become Chronic Users

3/22/2014

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SOURCE: MPR
March 06, 2014

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More than half of all veterans who are prescribed opioids continue to use them chronically or beyond 90 days, according to research presented at the recent American Academy of Pain Medicine Annual Meeting.

Mark Sullivan, MD, PhD, from the University of Washington, and colleagues analyzed 959,226 patient records from the national Veterans Healthcare Administration (VHA) database. Inclusion criteria was at least 2 outpatient visits at a VHA facility in 2009 and at least 90 days of opioid use within a 180-day time frame. Termination of opioid use was considered to be at least 6 months of no opioid use. Data showed 52.4% of veterans used opioids for more than 90 days and were more likely to suffer from post-traumatic stress disorder, use tobacco products, be married, have multiple chronic pain conditions, combine multiple opioids, and consume doses >100mg/day.

With the exception of tobacco use, this study found that mental health and substance use disorders were associated with increased rates of opioid discontinuation. This contradicts previous research that pointed to these disorders as factors in increased opioid use.

The authors hope that these predictors of chronic opioid abuse will contribute to understanding the role of abuse problems in returning veterans.

>> Click HERE to get a table of Opioids with Abuse Deterrent Properties 
>> For more information visit the American Academy Pain Medicine website
>> Read More:  VA’s opiate overload feeds veterans’ addictions, overdose deaths
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Research Review for March 2014

3/20/2014

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SOURCE: Global Medical Education
Guest Commentary by W. Vaughn McCall, MD

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GME Research Review is a monthly newsletter where internationally recognized experts select, summarize, and provide a clinical commentary on the latest published research in psychiatry. Each summary has been derived from the relevant article’s abstract and the clinical commentary has been provided by our expert. 

REVIEW INCLUDES:
  • Gabapentin Treatment for Alcohol Dependence: A Randomized Clinical Trial
  • The Natural History of Insomnia: Acute Insomnia and First-Onset Depression
  • Rapid Antidepressant Effects of Repeated Doses of Ketamine Compared With Electroconvulsive Therapy in Hospitalized Patients with Major Depressive Disorder
  • Electroconvulsive Therapy-induced Brain Plasticity Determines Therapeutic Outcome in Mood Disorders
  • Addressing Risks to Advance Mental Health Research

Gabapentin Treatment for Alcohol Dependence: A Randomized Clinical Trial
Mason BJ, Quello S, Goodell V, et al. JAMA Intern Med. 2014;174(1):70-77.

Objective
To determine if gabapentin, a widely prescribed generic calcium channel/γ-aminobutyric acid-modulating medication, increases rates of sustained abstinence and no heavy drinking and decreases alcohol-related insomnia, dysphoria, and craving, in a dose-dependent manner.

Conclusions
Gabapentin (particularly the 1800-mg dosage) was effective in treating alcohol dependence and relapse-related symptoms of insomnia, dysphoria, and craving, with a favorable safety profile. Increased implementation of pharmacological treatment of alcohol dependence in primary care may be a major benefit of gabapentin as a treatment option for alcohol dependence.

Clinical Commentary
Insomnia is a common symptom during abstinence in alcohol dependence, occurring in up to 50% of patients, and lasting for weeks or months into the period of abstinence. Further, the presence of insomnia during abstinence is a major risk factor for alcoholic relapse. Not surprisingly, clinicians are reluctant to use controlled substances such as hypnotics to address insomnia during abstinence. The present study is a larger replication/confirmation of prior work showing that moderate-dosed gabapentin improves sleep, reduces craving for alcohol, and extends the period of sobriety. This study adds to the accumulating evidence that gabapentin should be an early consideration in addressing insomnia among those with alcohol dependence.

The Natural History of Insomnia: Acute Insomnia and First-Onset Depression
Ellis JG, Perlis ML, Bastien CH, et al. Sleep. 2014;37(1):97-106.

Objective
While many studies have examined the association between insomnia and depression, no studies have evaluated these associations within a narrow time frame, with specific reference to acute and chronic insomnia, and using polysomnography. In the present study, the association between insomnia and first-onset depression was evaluated taking into account these considerations. 

Conclusion
The transition from acute to chronic insomnia is presaged by baseline differences in sleep architecture that have, in the past, been ascribed to major depression, either as heritable traits or as acquired traits from prior episodes of depression. The present findings suggest that the “sleep architecture stigmata” of depression may actually develop over the course transitioning from acute to chronic insomnia.

Clinical Commentary 
Research in the relationship between sleep and depression has revealed two strong findings, one of them a laboratory finding, the other a clinical finding. Forty years ago we received the first reports that a short latency to REM sleep was more commonly seen in depression than in normals. Over the last 20 years has come the discovery that insomnia is a risk factor for new-onset depression in persons who were never before mentally ill. These two relationships converge in this report by Ellis et al., who now report that persons with acute insomnia are more likely to progress to chronic insomnia if they have a short REM latency, and secondly that of those who do transition to chronic insomnia, a short REM latency is predictive of incident depression. The importance of this paper is the discovery that the polysomnographic marker of depression (short REM latency) actually precedes the onset of depressive illness.

Rapid Antidepressant Effects of Repeated Doses of Ketamine Compared With Electroconvulsive Therapy in Hospitalized Patients with Major Depressive Disorder
Ghasemi M, Kazemi MH, Yoosefi A, et al. Psychiatry Res. 2013 Dec 13. pii: S0165-1781(13)00771-3. doi: 10.1016/j.psychres.2013.12.008. 
 
Objective
Accumulating evidence suggests that N-methyl-d-aspartate receptor (NMDAR) antagonists (e.g. ketamine) may exert rapid antidepressant effects in MDD patients. In the present study, we evaluated the rapid antidepressant effects of  ketamine compared with the electroconvulsive therapy (ECT) in hospitalized patients with MDD.

Conclusion

This study showed that ketamine is as effective as ECT in improving depressive symptoms in MDD patients and have more rapid antidepressant effects compared with the ECT.

Clinical Commentary 
This study builds upon previous work showing that slow infusion of ketamine over 45 minutes is an effective antidepressant. However, the provocative aspect of this paper is the notion that, compared with ECT, ketamine has a superior antidepressant effect over one week of treatment with ketamine versus ECT, and that ketamine keeps the upper hand for the week which follows one week of treatment. This work is exciting, but there are several reasons to not over-interpret the meaning of the data. First, the study was small (N=9 per group), and hence warrants replication with a larger group. Second, one week of ECT treatment would never be construed as a full course of ECT.  So, while ketamine may perhaps work faster over the first week, it is still possible, perhaps even likely, that ECT has a more complete or durable antidepressant result as compared with ketamine. Indeed, some experts have postulated that antidepressants with the fastest treatment effect ( think about sleep deprivation) also have the fastest decay of therapeutic action.

Electroconvulsive Therapy-induced Brain Plasticity Determines Therapeutic Outcome in Mood Disorders
Dukart J, Regen F, Kherif F, et al. Proc Natl Acad Sci U S A. 2013 Dec 30.

Objective
There remains much scientific, clinical, and ethical controversy concerning the use of electroconvulsive therapy (ECT) for psychiatric disorders. This stems from a lack of information and knowledge about how such treatment might work, given its nonspecific and spatially unfocused nature. The mode of action of ECT has even been ascribed to as a "barbaric" form of placebo effect.

Conclusions
Our unique evidence shows that electrophysical therapeutic effects, although applied generally, take on regional significance through interactions with brain pathophysiology.

Clinical Commentary  
This fascinating paper on the topic of right unilateral (RUL) ECT-related changes in MRI-determined brain gray matter volumes (GMV) is encumbered by a relatively small sample size (5 bipolar patients and 5 unipolar depressives) and a complicated statistical analytic approach. Still, the results intriguingly show that RUL ECT is associated with regional changes in GMV only in the right hemisphere, and these manifest as increased GMV in the hippocampal complex, and decreases in GMV in the middle and inferior frontal cortex. The importance of these findings is that it further elaborates the idea that ECT promotes neuroplasticity with a regionally-differentiated effect. Whether the strict localization of the neuroplasticity findings to the right hemisphere is a function of RUL ECT is unknown, and in the future it would be interesting to contrast the investigative method in patients allocated to RUL versus bilateral ECT.

Addressing Risks to Advance Mental Health Research
Iltis AS, Misra S, Dunn LB, et al. JAMA Psychiatry. 2013;70(12):1363-1371. doi: 10.1001/jamapsychiatry.2013.2105.

Objective
Communication and management are essential to the ethical conduct of research, yet addressing risks may be time consuming for investigators and institutional review boards may reject study designs that seem too risky. This can discourage needed research, particularly in higher-risk protocols or those enrolling potentially vulnerable individuals, such as those with some level of suicidality. Improved mechanisms for addressing research risks may facilitate much needed psychiatric research. We endeavor to provide mental health researchers with practical approaches to (1) identify and define various intrinsic research risks, (2) communicate these risks to others (eg, potential participants, regulatory bodies, and society), (3) manage these risks during the course of a study, and (4) justify the risks.

Conclusions
Empirical data on risk communication, managing risks, and the benefits of research can support the ethical conduct of mental health research and may help investigators better conceptualize and confront risks and to gain institutional review board-approval.

Clinical Commentary 
Both pharmaceutical companies and institutional review boards (IRBs) are risk adverse…. No one wants a serious adverse event, a death, a complaint, or litigation “on their watch.” As a result, only a small proportion of clinical trials in psychiatry include patients with active suicidality, catatonia (or other forms if incapacity), or life-threatening medical illness. While the NIH and medical foundations may be somewhat more willing to support high-risk projects, IRBs are still reluctant to approve such projects. This tendency inadvertently leads to an injustice such that very little science is available to guide the clinical care of our most vulnerable populations. It is reminiscent of our past in which clinical trials and other medical science ignored women and minorities, leading to the NIH insistence of inclusiveness. In this paper, Iltis et al. describe a series of processes that investigators and IRBs can use to include psychiatric populations of great interest who have been previously excluded. 
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Clinical Update: Use of Methylphenidate During Pregnancy

3/20/2014

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SOURCE: MGH Center for Women's Mental Health
March 19th 2014 | Ruta Nonacs, MD PhD
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For women with mild to moderate attention-deficit/hyperactivity disorder (ADHD) symptoms, we frequently recommend discontinuing medication and switching to a non-pharmacological intervention.  Although these women might experience some decrease in their level of functioning, they typically are able to forgo pharmacological treatment and do quite well.  However, there are other women with more severe symptoms which interfere significantly with their daily functioning and may potentially affect their pregnancy.  In these women, we may consider maintaining pharmacological treatment.

Methylphenidate, the active ingredient in Ritalin and Concerta, is commonly used to treat ADHD. We now have several reports assessing its reproductive safety.

The most recent study comes from Denmark, where there was no statistically significant difference between the two groups (methylphenidate-exposed and unexposed) in terms of risk for major malformations or cardiac malformations.

In another report, four of 180 (2.2%) children exposed to methylphenidate had major malformations, which is similar to the rate of 2-4% observed in the general population; thus it appears that exposure during pregnancy does not appear to be associated with a substantially increased risk of congenital malformations.

While these two reports are reassuring with regard to the risk of malformations, they did not include information on other outcomes, such as gestational age or birth weight. In a small study, methylphenidate use during pregnancy was associated with increased risk of premature birth, growth retardation and neonatal withdrawal symptoms (Debooy 1993). Unfortunately, this study included only 38 participants and was further confounded by the fact that these women were abusing methylphenidate and may have also used nicotine, alcohol and other drugs during their pregnancy.

Based on the two studies we have, the available data for methylphenidate suggest no increase in the risk of malformation when used at therapeutic doses; however, these infants may be at increased risk for low birth weight or preterm birth.It is likely that these adverse outcomes are more of a risk in women taking very high, as opposed to therapeutic, doses of stimulant, but further study is required to determine the risk of these outcomes in women taking therapeutic doses of stimulants.

References
  • Debooy VD, Seshia MM, Tenenbein M, Casiro OG.  Intravenous pentazocine and methylphenidate abuse during pregnancy. Maternal lifestyle and infant outcome.<http://www.ncbi.nlm.nih.gov/pubmed/7692723>  Am J Dis Child. 1993 Oct;147(10):1062-5.
  • Dideriksen D, Pottegård A, Hallas J, Aagaard L, Damkier P.  First trimester in utero exposure to methylphenidate.<http://www.ncbi.nlm.nih.gov/pubmed/23136875>  Basic Clin Pharmacol Toxicol. 2013 Feb;112(2):73-6.
  • Pottegård A, Hallas J, Andersen JT, et al. First-trimester exposure to methylphenidate: a population-based cohort study.<http://www.ncbi.nlm.nih.gov/pubmed/24502866>  J Clin Psychiatry. 2014 Jan;75(1):e88-93.


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Doctor: ADHD Does Not Exist

3/19/2014

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SOURCE: Time Magazine
March 14, 2014 | Dr. Richard Saul

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Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Raising a generation of children — and now adults — who can't live without stimulants is no solution

This Wednesday, an article in the New York Times reported that from 2008 to 2012 the number of adults taking medications for ADHD increased by 53% and that among young American adults, it nearly doubled. While this is a staggering statistic and points to younger generations becoming frequently reliant on stimulants, frankly, I’m not too surprised. Over my 50-year career in behavioral neurology and treating patients with ADHD, it has been in the past decade that I have seen these diagnoses truly skyrocket. Every day my colleagues and I see more and more people coming in claiming they have trouble paying attention at school or work and diagnosing themselves with ADHD.

And why shouldn’t they?

If someone finds it difficult to pay attention or feels somewhat hyperactive, attention-deficit/hyperactivity disorder has those symptoms right there in its name. It’s an easy catchall phrase that saves time for doctors to boot. But can we really lump all these people together? What if there are other things causing people to feel distracted? I don’t deny that we, as a population, are more distracted today than we ever were before. And I don’t deny that some of these patients who are distracted and impulsive need help. What I do deny is the generally accepted definition of ADHD, which is long overdue for an update. In short, I’ve come to believe based on decades of treating patients that ADHD — as currently defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and as understood in the public imagination — does not exist.


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A Kind Word

3/15/2014

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I realized that it has been some time since I've posted about myself or my recent experiences as a new-ish Psychiatric NP.  So, I've decided to change that. This a blog after all. 
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How Others Feel Like I Am Doing
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How I Feel Like I'm Doing
Most days, I can handle what comes my way. I may not have all the answers but I am able to hold my own, making sound treatment choices for my clients. 

I have my strengths after all. Psychotherapeutic practices have always come fairly easily to me. I can typically get a sense of where someone is at emotionally, validate their current state, and start to work with them on building their coping skills without much hesitation. My experience as an educator has proven itself invaluable every day - everything from making accessible handouts to teaching symptom management skills. 

I also have my 'areas of opportunity' (which sounds nicer than weaknesses). My memory is a constant issue for me. It has always been problematic, but now its come to the fore. I have trouble recalling titration schedules, client's faces, etc... So, I do what I can. I create grids, I keep a PDF copy of Stahl's book open on my computer's desktop, I checkout the photocopy of their license right before I head to the waiting area, and frequently, I ask others for help. It is such a blessing to have found a workplace where the staff is not only friendly, but supportive. 
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I recently had my first 6 month evaluation and it was... wonderful! The head of my department is an approachable person who 'shoots from the hip'. I trust that she is upfront with me about areas I might improve my practice, and expected to hear quite a bit of that during our chat. But, instead I was left nearly speechless, bowled over by her overwhelmingly positive comments, each with specific examples. Truth be told, I hadn't even realized anyone was paying attention. Providers in our department are fairly independent, each with their own office and caseload. My work easily could have gone unnoticed... and didn't.  
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The positive feedback hasn't stopped there. I have had other providers and staff say supportive things casually in conversation about my performance or approach since that time. I literally had a fellow provider tell me she was happy I was working in the office. 

This all serves as a reminder that a single kind word or some positive feedback can go a long way to provide encouragement to my peers and to my clients.
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ADHD: Neurodevelopmental Disorder Through the Ages

3/15/2014

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SOURCE: Brain & Behavior Research Foundation
March 11, 2014 | Rachel Klein, PhD


ppwt_adhd-neurodevelopment.pdf
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Beyond the Brain Blog is Now on Facebook

3/15/2014

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Beyond the Brain is now on Facebook. 

>> Check us out HERE
>> "Like" us using the widget right on our blog page! 
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Fingers Crossed

3/15/2014

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I have submitted my application for the National Health Service Corps' Loan Repayment Program. Here is hoping they take pity on me and my monthly "brain mortgage".  
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Venlafaxine and Desvenlafaxine: Differences and Similarities

3/14/2014

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SOURCE: Psychopharmacology Institute (with additional videos)
Flavio Guzman, MD

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Venlafaxine (Effexor) is an SNRI that is metabolized to O-desmethylvenlafaxine or desvenlafaxine. In 2008, this active metabolite was approved as antidepressant (Pristiq).

Summary points:
  • They are similar in terms of efficacy, pharmacodynamics and side effects profile.
  • There are differences in pharmacokinetic aspects and dosing guidelines.
Included below:
  • Mechanism of Action and Pharmacodynamics
  • Indications
  • Pharmacokinetics
  • Adverse Effects & Tolerability
  • Dosing

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Drugs in Context: Takeda's and Lundbeck’s Brintellix

3/12/2014

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SOURCE: Formulary Watch
January 9th, 2014 | Vy P. Pham, PharmD and Adriana Alvidrez, PharmD, BCPS

>>> Join the conversation about Brintellix HERE

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Introduction
Major depressive disorder (MDD) is a medical illness that is characterized by depressed mood, hopelessness, and loss of interest. According to the National Institute of Mental Health (NIMH), approximately 6.7% of US adult population experienced MDD, with 30.4% of these cases (2.0% of US adult population) classified as severe.

The novel antidepressant agent vortioxetine (Brintellix) is comarketed by Takeda Pharmaceuticals and Lundbeck and was FDA approved for the treatment of MDD in adult patients earlier September. The exact mechanism of vortioxetine is not fully understood; however, it is thought that this agent enhances the serotonergic activity in the central nervous system (CNS) by inhibiting the reuptake of serotonin (5-HT). 

In addition, vortioxetine has other activities such as 5-HT3 receptor antagonism and 5-HT1A agonism. Thus, vortioxetine is the only compound that exhibits multimodal actions within the selective serotonin reuptake inhibitor drug class. This agent does carry a black-boxed warning cautioning physicians and patients that selective serotonin reuptake inhibitors (SSRIs) can increase the risk of suicidal ideations and behavior in children, adolescents and young adults between aged 18 and 24 years.

Relevance
Despite several antidepressants available in the market, there is a necessity for new treatment options, as treatment response to depression is heterogeneous. Vortioxetine provides benefits to patients who have failed first-line therapy, as it is the first and only compound within its drug class to have multiple pharmacodynamic activities.

The safety and efficacy of vortioxetine was evaluated in six 6- to 8-week randomized, double-blind, placebo-controlled, fixed-dose clinical studies in adults (aged 18 to 75 years), including 1 study in the elderly population (aged 64 to 88 years) and 1 maintenance study in inpatient and outpatient adults who met the criteria for MDD in accordance with the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-TR).5-7 These clinical trials also demonstrated that in patients taking vortioxetine, the likelihood of becoming clinically depressed after successful treatment for a previous episode was decreased. 

The recommended initial dose is 10 mg administered orally daily with or without food; if tolerated, increase dose to 20 mg per day. The safety and efficacy of doses greater than 20 mg/day have not been studied in controlled clinical trials. In patients who do not tolerate higher doses, it is recommended that the dose be reduced to 5 mg/day.

Impact on patient subpopulation
Patients with MDD have limited normal functioning capabilities due to the emotional, cognitive and physical symptoms associated with the complex illness. According to the World Health Organization (WHO), approximately 350 million people of all ages are affected by depression. Fewer than half of those affected by depression receive treatment; however, discontinuation of antidepressants are common.

There are no robust findings to establish a clinically significant difference between mechanisms of action of antidepressants, as there are currently no head-to-head clinical trials comparing vortioxetine to other SSRIs. In majority of patients, the efficacy is generally comparable between classes or within classes of antidepressants. Therefore, initial selection of antidepressants is primarily based on safety, tolerability and cost of the medication, patient preference, and history of prior medication therapy.

Vortioxetine may have positive impact on this patient population since it provides another treatment option for patients with MDD. This is increasingly important since MDD is a heterogeneous disorder that does not consistently respond to treatment. Due to the medication’s recent introduction into the market, vortioxetine is not available generically; however, the other SSRIs are. Consequently, the costs associated with this agent compared to the older SSRIs are substantial.


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