SOURCE: Parenting Magazine
By Sunday Stilwell 

Don’t get me wrong; my boys certainly bring out the “extreme” in parenting. However, when I talk with my friends who are raising neuro-typical (NT) children and I listen to their many frustrations in raising them, I have noticed a number of difficulties we do not share. In fact, I have a much easier time of parenting the Trouble Brothers because they don’t engage in many of the “normal” behaviors of their NT peers.

No Whining. 
My boys do not whine. Ever. They may scream loudly like wild banshees at times when their developmental limitations prevent them from using words to express their dissatisfaction with something but they never resort to that incessant nails-on-the-chalkbo​ard whine that lasts hours and leaves a mother white-knuckling it through the day.

Lack of Sibling Rivalry.
Growing up with two sisters I remember the antics we used to pull that left our mom wanting to sell us to the gypsies. Every trip in the car, grocery store visit, and family photography was laden with the whines of, “MOOOOMMMMM, Caryn poked me!”, “MOOOOMMMM, Sunday touched my new Barbie and gave it cooties," “MOOOOOMMMMM, Molly picked her nose and touched my pillow!” Truly, I don’t know how any of us lived past the age of 10.

Thankfully, I have never had to experience this with my own children. My boys tend to steer clear of one another and will gladly enjoy their own books, videos, or toys independently from one another.

No Fashion Awareness.
“But MOMMMMM, everyone has more Silly Bandz than me!”, “I can’t wear THAT! All the kids will make fun of me if I don’t have such and such jeans!”, “I am NOT wearing anything that comes from Walmart, Mom!”

Thankfully the Trouble Brothers will never utter these words. Individuals with autism do not recognize the social desire to fit in and follow the crowd. They are their own crowd and they like it that way.

Lack of Greed and Competition. 
Thankfully my boys don’t spend Christmas morning counting who has more presents than the other. If money is a little tight and they only have one present on their birthday they are overjoyed with what they do have instead of being mad that there wasn’t more.

In fact, I can visit the local children’s consignment shop and buy a gently-used toy for a quarter of the price of a new one and they could care less. They are happy to have anything that is new…even if its only new to them. 

Not hearing “WHY???” Endlessly.
If there is one thing I am most thankful for in having children with autism it is that I never have to listen to barrage of whiny ad-nauseam "WHY?" questions. In general, individuals with autism do not tolerate not knowing what is coming next. This is why the question "Why?" makes them uncomfortable. The autistic mind prefers knowing the answer to a question before asking it. At the very least, they prefer a simple "yes" or "no" answer over the unknown that can follow the question, "Why?"

Routine. 
My kids have a very set routine to their day-to-day life. Their diets are boring and quite limited but those limitations also make meal times a snap. I know that as long as I have bread, cheese, and chocolate chip cookies in the house the boys are set for life. Noah has a definite addiction to Pepperidge Farm Goldfish Crackers but other than that my kids are easy-peasy eaters. I don’t have to listen to my kids whine and complain that they are having peanut butter and jelly AGAIN or that they want to try those expensive yogurt snacks all their friends have in their lunch.

Similarly, the boys love watching the same DVDs and episodes of "Dora the Explorer" or "Yo Gabba Gabba" over and over again. And while I do sometimes complain about watching Finding Nemo for the 1,342,893rd time I am happy knowing the same movie makes them laugh in all the same spots each time. It's simple and yet, beautiful.

I’ve never been a Pollyanna optimist but I am neither a cold-hearted pessimist. Instead I find myself being more of a realist, and reality dictates that when you raise children with autism, whether it is high-functioning Asperger's or a diagnosis of profound autism, it's imperative that you find the joy in the small things. Like the above. 

SOURCE: HealthDay News
April 4, 2014 | Robert Preidt

Poor sleep is tied to a higher risk of mental decline in older men, according to a new study.

It included more than 2,800 men, average age 76, in six locations across the United States. Sleep data was collected from the men through a wrist device for an average of five nights, and participants underwent tests to assess their attention and executive function.

Executive function includes planning, making decisions, correcting errors, troubleshooting and abstract thinking.

The researchers found that higher levels of poor sleep quality were associated with a 40 percent to 50 percent increased risk of significant decrease in executive function, similar in degree to the effect of a five-year increase in age. Length of sleep did not affect the men's mental skills, according to the study published in the April issue of Sleep.

"It was the quality of sleep that predicted future cognitive decline in this study, not the quantity," lead author Terri Blackwell, senior statistician at the California Pacific Medical Center Research Institute in San Francisco, said in a journal news release.

"With the rate of [mental] impairment increasing and the high prevalence of sleep problems in the elderly, it is important to determine prospective associations with sleep and cognitive decline," Blackwell added.

The study did not find a cause-and-effect relationship between poor sleep and mental decline in older men, just an association.

The mechanisms that link poor sleep to mental decline aren't known, and further research is needed to determine if this association remains after a longer follow-up period, the study authors said.

The U.S. National Heart, Lung, and Blood Institute provided study funding.

SOURCE: The Carlat Psychiatry Report

There’s nothing like a close friend suffering psychiatric difficulties to motivate a psychiatrist to do some serious reading. Recently, your humble editor encountered this situation.

The patient is a young woman with no psychiatric history who noted more than a normal amount of anxiety after the birth of her child. She found herself worrying constantly about her child’s welfare, which interfered with her already limited amount of sleep, leading to daytime fatigue and increasing demoralization. She sought formal psychiatric consultation, was prescribed Celexa and Ativan, and was given a fair amount of complicated information about risks vs. benefits of medication while breast-feeding.

Her dilemma (and the dilemma of the millions of women who suffer postpartum depression or anxiety every year) was that, on the one hand, she wanted to breast-feed, because of the well known benefits. These include bonding between mother and infant, some measure of protection against infections, and possibly some benefit in terms of the child’s cognitive development in subsequent years. On the other hand, she was concerned about the possible detrimental effects on her infant of exposure to medication.

So what should she do?

In making decisions about the safety of breast-feeding on psychiatric medication, we’ve come a long way since 1996, when the first critical review of antidepressants during breast-feeding was published in the American Journal of Psychiatry (1). At that time, only 15 published reports were located on the topic; the most recent review, in the same journal in 2001 (2), cited 44 such studies, and much important research has been reported since then.

Before reviewing these findings, here are two helpful pearls on newborn physiology. First, newborns metabolize drugs slowly, because their cytochrome P-450 activity is about half that of adults. This effect is even more pronounced in preterm babies, who are likely to be at much higher risk of toxic exposure if the mother is breast-feeding while taking medications. The good news is that after the first two months of life, a baby’s liver gets revved up, to the point that it can metabolize drugs two or three times faster than adults. So, all things being equal, it’s better for a new mother to wait a couple of months before beginning meds.A second point is that the infant blood-brain barrier is less mature than in adults, meaning that CNS meds tend to concentrate in the infant brain much more so than in the adult brain. This effect is amplified by the fact that infants have very little fat, and thus have fewer “parking places” for lipophilic drugs (which include all SSRIs) to hang out, other than the brain. Why is this especially relevant? Because even though breast-fed infants have miniscule blood levels of antidepressants, there may be higher levels hidden from the assay in the CNS.

With that as background, here are the most clinically relevant findings to have emerged over the past several years:

1. Unfortunately, it is now clearer than ever that any medication that mom ingests will find its way into breast milk, and thus, ultimately, into the baby. While this may seem obvious to many, it was not demonstrated for some SSRIs until quite recently.

2. Among the SSRIs, the amount of drug that has been quantified in infant serum has been exceedingly low, to the point of being undetectable. For example, one of the most rigorous studies was conducted by Stowe and colleagues who measured levels of Paxil in breast milk and in the serum of nurslings (3). Using high performance liquid chromotography, no paroxetine was detected in any of the 16 infants studied, meaning that their levels were less than 2 nanograms per ml. For those rusty on their chemistry, this means less than 2 millionths of a gram per mililiter. There have been similar findings for Celexa, Zoloft, and Luvox. The exception to this trend is Prozac, which, because of its long half-life and the long half-life of its metabolite, has been detected in significant quantities in infants. For example, one case reported nursling serum levels of 340 ng/ml of fluoxetine and 208 ng/ml of norfluoxetine—significantly higher than the levels documented in the mother’s breast milk.

3. Well documented adverse events in exposed infants have been exceedingly rare, with two exceptions: Prozac and doxepin. In the recent American Journal review (2), 10 of 190 fluoxetine-exposed babies showed adverse events such as irritability and colic vs. 0 of 93 infants exposed to other SSRIs (mostly Zoloft and Paxil). Of course, Prozac has been around the longest, and has been used the most in breast-feeding women, so this higher incidence of Prozac-related problems may be partly artifactual. On the plus side for Prozac, the only study to have looked at long-term outcome of exposed infants was done with Prozac, and found that 4 exposed infants were developmentally normal at 1 year of age (4).

4. Zoloft is the only antidepressant that shows a clear time course between ingestion and high peak levels in breast milk (5). This means that it makes sense for mothers to pump and discard a feeding 7-10 hours after their dose of Zoloft, when the breast milk level peaks. Doing this will reduce an infant’s overall exposure to medication by about 25%, assuming that feedings occur about every 3 hours.

5. There is almost no useful information available on benzodiazepine safety in breast-feeding. There has been one reported case of persistent cyanosis in an infant exposed to Klonipin (this infant was fine by day 10), and one case of lethargy and weight loss in a Valiumexposed infant. Small case series of exposure with shorter half-life benzodiazepines have not reported any adverse events, leading to the usual practice of choosing shorter-acting meds such as Ativan when anxiety needs treatment. But not too short-acting: one case of xanax withdrawal in an infant has been reported.

The upshot? All of the SSRI’s except for Prozac appear to be quite safe in breast-feeding. This is good news for mothers and their babies.

TCR VERDICT: SSRIs in Breastfeeding? Fine…except for Prozac!

References

• Wisner KL, Perel JM, and Findling RL: Antidepressant treatment during breast-feeding.Am J Psychiatry 1996; 153:1132-1137. 
• Burt VK, Suri R, Altshuler L: The use of psychotropic medications during breastfeeding. Am J Psychiatry 2001; 158:1001-1009
• Stowe ZN, Cohen LS, Hostetter A, et al: Paroxetine in human breast milk and nursing infants. Am J Psychiatry 2000; 157:185-189.
• Yoshida K, Smith B, Craggs M, et al: Fluoxetine in breast milk and developmental outcome of breastfed infants. Br J Psychiatry 1998; 172:175-178.
• Stowe ZN, Owens MJ, Landry JC, et al: Sertraline and desmethylsertraline in human breast milk and nursing infants. Am J Psychiatry 1997; 154:1255-1260.
  

SOURCE: DocGuide News
April 15, 2014 | Children’s National Health System

Researchers have identified head circumference and head tilting reflex as 2 reliable biomarkers in the identification of autism spectrum disorders (ASD) in children aged 9 to 12 months.

While a number of studies have reported that parents of children with ASD notice developmental problems in children before their first birthday, there has yet to be a screening tool to identify those children.

“While the ‘gold standard’ screening tool is the M-CHAT questionnaire, it must be read and completed by parents and then interpreted by a healthcare provider,” said lead author Carole A. Samango-Sprouse, George Washington University School of Medicine and Health Sciences, Washington, DC. “What physicians are missing is a quick and effective screening measure that can easily be given to all infants regardless of background and identify ASD before 12 months. This screening is also helpful in identifying those babies who may not initially appear to be at risk and would otherwise be missed until much later in life.”

The current study looked at the use of head circumference and head tilting reflex as 2 biomarkers that can be used during their well-baby visits by their primary care providers. Both screenings were given to nearly 1,000 patients at the 4-, 6-, and 9-month well-baby visits.

At the end of 9 months, those infants with a head circumference above or equal to the 75th percentile, a head circumference that was in 10% discrepancy with the height of the baby, or those who failed the head tilting reflex test were considered at risk for ASD or a developmental language delay. These infants were then evaluated by a neuro-develomental specialist and paediatric neurologist to differentiate between these disorders.

Of the 49 infants that displayed abnormal results, without previous diagnosis, 15 were identified at-risk for ASD and 34 at risk for developmental language delay. Of the 15 children who were identified at-risk for ASD between 9 and 12 months, 14 (93%) sustained the diagnosis when it was made clinically at age 3 years.

“We will continue looking at the efficacy of the head circumference and head tilting reflex as a screening tool for these disorders,” said Andrea Gropman, MD, Children’s National Healthy System, Washington, DC. “As with all developmental delays, especially ASD, the sooner we can identify those children who are at risk, the sooner we can intervene and provide appropriate treatment. In other words, the sooner we identify these delays, the better the outcome for those affected.”

A basic but helpful guide to mental health issues for more visual learners

SOURCE: New Hampshire Union Leader
April 16, 2014 | Mark Hayward

Anyone who goes to the gym on a regular basis knows the benefits of a routine workout.

You strengthen some muscles. You tighten up some of the flabby paunch. And after your blood's raced through your body like it's a NASCAR course, you leave sucking on a water jug spiked with a shot of accomplisment, a splash of optimism.
Now imagine if you suffered from depression, anxiety or another chronic mental illness. Wouldn't a trip to the gym render a similar beneficial jolt?

That's what a couple hundred mentally ill people in Manchester are experiencing, thanks to a statewide, experimental program that is getting them out of lonely apartments and into gyms. There they are pumping iron, running treadmills and getting tips on proper eating.

"It's changed my whole life, my whole outlook on things," said Mary Keeler, who is 68. Twenty-one months ago, she was 230 pounds and gaining. She took 13 medications, had no energy, and stayed home. 

Now she carries 176 pounds on her 5-foot, 7-inch frame, and her arm muscles slightly ripple as she curls a barbell at the Manchester YMCA.
Keeler has eliminated medications for cholesterol, blood pressure and sleeping pills, and significantly lowered some of the psychiatric medications she takes for depression, she said. "I feel liberated," she said.

The liberation comes from In Shape, a program that The Mental Health Center of Greater Manchester (more commonly known as Manchester Mental Health) provides to about 200 of its clients. It's part of a statewide, $10 million research project funded by the Center for Medicaid Services. If successful, In Shape could become an evidence-based service eligible for Medicaid payments countrywide, Snow said.

Participants get a twice-weekly trainer to guide them through an exercise routine and a 1-year free membership at a local gym.

Local gyms are supportive, and gym membership helps to break down community barriers for the mentally ill, said Ken Snow, a social worker and spokesman for Manchester Mental Health.

The need for In Shape is obvious, given some of the health problems that many mentally ill people cope with. Research has shown the life span from some mentally ill people is 30 years shorter than the general population, Snow said.

Some of that is due to preventable behaviors — smoking, diet, overeating. Other health problems come from the side effects of psychiatric medications, which include weight gain, loss of appetite and lethargy. Finally, there is the social isolation, stigma and poverty associated with mental illness.

Of course, they reinforce one another. The newspaper runs an article about a violent attack by a schizophrenic. The stigma forces someone inside, where he smokes and overeats. Then he gets depressed, so he takes more medication. The side effects worsen, so he stays inside. Lather, rinse, repeat.
But could something as simple as physical activity break such a cycle?

Snow cautioned that a workout regiment won't cure mental illness, but it could help reduce symptoms enough so a patient can live comfortably, he said.
Like Jessica Gaertner. She was 260 pounds before she enrolled 21 months ago. She ate, she said, because it felt good — frozen dinners, cookies, chips, ice cream. She felt stuck in her room at a group home, where she watched TV, stayed on the computer and slept.

Now she's 155 pounds. The 26-year-old attends the gym two or three times a week, and it's nothing for her to walk a couple of miles to the Mall of New Hampshire or Fresh Market in Bedford.

Her trainer, John Curtis, said Gaertner has avoided hospital stays because of the activity. "I didn't like the way I was. It was depressing, I was big," Gaertner said. "I'm happier now."

SOURCE: Journal of Psychopharmacology
April 2014, 28 (4)

Background: Ketamine has a rapid antidepressant effect in treatment-resistant depression (TRD). The effects on cognitive function of multiple ketamine infusions and of concurrent antidepressant medication on response rate and duration are not known.

Method: Twenty-eight patients with uni- or bipolar TRD were treated over three weeks with either three or six ketamine infusions (0.5 mg/kg over 40 minutes) in the recovery room of a routine ECT clinic. Post-treatment memory assessments were conducted on day 21 (4–7 days after the final infusion). Patients were followed up for six months where possible, with severity of depression and side effects monitored throughout.

Results: Eight (29%) patients responded of whom four remitted. Only three (11%) patients had responded within six hours after a single infusion, but in all responders, the response had developed before the third infusion. The duration of response from the final infusion was variable (median 70, range 25–168 days). Discontinuations included two (7%) because of acute adverse reactions during the infusion and five (18%) because of failure to benefit and increasing anxiety. Ketamine was not associated with memory impairment. The ECT clinic was rated suitable by patients and offered appropriate levels of monitoring.

Conclusion: This small, open label naturalistic study shows that up to six low dose ketamine infusions can safely be given within an existing NHS clinical structure to patients who continue their antidepressants. The response rate was comparable to that found in RCTs of single doses of ketamine in antidepressant-free patients but took slightly longer to develop.

SOURCE: HealthDay News
April 3, 2013 | Steven Reinberg

The number of calls to poison control centers for nicotine poisoning from e-cigarettes has risen dramatically in recent years, U.S. health officials reported Thursday.

Calls related to poisoning from the liquid nicotine used in these devices were running at a rate of roughly one a month in 2010, but jumped to 215 in February of this year, according to the U.S. Centers for Disease Control and Prevention. Even more troubling, more than half (51 percent) of the poison calls involved children aged 5 and younger, while 42 percent involved people aged 20 and older.

"The time has come to start thinking about what we can do to keep this from turning into an even worse public health problem," said Dr. Tim McAfee, director of the CDC's Office on Smoking and Health. He added that many people are not aware that liquid nicotine is toxic. "We need to make sure we can avert the possibility of an unintended death from nicotine poisoning," he said.

"We have not had an unintentional poisoning death from e-cigarettes yet in the United States that we know of, but the potential is there given the amount of concentrated nicotine in these solutions -- it would not take a lot for a child death to occur," McAfee noted. 

CDC director Dr. Tom Frieden noted in a news release that e-cigarettes are particularly attractive to kids because they come in candy and fruit flavors. Dr. Vincenzo Maniaci, an emergency medicine specialist at Miami Children's Hospital, agreed that the danger to children is real.

"The concentration of nicotine in these solutions is significant and they need to be made childproof and regulated," Maniaci said. "Especially for kids under the age of 5, this amount of nicotine can be fatal."

McAfee noted that the U.S. Food and Drug Administration is planning to propose regulations for e-cigarettes. He added that he hopes these regulations will include how the product is packaged, including childproof caps and warning labels. "These things can be hardwired into these products, rather than being left to the whim of the manufacturer," he said.

In the meantime, McAfee advised keeping these devices, and their refills, out of the reach of children. "These should be treated with the same caution one would use for bleach. In some ways, this is more toxic than bleach," he said.

Poisoning from the liquid nicotine in e-cigarettes can happen in one of three ways: by swallowing it; inhaling it; or absorbing it through the skin or membranes in the mouth and lips or eyes, McAfee said. 

Once it is in a person's system, nicotine can cause nausea, vomiting or seizures. If those symptoms are occurring, the patient will typically be told to go straight to the emergency room, said Amy Hanoian-Fontana, from the Connecticut Poison Control Center.

If there are no symptoms, then the patient will be told to stay home and the center will call again in a few hours to see how the patient is doing. If liquid nicotine was spilled on the skin, the person should wash his or her skin in lukewarm water for about 20 minutes, Hanoian-Fontana added.

"We want to know what happened, when it happened and if the person is having any effects from the liquid nicotine," she explained. "Then we are going to make a determination whether this is something we can keep at home, or if they are having severe symptoms we may recommend that they go into the emergency department. It's very case-based, depending on the situation."

McAfee noted that the nicotine poisoning problem may be even bigger than the CDC report indicates.

"All we are reporting is calls to poison control centers. There are many people who had an episode, but didn't call a poison control center. This report also doesn't include people who had such severe symptoms that they called 911 or went to an emergency room," he said.

The report is published in the April 4 issue of the CDC's Morbidity and Mortality Weekly Report. As part of the study, the researchers compared the monthly volume of calls to poison centers involving e-cigarettes and regular cigarettes. They found the proportion of e-cigarette-related calls jumped from 0.3 percent in September 2010 to 41.7 percent in February 2014.

"The remarkable thing about this is that e-cigarettes account for less than 2 percent of tobacco product sales," McAfee said. The number of calls per month about regular cigarettes did not increase during the same period. The most common way regular cigarettes cause a problem is when a child eats one, the researchers said.

That more than half the calls were about children is very concerning, said Dr. Robert Glatter, an emergency medicine physician at Lenox Hill Hospital in New York City.

"That's a warning for parents who use these products. They need to keep them locked in a secure place, and it argues for tamperproof caps on these liquid nicotine products to prevent kids from getting into them," he said. "These can be deadly -- the risks are real."

Yesterday was not the day to have a blackout... 

I typically leave all my messages for the end of the day because trying to handle them in between clients is frustrating for all involved. So, when my Tuesday was cut short by loss of power and the consequent loss of all access to electronic charts and medication histories, I was unable to muddle through and had to 'close up shop' leaving all my work for today. I have to admit that at the time,I felt the glee of a child having a snow day.

Problem was.. yesterday was the full moon. This always means an extra dose of chaos in the life anyone working in the public arena, from retail to schools to mental health. Therefore, I had an extra dose of "med issues" on top of the typical refill requests and such. That glee I felt... gone. I spent my day trying to finagle refills in the brief moments between appointments. And do not get me started on prior authorization issues. 

Its not that I am blowing my clients off or that I don't see their needs as urgent, but there are only so many hours in that day to dedicate to calling folks back. Sometimes, I have to put these things off till the next day. And I will call once - just once. If your voicemail isn't set up, I'm sorry, but that isn't my problem. I struggle to leave discreet but informative voice messages as we play phone tag. 

I really yearn for email. So neat and tidy - just sitting in the inbox waiting for my reply. So efficient... but we are quite a ways away from that technology where I am at. So phone tag it is. 

I've mostly caught up for today and only stayed a half an hour or so after I was supposed to leave. Not too bad for a full moon. 

As I sit and stare at a clipboard full of unanswered messages, I realize I could cut my appointments just a bit shorter and not frantically scramble at the end of the day.  But, when sitting in front of a distressed client, who trusts me enough to tell me their story, it can be really difficult to remember to be efficient. 

I guess I'll just have to chalk this up to a work in progress. 

SOURCE:  Wisconsin Association for Perinatal Care

A medication chart intended for clinicians who provide care to pregnant and postpartum women who may be suffering from depression

What are tricyclic antidepressants and how do they work?

Tricyclic antidepressants (TCAs) are a class of antidepressant medications that share a similar chemical structure and biological effects. Scientists believe that patients with depression may have an imbalance in neurotransmitters, chemicals that nerves make and use to communicate with other nerves. 

Tricyclic antidepressants increase levels of norepinephrine and serotonin, two neurotransmitters, and block the action of acetylcholine, another neurotransmitter. Scientists believe that by restoring the balance in these neurotransmitters in the brain that tricyclic antidepressants alleviate depression. In addition to relieving depression, tricyclic antidepressants also cause sedation and block the action of histamine.

For what conditions are tricyclic antidepressants used?
Tricyclic antidepressants are approved by the Food and Drug Administration (FDA) for treating several types of depression, obsessive compulsive disorder, and bedwetting.

In addition, they are used for several off-label (non-FDA approved) uses such as:

• Panic disorder
• Bulimia
• Chronic pain 
• Phantom limb pain
• Chronic itching
• Premenstrual symptoms

Binding Profiles of Selected Tricyclic and Tetracyclic Antidepressants
The lower the number, the greater the strength.
SERT: Serotonin transport (a.k.a reuptake)
NET: Norepinephrine transport 
DAT: Dopamine transport

>>> Find the sortable chart HERE

What is the optimal dosage of tricyclic antidepressants in the acute phase of treatment of major depression in adults?

Although the quality of the data limits the strength of the recommendation, current evidence shows that 75 to 100 mg per day of a tricyclic antidepressant is more effective than placebo. Higher dosages (150 to 300mg) are not more effective and are associated with more dropouts because of side effects.

What are the side effects of tricyclic antidepressants?
Tricyclic antidepressants may cause:

• Blurred vision
• Dry mouth
• Constipation
• Weight gain or loss
• Low blood pressure on standing
• Rash
• Increased heart rate

Tricyclic antidepressants should be used cautiously in patients with seizures since they can increase the risk of seizures. They may worsen urinary retention (difficulty urinating) and narrow angle glaucoma. Abnormal heart rhythms and sexual dysfunction have also been associated with tricyclic antidepressants.

If tricyclic antidepressants are discontinued abruptly, withdrawal symptoms (for example, dizziness, headache, nausea, and restlessness) may occur. 

What happens with a tricyclic antidepressant overdose?
Tricyclic antidepressant (TCA) poisoning remains a major cause of morbidity and mortality. Deliberate self-poisoning may lead to the rapid onset of CNS and cardiovascular toxicity. Prompt intubation, hyperventilation and sodium bicarbonate administration at the first evidence of severe toxicity is life-saving.

Dose-related risk assessments: 

• <5 mg/kg lead to minimal symptoms
  
• 5-10 mg/kg leads to drowsiness and mild anticholinergic effects
  
• >10 mg/kg leads to the potential for all major effects to occur within 2-4 hours of ingestion
  
• > 30 mg/kg leads to severe toxicity with pH-dependent cardiotoxicity and coma expected to last > 24 hours
  

Signs and symptoms of overdose include:
The peripheral autonomic nervous system, central nervous system and the heart are the main systems that are affected following overdose. Initial or mild symptoms typically develop within 2 hours and include tachycardia, drowsiness, a dry mouth, nausea and vomiting, urinary retention, confusion, agitation, and headache.
More severe complications include hypotension, cardiac rhythm disturbances, hallucinations, and seizures. Seizures, cardiac dysrhythmias, and apnea are the most important life threatening complications.

Video: Treating Comorbid Anxiety and Depression with Tricyclic Antidepressants

SOURCE: Psychiatric Times
March 18th, 2014 | Edward J. Khantzian, MD

Why do so many die as a consequence of addiction? Is it in the inexorable, “progressive” nature of the disease? Or might it be the result of entrenched treatment approaches that repeatedly and increasingly become misaligned with the needs of individuals suffering from addictive disorders? 

For example, some need, and don’t get:
• Safety, structure, and support
• Medications for symptom reduction and control
• Nurturance and comfort
• The company and “fellowship” of others
• Storytelling and group sharing to understand their “errant” ways

The list goes on, and every clinician could add what else might be needed or beneficial to address and provide for those suffering from addictive disorders.
There continues to be a need for professionals who treat addiction, as well as all health care providers, to continue to fine tune approaches that work best and to avoid approaches that are exclusive or doctrinaire.

I write this piece to reach an audience of those who suffer with addictive illness, those who witness it as caring friends and family, and to all clinicians who treat it. I do so to counter attitudes of stigma that diminish empathic concerns for the fate of addicted individuals, and attitudes of therapeutic despair that addictive disorders can engender. And finally, I write it to foster awareness of a problem in the addiction field, where parochial attitudes and practice can be harmful for individuals in need of treatment.

At any given time, we learn of the death of one more celebrity as the media blazons us with such tragic and unwelcome news, a most recent example being the death of Philip Seymour Hoffman. Their achievements and promise, and for some celebrities their notoriety, and the magnitude of such loss, bring us up short. We wonder what addiction is and why it results in deadly consequences. We are left to worry whether it could have been prevented. Celebrity status succeeds in drawing media attention to the scourge of addiction, but we must not forget the countless incidents throughout society, among the rich or poor, gifted or ordinary, and promising or stuck individuals who unheralded and ignominiously suffer the same fate.

Clearly effective models and approaches for understanding and treating addictive illness exist. These include 12-step programs, relapse prevention, cognitive behavioral approaches, harm reduction therapy, motivational interviewing, medications, and dialectical behavioral therapy. In my clinical experience, modified psychodynamic individual and group treatments are also extremely effective in addressing and resolving the emotional and behavioral problems that drive addictive disorders. Shedler has documented robust evidence that supports the efficacy of psychodynamic psychotherapy [See: PDF]. Few empirical studies show such approaches work for addicted populations, but Shedler’s findings apply to treatment of addictive disorders, in my experience. Such application needs further empirical study.

One of the problems in treating addictive disorders is polemics. The debates and controversies go on and date back a half century: Is addiction a disease or a symptom? Do psychiatric disorders cause addiction or is it the other way around? Is it environment or heredity? That debates are rancorous and often bitter is bad enough, but worse, they play out tragically in treatment when adherents of one approach or another rigidly apply a particular model alone to the exclusion of others.

Sadly—and in some cases disastrously—affected individuals are never offered alternative approaches after one option fails. Too often in my own practice, a patient is referred for consultation by a psychotherapist who has adopted a symptom approach alone, trying to get to root causes of drug and alcohol abuse without considering first the need to get the addictive behavior under control; or on the other hand, the patient who has tried and failed 12-step work for decades is told that he or she hasn’t bottomed out or “doesn’t want” sobriety.

SOURCE: Global Medical Education
Guest Commentary by M. Zachary Rosenthal, PhD, and Marcus Rodriguez, MA

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:

• A Smartphone-Based Intervention with Diaries and Therapist-Feedback to Reduce Catastrophizing and Increase Functioning in Women with Chronic Widespread Pain: Randomized Controlled Trial  
  
• Behavioral Activation Versus Mindfulness-Based Guided Self-Help Treatment Administered Through a Smartphone Application: A Randomised Controlled Trial
  
• The Smartphone Psychology Manifesto 
  
• The Feasibility and Validity of Ambulatory Self-report of Psychotic Symptoms Using a Smartphone Software Application 
  
• A Pilot Study of the DBT Coach: An Interactive Mobile Phone Application for Individuals with Borderline Personality Disorder and Substance Use Disorder 
  

A Smartphone-Based Intervention with Diaries and Therapist-Feedback to Reduce Catastrophizing and Increase Functioning in Women with Chronic Widespread Pain: Randomized Controlled Trial 
Kristjánsdóttir J, Fors ÓB, Eide EA, et al  
Med Int Res. 2013;15(1).

Objective
This study examined the efficacy of a web-based CBT-grounded intervention delivered through smartphones.  Specifically, researchers in Norway conducted a randomized controlled trial (RCT) to investigate the efficacy of a smartphone delivered intervention based on Acceptance and Commitment Therapy (ACT) principles following an inpatient chronic pain program.

Conclusions
The present findings suggest this personalized web-based smartphone delivered intervention can change psychological processes related to Acceptance and Commitment principles among chronic pain patients. However, booster sessions may be needed to enhance prolonged effects. Providing immediate, situational feedback close to the moment dysfunctional thoughts (e.g., catastrophizing) and behaviors (e.g., avoidance) occur may help to increase patients’ self-management skills and alleviate their somatic complaints

Clinical Commentary
It is important for clinical scientists to develop accessible and cost-effective psychological interventions, as it is unlikely that clinicians will be able to serve all clients in need with traditional face-to-face interventions, particularly in developing countries. The present study makes a valuable contribution to the growing body of literature exploring ways that mobile technologies can be leveraged to facilitate this work. ACT has been shown to be an efficacious treatment for a variety of mental health problems (Strosahl et al., 2004). This study was an initial evaluation of a new platform for the delivery of an ACT-based intervention (Hayes et al., 1999) for patients suffering from chronic pain. The intervention made use of technology through four principal elements: Electronic diaries (where participants registered activities, emotions and pain cognitions three times daily using the smartphone), individualized written situational feedbacks (from clinicians), access to a website with information, and audio files with mindfulness exercises installed on the smartphone and available at the website. The implications of the present findings have potential to extend beyond rehabilitation programs for chronic pain patients. The generalizability of the results is reduced by several factors, including the withdrawal rate of 30% in the intervention group and the response rates (below 70%) at both follow-ups. Replication studies are needed, including the application of this intervention to populations with different mental health problems (e.g., depression, anxiety, or disordered eating). Note: Kristjánsdóttir and colleagues also published results of an 11-month follow-up of this randomized trial.

Behavioral Activation Versus Mindfulness-Based Guided Self-Help Treatment Administered Through a Smartphone Application: A Randomised Controlled Trial Ly KH, Trüschel A, Jarl L, et al 
BMJ Open. 2014;4(1):e003440.

Objective
The aim of this study was to evaluate the effectiveness of two smartphone-delivered treatments, one based on behavioral Activation (BA) and the other based on mindfulness. Both BA and mindfulness have strong empirical bases. However, the present study is the first to compare these treatments when delivered entirely via an application on participants’ personal smartphones.

Conclusions
When analyzing data from the whole sample (i.e., averaging across different levels of depression severity), the two interventions did not differ significantly from one another in terms of their efficacy. However, BA worked significantly better for participants with higher severity of depression (as measured by the PHQ-9), whereas mindfulness worked significantly better for participants with lower initial severity (as measured by both the BDI-II and the PHQ-9). 

Clinical Commentary
This study is one of the first to perform a randomized controlled trial comparing two evidence-based treatments delivered via smartphone applications. In contrast with results from Cuijpers et al.’s (2010) meta-analyses, BA was found to be comparable in efficacy to the alternative treatment for depression. These findings’ study suggest that BA might work better for a more severely depressed population, whereas mindfulness might work better for a mildly depressed population. Most importantly, the results from this study demonstrate the potential for mild-to-moderate MDD to be treated effectively among a non-treatment-seeking population by means of a smartphone application. Using mobile technology to disseminate interventions has potential to reach a broader group of people, since this platform attracts less attention and allows users to interact with a personal device without fear of judgment or stigma (Boschen & Casey, 2008). Future studies are needed to control for the different components of these treatments, because based on the present findings it is impossible to determine which parts of the treatments were effective. 

The Smartphone Psychology Manifesto 
Miller G. 
Perspectives on Psychological Science. 2012;7(3):221-237.

Objective
This article includes five parts: (1) A review of previous behavioral research using mobile electronic devices, (2) an outline of what smartphones can do now and may be able to do in the near future, (3) an illustration of how a smartphone study could work given current technology, (4) a discussion of limitations and challenges of smartphone research, and (5) a comparison of smartphones to other more traditional research methods. 

Conclusion
Smartphone assessment methods have significant advantages over traditional research methods. However, for some research questions field study and laboratory settings will remain more useful than smartphones (e.g., perception and cognition experiments that demand high contextual control or bio sampling). 

Clinical Commentary
Smartphones are powerful tools, and they are carried around by billions of people all around the world. Although they were not designed for psychological research, but they can be used for that purpose, and Miller (2012) argues they will ultimately revolutionize the way we conduct and think about research in our field. Adapting to this new era in psychological research (e.g., learning app development skills and advanced statistical analytic methods) will not be easy, especially considering the dizzying rates of technological progress. However, Miller (2012) argues it is well worth it, considering the potential payoff. Perhaps the most exciting aspect of smartphone-based research is the ability to collect data from vast amounts of people, across the planet, relatively easily. As smartphones become ever more versatile and powerful they will increase our capacity to run perceptually and behaviorally rich experiments. Moreover, smartphones will also allow us to gather precise, objective, sustained, ecologically valid field observations of real-world behavior in real time. Miller (2012) challenges readers to think about how this new technology is going to change our research questions, theories, and models of behavior change, funding sources, and even career tracks.

The Feasibility and Validity of Ambulatory Self-report of Psychotic Symptoms Using a Smartphone Software Application 
Palmier-Claus JE, Ainsworth J, Machin M, et al 
BMC Psychiatry. 2012;12(1):172.

Objective
Ambulatory, real-time, smartphone-based self-report assessment devices may have advantages over semi-structured interviews for assessing psychotic symptoms. The present study has two primary aims: (1) To assess the validity of using a smartphone-based monitoring system for the assessment of psychosis, compared to a gold-standard structured interview assessment method, and (2) to examine compliance to the procedure among individuals suffering with psychotic symptoms of varying severity.

Conclusions
Results from the present study suggest that ambulatory monitoring of symptoms several times daily using smartphone applications represents a feasible and valid way of assessing psychotic symptoms for clinical and research purposes. This smartphone-based monitoring system shows promise and should be studied further. 

Clinical Commentary
The present study aims to assess the validity, acceptability, and feasibility of using a smartphone-based monitoring system for assessing psychosis Future studies concerning the implementation of new technologies among potential users are needed. Kilbourne et al. [43] described a useful framework called Replicating Effective Programs (REP) for implementing health care interventions. Insights from the Technology Acceptance Model (TAM; Venkatesh & Davis, 2000) should also be considered throughout the implementation process. Palmier-Claus et al.’s (2012) research is important, as traditional face-to-face assessments have significant limitations, including recall bias, averaging (e.g., overlooking potential variability in the number, type and intensity of psychotic symptoms in different contexts), variable interrater reliability, and insensitivity to change. This study lays the groundwork to be able to develop future interventions to help individuals with psychotic symptoms. Further evaluation is required over longer assessment periods, in clinical trials and service settings.

A Pilot Study of the DBT Coach: An Interactive Mobile Phone Application for Individuals with Borderline Personality Disorder and Substance Use Disorder 
Rizvi SL, Dimeff LA, Skutch J, et al 
Behavior Therapy, 2011;42(4):589-600.
 
Objective
The aim of this study was to develop and test the feasibility of the DBT coach, a smartphone application designed to enhance generalization of a specific dialectical behavioral therapy (DBT) skill (opposite action) among individuals with borderline personality disorder (BPD) and comorbid substance use disorders (SUD). 

Conclusions
The present findings suggest that DBT coach, a smartphone application which offers in vivo (OA) skills coaching, may be a useful tool for increasing DBT skills use and adaptive coping behaviors, while reducing urges to use substances and levels of symptomatology.

Clinical Commentary
There is a significant body of literature that suggests DBT is an effective approach to the treatment of BPD and BPD with comorbid SUD. This study builds on this line of research to examine how mobile technology can be used to help DBT clients with BPD-SUD generalize newly acquired skills to the natural settings where they most often experience urges to engage in maladaptive behavior (e.g., substance use or abuse). Although there were numerous limitations to this small feasibility pilot trial which used a quasi-experimental design, the present findings are encouraging. Results suggest that, when used as an adjunct to DBT, the smartphone application DBT coach has the potential to decrease emotional intensity, urges to use substances, and overall distress. More generally, the present research supports the use of mobile-phone based psychological interventions for facilitating skills generalization, behavior change, and symptom-reduction. This study also contributes to this field by developing the Satisfaction and Usability Scale, which can be adopted in future research to evaluate the acceptability of smartphone application-based interventions

SOURCE: Associated Press
March 27, 2014

The government's estimate of autism has moved up again to 1 in 68 U.S. children, a 30 percent increase in two years.

But health officials say the new number may not mean autism is more common. Much of the increase is believed to be from a cultural and medical shift, with doctors diagnosing autism more frequently, especially in children with milder problems.

"We can't dismiss the numbers. But we can't interpret it to mean more people are getting the disorder," said Marisela Huerta, a psychologist at the New York-Presbyterian Center for Autism and the Developing Brain in suburban White Plains, N.Y.

The Centers for Disease Control and Prevention released the latest estimate Thursday. The Atlanta-based agency said its calculation means autism affects roughly 1.2 million Americans under 21. Two years ago, the CDC put the estimate at 1 in 88 children, or about 1 million.

The cause or causes of autism are still not known. Without any blood test or other medical tests for autism, diagnosis is not an exact science. It's identified by making judgments about a child's behavior.

Thursday's report is considered the most comprehensive on the frequency of autism. Researchers gathered data in 2010 from areas in 11 states - Alabama, Arizona, Arkansas, Colorado, Georgia, Maryland, Missouri, New Jersey, North Carolina, Utah and Wisconsin.

The report focused on 8-year-olds because most autism is diagnosed by that age. The researchers checked health and school records to see which children met the criteria for autism, even if they hadn't been formally diagnosed. Then, the researchers calculated how common autism was in each place and overall.

The CDC started using this method in 2007 when it came up with an estimate of 1 in 150 children. Two years later, it went to 1 in 110. In 2012, it went to 1 in 88.

Last year, the CDC released results of a less reliable calculation - from a survey of parents - which suggested as many as 1 in 50 children have autism.

Experts aren't surprised by the growing numbers, and some say all it reflects is that doctors, teachers and parents are increasingly likely to say a child with learning and behavior problems is autistic. Some CDC experts say screening and diagnosis are clearly major drivers, but that they can't rule out some actual increase as well.

"We cannot say what portion is from better diagnosis and improved understanding versus if there's a real change," said Coleen Boyle, the CDC official overseeing research into children's developmental disabilities.

For decades, autism meant kids with severe language, intellectual and social impairments and unusual, repetitious behaviors. But the definition has gradually expanded and now includes milder, related conditions.

One sign of that: In the latest study, almost half of autistic kids had average or above average IQs. That's up from a third a decade ago and can be taken as an indication that the autism label is more commonly given to higher-functioning children, CDC officials acknowledged.

Aside from that, much in the latest CDC report echoes earlier findings. Autism and related disorders continue to be diagnosed far more often in boys than girls, and in whites than blacks or Hispanics. The racial and ethnic differences probably reflects white communities' greater focus on looking for autism and white parents' access to doctors, because there's no biological reason to believe whites get autism more than other people, CDC officials said at a press briefing Thursday.

One change CDC officials had hoped to see, but didn't, was a drop in the age of diagnosis. Experts say a diagnosis can now be made at age 2 or even earlier. But the new report said the majority of children continue to be diagnosed after they turn 4.

"We know the earlier a child is identified and connected with services, the better," Boyle said.

The American Academy of Pediatrics issued a statement Thursday, saying the nation needs to step up screening for the condition and research into autism's causes.

"It's critical that we as a society do not become numb to these numbers," said Dr. Susan Hyman, head of the group's autism subcommittee.