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Dr. Rajiv Tandon
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Dr. Henry A. Nasrallah
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Dr. Andrew J. Cutler
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Dr. S. Nassir Ghaemi
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Dr Carol North with 2012 Winokur Award Winner Alina Suris, PhD
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General Session room
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Dr. Henry A. Nasrallah
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Dr. Marlene P. Freeman
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General Session room
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Dr. Murray B. Stein with Delegates
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Luncheon Symposium
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Exhibit Hall
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Fredrick Goodwin, MD speaking with colleagues
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Attendees in Conference
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Attendees mingling
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Question Queue
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Conference bag
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Exhibit hall
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2012 Conference Wrap-up
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The Current Psychiatry/American Academy of Clinical Psychiatrists 2012 Psychiatry Update: Solving Clinical Challenges, Improving Patient Care, took place March 29-31, at the Chicago Marriott Downtown Magnificent Mile, with more than 500 psychiatrists and psychiatric clinicians in attendance. Participants of this highly interactive, learning-focused meeting had the opportunity to earn up to 18 AMA PRA Category 1 Credits™.
Below is a summary of the sessions.
THURSDAY, MARCH 29, 2012
TMS and Other Forms of Neuromodulation
Philip G. Janicak, MD, Rush Medical College
Dr. Janicak summarized the latest data on electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), and deep brain stimulation (DBS), all of which are used for treatment-resistant depression. ECT remains the most effective neuromodulation modality. Patients who receive VNS often improve with long-term use, but lack of insurance reimbursement may limit its use. TMS is less invasive than ECT, VNS, and DBS and has reduced depressive symptoms in clinical trials.
Diagnosing and Treating PTSD
James W. Jefferson, MD, University of Wisconsin School of Medicine and Public Health
Dr. Jefferson pointed out that posttraumatic stress disorder (PTSD) is highly comorbid with depression, substance abuse, anxiety, and borderline personality disorder. Cognitive-behavioral therapy is a first-line treatment for PTSD. Paroxetine and sertraline are FDA-approved for PTSD; data for other pharmacotherapies, including atypical antipsychotics, venlafaxine, propranolol, and prazosin, are insufficient. Combining CBT and pharmacotherapy may help treatment-resistant patients.
New Pharmacologic Therapies for Depression and Anxiety
Philip G. Janicak, MD, Rush Medical College
Dr. Janicak reviewed novel treatments for depression, generalized anxiety disorder, obsessive- compulsive disorder, posttraumatic stress disorder, and sleep disorders. Atypical antipsychotics are the only FDA-approved augmentation strategies for depression. Alternate therapies that target the monoamine, glutamate, acetylcholine, and melatonin systems are under investigation but adequate data are lacking.
Treatment-Resistant Anxiety
James W. Jefferson, MD, University of Wisconsin School of Medicine and Public Health
Dr. Jefferson discussed evidenced-based approaches to treatment-resistant anxiety, including panic disorder, social anxiety disorder, and generalized anxiety disorder. Cognitive-behavioral therapy often is effective. If first-line pharmacotherapies fail, options include augmenting or switching medications; however, there is little data on these approaches
Challenges and Opportunities in Schizophrenia
Henry A. Nasrallah, MD, University of Cincinnati
In a promotional symposium sponsored by Sunovion Pharmaceuticals, Inc., Dr. Nasrallah reviewed recent data for the atypical antipsychotic lurasidone. Randomized controlled trials have shown that lurasidone, 40 mg/d and 80 mg/d, is superior to placebo in reducing schizophrenia symptoms in adults as assessed by the Positive and Negative Syndrome Scale and the Brief Psychiatric Rating Scale. Common adverse effects include somnolence, akathisia, nausea, parkinsonism, and agitation.
Sleep Disturbances in Patients with Dementia
George T. Grossberg, MD, St. Louis University
Dr. Grossberg described how patients with Alzheimer’s disease (AD) experience sleep disturbances such as insomnia, obstructive sleep apnea, and restless legs syndrome. Some of these difficulties may worsen AD. Behavioral interventions, including bright light therapy, cause fewer side effects than pharmacotherapy; however, results are mixed. Nonbenzodiazepine hypnotics are preferred to benzodiazepines because they are less likely to cause memory loss or disorientation.
Similarities and Differences Between 1st, 2nd, and 3rd Generation Antipsychotics
Henry A. Nasrallah, MD, University of Cincinnati
Dr. Nasrallah discussed the benefits and adverse effects of several pharmacologic options for treating schizophrenia, including first-generation antipsychotics and the newest agents lurasidone, asenapine, paliperidone, and iloperidone. Injectable antipsychotics, such as paliperidone and olanzapine, may improve adherence and prevent relapse.
Sleep Disturbances in the Elderly
George T. Grossberg, MD, St. Louis University
Dr. Grossberg reviewed common factors that can affect sleep among older adults, including medical and psychiatric illnesses, medications, and disrupted circadian rhythms. For insomnia, start with nonpharmacologic strategies, such as increasing physical activity, teaching sleep hygiene, and cognitive-behavioral therapy. When prescribing nonbenzodiazepine hypnotics, use the lowest effective dose for the shortest duration.
Treatment Strategies for Patients with Inadequate Response to First-Line Antidepressants
Andrew J. Cutler, MD, University of Florida
Dr. Cutler outlined treatment strategies for patients with depression who don’t fully respond to first-line antidepressants, including combining antidepressants or augmenting them with atypical antipsychotics, stimulants, other medications, or natural products. For switching antidepressants, no evidence supports preference for one agent or class over another; tricyclic antidepressants and monoamine inhibitors maybe underused options.
FRIDAY, MARCH 30, 2012
Chronic Insomnia
Thomas Roth, PhD, Henry Ford Health System
Dr. Roth discussed understanding insomnia as a disorder that merits treatment, and not merely as a symptom of other disorders. In addition to sleep difficulties, patients with insomnia experience daytime symptoms such as cognitive or mood symptoms and distress/impairment. Insomnia increases the risk of depression and other psychiatric illnesses, falls, and cardiovascular disorders.
Treatment-Resistant Schizophrenia
Henry A. Nasrallah, MD, University of Cincinnati
Dr. Nasrallah reviewed the definition of treatment resistance and refractoriness in schizophrenia, which often does not consider negative or cognitive symptoms. When first-line antipsychotics or clozapine monotherapy don’t work, evidence supports adding lamotrigine, an antidepressant, a glutamate receptor agent, neurosteroids, and hormones. He also reviewed the data for electroconvulsive therapy and repetitive transcranial magnetic stimulation.
How to Stabilize Acutely Psychotic Patients
Rajiv Tandon, MD, University of Florida
Dr. Tandon explained that the objectives when treating an acutely psychotic patient are to reduce acute symptoms as quickly as possible, provide interventions for the specific cause of their psychosis, and maintain safety. Treatment for extreme agitation can include behavioral approaches, such as de-escalation and seclusion, and pharmacotherapy with oral and injectable antipsychotics or benzodiazepines.
New Treatments for Sleep Disorders
Thomas Roth, PhD, Henry Ford Health System
Dr. Roth reviewed nonpharmacologic treatments for insomnia, including stimulus control therapy and sleep restriction therapy, and pharmacologic interventions, primarily benzodiazepine receptor agonists. Considering how neurotransmitter systems are affected by sleep and how medications affect these systems can help researchers develop new therapeutic targets for insomnia treatment.
Unraveling the Complexities of Schizophrenia: New Targets, New Opportunities
Henry A. Nasrallah, MD, University of Cincinnati
Daniel C. Javitt, MD, PhD, Columbia University
Andrew J. Cutler, MD, University of Florida
Dr. Nasrallah described multiple clinical features of schizophrenia and related genetic and environmental factors. Although no single gene appears to be necessary or sufficient for developing schizophrenia, many “susceptibility genes” contribute to liability for the illness.
Dr. Javitt discussed emerging perspectives and treatment opportunities in schizophrenia based on glutamate pathophysiology and models. New treatment opportunities may focus on glycine/D-serine, glycine transport inhibitors, and metabotropic receptors.
Dr. Cutler outlined how glutamate receptor dysfunction upstream of dopamine could explain schizophrenia symptoms. Various glutamate agonists, including glycine transporter inhibitors, may treat residual symptoms, particularly negative and cognitive symptoms.
Managing Schizophrenia's Medical Comorbidities
Rajiv Tandon, MD, University of Florida
Dr. Tandon discussed how medical comorbidities, particularly cardiovascular disease, are a primary cause of increased mortality in patients with schizophrenia. Switching antipsychotics and lifestyle interventions may help address weight gain and insulin resistance.
Use of Antidepressants in Bipolar Disorder
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine
Dr. Ghaemi examined evidence that indicates in bipolar disorder (BD), antidepressants do not alleviate depression and can lead to mania. He recommended using mood stabilizers without antidepressants initially in depressed BD patients, except for those with marked suicidality or severe melancholia. If antidepressants are used, consider serotonin reuptake inhibitors.
Complementary and Alternative Medicine and Nutrition in Psychiatry: Part I
Marlene P. Freeman, MD, Massachusetts General Hospital
Dr. Freeman reviewed evidence on several forms of commonly used complementary and alternative medicine (CAM), including omega-3 fatty acids, St. John’s wort, s-adenosyl-L-methionine (SAMe), and vitamin D. She recommended directly asking patients about their use of CAM and discussing the evidence.
SATURDAY, MARCH 31, 2012
EMSAM (selegiline transdermal system) for the Treatment of Major Depressive Disorder
Neil S. Kaye, MD, DFAPA
In a promotional symposium sponsored by Dey Pharma, L.P., Dr. Kaye reviewed efficacy, safety, and tolerability data on selegiline transdermal system, which is FDA-approved for major depressive disorder in adults. He discussed clinically meaningful differences between oral and transdermal formulations of selegiline. Compared with oral formulations, the transdermal delivery system results in higher exposure to the drug.
Differential Diagnosis and Management of Comorbid Bipolar Disorder and ADHD
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine
Dr. Ghaemi suggested that the high comorbidity of attention-deficit/hyperactivity disorder with mood and anxiety disorders may indicate that these patients may have a single distinct disorder. Amphetamines, including methylphenidate, could worsen manic symptoms in patients with bipolar disorder (BD). Lithium is neuroprotective, and could be a good choice for BD patients with cognitive impairment.
Complementary and Alternative Medicine and Nutrition in Psychiatry: Part II
Marlene P. Freeman, MD, Massachusetts General Hospital
Dr. Freeman focused on the evidence-based use of select complementary and alternative medicine modalities in women across the reproductive lifespan. Omega-3 fatty acids, exercise, and folate have known benefits for pregnancy health and may play a role in the treatment of depression. Some evidence suggests that premenstrual symptoms may respond to calcium; omega-3 fatty acids may reduce hot flashes and depressive menopausal symptoms. Large studies show a relationship between nutritional quality and risk of depressive disorders.
Use of Antipsychotics for Treating Phases of Bipolar Disorder
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine
Dr. Ghaemi discussed evidence on the use of neuroleptics for treating bipolar disorder patients during acute mania, acute bipolar depression, mixed states, and maintenance. He suggested that generally, neuroleptics could be used as adjuncts to mood stabilizers for these patients.
Managing Suicidal Behavior in Patients with Bipolar Disorder
S. Nassir Ghaemi, MD, MPH, Tufts University School of Medicine
Dr. Ghaemi outlined factors to consider when assessing suicide risk. Suicide ideation is not a useful predictor of suicide. Bipolar patients are at high risk for suicide when in a depression or mixed state. Focus treatment on symptom clusters that increase acute risk, including anxiety/panic, insomnia, impulsivity, mixed states, rapid cycling, and substance abuse. Lithium is the only mood stabilizer shown to reduce suicide.
View Video testimonials from attendees of the 2012 Current Psychiatry/AACP Psychiatry Update
• 2012 Attendee Video #1
• 2012 Attendee Video #2
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2011 Conference Wrap-up
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FRIDAY, APRIL 15, 2011
MORNING SESSIONS
Rajiv Tandon, MD, University of Florida, spoke about identifying psychotic symptoms in patients in the years before they experience their first psychotic episode. He said recognizing prodromal symptoms may allow early interventions to prevent deterioration.
John Lauriello, MD, University of Missouri, discussed monitoring all patients taking antipsychotics for weight gain, elevated triglyceride levels, and other metabolic side effects. He recommended that clinicians not sacrifice therapeutic efficacy to reduce side effects.
S. Charles Schulz, MD, University of Minnesota, spoke about how techniques to reduce aggression and violence among patients with schizophrenia differ in inpatient and outpatient settings. He emphasized recognizing antecedent behaviors to aggression, such as pacing, angry expressions, raised voice, and threatening behaviors.
Henry A. Nasrallah, MD, University of Cincinnati, examined the unique properties and side effect profiles of and differences among several new antipsychotics, including the oral agents asenapine, iloperidone, and lurasidone and injectable formulations of paliperidone and olanzapine.
In a luncheon symposium titled Challenges and Opportunities in the Treatment of Schizophrenia: An Interactive Case-Based Update, Greg Mattingly, MD, Washington University, discussed brain findings in schizophrenia, including functional abnormalities such as hypofrontality and structural abnormalities such as enlarged ventricles and loss of grey matter. Dr. Nasrallah explored several clinical issues in treating patients with schizophrenia, such as high burden of cardiovascular risk factors and medical illnesses, difficulty predicting individual treatment response, and challenges in maximizing adherence and minimizing side effects. Peter Weiden, MD, University of Illinois at Chicago, examined how nonadherence can influence schizophrenia treatment outcomes.
AFTERNOON SESSIONS
Dr. Lauriello, discussed extrapyramidal side effects of antipsychotics, which include parkinsonism, akathisia, tardive dyskinesia, and neuroleptic malignant syndrome. Dr. Nasrallah and Dr. Tandon ended the day by leading a lively point/counterpoint discussion of the pros and cons of emphasizing efficacy over tolerability when treating patients with antipsychotics. They debated the merits of typical vs atypical antipsychotics, the role of evidence-based medicine in schizophrenia treatment, and the impact of different types of adverse effects.
SATURDAY, APRIL 16, 2011
MORNING SESSIONS
Dr. Schulz explained that although clozapine is associated with serious adverse effects, the drug may help many patients who don’t respond to other antipsychotics. He examined evidence for add-on medications for treatment-resistant schizophrenia, such as lithium or anticonvulsants.
George T. Grossberg, MD, St. Louis University, discussed the role of neuroimaging, genetic considerations, and neuropsychological testing in assessing cognitive deficits, and suggested that we are moving toward combining biomarkers with clinical symptoms for earlier, more accurate diagnosis of Alzheimer’s disease and other dementias.
Marlene P. Freeman, MD, Massachusetts General Hospital, described treatment approaches for women who develop psychiatric symptoms during infertility treatment and those with a psychiatric history who are experiencing infertility. She also explored evidence for psychotropic use during pregnancy.
Dr. Grossberg emphasized that the first step of treating delirium in older adults is to determine if a medical problem or medication is the cause. He suggested addressing the underlying condition, then trying psychosocial and environmental interventions, such as reorientation or quiet environments..
In a luncheon symposium titled A Bridge to the Future: Redefining the Scientific Paradigm in the Treatment of Schizophrenia, Dr. Nasrallah discussed the historical evolution of schizophrenia, introducing the dopamine and glutamate hypofunction models of the disease. Leslie Citrome, MD, MPH, New York University, examined how glutamate receptor dysfunction upstream of dopamine could explain schizophrenia symptoms, and mentioned that several novel therapeutic targets involving glutamate receptors are being investigated. Diana O. Perkins, MD, MPH, University of North Carolina at Chapel Hill, discussed “next generation” strategies for schizophrenia treatment, including psychotherapeutic interventions and glycine reuptake inhibitors.
AFTERNOON SESSIONS
Dr. Freeman outlined approaches for treating psychosis, schizophrenia, and bipolar disorder during pregnancy and postpartum. She recommended that when treating a pregnant woman who has schizophrenia, a careful risk/benefit analysis should take into account that untreated psychosis likely carries a risk to the fetus.
Dr. Weiden discussed the importance of the interview approach and establishing a strong therapeutic alliance to improve medication adherence among patients with schizophrenia. He described pharmacologic strategies, such as switching to a long-acting injectable antipsychotic, and psychosocial interventions. D. P. Devanand, MD, Columbia University, described evidence on the use of antipsychotics for treating agitation and psychosis in patients with dementia. He said studies of depression treatment in dementia patients found limited evidence of efficacy for selective serotonin reuptake inhibitors.
SUNDAY, APRIL 17, 2011
Dr. Weiden recommended that when considering adding medications to an antipsychotic for a schizophrenia patient with persistent symptoms, first give full trials of a single drug at the high end of the therapeutic dose and establish well-defined target symptoms before adding a new medication. Dr. Devanand described several early markers of Alzheimer’s disease, including apolipoprotein E genotyping, mild cognitive impairment (MCI), hippocampal volume, olfactory deficits, and amyloid imaging tracers.
Susan K. Schultz, MD, University of Iowa, said that although diagnosis of MCI is well understood, prevention and treatment options are less well-defined. She discussed depression in MCI, and described evidence for using cholinesterase inhibitors (not routinely indicated), nutraceuticals, and exercise.
Dr. Schultz concluded the conference by describing pharmacologic and nonpharmacologic strategies for addressing behavioral disturbances in dementia. She said evidence supports modest symptom improvements with some antipsychotics.
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2010 Conference Wrap- up
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Mood And Anxiety Disorders: Solving Clinical Challenges, Improving Patient Care
CURRENT PSYCHIATRY and the American Academy of Clinical Psychiatrists were pleased to host 450 psychiatric practitioners in Chicago, IL for this 3- day conference, led by Richard Balon, MD, Meeting Chair and Donald W. Black, MD, Meeting Co-Chair. Attendees were able to earn up to 18 AMA PRA Category 1 Credits™.
THURSDAY, APRIL 8, 2010
Andrew Nierenberg, MD, Massachusetts General Hospital, discussed managing residual depressive symptoms after a first-line treatment trial. He highlighted how to use pharmacotherapy and psychotherapy to target residual symptoms such as insomnia, fatigue, and cognitive decline.
Murray B. Stein, MD, MPH, University of California, San Diego, reviewed the latest evidence on the diagnosis and pharmacotherapy of posttraumatic stress disorder. He pointed out that pharmacotherapy alone usually is inadequate to obtain optimum clinical outcomes.
Frederick K. Goodwin, MD, George Washington University, described unipolar vs bipolar depression and how to prevent misdiagnoses. He discussed subtle clinical clues that might suggest a depressed patient is bipolar.
Dr. Stein explained that although co-occurring panic disorder, social anxiety disorder, or other anxiety disorders with mood disorders generally predicts poorer outcomes, a solid evidence base supports effective treatments, including cognitive-behavioral therapy and antidepressants.
Philip R. Muskin, MD, Columbia University, chaired a luncheon symposium titled Effective Strategies for Patients with Complex Depression in Psychiatric Practice: A Case-Based Approach, and covered major depressive disorder (MDD) and medical illness. Other speakers were Dr. Nierenberg, who described results from the STAR*D trials, and George I. Papakostas, MD, Massachusetts General Hospital, who focused on augmentation and combination strategies for MDD treatment.
Audio commentary from Dr. Muskin.
Natalie Rasgon, MD, PhD, Stanford University School of Medicine, spoke on the risks and benefits of prescribing psychotropics during pregnancy, covering epidemiology, risk factors, clinical course, and controversies regarding treatment of women with perinatal mood disorders.
Audio commentary from Dr. Rasgon.
Dr. Goodwin presented strategies for monitoring and mitigating suicide risk in patients with mood and anxiety disorders.
Audio commentary from Dr. Goodwin.
Dr. Nierenberg described assessing and managing sexual dysfunction and other side effects of depression and anxiety treatment.
FRIDAY, APRIL 9, 2010
Dr. Rasgon focused on treating postpartum depression and anxiety, including treatment strategies for breast-feeding women.
Kiki D. Chang, MD, Stanford University School of Medicine, discussed suicidality in children, adolescents, and young adults and the possible role of antidepressants.
George T. Grossberg, MD, St. Louis University, described medical and psychosocial factors to consider in the workup of late-life depression and anxiety. He covered the latest non-pharmacologic and pharmacologic therapies for geriatric depression.
Dr. Chang reported on comorbidities in children and adolescents with bipolar disorder. He described treatment guidelines for bipolar youths who have co-occurring anxiety disorders, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders.
At a luncheon symposium, Lawrence Ginsburg, MD,discussed the role of L-methylfolate as an adjunct to antidepressants for treating depression.
Dr. Grossberg described how to avoid drug interactions and adverse effects when prescribing for older patients, focusing on herbal/drug interactions.
Audio commentary from Dr. Grossberg
Donald W. Black, MD, University of Iowa, spoke on how to treat depression and anxiety in patients with borderline personality disorder.
James W. Jefferson, MD, Madison Institute of Medicine, discussed pharmacotherapy of comorbid mood, anxiety, and substance use disorders. He emphasized methods of improving diagnostic accuracy and treatment considerations.
SATURDAY, APRIL 10, 2010
Dr. Jefferson described the latest evidence on obsessive-compulsive disorder in patients with psychiatric comorbidities, including major depression, bipolar disorder, and substance use disorders.
Marlene P. Freeman, MD, Massachusetts General Hospital, spoke on premenstrual mood disorders and the menopausal transition and considerations for treatment.
Dr. Black discussed how to correctly diagnose borderline personality disorder or a mood disorder. He described how the 2 disorders have overlapping symptoms that could lead to diagnostic confusion.
Dr. Freeman concluded the meeting by discussing complementary and alternative medicine and psychiatry: what the psychopharmacologist needs to know.
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Andrew Nierenberg, MD, Massachusetts General Hospital
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Q and A
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Dr Natalie Rasgon, MD, PhD
Stanford University
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Dr. Kiki Chang with Delegates
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George G. Grossberg, MD,
St. Louis University
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Donald W. Black, MD(right) and George Winokur Research Award winner Susan K. Schultz, MD
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| 2009 Conference Wrap-up |
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A windy Chicago welcomed 314 psychiatrists and advance practice psychiatric practitioners to “Bipolar Disorder and ADHD: Solving Clinical Challenges, Improving Patient Care,” April 2-4, 2009, at the Westin Chicago River North. Presented by CURRENT PSYCHIATRY and the American Academy of Clinical Psychiatrists (AACP), the interactive continuing medical education conference offered attendees up to 19.5 CME credits.
Thursday, April 2, 2009
Moderator: Richard Balon, MD, Program Chair
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Kiki Chang, MD, Associate Professor of Psychiatry at the Stanford University School of Medicine, kicked off the meeting with a discussion of diagnosis and treatment of ADHD in children and adolescents. Dr. Chang presented data on comorbidity and symptom overlap between ADHD and bipolar disorder and discussed stimulant and nonstimulant pharmacotherapy of ADHD.
Click here for video of Dr .Chang speaking about the importance of obtaining a baseline EKG in children before starting psychostimulants; how to distinguish between ADHD and bipolar disorder; and “ADHD Plus.”
Anthony L. Rostain, MD, director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania School of Medicine, discussed the challenges in diagnosing ADHD in adults and outlined how ADHD symptoms manifest differently in adults than in children. He also offered tips for making an accurate diagnosis of adult ADHD and listed screening scales that can be used in clinical practice.
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Kiki Chang, MD
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After a short networking break, Dr. Rostain continued the discussion of adult ADHD with a presentation on treatment strategies. He outlined stimulant and nonstimulant options and how to manage pharmacotherapy for adults with comorbid psychiatric disorders such as anxiety, substance abuse, or depression. Dr. Rostain also addressed concerns about adverse cardiac side effects with psychostimulant treatment and how to adjust medications to maximize treatment response.
Click here for video of Dr. Rostain as he discusses getting adult patients with ADHD ready for treatment.
Kevin Murphy, PhD, president of the Adult ADHD Clinic of Central Massachusetts, presented data showing why psychotherapy and other psychosocial interventions play a vital role in adult ADHD treatment. He recommended that clinicians help patients accept that negative symptoms are caused by a neurobiological disorder—not a character flaw or willful misconduct—that requires ongoing maintenance. Adult patients often need ongoing education and support to develop compensatory skills and strategies, avoid substance abuse, and address challenges with work, school, and family.
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Anthony Rostain, MD
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Click here for video of Dr. Murphy discussing the importance of instilling hope during treatment of adults with ADHD
In his second presentation, Dr. Murphy emphasized that serving as a partner/advocate for the adult with ADHD is key to continued treatment over time. To convince someone who is skeptical about starting treatment, he recommends that clinicians “take the powerplay” out of the conversation. Demystify the diagnosis, and explain why the patient meets criteria for ADHD, he said. Explain how the medication works and why treatment is important—without “jamming it down their throats,” he said. Emphasize the patient’s attributes, such as intelligence, creativity, high energy, “feistiness,” or sense of humor.
S. Nassir Ghaemi, MD, Director of the Mood Disorders and Psychopharmacology Programs and professor of psychiatry at Tufts, University, described the “hierarchy of diagnosis” implicit in DSM-IV-TR in his discussion of comorbid adult ADHD and bipolar disorder. Because of overlapping symptoms, mood disorders (bipolar and unipolar) should be ruled out before a clinician considers a psychotic or anxiety disorder. Similarly, he cautioned against diagnosing ADHD while a patient is experiencing a mood episode or psychotic illness.
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S Nassir Ghaemi, MD, MPH
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Early onset of bipolar disorder is common, according to Dr. Chang. One-half of adults with bipolar disorder experience onset as children (14%) or adolescents (36%). In children, the bipolar spectrum includes severe mood dysregulation, “full” bipolar disorder (types I and II), and possible prodromal states (such as ADHD or depression with a family history of bipolar disorder and bipolar disorder not otherwise specified). Children with bipolar disorder often show irritability, but this symptom is not specific to bipolar disorder. Randomized controlled trials have shown lithium and atypical antipsychotics to be effective for mood stabilization in pediatric bipolar disorder.
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Richard Balon, MD Meeting Chair
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Friday, April 3, 2009
Moderator: Sanjay Gupta, MD, AACP President
Anticipate unplanned pregnancies when choosing medications for women of reproductive age with bipolar disorder, advised Marlene P. Freeman, MD, Massachusetts General Hospital perinatal and reproductive psychiatry program. A patient may deny plans to become pregnant, but two-thirds of U.S. women have at least one unintended pregnancy, and 50% to 60% of pregnancies are unintended or mistimed. Because relapse rates for bipolar women who discontinue medication during pregnancy are high, it is recommended that patients consider the serious risks of untreated bipolar disorder as well as medication exposure. Valproate appears to be the mood stabilizer associated with the greatest teratogenic potential. Among the anticonvulsants, lamotrigine appears to have the most favorable reproductive safety profile, and lithium appears to have a much lower risk of teratogenicity than was thought years ago, with a very low absolute risk of malformations with first- trimester exposure. More data are needed to inform the use of atypical antipsychotics across pregnancy and breastfeeding.
Click here for video of Dr. Freeman discussing why it is important to consider unplanned pregnancy when prescribing medication to women of reproductive age.
In his second presentation at the conference, Dr. Ghaemi reviewed the use of stimulants in bipolar disorder treatment and the risk of mood destabilization. Because patients with bipolar disorder often also experience cognitive dysfunction, he reviewed nonstimulant strategies for preserving brain function and enhancing cognition.
Click here for video of Dr. Ghaemi discussing how to preserve brain function in patients with bipolar disorder; how to identify early signs of brain dysfunction; and if it is appropriate to use stimulants in patients with bipolar disorder.
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Sanjay Gupta, MD
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Next, Dr. Freeman returned to the podium to summarize of the latest evidence on subsyndromal depression in bipolar I disorder. She discussed the functional toll of subsyndromal depression, the risk of switching to mania with antidepressant therapy, effective use of mood stabilizers, and evidence supporting other therapies. These include psychotherapy, complementary and alternative medicine, omega-3 fatty acids, exercise, and light therapy.
Suicidal behavior in patients with bipolar disorder was the topic of the session presented by Frederick Goodwin, MD, Research Professor of Psychiatry at George Washington University Medical Center. Dr. Goodwin covered suicide risk factors, mood stabilizers’ efficacy in reducing suicide risk, and the importance of ongoing communication with patients and families about suicide and the underlying bipolar disorder.
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Charles Bowden, MD
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Dr. Ghaemi served as moderator at a luncheon symposium on “Maintaining wellness in patients with bipolar disorder.” Claudia Baldassano, MD, assistant professor of psychiatry at the University of Pennsylvania, discussed how to promote wellness in patients with bipolar disorder. Robert Hirschfeld, MD, professor and chairperson, cepartment of psychiatry and behavioral sciences, University of Texas Medical Branch, spoke on integrating pharmacotherapy and nonpharmacologic treatments for bipolar disorder.
Friday afternoon’s sessions began with a presentation of the evidence on rapid and ultradian cycling in bipolar disorder patients by Steven Dubovsky, MD, professor and chair, department of psychiatry, University at Buffalo. Dr. Goodwin then described how to use lithium in the acute treatment of mania, treatment of bipolar depression, and maintenance treatment bipolar disorder.
Click here for video of Dr. Baldassano discussing how she handles polypharmacy and her approach to simplifying regimens.
In a “Psychopharmacology Jam Session,” audience members stepped to the microphones to comment on clinical case reports presented by AACP members Sanjay Gupta, MD, president; Gregory Teas, MD, and Nagy Youssef, MD.
The day ended with a session by Dr. Chang, who discussed strategies for promoting treatment adherence in patients with bipolar disorder. Dr. Chang’s presentation covered patient, clinician, and system factors that contribution to nonadherence and included video from a patient interview that helped illustrate these issues.
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Luncheon Symposium
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Saturday, April 4, 2009
Moderator: Donald W. Black, MD, Program Co-Chair
The day’s sessions began with Dr. Ghaemi reviewing the latest evidence related to alcohol abuse in patients with bipolar disorder and ADHD. He covered the effect on alcohol use and dependence of medications used to treat bipolar disorder and ADHD.
Charles Bowden, MD, professor of Psychiatry and Pharmacology at University of Texas Health Science Center, continued the program with a session on antidepressant use in bipolar disorder. In his extensive evidence review, Dr. Bowden discussed implications for assessment, and how sample selection procedures can optimize the generalizability of a study’s findings.
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Steven Dubovsky, MD
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| Click here for video of Dr. Bowden discussing how the lack of generability of drug study findings informs clinical practice and how a psychiatrist can best assess for hypomania in bipolar disorder patients who are experiencing depressive symptoms.
After a break for networking and visiting the exhibitors, Dr. Ghaemi returned to discuss the use of antipsychotics for treating phases of bipolar disorder. He reviewed evidence from multiple studies of multiple drugs and suggested that clinicians balance the differential efficacy across agents against the risks and potential for using alternate medications.
Finally, the conference concluded with Dr. Bowden, who presented a session titled How to use mood stabilizers other than lithium for bipolar disorder. His presentation included guidelines for and caveats regarding using combination drug therapy for treatment of mania and evidence supporting the use of specific medications for preventing relapse.
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Psychopharmacology Jam Session - Gregory Teas, MD and Nagy Youssef, MD
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