Folks,

 

Dr. Raymond Crowel assumed the Chief, Behavioral Health and Crisis Services position yesterday [phone: 240 777 1058].  Among his past positions, Dr. Crowel was on the County Council Blue Ribbon Commission for mental health in 2001-2, was Director of Child and Youth Services in Baltimore’s Mental Health system, Vice-President, Research, Practice and Policy at Mental Health America, and most-recently Vice-President at ICF International.  His special interests in clinical psychology include: 1] Child and Family; 2] Trauma/stress management; 3] wellness and healthy development; 4] Work-life balance. Given the challenges of his new position, “4]” will likely be tested.

 

Years ago, when I was at Saint Es, I would drop by Fuller Torrey’s office to get updated on his initiatives, and during one of those visits, he showed me photos of a brain with huge sulci and ventricles – very little brain left.  He had me guess the dx and I kept guessing and he kept saying, “No.”  Eventually I gave up, and he said “normal,” that the man, in his 60s, had function well as a CEO until he died. So, I had no reason to be surprised by last week’s NEUROLOGY article that the brains of nurses whose cognitive functioning was fine at death and those whose cognitive functioning was poor were not pathologically different.

 

Over the weekend, a report that a fish oil supplement, docosahexaenoic acid (DHA), 2000 mg/d, failed to slow cognitive decline in pts who already have Alzheimer’s.  

 

Yesterday, another report that elderly moderate drinkers, 8-14 drinks/week, were less likely to develop dementia.  Also, on Sunday, another report that being consistently sedentary is associated with an increased rate of dementia. 

 

Last week a report that found that the three cholinesterase inhibitors -- donepezil, rivastigmine or galantamine – are effective in the management of the behavioral and psychological symptoms of Alzheimer's disease

 

Yesterday’s Lancet had a Finnish article that launched some media headlines like: “Thousands of people with schizophrenia worldwide could have been saved if doctors had prescribed them the anti-psychotic drug clozapine.” This report was not welcomed by the psychosocially oriented, not by those attacking psychopharm and not by those championing the newer antipsychotics. This study followed pts on clozapine, perphenazine, thioridazine, risperidone, olanzapine, quetiapine, and those receiving polypharm.  This broad study has the problem of who was prescribed clozapine, who took their meds, value of monitoring and so forth. Nor does the report clarify doses.  Even so, it suggests that clozapine, given the way it is prescribed and monitored, seems superior in preserving life, especially in preventing suicides. On preserving life, second to clozapine was perphenazine. Furthermore, polypharm did better than most of the other antipsychotics on preserving life and preventing suicide. 

 

Last week in the popular press, a summary of NIMH’s following kids with childhood schizophrenia. Two to three have made it to college.  The article also says that clozapine seems to get the best results.

 

This month’s ARCHIVES has a report concluding that combining antidepressant drugs with electroconvulsive therapy (ECT) does a better job of reducing symptoms of severe depression and causes less memory loss than using ECT alone. "The findings challenge the recommendations of the American Psychiatric Association and others that antidepressants not be combined with ECT," said Dr. Sackeim. This finding also could alleviate 1 of the primary concerns about ECT — that it causes memory loss, said W. Vaughn McCall, MD, principal investigator for the study’s Wake Forest Baptist University Medical Center site, in Winston-Salem, North Carolina. "Although ECT remains a powerful treatment, there are still a significant proportion of patients who do not respond — recent statistics show a 70% to 80% response rate," Dr. McCall said. "Even in patients who do respond, there still is a significant risk of relapse. Patients may become ill again with depression within a matter of weeks to a few months after ECT." The patients received at least 1 form of ECT — either moderate-dose bilateral or high-dose, right-sided unilateral ECT. Patients in this study received either right-sided unilateral ECT administered at 6 times the seizure threshold or bilateral ECT at 1.5 times the seizure threshold. ECT was given 3 times per week, and patients in either ECT group who did show substantial improvement after 8 or more treatments were crossed over to high-dose (2.5 times seizure threshold) bilateral ECT. ECT was continued as long as clinical progress continued and stopped after no improvement for at least 2 treatments. A battery of cognitive tests was administered before ECT and 1 to 4 days following all ECT. The researchers found that using either antidepressant during ECT improved depression more than ECT alone and that adding nortriptyline to ECT increased remission rates by about 15%. Moreover, patients who received nortriptyline during ECT had fewer memory problems than those in the venlafaxine group. Researchers also found that using a high dose of unilateral ECT on the right side of the brain was as effective as or superior to treating depression with moderate-dose bilateral ECT and that it produced less severe amnesia.

Also in the ARCHIVES, a report of a trial of 50 pts with trichotillomania with the over-the-counter amino acid N-acetylcysteine, 1,200-2,400/d, found more than half improved compared with 16% taking placebo. 

 

Beginning October 1, ICD-9-CM has some additional codes that we can add to the syndrome diagnosis.  For example, a patient with whose major complaint is nervousness day after day, and on review of symptoms finds she meets the criteria of dysthymia, could be coded 300.4 and 799.21.

 

New code 799.21 Nervousness

 

New code 799.22 Irritability

 

New code 799.23 Impulsiveness [only if the pt does not meet criteria for impulsive neurosis (300.3)] [Keep in mind that ICD-9-CM still uses “neurosis.”]

 

New code 799.24 Emotional lability

 

New code 799.25 Demoralization and apathy/Apathetic

 

New code 799.29 Other signs and symptoms involving emotional

state

 

Roger