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9 results

  • Chapter 20 - An Update on the Treatment of Manic and Hypomanic States

  • Edited by Allan Young, Institute of Psychiatry, King's College London, Marsal Sanches, Baylor College of Medicine, Texas, Jair C. Soares, McGovern Medical School, The University of Texas, Mario Juruena, King's College London
  • Book:
    Clinical Textbook of Mood Disorders
    Published online:
    16 May 2024
    Print publication:
    23 May 2024, pp 206-212

  • Summary

    Acute mania is a medical emergency and requires assiduous treatment to prevent significant risks to the individual, as well as effects on aspects of their psychosocial functioning. Hypomania has a similar clinical profile, with the absence of psychotic symptoms and disruption of functioning being the main factors differentiating it from mania. In this chapter we cover the key points in regard to clinical signs and management of mania and hypomania, predominantly focusing on pharmacological treatments. A number of national and international guidelines have covered this in depth, and we summarise their findings in this chapter. First-, second-, and third-line medication options for the acute phases are reviewed, while we also discuss combination strategies to address specific symptoms (e.g., agitation) and maintenance treatments aiming at relapse prevention and functional recovery.

  • Chapter 18 - Management of Major Depressive Disorder: Basic Principles

  • Edited by Allan Young, Institute of Psychiatry, King's College London, Marsal Sanches, Baylor College of Medicine, Texas, Jair C. Soares, McGovern Medical School, The University of Texas, Mario Juruena, King's College London
  • Book:
    Clinical Textbook of Mood Disorders
    Published online:
    16 May 2024
    Print publication:
    23 May 2024, pp 178-192

  • Summary

    Major depressive disorder (MDD) is manifested by mood, behavioural, cognitive, and somatic symptoms. This is reflected in the diagnostic criteria of both DSM-5 and ICD-10. Differential diagnosis typically includes the consideration of other mood and psychiatric disorders, neurological, medical and genetic conditions, as well as bereavement. Diagnostic investigations are commonly combined with the evaluation of functioning since the vast majority of MDD patients experience functional impairment. Suicidality is a major challenge in the management of MDD. Rigorous risk assessment, minimisation of risk factors, and promotion of protective factors are essential in suicide prevention. Treatment strategies can be split into acute, continuation, and maintentance phases. Depending on depression severity and other specifiers (e.g., psychosis, risk) both pharmacotherapy and psychotherapy can be efficacious first-line treatment options. Switching or augmenting initial treatment can be considered for non-responders. For continuation and maintenance phases, the primary aim of treatement is prolonging remission, preventing episode recurrence, and restoring psychosocial functioning.

  • Emergency Treatment of Anaphylactic Reactions in Air Rescue Missions: An Eight-Year Analysis of a German Rescue Helicopter Base

  • Theresa Lakner, Mandy Cuevas, Marie-Luise Polk, Katja Petrowski, Mark Frank
  • Journal:
    Prehospital and Disaster Medicine / Volume 36 / Issue 5 / October 2021
    Published online by Cambridge University Press:
    24 August 2021, pp. 586-592
    Print publication:
    October 2021
  • Introduction:

    Anaphylactic reactions can lead to a life-threatening situation. In the event of anaphylaxis, rapid and targeted emergency treatment is indicated.

    Study Objective:

    The study sought to determine the emergency therapy administered for anaphylaxis in children and adults. Focus was placed on therapy with adrenaline. In addition, the study aimed to investigate demographic data, triggers, and hospitalization rates of the different severities of anaphylaxis.

    Methods:

    A retrospective analysis of anaphylactic reactions was conducted using data from prehospital emergency missions performed by the Air Rescue Dresden/Germany from 2008 through 2015 using the standardized application protocol EPRO-5.0 (MIND 3) anonymized. Data from 152 adults and 29 children were evaluated, focusing especially on the acute treatment as well as demographic information, triggers, and symptoms of anaphylactic reactions.

    Results:

    In total, 152 adults (73 female, 79 male) from 18 to 87 years (mean 50.5 years) and 29 children (9 female, 20 male) from 1 to 16 years (mean 7.5 years) with anaphylactic reactions were analyzed. The most common trigger for severe anaphylactic reactions (Grade II-IV; classification modified according to Ring and Messmer) was food in children (33%) and insect venom in adults (59%). The data show that 19% of adults with Grade II-IV anaphylactic reactions (classification modified according to Ring and Messmer) received adrenaline. Regarding children, the appliance of adrenaline was only administered in seven percent of the cases of Grade II-IV anaphylactic reactions. Adults with Grade II or higher anaphylactic reactions were hospitalized in 92%. Three percent refused hospitalization and five percent were not transferred to hospital. One-hundred percent of the children with Grade II-IV anaphylaxis were hospitalized.

    Conclusions:

    Analysis of data from the Air Rescue Dresden/Germany shows that despite existing recommendations, only 19% of adults with severe anaphylaxis received adrenaline. Among children, only in seven percent was a treatment with adrenaline performed.

    On the other hand, all patients survived the acute emergency treatment without apparent adverse outcomes. Thus, further studies are needed to determine the proper use of adrenaline in anaphylactic reactions.

  • ECT response after relapse during continuation repetitive transcranial magnetic stimulation. A case report

  • A. Conca, W. Hrubos, J. Di Pauli, P. König, A. Hausmann
  • Journal:
    European Psychiatry / Volume 19 / Issue 2 / April 2004
    Published online by Cambridge University Press:
    16 April 2020, pp. 118-119

  • Research on repetitive transcranial magnetic stimulation (rTMS) indicates that the treatment of non-psychotic depression is comparable to electroconvulsive therapy (ECT) in terms of short-term outcome. We report on a woman who exerted a recurrent moderate major depressive episode, 6 months after discontinuation of maintenance ECT. She responded to acute rTMS treatment which was followed by the rTMS maintenance-protocol. Within 2 months of continuation rTMS she relapsed suffering from a severe non psychotic depressive episode and had to be switched to a successful ECT. In this patient rTMS had a good clinical impact as an acute treatment strategy, but failed to prevent relapse as the continuation ECT previously did in the same patient.

  • Home treatment for acute mental healthcare: randomised controlled trial

  • Niklaus Stulz, Lea Wyder, Lienhard Maeck, Matthias Hilpert, Helmut Lerzer, Eduard Zander, Wolfram Kawohl, Martin grosse Holtforth, Ulrich Schnyder, Urs Hepp
  • Journal:
    The British Journal of Psychiatry / Volume 216 / Issue 6 / June 2020
    Published online by Cambridge University Press:
    13 March 2019, pp. 323-330
    Print publication:
    June 2020
    • Article
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  • Background

    Home treatment has been proposed as an alternative to acute in-patient care for mentally ill patients. However, there is only moderate evidence in support of home treatment.

    Aims

    To test whether and to what degree home treatment services would enable a reduction (substitution) of hospital use.

    Method

    A total of 707 consecutively admitted adult patients with a broad spectrum of mental disorders (ICD-10: F2–F6, F8–F9, Z) experiencing crises that necessitated immediate admission to hospital, were randomly allocated to either a service model including a home treatment alternative to hospital care (experimental group) or a conventional service model that lacked a home treatment alternative to in-patient care (control group) (trial registration at ClinicalTrials.gov: NCT02322437).

    Results

    The mean number of hospital days per patient within 24 months after the index crisis necessitating hospital admission (primary outcome) was reduced by 30.4% (mean 41.3 v. 59.3, P<0.001) when a home treatment team was available (intention-to-treat analysis). Regarding secondary outcomes, average overall treatment duration (hospital days + home treatment days) per patient (mean 50.4 v. 59.3, P = 0.969) and mean number of hospital admissions per patient (mean 1.86 v. 1.93, P = 0.885) did not differ statistically significantly between the experimental and control groups within 24 months after the index crisis. There were no significant between-group differences regarding clinical and social outcomes (Health of the Nation Outcome Scales: mean 9.9 v. 9.7, P = 0.652) or patient satisfaction with care (Perception of Care questionnaire: mean 0.78 v. 0.80, P = 0.242).

    Conclusions

    Home treatment services can reduce hospital use among severely ill patients in acute crises and seem to result in comparable clinical/social outcomes and patient satisfaction as standard in-patient care.

  • Current management: migraine headache

  • Stephen D. Silberstein
  • Journal:
    CNS Spectrums / Volume 22 / Issue S1 / December 2017
    Published online by Cambridge University Press:
    19 January 2018, pp. 1-13

  • Migraine varies in its frequency, severity, and impact; treatment should consider these variations and the patient’s needs and goals. Migraine pharmacologic treatment may be acute (abortive) or preventive (prophylactic), and patients often require both. New medication devices are available or in development, including an intracutaneous, microneedle system of zolmitriptan and sumatriptan, and breath-powered powder sumatriptan intranasal treatment. Lasmiditan, a 5-HT1F receptor agonist, is in development for acute treatment, as are small molecule calcitonin gene-related peptide (CGRP) receptor antagonists (Gepants) for acute and preventive treatment. Antibodies to CGRP and its receptor are being developed for migraine prevention. All 4 treatments are effective and have, as of yet, no safety concerns.

  • Chapter 8 - The neuropsychiatry ofpsychosis and headache

  • Edited by Mark W. Green, Philip R. Muskin
  • Book:
    The Neuropsychiatry of Headache
    Published online:
    05 March 2013
    Print publication:
    07 March 2013, pp 75-94

  • Summary

    This chapter presents information on the background, diagnosis, clinical features, pathophysiology, forms, and precipitating factors of migraine. There are three major approaches to the treatment of migraines. It is often useful to view a migraine as a low threshold for the development of headache. There are three major approaches to the treatment of migraines: non-medication therapies; acute treatment; preventive treatment. Evidence-based guidelines support the use of cognitive behavior therapy. Most preventive agents for migraine are associated with weight gain, and this side effect, along with memory loss and depression, are the most common reasons for rejecting a particular agent. The Food and Drug Administration (FDA) in the United States issued an alert in 2006 that there would be a life-threatening risk when triptans were used in individuals taking selective serotonin reuptake inhibitors and selective serotonin/norepinephrine inhibitors.

  • Stroke as a medical emergency in older people

  • Davinia Ryan, Joseph Harbison
  • Journal:
    Reviews in Clinical Gerontology / Volume 21 / Issue 1 / February 2011
    Published online by Cambridge University Press:
    18 October 2010, pp. 45-54
    Print publication:
    February 2011

  • In the last 20 years a realization has developed that acute stroke is a condition that benefits from early intensive investigation and treatment. Older people are historically less likely to receive such active management through a combination of limited evidence due to their exclusion from clinical trials and a level of ‘therapeutic nihilism’ regarding older subjects with severe, acute illness.

    There is increasing evidence that many acute therapies, including thrombolysis, benefit older stroke patients. Older subjects may not achieve as good results as younger groups but differential benefits are often comparable when expected outcomes are considered. Risk of haemorrhagic complications with thrombolysis is not substantially increased and older subjects are now receiving this therapy despite a dearth of relevant trial data.

    Intensive physiological monitoring and stroke unit care has been found to be of benefit to patients of all ages. Surgical options for intracerebral haemorrhage are limited, but there is little difference in the management of intracranial haemorrhage in older people. There is unlikely to be a benefit to surgical hemicraniectomy for cerebral infarction in those >60 years. In conclusion, active management for acute stroke in older people is frequently beneficial and age should not be a barrier to such care.

  • Non-lithium pharmacological treatment of manic depression: a review

  • Brian O'Shea
  • Journal:
    Irish Journal of Psychological Medicine / Volume 10 / Issue 2 / June 1993
    Published online by Cambridge University Press:
    13 June 2014, pp. 114-120
    Print publication:
    June 1993

  • Objectives: To examine the reasons why manic-depressive patients often fail to respond to lithium and, the chief purpose of this paper, to review the present state of knowledge concerning alternative pharmacotherapies to lithium in this disorder. Method: Literature review. Findings: Lithium produces a clinically useful effect in 70-80% of cases. Factors such as non-compliance, side-effects, serum levels, and enduring psychosocial influences on the patient must be considered before treatment failure is diagnosed. Carbamazepine is the most studied alternative drug to date, and the most likely predictors of response to this agent are rapid-cycling, absence of a family history of affective disorder, mania, severe illness, and non-response to lithium. Conclusions: In view of the 20-25% of patients who do not respond to lithium, and the increased likelihood that lithium-responders may fail to respond again once the drug has been stopped for a period, further research is needed to find better and safer prophylactics against depression in bipolar disorders and to refine our knowledge of the indications for use of those already available.