The Journal of clinical psychiatry
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Antipsychotics are widely used in geriatric psychiatric disorders. A growing number of atypical antipsychotics are available, expanding clinical options but complicating decision-making. Many questions about use of antipsychotics in older patients remain unanswered by available clinical literature. We therefore surveyed expert opinion on antipsychotic use in older patients (65 years of age or older) for recommendations concerning indications for antipsychotics, choice of antipsychotics for different conditions (e.g., delirium, dementia, schizophrenia, delusional disorder, psychotic mood disorders) and for patients with comorbid conditions or history of side effects, dosing strategies, duration of treatment, and medication combinations. ⋯ The experts reached a high level of consensus on many of the key treatment questions. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for common clinical dilemmas in the use of antipsychotics in elderly patients. Clinicians should keep in mind that no guidelines can address the complexities of an individual patient and that sound clinical judgment based on clinical experience should be used in applying these recommendations.
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Cognitive-behavioral therapy (CBT) can be successfully used to treat generalized anxiety disorder (GAD), with or without the inclusion of anxiolytics. The treatment of GAD using cognitive-behavioral techniques involves cognitive restructuring, relaxation, worry exposure, behavior modification, and problem solving. This article will review the principles used in CBT for the treatment of GAD and will discuss recent modifications of CBTs and how they may be employed. The simultaneous use of CBT and antidepressants will also be reviewed.
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Insomnia is a pervasive condition with various causes, manifestations, and health consequences. Regardless of the initial cause or event that precipitates insomnia, it is perpetuated into a chronic condition through learned behaviors and cognitions that foster sleeplessness. This article reviews the rationale and objectives of cognitive-behavioral therapy (CBT), a safe and effective treatment for insomnia that may be used to augment hypnotic drugs or as a monotherapy. ⋯ The evidence supporting this behavioral approach shows that CBT is effective for 70% to 80% of patients and that it can significantly reduce several measures of insomnia, including sleep-onset latency and wake-after-sleep onset. Aside from the clinically measurable changes, this therapy system enables many patients to regain a feeling of control over their sleep, thereby reducing the emotional distress that sleep disturbances cause. Some clinical and practical issues that often arise when implementing this therapeutic approach for insomnia are also discussed.
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Childhood maltreatment strongly predicts poor psychiatric and physical health outcomes in adulthood. This overview of the literature shows that individuals who suffer abuse, neglect, or serious family dysfunction as children are more likely to be depressed, to experience other types of psychiatric illness, to have more physical symptoms (both medically explained and unexplained), and to engage in more health-risk behaviors than their nonabused counterparts. ⋯ Individuals with a history of childhood abuse, particularly sexual abuse, are more likely than individuals with no history of abuse to become high utilizers of medical care and emergency services. Childhood maltreatment is highly prevalent among both men and women, especially in specialty settings such as emergency psychiatric care.