Primary care companion to the Journal of clinical psychiatry
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Prim Care Companion J Clin Psychiatry · Oct 2003
New Generation Antipsychotic Drugs and QTc Interval Prolongation.
Recent regulatory and clinical concerns have brought into sharp focus antipsychotic drug-induced QTc interval prolongation, torsades de pointes, and sudden cardiac death. Several new generation (atypical) antipsychotic drugs have either been withdrawn from clinical use or delayed in reaching the marketplace due to these concerns. Because torsades de pointes is rarely found, QTc interval prolongation serves as a surrogate marker for this potentially life-threatening arrhythmia. Current methods of calculating this electrocardiographic parameter have limitations. The primary care physician is a key member of the team managing a patient who requires administration of antipsychotic drugs. This article focuses on new generation antipsychotic drugs and principles useful to both the primary care physician and the psychiatrist. ⋯ No evidence is currently available in the literature implicating new generation antipsychotic drugs in the production of torsades de pointes. However, the absence of such evidence does not prove that newer antipsychotic drugs do not cause torsades de pointes. Among patients free of risk factors for QTc interval prolongation and torsades de pointes, current literature does not dictate any specific consultative or laboratory intervention before administering new generation antipsychotic drugs. When risk factors are present, evaluation and intervention specific to those risk factors should dictate the clinician's course of action. More specific guidelines for monitoring the QT interval and risk of torsades de pointes await improved methods of measuring the QTc interval relevant to each patient.
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Prim Care Companion J Clin Psychiatry · Jan 2004
Undiagnosed Bipolar Disorder: New Syndromes and New Treatments.
Recent studies have indicated that bipolar disorder is more common than previously believed. The socioeconomic and personal burdens of this illness are significant, and the lifetime risk of suicide attempts by patients with bipolar II disorder is high. It is not uncommon for patients with bipolar disorder, especially those presenting with depression, to be seen first in a primary care setting; therefore, primary care physicians need to be ready to diagnose and manage patients with these mental illnesses. ⋯ A systematic and detailed initial history from the patient and a reliable family member is essential to making the correct diagnosis. The Mood Disorder Questionnaire, a validated screening instrument for bipolar disorder, may help primary care physicians make an appropriate diagnosis. Long-term management of patients with bipolar disorder should involve close liaison with a psychiatrist.
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Prim Care Companion J Clin Psychiatry · Apr 2002
Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management.
Approximately one quarter of patients who present to physicians for treatment of chest pain have panic disorder. Panic disorder frequently goes unrecognized and untreated among patients with chest pain, leading to frequent return visits and substantial morbidity. Panic attacks may lead to chest pain through a variety of mechanisms, both cardiac and noncardiac in nature, and multiple processes may cause chest pain in the same patient. ⋯ Furthermore, patients with panic disorder and chest pain have high rates of functional disability and medical service utilization. Fortunately, panic disorder is treatable; selective serotonin reuptake inhibitors, benzodiazepines, and cognitive-behavioral psychotherapy all effectively reduce symptoms. Preliminary studies have also found that treatment of patients who have panic disorder and chest pain with benzodiazepines results in reduction of chest pain as well as relief of anxiety.
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Prim Care Companion J Clin Psychiatry · Jan 2008
Level of agitation of psychiatric patients presenting to an emergency department.
The primary purpose of this study was to determine the level of agitation that psychiatric patients exhibit upon arrival to the emergency department. The secondary purpose was to determine whether the level of agitation changed over time depending upon whether the patient was restrained or unrestrained. ⋯ This study demonstrated that patients who were restrained were more agitated than those who were not, and that agitation levels in both groups decreased over time. Some restrained patients did not meet combativeness or severe agitation criteria, suggesting either that use of other criteria is needed or that restraints were used inappropriately. Further study of the level of agitation and the effects of restraints is needed.
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Prim Care Companion J Clin Psychiatry · Jan 2008
Chest pain and its importance in patients with panic disorder: an updated literature review.
Chest pain is a common symptom in primary care settings, associated with considerable morbidity and health care utilization. Failure to recognize panic disorder as the source of chest pain leads to increased health care costs and inappropriate management. ⋯ Chest pain during panic attacks is associated with increased health care utilization, poor quality of life, and phobic avoidance. Because the chest pain during panic attacks may be due to ischemia, the presence of panic attacks may go unrecognized. Ultimately, the diagnosis of panic disorder must be based on DSM criteria. However, once panic disorder is recognized, clinicians must remain open to the possibility of co-occurring coronary artery disease.