Current Psychiatry

Human nature is amazingly diverse. It is replete with behavioral quirks, oddities, eccentricities, and foibles. Most of these are idiosyncrasies that are outside the realm of psychopathology.

Frankly, the world would be a rather boring place without them. Contrary to the allegations that psychiatry medicalizes too many human behaviors that are in the “normal” range, only a small fraction of behavioral deviations are included in axis II of DSM-IV-TR. Unlike common peculiarities, the enduring personality disorders that psychiatrists diagnose and valiantly attempt to treat (no effective pharmacologic treatment has been approved for any of them) usually are significantly maladaptive and could lead to social or vocational dysfunction.

Many individuals exhibit “deplorable” behaviors that generally are frowned upon as a source of concern or are unlawful. Consider greed, bullying, chauvinism, fanaticism, extortion, demagoguery, or corruption. Very few, if any, of those who exhibit such fringe behaviors would consider seeking psychiatric help, although persons irked or injured by them wish they would. And what about bribery, power-seeking, malice, infidelity, laziness, mendacity, cheating, cruelty, narrow-mindedness, ruthlessness, and deceptiveness? Everyone has friends or relatives who exhibit such traits and flaunt them openly as a personal “brand.” Few such individuals would ever regard themselves as truly “flawed” or in need of change or professional help. In fact, those afflicted with such behavioral aberrations that are well outside the socially acceptable norms often are “successful” individuals who occupy prominent business or community roles despite their unendearing, even loathsome conduct. It sometimes appears that they have thrived despite their glaring lack of desirable social traits such as empathy, honesty, generosity, selflessness, and kindness.

Sometimes, it is not the oddities of behavior but extremes of political beliefs that can be most intriguing. They are reminiscent of delusions although they do not meet the DSM definition of delusional thinking (a fixed false belief inconsistent with one’s ethnic, cultural, educational, or religious background). Although real delusions are treatable with medications, para-delusional beliefs are not! A good example is the escalating prevalence of political fanaticism that has permeated society and dominated much of what used to be civilized discourse, even though most of the population continues to uphold middle-of-the-road political beliefs. The ideological polarization has even “infected” some media outlets, especially the free-wheeling blogosphere, where potentially venomous ideas are continuously spawned and instantly disseminated. Those who take diametrically opposite views often extend their conflicts over beliefs and ideas to personal hostilities and ad hominem attacks on “the other side.” This is an excellent example of how the entrenchment of beliefs and attitudes can directly shape behavior and transform an opinion into an “article of faith.”

Fanaticism is a long-standing human trait that has sparked wars and perpetuated prejudice and discrimination. Europe was ravaged by century-long wars instigated and fueled by religious fanaticism, proving that extreme beliefs can not only disrupt individual behavior but can impact cities, countries, and even the world, as depicted by World War II. Interestingly, when bizarre and fringe beliefs and behaviors are manifested on a large scale, it is regarded as political rather than psychopathological. Similarly, when religious beliefs become extreme, as sometimes happens in persons with acute bipolar mania, the unusual verbal output is regarded as a variant of religious exuberance rather than a psychiatric condition, which may delay medical treatment. It seems that in an age of intensifying secularism in developed western countries, political zealotry is the new religion!

Homo sapiens (wise man) is the only species that develops and harbors beliefs and whose behavior is inevitably guided, shaped, and determined by those beliefs. Obviously, some of our species’ beliefs are not consistently “wise,” but tenets can be vital to the health and survival of human individuals and communities. Émile Durkheim, the famous French sociologist, proposed in 1897 that “anomie,” or the lack of norms, values, and beliefs, is the main underpinning of suicide.¹ On the other hand, psychiatrists generally attribute suicide to multiple other factors and anomie rarely is mentioned. However, Durkheim, like all humans, is entitled to his idiosyncratic belief!

Human nature is amazingly diverse. It is replete with behavioral quirks, oddities, eccentricities, and foibles. Most of these are idiosyncrasies that are outside the realm of psychopathology.

Frankly, the world would be a rather boring place without them. Contrary to the allegations that psychiatry medicalizes too many human behaviors that are in the “normal” range, only a small fraction of behavioral deviations are included in axis II of DSM-IV-TR. Unlike common peculiarities, the enduring personality disorders that psychiatrists diagnose and valiantly attempt to treat (no effective pharmacologic treatment has been approved for any of them) usually are significantly maladaptive and could lead to social or vocational dysfunction.

Many individuals exhibit “deplorable” behaviors that generally are frowned upon as a source of concern or are unlawful. Consider greed, bullying, chauvinism, fanaticism, extortion, demagoguery, or corruption. Very few, if any, of those who exhibit such fringe behaviors would consider seeking psychiatric help, although persons irked or injured by them wish they would. And what about bribery, power-seeking, malice, infidelity, laziness, mendacity, cheating, cruelty, narrow-mindedness, ruthlessness, and deceptiveness? Everyone has friends or relatives who exhibit such traits and flaunt them openly as a personal “brand.” Few such individuals would ever regard themselves as truly “flawed” or in need of change or professional help. In fact, those afflicted with such behavioral aberrations that are well outside the socially acceptable norms often are “successful” individuals who occupy prominent business or community roles despite their unendearing, even loathsome conduct. It sometimes appears that they have thrived despite their glaring lack of desirable social traits such as empathy, honesty, generosity, selflessness, and kindness.

Sometimes, it is not the oddities of behavior but extremes of political beliefs that can be most intriguing. They are reminiscent of delusions although they do not meet the DSM definition of delusional thinking (a fixed false belief inconsistent with one’s ethnic, cultural, educational, or religious background). Although real delusions are treatable with medications, para-delusional beliefs are not! A good example is the escalating prevalence of political fanaticism that has permeated society and dominated much of what used to be civilized discourse, even though most of the population continues to uphold middle-of-the-road political beliefs. The ideological polarization has even “infected” some media outlets, especially the free-wheeling blogosphere, where potentially venomous ideas are continuously spawned and instantly disseminated. Those who take diametrically opposite views often extend their conflicts over beliefs and ideas to personal hostilities and ad hominem attacks on “the other side.” This is an excellent example of how the entrenchment of beliefs and attitudes can directly shape behavior and transform an opinion into an “article of faith.”

Fanaticism is a long-standing human trait that has sparked wars and perpetuated prejudice and discrimination. Europe was ravaged by century-long wars instigated and fueled by religious fanaticism, proving that extreme beliefs can not only disrupt individual behavior but can impact cities, countries, and even the world, as depicted by World War II. Interestingly, when bizarre and fringe beliefs and behaviors are manifested on a large scale, it is regarded as political rather than psychopathological. Similarly, when religious beliefs become extreme, as sometimes happens in persons with acute bipolar mania, the unusual verbal output is regarded as a variant of religious exuberance rather than a psychiatric condition, which may delay medical treatment. It seems that in an age of intensifying secularism in developed western countries, political zealotry is the new religion!

Homo sapiens (wise man) is the only species that develops and harbors beliefs and whose behavior is inevitably guided, shaped, and determined by those beliefs. Obviously, some of our species’ beliefs are not consistently “wise,” but tenets can be vital to the health and survival of human individuals and communities. Émile Durkheim, the famous French sociologist, proposed in 1897 that “anomie,” or the lack of norms, values, and beliefs, is the main underpinning of suicide.¹ On the other hand, psychiatrists generally attribute suicide to multiple other factors and anomie rarely is mentioned. However, Durkheim, like all humans, is entitled to his idiosyncratic belief!

Human nature is amazingly diverse. It is replete with behavioral quirks, oddities, eccentricities, and foibles. Most of these are idiosyncrasies that are outside the realm of psychopathology.

Frankly, the world would be a rather boring place without them. Contrary to the allegations that psychiatry medicalizes too many human behaviors that are in the “normal” range, only a small fraction of behavioral deviations are included in axis II of DSM-IV-TR. Unlike common peculiarities, the enduring personality disorders that psychiatrists diagnose and valiantly attempt to treat (no effective pharmacologic treatment has been approved for any of them) usually are significantly maladaptive and could lead to social or vocational dysfunction.

Many individuals exhibit “deplorable” behaviors that generally are frowned upon as a source of concern or are unlawful. Consider greed, bullying, chauvinism, fanaticism, extortion, demagoguery, or corruption. Very few, if any, of those who exhibit such fringe behaviors would consider seeking psychiatric help, although persons irked or injured by them wish they would. And what about bribery, power-seeking, malice, infidelity, laziness, mendacity, cheating, cruelty, narrow-mindedness, ruthlessness, and deceptiveness? Everyone has friends or relatives who exhibit such traits and flaunt them openly as a personal “brand.” Few such individuals would ever regard themselves as truly “flawed” or in need of change or professional help. In fact, those afflicted with such behavioral aberrations that are well outside the socially acceptable norms often are “successful” individuals who occupy prominent business or community roles despite their unendearing, even loathsome conduct. It sometimes appears that they have thrived despite their glaring lack of desirable social traits such as empathy, honesty, generosity, selflessness, and kindness.

Sometimes, it is not the oddities of behavior but extremes of political beliefs that can be most intriguing. They are reminiscent of delusions although they do not meet the DSM definition of delusional thinking (a fixed false belief inconsistent with one’s ethnic, cultural, educational, or religious background). Although real delusions are treatable with medications, para-delusional beliefs are not! A good example is the escalating prevalence of political fanaticism that has permeated society and dominated much of what used to be civilized discourse, even though most of the population continues to uphold middle-of-the-road political beliefs. The ideological polarization has even “infected” some media outlets, especially the free-wheeling blogosphere, where potentially venomous ideas are continuously spawned and instantly disseminated. Those who take diametrically opposite views often extend their conflicts over beliefs and ideas to personal hostilities and ad hominem attacks on “the other side.” This is an excellent example of how the entrenchment of beliefs and attitudes can directly shape behavior and transform an opinion into an “article of faith.”

Fanaticism is a long-standing human trait that has sparked wars and perpetuated prejudice and discrimination. Europe was ravaged by century-long wars instigated and fueled by religious fanaticism, proving that extreme beliefs can not only disrupt individual behavior but can impact cities, countries, and even the world, as depicted by World War II. Interestingly, when bizarre and fringe beliefs and behaviors are manifested on a large scale, it is regarded as political rather than psychopathological. Similarly, when religious beliefs become extreme, as sometimes happens in persons with acute bipolar mania, the unusual verbal output is regarded as a variant of religious exuberance rather than a psychiatric condition, which may delay medical treatment. It seems that in an age of intensifying secularism in developed western countries, political zealotry is the new religion!

Homo sapiens (wise man) is the only species that develops and harbors beliefs and whose behavior is inevitably guided, shaped, and determined by those beliefs. Obviously, some of our species’ beliefs are not consistently “wise,” but tenets can be vital to the health and survival of human individuals and communities. Émile Durkheim, the famous French sociologist, proposed in 1897 that “anomie,” or the lack of norms, values, and beliefs, is the main underpinning of suicide.¹ On the other hand, psychiatrists generally attribute suicide to multiple other factors and anomie rarely is mentioned. However, Durkheim, like all humans, is entitled to his idiosyncratic belief!

One of the greatest challenges for busy clinicians, such as Current Psychiatry readers, is keeping up with advances in the field of psychiatry in our limited available time. Because psychiatry is one of the most rapidly expanding medical specialties, psychiatrists, psychiatric nurse practitioners, and other mental health clinicians recognize the importance of ongoing self-driven learning to make sure they are practicing the latest standards of care in diagnosis and treatment.

Although continuously acquiring new knowledge that can improve patient care is stimulating and necessary, it also may be intimidating because most medical journals are packed with studies with arcane methodology, complicated designs, complex statistics, dense tables, and busy figures. Wading through the literature can be time-consuming—and even exhausting—for a busy clinician with limited time to learn the latest research findings, and this approach is not always guaranteed to provide the relevant “take-home nuggets” that can enhance clinical practice.

Enter Current Psychiatry. Established in 2002 as the brainchild of former University of Cincinnati Department of Psychiatry Chair Randy Hillard, MD (now Editor-in-Chief Emeritus) and publisher Thomas Pizor, Current Psychiatry was designed precisely to fill this vital unmet need for busy clinical psychiatrists.¹ Current Psychiatry provides practical, peer-reviewed, evidence-based reviews that are highly relevant to the realities of clinical psychiatric practice. Nationally recognized experts write articles about topics identified as “valued” by practitioners based on systematic surveys of clinicians in various community settings. A diverse editorial board of prominent academic teachers and researchers provides an ongoing stream of diverse articles and perspectives that distill the emerging science and practice of psychiatry into immediately useful applications.

From our first issue, Current Psychiatry has presented information that readers could use to care for their patients, in articles such as:

• Using antipsychotics in patients with dementia (Kasckow JW, et al; February 2004)
• How to reduce mania risk when prescribing stimulants (Dubovsky SL, et al; October 2005)
• Hypnotics and driving: FDA action, clinical trials show need for precautions (Freeman B, et al; April 2007)
• Fibromyalgia: Psychiatric drugs target CNS-linked symptoms (Stanford SB; March 2009)
• The re-emerging role of therapeutic neuromodulation (Janicak PG, et al; November 2010)

The impact has been spectacular. As Current Psychiatry celebrates its 10^th anniversary this month, we can relish its remarkable growth and success. In independent readership surveys, Current Psychiatry has grown to become the most widely read non-tabloid psychiatry journal.² As Editor-in-Chief, I derive great satisfaction from the rave reviews I receive from my colleagues around the country about how they regard Current Psychiatry as their number 1 resource for clinical updates. Stellar feedback such as this indicates that Current Psychiatry clearly meets clinicians’ educational needs.

However, we are not resting on our laurels. Current Psychiatry has continued to innovate and develop new approaches to ongoing self-education by growing its online presence. The offerings at CurrentPsychiatry.com have steadily increased to include the following features:

Online-exclusive content. CurrentPsychiatry.com provides additional resources such as tables, boxes, algorithms, and/or figures related to articles from the printed edition. Later this year, as our 10^th anniversary initiative for you, our readers, Current Psychiatry will offer complete online-exclusive articles that will be listed on the table of contents but published only on CurrentPsychiatry.com.

Multimedia library. Every month, the author of 1 article is invited to participate in a brief (5- to 10-minute) audiocast in which he or she provides additional commentary on clinical topics related to the article. This library currently houses nearly 50 audiocasts. Available at CurrentPsychiatry.com/pages.asp?id=6412.

Continuing Medical Education (CME). This section of our Web site provides peer-reviewed education programs that offer visitors the opportunity to earn free CME credits on a range of clinical topics, including schizophrenia, bipolar disorder, depression, and more. Available at CurrentPsychiatry.com/pages_cme.asp.

Supplements. Recent topics covered in these peer-reviewed, non-CME programs include managing schizophrenia, transcranial magnetic stimulation for depression, and more. Available at CurrentPsychiatry.com/pages_supplement.asp.

Going beyond our printed and online content, Current Psychiatry serves our readers’ educational needs through CME meetings such as the annual Psychiatry Update, which is hosted in conjunction with the American Academy of Clinical Psychiatrists. The next meeting will take place March 29 to 31, 2012 in Chicago, IL and will offer a maximum of 18 AMA PRA Category 1 Credits^TM (For more information, click here.). In addition, Current Psychiatry co-sponsors the University of Cincinnati’s Annual Psychopharmacology Update, which is scheduled for October 20, 2012 in Cincinnati, OH, offering AMA PRA Category 1 Credits^TM.

One of the gratifying aspects of producing a highly relevant educational vehicle such as Current Psychiatry is that my trainees at the University of Cincinnati tell me how useful they find it for their clinical practice. I am glad that they already have developed the good habit of reading Current Psychiatry from cover to cover during their training!

On behalf of Current Psychiatry’s Deputy Editor, Joseph F. Goldberg, MD, our Editorial Consultants, Section Editors, Associate Editors, editorial staff, and publishing staff, we thank you, our loyal readers, for valuing what we do and using the knowledge provided by Current Psychiatry to manage various psychiatric populations with the latest nosological and therapeutic advances. We invite you to continue interacting with us in person, by e-mail, or via CurrentPsychiatry.com and tell us how we can continue to meet your educational needs. We find it very rewarding to hear from you.

One of the greatest challenges for busy clinicians, such as Current Psychiatry readers, is keeping up with advances in the field of psychiatry in our limited available time. Because psychiatry is one of the most rapidly expanding medical specialties, psychiatrists, psychiatric nurse practitioners, and other mental health clinicians recognize the importance of ongoing self-driven learning to make sure they are practicing the latest standards of care in diagnosis and treatment.

Although continuously acquiring new knowledge that can improve patient care is stimulating and necessary, it also may be intimidating because most medical journals are packed with studies with arcane methodology, complicated designs, complex statistics, dense tables, and busy figures. Wading through the literature can be time-consuming—and even exhausting—for a busy clinician with limited time to learn the latest research findings, and this approach is not always guaranteed to provide the relevant “take-home nuggets” that can enhance clinical practice.

Enter Current Psychiatry. Established in 2002 as the brainchild of former University of Cincinnati Department of Psychiatry Chair Randy Hillard, MD (now Editor-in-Chief Emeritus) and publisher Thomas Pizor, Current Psychiatry was designed precisely to fill this vital unmet need for busy clinical psychiatrists.¹ Current Psychiatry provides practical, peer-reviewed, evidence-based reviews that are highly relevant to the realities of clinical psychiatric practice. Nationally recognized experts write articles about topics identified as “valued” by practitioners based on systematic surveys of clinicians in various community settings. A diverse editorial board of prominent academic teachers and researchers provides an ongoing stream of diverse articles and perspectives that distill the emerging science and practice of psychiatry into immediately useful applications.

From our first issue, Current Psychiatry has presented information that readers could use to care for their patients, in articles such as:

• Using antipsychotics in patients with dementia (Kasckow JW, et al; February 2004)
• How to reduce mania risk when prescribing stimulants (Dubovsky SL, et al; October 2005)
• Hypnotics and driving: FDA action, clinical trials show need for precautions (Freeman B, et al; April 2007)
• Fibromyalgia: Psychiatric drugs target CNS-linked symptoms (Stanford SB; March 2009)
• The re-emerging role of therapeutic neuromodulation (Janicak PG, et al; November 2010)

The impact has been spectacular. As Current Psychiatry celebrates its 10^th anniversary this month, we can relish its remarkable growth and success. In independent readership surveys, Current Psychiatry has grown to become the most widely read non-tabloid psychiatry journal.² As Editor-in-Chief, I derive great satisfaction from the rave reviews I receive from my colleagues around the country about how they regard Current Psychiatry as their number 1 resource for clinical updates. Stellar feedback such as this indicates that Current Psychiatry clearly meets clinicians’ educational needs.

However, we are not resting on our laurels. Current Psychiatry has continued to innovate and develop new approaches to ongoing self-education by growing its online presence. The offerings at CurrentPsychiatry.com have steadily increased to include the following features:

Online-exclusive content. CurrentPsychiatry.com provides additional resources such as tables, boxes, algorithms, and/or figures related to articles from the printed edition. Later this year, as our 10^th anniversary initiative for you, our readers, Current Psychiatry will offer complete online-exclusive articles that will be listed on the table of contents but published only on CurrentPsychiatry.com.

Multimedia library. Every month, the author of 1 article is invited to participate in a brief (5- to 10-minute) audiocast in which he or she provides additional commentary on clinical topics related to the article. This library currently houses nearly 50 audiocasts. Available at CurrentPsychiatry.com/pages.asp?id=6412.

Continuing Medical Education (CME). This section of our Web site provides peer-reviewed education programs that offer visitors the opportunity to earn free CME credits on a range of clinical topics, including schizophrenia, bipolar disorder, depression, and more. Available at CurrentPsychiatry.com/pages_cme.asp.

Supplements. Recent topics covered in these peer-reviewed, non-CME programs include managing schizophrenia, transcranial magnetic stimulation for depression, and more. Available at CurrentPsychiatry.com/pages_supplement.asp.

Going beyond our printed and online content, Current Psychiatry serves our readers’ educational needs through CME meetings such as the annual Psychiatry Update, which is hosted in conjunction with the American Academy of Clinical Psychiatrists. The next meeting will take place March 29 to 31, 2012 in Chicago, IL and will offer a maximum of 18 AMA PRA Category 1 Credits^TM (For more information, click here.). In addition, Current Psychiatry co-sponsors the University of Cincinnati’s Annual Psychopharmacology Update, which is scheduled for October 20, 2012 in Cincinnati, OH, offering AMA PRA Category 1 Credits^TM.

One of the gratifying aspects of producing a highly relevant educational vehicle such as Current Psychiatry is that my trainees at the University of Cincinnati tell me how useful they find it for their clinical practice. I am glad that they already have developed the good habit of reading Current Psychiatry from cover to cover during their training!

On behalf of Current Psychiatry’s Deputy Editor, Joseph F. Goldberg, MD, our Editorial Consultants, Section Editors, Associate Editors, editorial staff, and publishing staff, we thank you, our loyal readers, for valuing what we do and using the knowledge provided by Current Psychiatry to manage various psychiatric populations with the latest nosological and therapeutic advances. We invite you to continue interacting with us in person, by e-mail, or via CurrentPsychiatry.com and tell us how we can continue to meet your educational needs. We find it very rewarding to hear from you.

One of the greatest challenges for busy clinicians, such as Current Psychiatry readers, is keeping up with advances in the field of psychiatry in our limited available time. Because psychiatry is one of the most rapidly expanding medical specialties, psychiatrists, psychiatric nurse practitioners, and other mental health clinicians recognize the importance of ongoing self-driven learning to make sure they are practicing the latest standards of care in diagnosis and treatment.

Although continuously acquiring new knowledge that can improve patient care is stimulating and necessary, it also may be intimidating because most medical journals are packed with studies with arcane methodology, complicated designs, complex statistics, dense tables, and busy figures. Wading through the literature can be time-consuming—and even exhausting—for a busy clinician with limited time to learn the latest research findings, and this approach is not always guaranteed to provide the relevant “take-home nuggets” that can enhance clinical practice.

Enter Current Psychiatry. Established in 2002 as the brainchild of former University of Cincinnati Department of Psychiatry Chair Randy Hillard, MD (now Editor-in-Chief Emeritus) and publisher Thomas Pizor, Current Psychiatry was designed precisely to fill this vital unmet need for busy clinical psychiatrists.¹ Current Psychiatry provides practical, peer-reviewed, evidence-based reviews that are highly relevant to the realities of clinical psychiatric practice. Nationally recognized experts write articles about topics identified as “valued” by practitioners based on systematic surveys of clinicians in various community settings. A diverse editorial board of prominent academic teachers and researchers provides an ongoing stream of diverse articles and perspectives that distill the emerging science and practice of psychiatry into immediately useful applications.

From our first issue, Current Psychiatry has presented information that readers could use to care for their patients, in articles such as:

• Using antipsychotics in patients with dementia (Kasckow JW, et al; February 2004)
• How to reduce mania risk when prescribing stimulants (Dubovsky SL, et al; October 2005)
• Hypnotics and driving: FDA action, clinical trials show need for precautions (Freeman B, et al; April 2007)
• Fibromyalgia: Psychiatric drugs target CNS-linked symptoms (Stanford SB; March 2009)
• The re-emerging role of therapeutic neuromodulation (Janicak PG, et al; November 2010)

The impact has been spectacular. As Current Psychiatry celebrates its 10^th anniversary this month, we can relish its remarkable growth and success. In independent readership surveys, Current Psychiatry has grown to become the most widely read non-tabloid psychiatry journal.² As Editor-in-Chief, I derive great satisfaction from the rave reviews I receive from my colleagues around the country about how they regard Current Psychiatry as their number 1 resource for clinical updates. Stellar feedback such as this indicates that Current Psychiatry clearly meets clinicians’ educational needs.

However, we are not resting on our laurels. Current Psychiatry has continued to innovate and develop new approaches to ongoing self-education by growing its online presence. The offerings at CurrentPsychiatry.com have steadily increased to include the following features:

Online-exclusive content. CurrentPsychiatry.com provides additional resources such as tables, boxes, algorithms, and/or figures related to articles from the printed edition. Later this year, as our 10^th anniversary initiative for you, our readers, Current Psychiatry will offer complete online-exclusive articles that will be listed on the table of contents but published only on CurrentPsychiatry.com.

Multimedia library. Every month, the author of 1 article is invited to participate in a brief (5- to 10-minute) audiocast in which he or she provides additional commentary on clinical topics related to the article. This library currently houses nearly 50 audiocasts. Available at CurrentPsychiatry.com/pages.asp?id=6412.

Continuing Medical Education (CME). This section of our Web site provides peer-reviewed education programs that offer visitors the opportunity to earn free CME credits on a range of clinical topics, including schizophrenia, bipolar disorder, depression, and more. Available at CurrentPsychiatry.com/pages_cme.asp.

Supplements. Recent topics covered in these peer-reviewed, non-CME programs include managing schizophrenia, transcranial magnetic stimulation for depression, and more. Available at CurrentPsychiatry.com/pages_supplement.asp.

Going beyond our printed and online content, Current Psychiatry serves our readers’ educational needs through CME meetings such as the annual Psychiatry Update, which is hosted in conjunction with the American Academy of Clinical Psychiatrists. The next meeting will take place March 29 to 31, 2012 in Chicago, IL and will offer a maximum of 18 AMA PRA Category 1 Credits^TM (For more information, click here.). In addition, Current Psychiatry co-sponsors the University of Cincinnati’s Annual Psychopharmacology Update, which is scheduled for October 20, 2012 in Cincinnati, OH, offering AMA PRA Category 1 Credits^TM.

One of the gratifying aspects of producing a highly relevant educational vehicle such as Current Psychiatry is that my trainees at the University of Cincinnati tell me how useful they find it for their clinical practice. I am glad that they already have developed the good habit of reading Current Psychiatry from cover to cover during their training!

On behalf of Current Psychiatry’s Deputy Editor, Joseph F. Goldberg, MD, our Editorial Consultants, Section Editors, Associate Editors, editorial staff, and publishing staff, we thank you, our loyal readers, for valuing what we do and using the knowledge provided by Current Psychiatry to manage various psychiatric populations with the latest nosological and therapeutic advances. We invite you to continue interacting with us in person, by e-mail, or via CurrentPsychiatry.com and tell us how we can continue to meet your educational needs. We find it very rewarding to hear from you.

CASE: Hurt and confused

Emergency medical services (EMS) are called to Ms. K’s apartment after her roommate found her lying on the floor moaning. The roommate tells EMS that Ms. K, age 29, appeared confused and was slurring her words, and reports that this change in her awareness progressed rapidly over a few hours. EMS personnel find that Ms. K has multiple contusions on her arms and face, which they presume to be self-inflicted. A marijuana pipe is discovered at Ms. K’s apartment.

In the emergency room (ER), Ms. K is inattentive and has difficulty following simple commands. Her speech is mumbled and her thoughts are disorganized. She displays psychomotor restlessness in the form of combativeness. Ms. K cannot provide meaningful historical data and is disoriented to place and time. The ER staff requests a psychiatric consultation.

Family members reveal that Ms. K has no preexisting medical conditions, is not taking prescription medications, but has a history of substance abuse (sporadic cocaine and cannabis use). Her family is unaware of recent substance use.

Physical examination reveals tachycardia (heart rate 110 to 120 beats per minute), hypotension (blood pressure 78/49 mm Hg), hypothermia (temperature 88ºF), and peripheral pulse oximetry of 84%. Her pupils are dilated and reactive to light; no conjunctival injection is noted. Her lung fields are clear on auscultation, but she is noted to have a rapid, irregular heartbeat. The abdomen is positive for bowel sounds, soft on palpation, and without any repositioning or notable overt signs of tenderness. Ms. K’s toes show purple discoloration with poor capillary refill. The dorsalis pedis pulses are reported to be 1+ bilaterally; however, the remainder of the arterial pulse examination is normal.

Her sodium, potassium, and chloride values are normal, but she has an abnormal anion gap (28.1 mEq/L), blood urea nitrogen (53 mg/dL), creatinine (2.9 mg/dL), creatine kinase (10,857 U/L), creatine kinase MB (432.6 ng/mL), and hyperglycemia (glucose 425 mg/dL). Arterial blood gas reveals hypoxia (Po₂ of 55 mm Hg), with metabolic acidosis (sodium bicarbonate 10 with compensatory Pco₂ of 33 mm Hg). Her urine is cloudy, positive for protein, ketones, hemoglobin, and glucose. She is thought to have a high anion gap acidosis related to dehydration, lactic acidosis (lactic acid 20 mEq/L), and hyperglycemia. Urine toxicology is positive for cannabinoids; ethylene glycol and methanol screen negatively, which rules these out as potential contributors to her high anion gap acidosis.

Ms. K is intubated and IV fluids are initiated for rhabdomyolysis and acute renal failure. Dialysis is implemented on a short-term basis. Her mental state improves gradually over 3 days.

The authors’ observations

Based on the abrupt onset of inattention and confusion, disorganized speech, memory impairments, and psychomotor agitation, we made an initial diagnosis of delirium; however, the precise etiology remained unclear. DSM-IV-TR diagnostic criteria for delirium are described in Table 1. Although delirium due to multiple etiologies does not have a DSM-IV-TR coding designation, we speculated that multiple causes contributed to Ms. K’s presentation. Acute renal failure secondary to dehydration as well as rhabdomyolysis, hypoxia, and hyperglycemia were implicated as general medical conditions etiologically linked to delirium. Because Ms. K has no preexisting medical conditions and her roommate and family stated she had a history of substance abuse, we also considered a presumptive diagnosis of substance-induced delirium. The medical team speculated that, based on information provided by her family, Ms. K may have had a seizure or may have fallen, which would account for her multiple contusions, and could have led to muscle injury and breakdown and the resultant rhabdomyolysis.

The possibility of cannabinoid-induced delirium has been reported, albeit rarely.^1-3 However, Ms. K’s presentation—hypothermia, variable heart rate, lack of dry mucous membranes—was not consistent with significant anticholinergic toxicity or cannabinoid intoxication (Table 2).

By contrast, cocaine-induced delirium has been reported and initially appeared to be a plausible cause of Ms. K’s symptoms (Table 2). Delirium related to excess ingestion of cocaine may be related to the drug’s secondary effects resulting in rhabdomyolysis and renal dysfunction.^4-6 Although several mechanisms underlying this relationship have been proposed, no single specific mechanism has been identified. The basis for cocaine ingestion and the resultant metabolic and renal effects, as observed in Ms. K’s case, likely are multifactorial. Mechanisms of the rhabdomyolysis might include:

• blockade of synaptic catecholamine reuptake and induction of adrenergic agonism, resulting in vasoconstriction and ischemia and leading to muscle damage
• cocaine-induced seizures and/or prolonged unconsciousness, leading to muscle compression and breakdown of muscle tissue
• a period of exertion induced by cocaine, precipitating an excited delirium and associated rhabdomyolysis
• a surge in dopamine concentrations, similar to neuroleptic malignant syndrome, precipitates hyperthermia, muscle rigidity, and psychomotor agitation, disrupting neuromuscular homeostasis and leading to rhabdomyolysis.

We were uncertain about the plausibility that acute cocaine intoxication caused Ms. K’s medical sequelae, in light of her toxicology findings. If cocaine use was the inciting event, and because the delirium reportedly had developed over several hours, we would expect cocaine to be detected in the toxicology screen. However, it was not detected. Cocaine can remain detectable in urine for 2 to 4 days,⁷ which raised our speculation that remote cocaine abuse could account for Ms. K’s current presentation and the timeline the roommate initially relayed to EMS personnel was inaccurate. We needed to clarify the timeline and progression of Ms. K’s symptoms with the roommate. In addition, we suggested to the medical team that alternative substances of abuse could be causing Ms. K’s symptoms and the roommate might be the only person who could unveil this possibility.

Table 1

DSM-IV-TR criteria for delirium due to multiple etiologies

Table 2

Diagnostic criteria for cannabis and cocaine intoxication

HISTORY: Unknown substance

Ms. K’s roommate is contacted for supplemental history. The roommate reports that recently he observed Ms. K “snorting” a brown/tan-colored substance. He had not seen her use this substance previously, and when he asked her what it was, she reportedly said that it was “PeeVee” (also called “bath salts”) purchased over the Internet.

The authors’ observations

MDPV is a novel chemical compound that is used as a recreational drug (Table 3).⁸ It commonly is acquired from Internet sources and sold as “bath salts.” Its use first emerged in approximately 2004, and its popularity has been increasing because of its easy availability and relatively low cost.⁹ The American Association of Poison Control Centers received 302 calls related to MDPV toxicity in 2010 and 5,625 calls related to MDPV use between January 1 and October 31, 2011.^10,11

MDPV has psychoactive properties, with stimulant effects acting as a norepinephrine-dopamine reuptake inhibitor.^8,9,12 When snorted, ingested orally, or inserted rectally, the agent produces effects comparable to cocaine or psychostimulants such as methylphenidate or dextroamphetamine.

Acute effects of MDPV include heightened alertness, diminished need for sleep, hyperarousal, and euphoria.^8,9 These symptoms often are accompanied by increases in heart rate and blood pressure, sweating, and peripheral vasoconstriction. Individuals may abuse MDPV to acquire sustained attention, reduce their need for sleep, or for aphrodisiac effects. In many cases, anxiety and irritability can accompany the desired euphoric effects. For some, the euphoric effects can be superseded by anxiety or agitation. Mood and attention effects are estimated to last 3 to 4 hours; however, tachycardia and hypertension can persist for 6 to 8 hours.

MDPV use can trigger cravings and lead to binging. Euphoric stimulation with MDPV can become dysphoric as the dose and duration of use increase. Extended use has been associated with agitation, irritability, aggression, panic and marked anxiety, psychosis, and delirium.^8,9 Anxiety can range from mild dysphoric stimulation to extreme panic-like states. In moderate forms, a state of sympathetic discharge can occur, producing physiologic effects resembling panic attacks, including hypertension, tachycardia, sweating, and peripheral vasoconstriction. In more severe cases, users may experience a feeling of impending doom, marked distress, and frank psychosis. Patients may experience disorientation and unsystematized paranoid delusions. Case reports of intoxication have described self-injurious behaviors, such as cutting, which may account for the contusions observed on Ms. K’s face and arms. Increasingly, MDPV use has resulted in ER presentations with patients manifesting abrupt onset confusion, anxiety, and self-injurious behaviors.

The mechanisms underlying MDPV-induced delirium have not been definitively identified. Given the similarities in mechanism of action between MDPV and cocaine, causes for delirium related to MDPV are similarly presumed to be multifactorial. The course of delirium associated with MDPV intoxication is self-limited and requires supportive measures.^8,9

Suspect MDPV abuse in patients who present with signs or symptoms of stimulant intoxication but have a negative toxicology screen for cocaine and other psychostimulants. MDPV is not detected on routine toxicology assessments; however, it can be identified through laboratories with gas chromatography/mass spectroscopy capabilities. However, the time needed to obtain the results may exceed the clinical course of the patient’s delirium. One of the limitations in Ms. K’s case was the lack of gas chromatography/mass spectroscopy to confirm MDPV ingestion. Ms. K’s roommate could not locate any unused brown powder within their apartment to bring in for laboratory investigations. Recently, screening assessments for MDPV have become commercially available (see Related Resources).

Table 3

Overview of MDPV features

OUTCOME: Referral to treatment

Dialysis is discontinued within 1 day of hospitalization. Ms. K’s peripheral arterial perfusion improves, as does her thermoregulatory status. Her mental status improvements coincide with improvements in her physical and metabolic status.

Ms. K is able to sustain attention when speaking with interviewers. She is aware of her surroundings and is no longer distracted by extraneous stimuli. Her speech is articulate and her thoughts are linear. There is no evidence of any residual thought disorganization, delusions, or hallucinations.

Initially, Ms. K is reluctant to acknowledge her substance use, but eventually, she concedes to acquiring a stimulant from an Internet source and abusing it in undetermined amounts. She had no experience with using MDPV and did not know how to avoid ingesting dangerous amounts. We educate Ms. K about the dangers she faced during this hospitalization and the potential life-threatening outcomes. She is amenable to pursuing outpatient substance abuse treatment. Her roommate is enlisted to facilitate her follow-up with this treatment.

The authors’ observations

Managing MDPV toxicity presents a diagnostic dilemma for medical personnel and psychiatrists when evaluating and managing acute delirium. MDPV ingestion may go unrecognized in clinical settings because toxicology assessments for it are not readily available and patients’ historical information may be unreliable.

Because of the seriousness of sequelae associated with MDPV use, state and federal agencies have intervened. Until recently, bath salts did not have a controlled substance designation. In October 2011, the US Drug Enforcement Administration (DEA) ruled to make MDPV a controlled substance for 1 year, with the possibility of a 6-month extension.¹³ Although this ruling is temporary, it makes possession, sale, or distribution of these chemicals, or the products that contain them, illegal in the United States. In the interim, the DEA and the US Department of Health and Human Services will determine whether MDPV should remain a controlled substance.

Related Resources

• American Screening Corp. (MDPV screening). www.americanscreeningcorp.com.
• U.S. Drug Enforcement Administration. 3, 4-Methylenedioxypyrovalerone (MDPV). www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf.
• Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones [published online ahead of print November 23, 2011]. J Med Toxicol. doi: 10.1007/s13181-011-0193-z.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Hurt and confused

Emergency medical services (EMS) are called to Ms. K’s apartment after her roommate found her lying on the floor moaning. The roommate tells EMS that Ms. K, age 29, appeared confused and was slurring her words, and reports that this change in her awareness progressed rapidly over a few hours. EMS personnel find that Ms. K has multiple contusions on her arms and face, which they presume to be self-inflicted. A marijuana pipe is discovered at Ms. K’s apartment.

In the emergency room (ER), Ms. K is inattentive and has difficulty following simple commands. Her speech is mumbled and her thoughts are disorganized. She displays psychomotor restlessness in the form of combativeness. Ms. K cannot provide meaningful historical data and is disoriented to place and time. The ER staff requests a psychiatric consultation.

Family members reveal that Ms. K has no preexisting medical conditions, is not taking prescription medications, but has a history of substance abuse (sporadic cocaine and cannabis use). Her family is unaware of recent substance use.

Physical examination reveals tachycardia (heart rate 110 to 120 beats per minute), hypotension (blood pressure 78/49 mm Hg), hypothermia (temperature 88ºF), and peripheral pulse oximetry of 84%. Her pupils are dilated and reactive to light; no conjunctival injection is noted. Her lung fields are clear on auscultation, but she is noted to have a rapid, irregular heartbeat. The abdomen is positive for bowel sounds, soft on palpation, and without any repositioning or notable overt signs of tenderness. Ms. K’s toes show purple discoloration with poor capillary refill. The dorsalis pedis pulses are reported to be 1+ bilaterally; however, the remainder of the arterial pulse examination is normal.

Her sodium, potassium, and chloride values are normal, but she has an abnormal anion gap (28.1 mEq/L), blood urea nitrogen (53 mg/dL), creatinine (2.9 mg/dL), creatine kinase (10,857 U/L), creatine kinase MB (432.6 ng/mL), and hyperglycemia (glucose 425 mg/dL). Arterial blood gas reveals hypoxia (Po₂ of 55 mm Hg), with metabolic acidosis (sodium bicarbonate 10 with compensatory Pco₂ of 33 mm Hg). Her urine is cloudy, positive for protein, ketones, hemoglobin, and glucose. She is thought to have a high anion gap acidosis related to dehydration, lactic acidosis (lactic acid 20 mEq/L), and hyperglycemia. Urine toxicology is positive for cannabinoids; ethylene glycol and methanol screen negatively, which rules these out as potential contributors to her high anion gap acidosis.

Ms. K is intubated and IV fluids are initiated for rhabdomyolysis and acute renal failure. Dialysis is implemented on a short-term basis. Her mental state improves gradually over 3 days.

The authors’ observations

Based on the abrupt onset of inattention and confusion, disorganized speech, memory impairments, and psychomotor agitation, we made an initial diagnosis of delirium; however, the precise etiology remained unclear. DSM-IV-TR diagnostic criteria for delirium are described in Table 1. Although delirium due to multiple etiologies does not have a DSM-IV-TR coding designation, we speculated that multiple causes contributed to Ms. K’s presentation. Acute renal failure secondary to dehydration as well as rhabdomyolysis, hypoxia, and hyperglycemia were implicated as general medical conditions etiologically linked to delirium. Because Ms. K has no preexisting medical conditions and her roommate and family stated she had a history of substance abuse, we also considered a presumptive diagnosis of substance-induced delirium. The medical team speculated that, based on information provided by her family, Ms. K may have had a seizure or may have fallen, which would account for her multiple contusions, and could have led to muscle injury and breakdown and the resultant rhabdomyolysis.

The possibility of cannabinoid-induced delirium has been reported, albeit rarely.^1-3 However, Ms. K’s presentation—hypothermia, variable heart rate, lack of dry mucous membranes—was not consistent with significant anticholinergic toxicity or cannabinoid intoxication (Table 2).

By contrast, cocaine-induced delirium has been reported and initially appeared to be a plausible cause of Ms. K’s symptoms (Table 2). Delirium related to excess ingestion of cocaine may be related to the drug’s secondary effects resulting in rhabdomyolysis and renal dysfunction.^4-6 Although several mechanisms underlying this relationship have been proposed, no single specific mechanism has been identified. The basis for cocaine ingestion and the resultant metabolic and renal effects, as observed in Ms. K’s case, likely are multifactorial. Mechanisms of the rhabdomyolysis might include:

• blockade of synaptic catecholamine reuptake and induction of adrenergic agonism, resulting in vasoconstriction and ischemia and leading to muscle damage
• cocaine-induced seizures and/or prolonged unconsciousness, leading to muscle compression and breakdown of muscle tissue
• a period of exertion induced by cocaine, precipitating an excited delirium and associated rhabdomyolysis
• a surge in dopamine concentrations, similar to neuroleptic malignant syndrome, precipitates hyperthermia, muscle rigidity, and psychomotor agitation, disrupting neuromuscular homeostasis and leading to rhabdomyolysis.

We were uncertain about the plausibility that acute cocaine intoxication caused Ms. K’s medical sequelae, in light of her toxicology findings. If cocaine use was the inciting event, and because the delirium reportedly had developed over several hours, we would expect cocaine to be detected in the toxicology screen. However, it was not detected. Cocaine can remain detectable in urine for 2 to 4 days,⁷ which raised our speculation that remote cocaine abuse could account for Ms. K’s current presentation and the timeline the roommate initially relayed to EMS personnel was inaccurate. We needed to clarify the timeline and progression of Ms. K’s symptoms with the roommate. In addition, we suggested to the medical team that alternative substances of abuse could be causing Ms. K’s symptoms and the roommate might be the only person who could unveil this possibility.

Table 1

DSM-IV-TR criteria for delirium due to multiple etiologies

Table 2

Diagnostic criteria for cannabis and cocaine intoxication

HISTORY: Unknown substance

Ms. K’s roommate is contacted for supplemental history. The roommate reports that recently he observed Ms. K “snorting” a brown/tan-colored substance. He had not seen her use this substance previously, and when he asked her what it was, she reportedly said that it was “PeeVee” (also called “bath salts”) purchased over the Internet.

The authors’ observations

MDPV is a novel chemical compound that is used as a recreational drug (Table 3).⁸ It commonly is acquired from Internet sources and sold as “bath salts.” Its use first emerged in approximately 2004, and its popularity has been increasing because of its easy availability and relatively low cost.⁹ The American Association of Poison Control Centers received 302 calls related to MDPV toxicity in 2010 and 5,625 calls related to MDPV use between January 1 and October 31, 2011.^10,11

MDPV has psychoactive properties, with stimulant effects acting as a norepinephrine-dopamine reuptake inhibitor.^8,9,12 When snorted, ingested orally, or inserted rectally, the agent produces effects comparable to cocaine or psychostimulants such as methylphenidate or dextroamphetamine.

Acute effects of MDPV include heightened alertness, diminished need for sleep, hyperarousal, and euphoria.^8,9 These symptoms often are accompanied by increases in heart rate and blood pressure, sweating, and peripheral vasoconstriction. Individuals may abuse MDPV to acquire sustained attention, reduce their need for sleep, or for aphrodisiac effects. In many cases, anxiety and irritability can accompany the desired euphoric effects. For some, the euphoric effects can be superseded by anxiety or agitation. Mood and attention effects are estimated to last 3 to 4 hours; however, tachycardia and hypertension can persist for 6 to 8 hours.

MDPV use can trigger cravings and lead to binging. Euphoric stimulation with MDPV can become dysphoric as the dose and duration of use increase. Extended use has been associated with agitation, irritability, aggression, panic and marked anxiety, psychosis, and delirium.^8,9 Anxiety can range from mild dysphoric stimulation to extreme panic-like states. In moderate forms, a state of sympathetic discharge can occur, producing physiologic effects resembling panic attacks, including hypertension, tachycardia, sweating, and peripheral vasoconstriction. In more severe cases, users may experience a feeling of impending doom, marked distress, and frank psychosis. Patients may experience disorientation and unsystematized paranoid delusions. Case reports of intoxication have described self-injurious behaviors, such as cutting, which may account for the contusions observed on Ms. K’s face and arms. Increasingly, MDPV use has resulted in ER presentations with patients manifesting abrupt onset confusion, anxiety, and self-injurious behaviors.

The mechanisms underlying MDPV-induced delirium have not been definitively identified. Given the similarities in mechanism of action between MDPV and cocaine, causes for delirium related to MDPV are similarly presumed to be multifactorial. The course of delirium associated with MDPV intoxication is self-limited and requires supportive measures.^8,9

Suspect MDPV abuse in patients who present with signs or symptoms of stimulant intoxication but have a negative toxicology screen for cocaine and other psychostimulants. MDPV is not detected on routine toxicology assessments; however, it can be identified through laboratories with gas chromatography/mass spectroscopy capabilities. However, the time needed to obtain the results may exceed the clinical course of the patient’s delirium. One of the limitations in Ms. K’s case was the lack of gas chromatography/mass spectroscopy to confirm MDPV ingestion. Ms. K’s roommate could not locate any unused brown powder within their apartment to bring in for laboratory investigations. Recently, screening assessments for MDPV have become commercially available (see Related Resources).

Table 3

Overview of MDPV features

OUTCOME: Referral to treatment

Dialysis is discontinued within 1 day of hospitalization. Ms. K’s peripheral arterial perfusion improves, as does her thermoregulatory status. Her mental status improvements coincide with improvements in her physical and metabolic status.

Ms. K is able to sustain attention when speaking with interviewers. She is aware of her surroundings and is no longer distracted by extraneous stimuli. Her speech is articulate and her thoughts are linear. There is no evidence of any residual thought disorganization, delusions, or hallucinations.

Initially, Ms. K is reluctant to acknowledge her substance use, but eventually, she concedes to acquiring a stimulant from an Internet source and abusing it in undetermined amounts. She had no experience with using MDPV and did not know how to avoid ingesting dangerous amounts. We educate Ms. K about the dangers she faced during this hospitalization and the potential life-threatening outcomes. She is amenable to pursuing outpatient substance abuse treatment. Her roommate is enlisted to facilitate her follow-up with this treatment.

The authors’ observations

Managing MDPV toxicity presents a diagnostic dilemma for medical personnel and psychiatrists when evaluating and managing acute delirium. MDPV ingestion may go unrecognized in clinical settings because toxicology assessments for it are not readily available and patients’ historical information may be unreliable.

Because of the seriousness of sequelae associated with MDPV use, state and federal agencies have intervened. Until recently, bath salts did not have a controlled substance designation. In October 2011, the US Drug Enforcement Administration (DEA) ruled to make MDPV a controlled substance for 1 year, with the possibility of a 6-month extension.¹³ Although this ruling is temporary, it makes possession, sale, or distribution of these chemicals, or the products that contain them, illegal in the United States. In the interim, the DEA and the US Department of Health and Human Services will determine whether MDPV should remain a controlled substance.

Related Resources

• American Screening Corp. (MDPV screening). www.americanscreeningcorp.com.
• U.S. Drug Enforcement Administration. 3, 4-Methylenedioxypyrovalerone (MDPV). www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf.
• Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones [published online ahead of print November 23, 2011]. J Med Toxicol. doi: 10.1007/s13181-011-0193-z.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Hurt and confused

Emergency medical services (EMS) are called to Ms. K’s apartment after her roommate found her lying on the floor moaning. The roommate tells EMS that Ms. K, age 29, appeared confused and was slurring her words, and reports that this change in her awareness progressed rapidly over a few hours. EMS personnel find that Ms. K has multiple contusions on her arms and face, which they presume to be self-inflicted. A marijuana pipe is discovered at Ms. K’s apartment.

In the emergency room (ER), Ms. K is inattentive and has difficulty following simple commands. Her speech is mumbled and her thoughts are disorganized. She displays psychomotor restlessness in the form of combativeness. Ms. K cannot provide meaningful historical data and is disoriented to place and time. The ER staff requests a psychiatric consultation.

Family members reveal that Ms. K has no preexisting medical conditions, is not taking prescription medications, but has a history of substance abuse (sporadic cocaine and cannabis use). Her family is unaware of recent substance use.

Physical examination reveals tachycardia (heart rate 110 to 120 beats per minute), hypotension (blood pressure 78/49 mm Hg), hypothermia (temperature 88ºF), and peripheral pulse oximetry of 84%. Her pupils are dilated and reactive to light; no conjunctival injection is noted. Her lung fields are clear on auscultation, but she is noted to have a rapid, irregular heartbeat. The abdomen is positive for bowel sounds, soft on palpation, and without any repositioning or notable overt signs of tenderness. Ms. K’s toes show purple discoloration with poor capillary refill. The dorsalis pedis pulses are reported to be 1+ bilaterally; however, the remainder of the arterial pulse examination is normal.

Her sodium, potassium, and chloride values are normal, but she has an abnormal anion gap (28.1 mEq/L), blood urea nitrogen (53 mg/dL), creatinine (2.9 mg/dL), creatine kinase (10,857 U/L), creatine kinase MB (432.6 ng/mL), and hyperglycemia (glucose 425 mg/dL). Arterial blood gas reveals hypoxia (Po₂ of 55 mm Hg), with metabolic acidosis (sodium bicarbonate 10 with compensatory Pco₂ of 33 mm Hg). Her urine is cloudy, positive for protein, ketones, hemoglobin, and glucose. She is thought to have a high anion gap acidosis related to dehydration, lactic acidosis (lactic acid 20 mEq/L), and hyperglycemia. Urine toxicology is positive for cannabinoids; ethylene glycol and methanol screen negatively, which rules these out as potential contributors to her high anion gap acidosis.

Ms. K is intubated and IV fluids are initiated for rhabdomyolysis and acute renal failure. Dialysis is implemented on a short-term basis. Her mental state improves gradually over 3 days.

The authors’ observations

Based on the abrupt onset of inattention and confusion, disorganized speech, memory impairments, and psychomotor agitation, we made an initial diagnosis of delirium; however, the precise etiology remained unclear. DSM-IV-TR diagnostic criteria for delirium are described in Table 1. Although delirium due to multiple etiologies does not have a DSM-IV-TR coding designation, we speculated that multiple causes contributed to Ms. K’s presentation. Acute renal failure secondary to dehydration as well as rhabdomyolysis, hypoxia, and hyperglycemia were implicated as general medical conditions etiologically linked to delirium. Because Ms. K has no preexisting medical conditions and her roommate and family stated she had a history of substance abuse, we also considered a presumptive diagnosis of substance-induced delirium. The medical team speculated that, based on information provided by her family, Ms. K may have had a seizure or may have fallen, which would account for her multiple contusions, and could have led to muscle injury and breakdown and the resultant rhabdomyolysis.

The possibility of cannabinoid-induced delirium has been reported, albeit rarely.^1-3 However, Ms. K’s presentation—hypothermia, variable heart rate, lack of dry mucous membranes—was not consistent with significant anticholinergic toxicity or cannabinoid intoxication (Table 2).

By contrast, cocaine-induced delirium has been reported and initially appeared to be a plausible cause of Ms. K’s symptoms (Table 2). Delirium related to excess ingestion of cocaine may be related to the drug’s secondary effects resulting in rhabdomyolysis and renal dysfunction.^4-6 Although several mechanisms underlying this relationship have been proposed, no single specific mechanism has been identified. The basis for cocaine ingestion and the resultant metabolic and renal effects, as observed in Ms. K’s case, likely are multifactorial. Mechanisms of the rhabdomyolysis might include:

• blockade of synaptic catecholamine reuptake and induction of adrenergic agonism, resulting in vasoconstriction and ischemia and leading to muscle damage
• cocaine-induced seizures and/or prolonged unconsciousness, leading to muscle compression and breakdown of muscle tissue
• a period of exertion induced by cocaine, precipitating an excited delirium and associated rhabdomyolysis
• a surge in dopamine concentrations, similar to neuroleptic malignant syndrome, precipitates hyperthermia, muscle rigidity, and psychomotor agitation, disrupting neuromuscular homeostasis and leading to rhabdomyolysis.

We were uncertain about the plausibility that acute cocaine intoxication caused Ms. K’s medical sequelae, in light of her toxicology findings. If cocaine use was the inciting event, and because the delirium reportedly had developed over several hours, we would expect cocaine to be detected in the toxicology screen. However, it was not detected. Cocaine can remain detectable in urine for 2 to 4 days,⁷ which raised our speculation that remote cocaine abuse could account for Ms. K’s current presentation and the timeline the roommate initially relayed to EMS personnel was inaccurate. We needed to clarify the timeline and progression of Ms. K’s symptoms with the roommate. In addition, we suggested to the medical team that alternative substances of abuse could be causing Ms. K’s symptoms and the roommate might be the only person who could unveil this possibility.

Table 1

DSM-IV-TR criteria for delirium due to multiple etiologies

Table 2

Diagnostic criteria for cannabis and cocaine intoxication

HISTORY: Unknown substance

Ms. K’s roommate is contacted for supplemental history. The roommate reports that recently he observed Ms. K “snorting” a brown/tan-colored substance. He had not seen her use this substance previously, and when he asked her what it was, she reportedly said that it was “PeeVee” (also called “bath salts”) purchased over the Internet.

The authors’ observations

MDPV is a novel chemical compound that is used as a recreational drug (Table 3).⁸ It commonly is acquired from Internet sources and sold as “bath salts.” Its use first emerged in approximately 2004, and its popularity has been increasing because of its easy availability and relatively low cost.⁹ The American Association of Poison Control Centers received 302 calls related to MDPV toxicity in 2010 and 5,625 calls related to MDPV use between January 1 and October 31, 2011.^10,11

MDPV has psychoactive properties, with stimulant effects acting as a norepinephrine-dopamine reuptake inhibitor.^8,9,12 When snorted, ingested orally, or inserted rectally, the agent produces effects comparable to cocaine or psychostimulants such as methylphenidate or dextroamphetamine.

Acute effects of MDPV include heightened alertness, diminished need for sleep, hyperarousal, and euphoria.^8,9 These symptoms often are accompanied by increases in heart rate and blood pressure, sweating, and peripheral vasoconstriction. Individuals may abuse MDPV to acquire sustained attention, reduce their need for sleep, or for aphrodisiac effects. In many cases, anxiety and irritability can accompany the desired euphoric effects. For some, the euphoric effects can be superseded by anxiety or agitation. Mood and attention effects are estimated to last 3 to 4 hours; however, tachycardia and hypertension can persist for 6 to 8 hours.

MDPV use can trigger cravings and lead to binging. Euphoric stimulation with MDPV can become dysphoric as the dose and duration of use increase. Extended use has been associated with agitation, irritability, aggression, panic and marked anxiety, psychosis, and delirium.^8,9 Anxiety can range from mild dysphoric stimulation to extreme panic-like states. In moderate forms, a state of sympathetic discharge can occur, producing physiologic effects resembling panic attacks, including hypertension, tachycardia, sweating, and peripheral vasoconstriction. In more severe cases, users may experience a feeling of impending doom, marked distress, and frank psychosis. Patients may experience disorientation and unsystematized paranoid delusions. Case reports of intoxication have described self-injurious behaviors, such as cutting, which may account for the contusions observed on Ms. K’s face and arms. Increasingly, MDPV use has resulted in ER presentations with patients manifesting abrupt onset confusion, anxiety, and self-injurious behaviors.

The mechanisms underlying MDPV-induced delirium have not been definitively identified. Given the similarities in mechanism of action between MDPV and cocaine, causes for delirium related to MDPV are similarly presumed to be multifactorial. The course of delirium associated with MDPV intoxication is self-limited and requires supportive measures.^8,9

Suspect MDPV abuse in patients who present with signs or symptoms of stimulant intoxication but have a negative toxicology screen for cocaine and other psychostimulants. MDPV is not detected on routine toxicology assessments; however, it can be identified through laboratories with gas chromatography/mass spectroscopy capabilities. However, the time needed to obtain the results may exceed the clinical course of the patient’s delirium. One of the limitations in Ms. K’s case was the lack of gas chromatography/mass spectroscopy to confirm MDPV ingestion. Ms. K’s roommate could not locate any unused brown powder within their apartment to bring in for laboratory investigations. Recently, screening assessments for MDPV have become commercially available (see Related Resources).

Table 3

Overview of MDPV features

OUTCOME: Referral to treatment

Dialysis is discontinued within 1 day of hospitalization. Ms. K’s peripheral arterial perfusion improves, as does her thermoregulatory status. Her mental status improvements coincide with improvements in her physical and metabolic status.

Ms. K is able to sustain attention when speaking with interviewers. She is aware of her surroundings and is no longer distracted by extraneous stimuli. Her speech is articulate and her thoughts are linear. There is no evidence of any residual thought disorganization, delusions, or hallucinations.

Initially, Ms. K is reluctant to acknowledge her substance use, but eventually, she concedes to acquiring a stimulant from an Internet source and abusing it in undetermined amounts. She had no experience with using MDPV and did not know how to avoid ingesting dangerous amounts. We educate Ms. K about the dangers she faced during this hospitalization and the potential life-threatening outcomes. She is amenable to pursuing outpatient substance abuse treatment. Her roommate is enlisted to facilitate her follow-up with this treatment.

The authors’ observations

Managing MDPV toxicity presents a diagnostic dilemma for medical personnel and psychiatrists when evaluating and managing acute delirium. MDPV ingestion may go unrecognized in clinical settings because toxicology assessments for it are not readily available and patients’ historical information may be unreliable.

Because of the seriousness of sequelae associated with MDPV use, state and federal agencies have intervened. Until recently, bath salts did not have a controlled substance designation. In October 2011, the US Drug Enforcement Administration (DEA) ruled to make MDPV a controlled substance for 1 year, with the possibility of a 6-month extension.¹³ Although this ruling is temporary, it makes possession, sale, or distribution of these chemicals, or the products that contain them, illegal in the United States. In the interim, the DEA and the US Department of Health and Human Services will determine whether MDPV should remain a controlled substance.

Related Resources

• American Screening Corp. (MDPV screening). www.americanscreeningcorp.com.
• U.S. Drug Enforcement Administration. 3, 4-Methylenedioxypyrovalerone (MDPV). www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf.
• Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones [published online ahead of print November 23, 2011]. J Med Toxicol. doi: 10.1007/s13181-011-0193-z.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

References

1. Meador KJ, Baker GA, Browning N, et al. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs. N Engl J Med. 2009;360(16):1597-1605.

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

References

1. Meador KJ, Baker GA, Browning N, et al. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs. N Engl J Med. 2009;360(16):1597-1605.

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

References

1. Meador KJ, Baker GA, Browning N, et al. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs. N Engl J Med. 2009;360(16):1597-1605.

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

Concerns about valproate

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

Domains of excellence

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

Additional traits

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

Concerns about valproate

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

Domains of excellence

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

Additional traits

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

Concerns about valproate

I read Dr. Jain and Ms. Beste’s Pearl on treating alopecia developing during valproate use ("Valproate-induced hair loss: What to tell patients," Current Psychiatry, November 2011, p. 74) with some dismay.

Valproate is a valuable drug that has demonstrated efficacy in treating bipolar disorder; however, valproate use is associated with substantial side effects for women and developing fetuses.

I take no issue with any of the points made in the article, but I am concerned about the failure to mention critical side effects associated with valproate, including:

• weight gain and metabolic side effects
• for women, polycystic ovary syndrome—a serious and difficult-to-treat complication
• danger to fetuses—recent research suggests marked reductions in intelligence quotient in babies exposed to valproate in utero.¹

We would be wise to remind ourselves of these issues whenever considering initiating or continuing valproate therapy.

Edward Pontius, MD, DFAPA
Private Practice
Brunswick, ME

The authors respond

The concerns expressed by Dr. Pontius regarding clinical use of valproate are genuine and worthy. The purpose of our article was to call attention to a lesser-known side effect of valproate and how to intervene. We assumed that clinicians would discuss with patients the teratogenicity of valproate, along with other common side effects—weight gain, pancreatitis, effect on liver function tests, thrombocytopenia, and polycystic ovary syndrome—before initiating the drug. Such discussion about valproate was beyond the scope of our article, but we thank Dr. Pontius for bringing these concerns to our attention.

Shailesh Jain, MD, MPH, ABDA
Regional Chair
Associate Professor
Department of Psychiatry

Beth Beste, MS
Fourth-Year Medical Student
Texas Tech University Health Sciences Center, Permian Basin
Odessa, TX

Domains of excellence

I want to thank Dr. Nasrallah, whose monthly comments I find interesting and provocative, for his first-of-its-kind description of the “ideal” psychiatrist’s role and identity (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). This article should be mandatory reading and discussion material for every psychiatry residency program. For this elder psychiatrist, it was a thoughtful review of where I have been and where I am going in my field.

Ronald Blank, MD
Private Practice
Easthampton, MA

Additional traits

I find Current Psychiatry to be exceedingly useful for myself and the physician assistant students I teach. I agree with the 7 domains in Dr. Nasrallah’s editorial (“The model psychiatrist: 7 domains of excellence,” From the Editor, Current Psychiatry, November 2011, p. 5-6). However, I would like to add 2 more traits:

• The role that a psychiatrist plays in his or her family, especially with their children, because ignoring one’s family in the pursuit of clinical sainthood is not a mark of greatness
• The psychiatrist today is more of a team member than team leader. Failure to recognize this role creates intolerable stresses on the treatment environment in which the psychiatrist works. This does not minimize the need for personal excellence, but it certainly helps decrease destructive narcissism.

Kim J. Masters, MD
Medical Director
Three Rivers Midlands Campus Residential Treatment Center
West Columbia, SC

Discuss this article at www.facebook.com/CurrentPsychiatry

Mr. T, age 56, has major depressive disorder that is well controlled with fluoxetine, 40 mg/d. He has smoked ≥1 packs of cigarettes per day for the last 25 years. On a recent visit, he indicates that he has begun using a 21-mg nicotine patch as advised by his pharmacist and that things are going OK, although he has had some “slip ups.” He is on week 7 of his quitting regimen and now is stepping down the patch dosage.

Upon further questioning he says that he has been cutting the 21-mg patches in half to save money. Mr. T also explains that occasionally he has given in to a strong urge to smoke because it was “too much to handle.” He states that he does not think this is a big deal because he uses electronic cigarettes and has heard that these products don’t contain “the bad cancer stuff.” At the end of Mr. T’s visit, he asks for something to help him sleep because has been unable to sleep consistently and has been having vivid dreams since starting the patch. He also wants to know how to reduce itching from the patch.

Approximately 46 million Americans smoke and cigarette smoking accounts for 1 of every 5 deaths in the United States each year.¹ Since the advent of “Stop Smoking” campaigns, bans on smoking in public buildings, over-the-counter (OTC) nicotine replacement products, and Surgeon General recommendations, discussing smoking cessation with patients has become standard practice.

Research suggests that treatment to quit smoking should include a combination of pharmacotherapy and counseling, such as cognitive-behavioral strategies, support groups, and quitting hotlines.² Pharmacotherapy consists of OTC nicotine replacement therapy (NRT) products and prescription medications. This article briefly highlights how to counsel patients about using OTC NRT products (Table 1).^2-5 See Table 2 for a summary of prescription smoking cessation agents

Table 1

Over-the-counter nicotine replacement therapy products

Patches

Nicotine replacement patches are best used for maintenance treatment of nicotine cravings. They deliver a fixed amount of nicotine over 24 hours.³ Patches have a specially formulated transdermal matrix system and should not be cut. Doing so damages the drug delivery system and could lead to drug evaporation from the cut edges.⁴ Mr. T’s psychiatrist advises him not to cut patches but instead purchase the 14-mg patch because he is at this step of the smoking cessation regimen.

Skin irritation caused by adhesive is a common adverse event from nicotine patches. Rotating the location of each patch to a different hairless body area is the best way to prevent or combat skin irritation. If rotating the location of the patch does not relieve irritation, patients can apply a thin layer of an OTC hydrocortisone 1% cream to the affected site 2 to 4 times a day after gently washing the area.⁵ Instruct patients to avoid using occlusive dressings over the topical application.

Nicotine replacement patches also have been reported to cause vivid dreams and insomnia.³ These side effects may be caused by nighttime nicotine absorption, which might be avoided by switching to a different NRT product or removing the 24-hour patch when going to bed.⁴

Combining treatments

Many patients experience nicotine cravings while using the nicotine replacement patch. Stressful situations and events can trigger a patient’s desire for nicotine and withdrawal symptoms that a patch that delivers a continuous amount of nicotine over 24 hours cannot alleviate. Combining different forms of treatment could combat these symptoms.^2,3,5

Combination therapy might consist of using sustained-release bupropion or a nicotine patch with rapid-acting NRT products such as a lozenge, gum, nasal spray, or inhaler. In Mr. T’s case, clinicians recommend that he use nicotine polacrilex gum in addition to the patch to quell his cravings. Also, he is instructed to stop using electronic cigarettes because they are considered tobacco products, are not regulated by the FDA, and may contain toxic substances.⁶

Instruct patients who use nicotine gum to employ the “chew and park” method.⁴ First, they should chew the gum very slowly until they notice a minty taste or tingling feeling, then “park” the gum between the cheek and gums for 1 to 2 minutes to allow nicotine to be absorbed across the gum lining. After 2 minutes or when tingling ceases, patients should slowly resume chewing until a tingling or minty taste returns and then “park” the gum again in a different area of the gums. Tell patients to repeat the “chew and park” method until there is no more taste or tingling (approximately 30 minutes). Explain that chewing the gum too fast may result in nausea or lightheadedness and patients should refrain from eating or drinking 15 minutes before or while using the gum. Mr. T is instructed to use the gum only when the urge to smoke is overbearing, and not regularly.

The nicotine polacrilex gum is more viscous than ordinary chewing gum and may stick to or possibly damage dental work such as fillings, dentures, crowns, and braces. An acceptable alternative is the nicotine polacrilex lozenge. Advise patients who want to try lozenges to:

• place the lozenge in the mouth and allow it to dissolve slowly over 20 to 30 minutes (during this time patients may experience a tingling sensation as nicotine is released)
• rotate the lozenge to different areas of the mouth every few minutes to lessen irritation
• avoid chewing or swallowing the lozenge because doing so will lead to improper release of nicotine and side effects, including nausea, hiccups, and heartburn
• refrain from eating or drinking 15 minutes before or while using the lozenge.

For many patients, the breadth of pharmacologic agents available for smoking cessation has made quitting a more attainable goal. OTC smoking cessation products are available in most drug stores, which gives smokers easy access to taking this important step. Counseling patients on the proper use of OTC products may help them successfully stop smoking.⁷

Although a patient’s medical history, including cardiac status, must be considered before starting specific agents, in many instances patient preference is the prevailing factor when choosing therapy. Often, the risks of continued smoking outweigh the risks of using smoking cessation products. OTC smoking cessation products may be an appropriate first-line treatment for many individuals before trying prescription medications, such as bupropion or varenicline.

Related Resources

For patients

• Treat Tobacco. www.treatobacco.net.
• Smokefree.gov mobile application. http://smokefree.gov/apps.
• Medline Plus. Quitting smoking. www.nlm.nih.gov/medlineplus/quittingsmoking.html.
• Quit for Life Program. www.quitnow.net.
• American Lung Association. Stop Smoking. www.lungusa.org/stop-smoking.

For clinicians

• Agency for Health Research and Quality. Treating tobacco use and dependence: 2008 update. www.ahrq.gov/path/tobacco.htm#clinicians.

Drug Brand Names

• Bupropion SR • Zyban, Wellbutrin SR
• Fluoxetine • Prozac
• Varenicline • Chantix

Disclosure

Dr. Ellingrod receives grant/research support from the National Institute of Mental Health.

Dr. Burghardt reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Table 2

Prescription smoking cessation products^a

Discuss this article at www.facebook.com/CurrentPsychiatry

Mr. T, age 56, has major depressive disorder that is well controlled with fluoxetine, 40 mg/d. He has smoked ≥1 packs of cigarettes per day for the last 25 years. On a recent visit, he indicates that he has begun using a 21-mg nicotine patch as advised by his pharmacist and that things are going OK, although he has had some “slip ups.” He is on week 7 of his quitting regimen and now is stepping down the patch dosage.

Upon further questioning he says that he has been cutting the 21-mg patches in half to save money. Mr. T also explains that occasionally he has given in to a strong urge to smoke because it was “too much to handle.” He states that he does not think this is a big deal because he uses electronic cigarettes and has heard that these products don’t contain “the bad cancer stuff.” At the end of Mr. T’s visit, he asks for something to help him sleep because has been unable to sleep consistently and has been having vivid dreams since starting the patch. He also wants to know how to reduce itching from the patch.

Approximately 46 million Americans smoke and cigarette smoking accounts for 1 of every 5 deaths in the United States each year.¹ Since the advent of “Stop Smoking” campaigns, bans on smoking in public buildings, over-the-counter (OTC) nicotine replacement products, and Surgeon General recommendations, discussing smoking cessation with patients has become standard practice.

Research suggests that treatment to quit smoking should include a combination of pharmacotherapy and counseling, such as cognitive-behavioral strategies, support groups, and quitting hotlines.² Pharmacotherapy consists of OTC nicotine replacement therapy (NRT) products and prescription medications. This article briefly highlights how to counsel patients about using OTC NRT products (Table 1).^2-5 See Table 2 for a summary of prescription smoking cessation agents

Table 1

Over-the-counter nicotine replacement therapy products

Patches

Nicotine replacement patches are best used for maintenance treatment of nicotine cravings. They deliver a fixed amount of nicotine over 24 hours.³ Patches have a specially formulated transdermal matrix system and should not be cut. Doing so damages the drug delivery system and could lead to drug evaporation from the cut edges.⁴ Mr. T’s psychiatrist advises him not to cut patches but instead purchase the 14-mg patch because he is at this step of the smoking cessation regimen.

Skin irritation caused by adhesive is a common adverse event from nicotine patches. Rotating the location of each patch to a different hairless body area is the best way to prevent or combat skin irritation. If rotating the location of the patch does not relieve irritation, patients can apply a thin layer of an OTC hydrocortisone 1% cream to the affected site 2 to 4 times a day after gently washing the area.⁵ Instruct patients to avoid using occlusive dressings over the topical application.

Nicotine replacement patches also have been reported to cause vivid dreams and insomnia.³ These side effects may be caused by nighttime nicotine absorption, which might be avoided by switching to a different NRT product or removing the 24-hour patch when going to bed.⁴

Combining treatments

Many patients experience nicotine cravings while using the nicotine replacement patch. Stressful situations and events can trigger a patient’s desire for nicotine and withdrawal symptoms that a patch that delivers a continuous amount of nicotine over 24 hours cannot alleviate. Combining different forms of treatment could combat these symptoms.^2,3,5

Combination therapy might consist of using sustained-release bupropion or a nicotine patch with rapid-acting NRT products such as a lozenge, gum, nasal spray, or inhaler. In Mr. T’s case, clinicians recommend that he use nicotine polacrilex gum in addition to the patch to quell his cravings. Also, he is instructed to stop using electronic cigarettes because they are considered tobacco products, are not regulated by the FDA, and may contain toxic substances.⁶

Instruct patients who use nicotine gum to employ the “chew and park” method.⁴ First, they should chew the gum very slowly until they notice a minty taste or tingling feeling, then “park” the gum between the cheek and gums for 1 to 2 minutes to allow nicotine to be absorbed across the gum lining. After 2 minutes or when tingling ceases, patients should slowly resume chewing until a tingling or minty taste returns and then “park” the gum again in a different area of the gums. Tell patients to repeat the “chew and park” method until there is no more taste or tingling (approximately 30 minutes). Explain that chewing the gum too fast may result in nausea or lightheadedness and patients should refrain from eating or drinking 15 minutes before or while using the gum. Mr. T is instructed to use the gum only when the urge to smoke is overbearing, and not regularly.

The nicotine polacrilex gum is more viscous than ordinary chewing gum and may stick to or possibly damage dental work such as fillings, dentures, crowns, and braces. An acceptable alternative is the nicotine polacrilex lozenge. Advise patients who want to try lozenges to:

• place the lozenge in the mouth and allow it to dissolve slowly over 20 to 30 minutes (during this time patients may experience a tingling sensation as nicotine is released)
• rotate the lozenge to different areas of the mouth every few minutes to lessen irritation
• avoid chewing or swallowing the lozenge because doing so will lead to improper release of nicotine and side effects, including nausea, hiccups, and heartburn
• refrain from eating or drinking 15 minutes before or while using the lozenge.

For many patients, the breadth of pharmacologic agents available for smoking cessation has made quitting a more attainable goal. OTC smoking cessation products are available in most drug stores, which gives smokers easy access to taking this important step. Counseling patients on the proper use of OTC products may help them successfully stop smoking.⁷

Although a patient’s medical history, including cardiac status, must be considered before starting specific agents, in many instances patient preference is the prevailing factor when choosing therapy. Often, the risks of continued smoking outweigh the risks of using smoking cessation products. OTC smoking cessation products may be an appropriate first-line treatment for many individuals before trying prescription medications, such as bupropion or varenicline.

Related Resources

For patients

• Treat Tobacco. www.treatobacco.net.
• Smokefree.gov mobile application. http://smokefree.gov/apps.
• Medline Plus. Quitting smoking. www.nlm.nih.gov/medlineplus/quittingsmoking.html.
• Quit for Life Program. www.quitnow.net.
• American Lung Association. Stop Smoking. www.lungusa.org/stop-smoking.

For clinicians

• Agency for Health Research and Quality. Treating tobacco use and dependence: 2008 update. www.ahrq.gov/path/tobacco.htm#clinicians.

Drug Brand Names

• Bupropion SR • Zyban, Wellbutrin SR
• Fluoxetine • Prozac
• Varenicline • Chantix

Disclosure

Dr. Ellingrod receives grant/research support from the National Institute of Mental Health.

Dr. Burghardt reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Table 2

Prescription smoking cessation products^a

Discuss this article at www.facebook.com/CurrentPsychiatry

Mr. T, age 56, has major depressive disorder that is well controlled with fluoxetine, 40 mg/d. He has smoked ≥1 packs of cigarettes per day for the last 25 years. On a recent visit, he indicates that he has begun using a 21-mg nicotine patch as advised by his pharmacist and that things are going OK, although he has had some “slip ups.” He is on week 7 of his quitting regimen and now is stepping down the patch dosage.

Upon further questioning he says that he has been cutting the 21-mg patches in half to save money. Mr. T also explains that occasionally he has given in to a strong urge to smoke because it was “too much to handle.” He states that he does not think this is a big deal because he uses electronic cigarettes and has heard that these products don’t contain “the bad cancer stuff.” At the end of Mr. T’s visit, he asks for something to help him sleep because has been unable to sleep consistently and has been having vivid dreams since starting the patch. He also wants to know how to reduce itching from the patch.

Approximately 46 million Americans smoke and cigarette smoking accounts for 1 of every 5 deaths in the United States each year.¹ Since the advent of “Stop Smoking” campaigns, bans on smoking in public buildings, over-the-counter (OTC) nicotine replacement products, and Surgeon General recommendations, discussing smoking cessation with patients has become standard practice.

Research suggests that treatment to quit smoking should include a combination of pharmacotherapy and counseling, such as cognitive-behavioral strategies, support groups, and quitting hotlines.² Pharmacotherapy consists of OTC nicotine replacement therapy (NRT) products and prescription medications. This article briefly highlights how to counsel patients about using OTC NRT products (Table 1).^2-5 See Table 2 for a summary of prescription smoking cessation agents

Table 1

Over-the-counter nicotine replacement therapy products

Patches

Nicotine replacement patches are best used for maintenance treatment of nicotine cravings. They deliver a fixed amount of nicotine over 24 hours.³ Patches have a specially formulated transdermal matrix system and should not be cut. Doing so damages the drug delivery system and could lead to drug evaporation from the cut edges.⁴ Mr. T’s psychiatrist advises him not to cut patches but instead purchase the 14-mg patch because he is at this step of the smoking cessation regimen.

Skin irritation caused by adhesive is a common adverse event from nicotine patches. Rotating the location of each patch to a different hairless body area is the best way to prevent or combat skin irritation. If rotating the location of the patch does not relieve irritation, patients can apply a thin layer of an OTC hydrocortisone 1% cream to the affected site 2 to 4 times a day after gently washing the area.⁵ Instruct patients to avoid using occlusive dressings over the topical application.

Nicotine replacement patches also have been reported to cause vivid dreams and insomnia.³ These side effects may be caused by nighttime nicotine absorption, which might be avoided by switching to a different NRT product or removing the 24-hour patch when going to bed.⁴

Combining treatments

Many patients experience nicotine cravings while using the nicotine replacement patch. Stressful situations and events can trigger a patient’s desire for nicotine and withdrawal symptoms that a patch that delivers a continuous amount of nicotine over 24 hours cannot alleviate. Combining different forms of treatment could combat these symptoms.^2,3,5

Combination therapy might consist of using sustained-release bupropion or a nicotine patch with rapid-acting NRT products such as a lozenge, gum, nasal spray, or inhaler. In Mr. T’s case, clinicians recommend that he use nicotine polacrilex gum in addition to the patch to quell his cravings. Also, he is instructed to stop using electronic cigarettes because they are considered tobacco products, are not regulated by the FDA, and may contain toxic substances.⁶

Instruct patients who use nicotine gum to employ the “chew and park” method.⁴ First, they should chew the gum very slowly until they notice a minty taste or tingling feeling, then “park” the gum between the cheek and gums for 1 to 2 minutes to allow nicotine to be absorbed across the gum lining. After 2 minutes or when tingling ceases, patients should slowly resume chewing until a tingling or minty taste returns and then “park” the gum again in a different area of the gums. Tell patients to repeat the “chew and park” method until there is no more taste or tingling (approximately 30 minutes). Explain that chewing the gum too fast may result in nausea or lightheadedness and patients should refrain from eating or drinking 15 minutes before or while using the gum. Mr. T is instructed to use the gum only when the urge to smoke is overbearing, and not regularly.

The nicotine polacrilex gum is more viscous than ordinary chewing gum and may stick to or possibly damage dental work such as fillings, dentures, crowns, and braces. An acceptable alternative is the nicotine polacrilex lozenge. Advise patients who want to try lozenges to:

• place the lozenge in the mouth and allow it to dissolve slowly over 20 to 30 minutes (during this time patients may experience a tingling sensation as nicotine is released)
• rotate the lozenge to different areas of the mouth every few minutes to lessen irritation
• avoid chewing or swallowing the lozenge because doing so will lead to improper release of nicotine and side effects, including nausea, hiccups, and heartburn
• refrain from eating or drinking 15 minutes before or while using the lozenge.

For many patients, the breadth of pharmacologic agents available for smoking cessation has made quitting a more attainable goal. OTC smoking cessation products are available in most drug stores, which gives smokers easy access to taking this important step. Counseling patients on the proper use of OTC products may help them successfully stop smoking.⁷

Although a patient’s medical history, including cardiac status, must be considered before starting specific agents, in many instances patient preference is the prevailing factor when choosing therapy. Often, the risks of continued smoking outweigh the risks of using smoking cessation products. OTC smoking cessation products may be an appropriate first-line treatment for many individuals before trying prescription medications, such as bupropion or varenicline.

Related Resources

For patients

• Treat Tobacco. www.treatobacco.net.
• Smokefree.gov mobile application. http://smokefree.gov/apps.
• Medline Plus. Quitting smoking. www.nlm.nih.gov/medlineplus/quittingsmoking.html.
• Quit for Life Program. www.quitnow.net.
• American Lung Association. Stop Smoking. www.lungusa.org/stop-smoking.

For clinicians

• Agency for Health Research and Quality. Treating tobacco use and dependence: 2008 update. www.ahrq.gov/path/tobacco.htm#clinicians.

Drug Brand Names

• Bupropion SR • Zyban, Wellbutrin SR
• Fluoxetine • Prozac
• Varenicline • Chantix

Disclosure

Dr. Ellingrod receives grant/research support from the National Institute of Mental Health.

Dr. Burghardt reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Table 2

Prescription smoking cessation products^a