By E. Grubuz. Southwestern Oklahoma State University.

Linehan and colleagues (8) reported a randomized controlled trial of dialectical behavior therapy involving patients with borderline personality disorder whose symptoms included “parasuicidal” behavior (defined as any intentional acute self-injurious behav- ior with or without suicide intent) generic 10 mg isordil fast delivery. Control subjects in this study received “treatment as usual” (defined as “alternative therapy referrals cheap isordil 10mg, usually by the original referral source order 10 mg isordil otc, from which they could choose”). Of the 44 study completers, 22 received dialectical behavior therapy, and 22 re- ceived treatment as usual; patients were assessed at 4, 8, and 12 months. At pretreatment, 13 of the control subjects had been receiving individual psychotherapy, and 9 had not. Patients who received dialectical behavior therapy had less parasuicidal behavior, reduced medical risk due to parasuicidal acts, fewer hospital admissions, fewer psychiatric hospital days, and a greater capacity to stay with the same therapist than did the control subjects. Both groups improved with respect to depression, suicidal ideation, hopelessness, or reasons for living; there were no group differenc- es on these variables. Because there were substantial dropout rates overall (30%) and the number of study completers in each group was small, it is unclear how generalizable these results are. Nonetheless, this study is a promising first report of a manualized regimen of cognitive behavior treatment for a specific type of patient with borderline personality disorder. A second cohort of patients was subsequently studied; the same study design was used (148). In this report, there were 26 intent-to-treat patients (13 received dialectical behavior therapy, and 13 received treatment as usual). Nine of the 13 control patients were already receiving individual psychotherapy at the beginning of the study or entered such treatment during the study. Patients who received dialectical behavior therapy had greater re- duction in trait anger and greater improvement in Global Assessment Scale scores. One year after termination of their previously described study (8), the Linehan group re- evaluated their patient group (5). After 1 year, the greater reduction in parasuicide rates and in severity of suicide attempts seen in the dialectical behavior therapy group relative to the control subjects did not persist, although there were significantly fewer psychiatric hospital days for the dialectical behavior therapy group during the follow-up year. These findings suggest that al- though dialectical behavior therapy produces a greater reduction in parasuicidal behavior than treatment as usual, the durability of this advantage is unclear. In a subsequent report, Linehan and colleagues (149) compared dialectical behavior therapy with treatment as usual in patients with borderline personality disorder with drug dependence. Only 18 of the 28 intent-to-treat patients completed the study (7 who received dialectical be- havior therapy and 11 given treatment as usual). Patients receiving dialectical behavior therapy had more drug- and alcohol-abstinent days after 4, 8, and 16 months. All patients had reduced parasuicidal behavior as well as state and trait anger; there was no difference between the groups. This study, too, involved small numbers of patients and had substantial dropout rates, but it represents an important attempt to evaluate the impact of dialectical behavior therapy with severely ill patients with borderline personality disorder and comorbid substance abuse. In all of these studies, it is difficult to ascertain whether the improvement reported for pa- tients receiving dialectical behavior therapy derived from specific ingredients of dialectical be- havior therapy or whether nonspecific factors such as either the greater time spent with the patients or therapist bias contributed to the results. In a small study in which skills training alone was compared with a no-skills training control condition, no difference was found be- tween the groups (unpublished 1993 study of M. The research- ers concluded that the specific features of individual dialectical behavior therapy are necessary for patients to show greater improvement than control groups. Linehan and Heard (150) re- ported that more time with therapists does not account for improved outcome. Nonetheless, other special features of dialectical behavior therapy, such as the requirement for all therapists to meet weekly as a group, could contribute to the results. The patients with borderline personality disorder exhibited improvement in depression, hopeless- ness, and suicidal ideation, but the improvement was not greater than it was for a control group. In this study, compared with control subjects, patients receiving the dialectical behavior therapy treatment showed a paradoxical increase in parasuicidal acting out during the brief hospitalization (average length of stay was 12. Barley and colleagues (152) compared dialectical behavior therapy received by patients with borderline personality disorder on a specialized personality disorder inpatient unit with treat- ment as usual on a similar-sized inpatient unit. They found that the use of dialectical behavior therapy was associated with reduced parasuicidal behavior. It is unclear whether improvement was due to dialectical behavior therapy per se or to other elements of the specialized unit. Perris (153) reported preliminary findings from a small uncontrolled, naturalistic follow-up study of 13 patients with borderline personality disorder who received cognitive behavior ther- apy similar to dialectical behavior therapy. Twelve patients were evaluated at a 2-year follow-up point, and all patients maintained the normalization of functioning that had been evident at the end of the study treatment. Other controlled studies reported in the literature of cognitive behavior approaches are dif- ficult to interpret because of small patient group sizes or because the studies focused on mixed types of personality disorders without specifying borderline cohorts (154–156). Treatment of Patients With Borderline Personality Disorder 51 Copyright 2010, American Psychiatric Association. In summary, there are a number of studies in the literature suggesting that cognitive behavior therapy approaches may be effective for patients with borderline personality disorder. Most of these studies involved dialectical behavior therapy and were carried out by Linehan and her group. Replication studies by other groups in other centers are needed to confirm the validity and generalizability of these findings.

Abuse Tachyphylaxis is unusual effective isordil 10 mg, and thus they can be used on a Anxiety Psychopathologic Insomnia long-term basis isordil 10mg visa. Clinical comparison of these Respiratory agents suggests that zolpidem may have greater sleep- Mood Disorder Sleep Disorders inducing efficacy and zaleplon purchase isordil 10mg on line, fewer side effects. Disorder This decrease most likely reflects the public’s and the aMeta-analysis data from Sateia et al. Nonpharmacologic behavioral methods, such as sleep hy- In the 1970s benzodiazepines became available for the giene, hypnosis, relaxation training, sleep restriction, and treatment of insomnia. Insomnia is com- viewed therapeutically based on their pharmacodynamics monly a symptom of nocturnal discomfort, whether psy- (Table 1). Rapid onset of action is characteristic of flur- chological, physical, or environmental. Medications, in azepam and triazolam, indicating that both of these agents general, can be safely utilized on a short-term basis for the have excellent sleep-inducing effects. Therefore, the underlying reasons and diseases fect in the elderly has been associated with increased auto resulting in chronic insomnia should be addressed. For patients in this category syndrome of insomnia followed by persistent anxiety that and those with idiopathic insomnia (persistent lifelong in- may extend beyond the half-life of the agent. In patients with chronic insomnia, 22% report as triazolam, this rebound occurs during the same night in using ethanol as a hypnotic. Temazepam and estazolam have half-lives used in excess with other sedative/hypnotic agents, over- compatible with an 8-hour night of sleep. All benzodiazepines can result in respira- varyingly effective, but may result in daytime sleepiness, tory depression in patients with pulmonary disease and cognitive impairment, and anticholinergic effects that per- may lose sleep-inducing efficacy with prolonged use. Both have excellent efficacy with and hypnotics are generally more benign that those of the minimal side effects. Chronic insomnia itself can lead to depres- A sleep history in a patient with insomnia should include a sion. Com- different diagnostic entity than depression without insom- mon culprits include medications affecting neurotrans- nia, and treatment of the former with nonsedating anti- mitters, such as norepinephrine, serotonin, acetylcholine, depressants may produce no improvement in sleep even or dopamine. Less commonly, agents such as antibiotics, when the underlying depression resolves. Sedating antidepressants induce insomnia include decongestants (including nose include the tricyclics (amitriptyline, imipramine, nor- sprays), weight loss agents, ginseng preparations, and triptyline, etc. Depression-related insomnia responds to sedat- ing antidepressants more rapidly and with lower doses Daytim e Sleepiness compared with other symptoms of depression. Many patients with excessive daytime sleepiness, particularly those who also complain of snor- ing, will require overnight sleep evaluation (polysomnog- raphy) because of the potential diagnosis of obstructive sleep apnea. Symptoms of a mood disorder (depression), which is also a common cause of daytime sleepiness, can be difficult to distinguish from the symp- ologic functions of astronauts were adapted for sleep 17 toms of obstructive sleep apnea. In some ways, sleep staging is an artifi- neurologic diseases that induce sleepiness: narcolepsy cial construct designed for analysis of sleep based on our and idiopathic hypersomnolence. However, research has sleepy patients is the potential danger to self and others revealed that these sleep stages have physiologic and 25 while working and/or driving motor vehicles. Stages 3 and 4, (dextroamphetamine and methylphenidate), headaches, also known as deep sleep, include large amounts of the and gastrointestinal reflux. Even some nonpharmacologic therapies, Primary Care Companion J Clin Psychiatry 2001;3(3) 121 Pagel and Parnes Table 3. Arousal disorders in- can result in both sleep onset and sleep maintenance clude sleep terrors, somnambulism (sleep walking), and insomnia. Respiratory cations such as lithium that can increase deep sleep can 122 Primary Care Companion J Clin Psychiatry 2001;3(3) Medications for Sleep Disorders Table 4. Similarly, the arousal disorders can fortable limb sensations at sleep onset and motor restless- be treated with medications affecting deep sleep (benzo- ness exacerbated by relaxation. Respiratory Effects Historically, both periodic limb movement disorder Certain medications are known to affect respiratory and restless legs syndrome have been treated with benzo- drive. Benzodiazepines, barbiturates, and narcotics can diazepines, particularly clonazepam. These medi- at bedtime have been demonstrated to be efficacious in cations can also negatively affect obstructive sleep apnea. Possible side effects from these med- The newer hypnotics (zolpidem and zaleplon) have less ications, which include carbidopa/levodopa, pergolide, respiratory suppressant effects. Medroxyprogesterone, pramipexole, selegiline, and ropinirole, are nausea, head- 42,43 protriptyline, and fluoxetine have been documented to ache, and occasional augmentation of symptoms. These include delayed and ad- Enuresis, defined as persistent bed-wetting more than vanced sleep phase syndromes in which the sleep period twice a month past the age of 5 years, is present in 15% of is markedly later or earlier than what is socially accepted, 5-year-olds. Medication has been shown to be symptom- jet lag, shift work, and certain sleep abnormalities associ- atically useful. Melatonin is the photoneuroendocrine for decades in this disorder, but there has been concern transducer that conveys information controlling sleep- about long-term safety in children.

Research has been able to recognize several factors associad with non-compliance discount 10 mg isordil with mastercard, buour possibilities to improve compliance are very limid isordil 10 mg on line. We know thanon-compliance is associad with poor treatmenoutcomes in many diseases generic isordil 10mg with amex, including hypernsion. The high discontinuation ras of antihypernsive medications, aleasin the early stages of treatment, have been found to be more than alarming. On the other hand, hypernsion research has been able to recognize several factors associad with poor blood pressures, butoday, only a minority of hypernsive patients reach the targelevels of blood pressure in Finland as well as in many other countries. To describe the prevalence of differenperceived problems and attitudes in the treatmenof hypernsion. To evalua the association of perceived problems and attitudes with non- compliance with antihypernsive drug therapy. To evalua the association of perceived problems and attitudes as well as non- compliance with the control of blood pressure with antihypernsive drug therapy. To be eligible to participa in the study, the patients had to fulfil the following criria: born in the year 1921 or lar, buying antihypernsive medication for himself/herself and entitled to receive special reimbursemenfor antihypernsive medication under the national sickness insurance program. Of the patients invid to participa (n = 971), 105 refused and 866 agreed and received a questionnaire to be compled ahome (Figure 1). Of the respondents, 54 were excluded from the analyses due to missing data on aleasone variable. Men Women Total Characristic n % n % n % Age < 50 years 47 24 41 18 88 21 50 � 64 years 104 52 98 43 202 47 65 � 75 years 48 24 90 39 138 32 Education primary 75 38 126 55 201 47 secondary 97 49 87 38 184 43 academic 27 14 16 7 43 10 Years of treatmen< 5 45 23 48 21 93 22 5 � 9 57 29 47 21 104 24 10 � 19 56 28 64 28 120 28 > 20 41 21 70 31 111 26 Number of antihypernsive drugs 1 96 48 100 44 196 46 2 75 38 103 45 178 42 3 � 5 28 14 26 11 54 13 4. These findings motivad the initiation of a new study on the treatmensituation and problems in hypernsion care in 1996-1997. Thirty health centres ouof the a total of 250 health centres in Finland were randomly selecd by stratified sampling as representative of the basic population in rms of size and geographical location. Twenty-six health centres with a total of 255 general practitioners agreed to participa in the study. During one week in November 1996, these general practitioners identified all of the hypernsive patients who visid them (n = 2. During the following three 48 months, public health nurses sento these patients two questionnaires and an invitation to a health examination. Athe health examination a trained public health nurse checked any missing data in the firsquestionnaire. The second questionnaire, which contained confidential data on the local doctors, nurses and health care sysm, was handed to the nurse in a closed envelope to be mailed to the university. Eighty-four per cenof the patients had aleasthree blood pressure readings from the year 1996 and the early parof 1997. In these measurements, the patients had had mean systolic and diastolic blood pressures 2. The prevalence of patient-perceived problems analyses were also carried ouon the medically untread population, which consisd of 220 patients, 90 (40. If the systolic and diastolic blood pressure values had been calculad based on the smaller of the two recorded readings, the respective values would have been 149. Men Women Total Characristic n % n % n % Age < 55 years 144 23 186 20 330 21 55 � 64 years 183 30 224 24 407 26 65 � 74 years 217 35 308 33 525 34 > 75 years 71 12 228 24 299 19 Education a lower 431 71 739 79 1170 75 b higher 180 29 200 21 380 25 Duration of hypernsion < 5 years 166 27 228 24 394 25 5 � 9 years 134 22 186 20 320 21 > 10 years 312 51 525 56 837 54 Number of antihypernsive drugs 1 331 54 462 49 793 51 2 223 36 375 40 598 38 3 � 5 59 10 105 11 164 11 a basic school, junior secondary school, primary school or parts of these curricula b academic education, occupational school, vocational school, senior secondary school Pharmacy-based study population Primary health care based study population 971 Were invid to participa 2219 Were invid to participa 105 Refused to participa 437 Did noparticipa 866 Agreed to participa 1782 Participad 384 Did noreturn the 1 Was excluded due to questionnaire missing data 482 Returned the questionnaire 1781 Study population with adequaly filled questionnaires 54 Were excluded due to 220 Medically untread missing data population 428 Final study population 1561 Final study population Figure 1. The two questionnaires included a total of 82 questions aboulifestyle, health care sysm, medication, blood pressure measurements and the patient�s experiences relad to the treatmenof hypernsion. These areas were identified from the lirature as being critical for good hypernsion care. The original questions were answered on a five- poinLikerscale (1 = absoluly agree, 2 = somewhaagree, 3 = somewhadisagree, 4 = absoluly disagree, 5 = does noconcern me) or a three-poinscale (14 questions: 1 = correct, 2 = nocorrect, 3 = does noconcern me). Using factor analysis with varimax rotation on these 82 questions, 21 factors were identified (eigenvalue of > 1. Four factors, including aspects of nonpharmacological treatmenof hypernsion, such as weighreduction (three factors) and use of salt, were excluded. The questions in the factors were dichotomized as 1 (those with a problem: absoluly agree, somewhaagree, and correct) and 0 (those withoua problem: somewhadisagree, absoluly disagree, nocorrect, does noconcern me, and missing data). On the basis of reliability and inrnal validity analyses, some questions and four of the factors were excluded. One factor was splibecause of its poor inrnal validity, and a total of 14 problem areas covered by 45 questions were thus identified. Experiences concerning the symptoms of hypernsion and adverse 51 drug effects were elicid by asking the patienwhether his/her hypernsion (or drug treatment) had caused any symptoms (adverse effects). We assessed the perceived difficulties to be hypernsive by asking whether the patienfeliwas difficulto be a patienwith hypernsion. Perceived memory problems were assessed by asking whether iwas difficulto remember to take antihypernsive drugs. The patients were also asked whether they had had to give up any pleasanactivities due to hypernsion. Finally, they were asked whether hypernsion or drug taking had inrfered with their daily routines and hobbies. The number of problems was defined as the sum of positive responses to the above seven questions.

Another and women and may include reduced sex antidepressant that is commonly used is bupropion drive isordil 10mg fast delivery, and problems having and enjoying sex order isordil 10 mg online. Bupropion order isordil 10 mg free shipping, which works on the Tricyclic antidepressants can cause side effects, neurotransmitter dopamine, is unique in that it does including: not fit into any specific drug type. Older antidepressant medications the bladder, or the urine stream may not be include tricyclics, tetracyclics, and monoamine as strong as usual. Usually, antidepressants that addicted, or “hooked,” on the medications, but make you drowsy are taken at bedtime. If a medication does not work, it is helpful to Foods and medicines that contain high levels of a be open to trying another one. Tyramine is found in some cheeses, to-treat depression did not get better with a first wines, and pickles. The chemical is also in some medication, chances of getting better increased medications, including decongestants and over-the- when the person tried a new one or added a second counter cold medicine. A doctor can help a person figure out for centuries in many folk and herbal remedies. In the United States, it is one How should antidepressants be of the top-selling botanical products. The National Institutes of Health conducted a People taking antidepressants need to follow their clinical trial to determine the effectiveness of doctors’ directions. The medication should be taken treating adults who have major depression with in the right dose for the right amount of time. The study included 340 people take three or four weeks until the medicine takes diagnosed with major depression. John’s wort was no more effective than the placebo in treating Once a person is taking antidepressants, it is major depression. Johns wort may that gets worse, suicidal thinking or behavior, interfere with oral contraceptives. Families and caregivers other medications, people should always talk should report any changes to the doctor. Sometimes, s Olanzapine (Zyprexa), which helps people antipsychotics and antidepressants are used along with severe or psychotic depression, which with a mood stabilizer. In general, people continue s Ziprasidone (Geodon) treatment with mood stabilizers for years. Lithium s Clozapine (Clorazil), which is often used is a very effective mood stabilizer. They were originally developed to Antidepressants are sometimes used to treat treat seizures, but they were found to help control symptoms of depression in bipolar disorder. One anticonvulsant commonly Fluoxetine (Prozac), paroxetine (Paxil), or used as a mood stabilizer is valproic acid, also sertraline (Zoloft) are a few that are used. For some 6 people with bipolar disorder should not take an people, it may work better than lithium. Doing so can cause the anticonvulsants used as mood stabilizers are person to rapidly switch from depression to mania, carbamazepine (Tegretol), lamotrigine (Lamictal) which can be dangerous. Atypical antipsychotics Research on whether antidepressants help people Atypical antipsychotic medications are sometimes with bipolar depression is mixed. The people were taking mood stabilizers along with Mental Health Medications 7 the antidepressants. If you have any side effects, tell Valproic acid may cause damage to the liver or your doctor right away. He or she may change the pancreas, so people taking it should see their dose or prescribe a different medication. Different medications for treating bipolar disorder Valproic acid may affect young girls and women may cause different side effects. Sometimes, valproic acid may used for treating bipolar disorder have been increase testosterone (a male hormone) levels linked to unique and serious symptoms, which are in teenage girls and lead to a condition called described below. In some cases, s Slurred speech this rash can cause permanent disability or be life- s Fast, slow, irregular, or pounding heartbeat threatening. People If a person with bipolar disorder is being treated taking anticonvulsant medications for bipolar or with lithium, he or she should visit the doctor other illnesses should be closely monitored for new regularly to check the levels of lithium in the blood, or worsening symptoms of depression, suicidal and make sure the kidneys and the thyroid are thoughts or behavior, or any unusual changes in working normally. People taking these medications should not make any changes without talking to their health care professional. Treatment works best when talk with the doctor or pharmacist about any it is continuous, rather than on and off. Patients should be open with For information on side effects of antipsychotics, their doctors about treatment. Talking about how see the section on medications for treating treatment is working can help it be more effective. Doctors can use the chart to treat the illness most How should medications for bipolar effectively.