Clinical Guidance: Silent Cerebral Emboli in Dementia
Cerebral emboli were related to worse cognition, functioning, and neuropsychiatric symptoms in dementia patients (Purandare et al., p. 300)
Purandare et al. (CME, p. 300), using transcranial Doppler imaging, found middle cerebral artery emboli in nearly half of patients with either vascular or Alzheimer's dementia. Patients with emboli had more rapid progression of dementia over 2 years than those who were emboli free (figure), and their declines in overall functioning and behavior were over two times as great. Doraiswamy argues in an editorial (p. 251) that more aggressive treatment of vascular risk factors is an underutilized therapeutic approach to prevent deterioration from dementia.
Clinical Guidance: Clinical Presentations of Personality Disorders
Clinicians more generally diagnose syndromes as a whole, rather than summing the individual symptoms in a checklist. Westen et al. (p. 273) used clinician input to construct archetypical vignettes and then assessed their validity for diagnosis as templates that clinicians could use to match patients. The syndromes fell into three major groups: internalizing, externalizing, and borderline-dysregulated. Patients with higher levels of functioning also included hysterical-histrionic and obsessive types. The syndromes permit clearer distinctions between diagnoses, such as narcissistic personality disorder and borderline personality disorder, that have a common symptom, e.g., loss of empathy, that leads to the misimpression of frequent comorbidity. In an editorial, Michels (p. 241) praises the system as clinically astute but notes that occasional features are inconsistent, such as the schizoid-schizotypal syndrome, which includes both restricted affect and painful emotions. Because of the input from clinicians, other features, such as suggestibility in histrionic-hysterical patients, mirror clinicians' traditional teaching but are not fully validated by current research.
Clinical Guidance: Fluoxetine in Adult Autism
A randomized clinical trial of fluoxetine in adults with autism spectrum disorders, two-thirds with the Asperger's subtype, found decreased compulsions and repetitive behaviors in 50%, compared to 8% in those taking placebo, over 12 weeks. Hollander et al. (p. 292) also found global improvement in one-third of the fluoxetine-treated patients. An earlier trial of citalopram in 9-year-olds with more severe illness was not positive. The editorial by Emslie (p. 248) points out that developmental differences in pharmacodynamics may account for some of the differences: the mean dose of fluoxetine used in this study, 65 mg/day, is not tolerable for children.
Clinical Guidance: Pharmacokinetics of Serotonin Reuptake Inhibitors After Gastric Bypass
Morbidly obese patients treated with serotonin reuptake inhibitors for mood and anxiety disorders frequently relapse following gastric bypass surgery. Drug absorption 1 month postoperatively dropped to an average of 54% (SD=18%) of preoperative levels (range, 36%–80%) for eight of the 12 patients studied by Hamad et al. (CME, p. 256), but it returned to baseline levels by 6 months for six patients. Those who relapsed into depression with low blood levels frequently failed to lose weight as well. Psychiatric and pharmacokinetic monitoring of these patients, particularly in the first postsurgical month, is warranted.
Clinical Guidance: Reevaluation of Suicide Risk From Antiepileptics in Bipolar Disorder
The U.S. Food and Drug Administration in 2009 warned of increased suicidality with all antiepileptic drugs, regardless of the illness being treated. Leon et al. (CME, p. 285) examined longitudinal clinical observations of 199 bipolar patients taking carbamazepine, lamotrigine, or valproate in five U.S. medical centers. There was no evidence for increased suicidality. Kashner explains in an editorial (p. 244) that propensity analysis, the method used by Leon et al., is a recently developed strategy to control for the effects of other risk factors, including bipolar disorder itself, in such assessments, when data from randomized controlled trials do not exist.