The frequency with which prognosis is made in psychiatry is not known. This paper reports a study of the frequency and content of prognosis as recorded by staff psychiatrists and residents in a psychiatric teaching hospital. In addition, a review was carried out on the use of prognosis in ten psychiatric textbooks. The findings suggest that closer attention should be given to the teaching of prognosis. There is a clear need to consider moving away from the close dependence of prognosis on diagnosis, and from the unidimensional view of prognosis. Reasons are given for developing a prognosis, and suggestions are made regarding the organization of the prognostic statement.

Depressive Disorder↗

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Depression in the long-term care patient: new tools for evaluation and treatment.

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Journal Article↗

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Pharmacodynamic issues relevant to geriatric psychopharmacology.

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Aged↗

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Longitudinal analysis of nortriptyline side effects in elderly depressed patients.

Forty-five depressed elderly patients were closely monitored in a research setting during treatment with nortriptyline and interpersonal psychotherapy for 7 consecutive months of acute and continuation treatment. Overall, nortriptyline was efficacious and well tolerated in this group. The frequency of somatic complaints measured by the Rating Scale for Side Effects declined by 50% during the acute phase of treatment, suggesting that many somatic complaints that may be attributed to side effects of nortriptyline are actually somatic symptoms of depression. The authors discuss the implications of these findings and offer practical advice for the treating clinician.

Aged↗

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Clomipramine in the elderly: tolerance and plasma levels.

Five elderly, treatment-resistant, depressed, female patients were closely monitored in a research setting during treatment with clomipramine. Plasma clomipramine levels were determined to establish a steady state. Elderly patients (67 to 80 years old) reached a therapeutic steady state at doses lower than that reported for midlife patients. Overall, clomipramine was well tolerated in this group. Depression, measured by the Hamilton Rating Scale for Depression, decreased 42%, and the frequency of somatic complaints, measured by the Rating Scale for Side Effects, declined by 57%. Clomipramine is specifically indicated for the treatment of obsessive-compulsive disorder and may be an alternative for elderly depressed patients, provided that lower doses and plasma clomipramine monitoring are used.

Age Factors↗

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Early detection of neuroleptic-induced parkinsonism in elderly patients with dementia.

The recently promulgated Health Care Finance Administration guidelines regarding the use of neuroleptic medications for nursing home residents do not offer criteria for the frequency or nature of the required assessments of neuroleptic-induced parkinsonism (NIP). NIP has been poorly characterized in the elderly and empirical evidence on which to base guidelines for monitoring NIP is sparse. We examined the onset of NIP in 12 closely monitored, elderly psychiatric inpatients diagnosed with dementia being treated with perphenazine. Significant increases in the Simpson Extrapyramidal Side Effect Scale total score were detected by day 4 of treatment with perphenazine at a mean dose of 8.0 mg. This increase was highly correlated with the final NIP severity. This is the first report to demonstrate that routine screening of elderly patients can detect NIP within days of the initiation of neuroleptic treatment. Early detection of NIP may allow for effective intervention to reduce the ultimate severity and associated morbidity of NIP.

Age Factors↗

PubMedDate not supplied

Recent developments in drug metabolism of relevance to psychiatrists.

The discovery in 1977 of stable genetic differences (polymorphisms) in the oxidative metabolism of debrisoquine (P450 2D6) has led to an increasingly rapid growth in knowledge concerning the diversity of cytochrome P450 enzymes, their substrate-specific metabolism, and their interindividual variation. The current state of this knowledge for cytochromes P450 2D6, 2C19, 1A2, 3A3, and 2E1 is summarized, with a view toward their potential relevance to clinical psychopharmacology. To date, no prospective trials have tested the application of clinical tests of drug metabolism to treatment with psychotropics, and no guidelines have been formulated for such an application. The author reports preliminary findings from his studies of P450 2D6 phenotyping in elderly patients treated with nortriptyline and perphenazine. Research in this area may lead to earlier identification of patients at risk because of atypical drug metabolism. This might reduce drug-drug interactions, overmedication, or inadequate treatment.

Biotransformation↗

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Neuroleptics in the elderly: guidelines for monitoring.

The Nursing Home Reform Amendments of the Omnibus Reconciliation Act of 1987 provided guidelines for the use of neuroleptic medications in nursing home patients. Although the guidelines have been successful in reducing the inappropriate use of such drugs in this population, neuroleptics remain indicated in the treatment of many elderly patients. For these patients the new regulations also specified maximum daily neuroleptic doses, and they mandated monitoring for neuroleptic-induced movement disorders, although they did not provide guidelines for such monitoring. We review the existing empirical data base in an effort to refine the recommendations for neuroleptic dosage limits and to derive standards for the monitoring of neuroleptic-induced movement disorders in the elderly.

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