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S Nassir Ghaemi

Publications and source records attributed to S Nassir Ghaemi.

At least 19 recordsLinked to original sources
PubMed2007

Existence and pluralism: the rediscovery of Karl Jaspers.

Karl Jaspers has been recognized in psychiatry mostly for his influence on phenomenology and on certain aspects of psychopathology, such as our understanding of delusions. In this paper, I will highlight the need to rediscover Jaspers' work in terms of other important ideas that he can contribute to psychiatry, in particular the concepts of limit situations, transcendence and pluralism. Limit situations refer to the fact that human life is characterized by existential situations, or crises, which become opportunities for authentic existence. Transcendence refers to the notion that freedom is an important aspect of human existence and cannot be explained by purely scientific understanding or encompassed by any purely rationalistic system of thought. Pluralism is perhaps Jaspers' most original perspective, which has still failed to be adequately appreciated by the psychiatric profession. The idea here is that science means understanding the methods by which we obtain knowledge, along with the presuppositions and limits of those methods. Contemporary psychiatry has only a limited appreciation of Jaspers' work. In this paper, I attempt to describe these important concepts that can help us understand what we do in psychiatry, what we should be doing and why.

Attitude to Death↗
PubMed2006

Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy.

Phenomenological research suggests that pure manic and depressive states are less common than mixtures of the two and that the two poles of mood are characterized by opposite ways of experiencing time. In mania, the subjective experience of time is sped up and in depression it is slowed down, perhaps reflecting differences in circadian pathophysiology. The two classic mood states are also quite different in their effect on subjective awareness: manic patients lack insight into their excitation, while depressed patients are quite insightful into their unhappiness. Consequently, insight plays a major role in overdiagnosis of unipolar depression and misdiagnosis of bipolar disorder. The phenomenology of depression also is relevant to types of psychotherapies used to treat it. The depressive realism (DR) model, in contrast to the cognitive distortion model, appears to better apply to many persons with mild to moderate depressive syndromes. I suggest that existential psychotherapy is the necessary corollary of the DR model in those cases. Further, some depressive morbidities may in fact prove, after phenomenological study, to involve other mental states instead of depression. The chronic sub-syndromal depression that is often the long-term consequence of treated bipolar disorder may in fact represent existential despair, rather than depression proper, again suggesting intervention with existential psychotherapeutic methods.

Awareness↗
PubMed2006

Adjunctive risperidone, olanzapine and quetiapine for the treatment of hospitalized patients with bipolar I disorder: a retrospective study.

This study evaluated the overall effectiveness and tolerability of atypical antipsychotics (risperidone vs. olanzapine vs. quetiapine) used in the treatment of bipolar inpatients. After screening 463 patients, the medical records of 158 inpatients with bipolar I disorder, who were given olanzapine, risperidone or quetiapine as adjuncts to mood stabilizers for at least 1 month and not administered with any other antipsychotics, were examined. Details of the tolerability and effectiveness were reviewed according to the treatment records during their hospital stay. The results showed equivalent effectiveness based on the Clinical Global Impression (CGI) and Global Assessment Functioning (GAF) score between the three atypical antipsychotics. The frequency of the extrapyramidal symptom-related side effects were higher in the risperidone-treated group than in the olanzapine and quetiapine-treated group. This suggests that risperidone, olanzapine and quetiapine have a comparable effectiveness in inpatients with bipolar I disorder in a naturalistic setting. However, there were some differences in tolerability between these results as reported from previous Western studies.

Adolescent↗
PubMed2006

Improving the diagnosis of bipolar disorder: predictive value of screening tests.

OBJECTIVE: To examine the impact of assumptions about prevalence or prior clinical probability of bipolar disorder on the clinical performance (predictive values) of diagnostic screening tests. METHOD: Sensitivity and specificity data from four reports on two bipolar screening instruments (the Mood Disorders Questionnaire and the Bipolar Spectrum Diagnostic Scale) were used to calculate positive and negative predictive values at varying prevalence levels. Bayesian statistical concepts were employed. RESULTS: At low prevalence or low prior clinical probability, the sensitivity and specificity of the test have little impact on negative predictive value; the tests perform well, with low risk of false negatives. Similarly, at low prevalence or low prior clinical probability, positive predictive values are low regardless of which sensitivity and specificity data are used: the risk of false positives is substantial. CONCLUSIONS: At lower prevalence or prior probabilities, as in the community or primary care setting, these screening tests can rule out bipolarity (when patients have insight into their symptoms), but do not effectively rule it in. Clinicians' estimates of prior probability have as much, or in many cases more, impact on the clinical performance of the bipolar screening tools than the tests' sensitivity and specificity. To improve the performance of screening tools, the primary emphasis needs to be placed on improving clinicians' skill at recognizing clinical and historical features of bipolar diagnosis.

Bayes Theorem↗
PubMed2006

Extrapyramidal side effects with atypical neuroleptics in bipolar disorder.

OBJECTIVE: To examine, in a real-world clinical setting, the risk of extrapyramidal symptoms (EPS) with atypical neuroleptics in bipolar patients. METHODS: The authors assessed 51 individual patient trials of atypical neuroleptic agents (17 risperidone, 13 olanzapine, 11 quetiapine, 8 ziprasidone, and 2 aripiprazole) in 37 bipolar patients (type I or type II). Risk of EPS was assessed using the Abnormal Involuntary Movement Scale, Barnes Akathisia Rating Scale, and the Simpson-Angus Scale. Mean duration of treatment was 25.5 weeks (range 3-107 weeks) and 60.8% of patients were female. RESULTS: 62.7% of trials resulted in moderate to severe EPS. EPS and discontinuation frequencies were similar between specific neuroleptic agents or between high potency (risperidone/ziprasidone/aripiprazole; 52.9%, 27/51 trials) and low potency (quetiapine/olanzapine; 47.1%, 24/51 trials) agents. In a multiple regression model adjusted for confounders, akathisia was less common with low potency agents. Younger age was associated with more akathisia. 31.4% (11/35) of trials discontinued due to side effects. 7.8% (4/51) of trials led to mild de novo tardive dyskinesia. CONCLUSIONS: Over one-half of bipolar patients experienced EPS in this real world clinical setting. This rate is much higher than the 5-15% range reported in clinical trials, suggesting potential problems with clinical trial generalizability.

Adult↗
PubMed2006

Underdiagnosis of bipolar disorder in men with substance use disorder.

OBJECTIVE: Recent reports indicate that bipolar disorder is frequently underdiagnosed in the clinical population, leading to overuse of antidepressants and underuse of mood stabilizers. This study assessed rates of diagnosis of bipolar disorder in a substance abuse population. METHOD: The study involved a retrospective chart review of data from 295 patients admitted to an inpatient substance abuse program for men. Data were then analyzed from the 85 patients in the sample who were diagnosed as meeting DSM-IV criteria for bipolar disorder on intake into the program. Charts were reviewed for relevant clinical and demographic data. The primary outcome measure was the rate of previous misdiagnosis. RESULTS: Of the 85 patients diagnosed with bipolar disorder upon intake, 42 (49%) had not been previously diagnosed with bipolar disorder; of these 42, 6 (14%) patients had not been assessed previously, while 36 (86%) had been assessed previously and had received many other psychiatric diagnoses, including major depression (77%), attention-deficit/hyperactivity disorder (20%), and panic disorder (3%). Among the comorbid substance use disorders in these patients, alcohol dependence was the most common (62%), followed by cocaine (38%), opioid (26%), polysubstance (12%), and sedative-hypnotic (2%) dependence. Other comorbid Axis I disorders included posttraumatic stress disorder (14%), attention-deficit/hyperactivity disorder (10%), panic disorder (2%), and generalized anxiety disorder (2%). CONCLUSION: This study found that bipolar disorder had not been previously diagnosed in approximately 50% of a sample of Caucasian males in a substance abuse population who were diagnosed with bipolar disorder upon admission to an inpatient substance abuse program.

Adult↗
PubMed2006

Long-term lamotrigine plus lithium for bipolar disorder: One year outcome.

OBJECTIVE: To obtain pilot data in an observational setting on the use of lamotrigine plus lithium in the long-term treatment of patients with bipolar disorder, 87% of whom had failed to respond to at least one previous mood stabilizer. METHODS: Charts of 21 patients (11 females, 10 males, mean age 43.2 years) treated with the combination of lithium and lamotrigine were reviewed retrospectively for treatment response using the Clinical Global Impression-Bipolar Disorder-Improvement scale, divided into benefit for acute depressive symptoms, acute manic symptoms, and overall illness (including prophylaxis of mood episodes). Of the 21 patients, 76% were diagnosed with bipolar I disorder, and depressive symptoms were the most common acute indication for treatment (52%). Mean doses of lithium and lamotrigine were 963 mg/day and 179 mg/day, respectively, used for a mean of 55.7 weeks. RESULTS: Acute antidepressant benefit was observed in 48% of patients, acute anti-manic benefit in 14%, and overall prophylactic benefit in 29%. Side effects were observed in 38%, with cognitive problems most common (29%). 48% discontinued combination therapy, mainly due to lack of efficacy (19%) or activation of manic-like symptoms (19%). CONCLUSIONS: Among a group of largely treatment-resistant bipolar patients, the combination of lithium and lamotrigine appeared effective for acute depressive symptoms in about half of the patients, but acute anti-manic and long-term prophylactic efficacy appeared less robust.

Adult↗
PubMed2006

An open prospective study of zonisamide in acute bipolar depression.

OBJECTIVE: To examine the effectiveness and safety of zonisamide in the treatment of acute bipolar depression. METHODS: An open-label, prospective, nonrandomized, 8-week study conducted in bipolar outpatients (type I, type II, or not otherwise specified) with depressive symptoms. No patient was manic or mixed at study entry. Previous treatments were continued unchanged, but no new treatments were allowed. Montgomery Asberg Depression Rating Scale and the Mania Rating Scale from the Schedule of Affective Disorders and Schizophrenia-Change Version were used. RESULTS: Twenty patients (10 men, 10 women) with bipolar disorder (17 type I, 2 type II, 1 NOS), aged 38.1 +/- 8.81 years, received zonisamide at mean dose of 222.5 +/- 85.1 mg/d. Mean Montgomery Asberg Depression Rating Scale scores improved significantly from baseline to endpoint (mean difference = -8.4, 95% confidence interval [4.1, 12.6], P = 0.001). Ten patients (50%) terminated early due to adverse effects, mostly side effects including nausea/vomiting, cognitive impairment, and sedation. One patient experienced increased suicidal ideation, and one patient experienced hypomania. CONCLUSIONS: This study suggests improvement of depressive symptoms in this sample with 8 weeks of open-label zonisamide treatment.

Acute Disease↗
PubMed2006

Galantamine treatment of cognitive impairment in bipolar disorder: four cases.

OBJECTIVE: To determine if galantamine is effective in the treatment of chronic cognitive impairment in bipolar disorder. METHODS: All charts of patients meeting DSM-IV criteria for bipolar disorder treated with galantamine in an academic bipolar disorder specialty clinic psychiatric practice were reviewed and clinical response was assessed retrospectively using the Clinical Global Impression scale for Improvement. RESULTS: Galantamine was effective in two of four patients, both of whom took at least 24 mg/day. It was ineffective in two patients who only took 8 mg/day. Sedation limited higher dosing in one patient, and a second patient experienced sedation and tremor. Improvement in cognition was not associated with improvement in mood. Galantamine appeared neutral in its effect on mood. CONCLUSIONS: This pilot case series suggests that galantamine may have some utility in improving chronic cognitive impairment in bipolar disorder. Larger studies are required to clarify these initial pilot data.

Adult↗
PubMed2006

Pharmacological Treatment Patterns at Study Entry for the First 500 STEP-BD Participants.

OBJECTIVE: This study assessed patterns of psychopharmacological treatment for bipolar disorder. METHOD: Intake treatment data were examined for the first 500 patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study (1998 to 1999). Diagnoses were assessed by using the Structured Clinical Interview for DSM-IV mood modules. Data on treatments were obtained by interviewing patients during the initial psychiatric examination. RESULTS: Of the 500 participants, 73.6 percent had bipolar I disorder, 23.0 percent had bipolar II disorder, and 3.4 percent had bipolar disorder not otherwise specified. Upon examination, 63.4 percent were euthymic, 24.6 percent were depressed, and 12.0 percent were experiencing manic, hypomanic, or mixed states. Standard mood stabilizers (lithium, valproate, or carbamazepine) were the most commonly prescribed class of drugs that participants were taking at intake (71.9 percent). The next most common class of agents was antidepressants (40.6 percent), followed by novel anticonvulsants (31.8 percent), second-generation neuroleptics (27.2 percent), and benzodiazepines (25.0 percent). Eleven percent of patients were treated with standard mood stabilizer monotherapy. These prescribing patterns were further analyzed by subtype of illness and compared with patterns in other clinical and community settings. CONCLUSION: In a large, well-characterized cross-sectional analysis of prescription patterns in the U.S. psychiatric academic setting, patients with bipolar disorder were primarily treated with standard mood stabilizers, followed by moderate use of antidepressants, novel anticonvulsants, and second-generation neuroleptics. Results can be useful in understanding the current clinical standard of care, as well as in guiding research studies toward areas in which there is a relative absence of evidence to inform clinical practice. Studies of longitudinal prescribing patterns in bipolar disorder are also needed.

Academic Medical Centers↗
PubMed2006

Persistent posttraumatic stress disorder following September 11 in patients with bipolar disorder.

OBJECTIVE: We examined the development of posttraumatic stress disorder (PTSD) following indirect exposure to the September 11, 2001, terrorist attacks in a cohort at high risk for adverse trauma-related sequelae as a result of having bipolar disorder. METHOD: Subjects (N = 137) were participants in the ongoing, naturalistic, longitudinal study Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) prior to September 11, 2001. The present study examined prospectively collected pre-event information about bipolar disorder and other potential predictors of PTSD, along with assessment of the level of indirect trauma exposure (i.e., via media) and peritraumatic distress in the aftermath of September 11, and their association with 9/11-related, new-onset PTSD as assessed by a self-report measure, the Posttraumatic Stress Diagnostic Scale. RESULTS: Posttrauma assessments were completed a mean +/- SD of 430.6 +/- 78.7 days (range, 0.5-1.5 years) after September 11. Twenty percent (N = 27) of patients reported development of new-onset PTSD in response to the September 11 attacks. Rates of PTSD were significantly associated with the presence of a hypomanic, manic, or mixed mood state at the time of trauma (chi(2) = 4.25; p < .05); 62% of patients in these states developed PTSD. Mania/hypomania remained a significant predictor of PTSD in response to the September 11 attacks after controlling for peritraumatic exposure and distress variables, suggestive of a substantial increase in risk compared with those in recovery (OR = 17; 95% CI = 2.6 to 115.6; p = .0034). CONCLUSIONS: Rates of persistent new-onset PTSD among bipolar patients were elevated in the aftermath of the September 11 attacks. Our findings suggest that the presence of a manic state may be the most critical risk factor for adverse sequelae following indirect traumatic exposure in bipolar individuals.

Adult↗
PubMed2006

The prescription of psychotropic medications for patients discharged from a psychiatric emergency service.

OBJECTIVE: Considerable debate exists about the value and wisdom of initiating "definitive" pharmacotherapies, particularly antidepressants, in the psychiatric emergency setting. We evaluated the nature and prevalence of medication prescriptions for patients discharged from an urban psychiatric emergency service and the extent to which pharmacotherapy initiation was predictive of follow-through with aftercare. METHOD: Records were reviewed for 675 consecutive individuals evaluated and discharged from a community-based psychiatric emergency service over a 3-month period (January 2003-March 2003). Information was obtained regarding diagnoses, past and current treatments, and demographic and clinical features, as well as outcomes for the subgroup of patients who received aftercare appointments within the institutional system. RESULTS: Fifty-five percent of psychiatric emergency service visits resulted in discharge, with psychotropic drug prescriptions given to about 30% of this group. Prescriptions most often included antidepressants (64%), benzodiazepines (25%), nonbenzodiazepine sedatives (20%), anti-psychotics (18%), and mood stabilizers (10%). After controlling for potential confounders, the decision to prescribe was significantly associated with a clinical diagnosis of major depressive disorder or bipolar disorder and the preexisting use of psychotropic medications. Nonprescribing occurred most often in discharged patients who had suicidal ideation, substance abuse or dependence, and an existing outpatient psychiatrist. Follow-up emergency service and new outpatient appointments were more often given to patients discharged with a prescription, but follow-through with aftercare was not more likely in this group. CONCLUSIONS: Psychiatrists in an emergency service prescribe antidepressants or other major psychotropics for about one third of discharged patients, rarely in the presence of suicidality or substance abuse or dependence, and with little evidence that initiating such medications in the emergency setting promotes more successful bridging to outpatient treatment.

Adult↗
PubMed2006

Substance use disorder and other predictors of antidepressant-induced mania: a retrospective chart review.

OBJECTIVE: To determine if substance use disorder (SUD) is a predictor of antidepressant-induced mania (ADM) in bipolar disorder, correcting for confounding factors in a regression model. METHOD: 335 antidepressant trials were identified in 98 patients treated in an academic bipolar specialty clinic from 2000 to 2004. Patient charts were reviewed, and histories of SUD and ADM (primary outcome; defined as a hypomanic or manic episode within 12 weeks of beginning an antidepressant trial) were identified. Mood disorder diagnoses were made using the Structured Clinical Interview for DSM-IV mood module, and SUD diagnoses were defined using DSM-IV criteria. Potential confounding variables were also examined and included in a multivariable regression model. Concomitant mood stabilizer, antimanic, and antidepressant use was adjusted for in the regression model. RESULTS: In univariate analyses, there was no evidence of an association between ADM and past SUD. However, after adjustment for confounding variables in a multivariable regression model, there was a strong relationship (OR = 5.06, 95% CI = 1.31 to 19.64, p < .05). Other statistically significant predictors of ADM in the regression model were type II subtype of bipolar illness, female gender, and tricyclic antidepressant (TCA) use (vs. bupropion). CONCLUSIONS: Along with other factors, a history of SUD was a strong predictor of ADM. Possible underestimation of ADM in randomized clinical trials may occur due to the exclusion of subjects with SUD. Type II illness, female gender, and TCA use also appeared to be predictors of ADM, while bupropion use appeared to predict lower likelihood of ADM.

Adolescent↗
PubMed2005

Clinical variables associated with early administration of antipsychotics in bipolar mania.

This study evaluated the clinical variables associated with the early administration of antipsychotics for the treatment of bipolar mania. 63 out of 97 inpatients with bipolar I disorder according to the DSM-IV criteria and who were consecutively admitted to the Kangnam St. Mary's Hospital, between September 2002 and March 2004, were included in the study. Regression analysis was run on the clinical variables in order to identify the factors affecting the early administration of antipsychotics. The route of admission and exposure to antipsychotics at the last follow-up were found to be associated with the early administration of antipsychotics (odds ratios=33.0 and 13.1, respectively). This study suggests that some clinical factors in bipolar mania might be linked to the earlier antipsychotic treatment. However, more studies will be needed to confirm this finding.

Adult↗
PubMed2005

Patient-based utilities for bipolar disorder-related health states.

BACKGROUND: Bipolar disorder is a psychiatric disorder which impacts patient functioning and well-being. With increasing interest in cost-effectiveness of treatments, it is necessary to provide estimates of patient's perspectives on treatment outcomes. This study estimated health state utilities for hypothetical bipolar-related health states and patient's current health from bipolar I patients. METHODS: Clinicians completed Young Mania Rating Scale, Montgomery-Asberg Depression Rating Scale, and Global Assessment Score. Patients completed structured standard gamble (SG) utility assessment interviews, and the other patient-based measures. Interviews obtained utilities for hypothetical bipolar-related health states describing symptom severity, functioning and well-being, and treatment-related side effects. RESULTS: Ninety-six patients were recruited from psychiatry outpatient practices. Mean utilities for inpatient states ranged from 0.12 to 0.33; outpatient mania states ranged from 0.29 to 0.64; outpatient stable states ranged from 0.53 to 0.85. Mean utility for current health was 0.80 (S.D.=0.22). Patients preferred monotherapy compared with combination therapy health states. Ordinary least squares regression indicated weight gain was associated with a 0.066 decrease in health state utilities (P=0.013). LIMITATIONS: Study sample consisted of selected stable and educated patients and small sample sizes may limit generalizability for some utilities. CONCLUSIONS: Bipolar disorder patients are capable of participating in utility assessment and providing ratings for hypothetical health states associated with different mood stabilizer treatments.

Adolescent↗
PubMed2005

Sensitivity and specificity of a new bipolar spectrum diagnostic scale.

OBJECTIVE: To assess the sensitivity and specificity of a self-report questionnaire for bipolar disorder, the Bipolar Spectrum Diagnostic Scale (BSDS). METHODS: The BSDS was administered to 68 consecutive patients with bipolar illness and 27 consecutive patients with unipolar major depressive disorder. Created by Ronald Pies, it consists of a descriptive story that captures subtle features of bipolar illness, to which patients may assent on a sentence-by-sentence basis. BSDS scores were compared to clinicians' DSM-IV-based diagnoses. RESULTS: Sensitivity of the BSDS was 0.76, approximately equal in bipolar I and II/NOS subjects (0.75 and 0.79, respectively). The BSDS identified 85% of unipolar-depressed patients as not having bipolar spectrum illness. A shift in the threshold of the BSDS resulted in a large increase in specificity (from 0.85 to 0.93), without a significant loss of sensitivity. CONCLUSIONS: The BSDS was highly sensitive and specific for bipolar spectrum illness, especially with the amended threshold for positive diagnosis.

Awareness↗