Patient evaluation on intake

• 54-year-old man was admitted to the hospital for an MDE

• Experienced his first MDE at age 30; since then has had periodic MDEs of two-to-three months duration almost every fall/winter

Patient evaluation on intake

• 35-year-old woman with a chief complaint of difficulty coping at her job

Patient evaluation on intake

• 54-year-old woman with a chief complaint of “being depressed”

• Patient started interferon treatment for hepatitis C and became alarmingly depressed

Patient evaluation on intake

• 44-year-old woman with a chief complaint of “being confused”

• Many clinicians have issued several diagnoses and she presents for a consultation

• Patient states that she has been “depressed and anxious as long as she can remember”

Patient evaluation on intake

• 18-year-old man states he has been “depressed all year”

• He has been reasonably successful in high school, enjoys athletics, has a girlfriend, and should be happy

• He is not, he is despondent to the point of being suicidal

Patient evaluation on intake

• Patient #1

• – 60-year-old man with a chief complaint of “being angry and down”

• Patient #2

• – 15-year-old girl with a chief complaint of “everything sucks”

• Patient #1 states that he was involved in a fracas at work, was pushed down the stairs, and was in a coma for a week

• Patient #2 states that she has been having a difficult time at home and at school

Psychiatric history

• Patient #1 had been without any psychiatric issues until his head injury. He states his symptoms developed after this

• Patient #2 states that she has gradually become more emotionally labile, depressed, and anxious over the last one to two years

• Patient #1 has not been able to go back to work at all due to his depression, amotivation, and anger management problems

• Patient #2 has been absent from school due to her inability to get up and get ready for school

• Patient #1 admits to full syndrome MDD

• – He has passive suicidal thoughts that there is “not much to life” and he “wouldn’t mind if he didn’t wake up”

• – Admits to poor focus, concentration, and amotivation as chief Complaints

• He states that little things make him angry quickly

• – Experiences road rage and followed fellow drivers after Incidents

• He states that he was never like this prior to his accident

• – Denies PTSD-related avoidance, flashbacks, or nightmares as he does not remember the accident due to his head injury and coma

• – Is tense and hyperaroused most of the time

• He has relatively few friends as most were colleagues at his previous job. He is at home more and not motivated to leave his home

• Patient #2 admits to full MDD symptoms

• – Has suicidal thoughts that occur more when stressed

• – Admits to having an inability to focus, poor concentration, and lack of enjoyment as chief complaints

• She states that “little things make her angry quickly”

• – She is afraid that going to school puts her in situations where she may strike out and get into fights, even though this has never been her social pattern

• – She has friends but feels disenfranchised from them

Patient evaluation on intake

• 50-year-old woman with a chief complaint of unremitting depression for 30 years

Patient evaluation on intake

• 83-year-old man states he has been anxious for at least 40 years and is not getting better in the primary care setting

Patient evaluation on intake

• 31-year-old man with a chief complaint of anxiety of “different types”

• Patient states that he “has been successful in graduate school, has financial worries, but states that he worries and is tense most of the time”

Patient evaluation on intake

• Patient #1

• – 79-year-old woman whose chief complaint was of “feeling awful”

• Patient #2

• – 85-year-old man who had no chief complaint

Patient evaluation on intake

• 50-year-old woman with no chief complaint

• Spouse calls and states that she is “speaking nonsense” and describes soft neurological signs of ataxia and unstable gait

• • Violence can be impulsive, psychotic, or psychopathic.

• • There is a high association of violence with genetic susceptibility plus an unfavorable environment.

• • There are many routes to violence (e.g., mental illnesses and unfavorable factors such as substance abuse).

• • Various areas of the prefrontal cortex and the amygdala are hypothetically linked to symptoms of psychotic, impulsive, and psychopathic violence.

• • Understanding the topographical distribution of symptoms and their regulation by neurotransmitters provides a rationale for the psychopharmacological treatment of violence and aggression.

• • There are several treatment options available for reducing the occurrence of violent or aggressive behavior; however, much of the evidence is practicebased because violent individuals are often excluded from clinical drug trials.

• • Treatment with antipsychotics, especially at high doses, may be one of the most effective strategies for treating patients who are violent or aggressive.

• • Although standard doses of all antipsychotics target 60-80% occupancy of D2 receptors, this may not be sufficient to quell violence and aggression in all patients.

• • Pharmacokinetic treatment failure occurs when D2 receptors are inadequately occupied; such failure may be managed by high dosing, novel routes of administration, or the administration of some antipsychotics with food.

• • Pharmacodynamic treatment failure occurs when patients do not respond despite achieving 80% D2 receptor occupancy; such failure can be managed by high dosing, very long treatment duration, or polypharmacy.

• • Clozapine, polypharmacy, or high-dose antipsychotic monotherapy may be justified in some cases, especially if effective in reducing assaults and if side effects are carefully monitored.

• • Additional strategies for managing violent or aggressive behavior include mood stabilizers, antidepressants, stimulants, adrenergic blockers, opiate antagonists, and benzodiazepines; however, evidence for the efficacy of these agents is limited and controversial.

• • The addition of psychotherapy to pharmacological treatment may provide the most effective means for preventing violent or aggressive behavior.