Search

A review of research on pastoral nomads in Iran leads to a number of general observations about pastoral nomadism. Nomadic movement is highly purposeful and is oriented toward achieving specific production or other goals. Commonly nomadic mobility is used to advance production goals in a number of diverse sectors. However, nomadism is not tied to one type of economic system; some nomads have generalized, consumption-oriented production, while others are specialized and market-oriented. Nor is nomadism limited to one type of land tenure; some nomads migrate within a territory that they control, while others have no political or legal claim over the land they use. Furthermore, some pastoral nomads live in isolated regions far from other populations, while others live close to peasant and urban populations. Pastoral nomads vary in political structure from state-controlled peasants, to centralized chiefdoms, to weak chiefdoms, to segmentary lineages systems.

Depression is common across a broad spectrum of severity among nursing home residents. Previous research has demonstrated the effectiveness of antidepressants in nursing home residents with major depression, but it is not known whether antidepressants are helpful in residents with less severe forms of depression. We conducted a randomized double-blind placebo-controlled 8-week trial comparing paroxetine and placebo in very old nursing home residents with non-major depression. The main outcome measure was the primary nurse's Clinical Impression of Change (CGI-C). Additional outcome measures were improvement on the interview-derived Hamilton Depression Rating Scale (HDRS) and Cornell Scale for Depression (CS) scores. Twenty-four subjects with a mean age of 87.9 were enrolled and twenty subjects completed the trial. Placebo response was high, and when all subjects were considered, there were no differences in improvement between the paroxetine and placebo groups. Two subjects that received paroxetine developed delirium, and subjects that received paroxetine were more likely to experience a decrease in Mini Mental State Exam scores (P =.03). There were no differences in serum anticholinergic activity between groups. In a subgroup analysis of 15 subjects with higher baseline HDRS and CS scores, there was a trend toward greater improvement in the paroxetine group in an outcome measure that combined the CGI-C and interview-based measures (P =.06). Paroxetine is not clearly superior to placebo in this small study of very old nursing home residents with non-major depression, and there is a risk of adverse cognitive effects. Because of the high placebo response and the trend towards improvement in the more severely ill patients, it is possible that a larger study would have demonstrated a significant therapeutic effect for paroxetine as compared with placebo. The study also illustrates the discordance between patient and caregiver ratings, and the difficulties in studying very elderly patients with mood disorders.

This commentary focuses on psychopharmacology teachers and their teaching. The authors offer broadly based pedagogic suggestions on how to deliver evidence-based and neurobiologically informed prescribing information to clinicians at all levels of experience. They argue that teaching essential psychopharmacology knowledge and practice must be up-to-date, accurate, and consistent with the reality of an individual patient’s life experience and beliefs. They stress that educators must teach that nonpsychopharmacological factors in a patient’s life may be as relevant to the treatment setting as the actual pharmacological basis of psychotropic drug therapeutics.

Objective This article reports on the pharmacologic treatment of patients diagnosed with generalized anxiety disorder (GAD) enrolled in a naturalistic long-term study of anxiety disorders, with enrollment in 1989 through 1991 and follow-up in 1996. Method 711 patients were enrolled in the study during 1989-1991. At intake, 167 patients met DSM-III-R criteria for GAD; at 1996 follow-up, 103 patients met these criteria. The patients were divided into 3 groups by diagnosis: GAD alone (N = 18 at intake, N =11 at follow-up), GAD comorbid with another anxiety disorder (N = 84 at intake, N = 52 at follow-up), and GAD comorbid with Research Diagnostic Criteria-defined major depressive disorder, with or without another anxiety disorder (N = 65 at intake, N = 40 at follow-up). The groups were evaluated at intake and follow-up on whether they received medication and the types of medication they received. Results Nearly one third of patients in the 1989-1991 sample were not receiving any medication for treatment of their anxiety disorder; in 1996, 27% of patients still were receiving no medication. There was a decrease in benzodiazepine treatment and an increase in antidepressant treatment in 1996 for GAD patients who did not have comorbid depression or another anxiety disorder. Conclusion The finding of one quarter to one third of patients with GAD receiving no medication is consistent with previous observations of undertreatment of depression. The findings on medication type suggest a shift in the type of medications being prescribed for treatment of GAD from exclusive benzodiazepine treatment to the combination of benzodiazepine and antidepressant treatment.

There is a paucity of studies on the use of neuroleptic medication for treatment of the core symptoms of schizophrenia in elderly patients. The studies that are available have significant methodologic problems, including the mixing of early- and late-onset patients, inadequate outcome criteria, and the lack of control groups. Studies of conventional neuroleptics suggest that older patients have a moderate therapeutic response but are likely to develop side effects. The few studies of atypical antipsychotics now available suggest efficacy for treatment of behavioral disturbance in the elderly and a more favorable side-effect profile. The usefulness of all neuroleptics for the treatment of the core symptoms of late-life schizophrenia may depend on the duration and severity of the symptoms, with a poor response associated with greater severity and duration. It appears that patients with later-onset symptoms may respond better to all neuroleptics.

Quetiapine is an atypical antipsychotic agent that does not appear to increase patient risk for treatment-emergent extrapyramidal symptoms (EPS) or anticholinergic symptoms. Previous studies of quetiapine use in elderly patients with schizophrenia and other psychoses examined short-term administration (or = 12 weeks). Given the growing elderly population, the commensurate increase in elderly patients with psychoses, and the expected increase in disease treatment-years, the effect of long-term quetiapine administration in older patients is of considerable interest.This study assesses the long-term tolerability, safety, and clinical benefit of quetiapine in elderly patients with psychosis.Elderly patients (or = 65 years of age) with psychotic disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, participated in this 52-week, open-label, multicenter trial. Investigators increased (and later adjusted) daily doses of quetiapine on the basis of clinical response and tolerability, and assessed safety and efficacy. Efficacy assessments were made using the 18-item Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions (CGI), Simpson-Angus Scale, and the Abnormal Involuntary Movement Scale (AIMS). For patients who withdrew before week 52, analyses were performed using observed data and the last observation carried forward.One hundred eighty-four patients with psychotic disorders (98 women and 86 men) with a mean age of 76.1 years entered the trial. Seventy-two percent had psychotic disorders due to general medical conditions such as Alzheimer's disease, and 28% had other psychotic disorders, most commonly schizophrenia. Overall, 89 (48%) patients completed treatment through 52 weeks. Median total daily dose was 137.5 mg. Reasons, for withdrawal included lack of efficacy (19%), adverse events or intercurrent illness (15%), failure to return for follow-up (13%), protocol noncompliance (3%), and diminished need for treatment (2%). Somnolence (31%), dizziness (17%), and postural hypotension (15%) were common adverse events, but they rarely resulted in withdrawal from therapy. EPS-related adverse events occurred in 13% of patients. At end point (week 52), mean total score on the Simpson-Angus Scale had decreased from baseline by 1.8 points, whereas changes in AIMS scores were negligible. No clinically important effects were reported relative to mean changes in hematologic, thyroid function, or hepatic function variables. Quetiapine treatment appeared to have no associated cardiovascular adverse outcomes despite cardiovascular comorbidities and unrestricted use of concomitant cardiovascular medications. Significant decreases in BPRS total score (n = 170, P0.001) and CGI Severity of Illness item score (n = 177, P0.002) were seen at end point (observed data and last observation carried forward). Decreases ofor = 20% in mean BPRS total score were observed in 83 (49%) patients.These results provide preliminary information to clinicians regarding tolerability, safety, and clinical improvement with quetiapine in elderly patients with psychotic symptoms, and support controlled studies of quetiapine in this patient population.

Image and reality interplay in the chiefship of the Basseri tribe of southern Iran. We know the Basseri through the influential and rightly esteemed ethnography, Nomads of South Persia, by Fredrik Barth. Barth's account of the Basseri chief is vivid and striking, and, in placing the chiefship within the complex society of Iran, was an original contribution to the ethnographic literature. And yet there appear to be certain subtleties of the Basseri chiefship, which, while implied in the historical and ethnographic information provided by Barth, are not included in his explicit description. As a result, Barth overstates, I believe, the degree of the Basseri chief's power, and underestimates the extent to which the chief depended upon the consent of his tribemen. Image and reality interplay in social life because people present themselves and describe others pragmatically, in ways that help them to achieve their objectives and goals. The images that people thusly present of themselves and others-the "clever student," the "influential professor," the "honest used-car salesman," the "public-spirited politician," well known to us all-may be partial, incomplete, or totally false, but usually involve some degree of misrepresentation. To the extent that the claims people make in constructing their and others' images do not correspond to their actions and activities, to their practice and practices, the images diverge from reality. This is the criterion we apply in our everyday lives, and I believe it is appropriate for understanding other people's lives. But the story does not end with the simple distinction between words and actions, between image and reality. For while the referent of an image may be all or partly illusory, the presentation of that image to other people is itself social, intentional, goal-oriented action; it can and does lead others to act, and so the construction and management of images is itself part of reality. To this extent, image presentation shapes the worlds we wish to understand, and is thus a legitimate and necessary focus of our attention. Among the Basseri, "the chief

Tempus de Baristas. 1992 (released in 1993). 141 minutes, color. video directed by David MacDougall. Produced by the Istituto Superiore Regionale Etnografico di Sardegna (Italy). For more information contact the Center for Media and Independent Learning, University of California Extension, Berkeley, CA 94704, or the Royal Anthropological Institute Video Sales, London, UK.

Ethnographic characterizations of pastoralists as egalitarian have recently been contested on the grounds that new studies have demonstrated a widespread inequality in livestock ownership, thus proving that the notion of pastoral egalitarianism is a myth. This revisionist rejection of the egalitarianism of pastoralists appears difficult to sustain after examination of the literature. Ethnographic accounts show a wide range of pastoral societies, some more hierarchical and some quite egalitarian, and this variation was well recognized by at least 1940. “Egalitarian” is used in the literature to characterize pastoral tribesmen primarily in a political rather than an economic sense. Differences in livestock ownership were recognized by ethnographers characterizing the peoples they studied as “egalitarian”, but these differences were known not to cause either social stratification or economic class differentiation. To suggest as the revisionists do that all societies and cultures are characterized by inequali...

Benzodiazepines are sedative hypnotic medications that can induce a state of dependence. Dependence however is not the same as addiction. The development of dependence is a predictable phenomenon, influenced by dose, duration of treatment, and a number of other factors including individual characteristics of the benzodiazepine user. It is unclear whether there are meaningful differences among benzodiazepines in producing a state of dependence. Benzodiazepine dependence is also characterized by a predictable discontinuation syndrome. Benzodiazepines are rarely abused by non-substance abusers. The regulation of benzodiazepines although the legitimate therapeutic use has been significantly reduced.

It is my happy office as Chair of the Awards Committee to announce that the IUAES Commission on Nomadic Peoples presents its first ever 'Lifetime Achievement Award' to Professor Fredrik Barth for his contributions to the study of nomadic peoples. Through this honorific presentation, the Commission, on behalf of all students of nomadic peoples, wishes to express its appreciation to Professor Barth for his astute, imaginative, and powerful portrayals and analyses of nomadic peoples, and for his ground-breaking theoretical conceptions and formulations about their lives and circumstances. Each student of nomadic peoples will have her or his own reasons for being grateful to Professor Barth; each will in her or his own way have a debt to his work. I am confident that my colleagues will share in my enthusiasm for honouring Professor Barth. However, in these remarks about Professor Barth's work, I speak for myself out of my own experience, and each colleague will have to add his or her own perspective of appreciation. It is quite true that Professor Barth's work on nomads strongly influenced and inspired subsequent ethnographers of nomadic peoples (although clearly not in the way suggested by Street 1990; cf. Salzman 1995). In the mid-1960s, when I was a graduate student, I read Nomads of South Persia and various of Professor Barth's articles, and drew on them explicitly and implicitly, consciously and unconsciously in my own research, as did my coevals and those who followed. Ecologie Relationships of Ethnic Groups in Swat , North Pakistan (1956), Nomads of South Persia (1961), The Land Use Patterns of Migratory Tribes of South Persia (1960), and Nomadism in the Mountain and Plateau Areas of South West Asia (1960), offered the reader enlightening accounts of several, groundbreaking themes: first, understanding nomadic peoples in terms of their ecological adaptation; second, appreciating the role of ethnicity in ecological specialisation; third, placing nomadic peoples within a wider social and political context, and especially in their participation in a complex society involving markets and state institutions. These works went farther, demonstrating the interplay between ecology, ethnicity, and complex society, on the one hand, and, on the other hand, social, political and economic organisation among nomadic peoples. At the time of this research and writing by Professor Barth, a particular image and a model of nomadic peoples dominated anthropology. This representation

Benzodiazepines have been used in the United States for more than three decades as treatment for anxiety, panic, and disturbed sleep. l e 2 Nonpsychiatric physicians commonly prescribe them for brief periods as part of acute medical treatments; psychiatrists administer them more often on a prolonged or even chronic basis. Although benzodiazepines are members of the sedativehypnotic class of psychotropic drugs, they are among the safest medications known; they have virtually no lethal potential when taken alone, and few meaningful interactions when taken together with other drugs. Compared with previously available sedativehypnotic agents, they represent a major pharmacological advance in the treatment of anxiety.3 As with the barbiturates and with meprobamate before them, controversy has swirled around the use of benzodiazepines since their introduction, and it shows no sign of abating.'g The controversy is focused on three concerns: the potential for abuse, especially as a consequence of therapeutic use; the advisability of long-term use, in light of dependence and withdrapal symptoms; and side effects, particularly cognitive impairment. Conflicting opinions regarding these concerns (summarized in Table 1) leave patients and clinicians bewildered when they must decide whether a benzodiazepine is appropriate for therapeutic purposes.

Anxiety disorders are among the most prevalent psychiatric disorders in the elderly. Few systematic studies of their course and treatment, however, have been performed in this patient population. This article summarizes the available information in the field and discusses its clinical relevance. The article also presents a systematic way of assessing and managing anxiety in the elderly and raises questions for future research.

(1995). Resistant Depression in the Very Old—A Role for Maintenance ECT? Harvard Review of Psychiatry: Vol. 3, No. 3, pp. 152-155.

Most studies of the elderly use age 65 as the definition of the onset of old age, and most studies of the pharmacologic treatment of depression in the elderly focus on patients between the ages of 60 and 70. Very few patients over the age of 75 have been specifically studied, and virtually none over the age of 80. Data for this review of treatment of depressed patients over the age of 75 were derived from a larger review prepared for a 1992 NIMH consensus development conference on the diagnosis and treatment of depression in late life. Available studies were divided into three categories: 1) mixed-age studies that include subjects over 75 (n = 18); 2) mixed-age reports of patients having a mean age of 75 or older (n = 13); and 3) reports including only patients with minimum age of 75 years or older (>n = 5). Data are available from only 171 identifiable patients over the age of 75. Consequently, available data for patients in this very old age category are too limited for reliable or valid treatment recommendations to be made; further research is necessary.

Childhood abuse has been implicated as a leading factor in the development of borderline personality disorder (BPD). Data in this report, drawn from an ongoing study of the therapeutic effect of fluoxetine in BPD patients, were gathered in an attempt to replicate previous findings indicating a history of physical abuse in 71% and sexual abuse in 67% of adult BPD subjects. Thirty-one subjects for a study of the pharmacological treatment of BPD or BPD traits met criteria for the study. Those who had been previously hospitalized for a psychiatric disorder, who had recently been suicidal, or who had recent histories of self-mutilation were excluded. Specific information about childhood abuse was gathered using questions from a previous study of abuse histories in BPD patients. All subjects were then interviewed in greater depth regarding past experiences of abuse as part of the ongoing study of the relationship of childhood attachment experience and adult psychopathology. Six of 31 subjects (19.4%) reported a definite history of childhood physical and/or sexual abuse. Four of these subjects met criteria for full BPD, and two met criteria for BPD traits. Three of 31 subjects reported a history of physical abuse (9.7%); five reported a history of sexual abuse (16.1%). Two of the six who reported abuse reported both physical and sexual abuse. A history of childhood abuse is not necessarily linked to the development of BPD or BPD traits in all individuals. The following hypothesis is suggested: BPD may represent a spectrum of symptomatic severity. The least symptomatic individuals and those with traits rather than the disorder, as represented by our research cohort, are least likely to have a history of childhood abuse. The most symptomatic individuals, as represented by hospitalized patients or outpatients reporting frequent self-destructive behaviors, may be more likely to have suffered physical and/or sexual abuse in childhood. Language: en

The atypical neuroleptic clozapine has an unusual profile of clinical effects and a distinctive spectrum of pharmacological actions. Plasma measures of catecholamines and their metabolites have been used in the past to study the action of typical neuroleptics. We obtained longitudinal assessments of plasma measures of dopamine (pDA), norepinephrine (pNE), and their metabolites, homovanillic acid (pHVA) and 3-methoxy-4-hydroxyphenylglycol (pMHPG), in eight treatment-resistant or treatment-intolerant schizophrenic patients who were treated with clozapine for 12 weeks following a prolonged drug-washout period. Our findings from the study of these eight patients suggest the following: Plasma levels of HVA and possibly NE derived from the neuroleptic-free baseline period may predict response to clozapine; plasma levels of HVA and MHPG decrease during the initial weeks of treatment in responders but not in nonresponders; and plasma levels of DA and NE increase in both responders and nonresponders to clozapine.

Benzodiazepines are widely prescribed drugs. Most patients are prescribed benzodiazepines for short periods of time for anxiolytic or hypnotic purposes. However, some benzodiazepines are also used for extended periods at high doses to treat panic and agoraphobic disorders. When chronically prescribed benzodiazepines are discontinued, a predictable pattern of discontinuance symptoms may develop, indicating physiological dependence. Benzodiazepines also produce a variety of side effects including sedation, reduced coordination, and impaired cognition, which are primarily related to dose and duration of treatment. Benzodiazepines are commonly used by polysubstance abusers but their abuse as recreational drugs when taken alone is rare, and high-dose treatment for panic and agoraphobic symptoms does not lead to abuse. Prescribing guidelines are offered.

OBJECTIVE: To address issues concerning potential treatment-emergent "suicidality," a consensus conference was convened March 23-24, 2009. PARTICIPANTS: This gathering of participants from academia, government, and industry brought together experts in suicide prevention, clinical trial design, psychometrics, pharmacoepidemiology, and genetics, as well as research psychiatrists involved in studies of major depression, bipolar disorder, schizophrenia, substance abuse/dependence, and other psychiatric disorders associated with elevated suicide risk across the life cycle. The process involved reviews of the relevant literature, and a series of 6 breakout sessions focused on specific questions of interest. EVIDENCE: Each of the participants at the meeting received references relevant to the formal presentations (as well as the slides for the presentations) for their review prior to the meeting. In addition, the assessment instruments of suicidal ideation/behavior were reviewed in relationship to standard measures of validity, reliability, and clinical utility, and these findings were discussed at length in relevant breakout groups, in the final plenary session, and in the preparation of the article. Consensus and dissenting views were noted. CONSENSUS PROCESS: Discussion and questions followed each formal presentation during the plenary sessions. Approximately 6 questions per breakout group were prepared in advance by members of the Steering Committee and each breakout group chair. Consensus in the breakout groups was achieved by nominal group process. Consensus recommendations and any dissent were reviewed for each breakout group at the final plenary session. All plenary sessions were recorded and transcribed by a court stenographer. Following the transcript, with input by each of the authors, the final paper went through 14 drafts. The output of the meeting was organized into this scholarly article, which has been developed by the authors with feedback from all participants at the meeting and represents a consensus view. Any areas of disagreement have been noted. CONCLUSIONS: The term suicidality is not as clinically useful as more specific terminology (ideation, behavior, attempts, and suicide). Most participants applauded the FDA's effort to promote standard definitions and definable expectations for investigators and industry sponsors by endorsing the terminology in the Columbia Classification Algorithm of Suicide Assessment (C-CASA). Further research of available assessment instruments is needed to verify their utility, reliability, and validity in identifying suicide-associated treatment-emergent adverse effects and/or a signal of efficacy in suicide prevention trials. The FDA needs to build upon its new authority to systematically monitor postmarketing events by encouraging the development of a validated instrument for postmarketing surveillance of suicidal ideation, behavior, and risk within informative large health care-related databases in the United States and abroad. Over time, the FDA, industry, and clinical researchers should evaluate the impact of the current Agency requirement that all CNS clinical drug trials must include a C-CASA-compatible screening instrument for assessing and documenting the occurrence of treatment-emergent suicidal ideation and behavior. Finally, patients at high risk for suicide can safely be included in clinical trials, if proper precautions are followed, and they need to be included to enable premarket assessments of the risks and benefits of medications related to suicidal ideation, suicidal behavior, and suicide in such patients. Language: en

In a controlled study, benzodiazepine treatment was gradually discontinued from a group of elderly nursing home residents. In comparison with similar residents who continued on benzodiazepines, measures of memory and cognitive functioning showed significant improvement following discontinuance. There was no associated increase in anxiety, agitation, or sleeplessness. These data are consistent with previous observations suggesting that benzodiazepines impair cognitive function in the elderly and further indicate that such impairment is reversible upon benzodiazepine discontinuance.

Nonbarbiturate hypnotics• •? .[B] [C] [C]All cause respiratorydepression and increase sedation Alldecreaseantipsychotic serumlevels Hypotension ingarecommendation by the Food and DrugAdministration in Novem ber 1989 that its use be curtailed due to the incidence of eosinophilia myalgia syndrome. As in the past, because of space limitations references cannot be in cluded here but will be provided by the authors on request. Reprints are also available on request.

The most common complaints of older adults concern their difficulty initiating or maintaining sleep, which results in insufficient sleep and an increased risk of falls, difficulty with concentration and memory, and overall decreased quality of life. Difficulties sleeping are not, however, an inevitable part of aging. Rather, the sleep complaints are often comorbid with medical and psychiatric illness, associated with the medications used to treat those illnesses, or the result of circadian rhythm changes or other sleep disorders. Health care professionals specializing in geriatrics need to learn to recognize the different causes of sleep disturbances in this population and to initiate appropriate treatment. Nonpharmacological treatment techniques are discussed; pharmacological treatments are discussed in a companion article.

Disturbed sleep is common in the elderly, who, as a group, take a disproportionately large number of hypnotic medications. Benzodiazepine hypnotics, as well as the newer benzodiazepine receptor agonists, are the primary treatments for these late-life sleep disorders and are effective and safe when used within recommended prescribing guidelines. The elderly also receive other psychiatric medications to induce sleep, although these are off-label uses not well supported by research literature. There is also no literature support for the use of over-the-counter sleep preparations, although both melatonin and a melatonin receptor agonist appear to be moderately effective and safe. Prescribing guidelines for the elderly continue to emphasize short-term, low-dose use, with short-half-life medications. Hypnotic drugs should be used in conjunction with nonmedication treatments, including appropriate sleep hygiene practice, and treatment of other medical or psychiatric causes of disturbed sleep.

How do we best teach clinical psychopharmacology to trainees and clinicians, so they not only increase their knowledge base, but even more importantly also learn to practice the most informed, evidence-based practice possible? This article attempts to answer this elusive question by compiling the individual and combined wisdom of 5 expert psychopharmacology teachers, each of whom draws on years of their own experiences as master educators. The topics covered include teaching clinical psychopharmacological competence in adult psychiatry residency training and in issues specific to both pediatric and geriatric populations, teaching physicians to improve clinical outcomes through continuing medical education, and new developments in adult-centered pedagogy and assessment. Although the focus of this article is on practical pearls found useful in teaching psychiatric residents and practicing physicians, the lessons learned are applicable to other groups of learners such as medical students, other trainees, and nonmedical clinicians. Our goal is to help educators produce competent psychopharmacology clinicians schooled in the latest evidence, capable of keeping up with new knowledge as it becomes available, and practicing both the art and science of expert clinical care.

The central nervous system of humans supports a range of cognitive functions that contribute to conscious mental states. The neural systems underlying several of these cognitive functions, including perception, memory, planning and action, are proving susceptible to experimental analysis in lower primate species such as rhesus monkeys. In particular, recent investigations have generated striking new insights concerning the neural mechanisms that mediate visual perception. We briefly review the functional organization of the primate visual pathways and describe new experiments that demonstrate a causal link between neural activity in one of these pathways and a specific aspect of perceptual performance. The experiments illustrate an incisive method for linking perceptual abilities to their neural substrates. This approach may prove applicable to the analysis of other cognitive functions as well.

In elderly persons, antipsychotic drugs are clinically prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications (schizophrenia and bipolar disorder). The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia. In April 2005, the FDA, based on a meta-analysis of 17 double-blind randomized placebo-controlled trials among elderly people with dementia, determined that atypical antipsychotics were associated with a significantly (1.6-1.7 times) greater mortality risk compared with placebo, and asked that drug manufacturers add a 'black box' warning to prescribing information for these drugs. Most deaths were due to either cardiac or infectious causes, the two most common immediate causes of death in dementia in general. Clinicians, patients, and caregivers are left with unclear choices of treatment for dementia patients with psychosis and/or severe agitation. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there is a paucity of evidence-based treatment alternatives to antipsychotics for this population. Thus, there is insufficient evidence to suggest that psychotropics other than antipsychotics represent an overall effective and safe, let alone better, treatment choice for psychosis or agitation in dementia; currently no such treatment has been approved by the FDA for these symptoms. Similarly, the data on the efficacy of specific psychosocial treatments in patients with dementia are limited and inconclusive. The goal of this White Paper is to review relevant issues and make clinical and research recommendations regarding the treatment of elderly dementia patients with psychosis and/or agitation. The role of shared decision making and caution in using pharmacotherapy for these patients is stressed.

Drs. Torous, Stern, Padmanabhan, Keshavan and Perez are to be congratulated for defining and describing a psychiatric resident training program to encourage neuroscience learning. As these authors eloquently describe, specific knowledge of brain function is beginning to clarify our understanding of some, if not many, psychiatric disorders. The authors are careful to point out that our expanding neuroscience information base has not yet yielded reliable and always reproducible clinical treatment results, but the emerging data are encouraging. As the authors indicate, we now understand specific functions of many brain anatomical sites, their inter-site circuitry, their genetic origin, as well as the microcircuitry that is necessary for the extraordinary communication between neuronal pathways throughout the brain. The authors then provide a clinical example of neuroscience teaching using a clinical example: the neurological basis of symptoms of a depressed patient and the application of this information to suggest new and more specific therapeutic approaches. I was particularly taken by the analogy of impaired brain circuitry with an urban traffic jam that may have many causes: dysfunctional traffic signals (circuit nodes), street and highway construction (pathways), impaired road materials (neurotransmitters), and planning (genes). Together, dysfunction in these areas can bring traffic to a standstill, somewhat like some psychiatric disorders. Other traffic problems may contribute to broken restraints and traffic guidelines leading to wild and disorganized driving and potential mayhem. But here is where the analogy may become simplistic and potentially misleading, as is, I believe, the forecast of neuroscience based treatment that will finally bring about development of more effective psychiatric treatments. Automobile traffic may be halted by many different

M ost contemporary psychiatric literature describing the longterm treatment of bipolar illness emphasizes the benefit of pharmacotherapy. Although reference may be made to the need for concomitant psychotherapy (1–3), the techniques and problems in integrating these two therapeutic approaches are seldom discussed. The following case report, describing the treatment of a woman with bipolar disorder, illustrates problems common to the management of bipolar disorder and the usefulness of psychotherapy in the following aspects of treatment: 1) establishing a therapeutic alliance, 2) helping the patient overcome denial of illness, 3) addressing issues in transference and countertransference, 4) balancing therapeutic drug doses and side effects, and 5) encouraging significant others to provide ongoing mental status information.

African Pastoralist Systems: An Integrated Approach. Elliot Fratkin, A. Galvin, and Eric Albella Roth, eds. Boulder, CO: Lynne Reinner Publishers, 1994.viii+245 pp., Figures, maps, plates, tables, notes, references, contributors, index

Atypical antipsychotics have become a common pharmacologic option for the treatment of various psychiatric and behavioral symptoms in older adults, although these medications have been officially approved by the U.S. Food and Drug Administration for use only in schizophrenia and bipolar disorder. Despite the widespread use of these agents, there is a relative shortage of rigorously conducted trials. This review focuses on recently published randomized, blinded, controlled trials involving the use of atypical antipsychotics in elderly patients with dementia (n = 9) or schizophrenia (n = 3), with some discussion of published large, open-label studies and a few unpublished controlled trials. In general, the studies of patients with dementia reported modest efficacy of atypical antipsychotics when compared to placebo and conventional antipsychotics. In addition, an advantage in terms of motor side effects was consistently noted with atypical antipsychotics when compared to conventional antipsychotics. The studies have also shown, however, a greater risk of mortality and adverse cerebrovascular events with several of these agents than with placebo in individuals with dementia. There are insufficient data comparing atypical antipsychotics to one another. In the trials involving elderly persons with schizophrenia, atypical antipsychotics were associated with significant improvements in psychopathology; differences in efficacy among atypical antipsychotics were unclear. A careful consideration of the risk-benefit ratio of atypical antipsychotics, as well as that of available alternative treatments, is needed for each individual elderly patient. Clinical judgment, caution, and consent should be the watchwords in this area of psychopharmacology.

Objective: Benzodiazepines (BZs) are safe, effective drugs for treating anxiety, sleep, bipolar, and convulsive disorders, but concern is often expressed about their overuse and potential for abuse. We evaluated the effects of physician surveillance through a Triplicate Prescription Program (TPP) on problematic and non-problematic BZ use. Method: This study uses interrupted time series analyses of BZ use in the New York (intervention) and New Jersey (control) Medicaid programs for 12 months before and 24 months after the New York BZ TPP. The regulation required NY physicians to order BZs on triplicate prescription forms with one copy forwarded by pharmacies to a state surveillance unit. Study participants were community-dwelling persons over age 18 continuously enrolled between January 1988 and December 1990 in New York ( n = 125,837) or New Jersey Medicaid ( n = 139,405). Results: During the baseline year, 20.2% of New York and 19.3% of New Jersey cohort members received at least one BZ prescription. After the TPP, there was a sudden, sustained reduction in BZ use of 54.8% (95% CI = [51.4%, 58.3%]) in New York with no changes in New Jersey. Significantly greater reductions were experienced by young women, and persons living in zip codes that were urban, predominantly Black, or with a high density of poor households. Increases in potential substitute medications were modest. At baseline, nearly 60% of BZ recipients had no evidence of potentially problematic use. Despite a somewhat greater likelihood of discontinuation of BZ therapy among those with potentially problematic use, the largest impact of the TPP was a substantially greater relative reduction in access to BZs among non-problematic users. Conclusions: State-mandated physician surveillance dramatically reduces BZ use with limited substitution of alternative drugs, lowers rates of possible abuse, but may severely limit non-problematic BZ use.

The prevalence, natural course, risk profile, and treatment of anxiety disorders in the elderly are remarkably understudied. Anxiety disorders are less prevalent in the elderly than in younger adults, but rates of subsyndromal anxiety disorders in elderly persons are nearly as high as in their younger cohorts. The most common late-life anxiety disorders are mixed anxiety-depression and generalized anxiety disorder. Though the benzodiazepines are widely used in this population and are considered relatively safe given appropriate dosing and safety monitoring, important liabilities remain with the use of these agents. Antidepressants also are widely used in elderly patients, but there are no randomized controlled anxiety disorder treatment trials in this population. Gabapentin and low-dose atypical antipsychotics are beginning to be used and studies of the atypical antipsychotics are ongoing. Until studies are completed, treatment of late-life anxiety will continue to be guided by extrapolating data from the general adult population. Psychopharmacology Bulletin. 2004;38(Suppl 1): 25-30.

The aging of the world’s population has resulted in a new demographic phenomenon: a significant increase in the percentage of elderly compared with the general population. Between 1960 and 1990, the general population in the U.S. increased by less than 50%, while those over 65 increased by almost 100%, and those over 85 years of age increased by almost 250% (1).

To evaluate the efficacy and tolerability of mirtazapine orally disintegrating tablets in depressed, elderly nursing home residents, under naturalistic study conditions.In this open-label 12-week study, mirtazapine orally disintegrating tablets (15-45 mg/day) were administered to patientsor =70 years old with physician-diagnosed depression and a Mini-Mental State Examination (MMSE) scoreor =10. Patients with medical comorbidities, cognitive impairment and/or concomitant medications were enrolled if they met study inclusion criteria and had illnesses and/or medication dosages that were considered stable. Assessments were performed at baseline by physicians and at days 14, 28, 56, and 84 (or early termination) by physicians or nurse coordinators using the Clinical Global Impression (CGI) scale, the 16-item Hamilton Rating Scale for depression (Ham-D-16 (the standard 17-item scale minus item 14)), and the Cornell Scale for Depression in Dementia (CSDD). Tolerability was evaluated based on treatment-emergent adverse events.A total of 119 patients in the intent-to-treat (ITT) group were treated with mirtazapine orally disintegrating tablets (mean daily dose: 19.4 mg) and evaluated for efficacy. At endpoint, 54% of patients in the ITT group showed CGI-I response (defined as a CGI-I score of 1 or 2 ('very much' or 'much' improved) and 47% were Ham-D-16 responders (defined as decrease from baseline of at least 50% in Ham-D-16 total score). CSDD mean scores and Ham-D-16 mean total scores demonstrated a progressive decrease from baseline to trial completion. The decrease in Ham-D scores from baseline to day 84 was statistically significant (p0.0001). Mean changes from baseline to day 84 were -6.6 +/- 6.9 (CSDD score) and -7.9 +/- 7.4 (Ham-D-16 total score). Ham-D Factor I, Factor VI and item 1 scores also decreased. Fourteen of 124 patients in the all-subjects-treated (AST) group (11.3%) discontinued prematurely due to adverse events. The most frequently occurring adverse events were urinary tract infection (19%), accidental injury (18%), fall (18%), somnolence (12%), and upper respiratory infection (12%). Mean body weight increased by 0.7 +/- 2.25 kg (1.54 +/- 5 lb) from baseline to day 28, and by 1.3 +/- 3.36 kg (2.86 +/- 7.4 lb) from baseline to day 84.The results suggest that mirtazapine orally disintegrating tablets provide antidepressant efficacy and are a relatively well-tolerated treatment for depression in this patient population of elderly nursing home residents with medical and cognitive comorbidities.