Michael Casher

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The Inpatient with Depression

The Inpatient with Dual Diagnosis (Co-Occurring Disorder)

Manual of Inpatient Psychiatry, 2020

Benzodiazepines and Stimulants for Patients with Substance Use Disorders: Careful Assessment, Close Monitoring Are Essential When Prescribing Drugs with Abuse Potential

Current Psychiatry, May 1, 2011

Although benzodiazepines and stimulants have well-documented efficacy for numerous psychiatric di... more Although benzodiazepines and stimulants have well-documented efficacy for numerous psychiatric disorders, psychiatrists hesitate to prescribe these medications to patients with substance use disorders (SUDs)--even to those with a comorbid condition that likely would respond to a benzodiazepine or stimulant--because of risk of abuse or dependence. Conventional practice typically has focused on treating active substance use first rather than using simultaneous treatments. Prejudice, fear, and misinformation can influence this decision. [ILLUSTRATION OMITTED] [ILLUSTRATION OMITTED] We believe these cases lie on a continuum. At one extreme, ignoring a past or present SUD may lead a remitted patient toward relapse, or further delay recovery for an active user. At the other end, psychiatrists who overreact to a remote history of substance use may deprive patients of legitimate; pharmacologic symptom relief. Most cases lie somewhere in the middle. A literature review does not support the assertion that the use of these medications leads to future substance use or worsens active use, especially for stimulants. In fact, stepwise--as opposed to concurrent--treatment for both conditions actually may delay recovery and increase patients' risk for morbidity We outline issues involved in these complex clinical situations, point out controversies, review relevant research data, and offer guidelines for treatment. Table 1 Clinical uses of benzodiazepines Insomnia Anxiety disorders (eg, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, social phobia, and obsessive-compulsive disorder) Side effects of other psychiatric medications (eg, akathisia with antipsychotics or tremor with lithium) Alcohol or benzodiazepine withdrawal Acute agitation states, either as monotherapy or as adjuncts to antipsychotics or mood stabilizers Catatonia Source: Reference 1 CASE 1 Panic disorder in sobriety Since he was a teen, Mr. A, age 51, drank heavily, which cost him jobs and relationships. After being convicted for driving under the influence, he was court-ordered to attend a rehabilitation facility, where, as he describes it, he "finally turned [his] life around." He followed up residential treatment with regular attendance at Alcoholics Anonymous meetings. After 1 year of sobriety, Mr. A develops increasingly frequent episodes of intense anxiety with sweating, nausea, chest pain, and hyperventilation and is diagnosed with panic disorder. His internist prescribes alprazolam, 0.5 mg 3 times a day, which provides some symptom relief, and refers him for follow-up psychiatric care. At his first visit, Mr. A confides to his psychiatrist that he is taking much more I than the prescribed dosage of alprazolam, even when he is not experiencing anxiety, and is contemplating "buying it on the street" if his dosage is not raised to "at least 3 mg 3 times a day." CASE 2 Anxiety in controlled psychosis Ms. B, age 40, had her first psychotic break at age 18 and was diagnosed with schizophrenia. Since then, she has had multiple psychiatric hospitalizations, usually presenting with auditory hallucinations and a recurring delusion that the person who calls herself Ms. B's mother is really an actress "playing" her mother. At times this delusion has led Ms, B to attack her "imposter" mother. Over several years Ms, B began to drink heavily, but recently achieved a few months of sobriety by attending dual-diagnosis groups at her local community mental health center and individual psychotherapy sessions with her case manager. Fortunately, Ms. B's psychosis has been stabilized with risperidone long-acting injection, 25 mg every 2 weeks, which she tolerates well. When her beloved calico cat passes away, Ms. B experiences intense anxiety. Ms. …

Benzodiazepines: A Versatile Clinical Tool; Evidence Supports Their Use for Alcohol Withdrawal, Insomnia, Anxiety Disorders, and Other Conditions

Current Psychiatry, Apr 1, 2012

Since the discovery of chlordiazepoxide in the 1950s, benzodiazepines have revolutionized the tre... more Since the discovery of chlordiazepoxide in the 1950s, benzodiazepines have revolutionized the treatment of anxiety and insomnia, largely because of their improved safety profile compared with barbiturates, formerly the preferred sedative-hypnotic. (1) In addition to their anxiolytic and sedative-hypnotic effects, benzodiazepines exhibit anterograde amnesia, anticonvulsant, and muscle relaxant properties. (1) Psychiatrists use benzodiazepines to treat anxiety and sleep disorders, acute agitation, alcohol withdrawal, catatonia, and psychotropic side effects such as akathisia. This article highlights the evidence for using benzodiazepines in anxiety and other disorders and why they generally should not be used for obsessive-compulsive disorder and posttraumatic stress disorder (Box 1, page 59). Pharrnacolunetic properties Most benzodiazepines are considered to have similar efficacy; therefore, selection is based on pharmacokinetic considerations. Table 1 (page 60) compares the indica tion, onset, and half-life of 12 commonly used benzodiazepines. (2-6) Although Table 1 lists approximate equivalent doses, studies report inconsistent data. These are approximations only and should not be used independently to make therapy decisions. Table 1 Oral benzodiazepines: Indications, onset, half-life, and equivalent doses Drug FDA-approved Onset of Approximate action half-life (hours) indication(s) in healthy adults Aiprazolam Anxiety Intermediate 6.3 to 26.9 disorders, (IR), 10.7 panic to 15.8 disorder (XR) Chlordiazepoxide Anxiety Intermediate 24 to 48 disorders, acute alcohol withdrawal, preoperative apprehension and anxiety Clonazepam Seizure Intermediate 18 to 50 disorders, panic disorder Clorazepate Anxiety, Fast 40 to 50 seizures, acute alcohol withdrawal Diazepam Anxiety Very fast 20 to 100 disorders, acute alcohol withdrawal, muscle spasms, convulsive disorders Estazolam Insomnia Intermediate 10 to 24 Flurazepam Insomnia Intermediate 47 to 100 Lorazepam Anxiety intermediate 10 to 20 Oxazepam Anxiety, acute Slow to 5 to 20 alcohol intermediate withdrawal Quazepam Insomnia Intermediate 39 to 73 Temazepam Insomnia Intermediate 3.5 to 18.4 Triazolam Insomnia Fast 1.5 to 5.5 Drug Approximate Comments equivalent dose (mg) (a) Aiprazolam 0.5 Increased risk for abuse because of greater lipid solubility Chlordiazepoxide 10 Risk for accumulation because of long-acting metabolites (desmethyldiazepam, oxazepam) Clonazepam 0.25 to 0.5 Use caution in patients with liver disease Clorazepate 7.5 Risk for accumulation because of long-acting metabolites (desmethyldiazepam, oxazepam) Diazepam 5 Risk for accumulation because of long-acting metabolites (temazepam, desmethyldiazepam, oxazepam). …

How to Prevent Adverse Drug Events: Enhanced Awareness, Vigilant Monitoring Can Reduce Morbidity and Mortality

Current Psychiatry, Jul 1, 2011

Medication errors due to system-, provider-, or patient-related factors contribute significantly ... more Medication errors due to system-, provider-, or patient-related factors contribute significantly to increased costs, adverse drug events (ADEs), and morbidity and mortality. (1) One study found > 60% of ADEs that led to hospitalization could have been prevented by strategies such as adequate monitoring or appropriate prescribing. (2) Psychiatrists have an opportunity to reduce rates of ADEs; however, the possibility of disease symptoms overlapping with these adverse events is 1 of many obstacles prescribing clinicians face. (1) Prescribers also must contend with adverse effects of polypharmacy, which are common among psychiatric patients. Patient-related factors of concern include: * seeing multiple prescribers * medication nonadherence * failure to communicate use of herbal or over-the-counter products * lack of insight * comorbid medical and psychiatric diagnoses, such as dementia. (1) This article highlights potential ADEs and major medication safety concerns that may contribute to morbidity and mortality among patients taking psychotropics. Although many factors are beyond the prescribing clinician's control--such as medication dispensing and administration errors--psychiatrists can substantially reduce ADEs. We will cover potential adverse events associated with key medications or medication classes, drug interactions with potentially devastating consequences, and strategies to minimize risks of ADEs, including enhanced awareness and monitoring (Table 1, page 56). Table 1 How to avoid ADEs with psychotropics Establish a collaborative practice among physicians, pharmacists, nurses, and social workers to enhance patient care and reduce the risk of medication errors and negative outcomes Educate patients to increase their understanding of psychiatric diseases and medications and increase compliance with therapy. This may lead the patient to self-monitor drug efficacy and adverse effects Be aware of psychotropic medications' 'black-box' warnings that guide their safe use Pay particular attention to drugs with a narrow therapeutic index, such as lithium and tricyclic antidepressants, which have small safety margins and are lethal in overdose Avoid using 1 drug to treat the side effects of another. Minimizing polypharmacy can reduce medication errors, DDIs, and ADEs Remain vigilant for DDIs, which can be serious and life-threatening. Examples include sudden cardiac death from additive QTc prolongation effects and NMS. Early detection of NMS and discontinuing the offending agent(s) can help prevent patient morbidity and mortality Stay up-to-date on literature and drug warnings to employ best practices and avoid potentially serious adverse and/or lethal outcomes Encourage patients to disclose any prescription drugs, over-the-counter medications, and herbal therapies they are taking Develop strategies to prevent ADEs, such as personal formularies, suicide assessments, prescribing limited quantities, 'eyes on' medication administration, therapeutic drug monitoring, utilizing databases and resources for drug information, and patient education ADEs: adverse drug events; DDIs: drug-drug interactions; NMS: neuroleptic malignant syndrome Prescription drug overdose Each year, unintentional drug overdoses account for >20,000 deaths in the United States. (3) Prescription medications, particularly opioid analgesics, have contributed to the doubling of overdose mortality rates in recent years. A recent study reported that nearly 50% of unintentional drug overdose deaths were associated with psychotropics and one-third of these deaths were associated with benzodiazepines, many of which were not prescribed to the individual. (4) The risk of mortality from intentional drug overdose also must be assessed. Tricyclic antidepressants (TCAs) are a particularly lethal class of medications in suicide attempts and may result in arrhythmias, coma, seizures, respiratory failure, and death. …

Casher M, Gih D, Bess J, Agarwala P: Confounding Factors in TRD (Part 1): The role of subtyping and bipolarity. Psychiatric Times, vol. 29, No.7, p.36-38, July 2012

Psychiatric Times

Augmenting antidepressants with triiodothyronine: An underutilized strategy

Current psychiatry

43 Current Psychiatry Vol. 10, No. 7 P artial responsiveness to antidepressant monotherapy is a s... more 43 Current Psychiatry Vol. 10, No. 7 P artial responsiveness to antidepressant monotherapy is a struggle for many depressed patients. The literature sup-ports the effectiveness of augmenting tri-cyclic antidepressants (TCAs) with triiodo-thyronine (T3) in unipolar depression. One meta-analysis suggests that T3 may acceler-ate antidepressant response in patients with treatment-resistant depression. 1 Likewise, T3 augmentation can improve depressive symptoms in patients without subclinical hypothyroidism whose depression did not fully respond to selective serotonin reup-take inhibitors (SSRIs). 2 In the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, patients received lithium or T3 augmentation after they failed 2 antide-pressant trials. 3 Patients receiving lithium or T3 augmentation showed similar remission rates, but the latter was associated with low-er discontinuation rates because of its more favorable side effect profile. Despite its reported effectivenes...

Foreword by Laura D. Hirshbein

Manual of Inpatient Psychiatry

Emergence of borderline personality features in the sixth decade of life by Michael Casher and Daniel Gih

Personality and Mental Health, 2009

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The Academic Psychiatric Hospitalist

Journal of Psychiatric Practice, 2011

Recent years have seen the expanding presence of hospitalists, most prominently in internal medic... more Recent years have seen the expanding presence of hospitalists, most prominently in internal medicine, but also in other areas such as neurology, pediatrics, and psychiatry. In contrast to a burgeoning literature on general medicine hospitalists, very little has been written about the role of psychiatric hospitalists-psychiatrists who work exclusively in the hospital setting-and the advantages of this model in the inpatient setting. The authors trace the history of hospitalists in psychiatry and argue that this model can fit well with the clinical and teaching mission of the modern academic psychiatry inpatient program. High quality care of acutely ill psychiatric inpatients involves a body of knowledge and a set of core competencies that may be best served by psychiatric hospitalists.

Chronotherapy in Treatment-Resistant Depression

Psychiatric Annals, 2012

CASE 1 The patient, JK, was a 20-yearold female college student with a history of major depressiv... more CASE 1 The patient, JK, was a 20-yearold female college student with a history of major depressive disorder. She was admitted to the inpatient psychiatry unit after she was brought to an outpatient psychiatric clinic by friends who were concerned about her suicidal thoughts. On admission, the patient reported depression that had been present "for a long time" but had been worse for the previous 2 weeks. She had been sleeping only 5 hours per night, with frequent awakenings. The patient endorsed decreased energy, anhedonia, hopelessness, variable appetite, and decreased interest in socializing. She was unable to concentrate on reading for more than a few minutes, whereas she used to read "for hours at a

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Manual of Inpatient Psychiatry

... with schizophrenia 1 2 The inpatient with depression 21 3 The inpatient with mania 50 4 ... c... more

Foreword by Laura D. Hirshbein

by Michael Casher and Laura Hirshbein

Manual of Inpatient Psychiatry, 2010

Michael Casher

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