Psychiatry 2008 - September 2008 - (Page 48)

[research to practice] rapidly) in the service of providing treatment options that are more aggressive and more sophisticated than standard outpatient approaches. In fact, I believe that not to do so is a significant disservice to hospitalized patients and an inefficient use of resources. That philosophy has, in turn, therapy (also known as partial sleep deprivation), and morning bright light therapy. While space prevents me from providing an in-depth description of these therapies or a full review of the scientific rationale for this protocol, I will briefly touch on each of these elements. inpatient units should leverage the inherent advantages and opportunities of the inpatient setting in the service of providing treatment options that are more aggressive and more sophisticated than standard outpatient approaches. spurred my colleagues at UCSD and me to maintain an ever present eye toward the scientific literature for assessment and treatment techniques that offer the possibility of translating that philosophy into a reality. Indeed, it was surprising to find, right from the outset of our quest, that there was an extant and growing body of evidence to support established, biologically based interventions that are easily adapted and ideally suited for the inpatient settings. Over the years, we have adopted and sometimes innovated clinical protocols uniquely designed for the acutely ill psychiatric inpatient, such as rapid loading of medication, with the aim of stabilizing patients as quickly as possible.1–3 A protocol we frequently use to treat severely depressed inpatients, particularly ones who have not responded to standard outpatient treatments, is illustrative. In addition to intense psychosocial interventions, severely depressed patients admitted to our inpatient facility are likely to be offered an integrated, trimodality, biological treatment protocol aimed at “jump starting” their recovery, which comprises inpatient-oriented pharmacotherapy, partial wake 48 Psychiatry 2008 [S E P T E M B E R ] INPATIENT-ORIENTED PHARMACOTHERAPY Inpatient-oriented pharmacotherapy can mean different things depending on each patient’s individual medication history. However, the general guiding principle is that what may be the best choice for the average outpatient with depression may not necessarily be the optimal choice for an inpatient. For example, when considering inpatient-oriented pharmacotherapy, selective serotonin reuptake inhibitor (SSRI) medications do not occupy the exalted and uncontested first-choice status they occupy in the outpatient setting. Most patients admitted for depression will have already been on one or more SSRI without adequate response. In a previous installment of this “Research to Practice” column, I addressed the lack of evidence supporting the strategy of SSRI dose escalation in patients who have not responded to a therapeutic dose.4 While there exists a controversy as to whether dual mechanism (serotonin-noradrenaline reuptake inhibitor [SNRI] and certain tricyclic) antidepressants have superior or equivalent efficacy compared to SSRIs for depression on the whole,5,6 the evidence in favor of their superior efficacy and perhaps faster onset of action is strongest among hospitalized patients and those whose depression is severe.5–9 Concern over a heavier side effect load with these medications, especially early in the course of treatment, is obviated in inpatient settings where daily monitoring, dose adjustments, and ubiquitous psychological and medical support are available. As an example, when venlafaxine was the only SNRI on the market, our inpatient protocol included initiation and rapid upward titration of that drug to 375mg per day over five days—a procedure that was based upon a published report that it was efficacious and well tolerated in an inpatient setting.10 We learned with time that this loading regimen was surprisingly well tolerated by most patients, but the confidence to implement such an aggressive regimen was derived from the ability to intensively monitor and, if need be, react rapidly (e.g., holding doses and prescribing hypnotics) to any adverse events that might emerge. WAKE THERAPY Many clinicians are probably aware of the remarkable antidepressant properties of wake therapy (WT), perhaps recalling learning about it during their residency (as I first did) where it was likely presented in a perfunctory manner, primarily as a scientific curiosity but not a viable therapeutic intervention for consideration. However, WT is arguably the most rapid and reliable antidepressant treatment, bar none. A committee on chronotherapeutics formed by the International Society for Affective Disorders (ISAD) recently reviewed the literature and concluded that WT, whether administered over the whole night or restricted to the second half of the night, provides

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Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

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