____of December, 2014
Tricyclic antidepressants vs Selective Serotonin Reuptake Inhibitors (SSRIs) in treatment of Depression
In recent decades, SSRIs have become the first-choice treatment for depression. The efficacy and acceptability, as well as cost-efficiency of selective serotonin reuptake inhibitors (SSRIs) versus the older tricyclic antidepressants (TCAs) are studied by many researchers. Most of scholars agree that the both classes of antidepressants are almost equally efficient (Marton, 2003.) According to Marton (2003), a small trend towards greater efficacy of TCAs was found when the outcome was measured in terms of depression scales, and towards SSRIs – in terms of global impression scores.
But Faravelli and colleagues (2003) argue that in most studied cases, TCAs appeared to me more effective, especially in patients with higher recurrence rate. They studied the population of patients with had several episodes of illness and have been treated with both classes of drugs – both TCAs and SSRIs. Faravelli and colleagues have found that TCAs still have an important role in treatment of patients with depression; especially they can be a good strategy for those patients who didn’t respond to SSRIs treatment, unless SSRIs are reported to produce less adverse effects. Qin et al. (2014), on the contrary, considers SSRIs (especially fluoxetine) the best approaches in treatment of young adults. Authors of the article “Mental Health; New Depression Findings from National Taiwan University Discussed” (2014) support the point of view of higher treatment success rate of SSRIs, adding that this class of drugs is the most cost-effective as compared with TCAs and SNRIs.
In their meta-analysis of side effects associated with both categories of antidepressants Trinidade et.al. (1998) reported that both classes of drugs produce adverse effects. But those effects are different for each class of drug. For example, occurrence rate for SSRIs-associated nausea is 26%, which is 11% higher than for TCAs. SSRIs intake can also cause diarrhea, anxiety, insomnia. TCAs, in their turn, can cause dizziness, constipation, dry mouth, and hypotension (Trinidade at.al, 1998.) and also are associated with the higher risk of hip fractures in elderly populations (Liu et al, 1998.)
Suicide in Psychiatric patients
Suicide is a very “serious preventable public health problem” (Qusar et al., 2010) in all countries of the World. The risk of suicide attempts is very sufficient in patients with psychiatric disorders. According to Baldwin, Mayers & Elgie (2003), up to 40% of suicide victims have been in contact with various psychiatric services within the year before the suicide, 14% have been on in-patient care within the last year.
It’s very difficult to distinguish specific risk factors associated not only with the patient’s illness but with the propensity of the patient to suicide, and these few factors have a low predictive value. Wolfersdorf names such factors as depression, hopelessness, persecutory delusions, hallucinations of voices urging to suicide, agitation, previous suicide attempts, and suicidal thoughts during psychiatric care, etc. (as cited in Baldwin, Mayers & Elgie, 2003.) Wolfersdorf and Singareddy & Balon (2001) emphasize such risk factor as insomnia and sleep disorders in suicide patients. Those disorders are associated with decreased serotonergic function. Timely diagnosis and intervention (using agents enhancing serotonergic transmission) can decrease suicidal behavior and prevent suicide. Baldwin et al. (2003) state that the risk factors with the highest likelihood are the following: previous suicide attempts, delusions, family history of suicide and chronic mental illness.
The measures of prevention combine the following actions: risk assessment at admission and later on, establishing therapeutic relations with patient, adequate treatment and also elimination of environmental factors (Baldwin, Mayers & Elgie, 2003.) Both in adults and adolescents, where, according to some studies, after an inpatient psychiatric treatment, over 30% patient try to repeat suicide suicide at 3-month follow-up (Eltz et al., 2007), the clinicians use the Suicide Probability Scale (SPS) to assess the level of suicide risk, specifically, such major risk factors as suicide ideation and also negative self-evaluation. Use of such tools can identify and prevent suicide risk in in-patient populations.
But the most high-risk periods are first days and weeks after discharge (Hunt et al, 2009.) According to Hunt and colleagues (2009), the patients, most likely to commit suicide after discharge, are more likely to have a previous history of self-harm, signs of affective disorder and other clinical symptoms at last contact with psychiatric services. Measures to decrease suicide risk in discharged patients are “intensive and early community follow-up” (Hunt et al, 2009.) To decrease the occurrence of suicide attempts and to save lives, it’s necessary to introduce and maintain the comprehensive programs of prevention, identification and treatment of addictive and mental disorders (Qusar et al., 2010.)
Substance abuse in youth
Substance abuse in young population is a serious problem of a global scale. In the U.S., for example, about 20 million of people aged over 12 used illicit drugs in 2007 (NIDA, 2007.) According to the U.S. Substance Abuse and Mental Health Administration, Office of Applied Statistics data (2009), in 2008, 9.3% of young people used illicit drugs with substance dependence rate 7.6% in people aged 12-17. Street youth and children not attending school are more exposed to the risk of substance abuse, for example, they demonstrate higher rates of methamphetamine, ecstasy, ketamine and cocaine use and are more likely to use injection drugs than all young population in average (Leslie, 2008.) Except for homelessness, the other risk factors include family history of drug abuse, maltreatment, family problems, concurrent psychiatric disorders, etc.
According to Caminer (2012), substance use disorders are chronic illness with a relapsing-remitting course, that’s why it’s crucial to provide the young patients with the proper continuity of medical care. The substance use in youth increases until the adolescents reach their 20s, after this age many patients decrease or stop usage. Also, in contrast to adults, many young people are not sufficiently motivated to abstain during or after treatment (Caminer, 2012.)
Substance use produces substantial negative adverse effects on physical and mental health of children and adolescents. According to Leslie (2008), over a half of young people seeking substance abuse treatment, have a concurrent mental disorder. The most widespread mental diagnoses that accompany substance abuse are conduct and mood disorders, anxiety, depression, attention deficit hyperactivity disorder (Pratt & Pancost, 2014.) The affective disorder and hallucinations can be both substance induced or co-morbid.
Additional harm is caused by the fact that drug abuse results in various form of associated risky behaviors such as driving in intoxicated state, self-injurious actions, unwanted sexual behaviors, etc. So, substance abuse in youth causes a combination of health-related, social and legal issues.
Cognitive Behavioral therapy in treatment of Obsessive-Compulsive disorder (OCD)
Obsessive-compulsive disorder is a severe clinical condition arising in most cases in adolescence or in early adulthood. Without proper treatment, OCD has a chronic course (Abramowitz, 2009.) It’s the fourth most widespread psychiatric condition and is classified by WHO as a prevailing global reason of nonfatal illness (Solomon, 2014.) About 50% of people with the OCD have comorbid psychological diseases such as unipolar mood disorder, depression or anxiety disorder. There’re many theoretical approaches trying to explain the genesis of OCD. One of these approaches is cognitive-behavioral one, suggesting that obsessions and compulsions arise from “dysfunctional beliefs, the strength of which affects the risk that a person will develop obsessions and compulsions” (Abramowitz, 2009.)
The cognitive behavioral therapy is a gold standard for psychological type of OCD treatment. It involves exposure and ritual prevention, based on habituation to disliked stimuli, as a core technique (Riemann, 2006.) Cognitive therapy helps the patients to get exposed to the stimuli, to identify their dysfunctional beliefs and reactions and correct them, changing the interpretation (Solomon, 2014.) In contrast with the exposure-and-response-prevention therapy, cognitive therapy focuses not on anxiety reduction but mostly on challenging and re-evaluating the irrational beliefs. Cognitive therapy can be used in combination with pharmacotherapy, psychological education, exposure therapy (ERP) and blocking the rituals. The best response, according to Riemann (2006), is achieved through a combination of 85% ERP with 15% of “cognitive restructuring.”
E-Psychiatry
As the digital technologies penetrate into healthcare industry forming the new domains of knowledge and communication channels, it’s necessary to mention e-psychiatry – the disruptive innovation in the mental healthcare allowing the psychiatrists to connect with their patients via web-based communication channels in real-time.
E-psychiatry is also called telepsychiatry or telemental health. It combines the various solutions enabling communication between the patient and the doctor through video and voice, where diagnostics and proper prescriptions should be done without necessity for patient to visit mental health professional’s office. Telepsychiatry can be a good solution for people trying to save time and money on visiting psychiatrists, for business executives, for people with no insurance or with certain disabilities, for people fearing of leaving home or seeing other people, etc.
For psychiatrists, arising of digital and mobile health technologies in their domain bring specific challenges. Being mostly later adopters of disruptive technologies, mental health professionals are also very concerned that electronic communication seems to be more informal than business-like, that electronic channels (email, skype, social media, etc.) impose risks of confidentiality, security, privacy, timeliness and also clarity of interpretation regarding very sensitive medical information transferred between the patient and the doctor (Seeman et al., 2010.) Emergency messages and other time-sensitive information cannot be transmitted by email or social media, so it’s an important limitation of e-psychiatry as well as the existence of digital divide between various areas (lack of high-speed internet connection coverage, instability of internet connection, etc.) and relatively high costs on establishing proper infrastructure for telemental health care.
But with the common lack of mental health professionals and the large number of patients who suffer from various mental and behavioral disorders, e-psychiatry, providing the ability to reach a greater number of people gives more crucial benefits than disadvantages connected with the potential privacy risks. In developing countries, for example, in Africa, Asia and Latin America, with lack of proper mental health facilities in rural areas, telepsychiatry can be the best way to provide access to these professional services.
Taking into account future trend of digital technologies transforming traditional industries, telemedicine, and especially e-psychiatry, is a high-potential area for future research and applied innovation.
References
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