The DSM–5 incorporates a broad concept of mixed states and captured ≥3 nonoverlapping symptoms of the opposite polarity using a “with mixed features” specifier to be applied to manic/hypomanic and major depressive episodes. Pharmacotherapy of mixed states is challenging because of the necessity to treat both manic/hypomanic and depressive symptoms concurrently. High-potency antipsychotics used to treat manic symptoms and antidepressants can potentially deteriorate symptoms of the opposite polarity. This review aimed to provide a synthesis of the current evidence for pharmacotherapy of mixed states with an emphasis on mixed mania/hypomania. A PubMed search was conducted for randomized controlled trials (RCTs) that were at least moderately sized, included a placebo arm, and contained information on acute-phase and maintenance treatments of adult patients with mixed episodes or mania/hypomania with significant depressive symptoms. Most studies were post-hoc subgroup and pooled analyses of the data from RCTs for acute manic and mixed episodes of bipolar I disorder; only two prospectively examined efficacy for mixed mania/hypomania specifically. Aripiprazole, asenapine, carbamazepine, olanzapine, and ziprasidone showed the strongest evidence of efficacy in acute-phase treatment. Quetiapine and divalproex/valproate were also efficacious. Combination therapies with these atypical antipsychotics and mood stabilizers can be considered in severe cases. Olanzapine and quetiapine (alone or in combination with lithium/divalproex) showed the strongest evidence of efficacy in maintenance treatment. Lithium and lamotrigine may be beneficial given their preventive effects on suicide and depressive relapse. Further prospective studies primarily focusing on mixed states are needed.

De-institutionalization of mental health patients has evolved, over nearly 3 generations now, to a status quo of mental health patients experiencing myriad contacts with first-responders, primarily police, in lieu of care. The current institutions in which these patients rotate through are psychiatric emergency units, emergency rooms, jails, and prisons. Although more police are now specially trained to respond to calls that involve mental health patients, the criminalization of persons with mental illness has been steadily increasing over the past several decades. There have also been deaths. The Crisis Intervention Team (CIT) model fosters mental health acumen among first responders, and facilitates collaboration among first responders, mental health professionals, and mental health patients and their families. Here, we review some modern, large city configurations of CIT, the co-responder model, the mitigating effects of critically situated community-based programs, as well as barriers to the success of joint efforts to better address this pressing problem.

The habenula, which in humans is a small nuclear complex within the epithalamus, plays an essential role in regulating the intensity of reward-seeking and adversity-avoiding behavior in all vertebrate ancestors by regulating the activity of ascending midbrain monoaminergic tracts. In lampreys, considered to possess a brain comparable to humans’ earliest evolutionary vertebrate ancestor, the activity of the lateral habenula is controlled by a subset of glutamatergic neurons of the animal’s pallidum (habenula-projecting globus pallidus) that inhibit reward-seeking behavior when this conduct is not successful enough. The pathophysiological roles of the habenula and habenula-projecting globus pallidus in humans have hardly been studied, which is probably due to insufficient resolution of common neuroimaging techniques. Their dysregulation may, however, play an essential role in the pathogenesis of mood and stress disorders and addiction.

This article reviews the literature regarding the impact of cosmetic surgery on health-related quality of life (QOL). Studies were identified through PubMed/Medline and PsycINFO searches from January 1960 to December 2011. Twenty-eight studies were included in this review, according to specific selection criteria.

The procedures and tools employed in cosmetic surgery research studies were remarkably diverse, thus yielding difficulties with data analysis. However, data indicate that individuals undergoing cosmetic surgery began with lower values on aspects of QOL than control subjects, and experienced significant QOL improvement post-procedurally, an effect that appeared to plateau with time.

Despite the complexity of measuring QOL in cosmetic surgery patients, most studies showed an improvement in QOL after cosmetic surgery procedures. However, this finding was clouded by measurement precision as well as heterogeneity of procedures and study populations. Future research needs to focus on refining measurement techniques, including developing cosmetic surgery–specific QOL measures.

This paper describes a model of psychopathology termed the panic-agoraphobic spectrum. The model has been constructed by identifying different psychopathologic and clinical domains that incorporate and extend the diagnosis of panic disorder as described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Categorical classifications do not take into account the subthreshold, atypical, and often enduring symptoms that accompany the core manifestations of full-blown mental disorders. These often-neglected spectrums of symptoms, however, may be as distressing and debilitating as the full-blown disorders and can have unrecognized importance in selection of and response to treatment. At the Department of Psychiatry, Neurobiology, Pharmacology, and Biotechnology, Institute of Psychiatry of the University of Pisa, Italy, a spectrum approach to mental disorders (eg, bipolar, obsessive-compulsive, eating, and panic disorders) has been used extensively and has proven effective in clinical practice.

The need for systematic identification and assessment of a broad array of symptoms and behavioral features has led, as a first step, to the conceptualization of the panic-agoraphobic spectrum model. In collaboration with researchers from the University of Pittsburgh, PA, and elsewhere, the University of Pisa scientists have further refined the panic-agoraphobic spectrum model and have developed a structured interview for this spectrum called the Structured Clinical Interview for Panic-Agoraphobic Spectrum. The rationale, clinical usefulness, and heuristic significance of the panic-agoraphobic spectrum model are discussed below.

A 56-year-old male presented with compulsive hoarding along with attention-deficit/hyperactivity disorder and schizotypal personality disorder. Hoarding has been described as difficult to treat both pharmacologically and behaviorally, and this patient's comorbid conditions also contributed to his overall impairment. The patient's treatment regimen of fluvoxamine, amphetamine salts, and risperidone, along with behavioral therapy, has helped with hoarding behaviors, motivation, procrastination, and increased socialization. Hoarding may be a unique subtype of obsessive-compulsive disorder with poorer prognosis and distinct neuroanatomic dysfunction. Augmentation with stimulants may provide benefits in aspects of hoarding such as procrastination, especially in patients with comorbid attention-deficit hyperactivity disorder.

Brain stimulation methods in the treatment of affective disorder are electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS). Clinically, ECT is considered the strongest remedy in the treatment of severe depression, especially depression with psychotic features, and in the elderly. TMS, despite positive reports, is somewhat more controversial. VNS has, so far, only been used in treatment-resistant depression with limited results. DBS may be of potential use in rare cases of treatment-resistant cases of affective disorder. This article highlights the similarities and differences between the four stimulation methods. The main difference is the seizures necessary in ECT. A stronger involvement of the hippocampus following experimental seizures compared with effects in that region induced by TMS and VNS might explain the consistent findings of the superiority of ECT in the most severe cases of affective disorder.

Although Parkinson's disease is defined by its motor symptoms, the symptoms that are most devastating to patients and caregivers are dementia and psychosis. In addition, sleep has a tremendous impact on patient well being and quality of life. Eighty percent to 90% of Parkinson's disease patients have a sleep disorder affecting their ability to fall asleep, ability to stay asleep, dreams, motor activity during sleep, post-sleep behavior, or day-time somnolence. Treatment plans for patients with Parkinson's disease who experience sleep disorders aim to improve nighttime sleep or daytime wakefulness, and treatment options vary by sleep disorder.

Patients with psychiatric catatonias vs those with medical catatonias may differ in catatonic phenomenology. To determine if these could be distinguished, the following methods were used: 1) a review of the literature; 2) a chart review; and 3) a prospective series. The literature review of 467 report of medical catatonias yielded 240 cases that met research criteria. A chart review of 47 episodes of catatonia revealed a higher frequency of negativism in patients with medical catatonias. Prospective data obtained from rating scales revealed an increased frequency of echophenomena in patients with medical catatonias; however, no discriminate pattern of catatonic signs for medical catatonias arose. Overall, catatonic signs appear to share a similar distribution. These findings suggest that psychiatric and medical catatonias are indistinguishable based upon catatonic signs.

The two approved treatments for tardive dyskinesia both inhibit the vesicular monoamine transporter type 2 (VMAT2) yet have pharmacologic properties that distinguish one from the other. Knowing these differences may help optimize which treatment to select for individual patients.

The predominantly inattentive (IN) subtype of attention-deficit/hyperactivity disorder (ADHD) is a recently defined condition that is often overlooked by professionals and is still not completely understood. Characterized by symptoms of inattentiveness, such as distractibility, failure to complete work, forgetfulness, and disorganization, the IN subtype differs from the more commonly recognized combined (CB) subtype of ADHD in that symptoms of hyper activity and impulsivity are absent or minimal. Large-scale epidemiologic studies suggest that the IN subtype is at least as prevalent as the CB subtype, and is at least as likely to be associated with academic and/or social impairment. Diagnosis of the IN subtype, however, may be more challenging because in addition to inattentiveness, other symptoms, including learning problems, depression, and anxiety, may also present without externalizing behaviors. Several studies have shown that compared with the CB subtype, the IN subtype has a later age of onset and referral, a relatively larger proportion of affected females, and is much less likely to be associated with symptoms of oppositional defiant disorder or conduct disorder. Research is currently under way to examine the cognitive characteristics of the IN subtype and its genetic and neurobiologic underpinnings, as well as to evaluate the effectiveness of pharmacotherapy and other treatments.

The purpose of this article is to review aspects of the neuropsychology of temporal lobe epilepsy. Evidence will be presented to demonstrate that the cognitive consequences of this focal seizure disorder can be more generalized in nature than expected. Consistent with the extratemporal neurocognitive findings, careful quantitative magnetic resonance imaging volumetrics have shown that structural brain changes may be detected outside the temporal lobes. Many factors can potentially affect cognition and brain structure. We focus on the potential neurodevelopmental impact of early-onset temporal lobe epilepsy on brain structure and cognition positing that this disorder can have both immediate and lifespan implications for cognition and psychosocial status.

In the last decade, increasing literature focused on camouflaging as a strategy adopted to cope with social environment by patients with autism spectrum disorder (ASD). A better understanding of this phenomenon may shed more light on cognitive mechanisms and coping strategies of patients in the autism continuum, eventually leading to reconsider some previous “dogmas” in this field, such as the gender discrepancy in ASD diagnosis. Moreover, shared features can be observed in the camouflaging strategies adopted among the general population, among patients of the autism spectrum, and among patients with different kinds of psychiatric disorders, further challenging our perspectives. Camouflaging behaviors might be considered as a transdiagnostic element, closely associated with the continuous distribution of the autism spectrum among the general and the clinical population.

There are specific challenges to studying the design of pharmacologic trials in child/adolescent and adult autism, such as subject stratification and parallel versus crossover designs. This article describes how optimal study design is influenced by subject selection and outcome measures chosen. Lessons learned in study design from the Research Units on Pediatric Psychopharmacology Autism Network trial with risperidone, Seaver Center trials with fluoxetine and valproate, Dartmouth trials with amantadine, and National Institutes of Health secretin trials are highlighted. The Internet System for Assessing Autistic Children system for managing multicenter clinical trials in autism and statistical issues in autism research are also described.

Serotonin (5-hydroxytryptamine, 5-HT) has long been suspected to play a role in the etiology of depression, and modern neurochemical techniques have confirmed this suspicion. Furthermore, all drugs known to be selective (a relative term) serotonin transporter (SERT) inhibitors are effective antidepressants. Of the selective serotonin reuptake inhibitors (SSRIs) approved in a number of countries for use in depression, panic disorder, and obsessive-compulsive disorder, citalopram is the most selective. Citalopram has been used worldwide to treat an estimated 35 million patients, with an excellent safety record. Citalopram is a racemic drug, and its effects on serotonin transport are thought to reside in the S-enantiomer, known as (S)-citalopram or escitalopram. Escitalopram is the most selective SSRI yet developed. Its receptor binding properties and activity in preclinical animal models of depression predict that escitalopram would be effective in the treatment of depression, with approximately twice the potency of the racemate. The pivotal clinical trials of escitalopram not only support this conclusion, but also suggest escitalopram possesses advantages over citalopram in terms of both efficacy and safety. In conclusion, escitalopram is a promising candidate for use as a first-line antidepressant.

Introduction: A wealth of evidence indicates that neurocognitive deficits are evident in patients with schizophrenia at both illness onset and after many years of treatment. Little is known regarding if or how these deficits change during the lifespan. The goal of the study was to evaluate changes in full-scale intelligence quotient and neurocognitive test performance over a 10-year interval in patients with schizophrenia.

Methods: Twelve patients were administered the Wechsler Adult Intelligence Scale-Revised as a measure of intellectual function and a neuropsycshological test battery including measures of attention, verbal and nonverbal memory, language, visuospatial function, problem-solving, and motor function at entry to the study and at a 10-year follow-up.

Results: With the exception of performance on a measure of speeded motor sequencing, there was no significant decline in any of the measures at 10-year follow-up. Results from a measure of sustained auditory attention showed improvement at follow-up.

Discussion: These data support a neurodevelopmental model of schizophrenia for young adult to middle-age patients by suggesting that neurocognitive deficits that emerge either before disease onset or early in the course of the illness remain stable as the patient ages.

Conclusion: Overall, measures of intelligence quotient as well as specific neurocognitive skills, do not decline over a 10-year period in at least a subgroup of patients with schizophrenia.

In this article, the literature examining the relationship between testosterone and various cognitive domains in elderly men is reviewed. The review focuses on the role of endogenous testosterone levels and the effects of androgen depletion and replacement. The cognitive domains most commonly linked to testosterone include memory and visuospatial function. Indeed, the literature suggests that in certain conditions (ie, hypogonadism, cognitive impairment) testosterone levels may be significantly associated with memory and visuospatial function, but not other cognitive functions. Studies with larger sample sizes and more sensitive cognitive measures are indicated, as questions remain about the potential role of testosterone as a cognitive enhancer.