bluuebunny/crossref_metadata_2025 huggingface dataset:
Case histories
Authors: Khan Umraz , Perks Graeme , Morgan-Jones Rhidian , James Peter , Esler Colin , Smyth Vince , Gant Vanya
Published: January 2019

This chapter provides several typical cases encountered in patients who develop infection in prosthetic joints after surgery. Both the assessment and the definitive management are considered, as well as the microbiology profiles and the need for protracted antibiotics. The aim is that the decision-making process is enhanced. Although the treatment pathways are specific to those cases outlined, the surgical principles should remain constant for all cases. Comprehensive membrane resection remains a key event when surgically eradicating prosthetic joint infection (PJI). This act improves with experience. To improve outcomes for cases of PJI we encourage data collection within networks.
Health systems design
Authors: Echenique Jorge Castilla , Griekspoor Andre , Kim Hyo Jeong
Published: January 2019

This chapter examines the relationship between humanitarian assistance and long-term development goals, including outlining the World Health Organization building blocks for health systems, how they can be impacted in emergencies, and how humanitarian programming can support, rather than hinder, their development. This chapter highlights the challenges of providing effective healthcare in a resource-poor context and emphasizes mechanisms to provide assistance which consider the long-term development goals of the country. It clarifies what humanitarian healthcare workers can do to ensure effective aid that delivers immediate healthcare relief to patients, which considers connections with the existing healthcare system, and provides performance standards which can be used to guide responses.
Gender-based violence in humanitarian crises
Authors: Scott Jennifer , Molina Rose Leonard , Kelly Jocelyn T.D.
Published: January 2019

This chapter on gender-based violence (GBV) provides an overview of the management of patients of GBV and recommendations for a multisectoral approach to GBV programming in humanitarian settings. GBV is one of the most challenging aspects of humanitarian crises and complex emergencies, involving human sexuality, gender norms, cultural customs, and reproductive health, making it one of the most deeply private, stigmatized, and taboo issues. GBV is an important health and human rights challenge which is easily overlooked and under-recognized but is increasingly prevalent, particularly in complex emergencies.
Mental health in humanitarian settings
Authors: Cavallera Vanessa , Jones Lynne , Weissbecker Inka , Ventevogel Peter
Published: January 2019

This chapter provides the basic knowledge about mental health and psychosocial support that all health workers in humanitarian emergencies should have and includes descriptions of the presenting symptoms and management of common clinical conditions encountered. In addition to detailed approaches to specific conditions, including recognition and management, this chapter also emphasizes an understanding of the humanitarian context in which these conditions occur, including social and cultural considerations, and the necessity of collaboration with non-health actors to address the psychosocial needs of patients.
Epidemiology
Authors: Greenough P. Gregg , Willis Andrew James
Published: January 2019

This chapter provides the reader with a basic understanding of how epidemiology and population-based applications can guide humanitarian health operations and programming. It outlines the purpose and objectives of field epidemiology and reviews study design and sampling methods, the development of a measurement tool, and data gathering and analysis, particularly as it relates to humanitarian settings. Practical examples show the real-life application of these principles and how quality data collection can support solutions in humanitarian programming.
Understanding economic effects of humanitarian intervention
Authors: Omtzigt Dirk-Jan
Published: January 2019

This chapter provides the economic context and considerations to assist those working in a complex emergency to apply principles that assist rather than harm the society at large and the economy in particular. It covers the core principles of economic development and vulnerability, including income disparities and the multidimensional impact of poverty, and offers an overview of the real-life economic implications of development and humanitarian aid. It provides specific considerations related to both short- and long-term economic consequences for both the people being assisted and the host community in which the programme operates.
Medical care under fire: a perspective from the international medical organization Médecins Sans Frontières
Authors: Michel Camille , Lavelle Kenneth , Nierle Thomas
Published: January 2019

Violence against healthcare is a major humanitarian concern, which unfortunately has become increasingly common in recent years. From the 3 October 2015 bombing of the Médecins Sans Frontières hospital in Kunduz, Afghanistan, which killed patients and staff to the bombing a little over a year later of a humanitarian-supported hospital in northern Syria which caused seven deaths, the partial destruction of the hospital, and 47 wounded patients, this intolerable violence prevents medical humanitarian organizations from accessing patients and delivering care, and poses an unacceptable risk to the safety of staff and on the access to care for patients. This chapter outlines this situation and the initiatives which are currently tackling the issue of violence against healthcare. It discusses the risks and dangers faced in the field, the diversity of the victims, perpetrators and causes, and summarizes the lessons learnt.
Medical triage
Authors: Moons Peter
Published: January 2019

This chapter on medical triage outlines the fundamentals of providing care in humanitarian settings, including overall guidance to clinical care, key aspects of patient triage, and approaches for paediatrics, and emergency triage. It outlines the process of rapidly sorting patients into groups based on the urgency of their condition, ensuring that the most appropriate patients get treatment first hand.
Approach to paediatric care
Authors: Garcia Daniel Martinez , Roggeveen Harriet , Karsten Jaap
Published: January 2019

This chapter outlines the fundamentals of providing care in humanitarian settings, including overall guidance to clinical care, key aspects of patient triage, and approaches for paediatrics. This chapter on the approach to paediatric care in humanitarian, conflict, or disaster setting, aims to assist the non-paediatrician presented with paediatric patients, by highlighting approaches, key insights, and guidance to help with clinical judgement and decision-making.
Shock
Authors: Hawryluck Laura , Stavel Miroslav
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management for the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Fever
Authors: Sauve Laura , Chan Kevin
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management for the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Pain
Authors: O’Neill Joseph
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management for the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Lymphadenopathy
Authors: MacDonald Anna
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management of the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Cough and breathlessness
Authors: O'Neill Joseph
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management for the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Oedema
Authors: Aspler Anne
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management for the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Malaria
Authors: Ashley Elizabeth
Published: January 2019

This chapter covers all aspects of malaria control in a humanitarian emergency setting including diagnosis, treatment, prevention, and epidemic preparedness and management. With an estimated greater than 80% of humanitarian emergencies occurring in areas endemic for malaria, this chapter provides the essential background information on malaria epidemiology and health service development, as well as clinical management aspects including disease recognition, diagnosis, and management guidelines for the multiple clinical presentations. It also outlines special considerations for at-risk groups, and details information on surveillance and prevention.
Neglected tropical diseases
Authors: Hajek Jan
Published: January 2019

This chapter on neglected tropical diseases (NTDs) provides an overview of the background and main contextual features of NTDs, and includes clear guidance on their clinical recognition and management. Recognizing the prevalence of NTDs in humanitarian settings, with their disproportional effect on the poor, this chapter covers the fundamentals of management of NTDs, and is especially helpful for the provider who may have little prior clinical experience with such conditions. It also includes detailed guidance on recognition and diagnosis of the main NTDs, such as dengue, human African trypanosomiasis, leishmaniasis, leprosy, and schistosomiasis, in settings with very limited diagnostic testing available.
Clinical suspicion of Ebola
Authors: Jagatic Tim , Spencer Craig
Published: January 2019

This chapter provides guidance for clinicians who are working in low-resource settings when there is a suspicion of Ebola virus disease. Recognizing the recent surge in Ebola cases in West Africa, and the possibility of further presentations, this chapter outlines the basic measures that medical staff should follow, including whom to alert if there is a suspected Ebola case. There are also some basic measures the staff can take while waiting for trained personnel to arrive.
Respiratory illness
Authors: Nadimpalli Aditya , Boulle Philippa
Published: January 2019

This chapter outlines the spectrum of respiratory illnesses seen in humanitarian and low-resource settings, including acute and chronic conditions, and presentations not commonly seen in more developed settings. The chapter focuses on respiratory conditions, which in humanitarian settings are the cause of death in low-income countries and precarious contexts. It details the challenges of diagnosis and treating respiratory pathologies in low-resource settings, including specific guidance for the most commonly encountered clinical conditions such as pneumonia, bronchiolitis, asthma, and pertussis.
Gastrointestinal illness
Authors: Hartlapp Ingo
Published: January 2019

This chapter gives an overview of the most important clinical presentations involving the gastrointestinal (GI) tract commonly seen in the field, including hepatitis, cirrhosis, peptic ulcer disease, and GI bleeding, from typical clinical presentation to specific diagnosis and treatment. Recognizing the challenges with diagnosis and management of such conditions in humanitarian settings, this chapter provides doctors who practise in low-resource settings with the guidance to implement more specialized GI medicine
Urology
Authors: Bex Axel
Published: January 2019

This chapter provides the essential background on the primary genitourological conditions likely encountered by clinical providers, and provides guidance to differentiation and management, emphasizing those conditions which require urgent intervention. It provides a straightforward approach to history, symptoms, and clinical examination, recognizing the likely limitations in imaging, to allow the proper diagnosis of key presentations, such as scrotal pathologies, genitourinary infections, genital pathologies, and vesovaginal fistulas.
Reproductive health
Authors: Stephen Marianne
Published: January 2019

This chapter provides the fundamental principles of care in reproductive health, taking into account important cultural considerations in humanitarian settings. It provides a syndromic approach to sexually transmitted infections and detailed guidance on contraception and clinical presentations such as dysfunctional uterine bleeding, female genital mutilation, and fistulas.
Neonatology
Authors: Spector Jonathan , Bottineau Marie Claude
Published: January 2019

This chapter provides the fundamental principles of care in neonatology in humanitarian settings. Neonatal care recognizes newborn vulnerability, magnified in the context of humanitarian settings, and provides essential information on routine and emergent newborn care. As most neonatal deaths are avoidable with timely identification and management, it provides an approach to newborn assessment and outlines the essential clinical conditions which must be recognized and addressed with urgency.
Ear, nose, and throat
Authors: Bonnardot Laurent , Malard Olivier , Sauvaget Elisabeth , Giles Sarah
Published: January 2019

This chapter covers the essential background and clinical management of ear, nose, and throat conditions as seen in humanitarian settings. It provides essential guidance on disorders of the ear, nose, and throat, including congenital, infectious, neoplastic, or acquired conditions, with special attention to paediatric problems, and guides the reader through clinical diagnosis and management in low-resource humanitarian settings.
Laboratory
Authors: Kosack Cara
Published: January 2019

This chapter outlines how clinical management decisions in humanitarian emergency situations can be greatly enhanced by a well-functioning laboratory. It provides the fundamentals of diagnostic services, including quality assurance and specimen transport, and outlines the basic procedures for the most common tests.
Water, sanitation, and hygiene
Authors: Maes Peter , Van den Bergh Rafael , Van den Noortgate Joos
Published: January 2019

This chapter on water, sanitation and hygiene (WASH) outlines the principles of safe water and sanitation as essential determinants of health, quality of life, and dignity. It provides the health worker with the necessary information to appropriately prioritize WASH, understand the process of primary prevention of WASH-related diseases, to identify best practices for different contexts, and to recognize when specialized assistance might be required.
Clinical Psychopharmacology
Authors: Ghaemi Nassir
Published: January 2019

Clinical Psychopharmacology offers a comprehensive guide to clinical practice that explores the science and art of clinical research and its individualized application. Content is primarily based on clinical research and pharmacological studies, unlike most texts that rely on inferences from biological mechanisms. The text consists of 49 chapters, organized into 6 sections, focusing on disease-modifying versus symptomatic effects of available treatments, careful differential diagnosis including non-DSM diagnostic concepts, key clinical research studies, essential facts about the most common drugs, and more. Four appendices address key diagnostic controversies. This innovative book advocates a scientific and humanistic approach to practice and examines not only the benefits, but also the harms of psychotropic drugs. Providing a solid foundation of knowledge and a great deal of practical information, this book is a valuable resource for psychiatrists, nurse practitioners, medical students, trainees in psychiatry, pharmacists, and other mental health professionals.
Fundamentals of Neurobiology
Authors: Ghaemi S. Nassir
Published: January 2019

This chapter examines the basic pharmacology of psychotropic drugs. Besides knowing what drugs do to certain chemicals or proteins in the brain, it is important to know where drugs affect those chemicals or proteins. There is some basic knowledge about neuroanatomy that is relevant to the clinical practice of psychopharmacology. It is accepted that neurobiology is an important factor in the etiology and pathophysiology of major psychiatric conditions—like schizophrenia and manic-depressive disease, as well as in other psychiatric clinical pictures. The general summary usually provided is that neurobiology represents a diathesis to psychiatric conditions, which is supplemented by environmental stress to produce observed clinical pictures. This mixture of genetics and environment is oversimplified in the minds of most mental health professionals. In fact, the mix depends on the illness. The biochemical neuroanatomy of the monoamines, glutamate, and GABA in the brain are discussed. Pharmacokinetic aspects of psychopharmacology are reviewed, including hepatic metabolism, drug half-lives, dosing, and tolerance and sensitization.
Fundamental Psychotropic Drug Structures and Mechanisms
Authors: Ghaemi S. Nassir
Published: January 2019

A few basic ideas about fundamental psychotropic drug structures and mechanisms can be stated: Two drugs that are very similar in pharmacological structure can differ wildly in clinical effect. Two drugs that differ markedly in pharmacological structure can exert similar clinical effects. Understanding pharmacological structure is most useful for appreciating classification with similar agents structurally. Clinical conclusions should be based, however, on clinical confirmation or refutation of similarity of effect to other drugs in the same class. No a priori clinical judgments should be made based primarily on pharmacological structure. Structure is a beginning point to understand what drugs do, not the end. This chapter details the pharmacological structure of the main drug classes and specific agents within those drug classes. Similarities and differences of chemical structure are examined. Pharmacodynamic mechanisms of action in the brain, at the synapse and postsynaptically, are discussed.
The Limitations of Clinical Experience
Authors: Ghaemi S. Nassir
Published: January 2019

The most important idea in learning to practice clinical psychopharmacology scientifically, and in understanding clinical research, is the concept of bias. This chapter examines the scientific basis of clinical practice in the concept of bias, or systematic error. This means systematic error as opposed to chance, which reflects random error. With systematic error, one makes the same mistake repeatedly because of some inherent problem with observations. Chance, or random error, is described also, as is the concept of causation. Should a study pass the first two hurdles, bias and chance, it still should not be seen as valid unless we assess it in terms of causation. Clinical experience suffers from a specific kind of bias, called confounding bias, where unknown predictors influence results. The importance of this fact in the limitations of clinical experience is described.
Evidence-Based Medicine
Authors: Ghaemi S. Nassir
Published: January 2019

Evidence-based medicine (EBM) is the view that there are levels of evidence, with higher ones being more valid than lower ones. The higher levels of evidence have less confounding bias, with randomization being the best method to minimize such bias. Lower levels of evidence have more confounding bias, with clinical experience being the worst setting for such bias. However, evidence-based medicine is misinterpreted if it is oversimplified. The EBM literature has various definitions of specific levels of evidence. Standard EBM text uses letters (A through D). One could also use numbers (I through V). The basic idea is that randomized studies are higher levels of evidence than non-randomized studies, and that the lowest level of evidence consists of case reports, expert opinion, or the consensus of the opinion of clinicians or investigators. The pros and cons of the EBM approach are scrutinized in this chapter.
Negative Studies
Authors: Ghaemi S. Nassir
Published: January 2019

A major problem in clinical practice of psychopharmacology is that opinion often is influenced by published research studies that are biased in a positive direction. This bias occurs because negative clinical trials, which show inefficacy of a drug, tend to be unpublished, while positive clinical trials are published and often promoted heavily by pharmaceutical companies. And journals may also systematically reject negative studies—which will generate fewer readers, fewer citations, and lower impact factors for the journal—more frequently than positive ones. The example of lamotrigine is provided, where multiple negative trials, mostly unpublished, exist in acute depressive states and other mood subtypes, in contrast to positive data in maintenance prevention of bipolar illness.
Side Effects and Generalizability
Authors: Ghaemi S. Nassir
Published: January 2019

P-values are overused and abused in clinical research. An important clinical consequence is that side effects are not interpreted correctly in clinical trials. P-values are usable legitimately for the primary outcome of clinical efficacy in most clinical trials. The many potential side effects are assessed better with effect estimates and confidence intervals. The use of p-values for side effects leads to both underestimation (high p-values based on insufficient statistical power) and overestimation (low p-values based on multiple comparisons). These results are both falsely negative and falsely positive. A more valid approach is provided. Generalizability of clinical trials also is investigated, with the conclusion that clinical trials provide average results for the average patient, and should not be interpreted as applying wholesale to each patient.
Dopamine Blockers (“Antipsychotics”)
Authors: Ghaemi S. Nassir
Published: January 2019

The drug class of dopamine blockers includes agents called antipsychotics. It consists of dopamine blockers, often with serotonin blockade. Dopamine blockers are agents used to treat psychotic symptoms such as delusions and hallucinations. These medications have been developed mostly for use in schizophrenia, but they always have been found to be effective in acute mania as well. For the latter reason, they have been used in bipolar illness as well. Several of these agents have been proven effective in the depressive phase of bipolar illness, not just the manic phase. Also, some of them have been shown to be effective in the depressive phase of unipolar mood illness. The clinical pharmacology of specific agents within each class of dopamine blockers, including efficacy and side effects, is explored. Specific phenomena surveyed include metabolic syndrome, weight gain, extrapyramidal side effects, Parkinsonism, akathisia, and tardive dyskinesia.
Index of Selected Commonly Used Drugs with Brief Summaries
Authors: Ghaemi S. Nassir
Published: January 2019

Commonly used specific drugs are highlighted and summarized briefly, with descriptions of their main efficacy, side effects, biological mechanisms, dosing, and clinical uses.
Hippocratic Psychopharmacology
Authors: Ghaemi S. Nassir
Published: January 2019

The conceptual core of this chapter is that clinicians should treat diseases, not symptoms. This insight is the main idea in the Hippocratic approach to medicine, in contrast to the symptom-oriented approach, which was based on Galenic theories about the “four humors” of the body. Until about 1900, the practice of medicine had been Galenic for almost two millennia. Only in the last century has medicine caught up with the profound insights of the Hippocratic method. The practice of psychopharmacology today has much in common with the practice of 19th century medicine. The DSM approach is critiqued in this chapter as mostly false scientifically, and non-Hippocratic. An alternative non-DSM approach to practice is advocated, with future chapters providing clinical details on such a non-DSM-based clinical practice.
The Concept of a Diagnostic Hierarchy
Authors: Ghaemi S. Nassir
Published: January 2019

The concept of a diagnostic hierarchy implies that certain diagnoses should not be made when other are present. This approach contrasts with the DSM-based approach of making multiple diagnoses at the same time, which leads to the problem of comorbidity. A central aspect of taking a non-DSM approach to clinical psychopharmacology is the importance of tackling this “comorbidity” problem. In the DSM system, all diagnoses are created equal, and clinicians are encouraged to diagnose as many disorders as possible. In practice, multiple drugs are given for multiple “disorders,” thus comorbidities lead to polypharmacy. As discussed previously, since many DSM diagnoses are created for social/professional purposes, and thus overlap in content, the apparent comorbidity can lead to unnecessary treatment.
Treatment of Affective Illnesses
Authors: Ghaemi S. Nassir
Published: January 2019

The diagnosis and treatment of affective illnesses are examined. Depressive conditions are characterized in their subtypes, as opposed to the DSM-based broad and heterogeneous “major depressive disorder” (MDD) concept (which includes melancholia, mixed depression, neurotic depression, and vascular depression). Bipolar illness is seen as a subgroup of the larger manic-depressive illness (MDI) concept, which also included unipolar depression. MDI was seen as mania or depression, not mania and depression, as in bipolar illness. The treatment implications of this broader concept of MDI are explored, including: limited antidepressant efficacy in “MDD” and in bipolar depression, leading to the common report of “treatment-resistant” depression; worsening of bipolar illness with antidepressants; limited long-term benefit with dopamine blockers in bipolar illness; and good efficacy with dopamine blockers in mixed depressive states.
Anxiety Conditions
Authors: Ghaemi S. Nassir
Published: January 2019

The diagnosis and treatment of anxiety states are explored. Some DSM definitions are viewed as either invalid (generalized anxiety disorder [GAD]) or secondary to other conditions (panic attacks). Instead, constant anxiety is seen as part of the personality trait of neuroticism. Panic attacks are seen as lower in the hierarchy of diagnosis than mood states, and caused by the latter. Obsessive compulsive disorder (OCD) can be a disease by itself. The common report of purported comorbidity is seen as an overestimation, with anxiety symptoms often being part of other conditions. Symptomatic treatment is seen to be questionable in benefit over risk, both for benzodiazepines and for SRIs.
Treatment of Personality
Authors: Ghaemi S. Nassir
Published: January 2019

The diagnosis and treatment of personality are probed. Some DSM definitions are viewed as either invalid (narcissistic personality disorder) or related to other conditions (schizotypal personality). Instead, DSM-based personality “disorders” are seen as psychoanalytic speculations, with weak empirical support, except for borderline personality and antisocial personality. Other aspects of personality are best understood as traits, rather than “disorders,” or as symptomatic changes that are acute and occur lower in the hierarchy of diagnosis than mood or psychotic states, and are caused by the latter. The common report of purported comorbidity is seen as an overestimation, with personality changes often being part of other conditions. Symptomatic treatment is seen to be questionable in benefit over risk, both for dopamine blockers and for SRIs.
Seasonal Affective Illness
Authors: Ghaemi S. Nassir
Published: January 2019

Seasonal affective illness is seen as part of the seasonality of affective illness, not as a separate disease. All human beings are sensitive to light; the impact of light is hardwired in neuroanatomy. The body has intricate circadian rhythms that are regulated by the interaction of light with this neuroanatomy. Thus, everyone is affected by light, or its absence. Manic and depressive states, when part of the disease of manic-depressive illness, can have a seasonal pattern, with depression more prevalent in the fall/winter and mania in the spring/summer. The high prevalence of suicide in the spring likely relates to mixed manic states. Treatment with light boxes can be helpful symptomatically. Available studies are summarized. Importantly, light precautions, which involve behavioral interventions to increase or decrease light exposure, can prevent seasonal mood episodes.
Suicide
Authors: Ghaemi S. Nassir
Published: January 2019

About 41,000 persons kill themselves every year in the United States. That comes out to over 100 persons daily, about five persons per hour. The World Health Organization estimates that about 1 million people in the world commit suicide yearly. Suicide is to psychiatry what mortality is to medicine: preventing it is the ultimate goal and responsibility in treating psychiatric illnesses. Antidepressants are associated with suicidality, an important risk that should not be ignored. The absolute risk is small, for the population, but important in each case since the outcome is fatality. Risk factors included misdiagnosed bipolar illness and lack of recognition of mixed states. In contrast, lithium is the only psychotropic medication proven to prevent completed suicide in randomized data. Epidemiological studies also support such benefit at very small doses in the general population.
Older Persons
Authors: Ghaemi S. Nassir
Published: January 2019

In the older patient population, some special considerations are entailed for clinical psychopharmacology. This age group can be defined as persons at age 70 and above, although some of these principles may apply to individuals in their 60s or even their 50s, if they are medically compromised or otherwise fragile physiologically. In treating older persons, these principles are relevant to the use of psychotropic medications. In such older patients, pharmacokinetic inefficiency and a more porous blood–brain barrier lead to increased sensitivity to central nervous system (CNS) effects of drugs. Fewer agents at lower doses are indicated. Vascular depression and dementia are major risks, but monoamine agonists have notable medical risks in most cases in older persons. Other agents may have symptomatic benefits, which need to be weighed against a range of increased risks.
Women
Authors: Ghaemi S. Nassir
Published: January 2019

Use of psychotropic agents in women involves certain aspects that are unique to the pathophysiology of women. This chapter examines special issues for women. The use of psychotropic agents in women can be complicated by the effects of pregnancy, postpartum depression, menopause, menstrual cycles, and potential differential treatment effects. In pregnancy, a number of agents can be used with low risk of major fetal malformations, but they can still have longer-term effects, such as neurobehavioral harm. Mood and anxiety symptoms around the menstrual cycle and with menopause can be treated symptomatically with psychotropic agents, but there is limited evidence of benefit, and some notable risks.
Psychopharmacology in Medical Illnesses
Authors: Ghaemi S. Nassir
Published: January 2019

A variety of medical illnesses can cause psychiatric symptoms, most commonly depression, anxiety, manic states, and delusions or hallucinations, in that order. Before DSM-III in 1980, psychiatric symptoms caused by medical illnesses were classified as organic mental disorders. DSM-III changed the term “organic” to “secondary to a medical illness.” In DSM-5, mania and depression secondary or due to a medical illness were moved to “other mental disorders.” These days the terms “organic,” “secondary,” and “neuropsychiatric” are used interchangeably. Psychotropic agents mainly have symptomatic effects when used for mood or anxiety or cognitive symptoms in the context of medical illnesses. In chronic traumatic encephalopathy, low-dose lithium may assist with mood and impulsivity and suicidality, as well as potential dementia progression. In a range of neurological illnesses, symptomatic psychotropic treatments have limited value. In cardiovascular disease, monoamine agonists are limited in depressive benefit, have little definable cardiovascular benefit, and have some evidence of cardiovascular harm.
Cultural Aspects of Psychopharmacology
Authors: Ghaemi S. Nassir
Published: January 2019

The practice of psychopharmacology is influenced by cultural factors, including a tendency in the United States for patients and doctors to want to receive pills for symptoms. This therapeutic activism dates back centuries, and it has influenced aggressive treatments in the past such as bleeding the patient. The proponents of DSM-III sought to make psychiatry more empirical, and much of this drive came from the need to diagnose entities that could be treated with the newly emerging psychotropic drugs. In retrospect, it could be concluded that what happened was that the DSM-III–oriented practitioners implemented an American pragmatic attitude to psychiatry that has tended toward both polynosology and polypharmacy. The spirit of pragmatism still lives in the world of contemporary psychiatry. A debate still exists culturally between caution and liberality in the use of medication, for psychological states in particular.
The Pharmaceutical Industry
Authors: Ghaemi S. Nassir
Published: January 2019

A textbook on psychopharmacology that seeks to be comprehensive should not avoid addressing important economic aspects of this field. Central to the field of psychopharmacology is the existence and role of the pharmaceutical industry. In recent decades, there has been extensive public debate about the role of the pharmaceutical industry in psychiatric and other medical practice. It would seem worthwhile to acknowledge this debate, and to examine some of the claims and counterclaims made, as well as to suggest some potential avenues for contributing to this debate in a constructive manner. The pharmaceutical industry is central to the development of new drugs, and it has been essential for many new discoveries. However, it also can retard progress by focusing on “me-too” drugs, and on marketing agents for uses that are questionable scientifically and sometimes ethically. The beneficial and harmful impacts of the pharmaceutical industry should be appreciated by practitioners, not just one side or the other.
Drug Discovery
Authors: Ghaemi S. Nassir
Published: January 2019

Newer and better medications are obtained as part of the drug discovery process, which occurs mainly in the pharmaceutical industry. This process is hampered by excessive attention to marketing demands, as opposed to scientific exploration. It also is impaired by the psychiatric profession’s mistaken ideologies, whether psychoanalytic orthodoxy in the past or DSM beliefs of the present. Wrong clinical phenotypes impair finding new pharmacological mechanisms and targeting them well to the write clinical indications. Perhaps as a consequence, no treatments have been developed in the last few decades, since DSM-III, that are more effective than prior agents. Progress for the future in drug discovery will require not just better neurobiological work, but also a new approach to clinical diagnoses in psychiatry.
The Diagnostic Interview
Authors: Ghaemi S. Nassir
Published: January 2019

The diagnostic interview is the most important part of the psychiatric assessment, since diagnosis is based primarily on history. People are often reluctant or unable to explain psychiatric symptoms accurately, due either to poor insight, lack of awareness of symptoms, lack of understanding of symptoms, or stigma. Asking questions is often an ineffective and inaccurate method of obtaining psychiatric history. An alternative is to borrow psychotherapeutic methods: to make statements and observe responses to those statements, verbally and nonverbally. The purpose of the first interview, in part, is to have a second one. Special attention should be given to the course of illness, not just symptoms, in obtaining history for the purposes of diagnosis.
The Placebo Effect
Authors: Ghaemi S. Nassir
Published: January 2019

Until the 1960s, physicians in the United States could legally prescribe “placebo” on a prescription pad and handed to a patient. It was not unethical to do so. Placebo had long been known to be an effective treatment for various medical conditions. For millennia, physicians new that many of their treatments were ineffective and that many conditions could not be treated. Instead of giving treatments that have some pharmacological properties, which meant they would have some side effects and be harmful in some way, it was viewed as more ethical to give an inert pill, a placebo, which would cause no direct pharmacological harm. The view was that the patient might get some psychological benefit from the apparent treatment. The placebo response involves two major aspects: natural history and psychological expectation. Too much attention is given to the latter and not enough to the former. Clinicians see patients improve, as in acute depressive episodes, due to natural history, but they attribute such benefit to the drugs they use, or their psychotherapeutic relationship. Often Nature deserves the credit, and clinicians need to pay more attention to the natural course of psychiatric illnesses.
Legal Aspects of Psychopharmacology Practice
Authors: Ghaemi S. Nassir
Published: January 2019

The United States is characterized by a very aggressive legal system, where many complaints and lawsuits occur. Psychiatrists are vulnerable to such reactions by patients, sometimes justified, often not justified. Paying attention to legal risks is an unavoidable and necessary part of clinical practice. Besides malpractice concerns, which occur infrequently and with a high threshold, clinicians should be aware of the much more common practice of complaints to state medical regulatory boards. Such complaints have a low threshold and involve a bias against clinicians. Besides adequate documentation and attention to transference, clinicians should ensure that patients engage in agreed-upon treatment plans. Refusal to treat and/or termination of treatment is an important mechanism that clinicians need to employ to counteract legal risks.
Psychology of Psychopharmacology
Authors: Ghaemi S. Nassir
Published: January 2019

The practice of giving medications for psychiatric conditions has inevitable psychological aspects. A central one is transference and countertransference, the unconscious and conscious emotions that arise between patient and clinician. Secondary gain can be another factor, with conscious non-medical goals on the part of the patient—as in other psychiatric settings, patients either come to treatment, or avoid it, because of reasons or factors which may have nothing to do with the actual treatment itself. Pill-seeking patients who come for clinical care sometimes aggressively seek medications. The social role of the psychiatric clinician is relevant as well, as patients in the Western world in particular go to mental health professionals for concerns that sometimes are non-medical in nature. In the past, people with personal problems unrelated to diseases often went to priests or other religious guides. Currently, in the industrialized West, fewer people follow those traditions and many instead seek the help of mental health professionals.
Innovation in Clinical Practice
Authors: Ghaemi S. Nassir
Published: January 2019

Every new class of agents in psychopharmacology has begun with clinical innovation and novel observations at the outset. Clinicians in practice can either follow the standard of care to the letter, or they can innovate and try different ideas. An excessively arbitrary distinction is drawn between research, seeking new knowledge; and practice, seeking to help the patient. Often our knowledge is limited, and research does not occur on certain topics. Then clinicians are faced with the dilemma of how to help the patient by seeking new knowledge. This kind of clinical innovation has been central to progress in psychiatry, as in the case of lithium, and it should not be lost.
Curbside Consults
Authors: Ghaemi S. Nassir
Published: January 2019

Specific questions about psychopharmacology are provided and answered.
Key Research Studies in Clinical Psychopharmacology
Authors: Ghaemi S. Nassir
Published: January 2019

A number of key clinical research studies in psychopharmacology are presented and critiqued. They include some classic studies dating back decades, to current studies involving the most recent important studies or analyses of clinical research in psychopharmacology—such as diagnostic validators in psychiatry, a maintenance RCT of olanzapine in bipolar illness, brain effects of dopamine blockers, whether antidepressants prevent depression or not, the use of paroxetine in depression, the natural history of treated depression today, adult attention-deficit disorder, and treatment response in first-episode depression. The critiques provided often show that the claimed results of studies are different from the actual data, which need independent interpretation.
How nucleation and luminosity shape faint dwarf galaxies
Authors: Sánchez-Janssen R , Puzia T H , Ferrarese L , Côté P , Eigenthaler P , Miller B , Ordenes-Briceño Y , Peng E W , Ribbeck K X , Roediger J , Spengler C , Taylor M A
Published: January 2019

We study the intrinsic shapes of a sample of over 400 quiescent galaxies in the cores of the Virgo and Fornax clusters with luminosities 106 ≤ Lg/L⊙ ≤ 108. Similar to satellites of the Local Group and Centaurus A, these faint, low surface brightness cluster galaxies are best described as a family of thick (〈C/A〉 > 0.5), oblate-triaxial spheroids. However, the large sample size allows us to show that the flattening of their stellar distribution depends both on luminosity and on the presence of a nuclear star cluster. Nucleated satellites are thicker at all luminosities compared to their non-nucleated counterparts, and fainter galaxies are systematically thicker as well, regardless of nucleation. Once nucleation is accounted for, we find no evidence that the environment the satellites live in plays a relevant role in setting their 3D structure. We interpret both the presence of stellar nuclei and the associated thicker shapes as the result of preferential early and rapid formation, effectively making these faint nucleated galaxies the first generation of cluster satellites.
Comparison of Outcomes in Level I vs Level II Trauma Centers in Patients Undergoing Craniotomy or Craniectomy for Severe Traumatic Brain Injury
Authors: Chalouhi Nohra , Mouchtouris Nikolaos , Saiegh Fadi Al , Starke Robert M , Theofanis Thana , Das Somnath O , Jallo Jack
Published: January 2019

BACKGROUND

Traumatic brain injury (TBI) carries a devastatingly high rate of morbidity and mortality.

OBJECTIVE

To assess whether patients undergoing craniotomy/craniectomy for severe TBI fare better at level I than level II trauma centers in a mature trauma system.

METHODS

The data were extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients > 18 yr with severe TBI (Glasgow Coma Scale [GCS] score less than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania from January 1, 2002 through September 30, 2017.

RESULTS

Of 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline characteristics were similar between the 2 groups except for significantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I centers vs 40.4% in level II centers (P = .08). Mean Functional Independence Measure (FIM) scores at discharge were significantly higher in level I (10.9 ± 5.5) than level II centers (9.8 ± 5.3; P < .005). In multivariate analysis, treatment at level II trauma centers was significantly associated with in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.03-1.37; P = .01) and worse FIM scores (odds ratio, 1.4; 95% confidence interval, 1.1-1.7; P = .001). Mean hospital and ICU length of stay were significantly longer in level I centers (P < .005).

CONCLUSION

This study showed superior functional outcomes and lower mortality rates in patients undergoing a neurosurgical procedure for severe TBI in level I trauma centers.