Harvard review of psychiatry
-
Harv Rev Psychiatry · Mar 2015
ReviewTreatment of tobacco use disorders in smokers with serious mental illness: toward clinical best practices.
Addiction to tobacco-derived nicotine remains highly prevalent in the United States, with 18% using daily, and 53% of those with serious mental illness using daily. While smokers with serious mental illness have been excluded from most large nicotine-dependence treatment studies, a growing evidence base is available to guide clinicians in assisting their patients with psychiatric illness to quit smoking. The aim of this review is to present the evidence on safety and efficacy of smoking cessation interventions for those with serious mental illness. ⋯ Although more research is needed, preliminary evidence suggests that varenicline in combination with behavioral support is efficacious and well tolerated for smoking cessation for those with bipolar disorder and major depressive disorder. Controlled trials have found no evidence that in patients with serious mental illness, the use of pharmacotherapeutic cessation aids worsens psychiatric symptoms or increases the rate of psychiatric adverse events. Converging evidence indicates that a majority of smokers with serious mental illness want to quit smoking and that available pharmacotherapeutic cessation aids combined with behavioral support are both effective for, and well tolerated by, these smokers.
-
Harv Rev Psychiatry · Mar 2015
ReviewMedication-assisted treatment of opioid use disorder: review of the evidence and future directions.
Medication-assisted treatment of opioid use disorder with physiological dependence at least doubles rates of opioid-abstinence outcomes in randomized, controlled trials comparing psychosocial treatment of opioid use disorder with medication versus with placebo or no medication. This article reviews the current evidence for medication-assisted treatment of opioid use disorder and also presents clinical practice imperatives for preventing opioid overdose and the transmission of infectious disease. The evidence strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care. ⋯ Oral naltrexone demonstrates poor adherence and increased mortality rates, although the early evidence looks more favorable for extended-release naltrexone, which has the advantages that it is not subject to misuse or diversion and that it does not present a risk of overdose on its own. Two perspectives-individualized treatment and population management-are presented for selecting among the three available Food and Drug Administration-approved maintenance therapies for opioid use disorder. The currently unmet challenges in treating opioid use disorder are discussed, as are the directions for future research.
-
Borderline personality disorder (BPD) and major depressive disorder (MDD) commonly co-occur, but the relationship between these disorders remains unclear. While BPD patients often suffer from depression, their subjective experience and treatment response are different from that experienced by MDD patients without BPD. ⋯ BPD depression responds less well to biological treatments and may be fueled by the neurobiology of BPD. These findings suggest that clinicians should recognize the unique features of BPD depression and anticipate a clinical trajectory that may be different from MDD without BPD, keeping in mind that BPD depression tends not to improve until BPD improves.