Journal of psychiatric practice
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Review Case Reports
Charles Bonnet syndrome: are medications necessary?
Charles Bonnet syndrome (CBS) is a clinical entity in which patients develop vivid visual hallucinations in the absence of psychiatric illness. In the great majority of cases, a decline in visual acuity precedes the development of CBS. ⋯ We present the case of a 79-year-old man who presented with the onset of vivid visual hallucinations after developing cataracts. We also review previous case reports of CBS and discuss treatment options.
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Comment Review Case Reports
Commentary on visual hallucinations and Charles Bonnet syndrome.
The authors comment on two case reports of visual hallucinations due to non-psychiatric disorders: retinal detachment in a patient with schizophrenia, and Charles Bonnet syndrome. The physiology of visual misperception is reviewed, based on abnormalities along various points from the eye to the optic tracts to the occipital cortex. The approach to patients with visual hallucinations should include not only an evaluation for psychiatric disorders, but also an appreciation of possible non-psychiatric causes that may have major ramifications for care and potentially for preservation of sight.
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Full parity of health insurance benefits for treatment of mental illness, including substance use disorders, is a major achievement. However, the newly-published regulations implementing the legislation strongly endorse aggressive managed care as a way of containing costs for the new equality of coverage. Reductions in "very long episodes of out-patient care," hospitalization, and provider fees, along with increased utilization, are singled out as achievements of managed care. ⋯ Parity in out-of-network benefits could lead to aggressive management of care given by non-network practitioners. Since a large percentage of psychiatrists and other mental health professionals stay out of networks, implementation of parity for out-of-network providers will have to be done in a way that respects the conditions under which they would be willing and able to provide services, especially psychotherapy, to insured patients. The shortage of psychiatrists makes this an important access issue for the insured population in need of care.
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Neuroethics is a new subset of bioethics that addresses ethical issues pertaining to the brain, primarily in the fields of neuroscience, cognitive science, and neuroradiology. Research in brain science is progressing at a phenomenal rate and, as a result, the acquisition and application of knowledge and technology raises ethical questions of a practical and philosophical nature. ⋯ New knowledge in the mind-brain conundrum and increasingly sophisticated techniques for imaging and intervening in human cognition, emotion, and behavior pose ethical issues at the intersection of technology and psychiatry. This article presents a broad survey of the new directions in neuroethics, neuroscience, and technology and considers the implications of technological advances for the practice of psychiatry in the new millennium. (Journal of Psychiatric Practice 2009;15:391-401).
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Gabapentin (Neurontin) is approved by the US Food and Drug Administration for treatment of epilepsy and post-herpetic neuralgia. Despite lack of strong evidence, gabapentin is also often prescribed off-label for psychiatric conditions. The case described here involved a 38-year-old male physician with substance intoxication delirium and psychoactive substance dependence due to high self-administered doses of gabapentin, which had been prescribed at lower doses in combination with buspirone and bupropion for depression and anxiety. ⋯ Gabapentin is a central nervous system inhibitory agent with likely gamma-aminobutyric acid (GABA)-ergic and non-GABAergic mechanisms of action. The similarity between benzodiazepine withdrawal and what this patient experienced with gabapentin suggests a common role for GABA-related effects. The case reported here suggests the need for heightened concern regarding the off-label prescription of this drug to vulnerable individuals with psychiatric conditions.