An estimated 20%–30% of emergency department patients may be experiencing depression. Given its known morbidity and mortality, one emergency physician advocates screening for depression in the ED, and, in some cases, jumpstarting antidepressant treatment.

David Hoyer, MD, FAAEM
Clinical Assistant Professor of Emergency Medicine, The University of Texas Health Science Center, Houston, TX

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Ranging from acupuncture to chiropractic to herbal therapies, complementary and alternative medicine (CAM) accounts for a burgeoning category of healthcare spending, with consumers shelling out over $34 billion in annual out-of-pocket expenditures for such treatments. The use of “mind-body” therapies for treating neuropsychiatric symptoms in particular also appears to be increasing.

Maulik Purohit, MD, MPH
Neurorehabilitation and Traumatic Brain Injury, National Intrepid Center of Excellence: Intrepid Spirit One (NICoE ISO); Fort Belvoir Community Hospital, Department of Defense; Harvard Medical School, Department of Physical Medicine and Rehabilitation

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Treatment of Hyperemesis Gravidarum by Fluoxetine in a Depressed Pregnant Patient: A Psychosomatic Dimension

Hyperemesis gravidarum is a severe form of nausea and vomiting (N/V) during pregnancy, affecting 0.3% to 2.5% of all pregnancies, and it is the most frequent cause of hospitalization in the first half of pregnancy. In women with a history of psychiatric illness, the stressors associated with hyperemesis gravidarum can be a trigger for the onset of a new episode. This report describes the case of a pregnant woman with a psychiatric history who presented 6 times for in-hospital treatment of N/V by week 13 of pregnancy.

Pravesh Sharma, MD; Johnathan Heller, MS4; Sarah Wakefield, MD

Texas Tech University Health Sciences Center, Department of Psychiatry, Lubbock, TX

Dr. Sharma is a chief resident, Mr. Heller is a medical student, and Dr. Wakefield is a mentor and clinical assistant professor.

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In Session with Amy Salisbury, PhD: Newborn Infant Behaviors Following In Utero Exposure to SSRIs and Maternal Depression

Dr. Salisbury discusses research in which in utero exposure to maternal depression (with and without pharmacological treatment) was found to have some apparent influence on infants’ postnatal behavioral outcomes at one month following birth, reinforcing the importance of focusing on remission of maternal depression symptoms during pregnancy.

Amy L. Salisbury, PhD

Associate Professor, Departments of Pediatrics and Psychiatry & Human Behavior, Alpert Medical School at Brown University; Clinical Nurse Specialist, Child & Family Psychiatry, Brown Center for Children & Families at Women & Infants Hospital, Providence, RI

Interview by Lonnie Stoltzfoos

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This case report discusses the importance of ODT olanzapine in the treatment of a patient presenting with bipolar I disorder plus psychotic symptoms, and diminished gastrointestinal absorption, secondary to anatomical variability or inflammation.

Pravesh Sharma, MD; Kyle A. Schmucker, MS3; Ankit Parmar, MD, MHA; Deepti Vats, MD; Manish Aligeti, MD, MHA

Texas Tech University Health Sciences Center, Department of Psychiatry, Lubbock, TX

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In Session with Dr. David Meagher: Current Evidence on Pharmacotherapy for Delirium

David Meagher, MD, PhD
Department of Adult Psychiatry, University Hospital Limerick, Ireland

Disclosure: Dr. Meagher reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest. This article includes discussion of off-label treatment with atypical antipsychotics.

PP: You led a study1 reviewing the current evidence on pharmacotherapy for delirium. How did the need for this type of study became apparent to you and your co-authors?

DM: In 2006, during a gathering at Duke University, a group of delirium researchers from Europe decided to start the European Delirium Association. Very soon afterward, the American Delirium Society was started. These two organizations have served as a hub to attract delirium researchers and to encourage them to collaborate in their efforts. We’ve gone from perhaps a dozen active researchers 15 years ago to between 200–300 researchers today, which is still a relatively small number considering how common delirium is. For example, delirium occurs in 11%–42% of general hospital inpatients.2 We did the first point prevalence study of delirium in hospitals, which we published in the British Medical Journal.3 In that study we tested the longstanding assumption that one out of every five people in hospitals have delirium. Even I didn’t really believe that adage until we did this study, in which we found a delirium prevalence of approximately 18% in the general hospital population. Read >

When Working Memory isn’t Working: How and Why, and What it Means for Patients with Schizophrenia

Stephen I. Deutsch, MD, PhD
Anne Armistead Robinson Endowed Chair in Psychiatry; Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School; Attending Psychiatrist, Sentara Norfolk General Hospital, Norfolk, Va.

Disclosure: Dr. Deutsch has received grant support from the Commonwealth Health Research Board (State of Virginia).


Working memory is the ability to retain information on-line for short periods of time—seconds to minutes—in order to use this information to guide goal-directed behavior, eg, retention of a telephone number long enough to actually make the call. Working memory is commonly referred to as the “mental sketchpad” and is itself composed of component processes that are necessary for maintaining relevant information during encoding, inhibiting encoded information that is irrelevant to the desired goal from entering consciousness, and minimizing interference from distractors or irrelevant information at the time of retrieval when a goal-directed response is chosen, among other processes. Working memory is critical to learning, reasoning, verbal comprehension, and academic and vocational success, so it is perhaps unsurprising that a deficit in working memory—a cognitive deficit—would be likely to contribute to the poorer functional outcomes experienced by many schizophrenia patients.1

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One-Year Mother & Baby Outcomes Following Antipsychotic Use in Pregnancy

Jayashri Kulkarni, MBBS, MPM, FRANZCP, PhD
Director, Monash Alfred Psychiatry Research Centre, Melbourne, Australia
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Psychopharmacology in Treating Posttraumatic Stress Disorder with Co-occuring Mild Traumatic Brain Injury

Paul S. Hammer, MD
Captain, Medical Corps, US Navy; Navy Medicine
Information Systems Support Activity, San Antonio, TX

William M. Sauvé, MD
Medical Director, TMS NeuroHealth Centers of Richmond, VA

Disclosure: This article discusses off-label medication use. Dr. Hammer reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest. Dr. Sauvé has received speaker fees from Sunovion; and has served on the advisory board of Avanir.


This article reviews the unique therapeutic challenges associated with treating military-related brain injury with and without comorbid posttraumatic stress disorder. Specific symptoms, including anxiety symptoms, re-experiencing symptoms, sleep disturbance, and affective symptoms may be targeted discretely.


Healthcare providers face unique challenges when treating service members wounded in Operations Iraqi Freedom and Enduring Freedom. The predominant enemy tactic of improvised explosive devices (IED) and a long war have presented the military healthcare system with large numbers of patients with the two “signature wounds” of the war: mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD).1 These disorders often co-occur and require awareness of the subtleties and comorbidities of both diagnoses in order to appropriately identify, diagnose, and treat the service member. Furthermore, the unpredictable nature of IED attacks not only lead to chronic, sub-acute combat stress but can also result in numerous bodily injuries, sometimes resulting in physical disability and chronic pain. Wounded service members will often see numerous specialists and receive treatment with numerous classes of drugs meant to address chronic pain, sleep difficulty, and affective and anxiety symptoms related to multiple comorbidities. The potential of such medications to work at cross purposes with each other makes it all the more important that healthcare providers become experts in the psychopharmacology involved in both PTSD and mTBI. In addition, the high utilization of National Guard and Reserve forces in active combat ensure that many service members who need or seek care may not be seen in the Veterans Affairs (VA) or Department of Defense (DoD) medical systems. It is therefore imperative that all clinicians, and especially psychiatrists, military and civilian, maintain an awareness of combat-related PTSD, its co-occurrence with mTBI, and an understanding of the principles of medication management available to effectively treat this population.

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