To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
This article is a clinical guide which discusses the “state-of-the-art” usage of the classic monoamine oxidase inhibitor (MAOI) antidepressants (phenelzine, tranylcypromine, and isocarboxazid) in modern psychiatric practice. The guide is for all clinicians, including those who may not be experienced MAOI prescribers. It discusses indications, drug-drug interactions, side-effect management, and the safety of various augmentation strategies. There is a clear and broad consensus (more than 70 international expert endorsers), based on 6 decades of experience, for the recommendations herein exposited. They are based on empirical evidence and expert opinion—this guide is presented as a new specialist-consensus standard. The guide provides practical clinical advice, and is the basis for the rational use of these drugs, particularly because it improves and updates knowledge, and corrects the various misconceptions that have hitherto been prominent in the literature, partly due to insufficient knowledge of pharmacology. The guide suggests that MAOIs should always be considered in cases of treatment-resistant depression (including those melancholic in nature), and prior to electroconvulsive therapy—while taking into account of patient preference. In selected cases, they may be considered earlier in the treatment algorithm than has previously been customary, and should not be regarded as drugs of last resort; they may prove decisively effective when many other treatments have failed. The guide clarifies key points on the concomitant use of incorrectly proscribed drugs such as methylphenidate and some tricyclic antidepressants. It also illustrates the straightforward “bridging” methods that may be used to transition simply and safely from other antidepressants to MAOIs.
Objectives: More and more referrals to memory clinics are expected, but diagnostic routes are already challenged. In order to be able to follow the advice to diagnose dementia more often and earlier in the process, but also to be able to handle the increasing numbers of referrals, a fast but reliable triage test is needed.
According to the Cochrane review, “the MoCA can help identify people who need specialist assessment and treatment for dementia”. It has been validated in multiple institutions and languages. However, many of these studies are designed with a case-control design using healthy, community-based individuals as controls, which can lead to spectrum bias.
Our cohort of referrals to a memory clinic with patients suspected of having cognitive disorders (mild dementia and MCI) after initial assessment in an old age psychiatric clinic, needs to be validated because different settings can give different results.
Design: our reference standard consisted of a consensus-based diagnosis according to international criteria for detecting MCI and MD, and this was compared with patients suspected of MCI/MD - but excluded from cognitive disorders (NoCI)- from the same cohort.
Results: The mean MoCA scores differ significantly between the groups: 24 in NoCI, 21 in MCI and 16.5 in MD. The AUC of MD against non-demented (MCI+NoCI) was 0.83 resulting in 90% sensitivity, 65% specificity, 50% PPV and 94% NPV at a best cut-off of <21 according the Younden index. For CI (MD+MCI) against NoCI the results were respectively 0.77AUC, 95%sens, 47%spec, 88%PPV, 68%NPV at a cut-off <26.
On an individual basis, as a box plot of DSM IV diagnoses showed, the MoCA score has limitations and clinical aspects need to be taken into account: FTD, high education to the upside; MCI including psychiatric etiology to the downside.
Conclusions: by using a cut-off score of <21, 90% of people with positive MoCA have CI, while 94% of people with negative MoCA (≥21) will not have dementia. The MoCA can significantly reduce referrals (50%) by excluding patients for further diagnostic work-up at a memory clinic, even if they are suspected of CI after initial assessment.
The MoCA was developed as a screening tool for mild cognitive impairment (MCI) and mild dementia (MD) and validated in different settings. At the original suggested cutoff of <26, with 30 being flawless, it has a high sensitivity for detecting MCI and MD. The specificity is argued in clinical practice. Its high sensitivity makes it a good screener for identifying most MD-patients, however, for selecting those in need of a scarce neuropsychological assessment (NPA), the moderate specificity gives too many false positives. It is repeatedly suggested to lower the cut-off to <21, resulting in higher specificity for identifying MD. But lowering the cut-off, increasing the false negatives, will not decrease the number of classification errors. One needs to triage with a cut-off that finds all patients at high risk of MD without referring too many who are not (yet) in need of a NPA. A difficulty is who to consider at risk, as definitions for illnesses (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders. As MCI is a state of subthreshold dementia -of which 40% worsens 40% stabilizes 20% recovers, therefore justifying its own policy -it is essential to differentiate it from MD and no-cognitive impairment (NoCI). Double thresholds are a solution by using one threshold for health and one for illness. Especially where classifications create subthreshold disorders, regardless of whether these are disorders in their own right or are merely (minor) forms of major disorders. A double threshold MoCA gives the best accuracy and raises the opportunity to differentiate the clinical and subclinical states to their appropriate domain and hence their appropriate policy. Next to these clinical aspects, shown in our study, a double threshold also reduces random classification errors. By applying an uncertainty interval -most errors appear from 21 to 26- the PPV and NPV improves and becomes less dependent of the prevalence. Two thresholds, with <21 selecting patients for NPA and ?26 for clearing patients, gives the best results and achieves two aims at once. It also identifies most MCI (21<26) who’s intermediate state justifies active monitoring.
Background: The aim of this study was to evaluate the effectiveness of a stepped-care program to prevent the onset of depression and anxiety disorders in elderly people living in residential homes.
Methods: A pragmatic randomized controlled trial was conducted to compare the intervention with usual care in 14 residential homes in the Netherlands. A total of 185 residents with a minimum score of 8 on the Centre for Epidemiologic Studies Depression Scale, who did not meet the diagnostic criteria for a depressive or anxiety disorder, and were not suffering from severe cognitive impairment, were recruited between April 2007 and December 2008. They were randomized to a stepped-care program (N = 93) or to usual care (N = 92). The stepped-care participants sequentially underwent watchful waiting, a self-help intervention, life review, and a consultation with the general practitioner. The primary outcome measure was the incidence of a major depressive disorder (MDD) or anxiety disorder during a period of one year according to the Mini International Neuropsychiatric Interview.
Results: The intervention was not effective in reducing the incidence of the combined outcome of depression and anxiety (incidence rate ratio (IRR) = 0.50; 95% confidence interval (CI) = 0.23–1.12). However, the intervention was superior to usual care in reducing the risk of MDD incidence (IRR = 0.26; 95% CI = 0.12–0.80) contrary to anxiety incidence (IRR = 1.32; 95% CI = 0.48–3.62).
Conclusions: These results suggest that the stepped-care program is effective in reducing the incidence of depression, but is not effective in preventing the onset of anxiety disorders in elderly people living in residential homes.
Email your librarian or administrator to recommend adding this to your organisation's collection.