THE WESTERN JOURNAL OF MEDICINE

SEPTEMBER 1989

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younger adults and be increased gradually to minimize side effects and identify low-dose responses. Although few data are available from well-controlled clinical trials, these findings and clinical experience indicate that most psychotropic drugs used for younger adults are also effective in elderly patients. The choice of a particular medication depends on its side effects, given the similar efficacy within psychotropic drug classes. A low dosage of a highpotency neuroleptic drug, such as 0.5 mg to 2 mg of haloperidol in 24 hours, may lessen agitation and psychosis and have minor anticholinergic and cardiovascular effects. A clinician should reassess efficacy over time, however, because akathisia or motor restlessness develops in many patients, which is sometimes confused with the underlying agitation. Clinical trials indicate that antidepressant response rates for geriatric depression range from 30% to 80%. Tertiary amine tricyclic antidepressants, such as doxepin hydrochloride starting at a dose of 25 mg, appear to help agitated depressions; secondary amine agents, such as nortryptiline hydrochloride, tend to decrease retarded depressions. Benzodiazepines are useful in treating insomnia (for instance, temazepam, 15 mg an hour before bedtime) or daytime anxiety (lorazepam in 0.5-mg increments). Benzodiazepines with long half-lives tend to accumulate in the blood, are more likely to cause side effects, and their use should be avoided. Nonpharmacologic measures should always be attempted before using medications and often complement pharmacologic approaches. Psychotherapy is effective for many forms of geriatric depression. Anecdotal reports suggest that insomnia sometimes abates with such simple remedies as eliminating daytime napping and taking hot milk and tryptophan, 0.5 to 1 gram, at bedtime, although definitive data from controlled studies are lacking.
GARY W. SMALL, MD
Los Angeles REFERENCES

Gerson SC, Plotkin DA, Jarvik LF: Antidepressant drug studies, 1964 to 1986: Empirical evidence for aging patients. J Clin Psychopharmacol 1988; 8:311-322 Small GW: Psychopharmacological treatment of elderly demented patients. J Clin Psychiatry 1988; 49(suppl):8-13 Small GW: Tricyclic antidepressants for medically ill geriatric patients. J Clin

Psychiatry 1989; 50(suppl):27-31

for the chronically and severely mentally ill. The term asylum is in many ways an appropriate one, for these imperfect institutions did provide asylum and sanctuary from the pressures of the world with which, in varying degrees, most of these patients are unable to cope. Further, these institutions provided such services as medical care, patient monitoring, respite for patients' families, and a social network for the patients, as well as food, shelter, and needed support and structure. In the state hospitals, the treatment and services that did exist were in one place and under one administration. In the community, the situation is very different. Services and treatment are under various administrative jurisdictions and in various locations. Even mentally healthy persons have difficulty dealing with a myriad of bureaucracies, both governmental and private, and getting their needs met. Further, patients can get lost easily in the community compared with a hospital-they may have been neglected, but at least their whereabouts were known. It is these problems that have led to the recognition of the importance of case management. Many of the homeless mentally ill would probably not be on the streets if they were part of the caseload of a professional or paraprofessional case manager trained to deal with the problems of the chronically mentally ill, to monitor themwith considerable persistence when necessary-and to facilitate their receiving services. The concept of asylum and sanctuary becomes important because while some chronically mentally ill patients eventually attain high levels of social and vocational functioning, many others cannot meet simple demands of living on their own, even with long-term rehabilitative help. Many consciously limit their exposure to external stimuli and pressure, not from laziness but from a well-founded fear of failure. Professionals must realize that whatever degree of rehabilitation is possible for each patient cannot take place unless support and protection-whether from family, treatment program, therapist, or board and care home-are provided at the same time. If we do not take into account this need for asylum and sanctuary in the community, living in the community at all may not be possible for many patients.
H. RICHARD LAMB, MD
Los

Angeles

The Homeless Mentally Ill

HOMELESSNESS among mentally ill persons is but one symptom of the lack in this country of a comprehensive system of care for the chronically mentally ill generally. With the advantage of hindsight, we can see that the era of deinstitutionalization was ushered in with much naivete and many simplistic notions about what would become of the chronically and severely mentally ill. The importance of psychoactive medication and a stable source of financial support was perceived, but the importance of developing such fundamental resources as supportive living arrangements was often not clearly seen or at least not implemented. "Community treatment" was much discussed, but there was no clear idea what it should consist of. The resistance of community mental health centers to providing services to the chronically mentally ill was not anticipated, nor was it foreseen how reluctant many states would be to allocate funds for community-based services. In the midst of valid concerns about the shortcomings and antitherapeutic aspects of state hospitals, it was not appreciated that the state hospitals fulfilled some crucial functions

REFERENCES

Bachrach LL: Asylum and chronically ill psychiatric patients. Am J Psychiatry 1984; 141:975-978 Lamb HR (Ed): The Homeless Mentally Ill: A Task Report of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1984

Neuropsychiatric Aspects of HIV Infection

PROFOUND PSYCHIATRIC and neuropsychiatric complications of the acquired immunodeficiency syndrome (AIDS) have been recognized since this condition was defined in 1981. Organic mental syndromes include affective, delusional, and dementing disorders. A primary AIDS dementia complex, related to direct effects of human immunodeficiency virus type 1 (HIV-1) on the central nervous system, has been described. It may affect about a third of all patients with AIDS and involves deficits in remembering, concentrating, and learning new information, mental slowing, and mood and motor symptoms all in the presence of a clear consciousness. Currently in question are how early, and under what circumstances, infection with HIV-1 involves the central nervous system and how this relates to psychiatric morbidity. Early entry into the central nervous system appears to be

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common, and several laboratories report detecting HIV-1 in the cerebrospinal fluid of as many as 50% of asymptomatic seropositive persons. At present there appears to be no association between neurological, neuropsychological, and brain imaging abnormalities and the recovery of virus from the cerebrospinal fluid. Although there is general agreement that cognitive impairment is prevalent in patients with AIDS, controversy exists about such deficits in earlier stages of HIV disease. Differences in the design of investigative protocols and the interpretation of data have clouded this issue. Some evidence suggests that the rates of cognitive impairment may well increase with advancing clinical stages and that impairment may appear before clinical evidence of severe immunosuppression. The few systematic studies of the prevalence of psychopathology in HIV-1-seropositive persons indicate rates of 25 % for anxiety disorders and 15% for major depression. These exceed the point prevalence in the general population but are in the range reported for persons with other serious medical illnesses. Generally, rates of psychopathology are as high in patients with early infection as in those with advanced stages of illness. Rates of suicide may increase with HIV-1seropositivity or AIDS. The symptomatic treatment of these psychiatric syndromes uses conventional psychotherapeutic and psychopharmacologic approaches and can be highly effective.
J. HAMPTON ATKINSON, MD San Diego
REFERENCES Atkinson JH Jr, Grant I, Kennedy CJ, et al: Prevalence of psychiatric disorders among men infected with human immunodeficiency virus-A controlled study. Arch Gen Psychiatry 1988; 45:859-864 Grant I, Atkinson JH Jr, Hesselink JR, et al: Evidence for early central nervous system involvement in the acquired immunodeficiency syndrome (AIDS) and other human immunodeficiency virus (HIV) infections-Studies with neuropsychologic testing and magnetic resonance imaging. Ann Intern Med 1987; 107:828-836 Price RW, Brew B, Sidtis J, et al: The brain in AIDS: Central nervous system HIV-1 infection and AIDS dementia complex. Science 1988; 239:586-592

evaluation that may include a structured interview, rating scales, information from parents, if available, and occasionally a continuous performance test of attention and impulsivity, modified for adults. A comprehensive diagnostic workup is of paramount importance because the treatment of the disorder varies with the associated symptoms. The majority (50% to 60%) of patients with the attention deficit hyperactivity disorder, residual type, respond to the use of psychostimulants-dextroamphetamine, methylphenidate hydrochloride, and magnesium pemoline-in dosages similar to those used in children. A substantial number, especially those with depressive and anxiety symptoms, respond to antidepressant medication such as tricyclic antidepressants (desipramine hydrochloride) and the monoamine oxidase inhibitors (tranylcypromine sulfate). When alcohol or drug abuse is present, treatment is initiated with either pemoline or with desipramine. After six months to a year, if the patient stays off unprescribed drugs while the symptoms of the attention deficit disorder persist, a trial of psychostimulants may be given. Treatment with medication should be considered as only one approach among many. Individual, family, and group therapy and other methods suited for the associated conditions should be a part of a comprehensive treatment program.
WALID SHEKIM, MD Los Angeles
REFERENCES

Shekim WO, Asarnow R, Hess E, et al: A Clinical and Demographic Profile of Hyperactive Adults. Presented at the 141 st Annual Meeting of the American Psychiatric Association, Montreal, May 1988 Wender PH, Reimherr FW, Wood D, et al: A controlled study of methylphenidate in the treatment of attention deficit disorder, residual type, in adults. Am J Psychiatry 1985; 142:547-552

Seasonal Affective Disorder and Light Therapy

SEASONAL AFFECTIVE DISORDER, characterized by depression during the winter months, has been actively investigated for the past six years. Virtually every study examining this disorder has found that, compared with treatment with dim light, bright light ( >2,500 lux) causes clinical improvement. Therefore, the bulk of the more recent research has focused on two questions, one research oriented, the other clinical: What is the mechanism of light's efficacy? and What is the best way to administer light-what time of day and how many hours per day? Currently no theory consistently explains all the clinical data on light's efficacy. The most prominent explanation focuses on the effect of bright light on the circadian rhythm of the secretion of melatonin, a hormone produced by the pineal gland. Mediated by pathways beginning at the retina and continuing to the suprachiasmatic nucleus of the hypothalamus and terminating at the pineal gland, melatonin production is suppressed by bright light. Melatonin has a characteristic diurnal pattern even in the absence of bright light, with measurable levels at night diminishing to undetectable levels during the morning. Patients with seasonal affective disorder show evidence of phase-delay-that is, events occur later than usual, such as being hypersomnic, which can be viewed as being phase-delayed in the time of awakening-in the secretion of nocturnal melatonin. Bright light given in the morning causes a phase-advance in this secretion, thereby normalizing the circadian rhythm of melatonin. According

Residual Attention Deficit Disorder

IN THE REVISED THIRD EDITION of the Diagnostic and Statistical Manual ofMental Disorders (DSM III-R), the DSM III term of attention deficit disorder, residual type, was renamed attention deficit hyperactivity disorder, residual state. Both the DSM III and DSM III-R recognized the existence of the disorder in adults, but it is still listed among disorders first manifested in childhood. It is now recognized that the disorder commonly occurs in the adult years. Most adults with the disorder complain of attentional and concentration difficulties, restlessness and being fidgety, impatience and a low frustration threshold, and stress intolerance. Often they have associated symptoms of anxieties, depression, mood swings, and alcohol and drug dependence. Often the presenting complaints are temper outbursts and difficult marital or work relationships. The most common co-diagnosis is generalized anxiety disorder. The general anxieties these patients have are of the milder ones and are not usually associated with phobic, panic, and obsessivecompulsive disorders. When phobias, panic disorders, and the like are present, they are often of a mild type. The alcohol and drug dependence is not of the hard-core type, but drugs are sometimes self-administered to help them function. Because of the varied presenting problems and the associated morbidity, it is essential to do a comprehensive diagnostic