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In this program you will follow an educational curriculum in the core disciplines of neuropsychopharmacology. Each course will guide you through the complexities of the topic targeting your specific clinical needs, and meeting international requirements for professional re-validation. You will be encouraged to engage with self-assessment tools to establish your baseline competency and then guided through a series of interactive resources to build on, and improve, that knowledge.

Based on Dr Stahl's familiar and iconic materials and proven approaches to learning, and with the editorial guidance of the University of Cambridge Department of Psychiatry, the activities within each course include readings, lectures, animations and case studies. Please take some time to explore the Course Tasters available on this page.

Successful completion of each post-course test qualifies the successful candidate for CME credits and certification.

This program is evolving and growing, with new courses added on a regular basis.
 
Courses focus on core areas of psychiatric research and practice, and are an ideal resource for busy mental health professionals.

If you are interested in buying more than one unit of each course please follow our guidelines for purchasing multiples.
 
 
Mood disorders

This course looks at Mood Disorders occurring across the broad clinical spectrum. The content consists of interactive readings, short lectures, animations and case studies.

Contents: Pre-course self assessment; Description of mood disorders; The bipolar spectrum; Distinguishing unipolar depression from bipolar depression; Are mood disorders progressive; Neurotransmitters and circuits in mood disorders; Stress and depression; Symptoms and circuits in depression; Symptoms and circuits in mania; Neuroimaging in mood disorders; Post-course self assessment.

Course valid for CME certification (14.25 CME credits) until 31 March 2018.

Antidepressants

This course looks at Antidepressants and introduces you to:

  • the pharmacological concepts underlying the use of antidepressants
  • the mechanism of action of how the various antidepressants work
  • how to use antidepressants in clinical practice, including combination or augmentation strategies
  • novel agents in development

The content consists of interactive readings, short lectures, animations and case studies.

Contents: Pre-course assessment; General principles of action; Antidepressant classes; Augmenting antidepressants; How to choose an antidepressant; Future treatments; Post-course assessment.

Course valid for CME certification (18.25 CME credits) until 1 April 2018.

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Sample video lecture
Mood Disorders: Symptoms and Circuits in Depression
 

 
Sample animation
Mood Disorders: Neurotransmitters and Circuits in Mood Disorders
 

 
Sample case study
Mood Disorders: The Bipolar Spectrum
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Stephen M. Stahl

Dr StahlDr. Stephen M. Stahl received his undergraduate and medical degrees from Northwestern University in Chicago, as a member of the honors program in Medical Education, and his Ph.D. degree in pharmacology and physiology from the University of Chicago. Dr. Stahl has trained in three specialties: internal medicine at the University of Chicago; neurology at the University of California in San Francisco; and psychiatry at Stanford University. He is board certified in psychiatry.

Dr. Stahl has held faculty positions at Stanford University, the University of California at Los Angeles (UCLA), the Institute of Psychiatry London, the Institute of Neurology London, and, currently, as adjunct professor at the University of California at San Diego (UCSD) and as an Honorary Visiting Senior Fellow in the Department of Psychiatry at the University of Cambridge in the UK. He also directs psychopharmacology services and academic programs for the eight facility, 6500 patient California Department of State Hospital System, where he also heads their assessment and treatment efforts to reduce violence. Dr. Stahl was formerly Executive Director of Clinical Neurosciences at the Merck Neuroscience Research Center in the UK for several years. Dr. Stahl’s major interests are dedicated to producing and disseminating educational information about diseases and their treatments in psychiatry and neurology, with a special emphasis on multimedia, the internet and teaching how to teach.

Dr. Stahl currently serves as editor-in-chief of CNS Spectrums. He is also associate editor of Acta Psychiatrica Scandinavica, is former clinical field editor for theInternational Journal of Neuropsychopharmacology and is on numerous editorial boards of other leading journals including the ACNP’s journalNeuropsychopharmacology. He has conducted numerous research projects during his career awarded by the National Institute of Mental Health (NIMH), by the Department of Veteran Affairs (VA) and by the pharmaceutical industry. Author of over 500 articles and chapters, and more than 1600 scientific presentations and abstracts, Dr. Stahl is an internationally recognized clinician, researcher and teacher in psychiatry with subspecialty expertise in psychopharmacology. Dr. Stahl has written 33 books and edited ten others, including the best-selling and award winning textbook, Stahl’s Essential Psychopharmacology, now in its fourth edition, and the best-selling and award winning clinical manual, Essential Psychopharmacology Prescriber’s Guide, now in its fifth edition.

Lectures, courses and preceptorships based upon his textbooks have taken him to dozens of countries on 6 continents to speak to tens of thousands of physicians, mental health professionals and students at all levels. His lectures and scientific presentations have been distributed as more than a million CD-ROMs, internet educational programs, videotapes, audiotapes and programmed home study texts for continuing medical education to hundreds of thousands of professionals in many different languages. His courses and award-winning multimedia teaching materials are used by psychopharmacology teachers and students throughout the world.

Dr. Stahl serves as a fellow of the ACNP (American College of Neuro-psychopharmacology), of the British Association of Psychopharmacology (BAP) and of the CINP, where he was formerly vice president and is a Distinguished Life Fellow of the American Psychiatric Association (APA). He also has served on numerous medical and scientific advisory boards for the pharmaceutical industry, for the biotechnology and medical information industry, and for various nonprofit and public service organizations, including appointment by the State of California and past Chair of the Medi-Cal Oversight Board for Medicines (Drug Utilization Review Board).

His educational research programs are monitoring changes in diagnosing and prescribing behaviors as outcomes from various educational interventions for programs organized by the Neuroscience Education Institute, which he chairs. He also has an active clinical practice specializing in psychopharmacologic treatment of resistant cases.

He has been awarded the International College of Neuropsychopharmacology (CINP) Lundbeck Foundation Award in Education for his contributions to postgraduate education in psychiatry and neurology. His books have won the British Medical Association’s Book of the Year Award. Dr. Stahl is also the winner of the A.E. Bennett Award of the Society of Biological Psychiatry, the APA/San Diego Psychiatric Society Education Award, the UCSD department of psychiatry residency teaching award, and has been cited as both one of "America’s Top Psychiatrists” and one of the "Best Doctors in America.” He was honored with the Distinguished Psychiatrist Award of the APA and gave the Distinguished Psychiatrist Lecture for 2013.

Help

 

Access to courses

Existing and first time users must login on the homepage to access purchased courses. After logging in you will see the list of the courses you have access to (under ‘My Courses’) in the right hand column. Click the chosen course and proceed to the course homepage to start or continue your eLearning journey.

New customers may purchase access to undertake these courses, certified for CME credits. Click ‘BUY NOW’ on the homepage to purchase any of the courses

 

Change your password

You are advised to change your password to something memorable, on first login. Click on the button below the login to do so. You must be logged in to change your password.

 

CME Credits

All courses are certified for CME credits. ‘Mood Disorders’ is certified for 14.25 CME credits (valid until March 31, 2018) and ‘Antidepressants’ is certified for 18.25 CME credits (valid until April 1, 2018).

 

CUHP Accreditation

These courses are endorsed by Cambridge University Health Partners.

 

Feedback

We welcome your feedback in order to continue to improve the product. Throughout the courses you have a ‘send your feedback’ button at the bottom right hand of the screen, which may be used to send us a comment or report a problem.

 

Online orders

Please click ‘BUY NOW’ on the homepage in order to purchase the courses and proceed with your online order. You will receive an Order Confirmation Email from us and a separate email with your invoice, once payment has been confirmed. The login details will be sent to you for accessing these course(s) and you are advised to change your password on first login. If you wish to purchase more than one unit of each course please see guidelines for purchasing multiples on this page.

If you require assistance with online orders, please contact us at directcs@cambridge.org.

 

Post-test and Certification

Once you complete the course please go to the Post Course Self-Assessment, which is the last step of each course, and click ‘start now’.

You will then be transferred to the NEI site where you will need to login or create a guest account, you will then have 3 attempts to successfully complete the post-test for each course with a score of 75% or more, and be entitled to the correspondent CME credits.

After successful completion of the post-test for each course, you will be able to print a certificate from the Neuroscience Education Institute, with the stamp of the Cambridge University Health Partners and Cambridge University Press.

If you require assistance with the Post Course Self-Assessment and Certification, please contact NEI at customerservice@neiglobal.com.

 

Purchasing multiples

If you wish to purchase more than one unit, and less than 5, of the same course please go to ‘BUY NOW’ on the homepage and follow the standard route for purchasing. Please forward us the ‘Acknowledgement of Online Order’ email at onlinepublications@cambridge.org for setting up the needful accounts.

If you wish to purchase more than 5 units of the same course please contact us at onlinepublications@cambridge.org before purchasing to check the best offer for you.

 

Software and hardware

All that you need to take any of these courses is a PC or mobile device with an Internet connection and a browser. The following browsers / platforms are supported:

You will need JavaScript turned on in the browser you choose to use, and Flash or an HTML 5 compatible browser to watch the videos in the courses.

We will continue to test the platform on future releases of the above browsers as we are committed to developing the system to serve the widest possible audience for our courses.

 

Technical support and online access

If you require assistance with technical support and online access, please contact us at onlinepublications@cambridge.org. You can also send us a comment or report a problem by using the ‘send your feedback’ button, present throughout the courses, at the bottom right hand of the screen. This is the best option when reporting an issue related to a specific page of the course.

We welcome your feedback in order to continue to improve the product.

The Neuroscience Education Institute 

The Neuroscience Education Institute (NEI) is a privately owned medical education provider. Since its inception in 2000, NEI has been committed to delivering current, cutting-edge medical education that focuses on facilitating the highest levels of learning.

NEI has been a pioneer in creating unique, effective learning environments. Our wide variety of Web-based learning activities complements our live events to bring the most up-to-date and well-rounded education in psychopharmacology. In our print and Web-based materials, we create a visual vocabulary for complex concepts to make learning easy and fun. These images are consistent with our live activities, where we offer degrees of "edutainment" to enhance audience participation and retention, culminating in a remarkable learning experience. NEI's focus on you, the learner, is what allows each individual to learn and retain more information.

NEI’s Web site, NEIglobal.com, is a centralized online resource focused on the essentials of psychopharmacology. Designed as an integral part of NEI's curriculum and essential to enhancing retention of the material, NEIglobal.com is easy to search or browse for content focused on particular clinical topics.

NEI Membership provides valuable online resources and exclusive member-only benefits to mental health professionals from across the U.S.A. and internationally. Among the many benefits, NEI Membership includes access to the Master Psychopharmacology Program (an educational curriculum targeted to your specific needs), NEI Prescribe (an App providing full prescribing details and expert Tips & Pearls for over 130 psychiatric drugs, plus a unique filter feature to identify alternative medication options individualized for your patients), and CNS Spectrums (the journal of NEI, a peer-reviewed, Index Medicus/MEDLINE cited journal).

National Accreditation, with Commendation: NEI is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. NEI is recognized as a leader in quality education, having received ACCME Accreditation with Commendation continuously since its first full accreditation in 2006. Current accreditation with commendation is valid through 2019.

Contact Us

 

For the United States, Canada and Mexico

Cambridge University Press
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New York, NY 10006
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For queries regarding online orders:

Phone: +1 212 337 5000

Email: customer_service@cambridge.org

 

For technical support and online access problems and enquiries:

Email: onlinepublications@cambridge.org

You can also send us a comment or report a problem by using the ‘send your feedback’ button, present throughout the courses, at the bottom right end of the screen. This is the best option when reporting an issue related to a specific page of the course.

We welcome your feedback in order to continue to improve the product.

 

For United Kingdom, Europe and Rest of the World

Cambridge University Press UPH,
Shaftesbury Road
Cambridge
CB2 8BS
United Kingdom

 

For queries regarding online orders:

Phone: +44 (0) 1223 326050
Email: directcs@cambridge.org

 

For technical support and online access problems and enquiries:

Email: onlinepublications@cambridge.org

You can also send us a comment or report a problem by using the ‘send your feedback’ button, present throughout the courses, at the bottom right end of the screen. This is the best option when reporting an issue related to a specific page of the course.

We welcome your feedback in order to continue to improve the product.

 

Post-course and certification

If you require assistance with the Post Course Self-Assessment and Certification, please contact NEI at customerservice@neiglobal.com

 

Copyright Statement

Materials on these pages are copyright Cambridge University Press or reproduced with permission from other copyright owners. These may be downloaded and printed for personal reference, but not otherwise copied, altered in any way or transmitted to others (unless explicitly stated otherwise) without the written permission of Cambridge University Press. Please see our Terms of Use for more information.

Terms of use

Cambridge University Press is a syndicate of the University of Cambridge and our principal place of business is at the University Printing House, Shaftesbury Road, Cambridge, CB2 8BS.
 
By using the Cambridge University Press website at http://www.stahlmasterclass.com (the "Portal”) and by registering to access the content of the Stahl Masterclass courses (the "Materials”) you are indicating that you accept the terms and conditions set out below (together with any documents referred to in them). Users who do not accept these terms of use are not authorised to use or continue using this website.
 
We may amend these terms of use at any time and any revised version will be effective immediately that is displayed on this website.
 
In the event of any comment or question concerning these terms of use, please contact us by e-mailing The Legal and Business Affairs department at legalservices@cambridge.org or writing to Legal and Business Affairs, University Printing House, Shaftesbury Road, Cambridge, CB2 8BS.
 
The content placed directly on the Portal may be accessed free of charge by all users of Stahl Masterclass.
 
The full content of the Stahl Masterclass courses may be accessed only by an individual who has purchased access to the Materials through the Cambridge University Press marketing site at www.cambridge.org (an "Authorised User”).
 
 
Other Applicable Terms
  1. Our Privacy Policy: sets out the terms on which we process any personal data we collect from you, or that you provide to us. By using the Portal and/or the Materials, you consent to such processing and you warrant that all data provided by you are accurate.
  2. If you purchase access to the Materials, the terms and conditions on the www.cambridge.org website will also apply.
 
Access to and Use of this Website
 
We own or are licensed to use all intellectual property rights in and to this website and all technical infrastructure relating to it. The Materials are copyright © Cambridge University Press or published under license from the copyright holder by Cambridge University Press. Users undertake to ensure that the intellectual property rights of the copyright holder and the software owners and the moral rights of the authors of the Materials are not infringed.
 
Material contained in this website may be downloaded, viewed and printed for personal use only provided that no trade mark, copyright or other proprietary notices contained in or appearing on such material are removed in whole or in part. All other rights are reserved and users must seek our permission before making any other use of material contained in this website.
 
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Cambridge University Press reserves the right to withdraw the subscriber's access to the Materials in the event of systematic breach of these conditions by any authorised user.
 
 
Privacy Policy
 
If you supply personal details to us through this website then you consent to our maintaining, recording, holding and using such personal data in accordance with our Privacy Policy.
 
 
Exclusions and Limitations of Liability
 
This website has been prepared with the aim of providing information about Cambridge University Press, our products and services.
 
Owing to the nature of the Internet we cannot guarantee that this website or the websites to which it is linked will always be available to users. You should ensure that you have appropriate protection against viruses and other security arrangements in place whilst using the Internet.
 
Although every reasonable effort has been made to ensure that the information on this website was accurate at the time of publication, it is subject to variation at any time without notice and we do not give any warranty that any such information will be accurate or complete at any particular time or at all.
 
This website and any information or other material contained in it are made available strictly on the basis that you accept it on an 'as is' and 'as available' basis. Where you rely on any information or other material contained in it, you do so entirely at your own risk and you accept that all warranties, conditions and undertakings, express or implied, whether by common law, statute, trade usage, course of dealings or otherwise in respect of this website are excluded to the fullest extent permitted by law.
 
We exclude all liability whatever, to the fullest extent permitted by law, in respect of any loss or damage resulting or arising from any non-availability or use of this website or of any other website linked to it, or from reliance on the contents of this website or any material or content accessed through it.
 
 
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Links from this website are provided for information and convenience only and we have no control over and cannot therefore accept responsibility or liability for the content of any linked third party website. We do not endorse any linked website.
 
 
Jurisdiction
 
This website has been designed and these terms of use shall be governed by and construed in accordance with English law. Any dispute arising out of the accessing or use of this website shall be subject to the jurisdiction of the English courts.
 

Privacy Policy

This website is operated by Cambridge University Press, which is a Syndicate of the University of Cambridge. Our principal place of business is at the University Printing House, Shaftesbury Road, Cambridge, CB2 8BS.
 
 
ABOUT US
Cambridge University Press, the University of Cambridge and its associated companies will use the information we collect from you in accordance with this policy. A list of our associated companies is available on request.
 
 
OUR APPROACH
 
Your privacy is important to us. We want to make sure that when we collect information from you we do so in a way that does not infringe your privacy. Our policy explains how we do this.
 
By registering or placing an order on this site, you consent to the collection, use and transfer of your information under the terms of this policy.
 
 
COLLECTION OF INFORMATION
 
We may collect names, email and postal addresses, telephone numbers, professions, VAT numbers, purchase and mailing history from you if you order from us or complete an online form (for instance to register at www.cambridge.org for purchasing the courses).

 
USE OF INFORMATION

Your information will enable us to provide you with access to our website and to carry out administration, statistical analysis and market research. If you have requested any goods or services then we will use your information to supply the goods or services, to bill you and to contact you where necessary concerning your order. Where you have consented, we may contact you on occasion by post, telephone, fax and email about products and services we think might be of interest to you. If you decide in the future that do not want to receive such information, please email mlist@cambridge.org.

Where you have consented, we may make your details available to other reputable organisations whose product or services we think might be of interest to you. If you decide in the future that you do not want us to make your information available in this way please email mlist@cambridge.org.

We may transfer your personal details to other regions in which we have offices throughout the world, namely Europe, the Middle East and Africa; the Americas; and Asia-Pacific. You should be aware that some of our branches are in countries which do not have data protection laws. If you do not want us to make the information available in this way email mlist@cambridge.org.

We may disclose your information to our agents and service providers for the purposes set out above.

All personal information received from you is subject to processing centrally in the Europe branch of Cambridge University Press, England. We will retain your information for a reasonable period or as long as the law requires.
 
 
ACCESSING AND UPDATING INFORMATION

You are entitled to see the information held about you and you may ask us to make any necessary changes to ensure that it is accurate and kept up to date. If you wish to do this, please contact us using the details on the right. We are entitled by law to charge a fee of £10 to meet our costs in providing you with details of the information we hold about you.
 
 
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INFORMATION ABOUT OUR USE OF COOKIES

Our website uses cookies to distinguish you from other users of our website. This helps us to provide you with a good experience while you browse and also allows us to improve our site.

A cookie is a small file of letters and numbers that we store on your browser or the hard drive of your computer if you give us permission to. Cookies contain information that is transferred to your computer's hard drive.

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You can block cookies by activating the setting in your browser which allows you to refuse the setting of all or some cookies. If however you use your browser settings to block all cookies (including essential cookies) you may not be able to access some parts of, or our entire site.
 
 
CHANGES TO OUR PRIVACY POLICY
 
Any changes to our privacy policy in the future will be posted to the site and, where appropriate, through email notification.
 
 
CONTACT
 
If you have any requests in relation to the use we make of your information, please email mlist@cambridge.org.
 
All other comments and queries relating to the administration of your relationship with us, our use of your information and this privacy policy are welcomed and should be addressed to the Legal Services Director using the contact details in the Contact us menu.
 

Privacy Policy

This website is operated by Cambridge University Press, which is a Syndicate of the University of Cambridge. Our principal place of business is at the University Printing House, Shaftesbury Road, Cambridge, CB2 8BS.
 
 
ABOUT US
Cambridge University Press, the University of Cambridge and its associated companies will use the information we collect from you in accordance with this policy. A list of our associated companies is available on request.
 
 
OUR APPROACH
 
Your privacy is important to us. We want to make sure that when we collect information from you we do so in a way that does not infringe your privacy. Our policy explains how we do this.
 
By registering or placing an order on this site, you consent to the collection, use and transfer of your information under the terms of this policy.
 
 
COLLECTION OF INFORMATION
 
We may collect names, email and postal addresses, telephone numbers, professions, VAT numbers, purchase and mailing history from you if you order from us or complete an online form (for instance to register at www.cambridge.org for purchasing the courses).

 
USE OF INFORMATION

Your information will enable us to provide you with access to our website and to carry out administration, statistical analysis and market research. If you have requested any goods or services then we will use your information to supply the goods or services, to bill you and to contact you where necessary concerning your order. Where you have consented, we may contact you on occasion by post, telephone, fax and email about products and services we think might be of interest to you. If you decide in the future that do not want to receive such information, please email mlist@cambridge.org.

Where you have consented, we may make your details available to other reputable organisations whose product or services we think might be of interest to you. If you decide in the future that you do not want us to make your information available in this way please email mlist@cambridge.org.

We may transfer your personal details to other regions in which we have offices throughout the world, namely Europe, the Middle East and Africa; the Americas; and Asia-Pacific. You should be aware that some of our branches are in countries which do not have data protection laws. If you do not want us to make the information available in this way email mlist@cambridge.org.

We may disclose your information to our agents and service providers for the purposes set out above.

All personal information received from you is subject to processing centrally in the Europe branch of Cambridge University Press, England. We will retain your information for a reasonable period or as long as the law requires.
 
 
ACCESSING AND UPDATING INFORMATION

You are entitled to see the information held about you and you may ask us to make any necessary changes to ensure that it is accurate and kept up to date. If you wish to do this, please contact us using the details on the right. We are entitled by law to charge a fee of £10 to meet our costs in providing you with details of the information we hold about you.
 
 
COOKIES

INFORMATION ABOUT OUR USE OF COOKIES

Our website uses cookies to distinguish you from other users of our website. This helps us to provide you with a good experience while you browse and also allows us to improve our site.

A cookie is a small file of letters and numbers that we store on your browser or the hard drive of your computer if you give us permission to. Cookies contain information that is transferred to your computer's hard drive.

The cookies this website uses can be broken down into three categories:
Please note that our third-party suppliers and advertisers may also use cookies, over which we have no control.
 
BLOCKING COOKIES
 
You can block cookies by activating the setting in your browser which allows you to refuse the setting of all or some cookies. If however you use your browser settings to block all cookies (including essential cookies) you may not be able to access some parts of, or our entire site.
 
 
CHANGES TO OUR PRIVACY POLICY
 
Any changes to our privacy policy in the future will be posted to the site and, where appropriate, through email notification.
 
 
CONTACT
 
If you have any requests in relation to the use we make of your information, please email mlist@cambridge.org.
 
All other comments and queries relating to the administration of your relationship with us, our use of your information and this privacy policy are welcomed and should be addressed to the Legal Services Director using the contact details in the Contact us menu.
 

Accessibility Policy

We want everyone who visits the Stahl Masterclass website to feel welcome and find the experience rewarding.

 

What are we doing?

To help us make the Stahl Masterclass website a positive place for everyone, we've been using the Web Content Accessibility Guidelines (WCAG) 2.0. These guidelines explain how to make web content more accessible for people with disabilities, and user friendly for everyone.

The guidelines have three levels of accessibility (A, AA and AAA). We’ve chosen Level AA as the target for the Stahl Masterclass website.

 

Requests for the Reading Impaired

Cambridge University Press now publishes the majority of its new titles, and many older titles, in accessible e-book formats either for individual purchase or on platforms suitable for institutions. Where a work is unavailable for purchase in a suitable format, we welcome enquiries from both individuals and institutions to provide one. More information and the Accessibility Request Form can be found here.

 

Browser support

This website has been cross-platform and cross-browser tested. It is optimized for modern browsers including Microsoft Internet Explorer 8+, Mozilla Firefox, Apple Safari, Google Chrome. Older browsers may offer limited functionality.

 

Mobile device support

This website has been optimised for use on tablets and desktop computers. We test the experience on various devices including most popular IOS, Android and MS Windows phones and tablets.

 

How are we doing?

We've worked hard on the Stahl Masterclass website to achieve our goal of Level AA accessibility. We monitor the website regularly to maintain this, but if you do find any problems, please get in touch.

 

Let us know what you think

If you enjoyed using the Stahl Masterclass website, or if you had trouble with any part of it, please get in touch. We'd like to hear from you in any of the following ways:

 

Terms of use

Cambridge University Press is a syndicate of the University of Cambridge and our principal place of business is at the University Printing House, Shaftesbury Road, Cambridge, CB2 8BS.
 
By using the Cambridge University Press website at http://www.stahlmasterclass.com (the "Portal”) and by registering to access the content of the Stahl Masterclass courses (the "Materials”) you are indicating that you accept the terms and conditions set out below (together with any documents referred to in them). Users who do not accept these terms of use are not authorised to use or continue using this website.
 
We may amend these terms of use at any time and any revised version will be effective immediately that is displayed on this website.
 
In the event of any comment or question concerning these terms of use, please contact us by e-mailing The Legal and Business Affairs department at legalservices@cambridge.org or writing to Legal and Business Affairs, University Printing House, Shaftesbury Road, Cambridge, CB2 8BS.
 
The content placed directly on the Portal may be accessed free of charge by all users of Stahl Masterclass.
 
The full content of the Stahl Masterclass courses may be accessed only by an individual who has purchased access to the Materials through the Cambridge University Press marketing site at www.cambridge.org (an "Authorised User”).
 
 
Other Applicable Terms
  1. Our Privacy Policy: sets out the terms on which we process any personal data we collect from you, or that you provide to us. By using the Portal and/or the Materials, you consent to such processing and you warrant that all data provided by you are accurate.
  2. If you purchase access to the Materials, the terms and conditions on the www.cambridge.org website will also apply.
 
Access to and Use of this Website
 
We own or are licensed to use all intellectual property rights in and to this website and all technical infrastructure relating to it. The Materials are copyright © Cambridge University Press or published under license from the copyright holder by Cambridge University Press. Users undertake to ensure that the intellectual property rights of the copyright holder and the software owners and the moral rights of the authors of the Materials are not infringed.
 
Material contained in this website may be downloaded, viewed and printed for personal use only provided that no trade mark, copyright or other proprietary notices contained in or appearing on such material are removed in whole or in part. All other rights are reserved and users must seek our permission before making any other use of material contained in this website.
 
In accessing any part of this website, you agree NOT to:
Cambridge University Press reserves the right to withdraw the subscriber's access to the Materials in the event of systematic breach of these conditions by any authorised user.
 
 
Privacy Policy
 
If you supply personal details to us through this website then you consent to our maintaining, recording, holding and using such personal data in accordance with our Privacy Policy.
 
 
Exclusions and Limitations of Liability
 
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Cambridge University Health Partners (CUHP) unites a world-leading University and three high-performing NHS Foundation Trusts centred on the Cambridge Biomedical Campus.  This partnership has contributed to the Cambridge School of Clinical Medicine being ranked in the top handful worldwide, excellent clinical outcomes and high reputation of our hospitals.  The four organisations have complementary interests and the campus provides unrivalled opportunities for capital and intellectual investments from the public and private sectors.  CUHP catalyses Europe’s largest and most sophisticated biomedical community, in a region that has the highest concentration of lifescience industries outside the USA. Our aim is local integration of these unique assets to achieve global impact.

CUHP drives forward the partnership between the NHS and the University of Cambridge.

The NHS organisations in the partnership are those that work most closely with the University in performing research and education and that involve academic doctors in the delivery of their services: Cambridge and Peterborough NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Papworth Hospital NHS Foundation Trust.

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The purpose of CUHP is to generate, transmit and apply knowledge for improvement in health and health care. Within CUHP, each strand of our tripartite mission (patient care, research, education) strengthens the other to create capability and build capacity towards this purpose. Externally, CUHP serves as a catalyst to support more effective interaction and collaboration between industry, the NHS and academia unlocking the potential for delivering creative solutions more rapidly and effectively.

The strategic goals of CUHP include:

The Dilemma: What diagnosis? What treatment?

Use the button to read through the background information for this case activity.

Use the tabs to read through the patient's case notes and answer the questions in order:

41-year-old male with depression. He is one year sober from cannabis and cocaine dependence and six months sober from alcohol dependence (excluding two one-day relapses).
Symptoms include:
  • Interrupted sleep
  • Low energy
  • Poor concentration

He denies suicidality as well as mixed or psychotic symptoms.

Psychiatric history
  • Substance misuse began in teenage years
  • He reports repeated "high spells" since his early twenties, with depression more predominant since his thirties
  • While drinking in his thirties he became suicidal and sought care; he was diagnosed with bipolar disorder and prescribed divalproex
  • He was able to hold down a job and maintain relationships as his affect improved, but his substance misuse continued until a year ago
  • He avoided doctors in general for some time
  • Over time his high spells dissipated and his "depressed spells" began to dominate more
  • As depression continued during divalproex treatment, he was switched to quetiapine, with similar effects
  • Substance misuse and high spells occurred occasionally
  • Aripiprazole was added to quetiapine and high spells dissipated again, but depression remained
Medical history
  • During the course of divalproex treatment he experienced weight gain and increased abdominal girth
  • He has been diagnosed with hypertension, for which he must take three antihypertensive medications to maintain control
  • He developed hypercholesterol after antipsychotic medication was initiated
  • He does not have diabetes or any other medical issues
Medications
  • Quetiapine 600 mg/day
  • Aripiprazole 10 mg/day
  • Metoprolol (beta blocker, for hypertension)
  • Hydrochlorothiazide (diuretic, for hypertension)
  • Clonidine (alpha agonist, for hypertension)
  • Simvastatin (for cholesterol)
Family history
No significant family history
  • What are his depression symptoms?
  • What are his high spell symptoms?
  • How much is he using substances, and did this cause high or low spells?
  • Are any high or low spells occurring in the absence of substance use?

Next steps

  • Define high spells as a collection of symptoms consistent with DSM-IV-TR (hypo)mania versus lability from substance misuse or personality disorder
  • Determine if sustained mood elevation accompanied the target symptoms
  • Determine if symptoms were sustained for longer than seven days and if impairment was consistent with mania
  • Corroborate history with a family member if possible
Case Outcomes
  • Evaluation of the patient shows that many of his high spells in his twenties and thirties were fueled by substance abuse
  • As the patient has become relatively sober in his forties he has had no full mania spells, but will occasionally have 4-10 days of sustained hypomania while sober
  • There is no evidence of personality or adjustment issues precipitating the hypomania
  • He still suffers predominantly from depression, which interferes more with his life than the hypomania spells
  • He is engaged in activities that are helping to maintain his sobriety
  • He is diagnosed with bipolar II disorder, with polysubstance dependence issues
1) In regards to the current mixing of two atypical antipsychotics (quetiapine and aripiprazole), what is the best rationale for continuing or changing these medications?
 
A: They are controlling his hypomania and so both should be continued (both are approved for treating mania)
B: They are not treating his depression and so another agent should be added for this (quetiapine is approved for treating bipolar depression, aripiprazole is off-label)
C: There is very little evidence for ever adding two atypical antipsychotics, so one should be discontinued and another agent added for depression
D: They are not treating his depression and so both should be discontinued and another agent added
2) Of the following options, what would you do now?
 
A: Increase quetiapine above 800 mg/day, maintain aripiprazole
B: Increase aripiprazole above 10 mg/day, maintain quetiapine
C: Add lamotrigine
D: Add or switch to lithium
E: Switch to olanzapine- fluoxetine combination

Thank you

Compare your ideas to those of your peers. The popularity of each answer option is indicated by the percentages:

1)

A: Both should be continued (both are approved for treating mania)
B: Add another agent to treat his depression
C: Discontinue one atypical antipsychotic and add another agent for depression
D: Discontinue both and add another agent

2)

A: Increase quetiapine above 800 mg/day, maintain aripiprazole
B: Increase aripiprazole above 10 mg/day, maintain quetiapine
C: Add lamotrigine
D: Add or switch to lithium
E: Switch to olanzapine-fluoxetine combination

 

All of these options may be reasonable...
 
 Despite the lack of evidence regarding polypharmacy with antipsychotics, there is some rationale for continuing both quetiapine and aripiprazole:

  • The patient has experienced moderate improvement without significant side effects, and it may be best to attempt to maximize these before adding or switching medications
  • Both agents have antidepressant properties but unique pharmacodynamic profiles that may work synergistically to improve bipolar depression
  • That is, both block serotonin 2A receptors, which may allow downstream elevation of cortical dopamine and norepinephrine, but quetiapine additionally blocks the norepinephrine transporter and 5HT2C receptors while aripiprazole may promote dopamine activity partially at D2 and D3 receptors in brain areas with low dopamine activity and may partially stimulate serotonin 1A receptors as well 
  • Both are lower potency and might be more easily combined with lower rates of extrapyramidal side effects than other antipsychotics 

It may also be rational to increase the aripiprazole dose:

  • Evidence suggests that the average dose in unipolar depression may be less than 11 mg/day, while doses higher than this may diminish his future hypomania spells

It may be rational to add lamotrigine or add/switch to lithium, as he is relatively euthymic:

  • Use of either as a maintenance drug may delay relapse into hypomania or depression (both are approved for this)
  • Both have mechanisms distinctly different from the currently prescribed antipsychotics and thus may affect the patient's brain in a novel manner to promote symptom remission

Olanzapine-fluoxetine combination is an approved treatment option for bipolar depression (olanzapine is also approved for bipolar maintenance):

  • Because this patient experienced weight/metabolic issues on divalproex, olanzapine may not be the most appropriate atypical antipsychotic to use due to its high propensity of inducing weight gain. 
Case Outcomes
  • Aripiprazole dose is raised to 15 mg/day, quetiapine is maintained at 600 mg/day
  • Blood pressure and cholesterol are being monitored for evidence of any further metabolic syndrome issues
  • Patient is also being monitored for any signs of extrapyramidal side effects or tardive dyskinesia
  • The increased aripiprazole dose is tolerated well, but the patient continues to experience moderate depression and occasional hypomania spells
  • Aripiprazole is eventually escalated to 30 mg/day but without extra effect
  • Given fairly good control of symptoms but clear residual issues, consideration is made to add another agent
  • The patient is fully informed regarding treatment options, specifically addition of lithium or lamotrigine or switch to olanzapine-fluoxetine combination
  • The patient elects to add lamotrigine, which is titrated to 200 mg/day without clear effect
  • Lamotrigine is further titrated to 400 mg/day
  • The patient remains free of hypomania for several months and free of depression for several weeks; he is able to return to work as a volunteer coach for youth sports
  • Clarification of pre-existing diagnoses is important; this patient presented stating he was "bipolar," but better history-taking suggested a less severe diagnosis of bipolar II disorder with clear substance misuse issues
  • Clinicians must make accurate diagnoses in order to choose more accurate outcomes-based treatments; one should never assume that a single target symptom equals mania - the full syndrome and symptom collection must be sorted out
  • Although there is little evidence in support of combining antipsychotics, there may be occasions when it is warranted, particularly if a patient is already on such a combination and is experiencing at least moderate improvement, is being monitored for side effects, and there is a pharmacodynamic rationale for the combination
  • It is often beneficial to maximize current medications for dose and duration before adding or switching to another medication
  • Medication choices should be offered to the patient in an informed consent and psychoeducational model

 

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