Exploring the limited use of transdermal medications in psychiatry: Challenges and potential solutions

Transdermal medications are an useful yet underutilized tool in the field of psychiatry. Despite numerous advantages of using this route of medication delivery, transdermal medications remain less popular compared to other routes of medication administration such as oral and intramuscular routes in the management of various psychiatric conditions. In this editorial, we examine the advantages of transdermal medications with a brief overview of transdermal being used in psychiatry and other medical specialties. We discuss the factors that play a role in their limited usage in psychiatry. We highlight certain patient categories who can specifically benefit from them and discuss potential solutions that can broaden the perspective of treating clinicians making this an intriguing avenue in the field of psychiatry.

Selecting, implementing and evaluating control and placebo conditions in light therapy and light-based interventions

Introduction: Light profoundly influences human physiology, behaviour and cognition by affecting various functions through light-sensitive cells in the retina. Light therapy has proven effective in treating seasonal depression and other disorders. However, designing appropriate control conditions for light-based interventions remains a challenge.Materials and methods: This article presents a novel framework for selecting, implementing and evaluating control conditions in light studies, offering theoretical foundations and practical guidance. It reviews the fundamentals of photoreception and discusses control strategies such as dim light, darkness, different wavelengths, spectral composition and metameric conditions. Special cases like dynamic lighting, simulated dawn and dusk, complex interventions and studies involving blind or visually impaired patients are also considered.Results: The practical guide outlines steps for selection, implementation, evaluation and reporting, emphasizing the importance of α-opic calculations and physiological validation.Conclusion: In conclusion, constructing effective control conditions is crucial for demonstrating the efficacy of light interventions in various research scenarios.

Towards an evidence-based integrative lighting score: a proposed multi-level approach

Background: Human circadian clocks are synchronized daily with the external light-dark cycle and entrained to the 24-hour day. There is increasing evidence that a lack of synchronization and circadian entrainment can lead to adverse health effects. Beyond vision, light plays a critical role in modulating many so-called non-visual functions, including sleep-wake cycles, alertness, mood and endocrine functions. To assess (and potentially optimize) the impact of light on non-visual functions, it is necessary to know the exact 'dose' (i.e. spectral irradiance and exposure duration at eye level) of 24-hour light exposures, but also to include metadata about the lighting environment, individual needs and resources.

Problem statement: To address this problem, a new assessment tool is needed that uses existing metrics to provide metadata and information about light quality and quantity from all sources. In this commentary, we discuss the need to develop an evidence-based integrative lighting score that is tailored to specific audiences and lighting environments. We will summarize the most compelling evidence from the literature and outline a future plan for developing such a lighting score using internationally accepted metrics, stakeholder and user feedback.

Conclusion: We propose a weighting system that combines light qualities with physiological and behavioral effects, and the use of mathematical modelling for an output score. Such a scoring system will facilitate a holistic assessment of a lighting environment, integrating all available light sources.

Staying isolated indoors means that nobody sees me": ontological (in)security and living with significant appearance concerns before, during, and 'since' COVID-19

PURPOSE

Though a worldwide period of uncertainty (COVID-19) has 'ended', there exists a legacy of maladaptive experiences among people with significant appearance concerns (SAC) that requires care and attention.

METHODS

Using Giddens' concept of ontological security, we explored how people experienced their SAC before, during and "since" COVID-19. Qualitative surveys allowed us to capture diverse perspectives from individuals transnationally, analysed with deductive reflexive thematic analysis using ontological security as our theoretical foundation.

RESULTS

Themes named "More Mirror(ed) Time" and "Locked Out, Shut Down, and Shut Out" gave a contextual grounding for the embodied experiences of this group through times of social restrictions, and the theme "Redefining Relevance" explored the continued legacy of COVID-19 - and continued global uncertainties such as economic hardship and warfare - that impact the wellbeing of people with SAC.

CONCLUSIONS

People with SAC are still 'locked out' from essential healthcare support as those providing healthcare are overworked, under-resourced and rely on efficient interactive methods such as tele-health that may be triggers for people with SAC. Care providers may consider expanding appearance concerns verbiage, look to involve trusted others in the care-seeking process, and utilize modalities beyond digital health to support people with SAC.

Inhibition moderates the effect of attentional bias modification for reducing residual depressive symptoms: A randomized sham-controlled clinical trial

OBJECTIVES

Residual symptoms represent risk factor for relapse. Attention bias modification (ABM) may reduce clinical and sub-clinical depressive symptoms, indicating that is may be of relevance when preventing relapse. Current evidence suggests that executive functions may moderate the outcome of interventions targeting depressive symptoms.

METHODS

We assessed inhibition and shifting as indicators of executive functioning by means of the Color-Word Interference Test (i.e., "Stroop task"). These baseline characteristics were investigated as moderator of the effect of ABM on depression symptoms in a double-blinded randomized sham-controlled trial of ABM including patients with a history of recurrent depression (N = 301). Inclusion and follow-ups took place from January 2015 to October 2016. The trial was retrospectively registered #NCT02658682 January 2016.

RESULTS

The moderation analysis was based on the interaction term ABM x Stroop. Scaled inhibition scores ≤10.8, but not shifting ability, moderated the effect of ABM compared to sham on clinician-rated depression (HDRS). The difference from the 15th to the 85th percentile of the inhibition score was about 1 HDRS-point, indicating a small effect size. No moderation was found when self-reported depression and AB were the outcome. Post-hoc power calculation indicates risk of Type-II error.

CONCLUSION

When targeting depressive symptoms, ABM seems to be somewhat more effective in patients with weak inhibitory control. This suggests that evaluating the level of inhibition in individual patients could provide some information when making decisions about prescribing ABM to reduce residual symptoms, but the clinical implications of this is uncertain due to an overall small effect size attributable to ABM. Future studies should examine whether inhibitory control still is a relevant moderator when comparing ABM to treatment options other than the sham control condition.

Multiple mediation analysis of a task-shared psychosocial intervention for perinatal anxiety: Exploratory findings from a randomized controlled trial in Pakistan

BACKGROUND

The "Healthy Mother Healthy Baby" (HMHB) study is a phase three, single-blind randomized clinical trial conducted at Holy Family Hospital (HFH) in association with Rawalpindi Medical University (RMU). We aimed to examine the mediators of a specialized psychosocial approach based on Cognitive Behavioural Therapy principles, targeting pregnant women experiencing anxiety. The HMHB intervention was effective in treating perinatal anxiety symptoms and preventing future depressive episodes.

METHODS

The trial randomized participants into two arms: the HMHB intervention or Enhanced Usual Care (EUC), following World Health Organization guidelines. The HMHB intervention comprised strategies to strengthen social support networks, improving mother-baby bonding and strategies to deal with interpersonal conflicts, economic challenges, and societal gender preferences using cognitive and behavioural techniques and culturally resonant illustrations. Participants underwent rigorous data collection at three pivotal timepoints: baseline, third trimester, and 6-weeks postnatal. The primary outcome was anxiety symptom severity scores using the Hospital Anxiety and Depression Scale (HADS) at 6-weeks post-childbirth. Four potential mediators - social support, behavioural activation, perceived stress, and pregnancy experience - were assessed in the third trimester of pregnancy.

RESULTS

A total of 1200 participants were randomized to the HMHB and EUC arms. In the six-week follow-up time point, 379 participants remained in the EUC group, and 387 continued in the HMHB group. Post-intervention, HMHB participants displayed significant improvements in postnatal anxiety and depression scores. Mediation analyses revealed social support and pregnancy hassles as significant mediators of the intervention's effect on postnatal anxiety outcomes, while only social support emerged as a significant mediator for depression outcomes.

CONCLUSION

The HMHB intervention showed promising results in improving anxiety and depression scores among pregnant women. Significant mediation effects suggest the importance of targeting social support and managing pregnancy-related hassles for optimal intervention effectiveness.

Neuro-molecular perspectives on long COVID-19 impacted cerebrovascular diseases - a role for dipeptidyl peptidase IV

The coronavirus disease 2019 (COVID-19) has caused immense devastation globally with many outcomes that are now extending to its long-term sequel called long COVID. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects not only lungs, but also the brain and heart in association with endothelial cell dysfunction, coagulation abnormalities, and thrombosis leading to cardio-cerebrovascular health issues. Fatigue, cognitive decline, and brain fog are common neurological symptoms in persisting long COVID. Neurodegenerative processes and SARS-CoV-2 infection manifest overlapping molecular mechanisms, such as cytokine dysregulation, inflammation, protein aggregation, mitochondrial dysfunction, and oxidative stress. Identifying the key molecules in these processes is of importance for prevention and treatment of this disease. In particular, Dipeptidyl peptidase IV (DPPIV), a multifunctional peptidase has recently drawn attention as a potential co-receptor for SARS-CoV-2 infection and cellular entry. DPPIV is a known co-receptor for some other COVID viruses including MERS-Co-V. DPPIV regulates the immune responses, obesity, glucose metabolism, diabetes, and hypertension that are associated with cerebrovascular manifestations including stroke. DPPIV likely worsens persisting COVID-19 by disrupting inflammatory signaling pathways and the neurovascular system. This review highlights the neurological, cellular and molecular processes concerning long COVID, and DPPIV as a potential key factor contributing to cerebrovascular dysfunctions following SARS-CoV-2 infection.

Chromenone: An emerging scaffold in anti-Alzheimer drug discovery

Alzheimer's disease (AD) presents a growing global health concern. In recent decades, natural and synthetic chromenone have emerged as promising drug candidates due to their multi-target potential. Natural chromenone, quercetin, scopoletin, esculetin, coumestrol, umbelliferone, bergapten, and methoxsalen (xanthotoxin), and synthetic chromenone hybrids comprising structures like acridine, 4-aminophenyl, 3-arylcoumarins, quinoline, 1,3,4-oxadiazole, 1,2,3-triazole, and tacrine, have been explored for their potential to combat AD. Key reactions used for synthesis of chromenone hybrids include Perkin and Pechmann condensation. The activity of chromenone hybrids has been reported against several drug targets, including AChE, BuChE, BACE-1, and MAO-A/B. This review comprehensively explores natural, semisynthetic, and synthetic chromenone, elucidating their synthetic routes, possible mode of action/drug targets and structure-activity relationships (SAR). The acquired knowledge provides valuable insights for the development of new chromenone hybrids against AD.

Sex-Dependent Effects of Cardiometabolic Health and APOE4 on Brain Age: A Longitudinal Cohort Study

BACKGROUND AND OBJECTIVES

The aging population is growing faster than all other demographic strata. With older age comes a greater risk of health conditions such as obesity and high blood pressure (BP). These cardiometabolic risk factors (CMRs) exhibit prominent sex differences in midlife and aging, yet their influence on brain health in females vs males is largely unexplored. In this study, we investigated sex differences in relationships between BP, body mass index (BMI), and brain age over time and tested for interactions with APOE ε4 genotype (APOE4), a known genetic risk factor of Alzheimer disease.

METHODS

The sample included participants from 2 United Kingdom-based longitudinal birth cohorts, the Lothian Birth Cohort (1936) and Insight 46 (1946). Participants with MRI data from at least 1 time point were included to evaluate sex differences in associations between CMRs and brain age. The open-access software package brainageR 2.1 was used to estimate brain age for each participant. Linear mixed-effects models were used to assess the relationships between brain age, BMI, BP, and APOE4 status (i.e., carrier vs noncarrier) in males and females over time.

RESULTS

The combined sample comprised 1,120 participants (48% female) with a mean age (SD) of 73 (0.72) years in the Lothian Birth Cohort and 71 (0.68) years in Insight 46 at the time point 1 assessment. Approximately 30% of participants were APOE4 carriers. Higher systolic and diastolic BP was significantly associated with older brain age in females only (β = 0.43-0.56, p < 0.05). Among males, higher BMI was associated with older brain age across time points and APOE4 groups (β = 0.72-0.77, p < 0.05). In females, higher BMI was linked to older brain age among APOE4 noncarriers (β = 0.68-0.99, p < 0.05), whereas higher BMI was linked to younger brain age among carriers, particularly at the last time point (β = -1.75, p < 0.05).

DISCUSSION

This study indicates sex-dependent and time-dependent relationships between CMRs, APOE4 status, and brain age. Our findings highlight the necessity of sex-stratified analyses to elucidate the role of CMRs in individual aging trajectories, providing a basis for developing personalized preventive interventions.

GABAergic implications in anxiety and related disorders

Evidence indicates that anxiety disorders arise from an imbalance in the functioning of brain circuits that govern the modulation of emotional responses to possibly threatening stimuli. The circuits under consideration in this context include the amygdala's bottom-up activity, which signifies the existence of stimuli that may be seen as dangerous. Moreover, these circuits encompass top-down regulatory processes that originate in the prefrontal cortex, facilitating the communication of the emotional significance associated with the inputs. Diverse databases (e.g., Pubmed, ScienceDirect, Web of Science, Google Scholar) were searched for literature using a combination of different terms e.g., "anxiety", "stress", "neuroanatomy", and "neural circuits", etc. A decrease in GABAergic activity is present in both anxiety disorders and severe depression. Research on cerebral functional imaging in depressive individuals has shown reduced levels of GABA within the cortical regions. Additionally, animal studies demonstrated that a reduction in the expression of GABAA/B receptors results in a behavioral pattern resembling anxiety. The amygdala consists of inhibitory networks composed of GABAergic interneurons, responsible for modulating anxiety responses in both normal and pathological conditions. The GABAA receptor has allosteric sites (e.g., α/γ, γ/β, and α/β) which enable regulation of neuronal inhibition in the amygdala. These sites serve as molecular targets for anxiolytic medications such as benzodiazepine and barbiturates. Alterations in the levels of naturally occurring regulators of these allosteric sites, along with alterations to the composition of the GABAA receptor subunits, could potentially act as mechanisms via which the extent of neuronal inhibition is diminished in pathological anxiety disorders.

Use of service and treatment adequacy in medical students and residents suffering from depression in France: A nationwide study

Depression was already a public health issue before the Covid-19 pandemic. Use of service and treatment adequacy in medical students was poorly known. A 2021 French national study found the prevalence of 12-month major depressive disorder (MDD) was 25 % in medical school students and residents (MSSR). The main objective of our study was to measure the prevalence of service use and adequate treatment (therapy and/or recommended pharmacotherapy) and their associated factors. A national online survey was conducted in 2021. The Composite International Diagnostic Interview Short-Form questionnaire was used to assess MDD; 12-months service use and pharmacotherapy were assessed. Univariate and multivariate logistic regressions were performed between students' demographic characteristics, use of services, and treatment adequacy. Among included MSSR who experienced MDD in the last 12 months, only 32 % received adequate treatment, including 20 % with recommended pharmacotherapy. Being more advanced in medical studies and being treated both by a general practitioner and a psychiatrist were associated with receiving recommended pharmacotherapy. To our knowledge, our study is the largest to assess use of service and treatment adequacy in MSSR. Given the low percentage of depressed students receiving recommended treatment, it seems important to develop new interventions to better detect and treat MDD in MSSR.

A Potential Role for MAGI-1 in the Bi-Directional Relationship Between Major Depressive Disorder and Cardiovascular Disease

PURPOSE OF REVIEW

Major Depressive Disorder (MDD) is characterized by persistent symptoms such as fatigue, loss of interest in activities, feelings of sadness and worthlessness. MDD often coexist with cardiovascular disease (CVD), yet the precise link between these conditions remains unclear. This review explores factors underlying the development of MDD and CVD, including genetic, epigenetic, platelet activation, inflammation, hypothalamic-pituitary-adrenal (HPA) axis activation, endothelial cell (EC) dysfunction, and blood-brain barrier (BBB) disruption.

RECENT FINDINGS

Single nucleotide polymorphisms (SNPs) in the membrane-associated guanylate kinase WW and PDZ domain-containing protein 1 (MAGI-1) are associated with neuroticism and psychiatric disorders including MDD. SNPs in MAGI-1 are also linked to chronic inflammatory disorders such as spontaneous glomerulosclerosis, celiac disease, ulcerative colitis, and Crohn's disease. Increased MAGI-1 expression has been observed in colonic epithelial samples from Crohn's disease and ulcerative colitis patients. MAGI-1 also plays a role in regulating EC activation and atherogenesis in mice and is essential for Influenza A virus (IAV) infection, endoplasmic reticulum stress-induced EC apoptosis, and thrombin-induced EC permeability. Despite being understudied in human disease; evidence suggests that MAGI-1 may play a role in linking CVD and MDD. Therefore, further investigation of MAG-1 could be warranted to elucidate its potential involvement in these conditions.

Extended-Release Mixed Amphetamine Salts for Comorbid Adult Attention-Deficit/Hyperactivity Disorder and Cannabis Use Disorder: A Pilot, Randomized Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To determine if treatment of co-occurring adult ADHD and Cannabis Use Disorder (CUD) with extended-release mixed amphetamine salts (MAS-ER) would be effective at improving ADHD symptoms and promoting abstinence.

METHOD

A 12-week randomized, double-blind, two-arm pilot feasibility trial of adults with comorbid ADHD and CUD (n = 28) comparing MAS-ER (80 mg) to placebo. Main outcomes: ADHD: ≥30% symptom reduction, measured by the Adult ADHD Investigator Symptom Rating Scale (AISRS). CUD: Abstinence during last 2 observed weeks of maintenance phase.

RESULTS

Overall, medication was well-tolerated. There was no significant difference in ADHD symptom reduction (MAS-ER: 83.3%; placebo: 71.4%; p = .65) or cannabis abstinence (MAS-ER: 15.4%; placebo: 0%; p = .27). MAS-ER group showed a significant decrease in weekly cannabis use days over time compared to placebo (p < .0001).

CONCLUSIONS

MAS-ER was generally well-tolerated. The small sample size precluded a determination of MAS-ER's superiority reducing ADHD symptoms or promoting abstinence. Notably, MAS-ER significantly reduced weekly days of use over time.

The longitudinal course of psychological distress and resilience in patients with serious mental illnesses during the first two years of the Covid-19 pandemic

The positive effects of resilience on psychological distress has been found in previous studies in samples not including the seriously mentally ill. The present study aimed to investigate the course of psychological distress and resilience in the first two years of the Covid-19 pandemic in patients with severe mental illness (SMI) and major depressive disorder without psychotic features (MDD) compared to healthy control subjects. 141 patients with SMI or MDD who had been admitted to a psychiatric ward in Tyrol (Austria) or South Tyrol (Italy) in 2019 and 584 community controls participated in a longitudinal online survey. Next to collecting sociodemographic data, psychological distress was evaluated using the Brief Symptom Checklist (BSCL) and resilience by the 13-Item Resilience Scale (RS-13). Psychological distress was consistently significantly higher while resilience was consistently significantly lower among both patient groups compared to healthy controls. In the patient samples, those with MDD consistently exhibited a significantly higher prevalence and level of psychological distress and significantly lower resilience. Resilience had a moderating effect on psychological distress especially in the MDD group. Our results suggest that MDD patients represent a particularly vulnerable group and findings imply that these patients would profit the most from trainings fostering resilience.

Psychotropic drugs, eating behaviour and weight gain

PURPOSE OF REVIEW

Psychotropic drug related weight gain is a common side-effect of significant concern to both clinicians and patients. Recent studies and treatment guidelines strongly support taking preventive and early treatment approaches to psychotropic drug-related weight gain (PDWG). Arguably the main pathway that PDWG occurs is via changes in eating behaviour leading to increased caloric intake.

RECENT FINDINGS

Systematic reviews and meta-analyses have provided good data on the nature and prevalence of alterations in eating behaviour with psychotropic treatment including increased hunger, night eating and binge eating. These changes are unsurprisingly more prominent with agents like olanzapine and clozapine that have high propensity to cause weight gain.

SUMMARY

Altered eating behaviour can serve as an earlier measure of the risk of weight gain and can be examined easily in clinical practice. Detecting these changes can enable earlier action in terms of switching treatments and starting pharmacological and nonpharmacological preventive strategies.

Cognitive Behavioral Therapy for Insomnia Self-Management Mobile Apps: A Review of Efficacy and Quality

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for insomnia, yet multiple barriers limit utilization. Digital CBT-I may present a solution, though related reviews have focused on Internet-based delivery rather than app use. The high utilization of health apps and prevalence of sleep apps indicate the need to equip clinicians with app-specific research. Toward this end, we reviewed efficacy and quality data on self-management CBT-I smartphone apps, revealing efficacy research on eleven apps, five of which were publicly available. While preliminary, these efficacy studies showed consistent positive findings. When examining quantitative quality indicators for the five publicly available apps, two had consistent data. Overall, two apps, CBTi Coach and Insomnia Coach, had positive, empirical findings across all efficacy and quality assessment approaches. We provide recommendations to guide clinician decision making regarding CBT-I self-management apps based on the literature and publicly available methods of app evaluations.

Intentional Insulin Overdose and Depression in Subjects with and Without Diabetes Mellitus: A Commentary

Insulin is an essential medication for people with type 1 diabetes mellitus and for some people with type 2 diabetes. Interestingly, insulin abuse has been reported as a mode of suicide, not only among people with diabetes, but also among their relatives, and among medical and paramedical personnel who have access to insulin. The aim of the present commentary was to raise awareness of potential depression-related intentional insulin overdose and its complications, as well as of the diagnosis and treatment of this entity. Insulin overdose may lead to severe and prolonged hypoglycemia, hypoglycemic coma, and death. Moreover, hypokalemia, hypomagnesemia, hypophosphatemia, and elevated liver enzymes are common. Insulin overdose should be suspected among people with diabetes in case of unexplained prolonged hypoglycemia and among people without diabetes who exhibit hypoglycemia and may have access to diabetic medications. The ratio of insulin to C-peptide helps distinguish exogenous insulin administration from endogenous secretion. The cornerstone of therapy is prompt administration of concentrated glucose infusions for days with simultaneous oral intake, when possible, and intense glucose monitoring to prevent hypoglycemia. Moreover, monitoring of serum electrolyte levels is recommended. Finally, psychiatric evaluation aiming at early identification of depression and suicidality is of paramount importance.

Gender differences in risk and resilience for suicidal thoughts and behaviors: A national longitudinal survey study of United States veterans with a recent suicide attempt

BACKGROUND

This study reports on gender differences in psychosocial symptoms and suicidal thoughts and behaviors from the first longitudinal, national survey of veterans with a recent nonfatal suicide attempt to inform women-tailored suicide prevention.

METHODS

We recruited all female veterans with a documented nonfatal suicide attempt between October 2018 and September 2019 and a stratified matched sample of males. Surveys were administered at baseline, month 6, and month 12; 968 veterans completed the baseline survey with valid gender data. Surveys assessed psychosocial constructs, suicidal ideation severity, and suicidal behavior. Administrative datasets provided healthcare and suicide attempt data during the one year follow up.

RESULTS

Women retained higher social rejection and institutional betrayal, and lower self-compassion and autonomy than men over follow up. Higher overall self-compassion was associated with lower baseline suicide ideation for both women and men; however, this association was stronger for women (Δ = -0.19; 95 % CI = -0.31, -0.07; d = -0.15). Individuals with higher overall psychological distress had greater odds of a subsequent suicide attempt (AOR = 2.20, 95 % CI = 1.56, 3.11). Social rejection had the strongest association with worsening psychological distress, both within individuals (b = 0.18; 95 % CI = 0.14, 0.23; d = 0.23) and between individuals (b = 0.07; 95 % CI = 0.04, 0.10; d = 0.09).

LIMITATIONS

Results may not generalize beyond a VHA-utilizing veteran population.

CONCLUSIONS

Findings from this study inform potential therapeutic targets and topics for future research on tailoring suicide prevention for women veterans. While all veterans may need support reducing distress, women may need additional support in multiple other areas.

Increasing prevalence of self-harm, suicidal behavior and suicidal ideation throughout a three-year period in the context of COVID-19 pandemic in Spain

The COVID-19 pandemic had a great impact on mental health both in the general population and in individuals with preexisting mental disorders. Lockdown, social restrictions, changes in daily habits and limited access to health services led to changes in consultations in mental health services. This study aimed to determine changing trends in psychiatric admissions by the inclusion of adult patients admitted to the Emergency Department (ED) of Hospital Clínic of Barcelona between 2019 and 2021. Acute admissions, social issues and psychiatric diagnoses were compared between years, seasons and considering the interaction between both years and seasons. A total of 13,677 individuals were included in the analysis. An overall reduction in consultations to the ED and a higher proportion of acute admissions was observed in 2020 in context of the COVID-19 outbreak. Increased prevalence of sleeping disorders and substance use disorders was found in 2020. Self-harming behavior, suicidal thoughts and suicidal behavior showed an increasing tendency over time, with their highest rates in 2021. Prevention and management strategies should be considered in order to address increasing needs in mental health care.

Validation of the Revised Impact of Miscarriage Scale in the Republic of Burundi: A cross-sectional multicenter study

OBJECTIVE

The objective of this study was to translate and validate the Revised Impact of Miscarriage Scale (RIMS) into Kirundi for use among women and men in Burundi. Additionally, the study aimed to compare the experience and personal meaning of miscarriage between women and men.

METHODS

This is a cross-sectional multicentered study. The RIMS was translated into Kirundi. Cronbach coefficient alpha and its internal consistency were measured for both genders. An exploratory factor analysis (EFA) was used to determine the underlying factors and the shared variance. Both women and men completed the RIMS questionnaire, while women completed sociodemographic, reproductive and mental health questions.

RESULTS

In all, 79 couples completed the RIMS. The original factor structure was retained after the EFA, with 68% of the shared variance explained in the three-factor solution with 16 questions. Isolation/guilt, Loss of baby, and Devastating event. The internal consistency for women and men combined was α = 0.928. Although women scored higher on the factors of Isolation/guilt and Loss of baby, there were no significant differences in the Devastating event factor between women and men. Couples scores were positively correlated. Women who had experienced a previous miscarriage were more significantly impacted by all three factors compared to women experiencing their first miscarriage.

CONCLUSIONS

The Kirundi translation of the RIMS retained the original factor structure and demonstrated excellent internal consistency α = 0.928 in women and men combined. The RIMS could be a tool for caregivers to identify individuals who require additional support after a miscarriage.

When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis

Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.

Anxiety and Depression Among Pediatric Emergency Nurses and Physicians During the Coronavirus Disease 2019 Pandemic

INTRODUCTION

To determine anxiety and depression levels among pediatric acute care nurses and physicians before and after vaccine implementation during the coronavirus disease 2019 pandemic.

METHODS

Prospective cross-sectional study of emergency medicine and urgent care providers at a metropolitan quaternary pediatric emergency department, including 2 satellite emergency departments and 7 urgent care sites. Anxiety and depression symptoms were assessed using the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-2. Nurses and physicians were surveyed twice using the Generalized Anxiety Disorder-7 in May 2020 and March 2021 and once with the Patient Health Questionnaire-2 in March 2021.

RESULTS

In total, 189 surveys were completed in May 2020 (response rate 48%), and 243 surveys were completed in March 2021 (response rate 52%). Nurses reported higher Generalized Anxiety Disorder-7 scores compared to physicians for both years, though Patient Health Questionnaire-2 scores were similar. Mean Generalized Anxiety Disorder-7 scores decreased for both nurses and physicians between the 2 response periods. Amongst those who had a history of anxiety, chronic medical conditions, or were living with a high-risk individual, higher rates of anxiety were observed. Respondents endorsed the need for increased psychological support during a pandemic, with adequate and timely psychological support provided by the hospital, and stated their households were financially affected by the pandemic. Respondents reported fewer feelings of anxiety after self and public vaccination.

DISCUSSION

Study findings support increased psychological support for frontline nurses and physicians during a pandemic, particularly for those with a history of anxiety or chronic medical conditions, or those living with a high-risk individual.

Long-term prescribed opioid use after hospitalization or emergency department presentation among opioid naïve adults (2014-2020)-A population-based descriptive cohort study

AIMS

The aim of this work is to describe opioid initiation and long-term use after emergency department (ED) visits or hospitalizations in New South Wales, Australia, by patient, admission and clinical characteristics.

METHODS

This is a population-based cohort study, including all hospitalizations and ED visits between 2014 and 2020, linked to medicine dispensings, deaths and cancer registrations (Medicines Intelligence Data Platform), among adults with no opioid dispensings in the previous year. Outcome measures were opioid initiations (dispensed within 7 days of discharge) and long-term use (90 days of continuous exposure, 90-270 days after initiation).

RESULTS

The cohort included 16 153 096 admissions by 4.2 million opioid-naïve adults; 39.0% were ED presentations without hospital admission, 16.8% hospital admissions via ED and 44.2% direct hospital admissions. Opioids were initiated post-discharge for 6.2% of ED, 8.3% of hospital via ED and 10.0% of direct hospital admissions; of these 1.0%, 2.5% and 0.5% progressed to long-term opioid use, respectively. Initiation was lowest in obstetric admissions without surgery (1.0%), and highest among trauma admissions (25.4%), obstetric admissions with surgical intervention (19.8%) and non-trauma surgical admissions (12.0%). Long-term use was highest among medical admissions via ED (3.5%), trauma admissions (2.3%) and ED alone (1.0%). From 2014 to 2020, overall opioid initiations decreased 16% from 8.7% to 7.2%, and long-term opioid use decreased 33% from 1.3% to 0.8%.

CONCLUSIONS

Both opioid initiation and long-term use decreased over time; however, the higher rates of long-term use following trauma, and medical admissions via ED, warrant further surveillance. Strategies supporting appropriate prescribing and access to multidisciplinary pain services will facilitate best practice care.

Newer Treatments for Mood and Anxiety Disorders

For more than 20 years, the mainstay of pharmacologic treatment for depression and anxiety disorders has been serotonin reuptake inhibitors and selective serotonin and norepinephrine reuptake inhibitors. There are newer medications, many with novel mechanisms of action, that have come to market; however, first-line treatments remain the same. There are now more robust data on the use of various augmentation agents in the treatment of major depressive disorder providing better recommendations for use by the primary care provider. Data to support the use of psychedelic-assisted psychotherapy in the treatment of mood and anxiety disorders are not robust enough to recommend generalized use at this time.

The Mediating Role of Insomnia Severity in the Relationship Between Anxiety Symptoms and Suicidal Ideation: A Real-World Study in a Psychiatric Inpatient Setting

ABSTRACT

Insomnia and anxiety symptoms are independent clinical variables involved in suicidal ideation in psychiatric inpatients. In this article, we investigated the relationship among insomnia severity, severity of anxiety symptoms, and suicidal ideation in a sample of psychiatric inpatients with severe mental disorders. We used a mediation model considering insomnia severity as the possible mediator of the relationship between anxiety severity and suicidal ideation. We administered the Columbia Suicide Severity Rating Scale, the Insomnia Severity Index, and the Hamilton Anxiety Rating Scale to 116 consecutive inpatients to the psychiatric unit of Sant'Andrea Hospital in Rome. The effect of anxiety symptoms was mediated by insomnia severity; patients who perceive higher anxiety symptoms were more likely to experience higher levels of insomnia and, thus, higher suicidal ideation intensity. Results showed the importance of assessing and treating both insomnia and anxiety in clinical practice.

Serotonin syndrome: A rare yet crucial diagnosis

ABSTRACT

Serotonin syndrome is a rare, life-threatening toxidrome caused by serotonergic agents. This syndrome classically presents with a combination of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. However, diagnosing the condition is difficult because of its variable symptoms at presentation. As a result, serotonin syndrome often is underreported, making it harder to understand, recognize, and treat. Patients with this condition may present to primary or urgent care or an ED, and may become acutely symptomatic during an inpatient admission. Clinicians must be able to identify at-risk patients and intervene to prevent potentially lethal complications.

Mechanism-based inactivation of cytochromes P450: implications in drug interactions and pharmacotherapy

Cytochrome P40 (CYP) enzymes dominate the metabolism of numerous endogenous and xenobiotic substances. While it is commonly believed that CYP-catalysed reactions result in the detoxication of foreign substances, these reactions can also yield reactive intermediates that can bind to cellular macromolecules to cause cytotoxicity or irreversibly inactivate CYPs that create them.Mechanism-based inactivation (MBI) produces either irreversible or quasi-irreversible inactivation and is commonly caused by CYP metabolic bioactivation to an electrophilic reactive intermediate. Many drugs that have been known to cause MBI in CYPs have been discovered as perpetrators in drug-drug interactions throughout the last 20-30 years.This review will highlight the key findings from the recent literature about the mechanisms of CYP enzyme inhibition, with a focus on the broad mechanistic elements of MBI for widely used drugs linked to the phenomenon. There will also be a brief discussion of the clinical or pharmacokinetic consequences of CYP inactivation with regard to drug interaction and toxicity risk.Gaining knowledge about the selective inactivation of CYPs by common therapeutic drugs helps with the assessment of factors that affect the systemic clearance of co-administered drugs and improves comprehension of anticipated interactions with other drugs or xenobiotics.

Associations Between Opioid and Kratom Use in the USA: Differences by Race/Ethnicity and Sexual Orientation

BACKGROUND

Kratom is federally unregulated and is marketed as an opioid alternative despite limited evidence and known negative effects. Disparities in associations between opioid and kratom use may be partly attributed to race/ethnicity and sexual orientation given differences in marketing, use motives, and prescriber practices.

METHODS

Data: 2021 nationally representative National Survey on Drug Use and Health among individuals aged 18 + . We used weighted logistic regression analyses to assess race/ethnicity and sexual orientation as moderators of associations between past-year opioid (1) use (total sample, n = 44,877) and (2) misuse and use disorder (among those with past-year opioid use, n = 10,398) and the outcome of kratom use (lifetime, past year).

RESULTS

26.76% reported past-year opioid use, and among those, 12.20% and 7.54% reported past-year opioid misuse and use disorder, respectively; 1.72% and 0.67% had lifetime and past-year kratom use, respectively. Opioid use was positively associated with lifetime (aOR = 2.69, 95%CI = 1.98, 3.66) and past-year (aOR = 3.84, 95%CI = 2.50, 5.92) kratom use; associations among non-Hispanic Black and Hispanic (vs. non-Hispanic White) participants were weaker (p < 0.01). Among participants reporting past-year opioid use, misuse and use disorder were positively associated with lifetime (aORmisuse = 2.46, 95%CI = 1.60, 3.78; aORuse disorder = 5.58, 95%CI = 2.82, 11.04) and past-year (aORmisuse = 2.40, 95%CI = 1.26, 4.59; aORuse disorder = 3.08, 95%CI = 1.48, 6.41) kratom use; among bisexual (vs. heterosexual) participants, opioid use disorder was associated with a lower probability of lifetime kratom use (p < 0.01).

DISCUSSION

We observed positive associations between opioid and kratom use, with potential disparities among certain racial/ethnic and sexual orientation groups. Research should examine the mechanisms contributing to these differences to inform prevention and intervention efforts.

Sharing health care wishes among older adults with cognitive impairment in primary care: Results from a randomized controlled trial

INTRODUCTION

Best practices for conducting advance care planning (ACP) among persons with cognitive impairment exist, but evidence-based models are lacking for the primary care setting.

METHODS

We tested a remote multicomponent ACP model (SHARE) versus minimally enhanced usual care in 273 person-family dyads from eight primary care practices.

RESULTS

Mean patient age was 88.0 years, 85 (31.1%) were Black/Latino; 189 (69.2%) had moderate-to-severe cognitive impairment. Most (101/145; 69.6%) intervention dyads engaged in ACP. At follow-up, no treatment effect was observed for care partner-reported quality of communication about end-of-life care at 6 or 12 months, but intervention patients reported better quality of communication about end-of-life care at 12 months. Intervention care partners and patients reported greater readiness to engage in ACP at 6 and 12 months, respectively, and increased completion of key aspects of ACP.

DISCUSSION

SHARE supported key aspects of ACP processes and communication about end-of-life care.

HIGHLIGHTS

Primary care-based models of ACP for persons with dementia are lacking. Involving persons with cognitive impairment in remote ACP is feasible with care partner involvement. Results indicate benefit for aspects of ACP processes and communication about end-of-life care.

Neurokinin receptor antagonists as potential nonhormone treatments for vasomotor symptoms

Managing menopause symptoms is challenging for women unable or unwilling to take hormone therapy. All nonhormone options thus far have shown less overall efficacy compared with hormone therapy and significant adverse events that limit their use. New science has identified the source of vasomotor symptoms, achieving relief of these bothersome symptoms by directly targeting the neurokinin 3 receptor and its related pathways. This Practice Pearl reviews the clinical data available on neurokinin receptor antagonists.

Effects of 8-h time-restricted eating on energy intake, dietary composition and quality in adolescents with obesity

BACKGROUND

The precise mechanisms underlying the health benefits of time-restricted eating (TRE) are unclear, particularly in adolescents.

OBJECTIVES

This secondary analysis examines the impact of 8-h TRE on energy intake, dietary composition and quality in adolescents with obesity, using data from a 12-week randomized, controlled pilot trial.

METHODS

Participants (14-18 years with BMI >95th percentile) were assigned to either 8-h TRE with real-time or blinded continuous glucose monitoring or a control group with a 12+ h eating window. Dietary intake was analysed using the Nutrient Data System Recall 24-h Dietary Recall and the Healthy Eating Index (HEI-2020) for assessing diet quality.

RESULTS

The study included 44 participants (32 TRE, 12 control), predominantly female and Hispanic/Latino. The TRE group showed a significant reduction in mean energy intake (-441 kcal/day), carbohydrates (-65 g/day), added sugar (-19 g/day) and fat (-19 g/day), while the control group had a similar reduction in energy intake (-437 kcal/day) and carbohydrates (-63 g/day), but no significant changes in added sugar or fat. The percent energy intake from protein increased more in the TRE group compared to the control. The TRE group experienced a significant improvement in diet quality, with a 6.3-point increase in HEI-2020 score; however, between-group comparisons were not statistically significant.

CONCLUSION

There were no significant differences between the TRE and control groups in energy intake, dietary composition or quality. Future research with larger sample sizes is needed to further evaluate the potential impact of TRE on dietary behaviours.

Full-spectrum efficacy of cariprazine across manic and depressive symptoms of bipolar I disorder in patients experiencing mood episodes: Post hoc analysis of pooled randomized controlled trial data

INTRODUCTION

Patients with bipolar I disorder may experience mood destabilization or treatment-emergent affective switch (TEAS) from one symptom pole to the other spontaneously or following treatment. Optimal treatment should address symptoms from both poles without precipitating destabilization.

METHODS

These were pooled post hoc analyses of data from randomized, double-blind, placebo-controlled studies of cariprazine 3-12 mg/d for bipolar I mania (NCT00488618, NCT01058096, NCT01058668) and cariprazine 1.5 mg/d or 3 mg/d for bipolar I depression (NCT01396447, NCT02670538, NCT02670551). Changes from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) total score at week 6 and Young Mania Rating Scale (YMRS) total score at week 3 were analyzed in each indication using a mixed-effects model for repeated measures. Percentages of patients with increasing levels of endpoint response and TEAS (bipolar mania = MADRS total score ≥ 19; bipolar depression = YMRS score ≥ 16) were determined.

RESULTS

Cariprazine significantly reduced manic and depressive symptoms in patients with bipolar I disorder mood episodes. In patients with a manic episode and up to mild baseline depressive symptoms, cariprazine also significantly reduced depressive symptoms. In patients with a depressive episode and manic symptoms in remission at baseline, numerical reduction (without statistical significance) in YMRS indicated no worsening of mania. In both indications, cariprazine-treated patients had numerically greater response rates (presenting symptom pole) than placebo-treated patients; lower percentages of cariprazine- than placebo-treated patients had TEAS at visits where data were collected.

LIMITATIONS

Post hoc analysis.

CONCLUSION

Results suggested that cariprazine had full-spectrum efficacy across symptoms from both poles in patients with bipolar I disorder mood episodes; TEAS risk was low. Patient-level response suggested that improvement was clinically relevant.

Catatonia and epilepsy: An underappreciated relationship

Catatonia is currently conceived in the major diagnostic manuals as a syndrome with a range of possible psychiatric and general medical underlying conditions. It features diverse clinical signs, spanning motor, verbal and behavioural domains and including stupor, catalepsy, mutism, echolalia, negativism and withdrawal. The existing literature suggests that seizure activity may underlie catatonia in approximately 2% of cases. There are three possible temporal relationships between catatonia and seizure activity: (1) ictal catatonia, in which catatonia is a presentation of non-convulsive status epilepticus; (2) postictal catatonia, in which catatonia follows a seizure, and (3) interictal catatonia, in which catatonia and seizures occur in the same individual without any clear temporal relationship between them. Electroencephalographic (EEG) abnormalities are common in catatonia, even in those cases with a presumed primary psychiatric origin, and often consist of generalised background slowing. Paradoxically, electroconvulsive therapy is an effective treatment for catatonia. There are several converging pieces of evidence suggesting that there may be underlying seizure activity in more cases of catatonia than has hitherto been recognised, though identification of these seizures may require intracranial EEG recording.

Efficacy and safety of deferoxamine in moderately ill COVID-19 patients: An open label, randomized controlled trial

BACKGROUND

Deferoxamine is a potent iron chelator that could remove iron from the virus, and severe acute respiratory syndrome coronavirus 2 requires iron to replication. Also, deferoxamine has antioxidant and cytokine-modulating effects. Therefore, we evaluated the efficacy and safety of deferoxamine in patients with moderate coronavirus disease 2019 (COVID-19).

METHODS

In this randomized controlled trial, patients with moderate COVID-19 were randomly assigned in a 1:1 ratio to the deferoxamine group (received a solution of 500 mg deferoxamine divided into 4 doses a day through a nebulizer for 7 days) and the control group. The main outcomes were viral clearance, oxygen saturation (SPO2), body temperature, and respiratory rate (RR). Intensive care unit admission, hospital length of stay, and hospital mortality were also assessed.

RESULTS

A total of 62 patients, with 30 in the deferoxamine group and 32 in the control group, were randomly assigned. There was no statistically significant improvement in viral clearance after the intervention ended in the deferoxamine group (36.7%) compared to the control group (34.4%). The results showed there was no significant difference between the analyzed groups in terms of SPO2, body temperature, RR, and the number of patients with a worse prognosis (SPO2 < 96%, temperature ≥ 37.5 °C, or RR ≥ 16/min) at the end of the study. There were no significant differences seen between the groups in terms of intensive care unit admission, hospital length of stay, hospital mortality, and the occurrence of adverse medication events during the follow-up period.

CONCLUSION

Deferoxamine had no significant impact on improving moderately ill patients with COVID-19. However, it was well-tolerated in the patients, and this intervention demonstrated a safe profile of adverse events.

Italian report on RARE epilepsies (i-RARE): A consensus on multidisciplinarity

OBJECTIVE

Rare and complex epilepsies encompass a diverse range of disorders characterized by seizures. We aimed to establish a consensus on key issues related to these conditions through collaboration among experienced neurologists, neuropediatricians, and patient advocacy representatives.

METHODS

Employing a modified Delphi method, a scientific board comprising 20 physicians and 4 patient advocacy representatives synthesized existing literature with their expertise to formulate statements on contentious topics. A final 32-member expert panel, representing diverse regions of Italy, validated these statements through a two-round voting process, with consensus defined as an average score ≥7.

RESULTS

Sixteen statements reached a consensus, emphasizing the necessity for epidemiological studies to ascertain the true prevalence of rare epilepsies. Etiology emerged as a crucial factor influencing therapeutic strategies and outcome prediction, with particular concern regarding prolonged and tonic-clonic seizures. The importance of early implementation of specific drugs and non-pharmacological interventions in the treatment algorithm for developmental and epileptic encephalopathies (DEEs) was underscored. Multidisciplinary care involving experts with diverse skills was deemed essential, emphasizing non-seizure outcomes in adolescence and adulthood.

SIGNIFICANCE

This national consensus underscores the imperative for personalized, comprehensive, and multidisciplinary management of rare epilepsies/DEEs. It advocates for increased research, particularly in epidemiology and therapeutic approaches, to inform clinical decision-making and healthcare policies, ultimately enhancing patients' outcomes.

PLAIN LANGUAGE SUMMARY

The modified Delphi method is broadly used to evaluate debated topics. In this work, we sought the consensus on integrated and social care in epilepsy management. Both representatives of high-level epilepsy centers and patients' caregivers were directly involved.

Movement disorders related to antidiabetic medications: a real-world pharmacovigilance study

BACKGROUND

Diabetic Mellitus (DM) has progressively emerged as a worldwide health problem, leading to the widespread deployment of antidiabetic drugs as the primary therapy in the global population. The incidence of diabetes medications-related movement disorders (drMD) is noteworthy but underestimated by clinical practitioners.

RESEARCH DESIGN AND METHODS

In order to address the incidence of drMD in DM patients and realize the serious outcomes associated with drMD, we conducted a real-world pharmacovigilance study of 612,043 DM patients using the FDA Adverse Event Reporting System (FAERS) database from January 2004 to September 2023. Reporting Odd Ratio (ROR) was calculated to reflect the risk of drMD. A multivariable logistic regression analysis was employed to adjust crude ROR with the mixed factors including age, sex and various antidiabetic treatments. Afterward, a Mendelian Randomization (MR) study was performed to elucidate the underlying genetic correlation between the genetically proxied targets of antidiabetic drugs and motor disorders.

RESULTS

Among 11,729 cases of motor adverse events in DM patients, six categories of drMD were significantly associated with DM medications. Noticeably, metformin was revealed to drastically increase the incidence of parkinsonism (adjusted ROR:3.97; 95 %CI (3.03, 5.19), p = 5.68e-24), bradykinesia (adjusted ROR:1.69; 95 %CI (1.07,2.59), p = 0.02) and irregular hyperkinesia, including chorea, choreoathetosis and athetosis. Insulin/insulin analogues and GLP-1 analogues presented notably higher odds of tremor: the adjusted ROR (aROR) of insulin and GLP-1 analogue is respectively 1.24 (95 %CI (1.15,1.34), p = 2.51e-08) and 1.78 (95 %CI (1.65,1.91), p = 5.64e-54). The combined therapeutic effects of multiple genetic variants of metformin, especially AMP-activated protein kinase (AMPK) were markedly linked to a greater likelihood of developing secondary parkinsonism (OR:10.816, p = 0.049) according to MR analyses.

CONCLUSION

The use of antidiabetic medications was significantly related to an increased incidence of movement disorders in DM patients. Moreover, MR analyses provided further genetic evidence for the pharmacovigilance study. This comprehensive investigation might help physicians recognize neurological adverse events associated with antidiabetic treatments and administer effective interventions.

Catatonia related to tacrolimus: a real world pharmacovigilance study of FDA adverse event reporting system (FAERS) database

BACKGROUND

Emerging case reports have highlighted that catatonia may be a complication that is easily misdiagnosed. Our study aimed to summarize the clinical characteristics of patients with tacrolimus-induced catatonia and assess the association between tacrolimus and catatonia through disproportionality analysis.

RESEARCH DESIGN AND METHODS

We conducted a retrospective pharmacovigilance study using the FAERS database, analyzing data up to the third quarter of 2023. The clinical characteristics of the reported cases were summarized using descriptive statistics. Information component (IC) and reporting odds ratio (ROR) were used to evaluate the association between tacrolimus and catatonia.

RESULTS

There were 66 reports of tacrolimus-related catatonia, with the majority of cases occurring in the United States (78.79%). The risk signal for tacrolimus-related catatonia was significantly higher compared to all other drugs (ROR 3.222 [2.524, 4.111], IC 1.632 [1.273, 1.991]). A significant association was detected in both male and female, while the risk signal of tacrolimus-associated catatonia was only found in the subgroups aged over 40 years.

CONCLUSIONS

Our study identified a safety signal for the association between tacrolimus and catatonia compared to all other drugs in FAERS database, particularly in patients aged 40 and above.

Evaluating the Efficacy of a Digital Therapeutic (CT-152) as an Adjunct to Antidepressant Treatment in Adults With Major Depressive Disorder: Protocol for the MIRAI Remote Study

BACKGROUND

Major depressive disorder (MDD) is common worldwide and can be highly disabling. People with MDD face many barriers to treatment and may not experience full symptom relief even when treated. Therefore, new treatment modalities are needed for MDD. Digital therapeutics (DTx) may provide people with MDD an additional treatment option.

OBJECTIVE

This study aimed to describe a phase 3 remote, multicenter, randomized, masked, sham-controlled trial evaluating the efficacy of a smartphone app-based DTx (CT-152) in adult participants diagnosed with MDD, used as an adjunct to antidepressant therapy (ADT).

METHODS

Participants aged 22-64 years with a current primary diagnosis of MDD and an inadequate response to ADT were included. Participants were randomized 1:1 to CT-152 or a sham DTx. CT-152 is a smartphone app-based DTx that delivers a cognitive-emotional and behavioral therapeutic intervention. The core components of CT-152 are the Emotional Faces Memory Task exercises, brief lessons to learn and apply key therapeutic skills, and SMS text messaging to reinforce lessons and encourage engagement with the app. The sham DTx is a digital working memory exercise with emotionally neutral stimuli designed to match CT-152 for time and attention. Participants took part in the trial for up to 13 weeks. The trial included a screening period of up to 3 weeks, a treatment period of 6 weeks, and an extension period of 4 weeks to assess the durability of the effect. Sites and participants had the option of an in-person or remote screening visit; the remaining trial visits were remote. Efficacy was evaluated using the Montgomery-Åsberg Depression Rating Scale, the Generalized Anxiety Disorder-7, Clinical Global Impression-Severity scale, the Patient Health Questionnaire-9, and the World Health Organization Disability Assessment Schedule 2.0. The durability of the effect was evaluated with the Montgomery-Åsberg Depression Rating Scale and Generalized Anxiety Disorder-7 scale. Adverse events were also assessed. Satisfaction, measured by the Participant and Healthcare Professional Satisfaction Scales, and health status, measured by the EQ-5D-5L, were summarized using descriptive statistics.

RESULTS

This study was initiated in February 2021 and had a primary completion date in October 2022.

CONCLUSIONS

This represents the methodological design for the first evaluation of CT-152 as an adjunct to ADT. This study protocol is methodologically robust and incorporates many aspects of conventional pivotal pharmaceutical phase 3 trial design, such as randomization and safety end points. Novel considerations included the use of a sham comparator, masking considerations for visible app content, and outcome measures relevant to DTx. The rigor of this methodology will provide a more comprehensive understanding of the effectiveness of CT-152.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04770285; https://clinicaltrials.gov/study/NCT04770285.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/56960.

Assessing suicide risk in chronic pain management: a narrative review across drug classes

INTRODUCTION

Chronic pain presents a multifaceted challenge in clinical practice, necessitating a nuanced understanding of pharmacological interventions to optimize treatment outcomes. This review provides an outline of various pharmacological agents commonly used in chronic pain management and highlights their safety considerations, particularly regarding suicide risk.

AREAS COVERED

This review discusses the role of antidepressants, anticonvulsants, GABA receptor agonists, NMDA receptor antagonists, corticosteroids, cannabis and cannabinoids, bisphosphonates, calcitonin, and alpha-2 adrenergic receptor agonists in chronic pain management. It assesses their therapeutic benefits, potential for misuse, and psychiatric adverse effects, including the risk of suicide. Each pharmacological class is evaluated in terms of its efficacy, safety profile, and considerations for clinical practice. We searched peer-reviewed English literature on the topic using the MEDLINE database without time restrictions.

EXPERT OPINION

While pharmacological interventions offer promise in alleviating chronic pain, healthcare providers must carefully weigh their benefits against potential risks, including the risk of exacerbating psychiatric symptoms and increasing suicide risk. Individualized treatment approaches, close monitoring, and multidisciplinary collaboration are essential for optimizing pain management strategies while mitigating adverse effects. Ongoing research efforts are crucial for advancing our understanding of these pharmacological interventions and refining pain management practices.

Assessment of Navy Provider Knowledge of Women's Mental Health Services, Treatment Practices, and Training

INTRODUCTION

As female active duty populations increase in all military environments, it is critical that women's health be addressed in a comprehensive manner. The study's results will be utilized to assist Navy health care leaders in addressing female force readiness policies, treatment gaps, and training specific to women's mental health.

MATERIALS AND METHODS

In total, 212 active duty participants were recruited from the Navy's mental health specialties. The survey was hosted on the U.S. Government's MAX.gov survey website and received Institutional Review Board and Survey Review Board approval per Navy and Defense Health Agency requirements. Participants recorded their experiences with various patient presentations using Likert scale assessments, indicated their comfort in prescribing medication to patients with 11 distinct presenting concerns, and responded to six questions regarding their training and clinical experience in the field of women's mental health.

RESULTS

Differences were noted for provider gender, treatment setting, patient sex, provider rank, and years of independent practice. Female providers were more likely than males to report that their female patients presented with 15 of the 21 measured issues. Providers located at MTFs were significantly more likely than providers in operational billets to report female patients presenting with certain conditions and reported being more comfortable prescribing medication. Eighty percent of respondents authorized to prescribe medicine rated themselves as very or extremely comfortable prescribing medications to their patients for all specified conditions except two: women who are breastfeeding and women who are pregnant. Senior officers reported the most comfort prescribing medication to women who are planning to become pregnant and women who have experienced perinatal loss. Only a minority of providers (20%, female; 33%, males) reported receiving women's mental health education during their training. Of those who did receive training, it was limited to post-partum and pregnancy. Most participants (93%) agreed that women's mental health should be incorporated into training programs for military providers.

CONCLUSIONS

This exploratory study highlights that provider variables impact assessment and treatment of and for patients. The study highlights the interplay of gender, treatment setting, experiences, and level of comfort are associated with provider assessment of presenting concerns. The authors hope this study will help in prioritizing women's mental health practices, mental health training, and research, and in informing policy and decision-making.

Metabolic Monitoring for Adults Living with a Serious Mental Illness on a Second-Generation Antipsychotic Agent: A Scoping Review

Premature mortality in people living with a severe mental illness (SMI) is often attributed to multiple factors including the use of medicines such as antipsychotics. Second-generation antipsychotics (SGAs) are known to cause metabolic syndrome which can increase the risk of cardiovascular disease. Practice guidelines have recommended regular physical health monitoring, particularly of metabolic parameters, however, metabolic monitoring for people living with SMI using antipsychotics remains suboptimal. Therefore, highlighting the need for ongoing research. This scoping review aimed to provide an overview of current metabolic monitoring practices. We anticipate that this information will assist clinicians and policymakers and inform future research. The following databases were searched: MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Database of Systemic Reviews (Wiley), APA PsycInfo (Ovid) and Scopus (Elsevier Science Publishers). The target group was adults (aged ≥ 18) diagnosed with SMI (including bipolar disorder, major depressive disorder and psychotic disorders) and taking SGAs. In total, 44 studies from 14 countries were retrieved. Our findings highlighted that most studies conducted in hospitals did not report on metabolic monitoring practices. Additionally, the roles and responsibilities of healthcare professionals in metabolic monitoring for SMI were infrequently described and parameters such as waist circumference and BMI were often poorly monitored. The scoping review highlights that no streamlined approach towards metabolic monitoring currently exists. There is a need to stipulate and define the roles and responsibilities of all health professionals involved in metabolic monitoring in SMI to optimise care for these individuals. Moreover, there is a need for ongoing research, particularly in the community setting, to promote increased accessibility to metabolic monitoring for SMI.

State-of-the-Art Review: Evaluation and Management of Delusional Infestation

Delusional infestation is a condition encountered frequently by healthcare professionals across a variety of specialties in which patients have a fixed, false belief that they are infested with living creatures, such as bugs, parasites, worms, or mites, or nonliving objects, such as fibers. Delusional infestation can be debilitating for patients, who not only present with intense psychological distress and physical discomfort but are also at risk of developing numerous dermatological and psychiatric complications. This condition poses unique diagnostic challenges, as these symptoms can occur secondary to many metabolic or infectious causes, as well as unique treatment challenges, with patients frequently refusing psychiatric care and consequently seeking evaluation by other healthcare professionals. In this review, we aim to use existing literature to provide clinicians in infectious diseases or other specialties with sufficient clinical context and treatment guidance for the appropriate management of delusional infestation.

Glutamatergic Modulators for Major Depression from Theory to Clinical Use

Major depressive disorder (MDD) is a chronic, burdensome, highly prevalent disease that is characterized by depressed mood and anhedonia. MDD is especially burdensome as approved monoamine antidepressant treatments have weeks-long delays before clinical benefit and low remission rates. In the past 2 decades, a promising target emerged to improve patient outcomes in depression treatment: glutamatergic signaling. This narrative review provides a high-level overview of glutamate signaling in synaptogenesis and neural plasticity and the implications of glutamate dysregulation in depression. Based on this preclinical evidence implicating glutamate in depression and the rapid improvement of depression with ketamine treatment in a proof-of-concept trial, a range of N-methyl-D-aspartate (NMDA)-targeted therapies have been investigated. While an array of treatments has been investigated in registered phase 2 or 3 clinical trials, the development of most of these agents has been discontinued. Multiple glutamate-targeted antidepressants are actively in development, and two are approved. Nasal administration of esketamine (Spravato®) was approved by the US Food and Drug Administration (FDA) in 2019 to treat adults with treatment-resistant depression and in 2020 for adults with MDD with acute suicidal ideation or behavior. Oral combination dextromethorphan-bupropion (AXS-05, Auvelity® extended-release tablet) was FDA approved in 2022 for the treatment of MDD in adults. These approvals bolster the importance of glutamate in depression and represent an exciting breakthrough in contemporary psychiatry, providing new avenues of treatment for patients as first-line therapy or with either poor response or unacceptable side effects to monoaminergic antidepressants.

Current understanding of cardiovascular autonomic dysfunction in multiple sclerosis

Autoimmune diseases, including multiple sclerosis (MS), are proven to increase the likelihood of developing cardiovascular disease (CVD) due to a robust systemic immune response and inflammation. MS can lead to cardiovascular abnormalities that are related to autonomic nervous system dysfunction by causing inflammatory lesions surrounding tracts of the autonomic nervous system in the brain and spinal cord. CVD in MS patients can affect an already damaged brain, thus worsening the disease course by causing brain atrophy and white matter disease. Currently, the true prevalence of cardiovascular dysfunction and associated death rates in patients with MS are mostly unknown and inconsistent. Treating vascular risk factors is recommended to improve the management of this disease. This review provides an updated summary of CVD prevalence in patients with MS, emphasizing the need for more preclinical studies using animal models to understand the pathogenesis of MS better. However, no distinct studies exist that explore the temporal effects and etiopathogenesis of immune/inflammatory cells on cardiac damage and dysfunction associated with MS, particularly in the cardiac myocardium. To this end, a thorough investigation into the clinical presentation and underlying mechanisms of CVD must be conducted in patients with MS and preclinical animal models. Additionally, clinicians should monitor for cardiovascular complications while prescribing medications to MS patients, as some MS drugs cause severe CVD.

Experiences of intensive treatment for people with eating disorders: a systematic review and thematic synthesis

BACKGROUND

Eating disorders are complex difficulties that impact the individual, their supporters and society. Increasing numbers are being admitted to intensive treatment settings (e.g., for inpatient treatment, day-patient treatment or acute medical treatment). The lived experience perspectives of what helps and hinders eating disorder recovery during intensive treatment is an emerging area of interest. This review aims to explore patients' perspectives of what helps and hinders recovery in these contexts.

METHODS

A systematic review was conducted to identify studies using qualitative methods to explore patients' experiences of intensive treatment for an eating disorder. Article quality was assessed using the Critical Appraisal Skill Programme (CASP) checklist and thematic synthesis was used to analyse the primary research and develop overarching analytical themes.

RESULTS

Thirty articles met inclusion criteria and were included in this review. The methodological quality was mostly good. Thematic synthesis generated six main themes; collaborative care supports recovery; a safe and terrifying environment; negotiating identity; supporting mind and body; the need for specialist support; and the value of close others. The included articles focused predominantly on specialist inpatient care and were from eight different countries. One clear limitation was that ethnicity data were not reported in 22 out of the 30 studies. When ethnicity data were reported, participants predominantly identified as white.

CONCLUSIONS

This review identifies that a person-centred, biopsychosocial approach is necessary throughout all stages of eating disorder treatment, with support from a sufficiently resourced and adequately trained multidisciplinary team. Improving physical health remains fundamental to eating disorder recovery, though psychological support is also essential to understand what causes and maintains the eating disorder and to facilitate a shift away from an eating disorder dominated identity. Carers and peers who instil hope and offer empathy and validation are valuable additional sources of support. Future research should explore what works best for whom and why, evaluating patient and carer focused psychological interventions and dietetic support during intensive treatment. Future research should also explore the long-term effects of, at times, coercive and distressing treatment practices and determine how to mitigate against potential iatrogenic harm.

From bacteria to fish: ecotoxicological insights into sulfamethoxazole and trimethoprim

Sulfamethoxazole (SMX) and trimethoprim (TRIM) are two of the most used antibiotics in the last 50 years, to prevent and treat bacterial infections; however, the available literature about toxicity to non-target organisms is quite discrepant and incomplete. This study aims to assess the SMX and TRIM ecotoxicological effects in standard species: Aliivibrio fischeri (bioluminescence inhibition), Escherichia coli ATCC 25922 (growth inhibition), Lemna minor (growth inhibition and biochemical biomarkers), Daphnia magna (immobilization/mortality, life history traits, and biochemical biomarkers), and Danio rerio (survival, hatching, abnormalities, and biochemical biomarkers). The species tested showed different acute sensitivities to SMX (A. fischeri < D. magna < E. coli < L. minor) and TRIM (L. minor < A. fischeri < D. magna < E. coli). Overall, TRIM reveals less toxicity than SMX, except for E. coli (Ecotoxicological approach based on Antimicrobial Susceptibility Testing - EcoAST procedure). Both antibiotics affect individually (e.g., growth and survival) and sub-individually (e.g., antioxidant defenses) L. minor, D. magna, and D. rerio. This study allowed us to generate relevant data and fill gaps in the literature regarding the effects of SMX and TRIM in aquatic organisms. The here-obtained results can be used to (i) complete and re-evaluate the Safety Data Sheet to improve the assessment of environmental safety and management of national and international entities; (ii) clarify the environmental risks of these antibiotics in aquatic ecosystems reinforcing the inclusion in the 4th Watch List of priority substances to be monitored in whole inland waters by the Water Framework Directive; and (iii) combat the development of antimicrobial resistance, as well as supporting the definition of environmental measurements in the context of European One Health Action Plan. However, it is essential to continue studying these antibiotics to better understand their toxicity at ecologically relevant concentrations and their long-term effects under different climatic change scenarios.

Integrated behavioral health implementation and chronic disease management inequities: an exploratory study of statewide data

BACKGROUND

People with diabetes, vascular disease, and asthma often struggle to maintain stability in their chronic health conditions, particularly those in rural areas, living in poverty, or racially or ethnically minoritized populations. These groups can experience inequities in healthcare, where one group of people has fewer or lower-quality resources than others. Integrating behavioral healthcare services into primary care holds promise in helping the primary care team better manage patients' conditions, but it involves changing the way care is delivered in a clinic in multiple ways. Some clinics are more successful than others in fully integrating behavioral health models as shown by previous research conducted by our team identifying four patterns of implementation: Low, Structural, Partial, and Strong. Little is known about how this variation in integration may be related to chronic disease management and if IBH could be a strategy to reduce healthcare inequities. This study explores potential relationships between IBH implementation variation and chronic disease management in the context of healthcare inequities.

METHODS

Building on a previously published latent class analysis of 102 primary care clinics in Minnesota, we used multiple regression to establish relationships between IBH latent class and healthcare inequities in chronic disease management, and then structural equation modeling to examine how IBH latent class may moderate those healthcare inequities.

RESULTS

Contrary to our hypotheses, and demonstrating the complexity of the research question, clinics with better chronic disease management were more likely to be Low IBH rather than any other level of integration. Strong and Structural IBH clinics demonstrated better chronic disease management as race in the clinic's location became more White.

CONCLUSIONS

IBH may result in improved care, though it may not be sufficient to resolve healthcare inequities; it appears that IBH may be more effective when fewer social determinants of health are present. Clinics with Low IBH may not be motivated to engage in this practice change for chronic disease management and may need to be provided other reasons to do so. Larger systemic and policy changes are likely required that specifically target the mechanisms of healthcare inequities.

Effects of regulating gut microbiota by electroacupuncture in the chronic unpredictable mild stress rat model

OBJECTIVE

This study aims to investigate the effect of electroacupuncture (EA) treatment on depression, and the potential molecular mechanism of EA in depression-like behaviors rats.

METHODS

A total of 40 male Sprague Dawley rats were divided into three groups: normal control, chronic unpredictable mild stress (CUMS), and EA (CUMS + EA). The rats in CUMS and EA groups underwent chronic stress for 10 weeks, and EA group rats received EA treatment for 4 weeks starting from week 7. Body weight and behavioral tests, including the sucrose preference test (SPT), the forced swimming test (FST), and the open field test (OFT) were monitored. Gut microbiota composition was assessed via 16S rDNA sequencing, and lipid metabolism was analyzed by using UPLC-Q-TOF/MS technology.

RESULTS

In comparison to CUMS group, EA could improve the behavior including bodyweight, immovability time, sucrose preference index, crossing piece index and rearing times index. After 4 weeks of EA treatment, 5-HT in hippocampus, serum and colon of depressive rats were simultaneously increased, indicating a potential alleviation of depression-like behaviors. In future studies revealed that EA could regulate the distribution and functions of gut microbiota, and improve the intestinal barrier function of CUMS rats. The regulation of intestinal microbial homeostasis by EA may further affect lipid metabolism in CUMS rats, and thus play an antidepressant role.

CONCLUSION

This study suggested that EA has potential antidepressant effects by regulating gut microbiota composition and abundance, subsequently affecting lipid metabolism.