Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials

Predicting intentions towards long-term antidepressant use in the management of people with depression in primary care: A longitudinal survey study

BACKGROUND

Over the last two decades, antidepressant prescribing in the UK has increased considerably, due to an increased number of people staying on antidepressants for longer. Even when treatment is no longer clinically indicated, qualitative research suggests many people continue due to a fear of depressive relapse or antidepressant withdrawal symptoms. The quantitative effects of peoples' beliefs and attitudes towards long-term antidepressant use remain relatively unexplored.

OBJECTIVES

To determine the extent to which beliefs and attitudes towards antidepressant treatment are associated with intentions to stop or continue long-term use; and whether intentions translate into actual discontinuation.

METHODS

A questionnaire survey formed the main component of an embedded mixed-methods study. Twenty general practices posted questionnaires to adults aged over 18 receiving continuous antidepressant prescriptions for over two years. Outcomes and explanatory variables were determined using an extended model of the Theory of Planned Behaviour, conducting exploratory descriptive and regression analyses. The primary outcome was participants' intentions to discontinue antidepressants. The secondary outcome of behaviour change was determined by any change in antidepressant dosage at six months.

RESULTS

277 people were surveyed from 20 practices, with 10 years median antidepressant duration. Mean questionnaire scores for intention and subjective norms towards starting to come off antidepressants were low, and 85% of participants declared that continuing their antidepressant was necessary. Prescribing outcomes retrieved from 175 participants' medical records six months after they completed the survey found 86% had not changed their antidepressant, 9% reduced the dose, only 1% discontinued their antidepressant, and 4% increased the dose. All Theory of Planned Behaviour constructs and concerns were associated with intentions, with more favourable attitudes towards stopping and subjective norms having the strongest associations towards intentions to discontinue antidepressant use.

CONCLUSION

Given few intentions to stop taking antidepressants, patients should be made more aware of the importance of ongoing antidepressant monitoring and review from their primary care practitioners. This would promote discussion to support an attitudinal change and initiation of antidepressant tapering where appropriate.

Esketamine Treatment for Depression in Adults: A PRISMA Systematic Review and Meta-Analysis

OBJECTIVE

Intranasal esketamine has been approved as an adjunctive therapy for treatment-resistant major depressive disorder with acute suicidal ideation and behavior. The authors conducted a systematic review and meta-analysis of the available data on its efficacy against depression and suicidality as well as its side effects.

METHODS

MEDLINE was searched with the keyword "esketamine" on March 24, 2024, using the PRISMA method. Data processing and statistical analysis were performed with R, version 4.3.3, and the meta-analysis was performed with the METAFOR package.

RESULTS

Of 1,115 articles initially identified, 87 were included for analysis and discussion. At weeks 2-4, randomized controlled trials were mostly negative or failed; however, the meta-analysis returned a weak but significant positive effect for depression (effect size range, 0.15-0.23 at weeks 2-4), similar to augmentation strategies with atypical antipsychotics for treatment-resistant depression. The effect size concerning suicidality was not significant at any time point. The sensitivity analysis produced the same results.

CONCLUSIONS

The study findings suggest that esketamine's efficacy as an add-on to antidepressants is modest in treatment-resistant depression (similar to augmentation strategies with atypical antipsychotics) and is absent against suicidality itself. These findings need to be considered in light of esketamine's abuse potential and the fact that long-term effects are still not fully known. Some alarming signs concerning deaths and emerging suicidality during the testing phase are discussed, along with other regulatory issues.

A shared threat-anticipation circuit is dynamically engaged at different moments by certain and uncertain threat

Temporal dynamics play a central role in models of emotion: "fear" is widely conceptualized as a phasic response to certain-and-imminent danger, whereas "anxiety" is a sustained response to uncertain-or-distal harm. Yet the underlying neurobiology remains contentious. Leveraging a translationally relevant fMRI paradigm and theory-driven modeling approach in 220 adult humans, we demonstrate that certain- and uncertain-threat anticipation recruit a shared circuit that encompasses the central extended amygdala (EAc), periaqueductal gray, midcingulate, and anterior insula. This circuit exhibits persistently elevated activation when threat is uncertain and distal, and transient bursts of activation just before certain encounters with threat. Although there is agreement that the EAc plays a critical role in orchestrating responses to threat, confusion persists about the respective contributions of its major subdivisions, the bed nucleus of the stria terminalis (BST) and central nucleus of the amygdala (Ce). Here we used anatomical regions-of-interest to demonstrate that the BST and Ce exhibit statistically indistinguishable threat dynamics. Both regions exhibited activation dynamics that run counter to popular models, with the Ce showing sustained responses to uncertain-and-distal threat and the BST showing phasic responses to certain-and-imminent threat. For many scientists, feelings are the hallmark of fear and anxiety. Here we used an independently validated multivoxel brain 'signature' to covertly probe the moment-by-moment dynamics of anticipatory distress for the first time. Results mirrored the dynamics of neural activation. These observations provide fresh insights into the neurobiology of threat-elicited emotions and set the stage for more ambitious clinical and mechanistic research.

Adolescent social anxiety is associated with diminished discrimination of anticipated threat and safety in the bed nucleus of the stria terminalis

Social anxiety-which typically emerges in adolescence-lies on a continuum and, when extreme, can be devastating. Socially anxious individuals are prone to heightened fear, anxiety, and the avoidance of contexts associated with potential social scrutiny. Yet most neuroimaging research has focused on acute social threat. Much less attention has been devoted to understanding the neural systems recruited during the uncertain anticipation of potential encounters with social threat. Here we used a novel functional magnetic resonance imaging paradigm to probe the neural circuitry engaged during the anticipation and acute presentation of threatening faces and voices in a racially diverse sample of 66 adolescents selectively recruited to encompass a range of social anxiety and enriched for clinically significant levels of distress and impairment. Results demonstrated that adolescents with more severe social anxiety symptoms experience heightened distress when anticipating encounters with social threat, and reduced discrimination of uncertain social threat and safety in the bed nucleus of the stria terminalis, a key division of the central extended amygdala (EAc). Although the EAc-including the bed nucleus of the stria terminalis and central nucleus of the amygdala-was robustly engaged by the acute presentation of threatening faces and voices, the degree of EAc engagement was unrelated to the severity of social anxiety. Together, these observations provide a neurobiologically grounded framework for conceptualizing adolescent social anxiety and set the stage for the kinds of prospective-longitudinal and mechanistic research that will be necessary to determine causation and, ultimately, to develop improved interventions for this often-debilitating illness. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

An Honest Reckoning With the Amygdala and Mental Illness

Anxiety disorders are a leading source of human misery, morbidity, and premature mortality. Existing treatments are far from curative for many, underscoring the need to clarify the underlying neural mechanisms. Although many brain regions contribute, the amygdala has received the most intense scientific attention. Over the past several decades, this scrutiny has yielded a detailed understanding of amygdala function, but it has failed to produce new clinical assays, biomarkers, or cures. Rising to this urgent public health challenge demands an honest reckoning with the functional-neuroanatomical complexity of the amygdala and a shift from theories anchored on "the amygdala" to models centered on specific amygdala nuclei and cell types. This review begins by examining evidence from studies of rodents, monkeys, and humans for the "canonical model," the idea that the amygdala plays a central role in fear- and anxiety-related states, traits, and disorders. Next, the authors selectively highlight work indicating that the canonical model, while true, is overly simplistic and fails to adequately capture the actual state of the evidentiary record, the breadth of amygdala-associated functions and illnesses, or the complexity of the amygdala's functional architecture. The authors describe the implications of these facts for basic and clinical neuroimaging research. The review concludes with some general recommendations for grappling with the complexity of the amygdala and accelerating efforts to understand and more effectively treat amygdala-related psychopathology.

Intensive treatments for children and adolescents with anxiety or obsessive-compulsive disorders: A systematic review and meta-analysis

Anxiety and obsessive-compulsive disorders have a significant negative impact on youth. Cognitive behavioural therapy (CBT) is recommended and established as effective first-step treatment, but persistent symptoms and non-response are common. Intensive psychological treatments deliver more or longer sessions over a shorter time span, with fewer session gaps. However, an understanding of their effectiveness, characteristics, acceptability, and feasibility is lacking. Systematically searching five databases yielded four controlled and 36 uncontrolled studies (N=2707) involving youth with primary anxiety or obsessive-compulsive disorders, many of whom received prior treatments. Intensive treatments were acceptable and feasible, with low drop-out rates. Between-group analyses compared intensive treatment with standard treatment (k = 2) or waitlist (k = 2), revealing no significant post-treatment differences in symptom severity or remission. Uncontrolled within-group analyses of intensive treatments showed large improvements from pre- to post-treatment in symptoms (k = 47), remission (k = 17), impairment (k = 22), functioning (k = 5), and quality of life (k = 2), with larger effects at follow-ups. Intensive treatments show promise for youth with anxiety or obsessive-compulsive disorders by potentially offering high treatment completion rates and comparable outcomes to standard CBT, aiding earlier recovery and reducing overall suffering. This systematic review/meta-analysis provides a comprehensive overview of intensive treatments, their theoretical considerations, and empirical findings. Future RCTs should compare the effectiveness of standard and intensive treatments and identify optimal populations for their use.

Added Value of Medical Subject Headings Terms in Search Strategies of Systematic Reviews: Comparative Study

BACKGROUND

The massive increase in the number of published scientific articles enhances knowledge but makes it more complicated to summarize results. The Medical Subject Headings (MeSH) thesaurus was created in the mid-20th century with the aim of systematizing article indexing and facilitating their retrieval. Despite the advent of search engines, few studies have questioned the relevance of the MeSH thesaurus, and none have done so systematically.

OBJECTIVE

The objective of this study was to estimate the added value of using MeSH terms in PubMed queries for systematic reviews (SRs).

METHODS

SRs published in 4 high-impact medical journals in general medicine over the past 10 years were selected. Only SRs for which a PubMed query was provided were included. Each query was transformed to obtain 3 versions: the original query (V1), the query with free-text terms only (V2), and the query with MeSH terms only (V3). These 3 queries were compared with each other based on their sensitivity and positive predictive values.

RESULTS

In total, 59 SRs were included. The suppression of MeSH terms had an impact on the number of relevant articles retrieved for 24 (41%) out of 59 SRs. The median (IQR) sensitivities of queries V1 and V2 were 77.8% (62.1%-95.2%) and 71.4% (42.6%-90%), respectively. V1 queries provided an average of 2.62 additional relevant papers per SR compared with V2 queries. However, an additional 820.29 papers had to be screened. The cost of screening an additional collected paper was therefore 313.09, which was slightly more than triple the mean reading cost associated with V2 queries (88.67).

CONCLUSIONS

Our results revealed that removing MeSH terms from a query decreases sensitivity while slightly increasing the positive predictive value. Queries containing both MeSH and free-text terms yielded more relevant articles but required screening many additional papers. Despite this additional workload, MeSH terms remain indispensable for SRs.

Advances in Repetitive Transcranial Magnetic Stimulation for the Treatment of Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that develops and persists after an individual experiences a major traumatic or life-threatening event. While pharmacological treatment and psychological interventions can alleviate some symptoms, pharmacotherapy is time-consuming with low patient compliance, and psychological interventions are costly. Repetitive Transcranial Magnetic Stimulation (rTMS) is a safe and effective technique for treating PTSD, with advantages such as high compliance, low cost, and simplicity of implementation. It can even simultaneously improve depressive symptoms in some patients. Current research indicates that high-frequency rTMS shows better therapeutic effects compared to low-frequency rTMS, with no significant difference in the likelihood of adverse reactions between the two. Theta Burst Stimulation (TBS) exhibits similar efficacy to high-frequency rTMS, with shorter duration and significant improvement in depressive symptoms. However, it carries a slightly higher risk of adverse reactions compared to traditional high-frequency rTMS. Combining rTMS with psychological therapy appears to be more effective in improving PTSD symptoms, with early onset of effects and longer duration, albeit at higher cost and requiring individualized patient control. The most common adverse effect of treatment is headache, which can be improved by stopping treatment or using analgesics. Despite these encouraging data, several aspects remain unknown. Given the highly heterogeneous nature of PTSD, defining unique treatment methods for this patient population is quite challenging. There are also considerable differences between trials regarding stimulation parameters, therapeutic effects, and the role of combined psychological therapy, which future research needs to address.

Cannabidiol in anxiety disorders: Current and future perspectives

Anxiety disorders are highly prevalent psychiatric disorders, characterized by a chronic course and often accompanied by comorbid symptoms that impair functionality and decrease quality of life. Despite advances in basic and clinical research in our understanding of these disorders, currently available pharmacological options are associated with limited clinical benefits and side effects that frequently lead to treatment discontinuation. Importantly, a significant number of patients do not achieve remission and live with lifelong residual symptoms that limit daily functioning. Since the 1970s, basic and clinical research on cannabidiol (CBD), a non-psychotomimetic compound found in the Cannabis sativa plant, has indicated relevant anxiolytic effects, garnering attention for its therapeutic potential as an option in anxiety disorder treatment. This chapter aims to review the history of these studies on the anxiolytic effects of CBD within the current understanding of anxiety disorders. It highlights the most compelling current evidence supporting its anxiolytic effects and explores future perspectives for its clinical use in anxiety disorders.

Adolescent social anxiety is associated with diminished discrimination of anticipated threat and safety in the bed nucleus of the stria terminalis

Social anxiety-which typically emerges in adolescence-lies on a continuum and, when extreme, can be devastating. Socially anxious individuals are prone to heightened fear, anxiety, and the avoidance of contexts associated with potential social scrutiny. Yet most neuroimaging research has focused on acute social threat. Much less attention has been devoted to understanding the neural systems recruited during the uncertain anticipation of potential encounters with social threat. Here we used a novel fMRI paradigm to probe the neural circuitry engaged during the anticipation and acute presentation of threatening faces and voices in a racially diverse sample of 66 adolescents selectively recruited to encompass a range of social anxiety and enriched for clinically significant levels of distress and impairment. Results demonstrated that adolescents with more severe social anxiety symptoms experience heightened distress when anticipating encounters with social threat, and reduced discrimination of uncertain social threat and safety in the bed nucleus of the stria terminalis (BST), a key division of the central extended amygdala (EAc). Although the EAc-including the BST and central nucleus of the amygdala-was robustly engaged by the acute presentation of threatening faces and voices, the degree of EAc engagement was unrelated to the severity of social anxiety. Together, these observations provide a neurobiologically grounded framework for conceptualizing adolescent social anxiety and set the stage for the kinds of prospective-longitudinal and mechanistic research that will be necessary to determine causation and, ultimately, to develop improved interventions for this often-debilitating illness.

Treatment of Anxiety Disorders in Primary Care: What Nurse Practitioners Need to Know

Anxiety disorders are the most common mental illnesses and frequently co-occur with other mental and somatic symptoms or disorders. Primary care nurse practitioners (NPs) are key in reducing the treatment gap through early identification, treatment, and/or referral to behavioral health providers. Confronting primary care NPs are problems with time constraints, multiple comorbidities, and limited mental health training, particularly in relation to the differences in pharmacokinetic and pharmacodynamic actions of first-line anxiety disorder medications across age groups. The current article provides a brief summary of evidence-based treatment focusing on pharmacotherapy for anxiety disorders in the primary care setting. [Journal of Psychosocial Nursing and Mental Health Services, 62(5), 7-10.].

Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors

BACKGROUND

Many people will experience a potentially traumatic event in their lifetime and a minority will go on to develop post-traumatic stress disorder (PTSD). A wealth of literature explores different trajectories of PTSD, focusing mostly on resilient, chronic, recovered and delayed-onset trajectories. Less is known about other potential trajectories such as recurring episodes of PTSD after initial recovery, and to date there has been no estimate of what percentage of those who initially recover from PTSD later go on to experience a recurrence. This systematic review aimed to synthesise existing literature to identify (i) how 'recurrence' of PTSD is defined in the literature; (ii) the prevalence of recurrent episodes of PTSD; and (iii) factors associated with recurrence.

METHODS

A literature search of five electronic databases identified primary, quantitative studies relevant to the research aims. Reference lists of studies meeting pre-defined inclusion criteria were also hand-searched. Relevant data were extracted systematically from the included studies and results are reported narratively.

RESULTS

Searches identified 5,398 studies, and 35 were deemed relevant to the aims of the review. Results showed there is little consensus in the terminology or definitions used to refer to recurrence of PTSD. Because recurrence was defined and measured in different ways across the literature, and prevalence rates were reported in numerous different ways, it was not possible to perform meta-analysis to estimate the prevalence of recurrence. We also found no consistent evidence regarding predictors of PTSD recurrence.

CONCLUSION

A clear and consistent evidence-based definition of recurrence is urgently needed before the prevalence and predictors of recurrence can be truly understood.

Antidepressant prescribing patterns and adverse events following introduction of a National Prescribing Indicator to monitor dosulepin usage in Wales

AIMS

Limiting use of the antidepressant dosulepin has been encouraged due to associated risks of toxicity. In April 2011, the All Wales Medicines Strategy Group introduced a National Prescribing Indicator (NPI) to monitor dosulepin usage. The aim of this study was to investigate antidepressant prescribing patterns, and selected adverse events in patients prescribed dosulepin following introduction of the NPI.

METHODS

An e-cohort study was conducted. Adult patients receiving regular dosulepin prescriptions between October 2010 and March 2011 were included. Characteristics of patients who were continued on dosulepin, were switched to an alternative antidepressant or whose dosulepin was discontinued following introduction of the NPI were compared.

RESULTS

In total, 4121 patients were included. Of these, 1947 (47%) continued dosulepin, 1487 (36%) were switched and 692 (17%) discontinued. Of the 692 who discontinued, 92% did not receive a prescription for another antidepressant during the follow-up period. Patients whose dosulepin was discontinued were older and were less commonly coprescribed benzodiazepines. During follow-up, recorded incidence of selected adverse events was low across all groups and no significant difference was observed.

CONCLUSION

Over half of patients had discontinued dosulepin at the end of the period when the NPI was in place. Further interventions may have been required to have a greater impact on prescribing. This study provides some reassurance that dosulepin discontinuation can be a successful strategy, and that the risk of the adverse events investigated was unlikely to have been greater in those who had dosulepin discontinued than in those in whom dosulepin had been continued.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care

BACKGROUND, AIMS AND OBJECTIVES

This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care.

METHODS

Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations.

RESULTS

Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions.

CONCLUSIONS

Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.

Associations between Pharmacological Treatment Patterns during the Initial Treatment Period and the Relapse or Recurrence of Anxiety Disorders: A Nationwide Retrospective Cohort Study

Although the importance of proper pharmacological treatment for preventing the relapse/recurrence of anxiety disorders is well known, a real-world data-based study has not been conducted. We aimed to investigate the effect of the initial pharmacological patterns related to continuous treatment and the choice of medication on the relapse/recurrence of anxiety disorders. We used claim data from the Health Insurance Review and Assessment Service, South Korea, of 34,378 adults who received psychiatric medications, including antidepressants, after being newly diagnosed with anxiety disorders. We compared the relapse/recurrence rate in the patients receiving continuous pharmacological treatment with those who discontinued treatment early using Cox's proportional-hazards model. Patients receiving continuous pharmacological treatment experienced a higher risk of relapse/recurrence than those who discontinued treatment. Using three or more antidepressants during the initial treatment period decreased the risk of relapse/recurrence (adjusted hazard ratio (aHR) = 0.229 (0.204-0.256)); however, the combined use of antidepressants from the beginning of treatment increased the risk (aHR = 1.215 (1.131-1.305)). Factors other than continuous pharmacological treatment should be considered to effectively prevent the relapse/recurrence of anxiety disorders. The active use of antidepressants, including switching or adding medications based on progress and frequent follow-up visits during the acute phase, were significantly associated with a reduction in the relapse/recurrence of anxiety disorders.

Pharmacological Treatment of Generalised Anxiety Disorder: Current Practice and Future Directions

INTRODUCTION

Generalized Anxiety Disorder (GAD) is a common psychiatric condition, characterized by the presence of general apprehensiveness and excessive worry. Current management consists of a range of pharmacological and psychological treatments. However, many patients do not respond to first-line pharmacological treatments and novel anxiolytic drugs are being developed.

AREAS COVERED

In this review, the authors first discuss the diagnostic criteria and epidemiology of GAD. The effective pharmacological treatments for GAD and their tolerability are addressed. Current consensus guidelines for treatment of GAD are discussed, and maintenance treatment, the management of treatment resistance, and specific management of older adults and children/adolescents are considered. Finally, novel anxiolytics under development are discussed, with a focus on those which have entered clinical trials.

EXPERT OPINION

A range of effective treatments for GAD are available, particularly duloxetine, escitalopram, pregabalin, quetiapine, and venlafaxine. There is a limited evidence base to support the further pharmacological management of patients with GAD who have not responded to initial treatment. Although many novel anxiolytics have progressed to clinical trials, translation from animal models has been mostly unsuccessful. However, the potential of several compounds including certain psychedelics, ketamine, oxytocin, and agents modulating the orexin, endocannabinoid, and immune systems merits further study.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.

Relational victimization prospectively predicts increases in error-related brain activity and social anxiety in children and adolescents across two years

Recent research has focused on identifying neural markers associated with risk for anxiety, including the error-related negativity (ERN). An elevated ERN amplitude has been observed in anxious individuals from middle childhood onward and has been shown to predict risk for future increases in anxiety development. The ERN is sensitive to environmental influences during development, including interpersonal stressors. Of note, one particular type of interpersonal stressor, relational victimization, has been related to increases in anxiety in adolescents. We tested whether relational victimization predicts increases in the ERN and social anxiety symptoms across two years in a sample of 152 child and adolescent females (ages 8 - 15). Results indicated that children and adolescents' baseline ERN was positively related to the ERN two years later. Furthermore, greater relational victimization at baseline predicted greater increases in the ERN two years later, controlling for baseline ERN. Moreover, relational victimization at baseline predicted increases in social anxiety, and this relationship was mediated by increases in the ERN. These results suggest that relational victimization impacts the developmental trajectory of the neural response to errors and thereby impacts increases in social anxiety among children and adolescents.

Predictors of successful discontinuation of antipsychotics and antidepressants

BACKGROUND

To offer support for patients who decide to discontinue antipsychotic and antidepressant medication, identifying which potentially modifiable factors correlate with discontinuation success is crucial. Here, we analyzed the predictive value of the professional support received, circumstances prior to discontinuation, a strategy of discontinuation, and use of functional and non-functional coping strategies during discontinuation on self-reported discontinuation success and on objective discontinuation.

METHODS

Patients who had attempted discontinuing antipsychotics (AP) and/or antidepressants (AD) during the past 5 years (n = 316) completed an online survey including questions on subjective and objective discontinuation success, sociodemographic, clinical and medication-related factors, and scales to assess the putative predictors.

RESULTS

A regression model with all significant predictors explained 20-30% of the variance in discontinuation success for AD and 30-40% for AP. After controlling for baseline sociodemographic, clinical and medication-related factors, the most consistent predictor of subjective discontinuation success was self-care behavior, in particular mindfulness, relaxation and making use of supportive relationships. Other predictors depended on the type of medication: For AD, good alliance with the prescribing physician predicted higher subjective success whereas gradual tapering per se was associated with lower subjective success and a lower chance of full discontinuation. In those tapering off AP, leaving time to adjust between dose reductions was associated with higher subjective success and fewer negative effects.

CONCLUSIONS

The findings can inform evidence-based clinical guidelines and interventions aiming to support patients during discontinuation. Further studies powered to take interactions between variables into account are needed to improve the prediction of successful discontinuation.

Anxiety Disorders: A Review

Importance

Anxiety disorders have a lifetime prevalence of approximately 34% in the US, are often chronic, and significantly impair quality of life and functioning.

Observations

Anxiety disorders are characterized by symptoms that include worry, social and performance fears, unexpected and/or triggered panic attacks, anticipatory anxiety, and avoidance behaviors. Generalized anxiety disorder (6.2% lifetime prevalence), social anxiety disorder (13% lifetime prevalence), and panic disorder (5.2% lifetime prevalence) with or without agoraphobia are common anxiety disorders seen in primary care. Anxiety disorders are associated with physical symptoms, such as palpitations, shortness of breath, and dizziness. Brief screening measures applied in primary care, such as the Generalized Anxiety Disorder-7, can aid in diagnosis of anxiety disorders (sensitivity, 57.6% to 93.9%; specificity, 61% to 97%). Providing information about symptoms, diagnosis, and evidence-based treatments is a first step in helping patients with anxiety. First-line treatments include pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs, eg, sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs, eg, venlafaxine extended release) remain first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder. Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo (eg, generalized anxiety disorder: standardized mean difference [SMD], -0.55 [95% CI, -0.64 to -0.46]; social anxiety disorder: SMD, -0.67 [95% CI, -0.76 to -0.58]; panic disorder: SMD, -0.30 [95% CI, -0.37 to -0.23]). Cognitive behavioral therapy is the psychotherapy with the most evidence of efficacy for anxiety disorders compared with psychological or pill placebo (eg, generalized anxiety disorder: Hedges g = 1.01 [large effect size] [95% CI, 0.44 to 1.57]; social anxiety disorder: Hedges g = 0.41 [small to medium effect] [95% CI, 0.25 to 0.57]; panic disorder: Hedges g = 0.39 [small to medium effect[ [95% CI, 0.12 to 0.65]), including in primary care. When selecting treatment, clinicians should consider patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care.

Conclusions and Relevance

Anxiety disorders affect approximately 34% of adults during their lifetime in the US and are associated with significant distress and impairment. First-line treatments for anxiety disorders include cognitive behavioral therapy, SSRIs such as sertraline, and SNRIs such as venlafaxine extended release.

Personalised app-based relapse prevention of depressive and anxiety disorders in remitted adolescents and young adults: a protocol of the StayFine RCT

INTRODUCTION

Youth in remission of depression or anxiety have high risks of relapse. Relapse prevention interventions may prevent chronicity. Aim of the study is therefore to (1) examine efficacy of the personalised StayFine app for remitted youth and (2) identify high-risk groups for relapse and resilience.

METHOD AND ANALYSIS

In this Dutch single-blind parallel-group randomised controlled trial, efficacy of app-based monitoring combined with guided app-based personalised StayFine intervention modules is assessed compared with monitoring only. In both conditions, care as usual is allowed. StayFine modules plus monitoring is hypothesised to be superior to monitoring only in preventing relapse over 36 months. Participants (N=254) are 13-21 years and in remission of depression or anxiety for >2 months. Randomisation (1:1) is stratified by previous treatment (no treatment vs treatment) and previous episodes (1, 2 or >3 episodes). Assessments include diagnostic interviews, online questionnaires and monitoring (ecological momentary assessment with optional wearable) after 0, 4, 12, 24 and 36 months. The StayFine modules are guided by certified experts by experience and based on preventive cognitive therapy and ingredients of cognitive behavioural therapy. Personalisation is based on shared decision-making informed by baseline assessments and individual symptom networks. Time to relapse (primary outcome) is assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia-lifetime version diagnostic interview. Intention-to-treat survival analyses will be used to examine the data. Secondary outcomes are symptoms of depression and anxiety, number and duration of relapses, global functioning, and quality of life. Mediators and moderators will be explored. Exploratory endpoints are monitoring and wearable outcomes.

ETHICS, FUNDING AND DISSEMINATION

The study was approved by METC Utrecht and is funded by the Netherlands Organisation for Health Research and Development (636310007). Results will be submitted to peer-reviewed scientific journals and presented at (inter)national conferences.

TRIAL REGISTRATION NUMBER

NCT05551468; NL8237.

Use of Benzodiazepines and Z-Drugs in Inflammatory Bowel Disease

INTRODUCTION

We estimated the incidence and prevalence of benzodiazepine and Z-drug (separately and jointly as BZD) use in the inflammatory bowel disease (IBD) population compared with matched controls without IBD and examined the association of mood/anxiety disorders (M/ADs) with the use of BZD from 1997 to 2017.

METHODS

Using administrative data from Manitoba, Canada, we identified 5,741 persons with incident IBD who were matched in a 1:5 ratio to controls on sex, birth year, and region. Validated case definitions were used to identify M/AD. Dispensations of BZD were identified. Multivariable generalized linear models were used to assess the association between IBD, M/AD, and BZD use.

RESULTS

In 2016, the incident age/sex-standardized benzodiazepine use rates per 1,000 were 28.06 (95% confidence interval [CI] 26.41-29.81) in the IBD cohort and 16.83 (95% CI 16.28-17.39) in controls (adjusted rate ratio = 1.69 [95% CI 1.56-1.79]). Benzodiazepine incidence rates were higher for women with IBD than men, but the RR between cases and controls were similar for men and women. The incident age/sex-standardized Z-drug use rate per 1,000 was 21.07 (95% CI 19.69-22.41) in the IBD cohort. This was 1.87-fold higher than in controls (95% CI 1.73-2.01). In 2017, approximately 20% of persons with IBD used benzodiazepines and 20% used Z-drugs. There was a subadditive effect of both benzodiazepine and Z-drug uses between IBD and M/AD after adjusting for covariates.

DISCUSSION

The use of BZD is more common in people with IBD than in population controls. Strategies to reduce the use of BZDs in persons with IBD and to offer alternative management strategies for M/ADs, sleep disorders, and other symptomatic concerns are needed.

A network meta-analysis of 12,116 individuals from randomized controlled trials in the treatment of depression after acute coronary syndrome

BACKGROUND

Post-acute coronary syndrome (ACS) depression is a common but not well understood complication experienced by ACS patients. Research on the effectiveness of various therapies remains limited. Hence, we sought to conduct a network meta-analysis to assess the efficacy of different interventions for post-ACS depression in improving patient outcomes.

METHODS AND FINDINGS

Three electronic databases were searched for randomised controlled trials describing different depression treatment modalities in post-ACS patients. Each article was screened based on inclusion criteria and relevant data were extracted. A bivariate analysis and a network meta-analysis was performed using risk ratios (RR) and standardized mean differences (SMD) for binary and continuous outcomes, respectively. A total of 30 articles were included in our analysis. Compared to standard care, psychosocial therapy was associated with the greatest reduction in depression scores (SMD:-1.21, 95% CI: -1.81 to -0.61, p<0.001), followed by cognitive behavioural therapy (CBT) (SMD: -0.75, 95% CI: -0.99 to -0.52, p<0.001), antidepressants (SMD: -0.73, 95% CI: -1.14 to -0.31, p<0.001), and lastly, combination therapy (SMD: -0.15, 95% CI: -0.28 to -0.03, p = 0.016). No treatment modalities was found to be more effective in reducing depression scores when compared to one another. Additional analysis showed that these treatment modalities did not have significant impact on the overall mortality, cardiac mortality and recurrent myocardial infarction.

CONCLUSION

This network meta-analysis found that the treatment effect of the various psychological modalities on depression severity were similar. Future trials on psychological interventions assessing clinical outcomes and improvement in adherence to ACS-specific interventions are needed.

The Anxiolytic-Like Effects of Protocatechuic Acid in an Animal Model of Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a serious psychiatric disorder characterized by impaired fear extinction, depression, and anxiety caused by dysregulation of the hypothalamic-pituitary-adrenal axis and an imbalance of monoamines. Protocatechuic acid (PCA; 3,4-dihydroxybenzoic acid), a major polyphenol metabolite, has various pharmacological effects, such as anti-inflammatory, antioxidant, anti-apoptotic, and neuroprotective activities. In this study, the efficacy of PCA for fear extinction, antidepressant, and anxiolytic effects in PTSD-mediated psychiatric disorders, were evaluated by exposing rats to single prolonged stress (SPS). Male rats were administered PCA (100 or 200 mg/kg) once daily for 14 days after exposure to SPS. PCA significantly decreased situational fear, depressive and anxiety-like behaviors, and corticosterone levels. In addition, PCA regulated the imbalance of serotonin and norepinephrine in the fear circuit region (i.e., the medial prefrontal cortex and hippocampus [Hipp]), and suppressed the decrease in brain-derived neurotrophic factor mRNA expression in the Hipp. The results showed that PCA administration improves freezing behavior and has antidepressant and anti-anxiety effects through modulation of the serotonergic nervous system and monoamines in rats. These results indicated that PCA may be useful as a food ingredient to prevent PTSD.

Accurate Machine Learning Model to Diagnose Chronic Autoimmune Diseases Utilizing Information From B Cells and Monocytes

Heterogeneity and limited comprehension of chronic autoimmune disease pathophysiology cause accurate diagnosis a challenging process. With the increasing resources of single-cell sequencing data, a reasonable way could be found to address this issue. In our study, with the use of large-scale public single-cell RNA sequencing (scRNA-seq) data, analysis of dataset integration (3.1 × 10⁵ PBMCs from fifteen SLE patients and eight healthy donors) and cellular cross talking (3.8 × 10⁵ PBMCs from twenty-eight SLE patients and eight healthy donors) were performed to identify the most crucial information characterizing SLE. Our findings revealed that the interactions among the PBMC subpopulations of SLE patients may be weakened under the inflammatory microenvironment, which could result in abnormal emergences or variations in signaling patterns within PBMCs. In particular, the alterations of B cells and monocytes may be the most significant findings. Utilizing this powerful information, an efficient mathematical model of unbiased random forest machine learning was established to distinguish SLE patients from healthy donors via not only scRNA-seq data but also bulk RNA-seq data. Surprisingly, our mathematical model could also accurately identify patients with rheumatoid arthritis and multiple sclerosis, not just SLE, via bulk RNA-seq data (derived from 688 samples). Since the variations in PBMCs should predate the clinical manifestations of these diseases, our machine learning model may be feasible to develop into an efficient tool for accurate diagnosis of chronic autoimmune diseases.

Use of Benzodiazepines and Z-Drugs in Multiple Sclerosis

Objective

Use of benzodiazepines and Z-drugs (non-benzodiazepine sedative hypnotics) is controversial due to adverse health outcomes in the general population. However, little is known about their use in people with multiple sclerosis (MS). We estimated the incidence and prevalence of benzodiazepine and Z-drug use (jointly BZD) in the MS population as compared to an age-, sex- and geographically-matched population without MS, and examined the association of mood/anxiety disorders with the use of BZD over a twenty-year period.

Methods

Using administrative data from Manitoba, Canada, we identified 2,985 persons with incident MS and 14,891 persons without MS matched 5:1 on sex, birth year and region. We applied validated case definitions to identify persons with any mood/anxiety disorder. Dispensations of BZD were identified. To assess the association between MS, mood/anxiety disorders and BZD use we constructed generalized linear models adjusting for age, sex, index year, socioeconomic status, urban/rural residence, physical comorbidities, and health care use. We also examined patterns of BZD use.

Results

In 2016, the crude incidence of benzodiazepine use in the MS cohort was 2.10% (95%CI: 1.43–2.98%), 1.49-fold higher than in the non-MS cohort (1.41%; 95%CI: 1.18–1.67%). The crude incidence of Z-drug use in the MS cohort was 1.77% (95%CI: 1.20–2.51%), 1.78-fold higher than in the non-MS cohort (0.99%; 95%CI: 0.81–1.21%). After adjusting for covariates, among individuals without an active mood/anxiety disorder, the MS cohort had a 39% increased incidence rate of benzodiazepine use and a 72% increased incidence rate of Z-drug use as compared to the non-MS cohort. Among individuals with an active mood/anxiety disorder, the incidence of BZD use did not differ between the MS and non-MS cohorts. A higher proportion of people with MS used BZD for ≥6 months than people without MS.

Conclusion

Use of BZD is more common in people with MS than in general population controls, and use of these agents is in persons with MS is often chronic.

Research Review: A meta-analysis of relapse rates in cognitive behavioral therapy for anxiety and related disorders in youth

BACKGROUND

Cognitive behavioral therapy (CBT) is an effective treatment for youth with anxiety and related disorders, with a 59% remission rate at post-treatment. Results of reviews and meta-analyses indicate that treatment gains are maintained across long-term follow-up, at least in terms of symptom improvement. Less is known about relapse, defined as patients who initially achieve remission status but then experience a return of symptoms after a follow-up period.

METHOD

The current study used meta-analysis to determine the overall rate of relapse in CBT for children and adolescents (age 18 years or younger) with anxiety and related disorders. Potential moderating factors of relapse rates, including demographic, methodological, and clinical/intervention characteristics, were also examined. Out of a pool of 78 abstracts, 13 full-text articles were retained for meta-analysis. An additional two articles were identified from other sources (total N = 535 patients).

RESULTS

Results showed an overall relapse rate of 10.5% (including comorbid autism spectrum disorder) and 8% (excluding comorbid autism spectrum disorder) across studies. Moderator analyses demonstrated that relapse rates were higher among younger and more racially diverse samples, as well as among patients with comorbid externalizing disorders and those taking psychiatric medications. There were no differences in relapse rates as a function of primary diagnosis.

CONCLUSIONS

Taken together, the findings indicate that relapse rates in CBT for anxious youth are relatively low, suggesting that treatment development and refinement efforts should focus on improving treatment response and remission rates for this population.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol

BACKGROUND

The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings.

METHODS/DESIGN

We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months. TREATMENT AND CONTROL GROUPS: a) group self-management support (10 weekly 2.5-h group web-based sessions with 10-15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation.

STATISTICAL ANALYSIS

Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention.

DISCUSSION

This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients' self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.

Effects of medical service fee revision on reducing irrational psychotropic polypharmacy in Japan: an interrupted time-series analysis

PURPOSE

According to the revised Japanese medical service fees aimed at reducing irrational psychotropic polypharmacy, medical service fees are reduced if the number of simultaneously prescribed psychotropic drugs exceeds the standard. This study primarily aims to examine the effect of the 2018 revision.

METHODS

Using a large Japanese administrative claims database, we retrospectively identified five groups (April 2013-September 2018) prescribed at least one drug from the following drug groups: anxiolytics, hypnotics, sum of anxiolytics and hypnotics, antipsychotics, and antidepressants (study population in each group: 547,511, 406,524, 759,137, 112,929, and 201,046, respectively). We used an interrupted time-series design to evaluate changes in the proportion of patients prescribed more than the standard number of drugs.

RESULTS

After the 2018 revision, the proportion of patients prescribed more than the standard number of drugs significantly decreased only for the sum of anxiolytics and hypnotics; estimated changes in level and trend were - 0.60% [- 0.69%, - 0.52%] and - 0.04% [- 0.06%, - 0.02%] per month, respectively. The proportion of patients exhibiting a decrease in the number of prescribed drugs from more than the standard to within the standard increased when the revision was enforced (April 2018); this proportion in April 2018 was 36.3%, while all other proportions were in the range of 12.1-22.3%.

CONCLUSION

The 2018 revision promoted a reduction in the number of prescribed drugs, which served as an important factor in the decrease in the proportion of patients prescribed more than the standard number of drugs for the sum of anxiolytics and hypnotics.

Persistence of antidepressant use among refugee youth with common mental disorder

BACKGROUND

The objective of this study was to investigate whether persistence of antidepressant use differs between refugee youth and Swedish-born youth after a diagnosis of a common mental disorder (CMD), and if clinical and sociodemographic factors are associated with antidepressant discontinuation.

METHODS

Youth aged 16-25 years, with an incident diagnosis of CMD (depression, post-traumatic stress disorder (PTSD), anxiety disorders) accessing specialized healthcare in Sweden 2006-2016 were included. New users were identified with a one-year washout period. Refugees (N=1575) were compared with Swedish-born youth (N=2319). Cox regression models [reported as adjusted Hazard Ratios (HRs) with 95% confidence intervals (CIs)] were used to investigate factors associated with discontinuation of antidepressant use.

RESULTS

Among youth (mean age 20.9 years, SD 2.7, 50% females), the median duration of antidepressant use differed considerably between refugee (101 days, IQR 31-243) and Swedish-born youth (252 days, IQR 101-558). Refugees were more likely to discontinue treatment (HR 1.61, 95% CI 1.47-1.77). Factors associated with an increased risk for discontinuation in refugees included ≤5 years duration of formal residency (HR 1.28, 95% CI 1.12-1.45), antidepressant type, and dispensing lag (time from prescription to dispensing) of >7 days (1.43, 1.25-1.64), whereas PTSD (0.78, 0.64-0.97) and anxiolytic use (0.79, 0.64-0.96) were associated with a lower discontinuation risk.

LIMITATIONS

Only persons treated in specialized healthcare could be included.

CONCLUSION

The relatively short treatment durations among refugee youth suggest that antidepressant treatment may not be optimal in CMD, and better monitoring of treatment as well as transcultural education of healthcare personnel are warranted.

Yoga as an Integrative Therapy for Mental Health Concerns: An Overview of Current Research Evidence

Background: Because the prevalence of mental health concerns is high and access or full responsiveness to pharmacological or psychotherapeutic treatment for many individuals is low, there has been increased interest in yoga as a potential therapy for many mental health concerns. Approach: We synthesize and critique current research on the efficacy of yoga relative to pharmacological approaches for anxiety disorders, mood disorders, posttraumatic stress disorder, obsessive-compulsive disorder, and eating disorders. Results: Yoga has been tested mostly as a complementary treatment to standard psychiatric and psychotherapeutic approaches. Findings from efficacy trials largely support the notion that yoga can help reduce symptoms of many psychiatric conditions, including anxiety, depression, and PTSD symptoms, above and beyond the effects achieved by standard pharmacological treatments alone; however, most evidence is of poor to moderate quality. Plausible transdiagnostic bottom-up and top-down mechanisms of yoga’s therapeutic effects have been advanced but remain untested. Conclusions: While results should be considered preliminary until more rigorous evidence is available, yoga appears to have the potential to provide many people suffering with psychiatric symptoms additional relief at relatively little cost. Yoga may be a viable complementary therapy to psychiatric and psychotherapeutic approaches for people with mental health challenges.

The use of uncertain exposure-A method to define switching and add-on in pharmacoepidemiology

PURPOSE

When defining exposure to pharmacological treatments in pharmacoepidemiology, register data often do not provide information regarding if a pharmacological treatment is a switch or an add-on. This study aims to compare two methods defining switching and add-on therapies and their impact on exposure-outcome associations. Additionally, to guide bias reduction, it aims to describe how the methods relate to immortal time bias and selection bias.

METHODS

Cohort study using Swedish population-based health registers to identify antidepressant (AD) prescriptions as exposures while hospitalizations for psychiatric reasons were used as an empirical outcome example. The first method for exposure definition used conditioning on future exposure (FE), the second used the concept of uncertain exposure (UE). To estimate associations between outcome and exposure categories "Use of one AD," "Use of two or more ADs", and "UE" compared to "Unexposed," hazard ratios (HRs) and 95% confidence intervals were estimated using Cox regression adjusted for age and sex.

RESULTS

Using the UE method, 7.2% of time periods were classified as "UE" with a notable proportion of psychiatric hospitalizations (7.7%) occurring during this time, while when using the FE method these hospitalizations were distributed over unexposed time and AD use time. The FE method resulted in slightly higher associations than the UE method. The highest HR was found during "UE": HR (95% CI) 5.54 (5.06-6.07).

CONCLUSIONS

This study suggests that to reduce the potential immortal time bias, selection bias, and exposure misclassification inherent to the FE method, the UE method could be used for identifying switching and add-on therapies. If not used as a main exposure definition, the UE method may be used to investigate the impact of UE time in a sensitivity analysis.

Tackling the global problem of traumatic stress in low-income countries: a pilot clinical trial comparing reconsolidation therapy to paroxetine in Nepal

BACKGROUND

Traumatic stress is a global mental health problem requiring novel, easily implemented treatment solutions. We compared the effectiveness and efficiency of Reconsolidation Therapy (RT) to the well-established antidepressant paroxetine, in reducing symptoms of traumatic stress among patients from Nepal, a low-income country.

METHODS

Forty-six adults with posttraumatic stress disorder (PTSD) were randomized to one of two groups. The reconsolidation blocker propranolol was administered 90 min before briefly recalling a traumatic memory with a therapist, weekly for six consecutive weeks. This was compared to daily paroxetine for 26 weeks. Self-reported PTSD symptoms were assessed blindly at the 7th, 13th, and 26th weeks.

RESULTS

An intent-to-treat analysis revealed a robust pre- to post-treatment main effect (β1 = - 4.83, 95% CI = [- 5.66, - 4.01], p < .001), whereby both groups improved, with Cohen's effect sizes of d = 2.34 (95% CI = [1.57, 3.12]) for paroxetine, and of 2.82 (95% CI = [1.98, 3.66]) for RT after 7 weeks, suggesting treatment effectiveness for both groups in a real-world setting. Three and six-month follow-up yielded further significant improvement in both groups, which did not differ from each other.

CONCLUSION

RT also displayed promising efficiency, considering that it had been discontinued weeks earlier while the paroxetine treatment was continued, as recommended. RT could be taught in low-income countries as part of the local therapeutic resources to treat the core symptoms of PTSD, provided that such results are replicated on a broader scale.

TRIAL REGISTRATION

ISRCTN34308454 (11/10/2017).

Effect of comorbid mood and anxiety disorders on breast and cervical cancer screening in immune-mediated inflammatory disease

We aimed to examine rates of breast and cervical cancer screening in women with immune-mediated inflammatory diseases (IMID), including inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA) versus a matched cohort with IMID; and examine the association of psychiatric comorbidity with screening in these populations. We conducted a retrospective cohort study in Manitoba, Canada using administrative data. We identified women with IBD, MS and RA, and controls without these IMID matched on age and region. Annually, we identified individuals with any active mood/anxiety disorder. Using physician claims, we determined the proportion of each cohort who had cervical cancer screening within three-year intervals, and mammography screening within two-year intervals. We modeled the difference in the proportion of the IMID and matched cohorts who underwent mammography; and pap tests using log-binomial regression with generalized estimating equations, adjusting for sociodemographics, comorbidity and immune therapy use. We tested for additive interactions between cohort and mood/anxiety disorder status. During 2006–2016, we identified 17,230 women with IMID (4,623 with IBD, 3,399 with MS, and 9,458 with RA) and 85,349 matched controls. Having an IMID was associated with lower (-1%) use of mammography; however, this reflected a mixture of more mammography in the IBD cohort (+2.9%) and less mammography in the MS (-4.8 to -5.2%) and RA (-1.5%) cohorts. Within the IBD, MS and RA cohorts, having an active mood/anxiety disorder was associated with more mammography use than having an inactive mood/anxiety disorder. The MS and RA cohorts were less likely to undergo Pap testing than their matched cohorts. In the absence of an active mood/anxiety disorder, the IBD cohort was more likely to undergo Pap testing than its matched cohort; the opposite was true when an active mood/anxiety disorder was present. Among women with an IMID, mood/anxiety disorder influence participation in cancer screening.

Error-related negativity predicts increases in anxiety in a sample of clinically anxious female children and adolescents over 2 years

BACKGROUND

An increased neural response to making errors has emerged as a biomarker of anxiety. Error negativity (Ne) or errorrelated negativity (ERN) is an event-related potential generated when people commit errors; the Ne/ERN is greater among people with anxiety and predicts increases in anxiety. However, no previous study has examined whether the Ne/ERN can be used as a prognostic indicator among people with current anxiety. The present study addressed this gap by examining whether the Ne/ERN prospectively predicts increases in anxiety symptoms in clinically anxious children and adolescents.

METHODS

The sample included 34 female participants between the ages of 8 and 14 years who met the criteria for a clinical anxiety disorder based on clinical interview. The Ne/ERN was measured using a flanker task.

RESULTS

Increased Ne/ERN at baseline predicted increases in total anxiety symptoms 2 years later, even when accounting for baseline symptoms. The Ne/ERN predicted increases in the symptom domains of generalized anxiety, social anxiety and harm avoidance/perfectionism, but not panic, separation anxiety, school avoidance or physical symptoms.

LIMITATIONS

The sample size was small, which may have inflated the false discovery rate. To mitigate this possibility, we used multiple self-report measures, and the results for the 2 measures (as well as their symptom domains) converged.

CONCLUSION

These data suggest that the Ne/ERN can delineate specific risk trajectories, even among those who already meet the criteria for a clinical anxiety disorder. Considering the need for prognostic markers among people with clinical anxiety, the current findings are an important and novel extension of previous work.

Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications

Studies on psychotropic medications decrease, discontinuation, or switch have uncovered withdrawal syndromes. The present overview aimed at analyzing the literature to illustrate withdrawal after decrease, discontinuation, or switch of psychotropic medications based on the drug class (i.e., benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, antidepressants, ketamine, antipsychotics, lithium, mood stabilizers) according to the diagnostic criteria of Chouinard and Chouinard [Psychother Psychosom. 2015;84(2):63-71], which encompass new withdrawal symptoms, rebound symptoms, and persistent post-withdrawal disorders. All these drugs may induce withdrawal syndromes and rebound upon discontinuation, even with slow tapering. However, only selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, and antipsychotics were consistently also associated with persistent post-withdrawal disorders and potential high severity of symptoms, including alterations of clinical course, whereas the distress associated with benzodiazepines discontinuation appears to be short-lived. As a result, the common belief that benzodiazepines should be substituted by medications that cause less dependence such as antidepressants and antipsychotics runs counter the available literature. Ketamine, and probably its derivatives, may be classified as at high risk for dependence and addiction. Because of the lag phase that has taken place between the introduction of a drug into the market and the description of withdrawal symptoms, caution is needed with the use of newer antidepressants and antipsychotics. Within medication classes, alprazolam, lorazepam, triazolam, paroxetine, venlafaxine, fluphenazine, perphenazine, clozapine, and quetiapine are more likely to induce withdrawal. The likelihood of withdrawal manifestations that may be severe and persistent should thus be taken into account in clinical practice and also in children and adolescents.

Depression, antidepressants and fall risk: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical review was to summarize the existing knowledge on fall risk associated with antidepressant use in older adults, describe underlying mechanisms, and assist clinicians in decision-making with regard to (de-) prescribing antidepressants in older persons.

METHODOLOGY

We comprehensively examined the literature based on a literature search in Pubmed and Google Scholar, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in depression in geriatric patients. We discuss use of antidepressants, potential fall-related side effects, and deprescribing of antidepressants in older persons.

RESULTS

Untreated depression and antidepressant use both contribute to fall risk. Antidepressants are equally effective, but differ in fall-related side effect profile. They contribute to (or cause) falling through orthostatic hypotension, sedation/impaired attention, hyponatremia, movement disorder and cardiac toxicity. Falling is an important driver of morbidity and mortality and, therefore, requires prevention. If clinical condition allows, withdrawal of antidepressants is recommended in fall-prone elderly persons. An important barrier is reluctance of prescribers to deprescribe antidepressants resulting from fear of withdrawal symptoms or disease relapse/recurrence, and the level of complexity of deprescribing antidepressants in older persons with multiple comorbidities and medications. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antidepressants.

CONCLUSIONS

(De-) prescribing antidepressants in fall-prone older adults is often challenging, but detailed insight in fall-related side effect profile of the different antidepressants and a recently developed expert-based decision aid STOPPFalls assists prescribers in clinical decision-making.

Reasons for Participation and Nonparticipation in Psychological Relapse Prevention for Anxiety and Depression: A Qualitative Study

BACKGROUND

Anxiety and depressive disorders frequently recur, but participation in effective psychological interventions to prevent relapse is limited. The reasons for nonparticipation are largely unknown, hampering successful implementation. The aims of this study were: (1) to investigate reasons why patients with remitted anxiety or depressive disorders refuse cognitive-behavioral therapy relapse prevention interventions (RPIs), (2) to compare these reasons with reasons to participate, and (3) to gain insight into patients' preferences regarding relapse prevention.

METHODS

A qualitative study was conducted in which data were gathered from 52 semistructured interviews with patients who either refused or agreed to participate in psychological relapse prevention. The constant comparative method was used.

RESULTS

The data showed that those who refused to participate (1) did have knowledge about relapse risks in general, (2) but did not relate this risk to themselves, and therefore, did not feel the need for relapse prevention, or (3) declined to participate for logistical reasons or reasons related to the content of the intervention. Preferences concerning the form and content of RPIs were very diverse.

CONCLUSIONS

Psychoeducation on relapse should be provided to patients to help them relate recurrence risks to themselves. RPIs should also be individually tailored.

The Effect of a PTSD Service Dog on Military Veterans' Medication Regimens: A Cross-Sectional Pilot Study

Recent research suggests that service dogs may have clinically-relevant benefits for military veterans with posttraumatic stress disorder (PTSD). However, the effects of PTSD service dogs on veterans' medication use has been largely unexplored. The objective of this study was to quantify the effect of PTSD service dogs on medication use among a population of military veterans with PTSD. In a cross-sectional design, United States post-9/11 military veterans with PTSD were recruited from a single service dog provider including veterans living with a PTSD service dog (n = 52) and veterans on the waitlist (n = 44). Both populations of veterans received treatment as usual. Participants completed an online survey of self-reported medication regimens and medication changes. Regression models quantified the effect of having a service dog on physical health, mental health, pain, and sleep medications while controlling for confounding variables (age, sex, relationship status, traumatic brain injuries, and physical health). Results indicated that there were no significant effects of having a service dog on overall self-reported medication use nor any specific medication category (p's > 0.06). However, veterans with a service dog were more likely than those on the waitlist to report that their doctor had decreased dosage or removed medications since getting their service dog. The results of this preliminary cross-sectional research should be interpreted with caution, as future within-subject and pharmacy-verified research is necessary to understand the causality of these findings.

Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults

BACKGROUND

Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants.

OBJECTIVES

To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults.

SEARCH METHODS

We searched all databases for randomised controlled trials (RCTs) until January 2020.

SELECTION CRITERIA

We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety.

AUTHORS' CONCLUSIONS

Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression.   There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.

Childhood adversity trajectories and PTSD in young adulthood: A nationwide Danish register-based cohort study of more than one million individuals

We examine the association between trajectories of childhood adversities and Post-Traumatic Stress Disorder (PTSD) using a register-based Danish cohort. The DANish LIFE Course (DANLIFE) cohort includes and prospectively follows all individuals born in Denmark from 1980. We estimated the rate of PTSD diagnosed from age 16, according to childhood adversity trajectories from age 0 to 16 (n = 1 277 548). Trajectories were previously defined into 5 groups: Low Adversity, Early Life Material Deprivation, Persistent Material Deprivation, Loss or Threat of Loss, And High Adversity. We then estimated adjusted relative hazard ratios (aHR), and absolute hazards differences of PTSD according to childhood adversity trajectories in adjusted survival analysis. All analyses were stratified by sex. Individuals were followed for a median of 10·1 years a fter their 16th birthday, and 4966 individuals were diagnosed with PTSD. Compared with the low adversity group, children exposed to childhood adversity were more likely to be diagnosed with PTSD. The aHR for PTSD varied from 1·4 (95% CI: 1·3-1·5) in the Early Life Material Deprivation group, to 3·7 (3·3-4·1) in the High Adversity group, which corresponds to 8·3 extra cases of PTSD per 10 000 person years. The relative associations were comparable in men and women, but approximately twice as many women compared with men were affected. We report a clear association between exposure to childhood adversities and PTSD in young adulthood. The highest burden was among women in the high adversity group.

COVID-19 and mental health in Brazil: Psychiatric symptoms in the general population

Public health interventions at general population level are imperative in order to decrease the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but they may contribute to widespread emotional distress and increased risk for psychiatric illnesses. We report on the results of an investigation into the occurrence and determinants of psychiatric symptoms among the Brazilian general population (N = 1996). We assessed sociodemographic variables and general mental health (DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure), depression (PROMIS depression v.8a), anxiety (PROMIS anxiety v.8a), and post-traumatic stress symptoms (Impact of Event Scale-IES-R scale) using an online web-based survey. Anxiety (81.9%), depression (68%), anger (64.5%), somatic symptoms (62.6%) and sleep problems (55.3%) were the most common psychiatric symptoms. Younger age, female gender, low income, lower level of education, longer period of social distancing, and self-reported history of previous psychiatric illness were strongly associated with higher severity of symptoms. Our results support the negative impact of the COVID-19 pandemic on the mental health of the Brazilian population. The high prevalence of psychiatric symptoms observed in our sample indicates that the mental health impact of the COVID-19 pandemic should be considered a public health problem in Brazil. The health systems and individual clinicians must be prepared to offer and implement specific interventions in order to identify and treat psychiatric issues.

The association of occupational stress and sleep duration with anxiety symptoms among healthy employees: A cohort study

The aim of this study is to identify occupational stress associated with the development of new-onset anxiety symptoms and the dose-response relationship between sleep duration and the onset of anxiety symptoms. Data from 29,251 healthy employees who had undergone at least two comprehensive health examinations at Kangbuk Samsung Hospital Health Screening Center were analysed. Anxiety symptoms were assessed using the Beck Anxiety Inventory. Occupational stress and sleep duration were measured using a self-reported questionnaire about total sleep time and the Korean Occupational Stress Scale-Short Form (KOSS-SF), respectively. Flexible parametric proportional hazards model used to estimate the hazard ratios. Compared with the groups without case-level anxiety, discomfort in an organizational climate, high job demands, job insecurity, organizational injustice and lack of reward were associated with the onset of case-level anxiety. Compared with less than 6 hr of sleep per day, the beneficial level of sleep duration was 7 ≤ to <9 hr a day. Almost all subscales of job stress were associated with the development of anxiety symptoms. In addition, the efficacious level of sleep duration for reducing the onset of future anxiety symptoms was 7 ≤ to <9 hr a day.

Involvement of microglia in disturbed fear memory regulation: Possible microglial contribution to the pathophysiology of posttraumatic stress disorder

Microglia, immune cells in the brain, play a crucial role in brain inflammation and synaptic plasticity by releasing inflammatory mediators and neurotrophic factors as well as, phagocytosing synaptic elements. Recent studies have shown peripheral inflammation, immune alteration in the brain are associated with post-traumatic stress disorder (PTSD) in humans. Several preclinical studies using Pavlovian fear conditioning have suggested that microglia are involved in fear memory dysregulation and altered fear neuronal networks. Microglial priming resulting from previous stressful experiences may also have an effect. This review will introduce the current knowledge of microglial contribution to disturbed fear memory regulation, a fundamental feature of PTSD.

Treating Anxiety During Pregnancy: Patient Concerns About Pharmaceutical Treatment

OBJECTIVES

The purpose of the current study was to describe anxious pregnant women's concerns about using pharmacotherapy to treat anxiety symptoms, and the relationship of such concerns to women's willingness to use pharmacotherapy during pregnancy.

METHODS

Between April 2011 and May 2012, 148 women who were pregnant and reported elevated anxiety symptoms, as measured by the GAD-2, completed an online survey assessing their concerns about, and willingness to use, pharmacotherapy to treat anxiety symptoms during pregnancy. Qualitative responses were coded, and linear regression was used to assess the relationship between concerns and willingness.

RESULTS

Pregnant women with elevated anxiety symptoms reported low willingness to use pharmacotherapy to treat anxiety symptoms during pregnancy. The most common concerns reported were about negative effects on the baby or the self, and a general opposition to taking any medications during pregnancy. These concerns were significantly related to women's willingness to try pharmacotherapy (ps < .016).

CONCLUSION

Our findings underscore the importance of a pregnant woman's perceptions of potential side-effects and long-term effects of pharmacotherapy, both for herself and her offspring. These results point to specific factors that may be important to address in communication with patients about pharmacotherapy for anxiety disorders during pregnancy. Such an understanding may help clinicians provide more effective guidance and information about treatment options for anxiety disorders during pregnancy, and increase patients' willingness to engage in those treatments.

Effect of mood and anxiety disorders on health care utilization in multiple sclerosis

Background:

Little is known about the effects of changes in the presence or absence of psychiatric disorders on health care utilization in multiple sclerosis (MS).

Objective:

To evaluate the association between “active” mood and anxiety disorders (MAD) and health care utilization in MS.

Methods:

Using administrative data from Manitoba, Canada, we identified 4748 persons with MS and 24,154 persons without MS matched on sex, birth year, and region. Using multivariable general linear models, we evaluated the within-person and between-person effects of any “active” MAD on annual physician visits, hospital days, and number of drug classes dispensed in the following year.

Results:

Annually, the MS cohort had an additional two physician visits, two drug classes, and nearly two more hospital days versus the matched cohort. Individuals with any MAD had more physician visits, had hospital days, and used more drug classes than individuals without a MAD. Within individuals, having an “active” MAD was associated with more utilization for all outcomes than not having an “active” MAD, but the magnitude of this effect was much smaller for visits and drugs than the between-person effect.

Conclusion:

Within individuals with MS, changes in MAD activity are associated with changes in health services use.

Social context and the real-world consequences of social anxiety

BACKGROUND

Social anxiety lies on a continuum, and young adults with elevated symptoms are at risk for developing a range of psychiatric disorders. Yet relatively little is known about the factors that govern the hour-by-hour experience and expression of social anxiety in the real world.

METHODS

Here we used smartphone-based ecological momentary assessment (EMA) to intensively sample emotional experience across different social contexts in the daily lives of 228 young adults selectively recruited to represent a broad spectrum of social anxiety symptoms.

RESULTS

Leveraging data from over 11 000 real-world assessments, our results highlight the central role of close friends, family members, and romantic partners. The presence of such close companions was associated with enhanced mood, yet socially anxious individuals had fewer confidants and spent less time with the close companions that they do have. Although higher levels of social anxiety were associated with a general worsening of mood, socially anxious individuals appear to derive larger benefits - lower levels of negative affect, anxiety, and depression - from their close companions. In contrast, variation in social anxiety was unrelated to the amount of time spent with strangers, co-workers, and acquaintances; and we uncovered no evidence of emotional hypersensitivity to these less-familiar individuals.

CONCLUSIONS

These findings provide a framework for understanding the deleterious consequences of social anxiety in emerging adulthood and set the stage for developing improved intervention strategies.