Single-Dose Synthetic Psilocybin With Psychotherapy for Treatment-Resistant Bipolar Type II Major Depressive Episodes: A Nonrandomized Controlled Trial

Importance

Bipolar II disorder (BDII) is a debilitating condition frequently associated with difficult-to-treat depressive episodes. Psilocybin has evidence for rapid-acting antidepressant effects but has not been investigated in bipolar depression.

Objective

To establish the safety and efficacy of psilocybin in patients with BDII in a current depressive episode.

Design, Setting, and Participants

This was a 12-week, open-label nonrandomized controlled trial conducted at Sheppard Pratt Hospital. Participants aged 18 to 65 years with BDII, a current depressive episode longer than 3 months, and documented insufficient benefit with at least 2 pharmacologic treatments during the current episode were invited to participate. Of 70 approached, 19 met inclusion criteria and were enrolled. The trial was conducted between April 14, 2021, and January 5, 2023.

Interventions

A single dose of synthetic psilocybin, 25 mg, was administered. Psychotropic medications were discontinued at least 2 weeks prior to dosing. Therapists met with patients for 3 sessions during pretreatment, during the 8-hour dosing day, and for 3 integration sessions posttreatment.

Main Outcomes and Measures

The primary outcome measure was change in Montgomery-Åsberg Depression Rating scale (MADRS) at 3 weeks posttreatment. Secondary measures included MADRS scores 12 weeks posttreatment, the self-rated Quick Inventory of Depression Symptoms-Self Rating (QIDS-SR), and the self-rated Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), each completed at baseline and all subsequent visits. Safety measures included the Columbia Suicide Severity Rating Scale (CSSRS) and the Young Mania Rating Scale (YMRS) completed at each visit.

Results

Of the 15 participants in this study (6 male and 9 female; mean [SD] age, 37.8 [11.6] years), all had lower scores at week 3, with a mean (SD) change of -24.00 (9.23) points on the MADRS, (Cohen d = 4.08; 95% CI, -29.11 to -18.89; P < .001). Repeat measures analysis of variance showed lower MADRS scores at all tested posttreatment time points, including the end point (Cohen d = 3.39; 95% CI, -33.19 to -16.95; adjusted P < .001). At week 3, 12 participants met the response criterion (50% decrease in MADRS), and 11 met remission criterion (MADRS score ≤10). At the study end point, 12 patients met both response and remission criteria. QIDS-SR scores and Q-LES-Q-SF scores demonstrated similar improvements. YMRS and CSSRS scores did not change significantly at posttreatment compared to baseline.

Conclusions and Relevance

The findings in this open-label nonrandomized controlled trial suggest efficacy and safety of psilocybin with psychotherapy in BDII depression and supports further study of psychedelics in this population.

The mental health impact of contact with COVID-19 patients on healthcare workers in the United States

This study assessed the relationship between contact with COVID-19 patients and the mental health of healthcare workers (HCWs) in the United States (US). In a convenience sample of 957 HCWs who completed an anonymous online survey between April-May 2020, HCWs who provided direct care to confirmed or suspected COVID-19 patients reported increased depressive and posttraumatic symptoms compared to HCWs with no COVID-19 patient contact. Additionally, more frequent contact was associated with higher distress. More data drawn from diverse samples that better represent US HCWs are needed to fully assess the scope of this association.

Metastatic melanoma to the ovary in pregnancy: A case report

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Metastatic melanoma to the ovary is uncommon and can occur years after initial diagnosis.

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Ovarian metastatic melanoma can mimic various benign lesions on imaging and clinical history is key.

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If any suspicion in pregnancy, placenta should be evaluated due to possibility of transplacental transmission.

Metastatic melanoma to the ovary is an uncommon presentation. We report a case of metastatic melanoma to the ovary that presented as a growing left adnexal mass during pregnancy and was thought to be benign by imaging and frozen section pathology. Here we discuss the challenges in radiologic and pathologic diagnosis, as well as considerations for the mother and newborn.

A case of multiple AOT-like jawbone lesions in a young patient--a new odontogenic entity?

We assessed the immunohistochemical profile of an unusual case of multiple similarly looking tumors in the jawbone of a young patient. Histologically, the tumors exhibited features of adenomatoid odontogenic tumor (AOT) and adenomatoid dentinoma but showed no resemblance to any other defined odontogenic tumor entities. They expressed high amounts of cytokeratin (CK) 8 and 14 together with some Vimentin. A small rim of peripheral cells showed CK 5, 17, and 19 reactivity. Also, these lesions expressed some bcl-2 as well as p53 and Ki67. Histologically and immunohistochemically, the unusual multiple lesions differed in details from a simultaneously examined group of 24 classical AOT cases, suggesting that they may represent a hitherto less well-defined odontogenic tumor entity.

Relationship between velocity and temporal variables of the flat shod running walk

The running walk of the Tennessee Walking Horse is often described as a faster variation of the walk, indicating the importance of velocity on the mechanics of the gait. Variations in gait variables create difficulties in clearly identifying the normal and abnormal running walk in a clinical evaluation. The objectives of this study were, therefore, to describe the flat shod running walk and to determine the relationship between velocity and the running walk. From frame-by-frame analysis of 60 Hz film, temporal variables were averaged for 6 strides from 6 horses performing an 'easy' (slow) and 'strong' (fast) running walk during a flat shod, easy-rider Tennessee Walking Horse show class. The running walk at both velocities was a 4-beat, symmetrical stepping gait with a lateral footfall sequence and lateral couplets. The velocity ranged from mean +/- s.d. 2.66 +/- 0.34 to 3.80 +/- 0.18 m/s. For both velocities (slow, fast), hind stance as a percentage of stride duration (58 +/- 3%, 56 +/- 2%) was significantly longer than fore (51 +/- 5%, 48 +/- 1%); diagonal advanced placement (29 +/- 2%, 37 +/- 4%) and lift-off (35 +/- 5%, 39 +/- 2%) were significantly longer than lateral (advanced placement: 22 +/- 2%, 12 +/- 3%; lift-off: 18 +/- 4%, 10 +/- 2); and lateral bipedal support (50 +/- 9%, 67 +/- 7%) was significantly longer than diagonal (27 +/- 6%, 16 +/- 4%). Strong correlations were found between velocity and diagonal advanced placement (0.640), lateral lift-off (-0.924) and diagonal (-0.648) and lateral (0.904) bipedal support. Understanding the running walk and the gait variations due to velocity may be important to both the performance and soundness of the Tennessee Walking Horse.

Bacterial peptidoglycan-induced tnf-alpha transcription is mediated through the transcription factors Egr-1, Elk-1, and NF-kappaB

Bacteria and their ubiquitous cell wall component peptidoglycan (PGN) activate the innate immune system of the host and induce the release of inflammatory molecules. TNF-alpha is one of the highest induced cytokines in macrophages stimulated with PGN; however, the regulation of tnf-alpha expression in PGN-activated cells is poorly understood. This study was done to identify some of the transcription factors that regulate the expression of the tnf-alpha gene in macrophages stimulated with PGN. Our results demonstrated that PGN-induced expression of human tnf-alpha gene is regulated by sequences proximal to -182 bp of the promoter. Mutations within the binding sites for cAMP response element, early growth response (Egr)-1, and kappaB3 significantly reduced this induction. The transcription factor c-Jun bound the cAMP response element site, Egr-1 bound the Egr-1 motif, and NF-kappaB p50 and p65 bound to the kappaB3 site on the tnf-alpha promoter. PGN rapidly induced transcription of egr-1 gene and this induction was significantly reduced by specific mutations within the serum response element-1 domain of the egr-1 promoter. PGN also induced phosphorylation and activation of Elk-1, a member of the Ets family of transcription factors. Elk-1 and serum response factor proteins bound the serum response element-1 domain on the egr-1 promoter, and PGN-induced expression of the egr-1 was inhibited by dominant-negative Elk-1. These results indicate that PGN induces activation of the transcription factors Egr-1 and Elk-1, and that PGN-induced expression of tnf-alpha is directly mediated through the transcription factors c-Jun, Egr-1, and NF-kappaB, and indirectly through the transcription factor Elk-1.

Family income and crowd out among children enrolled in Massachusetts Children's Medical Security Plan

OBJECTIVE

To assess whether participation in a state publicly financed health insurance program, Massachusetts Children's Medical Security Plan (CMSP) , which is open to children regardless of income, was associated with disenrollment from private insurance.

DATA SOURCES/STUDY DESIGN

A survey of participants in CMSP who were enrolled as of April 1998 was used. We conducted analyses to detect differences in access to and uptake of private insurance between Medicaid-eligible and in eligible children, and between children eligible for the State Children's Health insurance Program (SCHIP) and in eligible children.

DATA COLLECTION METHODS

A stratified sample of children was drawn from administrative files. the sampling strategy allowed us to examine crowd out among children based on in come and eligibility for publicly funded coverage: those who were Medicaid-eligible (income pound 133 percent of the federal poverty level [FPL]) , those who were SCHIP-eligible (134-200 percent of FPL) , and those with family in comes that exceed SCHIP eligibility criteria (> 200 percent of FPL). The majority of telephone interviews were conducted with the child's parent/guardian between November 1998 and March 1999. The overall response rate was 61.8 percent , yielding a sample of 996 children.

PRINCIPAL FINDINGS

Of the children in our sample whose recent health coverage was employer-sponsored insurance (59 percent), 70 percent were no longer eligible. Few children who had employer-sponsored insurance at enrollment dropped this coverage to enroll in CM SP (1 percent, 4 percent, and 2 percent by income). Compared to Medicaid-eligible children, children with incomes > 133 percent of FPL were significantly more likely to be eligible for employer-sponsored insurance but they were no more likely to have purchased offered coverage. Access to employer-sponsored insurance was limited (19 percent), and uptake was low (13 percent). We found no significant difference between SCHIP-eligible children and those whose family incomes exceeded SCHIP guidelines.

CONCLUSIONS

The Massachusetts experience suggests that (1) coverage could be expanded to children with incomes up to 200 percent of FPL with little direct substitution of public coverage for private insurance, and (2) substitution among children with incomes > 200 percent of FPL, who paid a premium that may have restrained crowd out, did not differ from that among SCHIP-eligible children.

Markets for individual health insurance: can we make them work with incentives to purchase insurance?

Simple income-based incentives to purchase health insurance (tax credits or deductions, or subsidies) are unlikely to succeed in significantly reducing the number of uninsured because income is not a good predictor of the extent to which individuals use medical service. Proposals to provide incentives to low-income people so they will purchase individual health insurance need to address the inherent tension between the interests of low-risk and high-risk people who rely on individual coverage. If carriers are forced to cover all applicants and to community rate premiums, low-risk people will drop coverage or not apply for it because premiums will exceed their expected need for insurance. Concern for people who currently have access to individual coverage calls for careful examination of options to permit incentive programs to succeed with the individual insurance markets. In particular, attention should focus on using alternatives to simple income-based subsidies to spread the burden of high-risk people's costs broadly, rather than impose the costs on low-risk people who purchase individual coverage. This paper describes three such alternatives. One uses risk adjustments and two rely on reinsurance so that carriers are compensated for the higher costs of covering high-risk people who use incentives to buy insurance. One alternative also permits risk selection by insurance carriers.

The effectiveness of housing policies in reducing children's lead exposure

OBJECTIVES

This study evaluated the relation of housing policies to risk of subsequent lead exposure in addresses where lead-poisoned children had lived.

METHODS

Addresses where children with lead poisoning lived between May 1992 and April 1993 were selected from lead screening registries in 2 northeastern states differing in their enforcement of lead poisoning prevention statutes. Blood lead levels of subsequently resident children, exterior condition, tax value, age, and census tract characteristics were collected. The odds of elevated blood lead levels in subsequently resident children were calculated with logistic regression.

RESULTS

The risk of identifying 1 or more children with blood lead levels of 10 micrograms/dL or greater was 4 times higher in addresses with limited enforcement. Controlling for major confounders had little effect on the estimate.

CONCLUSIONS

Enforcement of housing policies interrupts the cycle of repeated lead exposure.

Adverse selection and price sensitivity when low-income people have subsidies to purchase health insurance in the private market

Policymakers interested in subsidizing low-income people's purchase of private insurance face two major questions: will such subsidies lead to adverse selection, and how large do the subsidies have to be to induce large numbers of eligible people to purchase the insurance? This study examines New Jersey's short-lived experience with a premium subsidy program, Health Access New Jersey (Access Program). The program was for people in families with incomes below 250% of the poverty level who were not eligible for health insurance provided by an employer, or Medicaid or Medicare, and who wished to purchase policies in the state's individual health insurance market, the Individual Health Coverage Program. Surveying a random sample of Access Program policyholders, we compared their demographic and socioeconomic characteristics, as well as their health status, to those of other New Jersey residents who had family incomes below 250% of the poverty level to determine whether there was any evidence of adverse selection among the people who enrolled in the Access Program. The people who enrolled were not in worse health than uninsured people with incomes below 250% of the poverty level, but they were quite price sensitive. Most enrollees had incomes within the low end of the income eligibility distribution, reflecting the structure of rapidly declining subsidies as income increased.

Meeting information needs: lessons learned from New Jersey's Individual Health Insurance Reform Program

At national and state levels, there have been significant changes in the regulations governing individual and small group health insurance markets. Reforms to the individual health insurance market in New Jersey exemplify the challenges of informing consumers about changes in the regulation of insurers, where the changes are intended to simplify and broaden access to health insurance. To best take advantage of expanded access to coverage under new regulations governing the individual health insurance market, individuals need to understand the changed rules under which carriers determine eligibility and premiums. Survey results from New Jersey indicate, however, that a significant proportion of people who purchased policies under the restructured individual health insurance market did not fully understand how the new market operates.

Can adverse selection be avoided in a market for individual health insurance?

Adverse selection is a potentially significant problem in the individual (nongroup) health insurance markets if states use regulations to restrict insurance companies' ability to select whom they will insure. In 1993, New Jersey implemented the Individual Health Coverage Program (IHCP), presenting an opportunity to test for adverse selection when insurers' ability to select enrollees is severely restricted. The authors collected socioeconomic, demographic, and health status data from a sample of 2,211 adults covered by IHCP policies and compared the IHCP enrollee characteristics with those of two control groups of New Jersey residents (uninsured adults and adults with employer group insurance). Adverse selection does not appear to have occurred against the IHCP. However, the IHCP premiums were not cheap, and the findings suggest that people who can afford to purchase individual insurance and do so are, on average, healthier than those who do not choose to enroll, probably because the latter cannot afford insurance.

The effect of change of health insurance on access to care

This study examines how changes in health insurance status affect patients and their care. Results show that, controlling for socioeconomic factors, condition, age, and urgency, patients who lost insurance and patients who changed insurance were more likely to delay seeking care within the four months after visiting an emergency department than people whose health insurance status did not change. Patients who lost coverage were more likely to report no primary care provider and were less likely to have recommended follow-up care within the four-month period. Loss of insurance also was associated with lower likelihood of vaccine use and check-ups in the prior year. The study confirms that a loss or change in health insurance in the prior year has a measurable effect on access to health care. The greatest impact was among patients who lost insurance, though patients who changed health plans also were more likely to delay seeking care than patients whose health insurance status did not change.

Wavelet analysis of neuroelectric waveforms: a conceptual tutorial

This paper presents a nontechnical, conceptually oriented introduction to wavelet analysis and its application to neuroelectric waveforms such as the EEG and event related potentials (ERP). Wavelet analysis refers to a growing class of signal processing techniques and transforms that use wavelets and wavelet packets to decompose and manipulate time-varying, nonstationary signals. Neuroelectric waveforms fall into this category of signals because they typically have frequency content that varies as a function of time and recording site. Wavelet techniques can optimize the analysis of such signals by providing excellent joint time-frequency resolution. The ability of wavelet analysis to accurately resolve neuroelectric waveforms into specific time and frequency components leads to several analysis applications. Some of these applications are time-varying filtering for denoising single trial ERPs, EEG spike and spindle detection, ERP component separation and measurement, hearing-threshold estimation via auditory brainstem evoked response measurements, isolation of specific EEG and ERP rhythms, scale-specific topographic analysis, and dense-sensor array data compression. The present tutorial describes the basic concepts of wavelet analysis that underlie these and other applications. In addition, the application of a recently developed method of custom designing Meyer wavelets to match the waveshapes of particular neuroelectric waveforms is illustrated. Matched wavelets are physiologically sensible pattern analyzers for EEG and ERP waveforms and their superior performance is illustrated with real data examples.

Insurance or a regular physician: which is the most powerful predictor of health care?

OBJECTIVES

This study compared the relative effects on access to health care of relationship with a regular physician and insurance status.

METHODS

The subjects were 1952 nonretired, non-Medicare patients aged 18 to 64 years who presented with 1 of 6 chief complaints to 5 academic hospital emergency departments in Boston and Cambridge, Mass, during a 1-month study period in 1995. Access to care was evaluated by 3 measures: delay in seeking care for the current complaint, no physician visit in the previous year, and no emergency department visit in the previous year.

RESULTS

After clinical and socioeconomic characteristics were controlled, lacking a regular physician was a stronger, more consistent predictor than insurance status of delay in seeking care (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2, 2.1), no physician visit [OR] = 4.5%, 95% CI = 3.3, 6.1), and no emergency department visit (OR = 1.8, 95% CI = 1.4, 2.4). For patients with a regular physician, access was no different between the uninsured and the privately insured. For privately insured patients, those with no regular physician had worse access than those with a regular physician.

CONCLUSIONS

Among patients presenting to emergency departments, relationship with a regular physician is a stronger predictor than insurance status of access to care.

Insurance agents: ignored players in health insurance reform

In this paper we use the reforms to the individual health insurance market in New Jersey to illustrate the intricate interaction between insurance agents and insurance reform initiatives. Until recently, policymakers who designed reforms to the health insurance market largely ignored the role of agents in selling individual health insurance policies. These reforms have the potential to overturn the agent's traditional role, and agents can influence how the reforms are implemented.

Changes in the 1995 Current Population Survey and estimates of health insurance coverage

This analysis compares the March 1994 and March 1995 Current Population Survey (CPS) counts of the numbers of people with different types of health insurance and without any health insurance coverage. The findings contain some surprises: there were no changes in the numbers of nonelderly people with Medicaid coverage and without any health insurance, and there were increases in the numbers of nonelderly people with employer-sponsored health insurance and with CHAMPUS/VA/military health care. Four changes were introduced in the CPS in 1995 and were likely, by themselves, to both raise and lower the estimates of the numbers of people with specific types of health insurance coverage. Three of the changes relate to questions about health insurance coverage; they coincide with the traditional mid-decade shift in the sample framework for the CPS.

Integrated health care, capitated payment, and quality: the role of regulation

Concerns about the effect of managed care techniques on the quality of medical care have been raised in many quarters. Physicians have advocated the reiteration of professional ethics or even the prohibition of market incentives in health care as solutions to the problem of cost-quality tradeoffs in managed care systems. However, few recognize the existing systems for the regulation of managed care or consider how additional regulation could alleviate some of the potential problems posed by market-based competition. We review the evolution and growth of managed care organizations and the payment techniques that could cause a conflict between patient welfare and physician income. We then discuss the existing types of federal and state regulation of managed care and suggest some new incentives that could buttress the ethical practice of medicine in the medical marketplace.