Early interventions in a US military FIRST episode psychosis program

AIM

Naval Medical Center San Diego's Psychiatric Transition Program is a specialized first episode psychosis treatment program that delivers coordinated specialty care to military service members with psychotic disorders. Due to the unique military environment, military service members with first episode psychosis are hypothesized to receive care very early after the emergence of first psychotic symptoms, resulting in significantly reduced duration of untreated psychosis. This study's aim is to calculate the duration of untreated psychosis for patients enrolled in Naval Medical Center San Diego's Psychiatric Transition Program (NMCSD PTP) from 01JUL2014-31DEC2016.

METHODS

Patients included in this study had a diagnosis of schizophreniform disorder (13.04%), schizophrenia (43.48%), schizoaffective disorder (8.70%), other specified schizophreniform disorder (30.43%), or brief psychotic disorder (4.35%) upon discharge from military service and NMCSD PTP. Duration of untreated psychosis was defined as the interval from emergence of positive psychotic symptoms to antipsychotic medication initiation. Duration of untreated psychosis was measured through retrospective review of the electronic medical record. A total of 69 subjects in the Naval Medical Center San Diego's Psychiatric Transition Program met inclusion criteria. Mean and median values as well as standard deviations were calculated for all included subjects.

RESULTS

The mean duration to scheduled (non-PRN) neuroleptic medication was 37 days (median: 4 days). The mean duration to PRN neuroleptic medication was 21 days (median: 2 days).

CONCLUSIONS

These data support our view that the structure of the military and military healthcare system markedly shortens the DUP for military service members who experience first episode psychosis.

Prescribing Trends in US Active Duty Service Members With Posttraumatic Stress Disorder: A Population-Based Study From 2007-2013

OBJECTIVE

The US Veterans Affairs (VA)/Department of Defense (DoD) Posttraumatic Stress Disorder (PTSD) Clinical Practice Guidelines provide evidence-based pharmacologic treatment recommendations. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are considered first-line medications. Benzodiazepines are relatively contraindicated with a warning that they may cause harm. This population-based study is the first to describe prescribing patterns for active duty service members (ADSMs) diagnosed with PTSD.

METHODS

Health-care-related administrative DoD data from federal fiscal years 2007 through 2013 identified ADSMs with PTSD using ICD-9 codes. Prescription frequencies for antidepressants, benzodiazepines, antipsychotics, anticonvulsants, and other psychotropic medications were calculated for each year.

RESULTS

Between 2007 and 2013, ADSMs with a PTSD diagnosis increased from 16,931 to 70,942. SSRI or SNRI prescribing decreased from 55.4% in 2007 to 41.8% in 2010 before increasing to 54.9% in 2013. Benzodiazepine prescribing was stable between 20.9% and 22.3% through 2010 before increasing to 24.7% by 2013. Antipsychotic prescribing declined from 22.6% in 2007 to 14.6% in 2013, driven by a decrease in low-dose quetiapine (≤ 300 mg/d) prescribing, which declined from 19.1% in 2007 to 8.2% in 2013.

CONCLUSIONS

The increase in SSRI or SNRI prescribing after 2010 and the overall increase in prazosin and decrease in low-dose quetiapine prescribing all suggest increased concordance with the VA/DoD PTSD Clinical Practice Guidelines. The decline in SSRI prescribing up to 2010 is not concordant. The increase in benzodiazepine prescribing, a trend opposite that observed in the VA, is concerning.

International trends in spice use: Prevalence, motivation for use, relationship to other substances, and perception of use and safety for synthetic cannabinoids

Synthetic cannabinoids (SC), commonly known as Spice, are a class of compounds that share affinity for the cannabinoid receptors. Recreational use of SCs has grown in recent years. A literature search was conducted of national and international organizations as well as peer-reviewed publications describing SC use in non-clinical populations. Our primary goal was summarizing SC use prevalence within the general population from representative surveys. Our secondary goals included describing SC use frequency, motivation for use, the relationship between SC use and use of other substances, and perception of SC use including beliefs about safety and use by peers. Nationally and regionally representative surveys describe lifetime prevalence of SC use in the general population as between 0.2% and 4%. Longitudinal data, though limited, shows decline in SC use with peak use occurring in the late teens and early twenties. Users tend to be males. The majority of SC users report using only a small number of times and use tends to not be sustained. The most common motive for SC use is curiosity. SC users generally report a history of extensive use of other substances. Perception of SC use by others tends to be significantly greater than actual SC use.

Limbic encephalitis presenting with seizures, anterograde amnesia, and psychosis in a patient seven weeks status post immature ovarian teratoma removal

A paraneoplastic syndrome associated with anti-N-methyl-D-asparate (NMDA) receptors can initially present as a neurologic or psychiatric disturbance. Removal of the tumor is usually curative, and the syndrome is associated with the presence, rather than the history, of tumor. We present a case in which a 25-year-old, Hispanic woman presented with seizures, memory loss, and unusual behavioral changes. The woman had a teratoma removed 2 months earlier. Because of the time course, a paraneoplastic syndrome was initially considered unlikely. Brain imaging, electroencephalography (EEG) and neurologic work-up were negative. The patient was treated for a suspected somatoform disorder and psychosis. Based on the clinical picture, the working diagnosis was changed to delirium due to paraneoplastic limbic encephalitis. A course of intravenous immunoglobins (IVIg), and high dose steroids was administered. The patient's symptoms improved, and she was discharged home. After discharge, studies came back positive for antibodies against NR1/NR2 of the NMDA receptor.