Journal of Psychiatric Practice最新文献

Untreated peripartum psychiatric illness is a major public health concern, with significant effects for both pregnant women and their infants. Despite high levels of need, barriers to care continue to obstruct access for women in the preconception, pregnant, and postpartum periods. Evidence from randomized controlled trials suggests that perinatal collaborative care service models can improve access and reduce mental health burden for peripartum women with posttraumatic stress and depression. However, the literature describing the implementation of such programs outside of formal clinical trials is sparse. Here, we report on our service model at the Maternal Outpatient Mental Health Services (MOMS) clinic, a collaborative care clinic within the Obstetrics and Gynecology department. We describe how we implement the core, evidence-based pillars of our model, including (1) integration into primary care, (2) coordinated care support, (3) attention to the parent-infant relationship, (4) trauma-informed care, and (5) measurement-based care. We report on descriptive data at intake from 204 pregnant and postpartum women who presented to our clinic between August 2023 and June 2024. We conclude with a reflection on the successes and challenges of this model as well as a discussion about future directions for the clinic.

This column completes a 3-part series offering an overview of psychodynamic therapy for trainees and their teachers seeking an accessible summary of key theoretical and technical elements. In a sense, this series is a quick start guide to psychodynamic therapy. This third column in the series summarizes the concept of projective identification, explains how projective identification contributes to the phenomenon of enactment, and addresses the importance of learning to detect, analyze, and utilize enactments. It also addresses the tension between making the unconscious conscious and "being with" patients in psychodynamic therapy. Finally, this column offers comments on how to put together and utilize all of the elements provided in this series.

Objective: A significant number of individuals with major depressive disorder (MDD) do not respond adequately to first-line treatment with selective serotonin reuptake inhibitors (SSRIs). Approximately 30% of patients fall into this category and often require a switch to a second-line antidepressant. These patients frequently experience more severe and persistent symptoms, along with an elevated risk of suicide. Switching to an alternative monotherapy such as duloxetine or bupropion is a common strategy in cases with inadequate response to SSRIs. Bupropion, in use for over 2 decades, works by inhibiting the reuptake of dopamine and norepinephrine and is sometimes used alongside SSRIs. Duloxetine, a serotonin-norepinephrine reuptake inhibitor, has demonstrated strong efficacy, safety, and tolerability in the treatment of MDD. However, antidepressants can occasionally increase suicidal thoughts or behaviors, particularly among adolescents. Therefore, the goal of this study was to compare not only the therapeutic outcomes of duloxetine and bupropion, but also the rates of any suicide attempts in female adolescents while taking these medications.

Methods: This retrospective study analyzed medical records of 990 female adolescents diagnosed with MDD who were treated with either duloxetine (120 mg/d; n=464) or bupropion (300 mg/d; n=526). Patients were selected according to strict inclusion and exclusion criteria and followed for up to 24 weeks. Clinical data were extracted from charts at time points corresponding approximately to weeks 4, 8, 12, 16, 20, and 24. Depression severity and treatment outcomes were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) and Goal Attainment Scaling for Depression (GAS-D). The sensitivity of MADRS to symptom changes was also evaluated. Suicide attempts were identified using ICD-9 codes (E950 to E959), clinical notes, and related medication history involving SSRIs and serotonin-norepinephrine reuptake inhibitors.

Results: The findings from the study revealed that bupropion led to a greater reduction in depressive symptoms compared with duloxetine. In addition, the incidence of suicide attempts was higher in the duloxetine group than in the bupropion group.

Originality: This study is distinct in its focus on female adolescents with MDD, applying a triple-blind design and utilizing both standardized (MADRS) and personalized (GAS-D) outcome measures. By including an analysis of suicide attempt rates, it offers important clinical insights into the comparative effectiveness and safety of bupropion and duloxetine in a particularly vulnerable population.

Bipolar disorder is a severe mental illness, and rates of diagnosis have risen in recent years. Accurately diagnosing bipolar disorder can be difficult when a patient is not actively manic, as screening questionnaires are not reliable diagnostic tools, patient self-report can be unreliable, and bipolar symptoms overlap with other psychiatric conditions. Much has been written about the overlap between bipolar disorder and borderline personality disorder, but many other disorders present with similar symptoms, including unipolar depression. Accurate diagnosis is important to ensure optimal treatment and patient outcomes. The goal of this article is to provide an evidence-based approach to diagnosing bipolar disorder and distinguishing it from other psychiatric disorders in clinical settings. Using the mnemonic "DIGFAST" (distractibility, impulsivity, grandiosity, flight of ideas, activity increase, sleeplessness, talkativeness), we review the DSM-5-TR diagnostic criteria for mania. Distinguishing features include the episodic nature of elevated/irritable moods, severity of symptoms, and the simultaneous occurrence of multiple manic symptoms. Insight is typically impaired in bipolar disorder, and collateral information can help improve diagnostic clarity. Hypomanic symptoms can be distinguished from other conditions by their duration and accompanying changes in functioning. A thorough clinical interview is the most important asset in making an accurate diagnosis of bipolar disorder.

Motivational interviewing (MI) is an evidence-based clinical approach that aims to assist patients in navigating ambivalence and in building motivation and commitment for behavior change. MI may be an especially helpful approach in lethal means safety (LMS) counseling, given the challenges in encouraging patients to adopt new firearm storage practices. The purpose of this 2-part series is to demonstrate how MI strategies might be applied to evoke motivation to change firearm storage practices. This column builds on part 1 of this series, in which we provided a rationale for considering an MI-based approach and discussed how the relational foundation of MI may help facilitate LMS counseling. In part 2, we focus on the technical strategies we use to evoke motivation to change behavior (eg, language and tools), including the use of "ask-offer-ask," recognizing and reflecting change talk, and using importance rulers.

"Placebo" is a short-handed way of summarizing good clinical management, or treatment as usual (TAU). While the media and others sometimes equate a placebo with a "sugar pill," by which they mean nothing, the placebo arm in a double-blind randomized controlled trial (RCT) is instead all the treatment received in such a trial except for the investigational treatment. For that reason, an antibiotic effective against bacteria causing an infection may not do better than TAU in an RCT depending on the specific conditions of the infection that the patient has. This finding is important to consider when evaluating the results of RCTs in psychiatric drug development.

This case study describes a 30-year-old patient with recurrent depressive disorder and pharmacological treatment resistance. After 2 courses of electroconvulsive therapy without significant improvement, the illness was classified as treatment-refractory. A comprehensive nutrient analysis and dietary history identified malnutrition, nutrient deficiencies, and gastrointestinal issues. By supplementing the treatment-as-usual approach with personalized nutritional and nutrient therapy, a significant reduction in depressive symptoms was achieved, and the pharmacological medication could be reduced. This case suggests that targeted nutritional and nutrient interventions may help enhance the effectiveness of pharmacological treatment and support mental health by promoting metabolic processes.

The rapid proliferation of Large Language Model (LLM)-based tools in mental health care presents an urgent need for clinical evaluation frameworks. With millions already engaging with Artificial Intelligence (AI) tools, mental health disciplines require immediate, practical evaluation approaches rather than awaiting idealized methodologies. This paper introduces a practical, implementable approach to evaluating LLM-based tools in mental health settings through both theoretical analysis and actionable assessment methods. We propose a tripartite evaluation framework comprising: (1) the technical profile layer, which assesses foundational model safety and infrastructure compliance; (2) the health care knowledge layer, which validates domain-specific clinical knowledge and safety boundaries; and (3) the clinical reasoning layer, which evaluates decision-making capabilities and reasoning processes. Each proposed layer includes concrete evaluation methods that clinical teams can implement immediately, from direct model questioning to adversarial testing approaches. As health care organizations conduct and share evaluations using this approach, the field can collectively develop the specialized benchmarks and reasoning assessments essential for ensuring LLM integrations enhance rather than compromise patient care in the mental health space. The framework serves both as an immediate practical guide and a foundation for building more sophisticated evaluation resources tailored to mental health contexts.