Journal of Psychiatric Practice最新文献

Psychiatrists increasingly practice psychotherapy by integrating their therapeutic training into brief medication visits. Insurance companies reimburse this approach using the 90833 Current Procedural Terminology code, which corresponds to 16-37 minutes of add-on psychotherapy combined with pharmacotherapy. As scholarship focused on such short-form combined therapy is scarce, this 4-part series addresses this practice gap, providing guidance to practicing professionals. This introductory installment reviews recent evolutions in psychotherapy training, the existing literature on abbreviating psychotherapy techniques, and some general guidelines and principles for adapting psychotherapy to shortened visits and selecting a specific therapeutic modality.

The interplay between psychiatric and neurological disorders often complicates diagnostic processes, leading to significant challenges in distinguishing between mental illnesses and neurological conditions. This complexity is further exacerbated by diagnostic overshadowing, a phenomenon where symptoms of one disorder may mask or alter the perception of the other. Through the lens of a nuanced case, we chronicle the journey of a 73-year-old male with longstanding schizophrenia whose later development of motor symptoms was initially attributed to side effects of his psychiatric medication. As his general condition tended to worsen over time, a more in-depth investigation revealed a more profound neurological underpinning, illustrating the perilous path of misdiagnosis that persisted for several months. We also interweave a brief review of analogous cases in the literature that underscore the impact of decision-making errors in medical practice, highlighting the necessity for critical thinking, continuous vigilance, and the implementation of strategies to mitigate diagnostic errors.

Non-suicidal self-injury (NSSI) is a significant clinical concern in adolescents. The goal of this study was to evaluate the efficacy of group interpersonal psychotherapy (G-IPT) combined with treatment as usual (TAU) compared with TAU alone in treating adolescents with NSSI. A randomized controlled trial was conducted in a psychiatric outpatient clinic in Hubei Province, China, involving 52 adolescents 12 to 17 years of age diagnosed with NSSI. Participants were randomly assigned to either the G-IPT combined with TAU group (n=26), who received 12 additional G-IPT sessions, or the TAU-alone group (n=26). Outcomes were assessed using the Ottawa Self-Injury Inventory (OSI), 9-item Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Interpersonal Disturbances Scale (IDS), and Interpersonal Communication Scale (ICS) at pre-treatment [Time Zero (T0)], immediately after completion of G-IPT, or 12 weeks after baseline assessment in the TAU group [Time 1 (T1)], and 3 months after treatment [Time 2 (T2)]. Forty-eight participants completed all assessments. The primary outcomes included a reduction in NSSI frequency and an increase in participants' ability to resist NSSI. Results demonstrated reductions in the OSI item "NSSI in the last month" at T1 (P<0.001) and T2 (P=0.008), as well as significant improvements in the OSI item "Strength to resist NSSI" (P<0.001 at T1; P=0.001 at T2). Significant between-group and interaction effects were observed, indicating that G-IPT combined with TAU was more effective than TAU alone in reducing NSSI behaviors. These findings underscore the potential of G-IPT as an effective adjunct to TAU in clinical settings for adolescent NSSI intervention.

Objective: The ethical complexity within psychiatric evaluations of decision-making capacity (DMC) often involves more than determining whether a patient retains DMC. Some psychiatrists propose that DMC evaluation may be requested due to distress regarding additional ethical dilemmas, even when capacitation status is not questioned. The present study quantitatively illustrates this additional ethical complexity and provides greater transparency regarding additional areas that may require psychiatric facilitation of care when consulted for the evaluation of DMC.

Methods: A total of 145 DMC evaluation case encounters were retrospectively analyzed for the presence of 27 total additional ethical context factors. Factor prevalence and number of factors per case were calculated. Cooccurrence of ethical context factors was determined through Fisher exact test pairwise comparisons.

Results: Almost all cases (93.1%) featured ≥1 additional ethical context factor (range = 0 to 13 factors/case). The most common factors included inpatient treatment refusal or nonadherence (34.5%), leaving against medical advice (26.2%), concerns about nonadherence to outpatient treatment (25.7%), surrogate determination (22.1%), palliative care and hospice consideration (20.7%), and disposition conflict (20.7%). Several ethical context factors demonstrated significant pairwise cooccurrence, many of which involved mandatory reporting of abuse and neglect.

Conclusions: Clinical scenarios encountered in DMC evaluations often contain ethical complexities beyond clarifying capacitation status. Often, consultation with psychiatrists to evaluate DMC may reflect the underlying desire for management of additional ethical context factors. The unique skillset of consultation liaison psychiatrists can help both patients and medical teams navigate these complicated clinical trajectories. Screening for additional ethical context factors in DMC evaluations may enable the facilitation of optimal care.

Objective: The authors sought to examine the racial and ethnic makeup of patients treated with transcranial magnetic stimulation (TMS) for treatment-resistant depression at an urban, Midwestern academic center.

Methods: This retrospective chart review study examined patients treated with TMS at the academic center from July 2018 to February 2024. Symptom scores were recorded before TMS initiation and following the course of treatment. Associations of gender, insurance status, and race with response or remission were compared using chi-squared tests. Association of age with response or remission was compared using paired t-tests.

Results: Of the 71 patients treated, roughly half responded, and a third of the total sample remitted. Only 6 patients (9%) identified as a racial minority, all of whom responded. There was no statistically significant association of age or insurance status with response or remission.

Conclusions: Racial and ethnic minorities were underrepresented in this treatment population. Our work suggests efforts are needed to address this disparity.

While psychiatric adverse effects to corticosteroids have been widely reported in the literature, only 6 reports of new-onset, steroid-induced obsessive-compulsive disorder (OCD) have been published. This article discusses what, to our knowledge, is the first reported case of oral budesonide-associated steroid-induced OCD. The patient was a 73-year-old female with a psychiatric history of bipolar disorder who developed pedophilic obsessive-compulsive symptoms as part of a constellation of psychiatric symptoms 14 days after starting oral budesonide 9 mg/d for the maintenance treatment of lymphocytic colitis. Following treatment recommendations for general psychiatric adverse effects to steroids, the patient was restarted on her original medications, tapered off budesonide over 14 days, and started on brexpiprazole 2 mg/d. The patient's symptoms fully resolved within 14 days of starting treatment. While this case demonstrates many risk factors for the general psychiatric adverse effects of steroids, there are notable differences between the characteristics shared by the reviewed cases of steroid-induced OCD and this case. This finding suggests that risk factors for steroid-induced OCD may vary from the general risk factors for psychiatric adverse effects and should be further researched. Despite some differences, both this case and previous cases in the literature demonstrated a resolution of OCD symptoms following discontinuation of the corticosteroid, adding evidence to current recommendations of discontinuing the corticosteroid, when possible, to treat steroid-induced psychiatric symptoms. Finally, despite a warning on the drug label concerning compulsive behaviors, augmentation with brexpiprazole was associated with a resolution of symptoms in this case. Brexpiprazole should be further researched for possible uses in both steroid-induced OCD and primary OCD.

Background: Race and ethnicity are important but often underexamined factors in psychopharmacology research and clinical practice. This review summarizes key findings on ethnic and racial considerations for researchers, medical practitioners, and clinical psychopharmacologists. We hope it serves an important function in highlighting a critically important, yet still emerging issue to inform research and therapeutic use of psychotropics to improve their effectiveness.

Methods: We queried major databases (PubMed, PsycInfo, Embase) using a search strategy that included MeSH (Medical Subject Headings) terms and conducted a snowball search to identify studies addressing ethnic or racial aspects of psychopharmacological practice. Findings were synthesized and presented in clinically applicable areas.

Results: The clinically relevant ethnic and racial considerations identified in this review can be broadly categorized into the following areas: (1) variations in therapeutic and adverse dose-responses (eg, non-Whites attaining therapeutic and adverse effects at lower doses with certain medications); (2) interracial differences in prescription patterns of psychotropics, with lower prescription rates among under-represented minority groups and greater use of first-generation antipsychotics in African American populations; and (3) variations in attitudes toward psychopharmacotherapy. While differences in medication response can be partially explained by genetic variations in metabolism or receptor sensitivity, systemic racism and social determinants of health continue to have an influence.

Conclusions: The evidence base for ethnic and racial considerations in psychopharmacology research and clinical practice continues to evolve with growing consideration for diversity and inclusivity in training, research, and clinical practice. This is critical to promoting equitable and effective care to a diverse population. Key questions are highlighted to draw attention to these critical needs.

Psychodynamic therapy (PDT), a technical adaptation of psychoanalysis, is one of the most widely practiced forms of psychotherapy, making evaluative research on it essential. Although research on PDT has been ongoing for several decades, theoretical and practical challenges initially hindered the adoption of evidence-based medicine standards in such research, a shift that has largely taken place over the past 20 years. This article reviews the evolution of evaluative research on PDT for mental disorders in adults, with a focus on those with complex conditions. Since the first prospective evaluative studies in the 1950s, an accumulating body of knowledge-including cohort studies, randomized controlled trials, and meta-analyses-has established PDT as an evidence-based treatment for common mental disorders such as depression, anxiety, somatic symptoms and related disorders, and personality disorders, as well as complex mental disorders involving combinations of these conditions. There is also evidence supporting PDT's usefulness in treating anorexia nervosa and opioid dependence, along with some findings suggesting its potential use for schizophrenia spectrum disorders, bulimia nervosa, and posttraumatic stress disorder. Recent studies indicate that PDT can serve as a personalized treatment, promoting deep and lasting psychopathological changes in patients with severe, complex, and chronic mental disorders, involving specific technical features and mechanisms of change. These findings support the inclusion of PDT in mental health care policies and training, while ongoing research continues to explore its optimal treatment parameters.