Journal of Clinical Psychiatry最新文献

Objectives: Unwanted intrusive thoughts (UITs) of intentional infant-related harm are common among birthing parents. Evidence to date has failed to find any association with physical aggression toward the infant. However, the relationship between UITs of infant-related sexual harm and sexual behaviors toward the infant has yet to be assessed. This is the purpose of the current study.

Methods: Data were collected from February 9, 2014, to February 14, 2017, via a prospective, province-wide, unselected cohort of N = 763 English-speaking birthing parents, n = 502 of whom provided data for the current analysis. Interview assessments of UITs of infant-related sexual harm were administered at approximately 7 weeks postpartum and 4 months postpartum. Sexual harming behaviors toward the infant were assessed via an anonymized questionnaire at the end of the study.

Results: UITs of infant-related sexual harm were reported by 9.2% (n = 38; 95% CI, 6.6-12.4) of participants. We found no evidence of an association between UITs of this nature and sexual behavior toward one's infant (Fisher exact, P = 1.00). Only 1 participant reported engaging in sexual behavior toward their infant, and they did not report any UITs of infant-related sexual harm.

Conclusions: Study findings add to growing evidence that UITs of infant-related harm are common, and when these thoughts are unwanted and intrusive, they are not associated with an increased risk of actually harming one's infant. Although findings suggest that this is also true for UITs of infant-related sexual harm and sexual behavior, due to the small sample employed in this research, replication with a larger sample is needed.

Objective: Suicide is a major public health concern with a significant global impact. Among children and adolescents, an increasing incidence of suicidal behavior is being observed. Several studies have noted an increase in the number of emergency department (ED) consultations involving children and adolescents presenting with self-injurious thoughts and behaviors (SITB). However, few studies have yet described risk factors associated with these repeated visits.

Methods: Our sample included all patients under 18 years of age who visited the Child and Adolescent Mental Health ED at Hospital Universitario 12 de Octubre between January 2, 2022, and November 30, 2023. A baseline interview was conducted by an attending psychiatrist during the patient's first emergency visit, followed by a review of their digital medical records 6 months later by the hospital's clinical staff.

Results: A total of 713 patients were treated in the ED during the study period, of whom 429 (60.16%) presented with suicidal behavior. Within 6 months of the initial ED visit, 25.4% of patients returned due to SITB. Specifically, 21.7% of those who initially attended for SITB returned for the same reason. Among patients who initially presented with suicidal ideation or suicide attempts, 25.8% and 25.3%, respectively, returned within 6 months. The variables independently associated with returning to the ED for SITB after the initial visit were nonheterosexual sexual orientation (odds ratio [OR]=2.10; 95% CI, 1.14-3.87) and prior SITB (OR=2.14; 95% CI, 1.27-3.60).

Conclusions: In our study, we found that a significant number of children and adolescents who come to the ED for SITB return for the same reason within 6 months. There is also a certain amount of switching between different types of SITB consultations, particularly from ideation to attempt. This should alert us to the significant recurrence of these consultations and the fact that mental health resources continue to be insufficient to address these behaviors.

Objective: Treatment-resistant depression (TRD) affects one-third of patients with major depressive disorder, leading to increased morbidity, health care costs, and suicide risk. TRD lacks a standardized definition, complicating treatment selection. Current guidelines often group treatments broadly without clear prioritization, and evidence gaps persist, particularly regarding newer interventions and real-world clinical complexity. A simulated case-based discussion, modeling a modified Delphi consensus, was conducted to offer a clinical perspective to this gap.

Participants: A panel of 10 psychiatrists, directly engaged in the treatment of TRD at the Mayo Clinic Depression Center, participated in the surveys.

Evidence: Results represent expert opinion from participants. The process included an initial group review of TRD, where participants reviewed and presented a summary on each TRD treatment option, followed by discussion.

Process: Using a structured clinical vignette of a patient with TRD after 3 antidepressant trials, statements regarding next-step treatments were created through iterative ranking of options. Six vignette variations reflecting common clinical considerations (eg, metabolic disease, age) were included. Agreement was measured in 3 anonymous survey rounds, with group discussions in between.

Conclusions: Strong consensus emerged recommending augmentation with second-generation antipsychotics, transcranial magnetic stimulation, and ketamine/ esketamine as next-step treatments in the base vignette. Treatment preferences shifted to include nonaugmentative antidepressants and electroconvulsive therapy based on changes in patient characteristics. This study highlights the importance of tailoring treatment strategies for TRD to patient factors that extend beyond conventional guideline tiers. Integrating multidisciplinary perspectives and patient preferences holds promise for enhancing therapeutic selection and advancing personalized care in TRD.

Background: During the past 2 decades, there has been intense interest in the clinical significance of the concurrence of manic symptoms in depressed patients. DSM-5 introduced a mixed features specifier for both bipolar depression and major depressive disorder. Studies of the DSM-5 mixed features specifier have generally found a low prevalence of mixed depression. One approach toward increasing the sensitivity of the DSM-5 mixed features criteria is to lower the classification threshold. In the present study, we examine the impact of lowering the DSM-5 diagnostic threshold from 3 to 2 criteria on the prevalence and validity of the DSM-5 mixed features specifier for depression.

Methods: Four hundred fifty-nine psychiatric patients in a depressive episode were interviewed by a trained diagnostic rater who administered semistructured interviews including the DSM-5 Mixed Features Specifier Interview. The patients were rated on clinician rating scales of depression, anxiety, and irritability and measures of psychosocial functioning, suicidality, and family history of bipolar disorder.

Results: When the DSM-5 diagnostic threshold was lowered from 3 to 2 symptoms, the prevalence of mixed features based on the DSM-5 majority of episode time frame tripled from 3.9% to 13.1% (n=60). Based on a past week time frame, the prevalence of mixed features more than doubled from 9.4% to 22.9% (n=105) upon lowering the threshold from 3 to 2 criteria. However, there was no difference between the patients with 2 mixed features and patients with 0 or 1 mixed features on family history of bipolar disorder, psychosocial impairment, presence of comorbid disorders, age of onset, or history of suicide attempts or psychiatric hospitalization.

Conclusions: The results of the present study do not support lowering the DSM-5-TR diagnostic threshold for the mixed features specifier in depressed patients from 3 to 2 criteria.