Journal of Clinical Psychiatry最新文献

Untreated depression may adversely affect pregnancy and offspring outcomes through several mechanisms; on the flip side, antidepressants used to treat depression may cross the placenta and affect the developing fetus and its brain. This article examines the research literature on gestational exposure to antidepressants and the risk of neurodevelopmental disorders (NDDs) in offspring. Two recent meta-analyses and 3 subsequently published observational studies, including 1 Asian study, are reviewed with especial focus on autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). Despite limitations of the literature, some conclusions can reasonably be drawn. In unadjusted analyses, which assist an understanding of real world risks, gestational exposure to antidepressant drugs is associated with an up to doubled risk of ASD and ADHD. However, in adjusted analyses, which assist an understanding of cause-effect relationships but not real world risks, the risks substantially attenuate and may lose statistical significance. The risks also lose statistical significance in analyses that address confounding by indication by comparing antidepressant-exposed and -unexposed pregnancies in women with psychiatric disorders. The likelihood of confounding by parental genes, parental environment, and parental health-related variables is suggested by findings that antidepressants remain significantly associated with NDDs when the exposure period is outside the pregnancy window (such as before or after but not during pregnancy) or when fathers are exposed to antidepressants during pregnancy. Finally, discordant sibling pair analyses suggest that whether or not a child develops an NDD is related to whether or not its sib has an NDD rather than whether or not the child was exposed to an antidepressant in utero. Discussion points are suggested for the shared decision-making process when counseling women about NDD risks associated with gestational exposure to antidepressant drugs. Take-home messages are summarized.

Functional recovery has emerged as a critical treatment goal in schizophrenia, extending beyond symptom reduction to encompass independent living, vocational and educational attainment, social integration, and overall quality of life. Despite advances in pharmacotherapy, many people with schizophrenia continue to experience significant functional impairments driven by persistent symptoms, cognitive deficits, comorbidities, stigma, and adverse social determinants. Psychosocial interventions have been shown to be effective in improving functional outcomes but are not extensively utilized. To address these challenges, a consensus panel of experts in psychiatry and psychology reviewed the evidence base and developed practical recommendations for optimizing functional outcomes.

Panel discussions highlighted 4 domains of functional drivers in schizophrenia: intrinsic, behavioral, comorbid/consequential, and societal/contextual, and evaluated psychosocial interventions with demonstrated benefits relative to these domains. Amidst lingering questions about further refinement and optimal individualization, evidence clearly supports the use of cognitive behavioral therapy, cognitive remediation, social skills training, supported employment and housing, and family-focused interventions; likewise, evidence supports the use of psychoeducation, motivational interviewing, mindfulness- and acceptance-based therapies, and lifestyle interventions, such as structured exercise. Implementation remains limited due to workforce shortages, resource constraints, and a lack of integration into routine care.

The panel recommends a comprehensive, patient-centered approach that integrates pharmacological treatment with evidence-based psychosocial strategies, guided by measurement-based care and individualized treatment planning. Validated functional assessment tools and emerging digital therapeutics offer scalable methods to monitor and enhance outcomes. By addressing both intrinsic and extrinsic drivers of disability, clinicians can more effectively support people with schizophrenia in achieving functional recovery and an improved quality of life.

Objective: To provide an up-to-date evaluation of valproic acid (VPA) use trends, patterns, and predictors in females of reproductive age in ambulatory care settings in the US.

Methods: A retrospective, cross-sectional study was conducted using 2017 through 2022 Medical Expenditure Panel Survey data to examine trends in VPA use. Prescription rates were calculated per 1,000 prescription events with 95% confidence intervals. VPA prescriptions were stratified by clinical indication and recipient group (females aged 12-49 years, females aged ≥50 years, and males aged 12-49 years). Multivariable logistic regression was used to identify predictors of VPA use among females aged 12-49 years and all females with comorbid bipolar disorder, headache, or seizure conditions.

Results: The cumulative total of VPA prescription events across the 2017-2022 study period was 29,754,849 (95% CI, 23,843,243-35,666,455). Of these, 5,442,682 (95% CI, 2,879,340-8,006,024) were issued to females aged 12-49 years (18.3% of all VPA prescriptions). From 2017 to 2022, VPA prescribing decreased by nearly 50% (P =.037). Most VPA prescriptions filled by females aged 12-49 years were for migraine or other headache syndromes (27.2%), followed by bipolar disorder (24.6%) and convulsions or epilepsy (20.7%). Of the estimated 153,120 females aged 12-49 years who filled a prescription for VPA between 2017-2022, 85.9% were not using contraception.

Conclusion: Approximately 1 in 5 VPA prescriptions between 2017 to 2022 were prescribed to females of reproductive age. VPA was most commonly used for the treatment of migraine or other headache syndrome, followed by bipolar disorder and convulsive disorder. Only 14.1% of females of reproductive age using VPA were also using contraception. Interventional studies aimed at reducing VPA use in females of reproductive age are needed.

Objective: The purpose of this study is to evaluate obstetric outcomes in pregnant women who received second-generation long-acting injectable antipsychotics (LAIAs) compared to a control group who received second-generation oral antipsychotics.

Methods: This was a retrospective study utilizing a global cohort of 148 health care organizations grouped into a network within the TriNetX database. Pregnant patients of any trimester were grouped into 2 cohorts: (1) exposure to long-acting aripiprazole, risperidone, paliperidone, or olanzapine (n=2,082) and (2) exposure to the corresponding oral formulations (n=31,376) and propensity matched. The primary outcome was the occurrence of one of the following obstetric complications: gestational diabetes, preeclampsia, eclampsia, or a newly diagnosed hypertensive disorder. Cesarean section rates were also assessed.

Results: After propensity matching, each cohort yielded 2,025 patients. No intergroup differences were observed in the composite primary end point, performed postmatching (odds ratio 0.95; 95% CI, 0.76-1.18; P=.61). No difference in rates of cesarean section was observed.

Conclusion: Similar rates of gestational diabetes, eclampsia, preeclampsia, and maternal hypertensive disorders were observed in women receiving long-acting injectable and oral second-generation antipsychotics.

Objective: This meta-analysis assessed the effectiveness of peer-administered interventions for treating perinatal depression or anxiety and whether variations in intervention characteristics impacted their effectiveness.

Data Sources: Records were identified through MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science until October 2024. We used terms related to the perinatal period, depression, anxiety, and peer support.

Study Selection and Data Extraction: We identified 5,700 articles, of which 19 were included and 18 were meta-analyzed. A total of 3,821 participants were included, with the majority from high-income countries. Studies involving a peer-administered intervention for perinatal depression or anxiety with a randomized controlled trial (RCT) design were eligible. Three intervention types were identified: peer-delivered psychotherapies, individual peer support, and peer discussion groups.

Results: Random-effects meta-analyses suggested that peer-administered interventions were more effective at improving depression symptoms than standard care (standardized mean difference [SMD]: -0.35; 95% CI, -0.54 to -0.17). Peer-delivered psychotherapy had the largest effect sizes (SMD: -0.51; 95% CI, -0.79 to -0.24), followed by individual support (SMD: -0.30; 95% CI, -0.63 to 0.04) and discussion groups (SMD: -0.09; 95% CI, -0.42 to 0.25). Subgroup analyses suggest that group interventions may lead to the greatest improvement. On the whole, peer-administered interventions were not effective for anxiety (SMD: -0.25; 95% CI, -0.57 to 0.08), but peer-delivered psychotherapies specifically improved anxiety symptoms (SMD: -0.63; 95% CI, -0.95 to -0.31).

Conclusions: Peer-administered interventions are effective at improving perinatal depression, with peer-delivered psychotherapies being the most effective. Large-scale RCTs are needed to explore long-term effectiveness on perinatal depression and anxiety.

Background: Bipolar disorder (BD) is a severe and chronic mental illness characterized by periods of mania/ hypomania and depression. Both disease phases are associated with increased risk of acquiring HIV. Despite this, use of highly effective preexposure prophylaxis (PrEP) for HIV prevention among people with BD is poorly understood.

Methods: We performed a retrospective cohort study using the Merative MarketScan Claims Database from 2010-2022 to identify people with BD. Additional clinical variables including outpatient encounters for sexually transmitted infections (STIs), use of long-acting injectable agents, psychiatric hospitalizations, and outpatient encounters with primary care providers (PCPs) and psychiatrists were included.

Results: There were 333,867 people with BD (61.9% female) in the cohort. A total of 435 new HIV diagnoses were identified, with diagnoses more common among males (adjusted odds ratio [aOR] [95% CI]=5.30 [4.22-6.65], P<.001) and those with comorbid stimulant use disorder (aOR [95% CI]=2.40 [1.71-3.39], P<.001). A total of 1,337 people with BD were prescribed PrEP, and 909 were prescribed at least 3 months of PrEP. Among people with ≥4 encounters for STIs, 3.53% (n=246) were prescribed PrEP of any duration, and 2.73% (n=190) were prescribed PrEP for at least 3 months. People with BD who had outpatient encounters only with psychiatrists had greater odds of HIV diagnosis compared to those who had follow-up encounters with PCPs only (aOR [95% CI]=1.58 [1.11-2.27], P=.01) and lower odds of receiving PrEP prescription (aOR [95% CI]=0.74 [0.56-0.98], P=.03).

Conclusions: PrEP use among commercially insured people with BD was critically low, with <1% prescribed PrEP. Even among those with multiple encounters for STIs, <4% were prescribed PrEP, despite this being an indication for prescription. Engagement of people with BD in the PrEP care continuum is essential for ending the HIV pandemic, and integration of PrEP prescription with psychiatric care may represent an efficient method for increasing PrEP use.

Objective: To investigate the alignment of self-harm ideation ratings with clinical assessments of suicidality in postpartum women diagnosed with unipolar and bipolar depression and the impact of trauma and psychiatric diagnosis on this alignment.

Methods: Data from the largest postpartum depression screening study (n=10,000) in the US were examined in this secondary analysis. Inclusion criteria were a positive depression screen (Edinburgh Postnatal Depression Scale [EPDS] ≥10), a psychiatric diagnosis (Structured Clinical Interview for DSM-IV), and a suicidality assessment derived from the Structured Interview Guide for the Hamilton Depression Rating Scale with Atypical Depression Supplement (SIGH-ADS). Trauma exposure, including both childhood and adult physical and sexual abuse, was measured using 4 yes/no questions from the Dissociative Disorders Interview Schedule. Associations between key variables were examined using independent samples t tests, analysis of variance, χ² tests, or Fisher exact tests. Nonparametric tests were used for skewed continuous data. To assess the consistency between the EPDS and SIGH-ADS scales, Cohen κ statistics were used, with weighted κ applied to severity ratings and simple κ for binary categorizations.

Results: Among 1,155 screen-positive postpartum women (68% White, 25.5% African American, 6.6% other; mean age 27.93 years), 21% endorsed self-harm ideation and 10.1% reported suicidality. Compared to those with unipolar depression, women with bipolar disorder had more than twice the odds of suicidality (odds ratio [OR] 2.77, 95% CI, 1.86 to 4.13, P<.001) and nearly 4 times the odds (OR 3.92, 95% CI, 1.18 to 13.00, P<.001) of not self-reporting self-harm ideation. Overall concordance between self-report (EPDS10) and clinical evaluation (SIGH-ADS11) was 78.6% (κ=0.28, 95% CI, 0.21 to 0.34, fair agreement) but varied significantly by diagnosis (P<.001), with lower concordance in the bipolar group (67.3%; κ=0.21) compared to the unipolar group (80.4%; κ=0.31). In the high-risk bipolar disorder group, concordance was no longer statistically significant, indicating poor alignment between self-report and clinical evaluation for these patients. Trauma was strongly associated with suicidality and a bipolar diagnosis.

Conclusion: The EPDS does not consistently detect suicidality in perinatal bipolar patients, with our study showing only slight and nonsignificant agreement with clinical assessment in this high-risk group. Given that risk can change quickly in postpartum bipolar patients, timely and frequent clinical assessments are needed to identify high-risk individuals. Tracking and integrating routine bipolar disorder screening and trauma assessments in perinatal care may enhance early identification of suicide risk and improve maternal mental health outcomes.