Journal of Clinical Psychiatry最新文献

Objective: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are common co-occurring conditions associated with a more severe clinical profile and poorer treatment outcomes than either disorder alone. To date, no medications have proven efficacious in the treatment of co-occurring PTSD/AUD.

Methods: This randomized, double-blind, placebo-controlled trial examined the efficacy of N-acetylcysteine (NAC; 2,400 mg/day) among individuals (N=182, aged 21-65 years) who met DSM-5 criteria for current PTSD/AUD. Participants were randomized 1:1 to receive 12 weeks of NAC (n=93) or placebo (n=89). All participants received weekly, individual, cognitive behavioral therapy (CBT) for AUD. Follow-up visits occurred at 3-, 6-, and 12-months posttreatment. Primary outcomes included the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), PTSD Checklist for DSM-5 (PCL-5), Timeline Follow-Back (TLFB), and the Obsessive Compulsive Drinking Scale at 12 weeks. The TLFB evaluated the frequency and amount of alcohol consumption. A secondary measure evaluated depression symptoms.

Results: Intent-to-treat analyses showed that participants in both the NAC and placebo groups evidenced significant reductions in the CAPS-5 (B=-0.19, P<.001) and PCL-5 (B=-0.20, P<.001) during treatment, with no significant group differences. Both groups also showed significant reductions in alcohol use (drinks per drinking day [B=-0.02, P<.001], percent heavy drinking days [B=-0.14, P<.001], percent days abstinent [B=0.29, P=.022]) and craving (B=-0.12, P<.001) during treatment, but with no significant group differences. There were no group differences in retention or adverse events.

Conclusions: Although NAC was well tolerated, it was not more effective than placebo in improving symptoms of PTSD or AUD when added to individual CBT for AUD.

Trial Registration: ClinicalTrials.gov identifier: NCT02966873.

Background: There has been increasing interest in the use of artificial intelligence (AI)-enabled clinical decision support systems (CDSS) for the personalization of major depressive disorder (MDD) treatment selection and management, but clinical studies are lacking. We tested whether a CDSS that combines an AI which predicts remission probabilities for individual antidepressants and a clinical algorithm based on treatment can improve MDD outcomes.

Methods: This was a multicenter, cluster randomized, patient-and-rater blinded and clinician-partially-blinded, active-controlled trial that recruited outpatient adults with moderate or greater severity MDD. All patients had access to a patient portal to complete questionnaires. Clinicians in the active group had access to the CDSS; clinicians in the active-control group received patient questionnaires; both groups received guideline training. Primary outcome was remission (<11 points on the Montgomery-Asberg Depression Rating Scale [MADRS]) at study exit.

Results: Forty-seven clinicians were recruited at 9 sites. Of 74 eligible patients, 61 patients completed a postbaseline MADRS and were analyzed. There were no differences in baseline MADRS (P = .153). There were more remitters in the active (n = 12, 28.6%) than in the active-control (0%) group (P = .012, Fisher's exact). Of 3 serious adverse events, none were caused by the CDSS. Speed of improvement was higher in the active than the control group (1.26 vs 0.37, P = .03).

Conclusions: While limited by sample size and the lack of primary care clinicians, these results demonstrate preliminary evidence that longitudinal use of an AI-CDSS can improve outcomes in moderate and greater severity MDD.

Trial Registration: ClinicalTrials.gov identifier: NCT04655924.

Objective: Lumateperone, a mechanistically novel antipsychotic, simultaneously modulates serotonin, dopamine, and glutamate neurotransmission. This phase 3, randomized, double-blind, placebo-controlled trial investigated efficacy and safety of adjunctive lumateperone 42 mg in patients with major depressive disorder (MDD) with inadequate antidepressant therapy (ADT) response.

Methods: From July 2021 to February 2024, eligible adult outpatients (18-65 years) had DSM-5-defined MDD with inadequate response to 1 or 2 ADTs in the current depressive episode and Montgomery-Åsberg Depression Rating Scale (MADRS) Total score ≥24, Clinical Global Impression Scale-Severity (CGI-S) score ≥4, and Quick Inventory of Depressive Symptomatology-Self Report-16 item (QIDS-SR-16) score ≥14. Patients were randomized to 6-week oral adjunctive placebo (n=243) or adjunctive lumateperone 42 mg (n=242). Primary and key secondary end points were change from baseline to day 43 in MADRS Total and CGI-S scores. Safety was assessed.

Results: Lumateperone + ADT met primary and key secondary end points, with significantly greater improvement at day 43 vs placebo + ADT in MADRS Total score (least squares mean difference [LSMD] vs placebo= -4.9; effect size [ES]= -0.61; P < .0001) and CGI-S score (LSMD =-0.7; ES = -0.67; P <.0001). Lumateperone + ADT significantly improved patient-reported depression vs placebo + ADT at day 43 (QIDS-SR-16 Total score, LSMD= -2.4; ES= -0.50; P < .0001). Lumateperone + ADT was generally well tolerated. Treatment-emergent adverse events (≥5%, twice placebo) were dry mouth (placebo + ADT, 2.1%; lumateperone + ADT, 10.8%), fatigue (2.1%; 9.5%), and tremor (0.4%; 5.0%), with minimal risk for weight gain or cardiometabolic abnormalities. Emergence of suicidal ideation was low (placebo + ADT, 3.5%; lumateperone + ADT, 1.4%).

Conclusions: Lumateperone 42 mg adjunctive to ADT significantly improved depression symptoms and disease severity vs adjunctive placebo and was generally well tolerated in patients with MDD with inadequate ADT response.

Trial Registration: ClinicalTrials.gov identifier: NCT04985942.

Objective: The primary aim of this study was to establish that levomilnacipran potently inhibits norepinephrine (NE) reuptake in human participants starting at a minimally efficacious regimen in major depressive disorder (MDD) and to determine the dose needed to significantly inhibit serotonin (5-HT) reuptake. The secondary aim was to confirm that duloxetine is a selective 5-HT reuptake inhibitor at its minimally effective regimen in MDD and that it significantly inhibits NE reuptake only with dose escalation.

Methods: Inhibition of the NE reuptake process was estimated by assessing the attenuation of the systolic blood pressure produced by intravenous injections of small doses of tyramine. Inhibition of the 5-HT reuptake process was estimated using depletion of whole blood 5-HT. Healthy male participants took ascending daily doses of levomilnacipran (40, 80, and 120 mg), duloxetine (60, 90, and 120 mg) each for 7 days, or a placebo pill (n=10, 9, and 10, respectively), and all assays were carried out 2-6 hours after the last dose. The study took place between February 2018 and October 2022.

Results: Plasma levels of both medications increased in dose-dependent levels. Neither the tyramine pressor responses nor 5-HT levels were significantly altered in the placebo group. For the attenuation of the tyramine pressor response, levomilnacipran separated from baseline starting at 40 mg and duloxetine separated from baseline only at 120 mg. Both drugs robustly decreased 5-HT levels to the same extent at all 3 doses.

Conclusions: Levomilnacipran is a potent dual reuptake inhibitor from its minimally effective dose in MDD, whereas the dose of duloxetine needs to reach 120 mg/day to consistently inhibit NE reuptake.

Trial Registration: ClinicalTrials.gov identifier: NCT03249311.

Schizophrenia is a major mental illness with a median lifetime prevalence, across studies, of 0.5%. Across definitions of treatment resistance, about 37% of schizophrenia patients do not respond to treatment, and about 24% are treatment resistant from the first-episode, itself. Treatment resistance is addressed by trialing different antipsychotics and with antipsychotic augmentation strategies; what augmenting agent is used depends on what the target symptoms are. A landmark study in 1988 demonstrated the efficacy of clozapine in treatment resistant schizophrenia (TRS). Confirmatory studies and meta-analyses followed, establishing clozapine as the drug of choice for TRS in schizophrenia treatment guidelines across the world. Between 2016 and 2025, 2 network meta analyses (NMAs) and 1 individual participant data meta-analysis (IPD-MA) examined randomized controlled trials (RCTs) of clozapine vs other antipsychotics in TRS. The NMAs found that clozapine was superior to first-generation antipsychotics; however, clozapine did not head rankings for overall symptoms, positive symptoms, or negative symptoms, and, in pairwise analyses, there was little difference between clozapine and olanzapine and clozapine and risperidone for overall symptoms, positive symptoms, and negative symptoms. The IPD-MA found that clozapine was no better than comparator second-generation antipsychotics, considered singly or together, for overall symptoms, positive symptoms, and negative symptoms, in the short term, intermediate term, and long term. These findings fly in the face of clinical experience and treatment guideline recommendations. Among possible explanations, notable was that clozapine was significantly superior to comparator drugs when disregarding RCTs sponsored by the manufacturer of olanzapine. Clozapine is associated with many inconveniencing, distressing, and serious adverse effects that may be rare or common. Given the findings that olanzapine and risperidone may be as good as clozapine in TRS, it may be worth trialing these drugs before clozapine in patients with TRS. These and related issues, including nuances, are discussed.

Bipolar I disorder (BP-I) is a severe and chronic psychiatric condition characterized by recurrent episodes of mania and depression that significantly impact quality of life and functioning. Early recurrence, high relapse rates, and poor adherence to daily oral medications complicate long-term management and increase the risk of hospitalization and suicide. Long-acting injectable antipsychotics (LAIs) offer a potential solution to these challenges by promoting sustained medication delivery and efficacy, reducing pharmacokinetic variability, and improving treatment adherence. Among available LAIs, aripiprazole is the only partial dopamine D₂ receptor agonist, which may contribute to its favorable tolerability and mood-stabilizing properties. Despite the robust evidence for the efficacy and tolerability of aripiprazole monohydrate LAIs in patients with BP-I, this agent remains underutilized in this population. Misperceptions about efficacy and tolerability, coupled with systemic and prescriber-level barriers, have limited broader clinical adoption. To address these issues, a round table panel of experts in psychopharmacology, the clinical treatment of bipolar disorder, and antipsychotic prescribing was convened to evaluate the clinical rationale for earlier use of aripiprazole monohydrate LAIs in BP-I and to identify key challenges limiting its use. This article summarizes their consensus on the pharmacological distinctiveness, practical advantages, and potential of aripiprazole monohydrate LAIs in improving long-term outcomes in individuals with BP-I.

Aripiprazole is a second-generation partial dopamine D₂ receptor agonist antipsychotic approved for the treatment of schizophrenia and maintenance treatment of bipolar I disorder. As the only partial dopamine D₂ receptor agonist available in both oral and long-acting injectable (LAI) formulations, it provides flexibility for tailoring treatment across different phases of the illness. Two LAI formulations of aripiprazole monohydrate are available: aripiprazole once-monthly 400 mg and aripiprazole 2-month ready-to-use 960 mg, offering options to accommodate patient needs and preferences and support adherence. The aripiprazole monohydrate LAIs are well-supported options for early intervention and maintenance treatment, with evidence demonstrating clinical effectiveness in reducing relapse and hospitalizations while supporting enhanced adherence. LAI antipsychotics, including aripiprazole monohydrate, offer practical benefits for patients with schizophrenia, particularly those at risk for nonadherence or recurrent episodes. However, these formulations are often underutilized due to lingering stigma and misperceptions, leading many clinicians to defer use of these agents until later in the treatment course. To support earlier and more informed use of aripiprazole monohydrate LAIs, a panel of psychiatric experts convened to review the latest evidence and share clinical strategies for integrating this agent into a comprehensive treatment plan. This Academic Highlights section presents the main points of their consensus recommendations, offering practical guidance for prescribers seeking to optimize outcomes in patients with schizophrenia.

Objective: This study compared the effects of augmenting antidepressants with aripiprazole or repetitive transcranial magnetic stimulation (rTMS) versus switching to venlafaxine XR/duloxetine on quality of life (QoL) among patients with treatment resistant depression (TRD).

Methods: In a predefined secondary analysis of a multisite, open-label, effectiveness trial, patients with TRD were randomly assigned to aripiprazole augmentation, rTMS augmentation, or switching to venlafaxine XR/duloxetine in a 1:1:1 ratio, and they were treated for 8 weeks. TRD was defined as an inadequate response to 2 or more antidepressant trials of adequate dose and duration, as defined by the Massachusetts General Hospital Antidepressant Treatment Response Questionnaire. QoL was predefined as a key secondary end point for this study and assessed using the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF). A mixed-effects model with repeated measures was applied. This study was conducted from July 13, 2017, to December 22, 2021.

Results: Among 258 randomized participants with at least 1 postbaseline Q-LES-Q-SF measurement, augmentation with aripiprazole demonstrated statistically significant superiority over switching on the Q-LES-Q-SF (P=.002), while rTMS did not (P=.326). At end point, changes from baseline in the Q-LES-Q-SF scores were 10.61 (SE=1.0) for aripiprazole augmentation, 11.59 (SE=1.1) for rTMS augmentation, and 8.68 (SE=0.9) for venlafaxine XR/duloxetine switch.

Conclusion: Augmentation with aripiprazole, but not rTMS, improved QoL significantly versus venlafaxine XR/duloxetine switch in TRD patients. However, a much smaller than expected sample size for the rTMS group may explain the lack of statistical significance rendering the latter finding of indeterminate nature.

Trial Registration: ClinicalTrials.gov identifier: NCT02977299.

Objectives: To estimate prevalence and impact of cognitive impairments in schizophrenia in the US.

Methods: Retrospective analyses of the Medical Expenditure Panel Survey (1997-2021) were conducted to identify adults living with schizophrenia and cognitive impairments. Cognitive limitations (CL; 1997-2021) were defined as interference with daily activities, confusion/memory loss, problems making decisions, or requiring supervision for safety. Cognitive difficulties (CD; 2013-2021) were defined as difficulty in concentration/memory/decision-making. Descriptive analyses covered demographic, clinical, and socioeconomic characteristics, health care resource utilization (HCRU), humanistic, and indirect burdens. Multivariable regression analyses were conducted for hospitalizations, emergency department (ED) visits, and total costs. Sampling weights were applied.

Results: Among 661,243 weighted adults living with schizophrenia (mean age: 45.6 years; male: 56.7%), 57.7% reported CL, and 53.8% reported CD. Compared to no CL, CL was associated with lower education (no degree: +2.2%) and annual income (-$4,332) and higher Charlson Comorbidity Index (0.89 vs 0.55) and HCRU. Total health care costs were higher for CL ($18,478 vs $11,689), demonstrating greater economic burden. Individuals reporting CL reported more limitations in activities of daily living (+13.3%) and lower health utilities scores with higher percentage of poor perceived health (+10.1%), indicating higher humanistic burden. For indirect burden, CL was associated with higher unemployment (+15.3%) (all P <.05). Multivariable regression analysis showed that CL was associated with higher odds of hospitalizations (1.47; 95% CI, 1.05-2.06), ED visits (1.64; 95% CI, 1.22-2.20), and total health care costs (1.56; 95% CI, 1.30-1.86). CD showed similar results except that CD was not significantly associated with hospitalizations or ED visits.

Conclusions: Cognitive impairments in schizophrenia are associated with higher multilevel burdens compared to those without, highlighting the need for targeted interventions.