Journal of Clinical Psychiatry最新文献

Objective: To compare rehospitalization outcomes and medication practice patterns between long-acting injectable antipsychotics (LAIs) and oral antipsychotics (OAs) in US patients with bipolar I disorder (BD-I).

Methods: This retrospective cohort study using the Premier Hospital database (October 2020-September 2023) grouped adults (aged ≥18 years) hospitalized with BD-I by discharge medication: OA, LAI, or second-generation LAI (SG LAI). LAI and SG LAI patients were propensity score matched (1:4) to OA patients. Rehospitalization rates and risk (BD-I-related and all-cause) within 30, 60, and 90 days were assessed. Medication continuation vs switching at rehospitalization was also analyzed.

Results: Among 98,088 eligible patients, 78.1% were in the OA and 2.4% in the LAI group. BD-I-related rehospitalization rates were lower for LAI users at 30 (3.9% vs 5.0%, P=.033) and 60 days (5.9% vs 7.2%, P=.030) vs OAs. SG LAI users showed reductions in rehospitalizations at 30 (3.6% vs 5.4%; P=.010), 60 (5.2% vs 7.5%; P=.008), and 90 (6.8% vs 9.1%; P=.015) days. Risk of first BD-I rehospitalization within 30-90 days was reduced for LAI (hazard ratio [HR]: 0.784-0.856) and SG LAI (HR: 0.653-0.742) groups vs OAs.

Conclusions: LAIs, especially SG formulations, are associated with reduced rehospitalization in BD-I compared to OAs, supporting their broader use to improve adherence and reduce readmissions.

Objective: This preliminary open-label study examined whether 12 weeks of cannabis abstinence was associated with posttraumatic stress disorder (PTSD) symptom improvement in people with comorbid PTSD and cannabis use disorder (CUD) (N=21).

Methods: Participants received progressive contingency reinforcement payments for successful abstinence at weeks 4, 8, and 12. Abstinence was defined as a 11-nor-9-carboxy-tetrahydrocannabinol (THC-COOH) level ≤50 ng/mL with no self-reported cannabis use. PTSD symptoms were evaluated using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), capturing total severity, symptom count, and cluster scores. Data were collected from January 2022 to April 2025.

Results: Participants who achieved abstinence (n=11) reported significantly greater reductions in total PTSD symptom severity and symptom count relative to those who did not (n=10). CAPS-5 total scores decreased from 36.2 to 10.5 among abstainers versus 34.6 to 21.8 among nonabstainers (P=.001). Time-by-group interactions revealed more pronounced improvements in avoidance, negative mood and cognition, and hyperarousal among abstainers. Reexperiencing symptoms improved across both groups over time, with no significant difference by abstinence status.

Conclusions: Sustained cannabis abstinence was associated with significant reductions in PTSD symptom severity and frequency over 12 weeks. While not definitive, the results raise questions about the assumption that long-term cannabis use improves symptoms or functioning in PTSD. The data instead suggest that continued cannabis use could limit recovery in some domains. This underscores the need to routinely assess cannabis use during PTSD treatment and to educate patients on the potential consequences of continued use. Larger randomized trials are warranted to replicate and extend these findings and to investigate mechanisms through which abstinence may relate to symptom changes in PTSD with CUD.

Trial Registration: ClinicalTrials.gov identifier: NCT05162651.

Objective: This study describes recent trends in benzodiazepine prescribing to US adults and characterizes patients who receive benzodiazepines and other central nervous system (CNS) depressants.

Method: This repeated cross-sectional study analyzed benzodiazepine use by adults (ages ≥18 years) in the 2018-2022 Medical Expenditure Panel Surveys, which are nationally representative surveys of the civilian noninstitutionalized population. We examined sex-adjusted annual trends (2018-2022) in benzodiazepine use by age group (ages 18-35, 36-55, and ≥56 years) and pooled marginal differences by age group in any benzodiazepine use and in benzodiazepine use and other CNS-depressant medications, stratified by sociodemographic and clinical characteristics.

Results: The analysis involved 104,231 participants. Between 2018 and 2022, annual benzodiazepine use by US adults decreased from 4.7% to 3.4%. This included a greater decrease for adults ages ≥56 years (7.2% to 4.7%) than for those ages 36-55 years (4.4% to 3.4%) or 18-35 years (2.1% to 1.8%). Approximately 41.6% adults treated with benzodiazepines also received other CNS-depressant medications in the same year including a higher percentage aged 36-55 years (44.6%) or ≥56 years (42.9%) than 18-35 years (30.0%). Most benzodiazepine-treated adults with fair or poor general health (72.0%) or with serious psychological distress (62.9%) also received other CNS-depressant medications.

Conclusions: Benzodiazepine treatment decreased among US adults between 2018 and 2022, with a greater decline among adults ≥56 years than those 36-55 or 18-35 years. Prescription of benzodiazepines to adults who also received other CNS depressants was common, especially among adults in fair or poor general health or with serious psychological distress.

Background: Transcranial magnetic stimulation (TMS) is an FDA-cleared neuromodulation technique with expanding clinical applications beyond major depressive disorder. Despite increasing utilization, there has been no published, device-agnostic analysis of TMS-related adverse events (AEs) using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

Objective: To characterize the real-world safety profile of TMS devices based on MAUDE-reported AEs, including symptom patterns, manufacturer-level variations, device issues, and reporting delays, while contextualizing findings through a review of technological advancements in TMS.

Methods: All reports under device code OBP were extracted from MAUDE through April 2025. After deduplication, 200 unique reports were analyzed descriptively. A focused literature review was also conducted to trace safety and innovation trends in TMS device development.

Results: Of 200 reports, 94.7% involved injury, 4.1% malfunction, and 1.2% death. Common symptoms included anxiety (8.2%), neurocognitive changes (8.0%), seizures (6.9%), headache (6.9%), and tinnitus (5.6%). Neuronetics accounted for 45.5% of reports, likely reflecting market share. Median reporting delay was 1.4 months, with some exceeding 6 years. The literature review identified major innovations, including figure-of-eight and H-coils, double-containment coils, seizure risk screening, and advanced circuitry (eg, insulated-gate bipolar transistors and metal-oxide-semiconductor field-effect transistors) enabling magnetic resonance imaging-guided and accelerated protocols. Exploratory developments include wearable systems, auricular stimulation, and artificial intelligence-based individualization.

Conclusion: MAUDE data provide novel insights into TMS safety in real-world settings. Although serious AEs are rare, standardized reporting and continued device innovation are essential to ensure safe and effective clinical use.

The E-value is most simply described as the smallest strength of association that 1 or more unmeasured confounds must have with both risk factor and outcome to nullify a significant relationship between the risk factor and the outcome in a fully adjusted regression. Thus, the E-value is a measure of how robust a finding may be against unmeasured confounding. This article provides the reader with a primer on the E-value, and with a cheat sheet that simplifies concepts. The full definition of the E-value is stated, and each element in the definition is explained. The E-value is most commonly applied to statistics such as the relative risk, odds ratio, and hazard ratio but can be applied to other statistics, as well. The E-value is usually calculated for 2 estimates: the statistic that measures risk and the limit of the 95% confidence interval (CI) of the statistic that is closest to the null. The former E-value tells us how strong unmeasured confounding should be to bring the value of the statistic to null. The latter E-value tells us how strong unmeasured confounding should be to bring the null value into the 95% CI, thereby making a statistically significant finding nonsignificant. This article also explains the calculation and the interpretation of the E-value. A detailed discussion is provided on what unmeasured confounding means with reference to the E-value. The specificity of the E-value to the context of the study, and the variables adjusted for, is emphasized. Interpretation of the E-value should be based on the plausibility of existence of the unmeasured confounds and the prevalence of these confounds in the population. E-values, surprisingly, are not commonly reported. They should be reported by researchers, requested by reviewers and editors, and calculated by readers to understand how robust statistically significant findings are against unmeasured confounding.

Objective: Long-acting injectable (LAI) antipsychotics are increasingly recommended for patients in the early phase of schizophrenia. We examined how the timing of LAI initiation affects treatment discontinuation and hospitalization duration in first-episode schizophrenia.

Methods: Using the Korean Health Insurance Review and Assessment Service claims database, we identified 6,380 patients with first-episode schizophrenia receiving continuous LAI treatment. The interval from diagnosis to LAI initiation was categorized into 6 groups (<1, 1-2, 2-3, 3-4, 4-5, and >5 years). Treatment discontinuation and the proportion of psychiatric hospitalization days during continuous LAI use were analyzed using Cox and linear regression models.

Results: Earlier LAI use increased over time, but the duration of continuous treatment declined. Patients who started LAIs >2 years after diagnosis had lower risks of discontinuation than those within the first year (2-3 years: hazard ratio [HR]=0.77 [0.69-0.87]; 3-4 years: HR=0.77 [0.68-0.86]; 4-5 years: HR=0.70 [0.61-0.79]; >5 years: HR=0.66 [0.59-0.74]). Later initiation was associated with greater psychiatric hospitalization burden, particularly among patients with prior hospitalizations (1-2 years: β=0.039, P=.039; 3-4 years: β=0.057, P=.010; >5 years: β=0.162, P <.001), and within the >5-year group, longer delays further increased hospitalization days (β=1.87×10^-4, P<.001).

Conclusion: Although delayed initiation was linked to better treatment adherence, early LAI use reduced hospitalization burden, supporting guidelines advocating earlier LAI treatment in schizophrenia.

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.