Journal of Clinical Psychiatry最新文献

Objective: To evaluate the effects of a 6-month digital multidomain cognitive intervention on cognitive function and psychosocial outcomes in older adults at high risk of dementia.

Methods: A 2-arm, randomized clinical trial was conducted at Fujian Provincial Hospital and 4 community health care centers (April 2024 to December 2024). Participants (N=166, aged ≥60 years, modified dementia risk score >79) were enrolled and randomized 1:1 to a 6-month digital multidomain cognitive intervention and control group. Primary outcomes included general cognitive function (Montreal Cognitive Assessment [MoCA]) scores; secondary outcomes covered memory (Rey-Osterrieth Complex Figure Test [ROCFT] and Auditory Verbal Learning Test), language (Verbal Fluency Test and Boston Naming Test), executive function and attention (Shape Trails Test), visuospatial skill (ROCFT), mobility (Activity of Daily Living and Berg Balance Scale), psychosocial status (15-item Geriatric Depression Scale, Zung Self-Rating Anxiety Scale, UCLA Loneliness Scale, and Quality of Life-Alzheimer's Disease), and health-promoting behaviors (Health-Promoting Lifestyle Profile II and Self-Rated Abilities for Health Practices). Intention-to-treat analysis with random forest imputation was performed.

Results: A total of 154 participants (92.77%) completed the trial. Compared to the control group, the intervention group demonstrated significant improvements in general cognitive function, visuospatial memory, and loneliness, including MoCA (t=2.106, P=.037), ROCFT immediate and long-delay recall (Z=-2.789, P=.05; t=2.797, P=.05), and UCLA Loneliness Scale (Z=-2.641, P=.008). No statistically significant between-group differences emerged in other indicators.

Conclusion: A 6-month digital multidomain intervention significantly enhanced general cognitive function and visuospatial memory and reduced loneliness in older adults at high risk for dementia. These results highlight the potential of WeChat-based delivery models to provide feasible, acceptable, and widely applicable solutions for dementia risk reduction in aging populations.

Trial Registration: ClinicalTrials. gov identifier: NCT06442943.

Objective: This study aims to characterize the rate of successful rechallenge considering the risk of recurrence of cutaneous adverse reactions with reintroduction of lamotrigine, as well as how to characterize cutaneous reactions appropriately, and important considerations in deciding whether to attempt reintroduction of lamotrigine.

Data Sources: A systematic review was conducted of PubMed, SCOPUS, and Web of Science databases. Search terms included lamotrigine, rash, and rechallenge or reintroduction.

Study Selection: The resulting articles (59) were imported into Covidence. After screening and application of inclusion/exclusion criteria, 11 articles were included.

Data Extraction and Synthesis: Variables extracted included study design, age of patient, lamotrigine dosing regimen, concomitant valproate use, use of other concomitant enzyme-inducing antiepileptic drugs, rash timing after starting lamotrigine, rash description, rash diagnosis, dermatologist evaluation, skin biopsy, hospitalization, time from initial rash onset until rechallenge, rechallenge lamotrigine dosing regimen, and response.

Results: There were 106 cases of rechallenge of lamotrigine. Over half (57%) of patients were female, and the average age was 35 years. Time from discontinuation of lamotrigine until rechallenge ranged from 1 week to 26 months, and there were 12 cases that continued lamotrigine without interruption or by reducing the dose. Patients who were rechallenged with lamotrigine successfully typically started the rechallenge with either 5 mg or 12.5 mg daily with a gradual upward titration until reaching desired dose. Successful rechallenge occurred in 84% of cases; reasons for unsuccessful rechallenge included severe or intolerable rash or other symptoms. Only 3 out of 106 cases had a dermatologist confirm the initial rash diagnosis.

Conclusions: Lamotrigine has been rechallenged safely in select cases; however, it is critical to confirm that the initial rash did not have specific features of a severe rash in order to proceed with safe reintroduction of lamotrigine. This article analyzes the cases in the literature to date and gives recommendations for how to assess whether to rechallenge lamotrigine.

Background: Health care professionals face elevated suicide risk, yet longitudinal studies during occupational crises are lacking. We investigated factors associated with suicide attempts and psychiatric hospitalizations in health care workers seeking emotional support during COVID-19.

Methods: We prospectively evaluated 3,087 Brazilian health care professionals enrolled in a digital mental health trial (May-July 2020). Participants were recruited nationwide from May 2020 to December 2021. From this cohort, 2,815 with complete baseline data comprised the intention-to-treat (ITT) sample. Outcomes were assessed at 4, 12, and 24 weeks. Baseline predictors included demographics, Patient Health Questionnaire-9 item 9 (suicidal ideation), Patient-Reported Outcomes Measurement Information System T-scores (depression, anxiety, irritability, sleep), life satisfaction, and burnout. Cox models examined associations; inverse probability weighting addressed attrition. Additive interaction was quantified using relative excess risk due to interaction (RERI).

Results: In the total sample, 53 participants (1.59%) attempted suicide. In the ITT sample (86% female, mean age 36.5), 46 (1.63%) attempted suicide (64 events), and 60 (2.22%) required psychiatric hospitalization. Nearly every day ideation (hazard ratio [HR]=39.58, 95% CI, 14.03-111.64, P<.001), severe sleep disturbances (HR=17.39, 95% CI, 2.05-147.46, P=.009), and male sex (HR=2.08, 95% CI, 1.01-4.26, P=.046) independently predicted attempts. The 24-week attempt probability reached 57.1% for individuals with both ideation and sleep problems versus 1.2% with neither, with 40% of the combined risk attributable to synergistic interaction (RERI=11.51). Notably, 28.3% of attempts occurred among individuals denying baseline ideation. For hospitalizations, only nearly every day ideation remained significant (HR=8.11, 95% CI, 3.10-21.18, P<.001). Results remained robust after weighting.

Conclusions: Daily suicidal ideation and severe sleep disturbances synergistically elevate suicide risk among health care professionals. Findings support a comprehensive assessment incorporating sleep disturbances and multicomponent interventions targeting both domains simultaneously.

Trial Registration: ClinicalTrials.gov identifiers: NCT04635618, NCT04632082.

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.