Journal of Clinical Psychiatry最新文献

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.

Background: Two recent studies demonstrated that brexpiprazole combined with sertraline was effective in reducing posttraumatic stress disorder (PTSD) symptoms, and an application has been submitted to the FDA for the combination treatment. When reading the inclusion and exclusion criteria of these studies, we suspected that many patients that we treat in our clinical practice would not have been eligible for the studies establishing the efficacy of the brexpiprazole-sertraline combination. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we estimated how many patients with PTSD in our practice would have qualified for the brexpiprazole-sertraline trials.

Methods: The sample was derived from the 3,800 psychiatric outpatients evaluated with semistructured diagnostic interviews, 417 of whom met DSM-IV criteria for PTSD upon presentation. The clinical protocol of the brexpiprazole-sertraline study listed the exclusion criteria. There were 11 exclusion criteria related to the patients' trauma history or psychiatric condition, almost all of which we assessed and applied to the sample.

Results: Three exclusion criteria were met by the majority of the patients: current major depressive disorder, PTSD age of onset before 16 years, and the interval between the onset of PTSD and patients' current age was 10 years or greater. Nearly 95% of patients met at least 1 of the exclusion criteria used in the brexpiprazole-sertraline studies.

Conclusions: While the effectiveness of the brexpiprazole-sertraline combination offers hope for addressing a significant unmet need in the treatment of PTSD, it is concerning that so few of our patients would have qualified for the clinical trials. As a result, we remain uncertain about the medications' effectiveness for most patients treated in clinical practice. We urge regulatory agencies to require industry to conduct studies that better reflect the patient populations seen in clinical practice.

Background: The association between functional dysconnectivity in the triple networks-the default mode network (DMN), salience network (SN), and frontoparietal network (FPN)-and current suicidal ideation (CSI) in young people with major affective disorders remains unclear.

Methods: This study included 158 young people (mean age: ∼18 years) with major affective disorders (101 with CSI and 57 without CSI) and 64 age- and sex-matched healthy control individuals. Both major depressive disorder and bipolar disorder were diagnosed according to the DSM-5 criteria. CSI was defined by a Montgomery-Åsberg Depression Rating Scale suicide item score of ≥2. All participants underwent resting-state functional connectivity magnetic resonance imaging. Seed-based connectivity analyses were performed, with adjustment for diagnosis and prior suicide attempts.

Results: Compared with the non-CSI group, the CSI group exhibited hyperconnectivity between the anterior insula (SN) and hippocampus as well as between the posterior parietal cortex (FPN) and rectus gyrus (DMN) and hypoconnectivity between the amygdala (SN) and cerebellum crus II. Both the CSI and non-CSI groups exhibited increased functional connectivity between the posterior parietal cortex and emotional perception-related regions, specifically, the superior and middle temporal gyri, compared with healthy control individuals.

Discussion: Suicidality is associated with extensive and pronounced functional dysconnectivity in the SN, FPN, and DMN in young people with major affective disorders.

Objective: Second-generation antipsychotic (SGA)-induced weight gain (AIWG) is a major factor contributing to SGA nonadherence. The aim of the study was to evaluate the effect of concurrent metformin treatment on SGA adherence and persistence.

Methods: A retrospective cohort study using MarketScan Commercial and Medicaid claims data included nondiabetic adults (≥18 years) with ≥30 days of overlapping prescriptions for SGAs and metformin. SGA-metformin concurrent users were 1:4 matched to SGA-only users and followed for 180 and 365 days to assess SGA adherence using proportion of days covered (PDC) and persistence (days until a 60-day gap). Additionally, concurrent users were classified into early (<30 days) and delayed (≥30 days) initiators based on the duration between SGA and metformin initiation. The differences between study groups were adjusted by propensity score using inverse probability of treatment weights (IPTW).

Results: In commercially insured patients, 575 concurrent users were matched to 2,300 SGA-only users, whereas Medicaid had 972 concurrent users matched to 3,888 SGA-only users. During the 180-day follow-up period, concurrent users demonstrated higher PDC and persistence to SGA than SGA-only users (PDC: commercial: 80.9% vs. 67.61%; Medicaid: 78.41% vs 68.27%; persistence: commercial: 139.0 vs 106.4 days; Medicaid: 149.1 vs 115.7 days). After IPTW adjustment, the differences in PDC between the study groups were 11.79% (commercial) and 9.64% (Medicaid), with corresponding differences in persistence of 32.14 (commercial) and 33.78 (Medicaid) days. The findings for the early and delayed initiators and the 365-day follow-up period were consistent with the main analysis.

Conclusion: The concurrent use of metformin with SGA drugs was associated with improved adherence and persistence to SGAs at both 180-and 365-day follow-up periods in adults with Medicaid and commercial insurance. Additionally, the observed improvement in SGA adherence among both early and delayed metformin initiators supports the effectiveness of metformin in enhancing adherence, whether used on a preventive basis or as a treatment for AIWG.