Journal of Clinical Psychiatry最新文献

The age-standardized global prevalence of epilepsy is about 0.3% in women. Seizures are associated with morbidity and mortality risks; so, women with epilepsy (WWE) are usually advised antiepileptic drug (AED) treatment even during pregnancy. Women may also knowingly or unknowingly be exposed during pregnancy to AEDs advised for other on- or off-label indications. In this context, a meta-analysis of 35 adverse gestational outcomes examined in 76 observational studies found that WWE were at increased risk of most of the adverse outcomes, regardless of gestational exposure to AEDs. AEDs, especially in polytherapy, further increased at least a few of the gestational risks, including risks of congenital conditions, neonatal intensive care unit admission, small for gestational age, low birth weight, and neonatal/infant death (it is unclear whether the lack of statistical significance for the remaining risks was because AED exposure was truly limited to these risks or whether the nonsignificant analyses were underpowered). Reassuringly, the increases in risk were mostly in the small to modest range. This meta-analysis pooled unadjusted risks (which would probably be larger than adjusted risks), so readers are informed about expected findings in the population but not about cause-effect relationships that may be cautiously hypothesized from adjusted analyses. A take-home message is that, because of the wide range of outcomes for which risk is increased, WWE should be closely monitored and followed all through pregnancy, regardless of treatment with AEDs. This article also provides readers with suggestions on how to critically interpret literature with regard to 8 matters: confounding by indication and confounding by severity of indication, as specific to the indication for AED prescription; unadjusted and adjusted analyses; the base rate of an outcome in the population; the examination of multiple outcomes; the uniform direction of findings; the sample numbers; the timing of AED exposure; and self-fulfilling prophecies.

Objective: To determine the objective cognitive effects of electroconvulsive therapy (ECT) in treatment-resistant schizophrenia (TRS).

Data Sources: A database search of MEDLINE, PsycINFO, and Embase was conducted on September 22, 2022, using the search terms "schizophrenia" and "electroconvulsive therapy." The search was limited to the articles published from 1985 to present, in English, and human studies.

Study Selection: A total of 4293 articles were identified. After screening by title and full text, 17 articles met eligibility criteria. Controlled, open-label, and retrospective studies of acute, maintenance, or continuation ECT were included. An objective cognitive measure(s) had to be the primary or secondary outcome of the study, with no other interventions administered, besides standard-of-care treatment (ie, antipsychotics).

Data Extraction: Data regarding the study design, type of ECT provided, cognitive outcome measures, and change in cognitive performance pre- to post-ECT were extracted. Results are presented as a narrative review.

Results: Overall, ECT was not associated with any significant cognitive deficits in participants with TRS across the domains of global cognition, attention, language, visuospatial function, and executive function. Findings for immediate effects on memory were equivocal, but the majority of studies found no change or an improvement in memory after treatment.

Conclusions: The current evidence supports the conclusion that ECT does not have negative long-term effects on cognition among patients with TRS. Larger, sham-controlled trials are needed to support these conclusions. All studies in this review assessed ECT adjunct to antipsychotics; therefore, the cognitive effects of ECT independent of antipsychotics remain unclear.

Objective: Shorter sleep duration has been linked to increased suicidal ideation (SI). However, limited research has examined the relationship between nightly sleep duration and short-term fluctuations in suicide risk, as well as the potential clinical utility of leveraging indices of recent (ie, past 3 days) patterns of sleep duration as a marker of acute suicide risk. This study examined associations between nightly and cumulative sleep duration and suicidal desire and intent utilizing ecological momentary assessment (EMA) in a high risk sample of community-based adults.

Methods: A sample of 237 community based adults with severe SI provided daily indices of self-reported sleep duration and ratings of suicidal desire and intent 6 times per day for 14 consecutive days of EMA monitoring. Data collection took place between February and May 2019.

Results: Between-person nightly sleep duration and cumulative sleep duration were negatively associated with suicidal desire (Bs = -3.48 and -4.78) and intent (Bs = -1.96 and -2.46). At the within person level, nightly sleep duration was negatively related to suicidal desire (Bs = -0.51 and -0.47) and intent. Within person cumulative sleep duration, on the other hand, was unrelated to both suicidal desire and intent (Bs = -0.26 and -0.09).

Conclusion: Our findings highlight the clinical utility of examining individual differences in sleep duration as a marker for suicide-related outcomes, as well as deviations from one's typical nightly sleep as a potential acute predictor of suicide-related outcomes, in addition to information about recent duration over one or more nights of sleep. Limitations and future directions are discussed.

Objective: We explored depressive symptom trajectories and their associations with underweight and obesity in Korean women.

Methods: This prospective cohort study involved 7,691 women enrolled in the Korean Longitudinal Survey of Women and Families, with a follow-up period spanning from 2014 to 2020. Depressive symptoms were evaluated through the 10-item version of the Center of Epidemiologic Studies Depression Scale. Growth mixture modeling was employed to identify trajectories of depressive symptoms. Multinomial logistic regressions were conducted to investigate the correlation between depression trajectories and the evolving risks of underweight and obesity over the study period.

Results: Five distinct trajectory classes were observed ("persistent low symptoms": N = 5,236, 68.1%; "decreasing symptoms": N = 930, 12.1%; "transient high symptoms": N = 421, 5.5%; "increasing symptoms" N = 825, 10.7%; and "persistent high symptoms": N = 279, 3.6%). Those with a low socioeconomic status, comorbidity, and who were divorced or widowed were more likely to follow the persistent high symptom trajectory. Among the 5 trajectories, the risks of underweight and obesity steadily increased in women following the trajectory with persistent high symptoms. For these women, the odds ratio (OR) of underweight increased from 2.27 (95% CI, 1.32-3.92) in 2014 to 3.39 (1.91-6.05) in 2020. They were not associated with obesity in 2014 (OR [95% CI]: 1.38 [0.61-3.11]) but exhibited an elevated risk of obesity in 2020 (3.76 [1.97-7.17]).

Conclusion: We observed considerable heterogeneity in the trajectories of depressive symptoms among women, and individuals with persistent high depressive symptoms face an escalating risk of both underweight and obesity.

Importance: Extensively researched, exposure-focused therapies have dominated the treatment of posttraumatic stress disorder (PTSD). No treatment benefits all patients. Interpersonal psychotherapy (IPT), a nonexposure, affect-focused treatment, has emerged over 2 decades as an alternative evidence-based PTSD intervention.

Objective: This narrative review critically assesses IPT outcomes for PTSD. Time limited IPT focuses on affect toleration and the interpersonal consequences of trauma rather than on reconstructing the trauma narrative and exposure to traumatic cues.

Evidence Review: The author searched the outcome literature on IPT for adults with syndromal PTSD and drew upon personal involvement in studies since 2001. Subsyndromal PTSD studies and 1 adolescent trial were excluded.

Findings: Thirteen published studies of IPT targeted PTSD in individual and group formats for 592 civilians (n = 8, 6 randomized controlled trials [RCTs]) and 187 military veterans (n = 5, 1 RCT). Some trials had methodological limitations. IPT surpassed outcomes of waiting lists and other weak controls and was noninferior to evidence-based PTSD treatments including Prolonged Exposure (n = 2) and sertraline (n = 1). Depression and other outcomes improved. The RCTs demonstrate IPT efficacy for PTSD and allow preliminary exploration of outcome mediators and moderators and differential therapeutics.

Conclusion: While the number of studies remains limited, research by multiple investigators in differing populations supports the efficacy of IPT as a non trauma-focused PTSD treatment and justifies its inclusion in PTSD treatment guidelines. More research is necessary to determine how IPT compares to exposure-focused treatments in patient preference, attrition, and response for PTSD comorbid with major depression or due to sexual trauma.

Objective: The Mind after Midnight hypothesis proposes that nocturnal wakefulness increases the risk for dysregulated behaviors. Prior studies highlight a greater risk for suicide at night after adjusting for population wakefulness. How this risk varies hour to hour, differs across subgroups, or applies to other behaviors is unknown.

Methods: Data on 78,647 suicides and 50,526 homicides from the National Violent Death Reporting System were combined with population wakefulness data for 2003-2017 from the American Time Use Survey. Hourly incident risk ratios (IRRs) were estimated after adjusting for population wakefulness. Two-way analysis of variances identified significant time-by-subgroup interactions that were quantified in post hoc analyses.

Results: Suicide counts peaked at 12:00 PM, while homicide counts peaked at 10:00- 11:00 PM. Adjusting for demographics and population wakefulness revealed a 5-fold greater risk for suicide at 3:00 AM (aIRR: 5.20 [4.74-5.70]) and an 8-fold greater risk for homicide at 2:00 AM (aIRR: 8.04 [6.35-10.2]). Hourly risk for suicide varied by age, ethnicity, blood alcohol level, and current partner conflict. Hourly risk for homicide varied by sex and blood alcohol level.

Conclusions: Risk for suicide and homicide is greater at night than expected based on the number of people awake at that time. Nighttime risk was greater among young adults and those intoxicated with alcohol, but not among those with a history of suicidal ideation or attempts. Further research should evaluate mechanisms of risk and confirm these findings at an individual level.