Journal of Clinical Psychiatry最新文献

Objective: To determine the prevalence of burnout among psychiatry residents, fellows, and attendings ("psychiatry doctors") prior to and following the COVID-19 pandemic.

Data sources: A systematic search of MEDLINE, Embase, PsycINFO, and PubMed databases was performed to identify studies reporting the prevalence of burnout pre-COVID-19 (pre-March 2020) and post-COVID-19 (post March 2020). The search was limited to articles written in English and published in peer-reviewed journals from January 1, 2010, until June 27, 2024.

Study selection: There were 1,825 studies screened by 2 independent reviewers, with 36 eligible for inclusion. Observational studies and randomized controlled trials reporting the prevalence of burnout using validated tools were eligible for inclusion.

Data extraction: Prevalence data were independently extracted by 2 authors and pooled using a random effects model. A subgroup analysis was performed, stratifying burnout by country income status.

Results: The prevalence of burnout was 37.5% (95% confidence interval [CI], 28.2-47.3; 25 studies; 12,524 psychiatry doctors) prior to the COVID-19 pandemic and 32.0% (95% CI, 18.6-47.0; 12 studies; 7,458 psychiatry doctors) following the COVID-19 pandemic. Almost 1 in 2 psychiatry doctors from middle-income countries reported burnout pre-COVID-19 (49.8% [95% CI, 34.5-65.1]; 3 studies), with no studies reporting the prevalence of burnout in low-income countries. There was significant heterogeneity between studies.

Conclusions: Burnout among psychiatry doctors is common, affecting 1 in 3 both prior to and following the COVID-19 pandemic. Additional studies are needed from psychiatrists in low- and middle-income countries to better characterize the prevalence of burnout in this cohort.

Objective: Individuals with bipolar II disorder (BD II) have among the highest rates of suicide ideation (SI), attempts, and deaths. No studies to date have examined psychosocial treatment of SI in adults with BD II. The purpose of this study was to investigate whether patients with BD II depression receiving interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for BD, experienced a decrease in SI, and whether this varied by use of adjunctive medication compared to IPSRT monotherapy.

Methods: In a post hoc analysis of Swartz et al (2018), adults meeting DSM-IV criteria for BD II, currently depressed (n=92), were randomly assigned to receive IPSRT+placebo (IPSRT+P) or IPSRT+quetiapine (IPSRT+Q) and treated for 20 weeks. SI was assessed at baseline and weekly using the 17-item Hamilton Depression Rating Scale item 3. Multilevel logistic regression was used to model SI categorically.

Results: The results demonstrate a decrease in odds of SI over time (OR=0.8719, 95% CI, 0.8166-0.9309, P≤.001), with a 13% decrease in the odds of having SI for each additional week of treatment. There was no significant difference between those receiving IPSRT+P vs IPSRT+Q.

Conclusions: IPSRT has the potential to mitigate suicidal ideation in patients with BD II depression, regardless of whether they receive medication in addition to IPSRT. IPSRT alone may be a reasonable option to treat SI in an outpatient setting for some patients with BD II, especially those for whom medication is contraindicated or who prefer avoiding medication.

Trial Registration: ClinicalTrials.gov identifier: NCT01133821.

Objective: Both intravenous (IV) racemic ketamine and intranasal (IN) esketamine have emerged as rapid-acting antidepressants for treatment-resistant depression (TRD) and are increasingly used in clinical settings. Relatively few studies, however, have compared these interventions in larger, naturalistic cohorts. This study was conducted to assess the comparative efficacy and rapidity of response observed with repeated IV ketamine versus IN esketamine in a psychiatric neurotherapeutics specialty service. Through retrospective chart review, we conducted what is, to the best of our knowledge, among the larger such comparisons to date.

Methods: Data from 153 patients with severe TRD were reviewed (111 patients received IV ketamine and 42 patients received IN esketamine). In accordance with consensus criteria for TRD and validated objective criteria for illness severity, included patients failed a minimum of 2 adequate antidepressant treatment trials and demonstrated a preketamine treatment score of 16 or higher on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR₁₆). Severity of depression was subsequently reassessed with the QIDS-SR₁₆ prior to each ketamine and esketamine administration. A 2-way analysis of variance was used to compare changes in QIDS-SR₁₆ scores between the IV ketamine and IN esketamine treatment groups.

Results: With equivalent depression severity measured by QIDS-SR₁₆ at pretreatment baseline, the IV ketamine treatment group showed significantly greater decreases in QIDS-SR₁₆ scores compared to the IN esketamine group, as measured immediately before each treatment from the third to the eighth session (all P values < .05). Patients who received IV ketamine infusions demonstrated a 49.22% reduction in QIDS-SR₁₆ scores by the eighth treatment, while patients who received IN esketamine over the same induction period showed a 39.55% reduction. As expected, both IV ketamine and IN esketamine treatments resulted in significant decreases in QIDS-SR₁₆ scores. In the IV ketamine group, the decrease in QIDS-SR₁₆ scores reached significance after 1 treatment, while in the IN esketamine treatment group, the decrease in QIDS-SR₁₆ scores reached significance after the second treatment.

Conclusion: In this naturalistic sample of patients with similarly severe TRD treated in a ketamine subspecialty service over a 4-5-week induction period, treatment with IV racemic ketamine was associated with a more rapid response and greater overall efficacy than treatment with IN esketamine.

Background: Finasteride, widely prescribed for androgenetic alopecia, has long been suspected of causing severe neuropsychiatric reactions, including depression, anxiety, and suicidality, even after the drug is discontinued. This study systematically reviews evidence that supports this suspicion and analyzes the reasons for this delayed recognition.

Observations: Concerns about depression from finasteride were raised in several studies as early as 2002. Between the years 2017 and 2023, 4 independent analyses of adverse event reporting systems and 4 studies using data mining of healthcare records indicated a significant increase in the risk for depression, anxiety, and/or suicidal behavior with the use of finasteride. There has been, therefore, a two-decade delay in the realization of the incidences and the gravity of neuropsychiatric effects, allowing harm from a medicine prescribed for a cosmetic indication of hair loss.

Potential Harms and Implications: Over 20 years worldwide, hundreds of thousands may have endured depression, and hundreds may have died by suicide. According to the precautionary principle, such a risk from a cosmetic medication suggests a benefit-to-harm balance that justifies action to protect the public, and the burden of proving that the intervention is not harmful falls on manufacturers.

Causes for Delayed Risk Recognition: The long delay in recognizing the risks associated with finasteride exposure includes the manufacturer's failure to perform and publish simple pharmacovigilance studies using database analyses and regulators' failure to request such studies from the manufacturer or to perform them.

Conclusions and Relevance: Current evidence shows that finasteride use can cause depression and suicidality. A historical literature review discloses gaps between research evidence and regulatory steps. The lesson is that before approving a medication for the market, regulators should require manufacturers to commit to performing and disclosing ongoing postapproval analytical studies, and this requirement needs to be enforced.

Objective: In treatment-resistant depression (TRD), augmentation with aripiprazole (A-ARI) or combination therapy by adding bupropion (C-BUP) has been reported as more effective than switching to bupropion (S-BUP), but C-BUP risks falls in older adults, and A-ARI risks weight gain and tardive dyskinesia (TD). The aim of this study was to clarify whether the enhanced effectiveness outweighs such risks.

Methods: In this risk-benefit decision analysis, lifetime quality-adjusted life-years (QALYs) following 1 year of A-ARI or C-BUP vs S-BUP treatment were simulated in a health-state transition model tracking depression remission, falls, weight gain, and TD, in age and baseline body mass index (BMI) subgroups, using data from the VAST-D and OPTIMUM trials and other literature. QALYs were converted to depression-free day-equivalents (DFDs), the QALYs gained from 1 day of remitted versus active depression.

Results: Simulated adults aged 18-64 years experienced a net benefit of C-BUP over S-BUP of 20.7 DFDs, equivalent to about 3 weeks of faster remission of depressive symptoms. In older adults, especially those aged 85+ years, this benefit over S-BUP was partially but not fully offset by a risk of falls. In adults aged 18-64 years, A-ARI was estimated to offer only 8.0 DFDs after subtracting the expected harms from TD, and this was further reduced to -22.8 DFDs once metabolic harms were considered, in those overweight at baseline. Overall, C-BUP was preferred over A-ARI in all subgroups except ages 85-89 years with BMI<25, in whom A-ARI was preferred.

Conclusion: In our model, C-BUP better balanced efficacy and tolerability in TRD in adults under 85 years than did S-BUP or A-ARI. A-ARI was least-preferred in overweight adults. These results may inform shared decision-making and clinical guidelines.

Background: Short-term studies have demonstrated antisuicidal effects of ketamine/esketamine for patients with treatment-resistant depression (TRD). However, long-term data and their impact in reducing suicidality-related health care utilization are limited. This 6-month mirror-image study compares suicidality-associated emergency department (ED) visits before and after acute treatment with ketamine/esketamine in a TRD cohort.

Method: This study included adults with TRD evaluated at Mayo Clinic Depression Center (Rochester, Minnesota) from May 2018 to May 2024, who received an acute series of intravenous (IV) ketamine or intranasal (IN) esketamine treatments. The primary outcome measure was the number of suicidality-associated ED visits in the 6 months before and after treatment. Negative binomial mixed-effects model was utilized to analyze suicidality-associated ED visits per person, estimating incidence rate ratios (IRRs) and 95% confidence intervals for the change between pre-and posttreatment periods.

Results: Of 124 eligible individuals, 27 were excluded due to unavailable data, leaving 97 for analysis. The cohort was 69% female, with a median age of 48.9 years; 97% had major depressive disorder, and most (75%) received IV ketamine. After the acute treatment phase, ED visits for suicidal ideation decreased by 84% (IRR=0.16, 95% CI, 0.06-0.46, P=.001), and total ED visits for suicidality decreased by 63% (IRR=0.37, 95% CI, 0.18-0.77, P=.007).

Conclusions: Ketamine and esketamine reduced long-term ED visits for suicidality in individuals with TRD. Further longer-term follow-up research is encouraged to ascertain if these benefits on suicidality reduction are mood state dependent or reflect an independent mechanism.