Focus (American Psychiatric Publishing)最新文献

Objective: The authors explored whether a digital literacy program, Digital Outreach for Obtaining Resources and Skills (DOORS), could improve self-reported functional skills and clinical outcomes among people with serious mental illness.

Methods: The 8-week program was offered to participants receiving treatment in community mental health centers (N=113) and an inpatient psychiatric unit (N=74). Pre- and postintervention self-report surveys were collected. Descriptive statistics and two-tailed t tests were used for analysis.

Results: For patients treated in a community center, improvements were observed in 27 of the 29 self-reported functional skills that measured digital literacy. Changes in seven of these skills were statistically significant. Although these participants reported larger improvements in clinical outcomes than did inpatient participants, no statistically significant changes in symptoms were seen in either setting.

Conclusions: Digital skills training is necessary to increase access to care through technology. DOORS can improve self-reported digital literacy, but further research is necessary to determine its immediate impact on symptoms.

Cognitive-behavioral therapy for psychosis (CBTp) is an evidence-based intervention targeting distress and impairment associated with psychotic symptoms. Despite strong empirical support and international endorsement, it remains underutilized in U.S. psychiatric and forensic settings. This article traces CBTp's theoretical foundations and chronicles its U.S. development, highlighting key milestones, policy shifts, and clinical applications. A narrative review of cognitive-behavioral models, landmark trials, and federal and state implementation initiatives reveals CBTp's evolution from educational and behavioral intervention models into a flexible approach incorporating cognitive, behavioral, motivational, and environmental strategies for the full psychosis spectrum. Recent years have seen diversification into group-based, low-intensity, and digital formats, with growing access via state-sponsored training. Persistent barriers include clinician training, reimbursement, and integration into routine care. Understanding CBTp's theoretical roots, evidence base, and U.S. history can help mental health practitioners advance its integration. Psychiatrists are well positioned to advocate for and participate in enhancing access.

Borderline personality disorder (BPD) is characterized by a long-term pattern of instability of interpersonal relationships, unstable self-image, marked impulsivity, and/or affective instability. In addition, these features can be evidenced by efforts to avoid real or feared abandonment, chronic feelings of emptiness, mood reactivity, recurrent self-injurious or suicidal behavior, other impulsive behaviors with potential for self-damaging effects, intense anger or difficulty with anger control, and transient paranoid ideation or stress-related dissociative symptoms. BPD is associated with substantial lifetime burdens and psychosocial impairments, including high rates of co-occurring psychiatric disorders; disruptions in interpersonal relationships, school, work, and housing; and suicide attempts and nonsuicidal self-injury. Consequently, early identification and treatment of BPD are crucial. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder aims to enhance knowledge and increase the appropriate use of interventions for BPD, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with BPD. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and ABPN Continuing Certification, Improvement in Medical Practice.

Clozapine remains the only medication approved by the U.S. Food and Drug Administration (FDA) for managing treatment-resistant schizophrenia and for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. Despite its known benefits, its use remains suboptimal with non-evidence-based treatments often trialed before clozapine. These delays have been shown to reduce the likelihood of clozapine response or increase the risk of early discontinuation. With the elimination of the Clozapine Risk Evaluation and Mitigation Strategy program, one barrier that had impeded clozapine use has been negated. However, barriers persist that are related to clinicians' perceptions of clozapine and knowledge related to appropriate titration, monitoring, and management of adverse drug reactions. With a growing body of evidence suggesting that current FDA-recommended hematologic monitoring is overly cautious, there is future potential that these requirements become less stringent. This marks an important time to bring forth a call to action for increased use of clozapine and focus on important clozapine-related initiation and monitoring strategies. Such strategies include slower initial titration, understanding differences in clozapine metabolism across different genetic ancestry groups, awareness of inflammatory reactions, recognition of pneumonia-related mortality, and appropriate bowel care. This review highlights best and evidence-based practices to help clinicians increase clozapine prescribing and ensure that patients have the greatest opportunity for a successful, potentially life-saving clozapine trial.

There is increasing interest in smartphone digital mental health interventions (DMHIs) for managing schizophrenia. Currently, numerous applications (or, apps) that target different specific domains (e.g., medication adherence, social functioning, relapse prediction, and general mental well-being) have been developed and evaluated in research studies; however, few are commercially available to patients. The emergence of DMHIs has also highlighted the critical role of app engagement and the therapeutic alliance in effective treatments. This has driven the adoption of hybrid care models that integrate traditional psychotherapy with smartphone-based tools for symptom monitoring and intervention delivery, such as psychoeducation, cognitive-behavioral therapy for psychosis modules, and other targeted supports. This clinical review examines the current landscape of DMHIs for managing schizophrenia, including research evaluating outcomes related to effectiveness and implementation.

Anticholinergic medications (ACMs) prescribed for the treatment of antipsychotic-associated extrapyramidal symptoms (EPSs) are frequently prescribed for durations that exceed expert guidelines and are associated with significant side-effect burden. Evidence suggests that education with regard to the risks of long-term prescribing of ACMs for resolved EPSs may be lacking in the health care community, and no best practices exist for deprescribing ACMs. This review discusses EPSs and their treatment with two ACMs, benztropine and trihexyphenidyl, and it presents evidence of the risks of chronic ACM prescribing, including serious side effects such as cognitive impairment, dry mouth, blurred vision, and risk for delirium, as well as sequelae of severe constipation and urinary retention. It is pertinent to remember that many psychotropic agents, including several antipsychotics, as well as other commonly prescribed medications have moderate to strong anticholinergic properties. Each ACM, when prescribed with other medications concomitantly, compounds ACM burden and associated side effects. Informed by the authors' extensive experience with quality improvement projects on deprescribing ACMs, this review examines both the benefits and risks of ACM deprescribing, with an emphasis on choosing appropriate patients and engaging in shared decision making while utilizing patient-facing assessments and decision-support tools. ACM tapering schedules are suggested, along with recommendations for closer patient monitoring during the deprescription process. Barriers to deprescription at the patient, prescribing clinician, and system level are then reviewed, along with relevant ethical considerations inherent to any medication changes, including ACM deprescribing.

The objective of this review is to examine the pharmacology, pharmacokinetics, clinical efficacy, and safety profile of the combination of xanomeline and trospium (XT) for the treatment of schizophrenia. A search was conducted of all publicly available information (including press releases) and specifically within the databases MEDLINE, Embase, and PsycINFO, from their inception to May 1, 2025, noting the keywords "muscarinic," "schizophrenia," "xanomeline," and "emraclidine." A first-in-class medication approved for the treatment of schizophrenia in adults, XT possesses no direct action on dopamine D₂ receptors. It is dosed twice daily without food and has demonstrated efficacy and safety in three 5-week double-blind, placebo-controlled trials and in two 52-week open-label studies. The pooled effect size of 0.61 (0.56 using the meta-analysis method) is greater than that for other agents approved for schizophrenia since 1996, with no risk for movement disorders, weight gain, and hyperprolactinemia. Post hoc analyses from the acute schizophrenia trials also indicate an impact on cognition among individuals with more significant baseline levels of cognitive impairment. Preliminary results of the adjunctive trial for adults with schizophrenia who are partial responders to other antipsychotics were not statistically significant, but ongoing studies are exploring XT for dementia-related psychosis and pediatric indications.