Focus (American Psychiatric Publishing)最新文献

Antipsychotic-induced weight gain (AIWG) is a pervasive and concerning side effect of treatment with antipsychotic medications (APs) that has grave implications for morbidity and mortality rates in individuals with serious mental illness. As such, acknowledging, identifying, and addressing the metabolic side effects of these medications are critical to improve the overall health and quality of life of individuals treated with APs. This review summarizes the key risk factors and predictors of AIWG and provides a comprehensive and prescriptive overview of the best-researched and evidenced nonpharmacological and pharmacological therapies available to address this problem. Age, prior exposure to APs, and AP type are strong determinants of AIWG. Metabolic monitoring and lifestyle changes remain the methods of choice for addressing metabolic risk in this population. Clinical guidelines have recommended the off-label use of metformin when such interventions are not effective, and there is emerging evidence for the effectiveness of other novel weight loss agents in this population that may represent an opportunity for greater metabolic improvements. Most of the research and guidelines to date have focused on treating AIWG; however, prevention efforts may confer greater benefits given the challenges of reversing weight gain. To effectively mitigate the metabolic risks associated with these medications, substantial system-level reforms in both education and clinical service delivery are essential, with a focus on proactive monitoring and early intervention based on up-to-date evidence and best-practice recommendations.

Psychological treatments are increasingly regarded as useful interventions for schizophrenia. However, a comprehensive evaluation of the available evidence is lacking and the benefit of psychological interventions for patients with current positive symptoms is still debated. The present study aimed to evaluate the efficacy, acceptability and tolerability of psychological treatments for positive symptoms of schizophrenia by applying a network meta-analysis approach, that can integrate direct and indirect comparisons. We searched EMBASE, MEDLINE, PsycINFO, PubMed, BIOSIS, Cochrane Library, World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov for randomized controlled trials of psychological treatments for positive symptoms of schizophrenia, published up to January 10, 2018. We included studies on adults with a diagnosis of schizophrenia or a related disorder presenting positive symptoms. The primary outcome was change in positive symptoms measured with validated rating scales. We included 53 randomized controlled trials of seven psychological interventions, for a total of 4,068 participants receiving the psychological treatment as add-on to antipsychotics. On average, patients were moderately ill at baseline. The network meta-analysis showed that cognitive behavioural therapy (40 studies) reduced positive symptoms more than inactive control (standardized mean difference, SMD=-0.29; 95% CI: -0.55 to -0.03), treatment as usual (SMD=-0.30; 95% CI: -0.45 to -0.14) and supportive therapy (SMD=-0.47; 95% CI: -0.91 to -0.03). Cognitive behavioural therapy was associated with a higher dropout rate compared with treatment as usual (risk ratio, RR=0.74; 95% CI: 0.58 to 0.95). Confidence in the estimates ranged from moderate to very low. The other treatments contributed to the network with a lower number of studies. Results were overall consistent in sensitivity analyses controlling for several factors, including the role of researchers' allegiance and blinding of outcome assessor. Cognitive behavior therapy seems to be effective on positive symptoms in moderately ill patients with schizophrenia, with effect sizes in the lower to medium range, depending on the control condition. Reprinted from World Psychiatry 2018; 17:316-329, with permission from World Psychiatric Association. Copyright © 2018.

Background: Study-level meta-analyses have demonstrated the efficacy of cognitive-behavioural therapy for psychosis (CBTp). Limitations of conventional meta-analysis may be addressed using individual-participant-data (IPD). We aimed to determine a) whether results from IPD were consistent with study-level meta-analyses and b) whether demographic and clinical characteristics moderate treatment outcome.

Methods: We systematically searched PubMed, Embase, PsychInfo and CENTRAL. Authors of RCTs comparing CBTp with other psychological interventions were contacted to obtain original databases. Hierarchical mixed effects models were used to examine efficacy for psychotic symptoms. Patient characteristics were investigated as moderators of symptoms at post-treatment. Sensitivity analyses were conducted for risk of bias, treatment format and study characteristics.

Results: We included 14 of 23 eligible RCTs in IPD meta-analyses including 898 patients. Ten RCTs minimised risk of bias. There was no significant difference in efficacy between RCTs providing IPD and those not (p >0.05). CBTp was superior vs. other interventions for total psychotic symptoms and PANSS general symptoms. No demographic or clinical characteristics were robustly demonstrated as moderators of positive, negative, general or total psychotic symptoms at post-treatment. Sensitivity analyses demonstrated that number of sessions moderated the impact of treatment assignment (CBTp or other therapies) on total psychotic symptoms (p = 0.02).

Conclusions: IPD suggest that patient characteristics, including severity of psychotic symptoms, do not significantly influence treatment outcome in psychological interventions for psychosis while investing in sufficient dosage of CBTp is important. IPD provide roughly equivalent efficacy estimates to study-level data although significant benefit was not replicated for positive symptoms. We encourage authors to ensure IPD is accessible for future research.

In the United States, mental health and substance use disorder care is provided by a range of professionals, including psychiatrists, psychologists, and master's-level clinicians. These professionals are overseen and regulated at the state level by field-specific boards. Considerable variation between states in the educational and clinical supervision requirements for licensure creates challenges for license portability. To address these challenges, beginning in 2014, states have adopted practice compacts in medicine, psychology, counseling, and social work that allow clinicians licensed in a participating state to practice either via telehealth or in person in other participating states. This article discusses the nature of these compacts and provides legal and practice considerations for clinicians interested in joining a practice compact in their profession.

In 2024, for the first time in more than a decade, the year-over-year rate of American opioid overdose deaths demonstrated a sustained downward trend. Years of public policy interventions that changed clinical practice, shaped population-level behaviors, and enacted measures to prevent overdoses finally prevailed. Advocacy from behavioral health professionals has been central to this milestone, which inspires a call to action for increased professional advocacy moving forward, yet research indicates that many practitioners do not feel empowered to engage in advocacy because they lack familiarity with the process. With limited training programs in advocacy, this article attempts to fill the gap, examining effective policy advocacy related to opioids and other substances, the role behavioral health professionals have played in successful policy changes, suggestions for integrating advocacy practice into clinical training programs, and guidelines for professionals to promote advocacy at local, regional, and national levels.

Advocacy is a fundamental responsibility of all physicians, and psychiatrists are uniquely positioned as advocates because of their expertise in understanding the intersection between mental health, social determinants, and systemic barriers. Defined as giving voice to advance patient and population health, physician advocacy spans a continuum of activities, including micro-level efforts focused on individual patients, meso-level initiatives targeting organizational and community improvements, and macro-level interventions addressing systemic changes. Advocacy training enhances competence in these domains, but significant gaps persist in advocacy integration into medical education. Although insufficient institutional support, lack of formalized requirements, and limited recognition in academic or career promotion hinder advocacy skill development, professional organizations provide opportunities to develop and refine advocacy competencies, obtain mentorship, and identify avenues for engaging with policy makers. Through advocacy, psychiatrists have made significant contributions at individual, community, and national levels-and continue to be essential in driving systemic change to improve health.