Focus (American Psychiatric Publishing)最新文献

Cognitive symptoms and deficits are core features of late-life depression (LLD), with an estimated 20%-50% of affected individuals meeting diagnostic criteria for mild cognitive impairment (MCI). Cognitive deficits, especially executive dysfunction, have consistently been associated with poorer treatment outcomes among people with LLD. Furthermore, distinguishing depression with cognitive complaints or cognitive impairment from the early stages of Alzheimer's disease (AD) can be challenging. Cognitive concerns are often emphasized among those with LLD, although, paradoxically, their description of memory difficulty may include detailed recall of specific memory lapses. Conversely, people with AD often have limited insight into their progressive cognitive decline, minimizing and concealing their cognitive difficulties. Neuropsychological assessment is one of the most useful means of clarifying this differential diagnosis. A subcortical cognitive pattern is commonly observed among people with LLD, including psychomotor slowing, variable attention, and executive dysfunction, which can affect memory encoding and free recall. A broad range of therapeutic approaches have been applied to older adults experiencing LLD along with cognitive symptoms, MCI, or dementia. Most studies focus on treatments to address LLD or MCI, with relatively fewer examining treatments specifically at this intersection. Nonpharmacological strategies, including aerobic exercise, cognitive remediation, and neuromodulation, are highly recommended to improve both depression and cognition. Antidepressants may have benefits for elements of cognition among people with LLD, but they have less evidence for their efficacy for people with cognitive deficits and dementia. This review provides an updated conceptual and practical framework for clinicians evaluating and treating LLD.

The effective treatment of major depressive disorder remains one of the biggest public health challenges globally. For moderate to severe cases, pharmacotherapy often falls short, leading to treatment-resistant depression. Electroconvulsive therapy (ECT) has generally been considered the gold standard for severe cases of treatment-resistant depression. However, emerging evidence suggests that ketamine may serve as a promising alternative. Two relatively large noninferiority trials and three meta-analyses support the efficacy of both treatments but report contradictory findings regarding superiority. The authors discuss possible reasons underlying these discrepant findings, including variations in patient selection criteria, study outcome measures, treatment delivery, and site experience. Additionally, the authors examine the unique risk and benefit profiles of each treatment, highlighting patient-specific considerations. By evaluating the most recent evidence for the efficacy of ketamine versus ECT alongside key patient-specific factors, the authors aimed to guide clinicians in recommending the optimal treatment choice for each patient.

Mood disorders are highly prevalent. Despite increased rates of treatment provision, treatment gaps are sustained by inadequate targeting of interventions and little emphasis on prevention. Here, the authors present an overview and analysis of the National Network of Depression Centers (NNDC) Mood Outcomes Program, which is both a measurement-based care program, with a standardized set of mood "vital signs" assessed as part of routine clinical care, and a learning health system. The authors analyzed all data collected since the program's inception in 2015 to assess whether baseline symptom severity, prior suicidal ideation or attempts, length of care, and longitudinal symptom severity differed across sociodemographic groups. The results show important treatment needs that are not being fulfilled. Most notably, the groups with the greatest symptom severity were not the groups with the most visits. Efforts to address systemic barriers that prevent access to mental health care are required. Given that the NNDC Mood Outcomes Program is integrated with clinical care, academic programs, and research at each site, the authors anticipate that the program is well suited to support efforts to dismantle systemic barriers to care.

Early life stress (ELS) has been established as a major risk factor for a multitude of psychiatric and medical disorders. ELS is highly prevalent in the general population and constitutes a major public health concern. The current review will focus on the clinical literature that suggests a link between adverse early life experiences and vulnerability for adolescent and adult substance use disorders. It will investigate the characteristics of ELS that appear to increase risk for disorder onset and a more severe disease course, characterized by earlier onset, greater risk of relapse, and treatment resistance. The authors explore how ELS may increase risk for adverse substance use outcomes through long-lasting changes in the HPA axis and development of stress, reward, and executive control brain systems. The review will also discuss potential pathways to substance use disorder following ELS, with a focus on the role of comorbid mood and anxiety disorders and other modifiable traits. Finally, the authors will discuss how the current body of work presents the potential for prevention and intervention strategies to reduce the psychosocial consequences following early life stress and minimize adverse substance use outcomes. Reprinted from Advers Resil Sci 2020; 1:29-47, with permission from Springer. Copyright © 2020.

Women with a history of traumatic experience, particularly adversity encountered during childhood, have an increased risk of developing depression. The authors review the biological mechanisms associating trauma with depression, including the role of the hypothalamic-pituitary-adrenal axis. Additionally, the psychosocial and cultural considerations associating traumatic experience with depression are discussed, and current gaps in knowledge about biological mechanisms, psychosocial factors, and cultural aspects relating trauma to depression that remain to be addressed are described. Women with a history of trauma are also at increased risk for engaging in suicidal behaviors, including suicidal ideation and attempts. Increased suicidality in women with a history of trauma has been observed in various populations, including among victims of intimate partner violence, female veterans, refugees, and individuals who identify as lesbian, gay, bisexual, transgender, queer or questioning, or other. Although associations between trauma and suicidality have been well documented, limited research has examined the impact of age or reproductive stage, an important area for future research. A wide range of biological, psychosocial, and cultural factors that can increase the risk for suicidality across the lifespan in women are described, and how they may be included when completing clinical assessments for women is highlighted. Machine learning, and its use in risk and outcome prediction of depression in women across reproductive stages toward individualized psychiatric services, is introduced, with future directions reviewed.

Individuals with bipolar disorder are at significant risk for having a co-occurring substance use disorder-particularly, alcohol and cannabis use disorders. Having a co-occurring substance use disorder is associated with a more pernicious clinical course, lower quality of life, and poorer treatment outcomes. Despite its increased morbidity, there is little research and clinical evidence-based guidelines on the treatment of individuals with co-occurring bipolar and substance use disorders. This review details current knowledge on the prevalence, clinical correlates, and biopsychosocial mechanisms underlying co-occurring bipolar and substance use disorders. The authors present recent research that highlights underlying mechanisms of comorbidity, including aberrant reward processing, stress sensitization, early childhood maltreatment, and gene-environment interactions. Next, the authors review current evidence-based recommendations for the assessment and treatment of co-occurring bipolar and substance use disorder, highlighting areas of needed future clinical research.