Toward a Definition of "No Meaningful Benefit" From Antidepressant Treatment: An Equipercentile Analysis With Cross-Trial Validation Across Multiple Rating Scales.

Background: Many patients with major depressive disorder (MDD) who experience no meaningful benefit (NMB) from antidepressive treatment go undetected. However, there is a lack of consensus on the definition of NMB from antidepressants.Methods: Equipercentile linking was used to identify a threshold for percent change in 17-item Hamilton Depression Rating Scale (HDRS-17) scores that equated with a Clinical Global Impressions-Improvement (CGI-I) score of 3 (minimally improved), a proxy for NMB, after 4 and 8 weeks of citalopram or escitalopram treatment, using data from the Pharmacogenomic Research Network Antidepressant Medication Pharmacogenomic Study (PGRN-AMPS). The NMB threshold for the HDRS-17 was validated by equating a CGI-I rating of 3 with percent change values from the clinician- and patient-rated versions of the Quick Inventory of Depressive Symptomatology (QIDS-C and QIDS-SR) using data from PGRN-AMPS and phase 1 of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. This study was conducted between June 2021 and September 2021.Results: In PGRN-AMPS, a 30% improvement in HDRS-17 score corresponded to a CGI-I rating of 3 at 4 and 8 weeks. The 30% improvement threshold was also observed for QIDS-C and QIDS-SR scores in both PGRN-AMPS and STAR*D. Similar results were observed for percent change in HDRS-17 and QIDS-based measures in lower- and higher-severity groups based on a median split of baseline total scores.Conclusions: Improvement in depressive severity of ≤ 30%, as assessed using the HDRS-17, QIDS-C, and QIDS-SR, may validly define NMB from antidepressants during short-term treatment.

Association of Depression and Anxiety With the Accumulation of Chronic Conditions.

Importance: Longitudinal associations between comorbid depression and anxiety with the accumulation of chronic illnesses are unclear, and questions remain about the contributions associated with each condition in the increasing prevalence of multimorbidity. Objective: To compare the risk and rate of accumulating chronic conditions in people with depression, anxiety, and comorbid depression and anxiety vs individuals with neither depression nor anxiety. Design, Setting, and Participants: This cohort study used the Rochester Epidemiology Project medical records-linkage system to identify residents of Olmsted County, Minnesota, from January 1, 2005, to December 31, 2014, with follow-up ending December 31, 2017. The sample was divided into cohorts anchored at birthday ages of 20, 40, and 60 years. Individuals were classified at anchoring birthday age as having depression alone, anxiety alone, comorbid depression and anxiety, or neither depression nor anxiety (reference group), using electronically extracted diagnosis codes from the International Classification of Diseases, Ninth Revision (ICD-9) in the 5 years before each anchoring birthday. Data were analyzed from August 2020 through November 2021. Exposures: Depression alone, anxiety alone, comorbid depression and anxiety, or neither depression nor anxiety (reference group). Main Outcomes and Measures: The main outcome was sex-specific risk, calculated as hazard ratios (HRs) and rates of accumulation, calculated as mean annual incidence rates per 100 person-years, of 15 common chronic conditions within each birthday age cohort through the end of study. Results: Among the 40 360 individuals included across all 3 age cohorts, 21 516 (53.3%) were women. After balancing cohorts on race, Hispanic ethnicity, education level, body mass index, smoking status, and calendar year at index birthday, the risk of accumulating chronic conditions was significantly increased among women with depression alone (cohort aged 20 years: HR, 1.20 [95% CI, 1.02-1.42]; cohort aged 40 years: HR, 1.20 [95% CI, 1.10-1.31]; cohort aged 60 years: HR, 1.09 [95% CI, 1.02-1.16]) and women with comorbid depression and anxiety (cohort aged 20 years: HR, 1.60 [95% CI, 1.28-1.99]; cohort aged 40 years: HR, 1.41 [95% CI, 1.21-1.65]; cohort aged 60 years: HR, 1.29 [95% CI, 1.15-1.44]) compared with referent women in the same birthday cohorts and in men with comorbid depression and anxiety compared with referent men in the cohort aged 20 years (HR, 1.77 [95% CI, 1.08-2.91]). For women, the rates of accumulation of conditions were significantly higher across birthday cohorts in the comorbid depression and anxiety group compared with the depression alone group (eg, cohort aged 20 years: difference, 1.2 [95% CI, 0.2-2.1] per 100 person-years) and reference group (eg, cohort aged 20 years: difference, 1.7 [95% CI, 0.9-2.6] per 100 person-years). For men, compared with the reference group, the rates of accumulation of conditions were significantly higher in men with comorbid depression and anxiety in the cohort aged 20 years (difference, 1.4 [95% CI, 0.1-2.6] per 100 person-years) and in men with depression in the cohort aged 40 years (difference, 2.0 [95% CI, 0.8-3.2] per 100 person-years). Conclusions and Relevance: In this cohort study, the risk of accumulating chronic conditions was increased with depression and comorbid depression and anxiety in women across the age span and in younger men with comorbid depression and anxiety. Compared with women without depression or anxiety, there was a more rapid rate of accumulation of chronic conditions in women with depression and anxiety individually and an even higher rate when depression and anxiety cooccurred.

Teaching psychiatry in a low-income country during the COVID-19 pandemic: A hybrid collaborative psychiatry course.

Amoud University in Borama is located in the self-declared state of Somaliland, in the Horn of Africa. Past conflicts and resulting economic hardship have led to a lack of local academic psychiatry faculty and resources. Amoud has been for some years partnering with voluntary faculty in the United Kingdom to teach psychiatry to its medical students through in-person "teaching missions." This was recently led by a Borama-native psychiatry resident in Ethiopia. COVID-19 added further hardships due to restrictions to travel and in-person gatherings. These challenges also created the opportunity for the development of an innovative, international, hybrid (online onsite), self-sustaining partnership model which has been successful in improving psychiatry teaching for undergraduate students in 2020-2021 and will continue in 2021-2022. An international, 'online-connected' department of psychiatry comprising a primary care physician in Somaliland, three postgraduate trainees in Ethiopia and the United States, and three senior psychiatrists in the United Kingdom developed a local faculty-led, hybrid-delivered, dynamic curriculum (bedside teaching, in person and online lecturing) that adapted to the needs, resources, faith and culture of Somaliland. While 2020-2021 has been the pilot year for the program, the overall experience has been enriching for students and faculty, leading to valuable cross-cultural conversations with impact on teaching and research. While learning about Somalilanders' and trauma, the program leads, also the authors of this article, have identified ways to harness the resilience and faith of students to bring about improvements in global mental health.

Internet and Pornography Use During the COVID-19 Pandemic: Presumed Impact and What Can Be Done.

The COVID-19 pandemic continues to cause an immense psychosocial strain worldwide. Excessive use of the internet during these psychologically trying times, fueled by physical isolation as a result of lockdowns, has translated into dysfunctional behaviors. A growing body of evidence suggests an unprecedented increase in internet use and consumption of online pornography during the pandemic, and possibly even directly caused by it. In this review, the authors report data from relevant sources to show the rise in pornography use during lockdowns in different countries worldwide. In addition to a brief overview of the neurobiology of internet addiction broadly and problematic online pornography use specifically, similarities with substance use disorders are explained. Further, the current status of the debate about defining diagnostic criteria is discussed. Finally, the review sheds light on the potential detrimental outcomes during the future post-pandemic "re-adaptation," while simultaneously offering preventative and management strategies for harm reduction. The authors conclude that foresightedness with utilizing existing tools and therapies and exercising appropriate amounts of caution could go a long way in addressing the challenges that lie ahead in the post-pandemic era.

International Medical Graduate Resident Physicians in Psychiatry: Decreasing Numbers, Geographic Variation, Community Correlations, and Implications.

OBJECTIVES: The number of International Medical Graduate (IMG) physicians matching into categorical psychiatry decreased steadily over the past decade. The authors sought to understand if this trend was occurring in other specialties, if US IMG physicians and non-US IMG physicians were equally affected, and if certain regions of the USA were more affected by this decrease than others. Finally, the authors compared the proportion of foreign-born individuals within a US census region to the proportion of non-US IMG physicians within that region. METHODS: The authors analyzed data from the National Resident Matching Program from the years 2014-2020. Statewide data was aggregated into nine geographic regions, as per the US Census Bureau. The number of foreign-born individuals within each US census region was calculated from the 2018 American Community Survey data. RESULTS: In comparison to eight other specialties, psychiatry saw the greatest decrease (46.3%) in IMG physicians matching into PGY-1 positions. Both US IMG physicians and non-US IMG physicians were equally affected. The percentage of IMG physicians decreased in each of the nine US census regions. In six out of nine geographic regions, non-US IMG physicians were under-represented when comparing their proportion to the number of foreign-born people that lived within that region. CONCLUSIONS: Decreasing numbers of IMG physicians in psychiatry training may have long-term implications for cultural competency, serving underserved populations, and fellowship recruitment. We advocate for program directors to recognize IMG physicians as an important source of diversity and to recruit residents that reflect the communities they serve.

Clinical Trials for Opioid Use Disorder.

This chapter describes recent clinical trials for opioid use disorder (OUD), an area that has rapidly accelerated in response to the opioid overdose crisis in the USA and newly appropriated funding. Trials involve a wide range of compounds including cannabinoids and psychedelics, new and existing compounds targeting domains emerging from addiction neuroscience, agents repurposed from other indications, and novel strategies including vaccines, enzymes, and other biologicals. In parallel, new formulations of existing compounds offer immediate promise, as do a variety of web-based interventions and smartphone-delivered apps. Trials focused on implementing existing effective interventions in mainstream healthcare settings, and others focused on special populations, e.g., adolescents, criminal justice, pregnant women, native Americans, etc., have the potential to vastly expand treatment in the near term. Given the range of ongoing and recent trials, this chapter is not intended to be an exhaustive review but rather to present an overview of approaches within the framework of the opioid treatment cascade and the context of current OUD pharmacotherapies.

Scaling the great wall: The impact of communication barriers on quality of psychiatric care in Chinese patients.

BACKGROUND: Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less equitable access to mental health services than Caucasians. These disparities have a powerful influence on minority groups that already endure a greater burden from mental health needs. AIM: The aim was to identify perceived provider barriers to care for CS patients. METHODS: The study involved an 11-item web-based survey to multidisciplinary health professionals in the department of psychiatry at a 75-bed teaching community mental health center. RESULTS: More than half the respondents agreed that there are disparities in the management of CS versus non-CS patients primarily due to the language barrier (46%). However, older participants and participants who worked fewer hours per week in patient care were less likely to agree (rho = -.27, p = .05 and rho = .33, p = .015, respectively) that these perceived difficulties prevented them from caring for these patients. CONCLUSION: The study revealed that certain modifiable factors like the limited availability of interpreters and culturally appropriate services, rendering psychoeducation and forming therapeutic alliances with CS patients, posed the greatest challenges on inpatient units. In light of these findings, we aim to make recommendations to remediate concerns of limited provider availability by proposing ways to efficiently utilize current resources and advocate for better staffing to improve the overall well-being of this challenging patient subset.

Is the Concept of Pseudoneurotic Schizophrenia Still Valid? A Case Series and Revisiting the Topic.

We describe two cases to emphasize the importance of recognizing symptoms of psychosis underlying a constellation of neurotic symptoms, and to highlight the overlap and potential for misdiagnosis with personality and anxiety disorders. We also provide an overview of pseudoneurotic schizophrenia and familiarize readers about the challenges in making accurate diagnoses in light of this term used in the past. We refer to cases in the literature and point out the implications of this concept on diagnosis, management, and prognosis. Based on the management strategies deployed for the two cases described, we finally recommend that it is imperative to perform accurate and detailed assessments and take into consideration the evolution of the concept of pseudoneurotic schizophrenia to currently accepted DSM-V disorders, in order to effectively treat patients.

Trends of Tobacco Consumption Among Women Admitted to and Visiting the Psychiatric Inpatient Unit of a Tertiary Care Center in Mumbai: A Cross-Sectional Study.

OBJECTIVE: To gain insight into the current prevalence of tobacco consumption in various forms among female psychiatric inpatients and their visiting female relatives in Mumbai, India. METHODS: In this cross-sectional study, survey questionnaires were administered to 127 female inpatients and 110 of their visiting female relatives from July to October 2016. A total of 100 patients and 108 of their relatives completed responses. Additionally, a modified version of the Fagerström Test for Nicotine Dependence was incorporated into the survey to assess the level of nicotine dependence, with higher scores corresponding to higher levels of dependence. RESULTS: The rates of tobacco use were higher in the patients than in their relatives (χ² = 12.13, P = .0003). Patients had shorter periods of abstinence and lower World Health Organization Quality of Life Assessment parameters. CONCLUSIONS: This study sheds light on certain data that may be utilized for future health programs and in the development of treatment plans for women with mental illness.​​.

The Implementation of Marijuana Legalization in New York.

In 2018, Governor Cuomo tasked the Department of Health (DOH) with studying the anticipated impact of legalizing recreational marijuana use in New York State. DOH concluded that the positive effects of a regulated marijuana market outweighed the potential negative impact but that implementation required close monitoring of usage, education of specific populations, and regular and rigorous evaluation. In states where cannabis is legal, studies have shown associated decreases in crime rates and increases in financial resources. Conversely, accidental ingestion in children and accidents following ingestion had increased. The road ahead is fraught with challenges, especially because of the nonuniformity in federal and state laws.

Violence Associated with Somatic Delusions.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) characterizes delusional disorder (DD) by the presence of delusions for longer than one month, without bizarre behavior or functional impairment. According to Kaplan and Saddock, the lifetime prevalence of DD (all subtypes) is about 0.2%. The persecutory subtype of delusional disorder (DD-PS) is the most common and the somatic subtype (DD-SS) is exceedingly rare. We aim to describe two cases of patients with somatic delusions, both presenting as imminently dangerous and threatening. We also discuss one case that resulted from our extensive literature review where somatic delusions were implicated in elevating a mass shooter's violence risk. Both patients whose cases are presented were involuntarily hospitalized after their doctors called 911 to report that they were being threatened by a weapon. These patients had no established psychiatric diagnoses and were evaluated thoroughly and diagnosed with DD-SS. Both perceived that their physicians were indifferent to their needs and cited their frustration as the trigger for planning attacks on the doctors. Unlike PS, SS is not traditionally described as increasing danger or risk of violence, and thorough risk assessments are not usually performed in DD-SS. We demonstrate that formal psychiatric violence risk assessments remain a useful tool to methodically stratify and effectively address risk, even in patients we do not typically expect to demonstrate premeditated violence.

Persistent Psychosis due to Single Dose of Ecstasy.

Ecstasy, a popular drug among the younger generation, the primary psychoactive component of which is 3,4-Methylenedioxymethamphetamine (MDMA), is rarely known to have acute psychiatric effects and when it does, it is usually short term. We describe a patient who presented to the emergency room in a psychotic state after using ecstasy recreationally. Given his aggressive behavior in the community and risk for self-harm, he was emergently hospitalized to ensure safety. He developed persistent psychotic symptoms (delusions) after one dose of recreational MDMA and the team had the opportunity to observe, monitor, and treat his psychosis. This case along with few other documented cases highlights the gaps in research about the chronic, persistent effects and long-term consequences of MDMA. It also suggests that neuropsychiatric symptoms may not be readily reversible after cessation of use. There is an emphasis on the need for physicians to inquire about MDMA use and include it in toxicology screenings and as a potential differential diagnosis.

Efficacy and Safety of Varenicline for Smoking Cessation in Schizophrenia: A Meta-Analysis.

Objective: Smoking represents a major public health problem among patients with schizophrenia. To this end, some studies have investigated the efficacy of varenicline for facilitating smoking cessation in schizophrenia patients. The present review seeks to synthesize the results of these studies as well as document the reported side effects of using this medication. Methods: An electronic search was performed using five major databases: PubMed, Scopus, EMBASE, Web of Science, and Cochrane Library. Included in the current analysis were randomized clinical trials (RCTs) that have investigated the effect of varenicline in promoting smoking cessation in patients with schizophrenia. Risk of bias among included RCTs was assessed using the Cochrane Collaboration's quality assessment tool. Results: Among the 828 screened articles, only four RCTs, which involved 239 participants, were eligible for meta-analysis. In patients with schizophrenia, varenicline treatment when compared to placebo significantly reduced the number of cigarettes consumed per day [SMD (95% CI) = 0.89(0.57-1.22)] and expired carbon monoxide levels [SMD (95% CI) = 0.50 (0.06-0.94)] respectively. Conclusion: Despite a limited number of studies included in the meta-analysis, our results suggest that varenicline is an effective and safe drug to assist smoking cessation in patients with schizophrenia. Future large-scale well-designed RCTs are required to validate these findings.

Gender Differences and Comorbidities in U.S. Adults with Bipolar Disorder.

BACKGROUND: Past studies have evaluated the association of various comorbidities with bipolar disorder. This study analyzes differences in the prevalence and association of medical and psychiatric comorbidities in bipolar patients by gender. METHODS: A retrospective analysis was conducted using the Nationwide Inpatient Sample (2010⁻2014). Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, we narrowed the study population to comprise those with a primary diagnosis of bipolar disorder and then obtained information about comorbidities. The differences in comorbidities by gender were quantified using chi-square tests and the logistic regression model (odds ratio (OR)). RESULTS: Hypertension (20.5%), asthma (12.5%) and hypothyroidism (8.1%) were the top medical comorbidities found in bipolar patients. Migraine and hypothyroidism were seen three times higher in females (OR = 3.074 and OR = 3.001; respectively). Females with bipolar disorder had higher odds of comorbid inflammatory disorders like asthma (OR = 1.755), Crohn's disease (OR = 1.197) and multiple sclerosis (OR = 2.440) compared to males. Females had a two-fold higher likelihood of comorbid post-traumatic stress disorder (PTSD) (OR = 2.253) followed by personality disorders (OR = 1.692) and anxiety disorders (OR = 1.663) compared to males. CONCLUSION: Women with bipolar disorder have a much higher medical comorbidity burden than men and may highly benefit from an integrated team of physicians to manage their condition and improve their health-related quality of life.

Decoding New York State's Prescription Monitoring Program.

This column describes the Internet System for Tracking Over-Prescribing (I-STOP), New York State's prescription monitoring program, and its compatibility with HIPAA and Part 2 of Volume 42 of the Code of Federal Regulations (CFR). The authors review use of information that is permitted by I-STOP and CFR for health care operations, including disclosure, and present information from the state Bureau of Narcotics Enforcement about appropriate use of the program. Physicians are permitted, for example, to contact other prescribers in I-STOP, even without explicit permission from the patient, an area in which physicians need more training. Common clinical scenarios encountered while navigating I-STOP are described.

Burnout, Moral Distress, Work-Life Balance, and Career Satisfaction among Hematopoietic Cell Transplantation Professionals.

A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work-life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale-Revised) were examined to identify work-related distress. Additional questions addressed demographics, work-life balance, and career satisfaction. Of 5759 HCT providers who received an individualized invitation to participate, 914 (16%) responded; 627 additional participants responded to an open link survey. Significant differences in demographic and practice characteristics existed across disciplines (P < .05). The prevalence of burnout differed across disciplines (P < .05) with an overall prevalence of 40%. Over one-half of pharmacists had burnout, whereas social workers had the lowest prevalence at less than one-third. Moral distress scores ranged from 0 to 336 and varied by discipline (P < .05); pharmacists had the highest mean score (62.9 ± 34.8) and social workers the lowest (42.7 ± 24.4). In multivariate and univariate analyses, variables contributing to burnout varied by discipline; however, moral distress was a significant contributing factor for all providers. Those with burnout were more likely to report inadequate work-life balance and a low level of career satisfaction; however, overall there was a high level of career satisfaction across disciplines. Burnout, moral distress, and inadequate work-life balance existed at a variable rate in all HCT disciplines, yet career satisfaction was high. These results suggest specific areas to address in the work environment for HCT health professionals, especially the need for relief of moral distress and a greater degree of personal time. As the creation of healthy work environments is increasingly emphasized to improve quality care and decrease costs, these findings should be used by HCT leadership to develop interventions that mitigate work-related distress and in turn foster recruitment and retention of HCT providers.