A case report of persistent risky dietary behaviors in a bipolar disorder patient.

BACKGROUND: Bipolar disorder is associated with complicated medical comorbidities. The risk-taking behavior of bipolar disorder patients may lead to many problems. CASE PRESENTATION: A 40-year-old male patient had gastrointestinal symptoms for 4 months. He was talkative, agitative, and grandiose but showed poor cognition. Multisystem injury required multidepartment, multidisciplinary consultation. Repeated fecal examination found multiple infections of Opisthorchis sinensis, Heterophyes, and Echinostomatidae. The diagnostic criteria for parasitic infections, bipolar disorder and organic mental disorder were met. After treatment with a mood stabilizer and helminthic, his mood became stable, but risky dietary behavior continued. CONCLUSIONS: The case describes persistent risky dietary behaviors in a bipolar patient even after affective symptoms were under control, which ultimately led to diverse parasitic infections and chronic encephalopathy. We call for clinical and scientific attention to possible dangerous behavior changes in bipolar patients even after their emotions are stabilized.

Parameters of training, academic involvement, and practice setting predictive of retention in combined medical-psychiatric practice.

OBJECTIVE: The authors contrasted physicians trained in both psychiatry and another specialty who continue to practice both specialties vs. those who practice only psychiatry, in terms of their training, academic profile, and practice setting. METHOD: The authors analyzed survey responses from 132 doubly boarded physicians who vary in whether or not they continue to practice both specialties. Group results were compared using chi square, Fisher exact, and t tests. RESULTS: Of graduates of double-board programs, 79.2% continue in dual practice. Other factors associated with continued combined practice were training in neurology-psychiatry, greater academic involvement, high motivation, practice in a non-public hospital setting, and demonstrated leadership capacity. CONCLUSION: Double-board training programs have been successful in producing a group of clinicians committed to long-term combined medical-psychiatric practice, but this effect is stronger in psychiatry-neurology than in other types of combined practice. Future research should investigate other practice parameters that foster or impede integrated medical-psychiatric care.

Developing an Ethics and Policy Framework for Psychedelic Clinical Care: A Consensus Statement.

Importance: As government agencies around the globe contemplate approval of the first psychedelic medicines, many questions remain about their ethical integration into mainstream medical practice. Objective: To identify key ethics and policy issues related to the eventual integration of psychedelic therapies into clinical practice. Evidence Review: From June 9 to 12, 2023, 27 individuals representing the perspectives of clinicians, researchers, Indigenous groups, industry, philanthropy, veterans, retreat facilitators, training programs, and bioethicists convened at the Banbury Center at Cold Spring Harbor Laboratory. Prior to the meeting, attendees submitted key ethics and policy issues for psychedelic medicine. Responses were categorized into 6 broad topics: research ethics issues; managing expectations and informed consent; therapeutic ethics; training, education, and licensure of practitioners; equity and access; and appropriate role of gatekeeping. Attendees with relevant expertise presented on each topic, followed by group discussion. Meeting organizers (A.L.M., I.G.C., D.S.) drafted a summary of the discussion and recommendations, noting points of consensus and disagreement, which were discussed and revised as a group. Findings: This consensus statement reports 20 points of consensus across 5 ethical issues (reparations and reciprocity, equity, and respect; informed consent; professional boundaries and physical touch; personal experience; and gatekeeping), with corresponding relevant actors who will be responsible for implementation. Areas for further research and deliberation are also identified. Conclusions and Relevance: This consensus statement focuses on the future of government-approved medical use of psychedelic medicines in the US and abroad. This is an incredibly exciting and hopeful moment, but it is critical that policymakers take seriously the challenges ahead.

Efficiency is not enough; you have to prove that you care: role modelling of compassionate care in an innovative resident-as-teacher initiative.

INTRODUCTION: The current emphasis on providing holistic competent and efficient healthcare has revealed a need to nurture providers' compassionate and relationship-centred care throughout the continuum of medical education. METHODS: Our resident-as-teacher programme trained 41 residents from core clerkships at six clinical sites in the United States of America (USA) to teach and practice compassionate care through role-modelling. The programme focused on resident's demonstrations or failures to demonstrate compassionate care with peers, students and healthcare providers, and engaged residents in disseminating their experience to their colleagues. A mixed-method evaluation assessed short-term outcomes at multiple levels through the collection of resident's: pre- and post-programme scores on empathy scale, performance on standardised patient (SP) exercise, and self-assessment of their performance on relationship-centred care skills; journal reflections; presentations delivered at their site and attendees' evaluation; evaluation of the programme. Quantitative data was analysed calculating descriptive statistics and paired sample t-tests, using SAS. Qualitative data was analysed performing open coding and code frequency counts to identify emergent themes. RESULTS: Residents had empathy scores within the average range, and high scores on SP assessments throughout the programme. The programme had a positive impact on resident's perceptions of their relationship-centred skills. Residents found the programme useful, and emphasised the importance of mindfulness, active presence and slowing down-and were concerned with addressing these needs in daily practice. Eighteen presentations were delivered across sites. Attendees found the presentations useful and necessary in their training. CONCLUSIONS: Residents successfully reflected on, embodied and disseminated the programme's core concepts on their rotations. This group required validation of their commitment to compassionate care, and sought strategies to embody their commitment while inspiring other providers, residents and students.

Pre-treatment amygdala activation and habituation predict symptom change in post-traumatic stress disorder.

Trauma-focused psychotherapy approaches are the first-line treatment option for post-traumatic stress disorder (PTSD); however, up to a third of patients remain symptomatic even after completion of the treatment. Predicting which patients will respond to a given treatment option would support personalized treatments and improve the efficiency of healthcare systems. Although previous neuroimaging studies have examined possible pre-treatment predictors of response to treatment, the findings have been somewhat inconsistent, and no other study has examined habituation to stimuli as a predictor. In this study, 16 treatment-seeking adults (MAge = 43.63, n = 10 women) with a primary diagnosis of PTSD passively viewed pictures of emotional facial expressions during functional magnetic resonance imaging (fMRI). After scanning, participants rated facial expressions on both valence and arousal. Participants then completed eight weekly sessions of prolonged exposure (PE) therapy. PTSD symptom severity was measured before and after treatment. Overall, participants showed symptomatic improvement with PE. Consistent with hypotheses, lesser activation in the amygdala and greater activation in the ventromedial prefrontal cortex during the presentation of fearful vs. happy facial expressions, as well as a greater decline in amygdala activation across blocks of fearful facial expressions at baseline, were associated with greater reduction of PTSD symptoms. Given that the repeated presentation of emotional material underlies PE, changes in brain responses with repeated stimulus presentations warrant further studies as potential predictors of response to exposure therapies.

Practice and career outcomes of double-boarded psychiatrists.

BACKGROUND: The practice patterns and career paths of physicians who are double-boarded in medicine, family practice, or neurology and psychiatry are not well understood. Given increased attention to integrated medical and psychiatric care, these individuals may play an important role. OBJECTIVE: To compare the practice patterns and career paths of physicians who are double-boarded in medicine, family practice, or neurology and psychiatry with physicians who are boarded in general psychiatry, and among double-boarded physicians with various training sequences and specialty types. METHOD: A survey was distributed to all physicians identified by the American Board of Medical Specialties (ABMS) as double-boarded in medicine, family practice, or neurology and psychiatry, and an equal number of physicians who are boarded in general psychiatry. RESULTS: Compared with psychiatrists who are not double-boarded, double-boarded psychiatrists are significantly more likely to be older, more likely to be male, to practice in consultation-liaison or inpatient settings, and to assume positions of leadership in departments of psychiatry or in general health care organizations. Among the various groups of double-boarded physicians, 39% continue to practice their medical specialty in addition to their psychiatry practice, although this varies by medical specialty, sequence or type of program, and motivation for double-board training. CONCLUSION: Double-boarded physicians appear to be a distinct group within psychiatry and may serve as an important bridge to the general medical environment because of their leadership roles and medical psychiatric practice patterns. Further understanding of their career development and roles is warranted.

The evolving academic health center: challenges and opportunities for psychiatry.

OBJECTIVE: Regardless of the outcome of current efforts at healthcare reform, the resources that academic health centers need-to provide care for increasingly complex patient populations, support clinical innovation, grow the clinical enterprise, and carry out their research and teaching missions-are in jeopardy. This article examines the value proposition for psychiatry. METHOD: The authors describe areas where academic departments of psychiatry have opportunities to help shape the future of academic health centers in a rapidly-changing healthcare environment and share their experience in leadership roles in academic psychiatry and in consulting to academic health center leaders. RESULTS: Many academic health centers are reexamining both their mission and their use of available resources. Some are questioning their ability to sustain traditionally low-margin clinical specialties like internal medicine, pediatrics, and psychiatry, where, all too often, clinical revenues alone are insufficient to cover the full cost of caring for the patients they serve. CONCLUSION: Academic departments of psychiatry must continually demonstrate their value to the academic health centers' clinical and academic mission.

Plasma Anthranilic Acid and Leptin Levels Predict HAM-D Scores in Depressed Women.

OBJECTIVES: Major depressive disorder (MDD) is associated with dysregulations of leptin and tryptophan-kynurenine (Trp-Kyn) (TKP) pathways. Leptin, a pro-inflammatory cytokine, activates Trp conversion into Kyn. However, leptin association with down-stream Kyn metabolites in MDD is unknown. METHODS: Fasting plasma samples from 29 acutely ill drug-naïve (n = 16) or currently non-medicated (⩾6 weeks; n = 13) MDD patients were analyzed for leptin, Trp, Kyn, its down-stream metabolites (anthranilic [AA], kynurenic [KYNA], xanthurenic [XA] acids and 3-hydroxykynurenine [3HK]), C-reactive protein (CRP), neopterin, body mass index (BMI), and insulin resistance (HOMA-IR). Depression severity was assessed by HAM-D-21. RESULTS: In female (n = 14) (but not in male) patients HAM-D-21 scores correlated with plasma levels of AA (but not other Kyn metabolites) (rho = -0.644, P = .009) and leptin (Spearman's rho = -0.775, P = .001). Inclusion of AA into regression analysis improved leptin prediction of HAM-D from 48.5% to 65.9%. Actual HAM-D scores highly correlated with that calculated by formula: HAM-D = 34.8518-(0.5660 × leptin [ng/ml] + 0.4159 × AA [nmol/l]) (Rho = 0.84, P = .00015). In male (n = 15) (but not in female) patients leptin correlated with BMI, waist circumference/hip ratio, CRP, and HOMA-IR. CONCLUSIONS: Present findings of gender specific AA/Leptin correlations with HAM-D are important considering that AA and leptin are transported from plasma into brain, and that AA formation is catalyzed by kynureninase-the only TKP gene associated with depression according to genome-wide analysis. High correlation between predicted and actual HAM-D warrants further evaluation of plasma AA and leptin as an objective laboratory test for the assessment of depression severity in female MDD patients.

Benserazide, an Inhibitor of Peripheral Kynurenine Metabolism, Attenuates Olanzapine-Induced Weight Gain, Insulin Resistance, and Dyslipidemia in C57Bl/6j Mice.

Schizophrenia (Sz) patients, especially treated with atypical antipsychotics, are at high risk of the development of metabolic syndrome that increases morbidity and mortality and impairs compliance with treatment. Mechanism of the high association of metabolic syndrome with the use of atypical antipsychotics is not clear. Literature and our data suggest that chronic inflammation- or stress-induced dysregulation of the peripheral down-stream kynurenine (Kyn) metabolism, shared by both Sz and metabolic syndrome, contributes to the development of metabolic syndrome in Sz patients treated with atypical antipsychotics. Correction of dysregulation of the peripheral down-stream metabolism of Kyn would prevent/treat metabolic syndrome. This is a pre-clinical trial of the effect of benserazide (BRZ), an inhibitor of the key enzymes of Kyn metabolism, on olanzapine-induced mouse model of metabolic syndrome. Olanzapine is one of the most effective atypical antipsychotics but has high potential to induce metabolic syndrome. Olanzapine (4 mg/kg, p.o) and/or BRZ (100 mg/day, p.o.) were administered to 6-week-old C57Bl/6 female mice, 5 days/week, for 10 weeks. The study was approved by the Tufts Medical Center Institutional Animal Care and Use Committee. BRZ attenuated olanzapine-induced excessive weight gain, impairment of glucose tolerance, and elevation of plasma cholesterol and triglycerides. Present results suggest that peripheral down-stream Kyn metabolism is a new target for prevention/treatment of olanzapine-induced metabolic syndrome. BRZ has a high translational potential as medication already approved for human use.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface.

BACKGROUND: In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

Preventing suicide, promoting resilience: Is this achievable from a global perspective?

Suicide continues to be a major health concern globally despite many initiatives to identify risk factors and methods for suicide prevention. We have carried out a detailed narrative review of the literature from 2016 to 2019 using the headings of Personal resilience (P1), People (P2), Places (P3), Prevention (P4), Promoting collaboration (P5), and Promoting research (P6) in order to support an integrated approach to suicide prevention and the promotion of personal and population resilience. We have made 10 key recommendations on how this can be moved forward.

Stigma of depression is more severe in Chinese Americans than Caucasian Americans.

Stigma of mental illness is a major obstacle to its diagnosis and treatment and may be worse among Asians than Caucasians. This study compared the stigma of depression in 50 Chinese Americans (CA) and 50 Caucasian Americans (WA). Subjects were asked to read 5 case vignettes in the following order: diabetes mellitus (DB), major depressive disorder (MDD), somatoform depression (SD), psychotic depression (PD), and fever of unknown origin (HA). Diagnosis of each case was not revealed. Subjects then rated their response to each case, on a Likert scale from "strongly disagree" to "strongly agree," to 25 statements that contained 6 stigma factors: fear, shame, cognitive distortion, social consensus, discrimination, and sanction. Composite scores constructed from ratings of each factor were used to calculate the severity of stigma. Stigma of all 5 cases was worse in CA than WA. Both groups ranked DB and HA to be least and PD to be most stigmatizing. CA rated SD to be less stigmatizing than MDD but not WA. We concluded that stigma formation and severity were determined by fear, shame, cognitive distortion, social communication, consensus, and sanction. Mental symptoms, particularly psychotic symptoms, were more stigmatizing than physical symptoms, especially for CA. Belief that depression was like a physical illness did not diminish its stigma.

Peripheral kynurenine-3-monooxygenase deficiency as a potential risk factor for metabolic syndrome in schizophrenia patients.

Increased predisposition of schizophrenia patients (SP) to development of obesity and insulin resistance suggested common signaling pathway between metabolic syndrome (MetS) and schizophrenia. Deficiency of kynurenine-3-monooxygenase (KMO), enzyme catalyzing formation of 3-hydroxykynurenine (3-HK) from kynurenine (Kyn), a tryptophan (Trp) metabolite, might contribute to development of MetS as suggested by non-expression of KMO genes in human fat tissue and elevated serum concentrations of Kyn and its metabolites, kynurenic (KYNA) and anthranilic (ANA) acids, in diabetic patients and Zucker fatty rats (ZFR). Markers of KMO deficiency: decreased 3-HK and elevated Kyn, KYNA and ANA, were observed in brains and spinal fluids of SP, and in brains and serum of experimental animals with genetically- or pharmacologically-induced KMO deficiency. However, elevated concentrations of ANA and decreased 3-HK were reported in serum of SP without concurrent increase of Kyn and KYNA. Present study aimed to re-assess serum Kyn metabolites (HPLC-MS) in a sub-group of SP with elevated KYNA. We found increased Kyn concentrations (by 30%) and Kyn:Trp ratio (by 20%) in serum of SP with elevated KYNA concentrations (by 40%). Obtained results and our previous data suggest that peripheral KMO deficiency might be manifested by, at least, two different patterns: elevated ANA with decreased 3-HK; and elevated KYNA and KYN. The latter pattern was previously described in type 2 diabetes patients and might underline increased predisposition of SP to development of MetS. Assessment of peripheral KMO deficiency might identify SP predisposed to MetS. Attenuation of the consequences of peripheral KMO deficiency might be a new target for prevention/treatment of obesity and diabetes in SP.

Peripheral Tryptophan - Kynurenine Metabolism Associated with Metabolic Syndrome is Different in Parkinson's and Alzheimer's Diseases.

Insulin resistance (IR), obesity and other components of metabolic syndrome [MetS] are highly associated with Alzheimer's (AD) and Parkinson's (PD) diseases. Dysregulation of kynurenine (Kyn) pathway (KP) of tryptophan (Trp) metabolism was suggested as major contributor to pathogenesis of AD and PD and MetS. KP, the major source of NAD+ in humans, occurs in brain and peripheral organs. Considering that some, but not all, peripherally originated derivatives of Kyn penetrate blood brain barrier, dysregulation of central and peripheral KP might have different functional impact. Up-regulated Kyn formation from Trp was discovered in central nervous system of AD and PD while assessments of peripheral KP in these diseases yield controversial results. We were interested to compare peripheral kynurenines in AD and PD with emphasis on MetS-associated kynurenines, i.e., kynurenic (KYNA) and anthranilic (ANA) acids and 3-hydroxykynurenine (3-HK). Serum concentrations of KP metabolites were evaluated (HPLC-MS method). In PD patients Trp concentrations were lower, and Kyn: Trp ratio, Kyn, ANA and KYNA were higher than in controls. 3-HK concentrations of PD patients were below the sensitivity threshold of the method. In AD patients. ANA serum concentrations were approximately 3 fold lower, and KYNA concentrations were approximately 40% higher than in controls. Our data suggest different patterns of KP dysregulation in PD and AD: systemic chronic subclinical inflammation activating central and peripheral KP in PD, and central, rather than peripheral, activation of KP in AD triggered by Aß1-42. Dysregulation of peripheral KP in PD and AD patients might underline association between neurodegenerative diseases and MetS.

A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders.

IMPORTANCE: Several studies now provide evidence of ketamine hydrochloride's ability to produce rapid and robust antidepressant effects in patients with mood and anxiety disorders that were previously resistant to treatment. Despite the relatively small sample sizes, lack of longer-term data on efficacy, and limited data on safety provided by these studies, they have led to increased use of ketamine as an off-label treatment for mood and other psychiatric disorders. OBSERVATIONS: This review and consensus statement provides a general overview of the data on the use of ketamine for the treatment of mood disorders and highlights the limitations of the existing knowledge. While ketamine may be beneficial to some patients with mood disorders, it is important to consider the limitations of the available data and the potential risk associated with the drug when considering the treatment option. CONCLUSIONS AND RELEVANCE: The suggestions provided are intended to facilitate clinical decision making and encourage an evidence-based approach to using ketamine in the treatment of psychiatric disorders considering the limited information that is currently available. This article provides information on potentially important issues related to the off-label treatment approach that should be considered to help ensure patient safety.