Clinical Recommendations for Augmentation Agents in Obsessive-Compulsive Disorder Partially Responsive to Serotonin Reuptake Inhibitors.

BACKGROUND: Obsessive-compulsive disorder (OCD) affects 2% to 3% of adults worldwide. Although serotonin reuptake inhibitors (SRIs) reliably demonstrate efficacy for this condition, 40% to 60% of patients only achieve partial recovery. The purpose of this systematic review was to assess the efficacy of other agents that may be used as augmentation agents for patients who are partial responders to SRI monotherapy. METHODS: Using PRISMA-P guidelines, PubMed and Embase were searched using the randomized controlled trial (RCT) filter and the key word "obsessive-compulsive disorder." To be considered for analysis, a potential augmentation agent needed to have at least 2 RCTs. This review specifically analyzes the effect of each augmentation agent on OCD symptoms as measured by the Yale-Brown Obsessive-Compulsive Scale. RESULTS: The augmentation agents analyzed in this review are d -cycloserine (2 RCTs), memantine (4 RCTs), N -acetylcysteine (5 RCTs), lamotrigine (2 RCTs), topiramate (3 RCTs), riluzole (2 RCTs), ondansetron (2 RCTs), celecoxib (2 RCTs), aripiprazole (5 RCTs), risperidone (7 RCTs), quetiapine (9 RCTs), and olanzapine (3 RCTs). IMPLICATIONS: The augmentation agents most supported by this review for OCD that is only a partial response to SRI monotherapy are lamotrigine, memantine, and aripiprazole. If an antipsychotic must be used and aripiprazole is not tolerated, risperidone may be considered as an alternative. Unlike the SRI class effect for OCD symptom reduction, augmentation agents demonstrate considerable intraclass variability.

Kratom & Stimulant Co-Addiction: A Case Series and Brief Review.

Kratom (Mitragyna speciosa) is an easily accessible dietary supplement gaining notoriety in medicine for its use as a surrogate form of self-driven opioid use disorder treatment, albeit one with a lack of evidence and significant risks. Both misuse and withdrawal from kratom have been appreciated in the literature and addressed in a fashion analogous to that of opioids. Because of this, it has largely been studied through the looking glass of its properties of agonizing µ-opioid and likely α2-adrenergic receptors. While an important area of study, the correlation with kratom and stimulant use, reflected in the National Survey on Drug Use and Health, is one that often gets neglected clinically. In our manuscript we present three unique cases, demonstrative of the overlap kratom misuse may have with stimulant use disorders in distinct settings. We provide a discussion and review of this correlation in light of kratom use increasing in the United States.

Transfusion induced Graft versus host disease - Case report in a 2 year child.

Graft-versus-host disease (GVHD) is a rare, almost always fatal complication of a blood transfusion. It occurs much more commonly after bone marrow transplantation, a setting in which it is less severe-mortality rate of 20-25% following transplantation versus 80-90% when associated with a transfusion. Transfusion associated GVHD occurs in two settings: when the recipient is immunodeficient; and when there is a specific type of partial HLA matching between the donor and recipient. Here we present a case of transfusion associated GVHD which developed when a 2 year old immunocompetent girl was given whole blood which was taken by his father. Inspite of very intense therapy with parental steroids and oral cyclosporine the child succumbed to death.

Practice patterns of bupropion co-prescription with antipsychotic medications.

Objective: Bupropion is one of the few medications with an FDA indication for smoking cessation. This is of particular significance due to the high co-morbidity of tobacco use disorder in patients with schizophrenia spectrum and other psychotic disorders. We sought to determine whether historical suggestions of bupropion's pro-dopaminergic activity lead prescribers to withhold bupropion in populations receiving antipsychotic medications. Methods: The prevalence in clinical practice of the combination of bupropion and 10 antipsychotic formulations was determined by a computer review of the Genoa Healthcare database for all prescribers at 10 participating community mental health centers. Actual prevalence was compared with expected prevalence using the test of proportions. A Bonferroni correction for multiple comparisons was included. Results: Clozapine, p = 0.0004, and the microsphere formulation of risperidone, p = 0.0045, were prescribed with bupropion significantly less often that chance. None of the other eight antipsychotic formulations were prescribed significantly differently than chance. Conclusions: The co-prescription of bupropion and antipsychotic medication may be affected by historical misconceptions regarding bupropion's purportedly pro-dopamine properties. Viable options for the treatment of tobacco use disorder should not be discounted prematurely in patients with schizophrenia spectrum and other psychotic disorders. We suggest further study on the safety and efficacy of the combination of bupropion and antipsychotic medication is needed.

The diagnosis of severe obsessions in the setting of kratom withdrawal and treatment with lorazepam: Case report.

Commercially available Kratom (Mitragyna speciosa) is a dietary supplement that has gained popularity in the United States for its psychoactive effects and potential medicative properties as an opioid receptor agonist. Likewise, sudden discontinuation may be accompanied by an opioid-like withdrawal. We present the first case in the literature of the withdrawal manifesting in disturbing obsessive thoughts after the substance was used as an opioid replacement treatment by our patient, as well as the first case where lorazepam is utilized for mitigation of these thoughts.

Current and Future Challenges in the Delivery of Mental Healthcare during COVID-19.

The USA is in the midst of the COVID-19 pandemic. We assess the impact of COVID-19 on psychiatric symptoms in healthcare workers, those with psychiatric comorbidities, and the general population. We highlight the challenges ahead and discuss the increased relevance of telepsychiatry. We analyzed all available literature available as of March 25, 2020, on PubMed, Ovid Medline, and PsychInfo. We utilized the MeSH term "covid AND (psychiatry OR mental health)" and included all articles. Duplicates were removed resulting in 32 articles, of which 19 are cited. Four additional references are included to examine suicide data. During the review process, an additional 7 articles were identified which are also included. Frontline healthcare workers are currently experiencing increased psychiatric symptoms and this is more severe in females and nurses. Non-frontline healthcare workers, as well as the general population, are experiencing vicarious traumatization. People with psychiatric comorbidities, and the general population, face increased psychiatric symptom burden. Migrant workers, the elderly, children, and the homeless may be disproportionately impacted. Suicide rates may be impacted. The COVID-19 pandemic has resulted in a severe disruption to the delivery of mental healthcare. Psychiatric facilities are facing unprecedented disruptions in care provision as they struggle to manage an infected population with comorbid psychiatric symptoms. Telepsychiatry is a flawed but reasonable solution to increase the availability of mental healthcare during COVID-19.

An Increased Presence of Male Personalities in Dissociative Identity Disorder after Initiating Testosterone Therapy.

Patients with gender dysphoria (GD) report significant dissociative symptoms and are found to have a high prevalence of a dissociative disorder of any kind. When GD patients elect to undergo cross-sex hormone therapy, there is a significant reduction in dissociative symptoms. However, to the best of our knowledge, there are no known case reports that describe an alteration of personalities in dissociative identity disorder after initiating cross-sex hormone therapy. Thus, we present a case of a 20-year-old transgender male with GD, whom after initiating cross-sex hormone therapy with testosterone experienced an increased presence of his existing male personalities.

The Impact of Socioeconomic Status, Race/Ethnicity, and Patient Perceptions on Medication Adherence in Depression Treatment.

OBJECTIVE: Nonadherence to pharmacotherapy for psychiatric conditions is associated with poor outcomes, including increased risk of relapse, increased health care costs, and reduced quality of life. The objective of this study was to investigate the strength of association between socioeconomic factors, race/ethnicity, and patient perceptions with medication adherence in individuals with depression. METHODS: Baseline surveys were sent out in 2012 to 4,216 adult patients within a large health system who presented with a clinical diagnosis of major depressive disorder (ICD-9), recorded at least twice in the electronic medical record in the year 2011. A total of 1,573 patients responded to the baseline survey. Of those, 1,209 patients who completed the survey and had used antidepressants in the last 12 months were recruited for the study. Perception of medication risk was assessed using the Beliefs About Medicines Questionnaire, and adherence to medications was assessed using the Morisky Medication Adherence Scale. Logistic regression was used to investigate the relationship between perception of medicine risk and treatment adherence. RESULTS: For non-Hispanic white individuals, medication adherence was higher among those who were least concerned about the risk of medications (64%; 95% CI, 58-70) compared to those who were most concerned (34%; 95% CI, 26-43). In the logistic regression model, less concern about medications and their side effects was associated with higher medication adherence (odds ratio = 2.6; 95% CI, 1.77-3.84; P < .0001). This association remained significant after adjustment for age, race, education level, and extramedical use of other medications or substances. Moreover, patients with older age and lower education level as well as those who were non-Hispanic white and had no extramedical use of other medications/substances were more likely to be adherent to medications. CONCLUSIONS: This study contributes quantitative data on factors that impact treatment adherence. Identifying patients at increased risk of nonadherence, having discussions with patients early in the treatment process to understand their concerns regarding treatment options, being sensitive to cultural beliefs, and patiently proceeding with the decision-making process could help ensure better outcomes.

Levomilnacipran: More of the Same?

OBJECTIVE: The primary objective of this narrative review is to provide clinicians an in-depth analysis of the mechanism of action, pharmacokinetics, toxicology, and efficacy of levomilnacipran. We propose that unlike selective serotonin reuptake inhibitors (SSRIs), or even their precursor serotonin-norepinephrine reuptake inhibitors (SNRIs), levomilnacipran demonstrates a potentially unique ability to alleviate the fatigue symptom cluster of major depressive disorder (MDD). DATA SOURCES: A literature review was completed in PubMed using the MeSH term levomilnacipran. STUDY SELECTION: Inclusion criteria were English-language only, randomized controlled trials and systematic reviews published through March 2019. Analyses using product labels and anecdotal or uncontrolled reports of clinical applications were excluded. Only published data from short-term and long-term trials were analyzed. The search resulted in 73 articles. The evidence-based review comprises a total of 31 articles. DATA SYNTHESIS: The data analyzed suggest that levomilnacipran has evidence in the treatment of MDD. More specifically, data suggest that levomilnacipran may be unique among SSRI and SNRI antidepressants in its ability to improve the fatigue symptom cluster in MDD. CONCLUSIONS: Further investigations are warranted into levomilnacipran's potentially unique ability to alleviate the fatigue symptom cluster of MDD. Future head-to-head studies and studies that assess for clinically relevant improvements in fatigue are needed.

Stimulant Formulations for the Treatment of Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: Clinicians have access to a variety of formulations of methylphenidate and amphetamine to treat attention-deficit/hyperactivity disorder (ADHD). However, due to new emerging formulations, clinicians may lack up-to-date knowledge about all available stimulant formulations. Presented here is a comprehensive guide to13 formulations of methylphenidate and 10 formulations of amphetamine that have US Food and Drug Administration approval to treat ADHD. DATA SOURCES: PubMed was searched using the following MeSH terms: attention-deficit/hyperactivity disorder, ADHD, stimulant, amphetamine, and methylphenidate. Inclusion criteria were randomized controlled trials and systematic reviews published through 2017. STUDY SELECTION AND EXTRACTION: Forty-eight articles were identified; however, these included analyses using product labels and anecdotal or uncontrolled reports of apparent clinical inequivalence. Thus, 34 articles were included in the final review to provide a thorough evidence-based guide. RESULTS: Each formulation has a unique pharmacokinetic profile. Clinically, one formulation may not be suitable for all patients. To select the most appropriate formulation, clinicians should consider the individual patient's preferences such as dosing schedule, time required to reach peak plasma concentration and duration of action, and tolerability. CONCLUSION: This review provides clinical guidance to help clinicians prescribe the most suitable treatment for an individual.​​​.