Bipolar I Disorder Exacerbation Following COVID-19 Vaccination.

We present the cases of a 60-year-old female patient and 40-year-old male patient who experienced exacerbations of previously well-controlled symptoms of bipolar I disorder (BD1) after receiving COVID-19 vaccines, despite being stable for years on the same medications. The first patient experienced worsened depression, mania, and psychosis that improved with an increase in risperidone. The second patient experienced depression, mania, psychosis, and suicidal ideation that resulted in hospitalization. Prior to hospitalization, he took lamotrigine and bupropion, the latter of which was changed to aripiprazole in hospital. We reviewed current literature on inflammation in mental disorders, vaccination-related inflammatory changes, and the type of inflammation induced by COVID-19 vaccines. Inflammation is a component of psychiatric disorders, and the inflammatory response induced by vaccines might potentiate acute mental health exacerbations, necessitating treatment changes. However, this case series should not be used to justify recommendations against vaccination without larger, well-designed studies. At this time, the known benefits of vaccination outweigh these unknown risks, especially because individuals with serious mental illness are more likely to die from COVID-19 than the general population.

Neurodevelopmental Disorders, Criminality, and Criminal Responsibility.

Although individuals with neurodevelopmental disorders (ND), such as intellectual disability (ID) and autism, are overrepresented in the criminal justice system, most psychiatry training is limited regarding NDs, and forensic psychiatry training tends to focus on psychotic and mood disorders. This article explores the complex interactions between NDs and criminality, including direct etiological explanations and potential mediating variables (e.g., trauma), to address common training gaps. We compare and contrast current laws relevant to assessing NDs in criminal responsibility evaluations. Not guilty by reason of insanity (NGRI) criteria vary by jurisdiction, with some specifying ID as one possible insanity defense prerequisite while most jurisdictions are nonspecific. NDs in the absence of psychosis or mania often involve impaired cognition (e.g., comprehension, reasoning, social cognition) and behavioral dysregulation. This article provides potential scenarios by which those with NDs might be competent to stand trial but qualify for one or more NGRI prongs. Suggestions for assessment methods (including for malingering) are addressed for this unique population.

Trauma and Suicide Attempts among Insanity Acquittees.

Although many studies have assessed trauma as a suicide risk factor, to the authors' knowledge this is the first study of that risk factor among forensic psychiatric populations. Using a cross-sectional self-report survey methodology, this study investigated trauma histories, adverse childhood experiences (ACEs), posttraumatic stress disorder symptoms, and lifetime suicide attempts among forensic hospital patients adjudicated not guilty by reason of insanity ( n = 107). About 45 percent reported a previous suicide attempt and 22 percent reported multiple attempts, higher than the general population. The average number of attempts was 1.05 (2.39 among those with at least one attempt). The only PTSD symptoms significantly associated with attempting suicide were negative emotions and anhedonia, both in the cognitive/mood cluster, which was the only one of the four clusters to be significantly associated with attempting suicide. Childhood physical abuse was the only trauma significantly associated with attempting suicide. Higher number of attempts was significantly associated with ACEs (emotional neglect and abuse, sexual abuse, physical neglect, and household members with substance-related problems), number of traumas, substance-related problems (especially from alcohol), arousal symptoms (excessive startle, inattention) and negative emotions. We found several statistically significant suicide risk factors, particularly ACEs. Possible explanations and implications of the results are discussed.

A 20-year follow-up survey of police officers' experience with Tarasoff warnings: How law enforcement reacts to clinicians' duty to protect.

Since the Tarasoff case of 1976, mental health professionals are recognized to have a "duty to protect" third-party targets from violence-threatening patients, but little is known about what happens after clinicians warn law enforcement. In 2000, Huber et al. published a study that surveyed Michigan police about "Tarasoff warnings." We conducted a 20-year follow-up study, inviting all Michigan police and sheriff departments to participate. There were no significant differences between studies about knowledge of Tarasoff-related policies, which was low in both surveys. We found significant decreases in the number of officers who had ever intervened due to warning calls. Of the survey respondents, 83% supported documenting warning calls. For those who received warnings, 96% followed up with at least one intervention. In both studies, notifying other officers was the most common action taken. 56% said they would take action to remove a firearm. We identified opportunities for training law enforcement.

Prevalence of Traumas and PTSD Among Individuals Adjudicated Not Guilty by Reason of Insanity.

Trauma and posttraumatic stress disorder (PTSD) are common among psychiatric and criminal populations, yet there have been few studies among forensic psychiatric populations and no known studies have specifically examined insanity acquittees. This study aimed to identify the prevalence of trauma and to assess recognition of PTSD in forensic settings. Using a cross-sectional self-report survey methodology, we examined traumas, adverse childhood experiences (ACEs), and PTSD in insanity acquittees (n = 107). Most insanity acquittees experienced trauma (86%, averaging 11 events) and ACEs (76%, averaging 3 types). The most commonly experienced traumas were sudden death of a loved one, witnessed death or serious injury, adult physical assault, and motor vehicle accident. Women were significantly more likely to experience any ACE (especially witnessing domestic violence, household members with mental illness, emotional abuse, and emotional neglect) and adult sexual assault. PTSD prevalence was 25 percent, with 97 percent of cases being previously undiagnosed. Sexual traumas and younger age were significantly associated with PTSD. These results suggest that insanity acquittees have high levels of trauma, ACEs, and PTSD. While PTSD was about seven times more common than in previous findings in the general population, it frequently goes undiagnosed in forensic settings. Potential explanations and implications of our findings are discussed.

Psychiatry and Fitness to Fly After Germanwings.

In March 2015, a co-pilot flying Germanwings Flight 9525 deliberately pointed his airplane into a descent, killing himself, five other crew members, and 144 passengers. Subsequent investigation and review teams examined the incident and considered potential lessons to maximize air safety. In this article, aviation industry clinical leaders, including the U.S. Federal Air Surgeon and Chief Psychiatrist from the Federal Aviation Administration (FAA), along with a professional pilot and collaborating forensic psychiatrists, discuss suicide-by-plane, evolving themes related to public safety responsibilities for psychiatrists treating pilots, and forensic trends in pilot evaluation for medical certification from an aerospace psychiatric perspective. We explore how psychiatric aspects of pilot fitness and aviation safety are examined across perspectives, including unsafe acts, preconditions, organizational factors, and unsafe supervision. We explore practices for civilian pilots and offer information related to military pilot fitness. Lessons from Germanwings are presented, as is the need for increased support for pilots who might be concerned about revealing mental health challenges for fear of loss of medical certification and pilot employment. The Air Line Pilots Association Pilot Assistance Network is highlighted as one example of pilots supporting pilots to increase airway safety.

Are Gender Differences in DSM-5 PTSD Symptomatology Explained by Sexual Trauma?

Although many studies have assessed gender differences in posttraumatic stress disorder (PTSD) prevalence, few examine individual PTSD symptoms (PTSSs). Hypothesizing that trauma differences explain many gender differences in symptomatology, this is the first known study to adjust PTSSs for trauma type, and to compare gender differences in those with sexual traumas. Using a cross-sectional survey methodology in a sample of adult outpatients (n = 775), we examined gender, trauma type, PTSSs, suicide, alcohol, and tobacco. Among those with trauma (n = 483), women generally had more severe symptoms than men, but after adjusting for trauma type, only physical reactivity (p = .0002), excessive startle (p = .0005), external avoidance (p = .0007), internal avoidance (p = .0008), psychological reactivity (p = .0009), and suicide attempts (p = .001) remained significantly worse among women, whereas men more commonly reported alcohol problems (p = .007). Among those with PTSD (n = 164), there were no significant PTSS gender differences. Those with sexual trauma had worse symptoms (particularly amnesia) compared with non-sexual trauma (p < .0001 for PTSD diagnosis and total severity), including within each gender. Among those with sexual trauma (n = 157), men had worse recklessness (p = .004) and more commonly reported tobacco (p = .02), whereas women more commonly attempted suicide (p = .02) and had worse avoidance (p = .04). However, when isolating the effects of sexual trauma beyond other traumas, there were no significant symptom difference-in-differences between genders. Our findings suggest that, while women have higher PTSD rates, men with PTSD present similarly. In addition, while women have higher sexual trauma rates, men may have similarly severe responses. Most gender differences in PTSD presentation appear to be explained by trauma type, particularly women having higher rates of sexual trauma. We discuss potential biopsychosocial explanations.

PTSD Symptom Severity, but Not Trauma Type, Predicts Mental Health Help-seeking in the Military.

OBJECTIVE: Although veterans with posttraumatic stress disorder (PTSD) have been reported to have high rates of inadequate treatment, to our knowledge this is the first study to evaluate associations between each individual PTSD symptom and treatment-seeking, and the first PTSD help-seeking study to evaluate variables across all-rather than specific-types of trauma. METHODS: This case-control study surveyed a consecutive sample of active duty military outpatients with trauma histories (N=211), comparing those attending voluntary mental health services (help-seeking cases, n=128) or mandatory dental services required for all active duty personnel (general military population controls, n=83). We used logistic regression to estimate associations between help-seeking and demographics, PTSD symptoms, trauma type, suicide attempts, substance use problems, and chronic pain, with each variable adjusted for sex, age, and race. RESULTS: Significant associations were found between help-seeking and PTSD diagnosis (adjusted odds ratio=4.15, P<0.001) and between help-seeking and severities of PTSD symptoms (total, clusters, all individual symptoms except recklessness; each adjusted odds ratio>1, P<0.05). CONCLUSIONS: In this clinical sample, a clear positive relationship was found between help-seeking and PTSD symptom severity, but not with trauma type, suicide attempts, substance use problems, or pain, after adjusting for multiple testing. Possible explanations and implications of these findings are discussed.

Wants Talk Psychotherapy but Cannot Talk: EMDR for Post-stroke Depression with Expressive Aphasia.

While post-stroke depression (PSD) is a common sequelae of stroke, many stroke survivors also have expressive aphasia (i.e., the inability to produce spoken or written language), which limits or prevents treating depression with talk psychotherapy. Unlike most psychotherapy modalities, eye movement desensitization and reprocessing (EMDR) does not require extensive verbal communication to therapists, which might make EMDR an ideal treatment modality for aphasic patients with mental health concerns. The authors present the first known case reporting EMDR in aphasia, describing the treatment of a 50-year-old woman with a history of depression following a left middle cerebral artery stroke. Left frontal lobe strokes are independently associated with both PSD and expressive aphasia. EMDR began two years following the stroke, at which point the patient continued to have persistent expressive aphasia despite previously completing more than a year of speech therapy. Using the Blind to Therapist Protocol, EMDR successfully led to improvement in depressive symptoms and, surprisingly, improvement in aphasia. This case report suggests that EMDR might be beneficial for those with mental health concerns who have expressive communication impairments that might prevent treatment with other psychotherapy modalities. We discuss potential challenges and technical workarounds with EMDR in aphasia, we speculate about potential biopsychosocial explanations for our results, and we recommend future research on EMDR for PSD and other mental health concerns in the context of aphasia, as well as possibly for aphasia itself.

Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives.

Benzodiazepines are some of the most commonly prescribed medications in the world. These sedative-hypnotics can provide rapid relief for symptoms like anxiety and insomnia, but are also linked to a variety of adverse effects (whether used long-term, short-term, or as needed). Many patients take benzodiazepines long-term without ever receiving evidence-based first-line treatments (e.g., psychotherapy, relaxation techniques, sleep hygiene education, serotonergic agents). This review discusses the risks and benefits of, and alternatives to benzodiazepines. We discuss evidence-based indications and contraindications, and the theoretical biopsychosocial bases for effectiveness, ineffectiveness and harm. Potential adverse effects and drug-drug interactions are summarized. Finally, both fast-acting/acute and delayed-action/chronic alternative treatments for anxiety and/or insomnia are discussed. Response to treatment-whether benzodiazepines, other pharmacological agents, or psychotherapy-should be determined based on functional recovery and not merely sedation.

Benzodiazepines II: Waking Up on Sedatives: Providing Optimal Care When Inheriting Benzodiazepine Prescriptions in Transfer Patients.

This review discusses risks, benefits, and alternatives in patients already taking benzodiazepines when care transfers to a new clinician. Prescribers have the decision-sometimes mutually agreed-upon and sometimes unilateral-to continue, discontinue, or change treatment. This decision should be made based on evidence-based indications (conditions and timeframes), comorbidities, potential drug-drug interactions, and evidence of adverse effects, misuse, abuse, dependence, or diversion. We discuss management tools involved in continuation (e.g., monitoring symptoms, laboratory testing, prescribing contracts, state prescription databases, stages of change) and discontinuation (e.g., tapering, psychotherapeutic interventions, education, handouts, reassurance, medications to assist with discontinuation, and alternative treatments).

The Influence of Trauma Type and Timing on PTSD Symptoms.

Although it is well known that different trauma histories can uniquely affect subsequent trauma-related symptoms, this is the first study to evaluate individual posttraumatic stress symptoms (PTSSs) in relation to trauma type and timing. This cross-sectional study surveyed a consecutive sample of mental health outpatients (n = 602), using regression to estimate associations between DSM-5 PTSSs and demographics, several trauma types, and age at first trauma in those with trauma (n = 367). Combat and sexual trauma were associated with worse total PTSS severity. Combat was significantly associated with arousal and intrusions (especially physical symptoms), sexual trauma with conscious avoidance and negative cognitions/mood (especially amnesia, an unconscious avoidance symptom), and physical assault with blame. Interpersonal traumas were the most common first traumas experienced, but age at first trauma was not significantly associated with PTSS severity. We discuss potential explanations and implications of these findings.

Which Posttraumatic Stress Disorder Symptoms, Trauma Types, and Substances Correlate With Suicide Attempts in Trauma Survivors?

OBJECTIVE: To examine among trauma survivors several potential suicide risk factors, some of which have never been studied in this population (eg, DSM-5 posttraumatic stress disorder [PTSD] symptoms, benzodiazepines). METHODS: Using a cross-sectional self-report survey methodology in a consecutive sample of adult outpatients with trauma (N = 480), we examined relationships between suicide attempts and demographics, trauma types, PTSD symptoms, substance-related problems, and benzodiazepine prescriptions. The study was conducted from October 2014 to February 2015. RESULTS: PTSD diagnosis was significantly correlated with suicide attempt prevalence (adjusted odds ratio [AOR] = 2.6) and was the variable most strongly associated with the number of attempts among participants with at least 1 suicide attempt. PTSD symptom severities (total, cluster, and all but 3 individual symptoms) significantly correlated with attempted suicide; recklessness (AOR = 1.7), anhedonia (AOR = 1.7), and negative beliefs (AOR = 1.6) were most strongly correlated. Mood/cognitive alterations-a cluster new to the DSM-5-were particularly associated with suicide attempts (AOR = 3.2). Childhood maltreatment was strongly associated with attempted suicide; childhood physical abuse (AOR = 2.9) was the only trauma type significantly correlated with suicide attempts after adjustment for multiple testing. Attempted suicide was significantly correlated with substance-related problems in general (AOR = 2.6) and alcohol specifically (AOR = 2.9). CONCLUSIONS: As predicted, suicide attempts correlated with PTSD symptom severity, childhood maltreatment, and substance-related problems. Our hypothesized correlation between suicide and benzodiazepine prescriptions was in part explained by PTSD symptom severity.

Should Posttraumatic Stress Be a Disorder or a Specifier? Towards Improved Nosology Within the DSM Categorical Classification System.

PURPOSE OF REVIEW: Since 1980, posttraumatic stress (PTS) disorder has been controversial because of its origin as a social construct, its discriminating trauma definition, and the Procrustean array of symptoms/clusters chosen for inclusion/exclusion. This review summarizes the history of trauma-related nosology and proposed changes, within current categorical models (trauma definitions, symptoms/clusters, subtypes/specifiers, disorders) and new models. RECENT FINDINGS: Considering that trauma is a risk factor for virtually all mental disorders (particularly depressive, anxiety, dissociative, personality), the multi-finality of trauma (some survivors are resilient, and some develop PTS and/or non-PTS symptoms), and the various symptoms that trauma survivors express (mood, cognitive, perceptual, somatic), it is difficult to classify PTS. Because the human mind best comprehends categories, reliable classification generally necessitates using a categorical nosology but PTS defies categories (internalizing and/or externalizing, fear-based and/or numbing symptoms), the authors conclude that PTS-like DSM-5's panic attacks specifier-is currently best conceptualized as a specifier for other mental disorders.

Oral glucose tolerance test performance in olanzapine-treated schizophrenia-spectrum patients is predicted by BMI and triglycerides but not olanzapine dose or duration.

OBJECTIVE: Olanzapine, an atypical antipsychotic, is associated with glucoregulatory abnormalities, but the nature of this link is not fully elucidated. This is the first olanzapine oral glucose tolerance test (oGTT) study to consider treatment dose and duration, and to compare complementary indices respectively assessing insulin sensitivity (Matsuda index) and resistance (homeostasis model assessment). METHODS: Body mass index (BMI), body composition, plasma lipids, and oGTT were measured in olanzapine-treated nondiabetic patients with DSM-IV-TR diagnosis of schizophrenia or schizoaffective disorder (n = 35). RESULTS: While only one previously undiagnosed participant met diabetes criteria based on fasting plasma glucose alone (≥126 mg/dL), seven were diagnosed with oGTT (2-hr plasma glucose ≥200 mg/dL). Multiple regression analyses revealed that the Matsuda index correlated with BMI (p < 0.0001) and plasma triglycerides (p = 0.01), but not with age, olanzapine dose, olanzapine treatment duration, or plasma cholesterol. Homeostasis model assessment and fasting plasma glucose correlated with triglycerides only (p < 0.0001 for both). CONCLUSIONS: Our data suggest that BMI and triglycerides may be implicated in olanzapine-related glucoregulatory abnormalities. The lack of correlation between glucoregulatory abnormalities and olanzapine dose or treatment duration suggests preexisting metabolic disturbances and/or disturbances arising early in the course of treatment. Clinicians prescribing antipsychotics should consider oGTT, especially in patients with obesity and/or hypertriglyceridemia.

Serotonergic Synergy in the Pharmacotherapy of Acute Posttraumatic Stress Disorder Exacerbation: A Case Report.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is often associated with acute panic, dissociation, suicidality, and aggression. However, pharmacologic interventions for such acute exacerbations are understudied. In this article, we report a case of combat-related PTSD with severe panic, suicidality, and agitation which responded favorably to a combination of ziprasidone, propranolol, and hydroxyzine. METHODS: An extensive literature search did not reveal any use of this combination, and there were few studies about each medication individually, with regard to PTSD. We reviewed current literature to provide potential explanations for the case. RESULTS: Our case report describes a novel medication regimen which was used to treat an acute PTSD exacerbation. We explore possible biochemical explanations examining the pharmacologic profiles of ziprasidone, propranolol, and hydroxyzine. CONCLUSION: These medications each have relatively rapid onset and unique serotonergic activities. Given the role of serotonin in fear conditioning and traumatic memory consolidation, these treatments could be of significant benefit for PTSD patients, especially in the acute setting. We believe the treatments warrant further research to determine whether they are potential alternatives for anxiolytics like benzodiazepines, which are frequently used clinically but have evidence of risks in and little efficacy for PTSD.

Mental Health Referrals Reduce Recidivism in First-Time Juvenile Offenders, But How Do We Determine Who is Referred?

While psychiatric disorders are common among juvenile delinquents, many mental health problems go undetected, increasing the likelihood for persistent difficulties. This is the first known study to examine mental health referral rates and recidivism in the juvenile justice system. In addition to the study, we review juvenile justice mental health screening to improve detection and treatment. Juvenile criminal records in conjunction with behavioral health screenings were analyzed to determine differences in referrals and recidivism among first time offenders. Recidivism rates were significantly lower (p = 0.04) and time to recidivism was significantly longer (p = 0.03) for those referred specifically for mental health services than for those without any referrals, even after adjusting for offense severity. While black youths had a significantly higher recidivism rate (p = 0.02) and a shorter time to recidivism (p = 0.009) than white youths, there was no significant difference between races when referred specifically for mental health services. Among the groups studied, black youths had the most profound positive effect from mental health referrals (p < 0.0001). This study indicates the importance of detecting mental health problems among juvenile delinquents, especially for black offenders. The apparent protective effect of mental health interventions necessitates screening that better identifies underlying psychosocial factors rather than strict reliance upon diagnostic criteria and self-report. Broader or even universal mental health referrals for juvenile offenders could reduce future legal system involvement and costs to society. We review potential reasons that mental health problems go undetected and provide recommendations.

Eszopiclone-induced Parasomnia with Suicide Attempt: A Case Report.

Eszopiclone is a benzodiazepine-like hypnotic that is commonly prescribed to treat insomnia. However, eszopiclone's efficacy has been questionable in several clinical trials, and its pharmacologic profile makes its effects on sleep and behavior difficult to predict. We report a case demonstrating an instance of eszopiclone-induced parasomnia involving paranoia and a suicide attempt in a patient taking eszopiclone. We explore possible biochemical explanations examining the pharmacologic profile of eszopiclone and its potential for drug-drug interactions, especially with concomitant administration of monoaminergic medications such as antidepressants. Caution should be exercised when prescribing these medications, and evidence-based treatments for insomnia (e.g., cognitive behavioral therapy, biofeedback, sedating antidepressants) should be considered prior to sedative-hypnotic administration.