Optimally combining transcranial magnetic stimulation with antidepressants in major depressive disorder: A systematic review and Meta-analysis.

There is a critical knowledge gap in optimally combining transcranial magnetic stimulation (TMS) and antidepressants to treat patients with major depressive disorder (MDD). TMS is effective in treating MDD in patients who have failed at least one antidepressant trial, with accelerated protocols showing faster remission in treatment-resistant depression (TRD). Although clinicians routinely augment antidepressants with TMS, there is a knowledge gap in stopping versus continuing antidepressants or the dosing strategies when starting or tapering TMS. These considerations are important when considering maintenance TMS (delivered alone or in combination with suitable antidepressants) to maintain remission in MDD after the index course of TMS. As the first step towards filling this knowledge gap, we reviewed randomized controlled trials (RCTs) and open-label trials from 2 databases (PubMed/Medline and EMBASE) that compared active TMS combined with a pre-specified antidepressant dosed in the same manner for adults with MDD versus sham TMS combined with the same antidepressant as in the active arm. All studies were published between January 1, 2000, and December 31, 2023. We excluded case reports, case series, and clinical studies that augmented TMS with antidepressants and vice versa. We found 10 RCTs (n = 654 participants) and performed a meta-analysis. This showed active TMS combined with pre-specified antidepressants had greater efficacy for MDD treatment than sham TMS combined with the same antidepressants as in the active arm (Hedge's g = 1; 95 % CI [0.27, 1.73]). The review and meta-analysis indicate greater short-term efficacy in combining antidepressants with TMS from the get-go in MDD. Given the increasing role of accelerated TMS protocols in expediting remission in MDD and the results of our meta-analysis, we advocate for RCTs examining the short-term and long-term effects of various antidepressant classes on these TMS protocols in MDD. This can also optimize and individualize maintenance TMS protocols to prevent relapse in MDD.

Intermittent theta burst stimulation and functional connectivity in people living with HIV/AIDS who smoke tobacco cigarettes: a preliminary pilot study.

Background: People living with HIV (PLWHA) smoke at three times the rate of the general population and respond poorly to cessation strategies. Previous studies examined repetitive transcranial magnetic stimulation (rTMS) over left dorsolateral prefrontal cortex (L. dlPFC) to reduce craving, but no studies have explored rTMS among PLWHA who smoke. The current pilot study compared the effects of active and sham intermittent theta-burst stimulation (iTBS) on resting state functional connectivity (rsFC), cigarette cue attentional bias, and cigarette craving in PLWHA who smoke. Methods: Eight PLWHA were recruited (single-blind, within-subject design) to receive one session of iTBS (n=8) over the L. dlPFC using neuronavigation and, four weeks later, sham iTBS (n=5). Cigarette craving and attentional bias assessments were completed before and after both iTBS and sham iTBS. rsFC was assessed before iTBS (baseline) and after iTBS and sham iTBS. Results: Compared to sham iTBS, iTBS enhanced rsFC between the L. dlPFC and bilateral medial prefrontal cortex and pons. iTBS also enhanced rsFC between the right insula and right occipital cortex compared to sham iTBS. iTBS also decreased cigarette craving and cigarette cue attentional bias. Conclusion: iTBS could potentially offer a therapeutic option for smoking cessation in PLWHA.

Comparing cigarette-cue attentional bias between people with HIV/AIDS and people with opioid use disorder who smoke.

Background: Special populations like people living with HIV/AIDS (PLWHA) and people with opioid use disorder (OUD) smoke tobacco cigarettes at rates three to four times greater than the general population. Patients with tobacco use disorder exhibit attentional bias (AB) for cigarette cues. Eye tracking can quantify this bias by measuring fixation time (FT) on cigarette and matched neutral cues, to calculate an AB score. Although previous studies have measured this bias in people who smoke without any other comorbid conditions, no study, to our knowledge, has measured or compared this bias in special populations. Methods: We performed exploratory analyses on eye tracking data collected in two separate randomized clinical trials (RCTs) (NCT05049460, NCT05295953). We compared FT and cigarette-cue AB score (measured by subtracting FT on neutral cues from FT on cigarette cues) between PLWHA and people with OUD who smoke, using a visual probe task and Tobii Pro Fusion eye tracker. We used two cigarette cue types, one encompassing people smoking cigarettes and the other consisting of cigarette paraphernalia. We used two cue presentation times, 1000 and 2000 milliseconds (ms). Results: Cues of people smoking cigarettes elicited greater AB than cues of cigarette paraphernalia across both subject groups when cues were presented for 2000 ms, but not 1000 ms. PLWHA who smoke exhibited greater AB for cues of people smoking cigarettes than cigarette paraphernalia when presented for 2000 ms compared to people with OUD who smoke. Conclusion: We use cigarette-cue AB to quantify craving and cigarette consumption in two populations smoking at elevated rates. The addition of social cues potentiates cigarette cue AB, based on cue type and stimulus presentation time. Understanding the neurobiology of this relationship can help design novel smoking cessation treatments that target AB and prevent relapse in these populations with suboptimal response to smoking cessation treatments. Trial registration: Clinical trials that provided the data for post hoc analyses are NCT05049460 and NCT05295953.

Cigarette Smoking Behaviors and Beliefs in Persons Living With HIV in Nairobi, Kenya.

INTRODUCTION: Persons living with HIV (PLWH) use tobacco at higher rates than the general population in both high-income countries and low- and middle-income countries. Tobacco use rates are increasing in sub-Saharan Africa, the home to most of the world's PLWH. As the reach of antiretroviral therapy (ART) expands and HIV-related morbidity and mortality wanes, tobacco use is emerging as a leading cause of disease and death in PLWH. A better understanding of tobacco use behaviors in various settings will be crucial to designing optimal tobacco control strategies. METHODS: In late 2019, we enrolled 50 PLWH cigarette smokers from 6 clinical sites in Nairobi, Kenya (4 HIV care clinics and 2 methadone maintenance programs) for one-on-one interviews focusing on their behaviors and beliefs related to tobacco use. RESULTS: Fifty PLWH smokers completed the interviews. The mean age was 38.5 ± 9.7 years (range 20-57 years) and 68% were male. All were currently receiving ART. They smoked a mean of 14.9 ± 12.4 cigarettes per day, and 82% reported smoking every day. Only 6% reported dual use of smokeless tobacco products. Nicotine dependence was moderate or high in 74%. More than a third (36%) reported a prior history of tuberculosis. In our sample, use of other substances was common, especially alcohol, marijuana, and methadone. On the motivation to quit scale, 90% were at least in the contemplation stage, but only 2% had ever received behavioral cessation counseling, and only 8% had ever used pharmacotherapy (exclusively nicotine replacement therapy). Participants reported significant concern about developing smoking-related illness, exposing others to secondary smoke, and the financial burden associated with their tobacco use. Measures of intrinsic and extrinsic motivation to quit, smoker and abstainer self-concept, and social support yielded encouraging results regarding the possibility of successful quitting. CONCLUSIONS: Tobacco use is an important health concern in PLWH in Kenya. A more thorough understanding of their tobacco use behaviors and beliefs will provide critical information for providers, public health officials, and policy makers as they redouble their efforts to confront this urgent health challenge.

Outcomes for patients receiving telemedicine-delivered medication-based treatment for Opioid Use Disorder: A retrospective chart review.

This report builds on a previous study that describes the collaboration between an urban academic medical center and a rural drug treatment center, the goal of which is to provide medication-based treatment to individuals with OUD via videoconferencing. We describe results of a retrospective chart review of 472 patients treated in the program between August 2015 and April 2019. We examined several demographic and substance use variables for individuals who consented to telemedicine treatment, retention in treatment over time, and opioid use over time to understand further the impact of prescribing buprenorphine and naltrexone via telemedicine to patients in a rural OUD treatment setting. Our findings support the effectiveness of prescribing medications via telemedicine. The inclusion of more than three times as many patients as in our prior report revealed retention rates and toxicology results that are comparable to face-to-face treatment. These findings have implications for policymakers and clinicians considering implementation of similar programs.

HIV Stigma and Its Relation to Mental, Physical and Social Health Among Black Women Living with HIV/AIDS.

Black women living with HIV/AIDS (LWHA) are a subgroup with the highest growing rates of HIV infection in the United States. Stigma and co-occurring mental and physical health problems have been reported among Black women LWHA, and research on the benefits of social and religious support, often major protective factors among Black women, has been met with mixed findings. The current study examined the relation between anticipated HIV stigma and mental and physical health symptoms and risk and protective factors (discrimination, coping, social support) among Black women LWHA (N = 220). Results showed that greater anticipated stigma was significantly related to poorer mental health status, greater discrimination, and greater use of negative coping strategies. Stigma was not related to physical health, perceived social support or use of positive coping strategies. This study lends support to the need for psychosocial interventions that reduce anticipated stigma among individuals LWHA, particularly Black women LWHA.

Twelve-Month Prevalence of DSM-5 Gambling Disorder and Associated Gambling Behaviors Among Those Receiving Methadone Maintenance.

This study sought to: (1) determine the prevalence of gambling disorder using the Diagnostic and Statistical Manual of Mental Disorders Version 5 (DSM-5; American Psychiatric Association in Diagnostic and statistical manual of mental disorders, American Psychiatric Publishing, Arlington, 2013) criteria; (2) identify the frequency and amount of money spent on gambling behaviors; and (3) determine demographic and treatment related predictors associated with gambling disorder in a substance using population. People receiving methadone maintenance treatment (N = 185) in an urban medical center consented to participate in the study. We used DSM-5 criteria to assess the 12-month prevalence of gambling disorder. Questions adapted from a previously developed measure were used to identify, describe and quantify the frequency of use and amount of money spent on gambling behaviors. Most participants were African-American (71.4 %), male (54.1 %), unmarried (76.8 %), unemployed (88.1 %) and had an income of <$20,000 (88.5 %). On average, participants were receiving 81.0 mg of methadone (SD: 22.8) daily. Nearly half (46.2 %) of participants met DSM-5 criteria for gambling disorder. Compared to those without gambling disorder, those with gambling disorder did not differ significantly with respect to demographic characteristics nor methadone dose. However, those with gambling disorder had been in methadone maintenance treatment for significantly less time. Those with gambling disorder were significantly more likely to report engaging in a variety of gambling behaviors. Given that the 12-month prevalence of DSM-5 defined gambling disorder was nearly 50 % future efforts to screen and treat gambling disorder in the context of methadone maintenance treatment are clearly warranted.

Evaluation of brief screens for gambling disorder in the substance use treatment setting.

BACKGROUND AND OBJECTIVES: The goal of this study was to determine the diagnostic accuracy of brief screens for Gambling Disorder within a sample of people receiving outpatient treatment for substance use disorders. METHODS: Individuals (n = 300) recruited from intensive outpatient substance use treatment (23.67%) or methadone maintenance programs (76.34%) participated in the study. Four brief screens for Gambling Disorder were administered and compared to DSM-5 criteria. Receiver operator curves were created and an Area Under the Curve (AUC) analysis (an overall summary of the utility of the scale to correctly identify Gambling Disorder) was assessed for each. RESULTS: On average participants were aged 46.4 years (SD = 10.2), African American/Black (70.7%), with an income less than $20,000/year (89.5%). Half the participants were female. Approximately 40% of participants (40.5%; n = 121) met DSM-5 criteria for Gambling Disorder. Accuracy of the brief screens as measured by hit rate were .88 for the BBGS, .77 for the Lie/Bet, .75 for NODS-PERC, and .73 for the NODS-CLiP. AUC analysis revealed that the NODS-PERC (AUC: .93 (95% CI: .91-.96)) and NODS-CLiP (AUC: .90 (95% CI: .86-.93)) had excellent accuracy. DISCUSSION AND CONCLUSIONS: The NODS-PERC and NODS-CLiP had excellent accuracy at all cut-off points. However, the BBGS appeared to have the best accuracy at its specified cut-off point. SCIENTIFIC SIGNIFICANCE: Commonly used brief screens for Gambling Disorder appear to be associated with good diagnostic accuracy when used in substance use treatment settings. The choice of which brief screen to use may best be decided by the needs of the clinical setting.

Trauma history in African-American women living with HIV: effects on psychiatric symptom severity and religious coping.

Women living with HIV (WLHIV) have rates of post-traumatic stress disorder (PTSD) up to 5 times higher than the general population. Individuals living with HIV and a concurrent diagnosis of PTSD have poorer HIV-related outcomes; however, the prevalence and impact of PTSD on African-American WLHIV seeking mental health treatment is unknown. The aim of this study is to examine the associations between PTSD symptoms with psychiatric symptom severity and psychological/religious coping strategies in African-American WLHIV who are seeking mental health treatment. This is a cross-sectional study of 235 African-American WLHIV attending an urban community mental health clinic. Bivariate analyses were conducted to evaluate associations between a PTSD symptoms scale (PSS≥21 versus PSS<21) and (1) psychiatric severity, (2) coping strategies, and (3) religious coping strategies. Thirty-six percent reported symptoms consistent with PTSD (PSS≥21). These women were significantly more likely to have worse mental health symptoms and were more likely to employ negative psychological and religious coping strategies. On the contrary, women with a PSS<21 reported relatively low levels of mental health symptoms and were more likely to rely on positive psychological and religious coping strategies. Over one-third of African-American WLHIV attending an outpatient mental health clinic had symptoms associated with PTSD. These symptoms were associated with worse mental health symptoms and utilization of dysfunctional religious and nonreligious coping strategies. Untreated PTSD in WLHIV predicts poorer HIV-related health outcomes and may negatively impact comorbid mental health outcomes. Screening for PTSD in WLHIV could identify a subset that would benefit from evidence-based PTSD-specific therapies in addition to mental health interventions already in place. PTSD-specific interventions for WLHIV with PTSD may improve outcomes, improve coping strategies, and allow for more effective treatment of comorbid mental health disorders.

A multisite study of the prevalence of HIV with rapid testing in mental health settings.

OBJECTIVES: We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS: We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS: Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS: HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.

Depression, anxiety, and moods of hospitalized patients under contact precautions.

OBJECTIVE: To determine the association between contact precautions and depression or anxiety as well as feelings of anger, sadness, worry, happiness, or confusion. DESIGN: Prospective frequency-matched cohort study. SETTING: The University of Maryland Medical Center, a 662-bed tertiary care hospital in Baltimore, Maryland. PARTICIPANTS: A total of 1,876 medical and surgical patients over the age of 18 years were approached; 528 patients were enrolled from January through November 2010, and 296 patients, frequency matched by hospital unit, completed follow-up on hospital day 3. RESULTS: The primary outcome was Hospital Anxiety and Depression Scale (HADS) scores on hospital day 3, controlling for baseline HADS scores. Secondary moods were measured with visual analog mood scale diaries. Patients under contact precautions had baseline symptoms of depression 1.3 points higher (P<.01) and anxiety 0.8 points higher (P=.08) at hospital admission using HADS. Exposure to contact precautions was not associated with increased depression (P=.42) or anxiety (P=.25) on hospital day 3. On hospital day 3, patients under contact precautions were no more likely than unexposed patients to be angry (20% vs 20%; P=.99), sad (33% vs 38%; P=.45), worried (51% vs 46%; P=.41), happy (58% vs 67%; P=.14), or confused (23% vs 24%; P=.95). CONCLUSIONS: Patients under contact precautions have more symptoms of depression and anxiety at hospital admission but do not appear to be more likely to develop depression, anxiety, or negative moods while under contact precautions. The use of contact precautions should not be restricted by the belief that contact precautions will produce more depression or anxiety.

Medical inpatients' adherence to outpatient psychiatric aftercare: a prospective study of patients evaluated by an inpatient consultation liaison psychiatry service.

OBJECTIVE: This study sought to determine whether patients on psychiatric medication evaluated by inpatient consultation psychiatrists followed up with psychiatric aftercare and continued psychiatric medication 8 weeks post-discharge. Barriers to care and their effect on aftercare follow-up were assessed. METHOD: This was a prospective study of a consecutive sample of adults who received a psychiatric consultation and were prescribed psychotropic medication during hospitalization on the general medical or surgical inpatient units at the University of Maryland Medical Center. Baseline information was collected from 36 patients who received an inpatient psychiatric consultation and were: (1) prescribed psychiatric medications; and (2) discharged to home. Follow-up data was collected from 21 (58.3%) of these patients 8 weeks post-discharge. RESULTS: Of 36 patients who provided baseline data, 93% recognized they had a psychiatric disorder, 90% recognized the importance of taking psychiatric medication, and 80% recognized the importance of psychiatric aftercare. Aftercare recommendations were included in only 33% of patient discharge instructions. Of 21 patients providing follow-up data, 57% reported receiving psychiatric aftercare. Patients who did not receive psychiatric aftercare were significantly more likely to be at risk for poor literacy (88.9% vs. 33.3% Fisher's exact test = 0.024) and were less often given psychiatric aftercare instructions at discharge (22% vs. 42%). CONCLUSIONS: Poor communication of aftercare instructions as well as poor literacy may be associated with lack of psychiatric aftercare. Consultation psychiatrists should assess literacy and insure aftercare information is provided to patients.

Association between contact precautions and delirium at a tertiary care center.

OBJECTIVE: To investigate the relationship between contact precautions and delirium among inpatients, adjusting for other factors. DESIGN: Retrospective cohort study. SETTING: A 662-bed tertiary care center. PATIENTS: All nonpyschiatric adult patients admitted to a tertiary care center from 2007 through 2009. METHODS: Generalized estimating equations were used to estimate the association between contact precautions and delirium in a retrospective cohort of 2 years of admissions to a tertiary care center. RESULTS: During the 2-year period, 60,151 admissions occurred in 45,266 unique nonpsychiatric patients. After adjusting for comorbid conditions, age, sex, intensive care unit status, and length of hospitalization, contact precautions were significantly associated with delirium (as defined by International Classification of Diseases, Ninth Revision), medication, or restraint exposure (adjusted odds ratio [OR], 1.40 [95% confidence interval {CI}, 1.24-1.51]). The association between contact precautions and delirium was seen only in patients who were newly placed under contact precautions during the course of their stay (adjusted OR, 1.75 [95% CI, 1.60-1.92]; P < .01) and was not seen in patients who were already under contact precautions at admission (adjusted OR, 0.97 [95% CI, 0.86-1.09]; P = .06). CONCLUSIONS: Although delirium was more common in patients who were newly placed under contact precautions during the course of their hospital admission, delirium was not associated with contact precautions started at hospital admission. Patients newly placed under contact precautions after admission but during hospitalization appear to be at a higher risk and may benefit from proven delirium-prevention strategies.