First-Onset Psychosis After COVID-19 Infection: A Systematic Review of the Literature.

BACKGROUND: The COVID-19 pandemic has been an inciting factor for a wide variety of neuropsychiatric symptoms, including first-episode psychosis (FEP). OBJECTIVE: The aim of this systematic review was to summarize the current literature on COVID-19 associated postviral FEP. METHODS: A systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 81 articles that met inclusion criteria. RESULTS: Articles included case reports, case series, and cohort studies with postviral FEP occurring outside the setting of delirium, demonstrating a broad range of symptoms. CONCLUSIONS: This systematic review shows that postviral FEP associated with COVID-19 follows a pattern similar to psychosis associated with other viral infections and is an important consideration when building a differential for FEP when delirium has been ruled out. Better understanding of postviral FEP associated with COVID-19 and other viral illnesses may help clarify aspects of underlying pathophysiology of psychotic symptoms broadly.

Scoping Review on Educational Programs for Medical Professionals on the Management of Acute Agitation.

BACKGROUND: Agitation is a common reason for psychiatric consultation in the general hospital. The consultation-liaison (CL) psychiatrist is often tasked with teaching the medical team how to manage agitation. OBJECTIVE: The purpose of this scoping review is to explore what resources the CL psychiatrist has for educational tools on teaching about agitation management. Given the frequency with which CL psychiatrists help with on-the-ground management of agitation, we hypothesized that there would be a scarcity of educational resources to teach front-line providers how to manage agitation. METHODS: Following current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a scoping review was conducted. The literature search focused on the electronic databases MEDLINE (PubMed), Embase (Embase.com), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), PsycInfo (EbscoHost), Cumulated Index to Nursing and Allied Health Literature (CINAHL) (EbscoHost), and Web of Science. Using Covidence software, after screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, we created a predefined set of criteria according to which each article was analyzed. We then grouped the articles in the full-text review according to which patient population a curriculum was designed for. RESULTS: The search yielded a total of 3250 articles. After removing duplicates and reviewing procedures, we included 51 articles. Data extraction captured article type and details; educational program information (staff training, web modules, instructor led seminar); learner population; patient population; and setting. The curricula were further divided based on their target patient population, specifically the acute psychiatric patient (n = 10), the general medical patient (n = 9), and the patient with a major neurocognitive disorder such as dementia or traumatic brain injury (n = 32). Learner outcomes included staff comfort, confidence, skills, and knowledge. Patient outcomes included measurements of agitation or violence using validated scales, PRN medication use, and restraint use. CONCLUSIONS: Despite there being numerous agitation curricula in existence, we found that a large majority of these educational programs were done for patients with major neurocognitive disorders in the long-term care setting. This review highlights the gap in education related to agitation management for both patients and providers in the general medical setting, as less than 20% of total studies are focused on this population. The CL psychiatrist plays a critical role in assisting in agitation management in this setting, which often requires collaboration between technicians, nurses, and nonpsychiatric providers. It calls into question whether the lack of educational programs makes the implementation of management interventions more difficult and less effective, even with the assistance of the CL psychiatrist.

Longitudinal Trajectories of Post-Concussive Symptoms Following Mild Traumatic Brain Injury.

BACKGROUND: Individuals recovering from mild traumatic brain injury (TBI) represent a heterogenous population that requires distinct treatment approaches. Identification of recovery trajectories improves our ability to understand the natural history of mild TBI recovery and develop targeted interventions. OBJECTIVE: To utilize group-based trajectory modeling (GBTM) to identify distinct patterns of symptom recovery following mild TBI in the first 6 months after mild TBI. METHODS: This study is comprised of 253 adults who presented to the emergency department with mild TBI and completed assessments for six-months post-injury. Patients were recruited for the prospective observational cohort study, HeadSMART. The primary outcome measure was the Rivermead Postconcussion Symptom Questionnaire. GBTM was used to identify longitudinal trajectories of recovery following mild TBI using Rivermead scores at baseline, one, three, and six months following diagnosis. RESULTS: Findings identified four distinct trajectories of symptom recovery follwing mild TBI including 9% of participants who were categorized with minimal acute symptoms that decreased over time, 45% with mild acute symptoms that decreased over time, 33% with relatively higher acute symptoms that decreased over time, and 13% with relatively higher acute symptoms that increased over time. CONCLUSIONS: GBTM identified four distinct trajectories of recovery following mild TBI and GBTM may be useful for research interventions that can alter recovery trajectories.

Prevalence and Correlates of Depressive Symptoms Within 6 Months After First-Time Mild Traumatic Brain Injury.

OBJECTIVE: Depressive symptoms are among the most common neuropsychiatric sequelae of mild traumatic brain injury (mTBI). Very few studies have compared correlates of depressive symptoms within the first 6 months of injury in cohorts experiencing their first TBI. The authors investigated whether the correlates of depressive symptoms (being female, older, lower education, having brain lesions, experiencing worse postconcussive symptoms, and incomplete functional recovery) that have been established in populations with moderate to severe TBI were the same for individuals with first-time mTBI within the first 6 months of recovery. METHODS: Two hundred seventeen individuals with first-time mTBI were divided into subgroups-new-onset depressive symptoms, recurrent depressive symptoms, prior depression history only, and never depressed-and compared on clinical and demographic variables and the presence of postconcussive symptoms and functional recovery at 3 and 6 months. RESULTS: New-onset depressive symptoms developed in 12% of the cohort, whereas 11% of the cohort had recurrent depressive symptoms. Both depressive symptoms groups were more likely to comprise women and persons of color and were at higher risk for clinically significant postconcussive symptoms and incomplete functional recovery for the first 6 months postinjury. CONCLUSIONS: Presence of depressive symptoms after first-time mTBI was associated with persistent postconcussive symptoms and incomplete functional recovery in the first 6 months. Adding to the existing literature, these findings identified correlates of depressive symptom development and poor outcomes after mTBI, thus providing further evidence that mTBI may produce persistent symptoms and functional limitations that warrant clinical attention.

Neuroimaging Correlates of Depression after Traumatic Brain Injury: A Systematic Review.

Depression is the most frequent neuropsychiatric complication after traumatic brain injury (TBI) and is associated with poorer outcomes. Neuroimaging has the potential to improve our understanding of the neural correlates of depression after TBI and may improve our capacity to accurately predict and effectively treat this condition. We conducted a systematic review of structural and functional neuroimaging studies that examined the association between depression after TBI and neuroimaging measures. Electronic searches were conducted in four databases and were complemented by manual searches. In total, 2035 citations were identified and, ultimately, 38 articles were included, totaling 1793 individuals (median [25-75%] sample size of 38.5 [21.8-54.3] individuals). The most frequently used modality was structural magnetic resonance imaging (MRI) (n = 17, 45%), followed by diffusion tensor imaging (n = 11, 29%), resting-state functional MRI (n = 10, 26%), task-based functional MRI (n = 4, 8%), and positron emission tomography (n = 2, 4%). Most studies (n = 27, 71%) were cross-sectional. Overall, depression after TBI was associated with lower gray matter measures (volume, thickness, and/or density) and greater white matter damage. However, identification of specific brain areas was somewhat inconsistent. Findings that were replicated in more than one study included reduced gray matter in the rostral anterior cingulate cortex, pre-frontal cortex, and hippocampus, and damage in five white matter tracts (cingulum, internal capsule, superior longitudinal fasciculi, and anterior and posterior corona radiata). This systematic review found that the available data did not converge on a clear neuroimaging biomarker for depression after TBI. However, there are promising targets that warrant further study.

A Case Study on the Management of the Behavioral Sequelae of Traumatic Brain Injury.

We present the case of a 46-year-old male with a history of post-traumatic stress disorder and opioid use disorder who sustained a severe traumatic brain injury secondary to motor vehicle accident and was brought to the attention of our psychiatry consultation-liaison team owing to significant physical and verbal aggression. This article will detail the specific behavioral and pharmacological management for this patient's symptoms. Additionally, experts in the field of consultation and liaison psychiatry will provide guidance based on their experience and a review of the available literature. Key teaching topics include the pathophysiology and cognitive evaluation of traumatic brain injury, conducting a behavioral analysis and developing a behavioral management plan and finally how to utilize appropriate symptom-based pharmacology while taking into account evidence-based treatment. Neuropsychiatric symptoms in traumatic brain injury are often challenging to manage owing to the varied symptom profile. Thus, treatment requires continued re-evaluation and a mixture of behavioral therapy and psychopharmacologic approaches.

The Current State of Journal Clubs in Psychiatry Residency Programs: Results from a National Survey of Program Directors.

OBJECTIVE: This study aimed to investigate journal club prevalence, implementation, and perceived effectiveness among psychiatry residency program directors in order to highlight best practices. METHODS: The authors distributed a 44-item thoughtfully designed and peer-reviewed questionnaire electronically via Qualtrics to 235 accredited U.S. psychiatry residency program directors identified using the American Medical Association database. RESULTS: Eighty-nine programs (38%) responded. Of these, 83 (93%) had a journal club. Journal clubs were mandatory in 80 programs (96%), met biweekly or monthly in 62 programs (75%), and lasted 46-60 min in 66 programs (80%). Twenty-three programs (28%) offered a list of articles to choose from, and 22 programs (27%) provided a critical appraisal tool. Only 7 programs (8%) measured learner outcomes from journal clubs. Respondents believed that promoting lifelong learning and practicing evidence-based psychiatry were the most relevant educational goals of journal club (2.57 and 2.51 on a Likert scale of 0 to 3). Journal club's effectiveness in achieving those goals was believed to be lower (2.16 and 2.09). CONCLUSIONS: Journal clubs are common in U.S. psychiatry residency programs and tend to follow a traditional format. In order to boost journal club's effectiveness in achieving the desired educational goals, more programs might elect to infuse elements known to augment learning.

When Mind Meets the Brain: Essentials of Well-Coordinated Management of Psychiatric Disorders in Neurological Diseases.

BACKGROUND: The management of psychiatric disorders in neurological diseases (PDND) creates special challenges that cannot be adequately addressed by either psychiatry or neurology alone. However, the literature on clinician-friendly recommendations on how to coordinate neurological and psychiatric care is limited. OBJECTIVE: This narrative review will provide practical instructions on how to efficiently integrate psychiatric and neurological care in inpatient management of PDND. METHODS: We reviewed articles published as recently as January, 2021 in five electronic databases. We included articles that assessed human care, focused on adults, and examined how to better coordinate care between different medical specialties, particularly, between psychiatry and neurology. RESULTS: Eighty-four manuscripts were included in this review, of which 23 (27%) discussed general principles of well-coordinated care of PDND in inpatient settings (first part of this review), and 61 (73%) were used to provide recommendations in specific neurological diseases (second part of this review). CONCLUSIONS: General principles of well-coordinated care of PDND include recommendations for both the primary team (usually neurology) and the consulting team (psychiatry). Primary teams should delineate a specific question, establish roles, and follow up on the recommendations of the consulting team. Consultants should do their independent assessment, be organized and specific in their recommendations, and anticipate potential problems. One of the most important aspect to develop well-coordinated care is the establishment of clear, frank and, preferably oral, communication between the teams. Practical difficulties in the management of PDND include pharmacodynamic and pharmacokinetic interactions as well as mutual dependency between psychiatry and neurology.

A Prognostic Model for Predicting One-Month Outcomes among Emergency Department Patients with Mild Traumatic Brain Injury and a Presenting Glasgow Coma Scale of Fifteen.

The lack of well-performing prognostic models for early prognostication of outcomes remains a major barrier to improving the clinical care of patients with mild traumatic brain injury (mTBI). We aimed to derive a prognostic model for predicting incomplete recovery at 1-month in emergency department (ED) patients with mTBI and a presenting Glasgow Coma Scale (GCS) score of 15 who were enrolled in the HeadSMART (Head Injury Serum Markers for Assessing Response to Trauma) study. The derivation cohort included 355 participants with complete baseline (day-of-injury) and follow-up data. The primary outcome measure was the Glasgow Outcome Scale Extended (GOSE) at 1-month and incomplete recovery was defined as a GOSE <8. At 1-month post-injury, incomplete recovery was present in 58% (n = 205) of participants. The final multi-variable logistic regression model included six variables: age in years (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.97-1.00), positive head CT (OR = 4.42; 95% CI: 2.21-9.33), history of depression (OR = 2.59; 95% CI: 1.47-4.69), and self-report of moderate or severe headache (OR = 2.49; 95% CI: 1.49-4.18), difficulty concentrating (OR = 3.17; 95% CI: 1.53-7.04), and photophobia (OR = 4.17; 95% CI: 2.08-8.92) on the day-of-injury. The model was validated internally using bootstrap resampling (1000 resamples), which revealed a mean over-optimism value of 0.01 and an optimism-corrected area under the curve (AUC) of 0.79 (95% CI: 0.75-0.85). A prognostic model for predicting incomplete recovery among ED patients with mTBI and a presenting GCS of 15 using easily obtainable clinical and demographic variables has acceptable discriminative accuracy. External validation of this model is warranted.

Assessing Sleep Concerns in Individuals With Acquired Brain Injury: The Feasibility of a Smartpad Sleep Tool.

OBJECTIVE: The investigators examined the presence of disrupted sleep in acquired brain injury (ABI) and the utility of a mobile health program, MySleepScript, as an effective clinical tool to detect sleep disturbances. METHODS: A cross-sectional pilot study of MySleepScript, a customizable electronic battery of validated sleep questionnaires, was conducted. Participants were recruited at the Acquired Brain Injury Clinic at Johns Hopkins Bayview Medical Center. RESULTS: Sixty-eight adults with ABI (mean age, 46.3 years [SD=14.8]) participated in the study, with a mean completion time of 16.6 minutes (SD=5.4). Time to completion did not differ on individual completion or staff assistance. The mean score on the Pittsburgh Sleep Quality Index was 9.2 (SD=4.7); 83.9% of individuals had poor sleep quality (defined as a score >5). Insomnia Severity Index scores indicated moderate to severe insomnia in 45% of participants; 36.5% of participants screened positive for symptoms concerning sleep apnea, while 39.3% of individuals screened positive for restless legs syndrome. CONCLUSIONS: Poor sleep quality was highly prevalent in this ABI cohort. MySleepScript may be an effective method of assessing for sleep disturbance in ABI. Further efforts to identify sleep disorders in this patient population should be pursued to optimize ABI management.

Treatment of Depression After Traumatic Brain Injury: A Systematic Review Focused on Pharmacological and Neuromodulatory Interventions.

BACKGROUND: Depression is the most common psychiatric sequela after traumatic brain injury (TBI) and poses a variety of treatment challenges. There is a lack of clinical trials focused on biological interventions used to manage TBI depression. OBJECTIVE: The aim of this systematic review is to summarize the current evidence of psychotropic and neuromodulatory interventions used to treat TBI depression and to provide directions for future research. METHODS: Key words were used to describe the following search terms: "traumatic brain injury", "depression", "pharmacological/drug therapy", and "neuromodulation". Studies focused on pharmacotherapy or neuromodulation in TBI depression were identified in 5 databases: Medline (PubMed), EMBASE (Embase.com), the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), PsycINFO (EbscoHost), and Web of Science. Article inclusion/exclusion using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic protocol of extraction and evaluation was applied. Level of evidence for each study was determined using the American Academy of Neurology criteria. RESULTS: The initial search provided 1473 citations. Twenty-two studies met inclusion criteria. Sixteen studies explored pharmacological interventions with emphasis on serotonergic agents. Results between studies were conflicting, and interventions did not always outperform placebos, although sertraline provided the highest level of evidence for treatment of TBI depression. Six studies examining neuromodulatory interventions show preliminary evidence of efficacy with a range of interventions and modes of delivery used. CONCLUSIONS: Additional research including large-sample randomized-controlled trials using pharmacological, neuromodulation, or combination treatment is needed. These studies should incorporate premorbid psychosocial functioning, preinjury psychiatric disease, cognitive deficits, and functional recovery when examining outcomes.

Post-stroke depression: A 2020 updated review.

BACKGROUND: Post-stroke depression (PSD) is common and associated with higher mortality, poorer recovery, more pronounced cognitive deficits, and lower quality of life than is stroke without depression. This manuscript will conduct an updated, comprehensive and clinically-useful review of the risk factors, pathophysiology, assessment, prevention, and treatment of PSD. METHODS: This narrative review summarizes articles obtained on PubMed, Medline, EMBase, Google Scholar and the Cochrane Database. This review prioritized articles with a more robust level of evidence, such as original articles with longitudinal data and/or larger samples, randomized controlled trials, systematic reviews, and metaanalyses. RESULTS: One hundred twenty-four articles were reviewed, of which 44 (35%) were published before 2016 and 80 (65%) that were published since 2016. DISCUSSION: Rates of PSD range from 18 to 33%, yet it is vastly underdiagnosed and undertreated. Risk factors for PSD include female sex, history of psychiatric illness, large or multiple strokes, injuries in frontal/anterior areas or in the basal ganglia, stroke occurrence within the past year, poor social support, and pronounced disability. The pathophysiology of PSD is multifactorial and likely involves decreased levels of monoamines, abnormal neurotrophic response, increased inflammation with dysregulation of hypothalamic-pituitary-adrenal axis, and glutamate-mediated excitotoxicity. The evidence for preventive interventions for PSD is somewhat inconsistent and modest. The best treatment for PSD consists of the combination of pharmacological, psychosocial and stroke-focused interventions. CONCLUSION: PSD is a common, treatable condition that is associated with several negative outcomes. Early detection and proper management are critical to obtain better outcomes in individuals with PSD.

Age differences in outcome after mild traumatic brain injury: results from the HeadSMART study.

This study longitudinally examined age differences across multiple outcome domains in individuals diagnosed with acute mild traumatic brain injury (mTBI). A sample of 447 adults meeting VA/DoD criteria for mTBI was dichotomized by age into older (≥65 years; n = 88) and younger (<65 years; n = 359) sub-groups. All participants presented to the emergency department within 24 hours of sustaining a head injury, and outcomes were assessed at 1-, 3-, and 6-month intervals. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), post-concussive symptoms (PCS) were ascertained with the Rivermead Post-Concussion Questionnaire (RPQ), and functional recovery from the Extended Glasgow Outcome Scale (GOSE). Mixed effects logistic regression models showed that the rate of change over time in odds of functional improvement and symptom alleviation did not significantly differ between age groups (p = 0.200-0.088). Contrary to expectation, older adults showed equivalent outcome trajectories to younger persons across time. This is a compelling finding when viewed in light of the majority opinion that older adults are at risk for significantly worse outcomes. Future work is needed to identify the protective factors inherent to sub-groups of older individuals such as this.

Loss of Consciousness and Altered Mental State as Predictors of Functional Recovery Within 6 Months Following Mild Traumatic Brain Injury.

OBJECTIVE: The authors tested the hypothesis that a combination of loss of consciousness (LOC) and altered mental state (AMS) predicts the highest risk of incomplete functional recovery within 6 months after mild traumatic brain injury (mTBI), compared with either condition alone, and that LOC alone is more strongly associated with incomplete recovery, compared with AMS alone. METHODS: Data were analyzed from 407 patients with mTBI from Head injury Serum Markers for Assessing Response to Trauma (HeadSMART), a prospective cohort study of TBI patients presenting to two urban emergency departments. Four patient subgroups were constructed based on information documented at the time of injury: neither LOC nor AMS, LOC only, AMS only, and both. Logistic regression models assessed LOC and AMS as predictors of functional recovery at 1, 3, and 6 months. RESULTS: A gradient of risk of incomplete functional recovery at 1, 3, and 6 months postinjury was noted, moving from neither LOC nor AMS, to LOC or AMS alone, to both. LOC was associated with incomplete functional recovery at 1 and 3 months (odds ratio=2.17, SE=0.46, p<0.001; and odds ratio=1.80, SE=0.40, p=0.008, respectively). AMS was associated with incomplete functional recovery at 1 month only (odds ratio=1.77, SE=0.37 p=0.007). No association was found between AMS and functional recovery in patients with no LOC. Neither LOC nor AMS was predictive of functional recovery at later times. CONCLUSIONS: These findings highlight the need to include symptom-focused clinical variables that pertain to the injury itself when assessing who might be at highest risk of incomplete functional recovery post-mTBI.