Coping With Pandemics: A Historical Perspective About Society's Tools to Deal With Global Infectious Diseases.

ABSTRACT: Throughout history, society has dealt with several devastating pandemics. Our objective is to analyze society's coping mechanisms to deal with pandemic-related stress in history congruent with the values of the time. For that purpose, we have carefully selected some of the most significant pandemics based on their impact and the available psychosocial literature. After a brief introduction, society's coping tools are reviewed and analyzed for the Antonine Plague, the second bubonic plague, the third cholera pandemic, the Spanish flu, the HIV pandemic, and the COVID-19 pandemic. Despite occurring at different times in history, parallels can be established in the study of society's psychological reactions among different pandemics. Magical thinking, political skepticism, fake accusations, and discrimination of minorities are recurrent reactions in society among different pandemics in history.

Mobile Vaccine Clinics for Patients With Serious Mental Illness and Health Care Workers in Outpatient Mental Health Clinics.

OBJECTIVE: People with serious mental illness are particularly vulnerable to COVID-19 but face barriers to vaccinations. The authors describe the implementation of a mobile vaccine clinic at an outpatient mental health clinic for patients and health care workers to increase vaccination rates. METHODS: In late 2021, mobile vaccine clinics were held in collaboration with a local pharmacy to provide COVID-19 and influenza vaccines to patients and health care workers. Participants in one clinic were asked to fill out a questionnaire about their experience. RESULTS: Of 69 individuals who completed the questionnaire, 96% received the COVID-19 booster and 17% received the seasonal flu vaccine. Most patients and health care workers reported that the mobile vaccine clinic was easily accessible and preferable and that they would recommend it. Moreover, the mobile vaccine clinic was cost-effective. CONCLUSIONS: Mobile vaccine clinics can improve vaccine access for patients and health care workers in community mental health settings and can be cost-effective.

Hippocampal Subfield Volumes Predict Disengagement from Maintenance Treatment in First Episode Schizophrenia.

OBJECTIVES: Disengagement from treatment is common in first episode schizophrenia (FES) and is associated with poor outcomes. Our aim was to determine whether hippocampal subfield volumes predict disengagement during maintenance treatment of FES. METHODS: FES patients were recruited from sites in Boston, New York, Shanghai, and Changsha. After stabilization on antipsychotic medication, participants were randomized to add-on citalopram or placebo and followed for 12 months. Demographic, clinical and cognitive factors at baseline were compared between completers and disengagers in addition to volumes of hippocampal subfields. RESULTS: Baseline data were available for 95 randomized participants. Disengagers (n = 38, 40%) differed from completers (n = 57, 60%) by race (more likely Black; less likely Asian) and in more alcohol use, parkinsonism, negative symptoms and more impairment in visual learning and working memory. Bilateral dentate gyrus (DG), CA1, CA2/3 and whole hippocampal volumes were significantly smaller in disengagers compared to completers. When all the eight volumes were entered into the model simultaneously, only left DG volume significantly predicted disengagement status and remained significant after adjusting for age, sex, race, intracranial volume, antipsychotic dose, duration of untreated psychosis, citalopram status, alcohol status, and smoking status (P < .01). Left DG volume predicted disengagement with 57% sensitivity and 83% specificity. CONCLUSIONS: Smaller left DG was significantly associated with disengagement status over 12 months of maintenance treatment in patients with FES participating in a randomized clinical trial. If replicated, these findings may provide a biomarker to identify patients at risk for disengagement and a potential target for interventions.

Increasing COVID-19 Vaccination Rates Among Patients With Serious Mental Illness: A Pilot Intervention Study.

OBJECTIVE: This pilot project aimed to maximize COVID-19 vaccine uptake among patients with serious mental illness. Psychiatric providers were engaged to directly address COVID-19 vaccine-related concerns with patients during outpatient visits. METHODS: A quality improvement project encouraged COVID-19 vaccinations in a cohort of outpatients treated with clozapine (N=193, ages 19-81 years, mean age=46.4 years) at a community mental health center. In-service education was provided to clinicians to identify vaccine-hesitant patients and build vaccine confidence. A vaccination-monitoring tool was created and embedded in patients' electronic medical records. Starting in February 2021, the tool guided semistructured interviews at each visit and supported population-based management. RESULTS: The full COVID-19 vaccination rate by June 30, 2021, was 84% among the outpatients, compared with the estimated state rate on the same date of between 62.1% and 77.3%. CONCLUSIONS: The active involvement of psychiatric providers in preventive health care can help increase vaccination rates among patients with serious mental illness.

Monitoring for myocarditis during treatment initiation with clozapine.

OBJECTIVE: Clozapine use is associated with myocarditis. In this study, we investigated what clinical signs and symptoms, and/or laboratory test(s), alert clinicians to presumptive myocarditis (PrMy) most accurately and at the earliest time point. We also investigated the incidence of PrMy during the initial exposure to clozapine versus in patients restarted on clozapine after extended interruption of prior prolonged treatment. METHODS: 100 patients admitted to state psychiatric hospital started on clozapine were recruited into the study. 76 patients were treated with clozapine for the first time and 24 patients were restarts. Creatine kinase (CK), troponin I (TROP), eosinophil count (EOS), and C-reactive protein (CRP) were obtained at baseline and weeks 1, 2, 3, and 4. Descriptive statistics were calculated for demographic and clinical variables. Student's t test and chi-squared test were used to compare means and proportions between initial exposure and restart groups. RESULTS: Clinical features and laboratory tests suggestive of PrMy were seen in 4 patients (5.3%) in initial exposure group and none in restart group. 3.5% of TROP levels were abnormal in initial exposure group and no abnormal levels were found in the restart group. 30% and 46% of CK, 23% and 39% of CRP, and 14% and 23% of EOS were abnormal in initial exposure group and restart groups, respectively. CONCLUSIONS: PrMy was common (5.3%) during clozapine initiation. Prospective management through serial laboratory monitoring with weekly TROP levels was sensitive enough to allow for timely clozapine discontinuation.

Effect of citalopram on hippocampal volume in first-episode schizophrenia: Structural MRI results from the DECIFER trial.

Hippocampal volume loss is prominent in first episode schizophrenia (FES) and has been associated with poor clinical outcomes and with BDNF genotype; antidepressants are believed to reverse hippocampal volume loss via release of BDNF. In a 12-month, placebo-controlled add-on trial of the antidepressant, citalopram, during the maintenance phase of FES, negative symptoms were improved with citalopram. We now report results of structural brain imaging at baseline and 6 months in 63 FES patients (34 in citalopram group) from the trial to assess whether protection against hippocampal volume loss contributed to improved negative symptoms with citalopram. Hippocampal volumetric integrity (HVI) did not change significantly in the citalopram or placebo group and did not differ between treatment groups, whereas citalopram was associated with greater volume loss of the right CA1 subfield. Change in cortical thickness was associated with SANS change in 4 regions (left rostral anterior cingulate, right frontal pole, right cuneus, and right transverse temporal) but none differed between treatment groups. Our findings suggest that minimal hippocampal volume loss occurs after stabilization on antipsychotic treatment and that citalopram's potential benefit for negative symptoms is unlikely to result from protection against hippocampal volume loss or cortical thinning.

Association of Aripiprazole With Reduced Hippocampal Atrophy During Maintenance Treatment of First-Episode Schizophrenia.

PURPOSE/BACKGROUND: Hippocampal volume loss in early schizophrenia has been linked with markers of inflammation and oxidative stress, and with less response of negative symptoms. Aripiprazole has been reported to preserve hippocampal volume and to reduce inflammation. METHODS/PROCEDURES: Study 1 was a 12-month multicenter randomized placebo-controlled trial of citalopram added to clinician-determined second-generation antipsychotic medication in 95 patients with first-episode schizophrenia (FES), 19 of whom received aripiprazole. We compared participants taking aripiprazole with those on other antipsychotics to determine whether those on aripiprazole had less hippocampal volume loss. We also examined peripheral biomarker data from medication-naive patients with schizophrenia receiving 8 weeks of antipsychotic treatment (n = 24) to see whether markers of inflammation and oxidative stress that previously predicted hippocampal volume differed between aripiprazole (n = 9) and other antipsychotics (study 2). FINDINGS/RESULTS: Aripiprazole was associated with a mean increase in hippocampal volume of 0.35% (SD, 0.80%) compared with a 0.53% decrease (SD, 1.2%) with other antipsychotics during the first year of maintenance treatment in patients with FES. This difference was significant after adjusting for age, sex, citalopram treatment, and baseline Brief Psychiatric Rating Scale score (B = 0.0079, P = 0.03). Aripiprazole was also associated with reduced concentrations of the inflammatory cytokines interleukin-8 and tumor necrosis factor (P < 0.01) during the first 8 weeks of treatment in medication-naive patients with FES. IMPLICATIONS/CONCLUSIONS: These results suggest that aripiprazole may protect against hippocampal atrophy via an anti-inflammatory mechanism, but these results require replication in larger, randomized trials, and the clinical relevance of hippocampal volume loss is not established.

Neural Abnormalities in Fear Generalization in Schizophrenia and Associations With Negative Symptoms.

BACKGROUND: Associative learning and memory processes, including the generalization of previously learned associations, may be altered in schizophrenia. Deficits in schizophrenia in stimulus generalization, one of the simplest forms of memory, could interfere with the ability to efficiently categorize related, similar information, potentially leading to impairments in daily functioning. METHODS: To measure generalization in schizophrenia, 37 individuals with a nonaffective psychotic disorder and 32 demographically matched healthy control subjects underwent a Pavlovian fear conditioning and generalization procedure, which accounted for variation in perceptual ability across participants, while undergoing functional magnetic resonance imaging. Skin conductance and neural responses to conditioned (CS+), neutral (CS-), and generalization stimuli were measured. Explicit memory ratings reflecting successful generalization were also collected after the scanning, as well as measures of symptom severity. RESULTS: Compared with healthy control subjects, individuals with nonaffective psychotic disorders showed significant deficits in fear generalization across multiple measurements, with impairments in memory ratings and reductions in activation and deactivation of the salience and default networks, respectively, during fear generalization. Moreover, in the psychotic disorder group, greater behavioral and neural abnormalities in generalization were associated with higher levels of negative symptoms. CONCLUSIONS: Fear generalization is impaired in psychotic illness. Given that successful generalization relies on a dynamic balance between excitatory and inhibitory neurotransmission, these results reveal a potentially quantifiable mechanism linked to negative symptoms that can be investigated further in future human and experimental animal studies.

COVID-19 Emergency Reforms in Massachusetts to Support Behavioral Health Care and Reduce Mortality of People With Serious Mental Illness.

People with serious mental illness are at disproportionate risk of COVID-19 morbidity and mortality because of high rates of risk factors that directly parallel those related to poor coronavirus outcomes, including smoking, chronic obstructive pulmonary disease, cardiovascular disease, and diabetes, along with housing instability, homelessness, food insecurity, and poverty. Community-based behavioral health organizations are also at risk of adverse outcomes because of dramatic declines in revenues and a diminished workforce. The State of Massachusetts has responded to this crisis by rapidly implementing a variety of policy, regulatory, and payment reforms. This column describes some of these reforms, which are designed to enhance remote telehealth delivery of care, ensure access to needed medications and residential care staff, and support the financial livelihood of community-based behavioral health services.

Blood Levels to Optimize Antipsychotic Treatment in Clinical Practice: A Joint Consensus Statement of the American Society of Clinical Psychopharmacology and the Therapeutic Drug Monitoring Task Force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie.

OBJECTIVE: The quantification of antipsychotic levels in blood, also known as therapeutic drug monitoring (TDM), is a potentially useful tool of modern personalized therapy that can be applied to augment antipsychotic use and dosing decisions. The application of TDM for antipsychotics can be helpful in numerous challenging clinical scenarios, such as lack of therapeutic response, relapse, or adverse drug reactions (ADRs) related to antipsychotic treatment. The benefits of TDM may be particularly evident in the treatment of highly vulnerable patient subgroups, such as children, adolescents, pregnant women, and the elderly. The main aim of this article is to aid clinicians who routinely prescribe antipsychotics to successfully apply TDM in routine clinical practice in order to help optimize the efficacy and safety of those antipsychotics. PARTICIPANTS: Participants were clinicians and researchers, members of the American Society of Clinical Psychopharmacology, and the Therapeutic Drug Monitoring Task Force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (Association of Neuropsychopharmacology and Pharmacopsychiatry). EVIDENCE: TDM literature on antipsychotics was critically reviewed to provide a condensed clinical decision-making algorithm with therapeutic reference ranges for blood antipsychotic levels, within which patients are most likely to respond and tolerate treatment, although TDM is not equally recommended/supported for all antipsychotics. CONSENSUS PROCESS: A preliminary draft was prepared and circulated to the writing group members. Consensus was achieved in all cases, and resulting recommendations focused on following areas: steady-state and sampling time, levels of recommendations, indications, therapeutic reference ranges and laboratory alert levels, practical issues, and interpretation, as well as limitations. CONCLUSIONS: The utilization of TDM as a tool for problem solving in antipsychotic treatment offers a unique method to improve safety and efficacy. This consensus statement summarizes essential information on the routine use of TDM for antipsychotics and encourages clinicians to perform TDM with the appropriate indications as part of the clinical decision-making process.