A Novel Treatment of Postpartum Depression and Review of Literature.

Early-onset postpartum depression has been shown to have a unique neurobiological basis compared to major depressive disorder, implying a need for targeted treatments such as the recent Food and Drug Administration (FDA)-approved brexanolone. In this case report, a woman with a past medical history of major depressive disorder was diagnosed with postpartum depression due to worsening mood with suicidal and homicidal ideations. She was treated with vilazodone and aripiprazole with good effect after consideration of her past medication trials. Her regimen is unique in clinical practice and not reported in current literature for the treatment of postpartum depression. It may represent a safe and effective medication choice, especially in the context of current first-line treatments that have a high treatment failure rate. More research is needed to find treatments that address the unique challenges of postpartum women.

Clinical Trends Over the First Year of a Psychiatric Electronic Consult Service.

BACKGROUND: Electronic consultations (e-consultations) offer rapid, direct, and documented communication through the electronic medical record between primary care physicians (PCPs) and specialists. Psychiatric e-consultations are increasingly being implemented across hospital networks with the recommendation for face-to-face psychiatric evaluation periodically being made by the consulted psychiatrist. It remains to be seen what clinical factors lead the consultant to make this type of recommendation and whether the question asked by the PCP and the diagnosis of the patient has any bearing. OBJECTIVES: To determine which psychiatric diagnoses are most commonly electronically consulted on, what types of questions are being asked by primary care providers to electronically consulted psychiatrists, and what questions and which diagnoses result in an electronically consulted psychiatrist to recommend further in-person evaluation. METHODS: A retrospective chart review of an e-consultation service was conducted. One hundred sixty-four charts were reviewed. Data were collected on the psychiatric diagnosis, type of question posed by the PCP to the psychiatrist, the number of recommendations for an in-person evaluation made, and the percentages of the diagnoses and questions that were associated with a recommendation for in-person evaluation. RESULTS: Two hundred twenty-three diagnoses were consulted on. The most common diagnoses were anxiety disorders (34.5%, N = 77), depressive disorders (32.3%, N = 72), and bipolar disorders (13.5%, N = 30). One hundred eighty-one questions were asked by PCPs. One hundred fifty-one (83.4%) questions regarded pharmacological management. Of the 164 charts, 40 (24.4%) e-consultations resulted in the psychiatrist recommending an in-person evaluation. The in-person evaluation recommendation rates did not change with increasing provider familiarity as the inaugural year went on. Three (7.5%) patients who were recommended for an outpatient psychiatry evaluation were scheduled to be seen by the consulted psychiatrist. Depressive (N = 12) and anxiety disorders (N = 13) were both recommended for in-person follow-up 17% of the time. Bipolar disorder was recommended for follow-up 53% (N = 16) of the time. Of the 181 question types posed by PCPs, 34 (22.5%) pharmacological management questions were recommended for in-person follow-up. CONCLUSIONS: Certain diagnoses and question types appear to influence the likelihood that an electronically consulted psychiatrist will recommend a face-to-face evaluation. It also suggests that e-consultation services can be particularly serviceable for certain diagnoses, that is, depression and anxiety, as well as certain question types, that is, pharmacological management. This information can guide PCPs and psychiatrists about which patients are best suited for an e-consultation versus an in-person referral from the outset.

Continuous measurement of attachment behavior: A multimodal view of the strange situation procedure.

Infant attachment is a critical indicator of healthy infant social-emotional functioning, which is typically measured using the gold-standard Strange Situation Procedure (SSP). However, expert-based attachment classifications from the SSP are time-intensive (with respect both to expert training and rating), and do not provide an objective, continuous record of infant behavior. To continuously quantify predictors of key attachment behaviors and dimensions, multimodal movement and audio data were collected during the SSP. Forty-nine 1-year-olds and their mothers participated in the SSP and were tracked in three-dimensional space using five synchronized Kinect sensors; LENA recordings were used to quantify crying duration. Theoretically-informed multimodal measures of attachment-related behavior (e.g., dyadic contact duration, infant velocity of approach toward the mother, and infant crying) were used to predict expert rating scales and dimensional summaries of attachment outcomes. Stepwise regressions identified sets of multimodal objective measures that were significant predictors of eight of nine of the expert ratings of infant attachment behaviors in the SSP's two reunions. These multimodal measures predicted approximately half of the variance in the summary approach/avoidance and resistance/disorganization attachment dimensions. Incorporating all objective measures as predictors regardless of significance levels, predicted individual ratings within an average of one point on the original Likert scales. The results indicate that relatively inexpensive Kinect and LENA sensors can be harnessed to quantify attachment behavior in a key assessment protocol, suggesting the promise of objective measurement to understanding infant-parent interaction.

Provider Satisfaction from a New Telepsychiatry Inpatient Consultation Service.

Background:Telepsychiatry is a well-studied modality that has been shown to perform as well as, if not better than, in-person mental health services. However, acceptability of this modality to practitioners, especially as it relates to the type of consult, has not been well studied. To address barriers to implementing a new telepsychiatry consultation-liaison (CL) service at a rural campus of a large tertiary care health network, authors designed a survey to assess consultee attitudes before and after the service launch. A secondary objective was to examine the consult data.Materials and Methods:The new telepsychiatry CL service at the rural hospital was delivered by providers at the main campus of the health network. Authors surveyed all consultees before the launch and every 3 months for 12 months thereafter. Consult data was also tracked in that same period.Results:Over a 12-month period, 442 initial and follow-up consults were completed. Consultees were most concerned with assessing delirium, agitation, and neurocognitive disorder over live video. Consultees generally held their belief that telepsychiatry consults are not as enjoyable as in-person consults, but they recognized its value, specifically regarding improved access for patients.Discussion:The service was successfully launched and was well received as evidenced by the continued use of the service.Conclusions:The project revealed valuable insight which has been used to improve the service and to replicate it at another campus within the health network.

Attachment security differs by later autism spectrum disorder: A prospective study.

Although difficulties with social relationships are key to autism spectrum disorder (ASD), no previous study has examined infant attachment security prior to ASD diagnosis. We prospectively assessed attachment security at 15 months in high-risk infants with later ASD (high-risk/ASD, n = 16), high-risk infants without later ASD (high-risk/no-ASD, n = 40), and low-risk infants without later ASD (low-risk/no-ASD, n = 39) using the Strange Situation Procedure. High-risk/ASD infants were disproportionately more likely to be classified as insecure (versus secure) and more likely to be classified as insecure-resistant (versus secure or avoidant) than high-risk/no-ASD and low-risk/no-ASD infants. High-risk infants with insecure-resistant attachments were over nine times more likely to receive an ASD diagnosis than high-risk infants with secure attachments. Insecure-resistant attachment in high-risk infants suggests a propensity toward negative affect with the parent in conditions of stress. Insecure-resistant attachment may prove useful as a potential early index of propensity toward ASD diagnosis in high-risk siblings, while insecure-resistant attachment in the context of emergent autism may contribute to difficulties experienced by children with ASD and their families.

Accuracy of Psychiatrists' Assessment of Medication Adherence in an Outpatient Setting.

BACKGROUND:  Many patients have uncontrolled psychiatric symptoms because they are not taking their medication as prescribed. Psychiatrists may have difficulty accurately assessing medication adherence, which is important because it helps guide them in how they prescribe. If nonadherence is the cause of uncontrolled symptoms, then strategies to improve adherence are advised. However, if nonadherence is not the cause, then the usual course of action would be to intensify or modify the medication regimen. Knowing whether nonadherence is a factor at the time of an appointment could help guide clinical decision making in real-time. METHODS: A cohort of established patients in an outpatient mental health treatment clinic at a large health network was studied from November 2018 to August 2019. Blood drug levels of several oral antipsychotic medications were obtained and placed in the following three categories: below, within, or above the therapeutic range of published cutoff points. Treating physicians answered Likert-scale questions regarding their assessment of patient adherence. Subsequently, blood drug levels were compared to the psychiatrists' assessment of adherence using a Kappa coefficient.  Results: Sixty-four patients being prescribed antipsychotic medications were analyzed. A total of 87.5% of treating psychiatrists thought their patients were always adherent or adherent greater than 50% of the time. However, based on blood levels, 14% of the 42 patients at target FDA dosing for their medication and diagnosis were below the therapeutic range. The Kappa coefficient was used to find the level of agreement between the treating psychiatrist's perception of patient adherence and the blood drug level. It was determined to be 0.14 which is consistent with no agreement between the two measurements.  Conclusions: Treating psychiatrists inaccurately estimated oral antipsychotic medication adherence based on clinical impression alone. Making an objective measure of adherence available at the time of an appointment could help psychiatrists recognize nonadherence in real-time and inform prescribing decisions.

Objective measurement of head movement differences in children with and without autism spectrum disorder.

Background: Deficits in motor movement in children with autism spectrum disorder (ASD) have typically been characterized qualitatively by human observers. Although clinicians have noted the importance of atypical head positioning (e.g. social peering and repetitive head banging) when diagnosing children with ASD, a quantitative understanding of head movement in ASD is lacking. Here, we conduct a quantitative comparison of head movement dynamics in children with and without ASD using automated, person-independent computer-vision based head tracking (Zface). Because children with ASD often exhibit preferential attention to nonsocial versus social stimuli, we investigated whether children with and without ASD differed in their head movement dynamics depending on stimulus sociality. Methods: The current study examined differences in head movement dynamics in children with (n = 21) and without ASD (n = 21). Children were video-recorded while watching a 16-min video of social and nonsocial stimuli. Three dimensions of rigid head movement-pitch (head nods), yaw (head turns), and roll (lateral head inclinations)-were tracked using Zface. The root mean square of pitch, yaw, and roll was calculated to index the magnitude of head angular displacement (quantity of head movement) and angular velocity (speed). Results: Compared with children without ASD, children with ASD exhibited greater yaw displacement, indicating greater head turning, and greater velocity of yaw and roll, indicating faster head turning and inclination. Follow-up analyses indicated that differences in head movement dynamics were specific to the social rather than the nonsocial stimulus condition. Conclusions: Head movement dynamics (displacement and velocity) were greater in children with ASD than in children without ASD, providing a quantitative foundation for previous clinical reports. Head movement differences were evident in lateral (yaw and roll) but not vertical (pitch) movement and were specific to a social rather than nonsocial condition. When presented with social stimuli, children with ASD had higher levels of head movement and moved their heads more quickly than children without ASD. Children with ASD may use head movement to modulate their perception of social scenes.

Positive emotional engagement and autism risk.

Positive emotional engagement develops in the context of face-to-face interactions during the first 6 months of life. Deficits in emotional engagement are characteristic of autism spectrum disorder (ASD) and may characterize the younger siblings of children with ASD (high-risk siblings). High-risk siblings are likely to exhibit a broad range of positive emotional engagement that may or may not be associated with ASD outcomes. We examined positive emotional engagement (i.e., smiling rate and contingent responsiveness to the partner's smile) during the infant-parent interaction episodes of the face-to-face/still face protocol at 6 months of age. The sample included 43 high-risk infant siblings, 11 of whom went on to an ASD diagnosis, and 25 low-risk siblings with no family history of ASD. Low-risk siblings and high-risk siblings without ASD showed the typical still-face effect (i.e., decreases in smiling rate after period of parental nonresponsiveness), but high-risk siblings with later ASD outcomes did not show this decrease. Although high-risk siblings without an ASD diagnosis were less likely to respond to their parents' smiles than were low-risk siblings, the children with eventual ASD did not differ from the other groups in contingent responsiveness. Findings suggest that subtle differences in positive emotional engagement are present in the early development of high-risk siblings but are not consistently associated with ASD outcomes.