Enhancing return to work or school after a first episode of schizophrenia: the UCLA RCT of Individual Placement and Support and Workplace Fundamentals Module training.

BACKGROUND: This study evaluated in a rigorous 18-month randomized controlled trial the efficacy of an enhanced vocational intervention for helping individuals with a recent first schizophrenia episode to return to and remain in competitive work or regular schooling. METHODS: Individual Placement and Support (IPS) was adapted to meet the goals of individuals whose goals might involve either employment or schooling. IPS was combined with a Workplace Fundamentals Module (WFM) for an enhanced, outpatient, vocational intervention. Random assignment to the enhanced integrated rehabilitation program (N = 46) was contrasted with equally intensive clinical treatment at UCLA, including social skills training groups, and conventional vocational rehabilitation by state agencies (N = 23). All patients were provided case management and psychiatric services by the same clinical team and received oral atypical antipsychotic medication. RESULTS: The IPS-WFM combination led to 83% of patients participating in competitive employment or school in the first 6 months of intensive treatment, compared with 41% in the comparison group (p < 0.005). During the subsequent year, IPS-WFM continued to yield higher rates of schooling/employment (92% v. 60%, p < 0.03). Cumulative number of weeks of schooling and/or employment was also substantially greater with the IPS-WFM intervention (45 v. 26 weeks, p < 0.004). CONCLUSIONS: The results clearly support the efficacy of an enhanced intervention focused on recovery of participation in normative work and school settings in the initial phase of schizophrenia, suggesting potential for prevention of disability.

Automation to optimise physician treatment of individual patients: examples in psychiatry.

There is widespread agreement by health-care providers, medical associations, industry, and governments that automation using digital technology could improve the delivery and quality of care in psychiatry, and reduce costs. Many benefits from technology have already been realised, along with the identification of many challenges. In this Review, we discuss some of the challenges to developing effective automation for psychiatry to optimise physician treatment of individual patients. Using the perspective of automation experts in other industries, three examples of automation in the delivery of routine care are reviewed: (1) effects of electronic medical records on the patient interview; (2) effects of complex systems integration on e-prescribing; and (3) use of clinical decision support to assist with clinical decision making. An increased understanding of the experience of automation from other sectors might allow for more effective deployment of technology in psychiatry.

Antidepressants in Bipolar Depression: An Enduring Controversy.

(Reprinted with permission from Int J Bipolar Discord (2018) 6:25).

Antidepressants in bipolar depression: an enduring controversy.

The proper place and the optimal use of antidepressants in treating bipolar depression continues to be an area of great interest and greater controversy with passionate opinions more common than good studies. Even the handful of meta-analyses in the area disagree with each other. Overall, the evidence that antidepressants are effective in treating bipolar depression is weak. Additionally, many experts and clinicians worry greatly about the capacity of antidepressants to cause affective switching or mood destabilization. Yet, in short term controlled studies, with most patients also taking mood stabilizers, antidepressants are not associated with switches into mania/hypomania. Evidence of cycle acceleration with antidepressants primarily reflects treatment with older antidepressants, e.g., tricyclics. Similar evidence with modern antidepressants such as selective serotonin reuptake inhibitors (SSRIs) is lacking. The key questions should not be: are antidepressants effective in bipolar depression?; And: do antidepressants worsen the course of bipolar disorder? Rather, the question should be focused on subgroups: for which patients are antidepressants helpful and safe, and for which patients will they be harmful? Predictors of affective switching with antidepressants include: bipolar I disorder (vs. bipolar II), mixed features during depression, tricyclics vs. modern antidepressants, rapid cycling and possibly a history of drug abuse, especially stimulant abuse. Additionally, a number of recent studies have demonstrated both the safety and efficacy of antidepressant monotherapy in treating bipolar II depression. Finally, a subgroup of bipolar individuals need antidepressants in addition to mood stabilizers as part of an optimal maintenance treatment regimen.

Internet use by older adults with bipolar disorder: international survey results.

BACKGROUND: The world population is aging and the number of older adults with bipolar disorder is increasing. Digital technologies are viewed as a framework to improve care of older adults with bipolar disorder. This analysis quantifies Internet use by older adults with bipolar disorder as part of a larger survey project about information seeking. METHODS: A paper-based survey about information seeking by patients with bipolar disorder was developed and translated into 12 languages. The survey was anonymous and completed between March 2014 and January 2016 by 1222 patients in 17 countries. All patients were diagnosed by a psychiatrist. General estimating equations were used to account for correlated data. RESULTS: Overall, 47% of older adults (age 60 years or older) used the Internet versus 87% of younger adults (less than 60 years). More education and having symptoms that interfered with regular activities increased the odds of using the Internet, while being age 60 years or older decreased the odds. Data from 187 older adults and 1021 younger adults were included in the analysis excluding missing values. CONCLUSIONS: Older adults with bipolar disorder use the Internet much less frequently than younger adults. Many older adults do not use the Internet, and technology tools are suitable for some but not all older adults. As more health services are only available online, and more digital tools are developed, there is concern about growing health disparities based on age. Mental health experts should participate in determining the appropriate role for digital tools for older adults with bipolar disorder.

Bupropion Use During Pregnancy: A Systematic Review.

OBJECTIVE: To evaluate data on birth outcomes following bupropion use during pregnancy. DATA SOURCES: A systematic literature review of PubMed and PsycINFO was performed through June 2017 for clinical studies published in English. The following keywords were used: bupropion, pregnancy, depression, smoking cessation, birth outcomes, miscarriage, and spontaneous abortion. References and related articles were also searched to yield additional publications. With the exception of limiting the search to human subjects, no other limitations were applied in an effort to capture all relevant published studies. STUDY SELECTION/DATA EXTRACTION: No studies were excluded. A total of 8 studies were included in this review. RESULTS: Bupropion's use in the first trimester has been linked with a small elevation in the risk of cardiovascular defects, although the absolute risk was low and confounding by indication (eg, use for smoking cessation) cannot be excluded. While the risk of miscarriage following prenatal bupropion exposure was higher than that of a control group of women in one study, it remained within the general population rate. CONCLUSIONS: While more studies are needed, research to date suggests that bupropion may be a reasonable treatment option for depressed pregnant women who require pharmacotherapy, particularly when they also are attempting to reduce nicotine use during pregnancy.

Self-Harm, Affective Traits, and Psychosocial Functioning in Adults With Depressive and Bipolar Disorders.

Self-harm refers to the purposeful destruction of bodily tissue without suicidal intention and for purposes that are not socially sanctioned. Little is known about the associations between a history of self-harm, mood symptoms, and functioning in adults with different types of mood disorders. Lifetime histories of self-harm, current mood symptoms, global functioning, and affective traits were collected on 142 adults with mood disorders. The prevalence of lifetime self-harm was higher in patients with bipolar disorder compared with patients with a unipolar depressive disorder. Self-harm was also more strongly linked to impulsivity in individuals with bipolar disorder compared with unipolar depressive disorder. Across both diagnoses, histories of self-harm were related to lower levels of current global functioning, more severe depressive symptoms, and high self-reported emotional dysregulation and neuroticism. Findings indicate that self-harm is a potent prognostic variable for symptoms, global functioning, and personality functioning in individuals with mood disorders.

The difficult lives of individuals with bipolar disorder: A review of functional outcomes and their implications for treatment.

BACKGROUND: Most longitudinal or treatment studies in bipolar disorder have used symptomatic or syndromal status as the primary outcome variable. More recently, psychosocial functioning has been highlighted as a key domain of outcome. Patients with bipolar disorder appear to be impaired in all functional domains, although the factors that cause impairment have not been clearly specified. METHODS: This paper reviews cross-sectional and longitudinal studies on functional impairment and its relationship to symptomatic, neurocognitive, personality, and stress variables in bipolar disorder; and the implications of these relationships for defining treatment targets. 93 articles were located through comprehensive MEDLINE, SCOPUS and Web of Science searches. RESULTS AND DISCUSSION: Functional recovery following a mood episode consistently lags behind symptomatic and syndromal recovery. Longer term functional impairment is only partly explained by the number of manic/hypomanic episodes. Depression (including subsyndromal states) and persistent neurocognitive impairment are the strongest correlates of functional impairment in bipolar disorder, with personality and psychosocial stressors playing secondary roles. Possible treatment options include: more aggressive treatment of subthreshold depressive states, pharmacotherapies that target cognition (e.g., stimulants), and adjunctive psychotherapies including cognitive remediation.

Split treatment: Recommendations for optimal use in the care of psychiatric patients.

BACKGROUND: Split treatment refers to the involvement of 2 mental health professionals in the care of a psychiatric patient-one providing psychotherapy and the other psychopharmacologic management. Despite the widespread use of split treatment in outpatient psychiatric care, little data exist on its core features or cost-effectiveness compared with other models of treatment. METHODS: We reviewed published studies on split treatment, summarized the research data on split treatment, and created principles to guide its use in practice. RESULTS: Few data-based studies have examined the split treatment model. Both prescribing psychiatrists and psychotherapists have specific and unique concerns and sensitivities in the split model that are likely to affect the overall success of treatment. Among the concerns are respect for the other treating professional, staying within the appropriate boundaries of one's expertise, efficient communication with the co-treater, and parallel accessibility in emergency situations. CONCLUSIONS: Proper application of split care principles is likely to result in a better-coordinated and more effective approach to treatment of psychiatric patients. Recommendations for future research are offered.

Negative symptoms and functioning during the first year after a recent onset of schizophrenia and 8 years later.

BACKGROUND: Understanding the longitudinal course of negative symptoms, especially in relationship to functioning, in the early phase of schizophrenia is crucial to developing intervention approaches. The course of negative symptoms and daily functioning was examined over a 1-year period following a recent onset of schizophrenia and at an 8-year follow-up point. METHODS: The study included 149 recent-onset schizophrenia patients who had a mean age of 23.7 (SD=4.4)years and mean education of 12.9 (SD=2.2)years. Negative symptom (BPRS and SANS) and functional outcome (SCORS) assessments were conducted frequently by trained raters. RESULTS: After antipsychotic medication stabilization, negative symptoms during the first outpatient year were moderately stable (BPRS ICC=0.64 and SANS ICC=0.66). Despite this overall moderate stability, 24% of patients experienced at least one period of negative symptoms exacerbation. Furthermore, entry level of negative symptoms was significantly associated with poor social functioning (r=-.34, p<.01) and work/school functioning (r=-.25, p<.05) at 12months, and with negative symptoms at the 8-year follow-up (r=.29, p<.05). DISCUSSION: Early negative symptoms are fairly stable during the first outpatient year, are predictors of daily functioning at 12months, and predict negative symptoms 8years later. Despite the high levels of stability, negative symptoms did fluctuate in a subsample of patients. These findings suggest that negative symptoms may be an important early course target for intervention aimed at promoting recovery.

A review of the use of stimulants and stimulant alternatives in treating bipolar depression and major depressive disorder.

OBJECTIVE: Prescribers often consider the off-label use of stimulants or stimulant alternatives as adjunctive antidepressants. The authors reviewed the available literature on the efficacy of these agents for treatment of refractory unipolar and bipolar depression. DATA SOURCES: PubMed, MEDLINE, and relevant English-language literature from 1988-2013 were searched. Keywords were dopaminergic, stimulant, augmentation, treatment refractory depression, dextroamphetamine, methylphenidate, modafinil, atomoxetine, and cardiovascular safety. STUDY SELECTION: All randomized controlled trials (RCTs) published during this time period were included. When RCTs were unavailable, open studies were summarized. DATA EXTRACTION: Data on the efficacy of stimulants and stimulant alternatives as treatment augmentation for unipolar and bipolar depression were extracted. RESULTS: Three open studies showed positive findings for dopaminergic stimulants, and, although 2 RCTs showed negative findings, a recent RCT revealed positive results for lisdexamfetamine as an adjunctive agent. To date, dopaminergic stimulants have not been tested in bipolar depression RCTs. Four completed RCTs suggested that modafinil/armodafinil were beneficial as treatment adjuncts for unipolar and bipolar depression, with very low rates of mood switch in bipolar depression. One study was stopped prematurely due to safety concerns of increased suicidality. CONCLUSIONS: Modafinil and armodafinil are recommended treatment adjuncts for refractory unipolar and bipolar depression. Until recently, RCT data on dopaminergic stimulants were too limited to warrant their use as first-line treatment adjuncts. However, the promising results of 1 recent lisdexamfetamine RCT, when considered in the context of the deleterious effect of subsyndromal depression, suggest consideration of dopaminergic medications in treatment-refractory unipolar or bipolar depression when modafinil is cost prohibitive or otherwise contraindicated.