Protecting and promoting editorial independence.

We argue that editorial independence, through robust practice of publication ethics and research integrity, promotes good science and prevents bad science. We elucidate the concept of research integrity, and then discuss the dimensions of editorial independence. Best practice guidelines exist, but compliance with these guidelines varies. Therefore, we make recommendations for protecting and strengthening editorial independence.

The integrity of the research record: a mess so big and so deep and so tall.

SUMMARY: Poor research integrity is increasingly recognised as a serious problem in science. We outline some evidence for this claim and introduce the Royal College of Psychiatrists (RCPsych) journals' Research Integrity Group, which has been created to address this problem.

A systematic review and meta-analysis of treatments for rapid cycling bipolar disorder.

OBJECTIVES: Rapid cycling is a common and disabling phenomenon in individuals with bipolar disorders. In the absence of a recent literature examination, this systematic review and meta-analysis aimed to synthesise the evidence of efficacy, acceptability and tolerability of treatments for individuals with rapid cycling bipolar disorder (RCBD). METHOD: A systematic search was conducted to identify randomised controlled trials assigning participants with RCBD to pharmacological and/or non-pharmacological interventions. Study inclusion and data extraction were undertaken by two reviewers independently. The primary outcome was continuous within-subject RCBD illness severity before and after treatment. Pre-post random effects meta-analyses were conducted for each outcome/intervention arm studied, generating a standardised effect size (hedge's g) and 95% confidence interval (CI). RESULTS: A total of 34 articles describing 30 studies were included. A total of 16 separate pharmacological treatments were examined in contrast to 1 psychological therapy study. Only quetiapine and lamotrigine were assessed in >5 studies. By assessing 95% CI overlap of within-subject efficacy effects compared to placebo, the only interventions suggesting significant depression benefits (placebo g = 0.60) were olanzapine (with/without fluoxetine; g = 1.01), citalopram (g = 1.10) and venlafaxine (g = 2.48). For mania, benefits were indicated for quetiapine (g = 1.01), olanzapine (g = 1.19) and aripiprazole (g = 1.09), versus placebo (g = 0.33). Most of these effect sizes were from only one trial per treatment. Heterogeneity between studies was variable, and 20% were rated to have a high risk of bias. CONCLUSIONS: While many interventions appeared efficacious, there was a lack of robust evidence for most treatments. Given the limited and heterogeneous evidence base, the optimal treatment strategies for people with RCBD are yet to be established.

Ensuring research integrity: setting standards for robust and ethical conduct and reporting of research.

We present an account of why we decided to retract a paper. We discovered a lack of adherence to conventional trials registration, execution, interpretation and reporting, and consequently, with the authors, needed to correct the scientific record. We set out our responses in general to strengthen research integrity.Declaration of interestK.S.B. is Editor-in-Chief of the British Journal of Psychiatry. W.L., K.R.K. and S.M.L. are members of the senior editorial committee and the research integrity committee for the journal. In the past three years, S.M.L. has received research support from Janssen and Lundbeck, and personal support from Janssen, Otsuka and Sunovion.

Epilepsy, seizures, physical exercise, and sports: A report from the ILAE Task Force on Sports and Epilepsy.

People with epilepsy (PWEs) are often advised against participating in sports and exercise, mostly because of fear, overprotection, and ignorance about the specific benefits and risks associated with such activities. Available evidence suggests that physical exercise and active participation in sports may favorably affect seizure control, in addition to producing broader health and psychosocial benefits. This consensus paper prepared by the International League Against Epilepsy (ILAE) Task Force on Sports and Epilepsy offers general guidance concerning participation of PWEs in sport activities, and provides suggestions on the issuance of medical fitness certificates related to involvement in different sports. Sports are divided into three categories based on potential risk of injury or death should a seizure occur: group 1, sports with no significant additional risk; group 2, sports with moderate risk to PWEs, but no risk to bystanders; and group 3, sports with major risk. Factors to be considered when advising whether a PWE can participate in specific activities include the type of sport, the probability of a seizure occurring, the type and severity of the seizures, seizure precipitating factors, the usual timing of seizure occurrence, and the person's attitude in accepting some level of risk. The Task Force on Sports and Epilepsy considers this document as a work in progress to be updated as additional data become available.

Epilepsy and secondary perceived stigma in a social setting: A night at the theater.

Stigma impacts >50% of persons with epilepsy (PWE) and is a key factory in quality of life. Stigma can be both enacted (external factors) and felt (internal factors). In this article, felt/perceived stigma is more broadly defined as a combination of internal factors and perceptions of external factors. Secondary perceived stigma is felt/perceived stigma by a third party. A key, but often underappreciated, consideration in felt/perceived stigma may occur when a seemingly innocuous statement by a speaker is perceived as stigmatizing by the PWE and/or even by an unintended third party. This autobiographic short report addresses secondary perceived stigma in a social setting, the theater.

Epilepsy and AED-induced decreased libido - The unasked psychosocial comorbidity.

Therapeutic treatment for persons with epilepsy (PWE) should address seizure control and the broad spectrum of associated comorbidities. Since both epilepsy and antiepileptic drugs (AEDs) can induce decreased libido, sexual health assessment is an important aspect of quality care in PWE as well as other patients receiving AEDs. This paper presents findings from a pilot quality initiative conducted in the ambulatory care epilepsy, pain management, and psychiatric services (N=15 clinicians) which addressed two themes: 1) whether libido is routinely questioned with/without the electronic medical record (EMR) and 2) clinicians' knowledge that both epilepsy and AEDs can induce decreased libido. All clinicians used the EMR, 40% used the GU-ROS section, but only 1 clinician (6.67%) questioned patients regarding libido. Of the clinicians, 26.7% demonstrated knowledge that both AEDs and epilepsy can cause decreased libido. Our results suggest that a treatment gap for epilepsy-induced and AED-induced decreased libido may be related to systems issues (duration of clinical visit, billing codes, EMR template) and physician barriers including decreased knowledge. Further research in this field and replication of this pilot quality initiative are indicated.

Capgras delusion with violent behavior in Alzheimer dementia: case analysis with literature review.

BACKGROUND: Capgras delusion (CD) has multiple etiologies including neurodegenerative disorders and can be associated with violent behavior. CD is a common complication of Alzheimer dementia (AD); however, CD with violent behavior is uncommon in AD. We report escalating violent behavior by a patient with advanced AD and CD who presented to the emergency department (ED) and required admission to an academic medical center. METHODS: Case analysis with PubMed literature review. RESULTS: A 75-year-old male with a 13-year history of progressive AD, asymptomatic bipolar disorder, chronic kidney disease, hypertension, hyperlipidemia, and benign prostatic hypertrophy presented to the ED with recurrent/escalating violence toward his wife, whom he considered an impostor. His psychotropic regimen included potentially inappropriate medications (PIMs) for geriatric/AD patients-topiramate/amitriptyline/chlordiazepoxide/olanzapine-that are associated with delirium, cognitive decline, dementia, and mortality. Renal dosing for topiramate, reduction in PIMs/anticholinergic burden, and substituting haloperidol for olanzapine resolved his violent behavior and CD. CONCLUSIONS: CD in AD is a risk factor for violent behavior. As the geriatric population in the United States grows, CD in patients with AD may present more frequently in the ED, requiring proper treatment. Pharmacovigilance is necessary to minimize PIMs in geriatric/AD patients. Clinicians and other caregivers require further education to appropriately address CD in AD.

Antidepressant-selective gynecomastia.

OBJECTIVE: To describe what we believe is the first reported case of synergistic gynecomastia during treatment of depressive and anxiety disorders when sertraline was added to a stable medication regimen including duloxetine, rosuvastatin, and amlodipine. CASE SUMMARY: A 67-year-old male with major depression, dysthymia, obsessive-compulsive disorder, social anxiety, hypertension, diabetes, and hyperlipidemia presented with new-onset gynecomastia and breast tenderness. Mammography revealed bilateral gynecomastia (fibroglandular tissue posterior to the nipples bilaterally) without suspicious mass, calcification, or other abnormalities. These new symptoms developed after sertraline was added to his stable medication regimen (duloxetine, alprazolam, rosuvastatin, metoprolol, amlodipine, hydrochlorothiazide/triamterene, metformin, and sitagliptin). These symptoms were dose-dependent, with gynecomastia and breast tenderness more severe as sertraline was titrated from 25 mg/day to 50 mg/day and then to 75 mg/day. When sertraline was discontinued, gynecomastia and breast tenderness rapidly resolved. DISCUSSION: Mammoplasia and gynecomastia are associated with altered dopamine neurotransmission and/or perturbations in sexual hormones. These adverse effects may be medication induced. Selective serotonin reuptake inhibitors (sertraline), serotonin-norepinephrine reuptake inhibitors (duloxetine), rosuvastatin, and amlodipine have been reported to cause these adverse effects. This case was unique, since the patient had been on both sertraline and duloxetine previously as independent psychotropics without the development of gynecomastia. In the context of an additive drug adverse effect, the probability of sertraline as the precipitant drug was determined by both the Naranjo probability scale and the Horn drug interaction probability scale as probable. CONCLUSIONS: Gynecomastia is associated with antidepressants and other medications but is rarely addressed. Gynecomastia may be antidepressant selective or may be the result of additive adverse effects. Clinicians are advised to question patients regarding this potential adverse effect. Further education of clinicians is indicated.

Stand up for epilepsy San Diego photo-shoot: a personal odyssey.

Stigma towards epilepsy results in barriers to social integration, education, employment, and marriage, with increased divorce rates. There is a societal need to realise that many persons with epilepsy (PWE) lead normal lives and can be highly educated with effective employment. Integration of PWE into sports is therapeutic both for PWE (decreased seizure frequency, decreased comorbid conditions, and increased psychosocial skills) and society. Stand Up For Epilepsy (SUFE), overseen by the ILAE Task Force on Sports and Epilepsy, is an international project in which action photographs with PWE were taken as a means to destigmatise epilepsy. This autobiographical narrative describes how SUFE initiated effective athlete-PWE interactions with positive PWE, athlete, and parent responses. Expansion of SUFE is recommended to further destigmatise epilepsy. Participation in SUFE can serve as a personal odyssey for PWE.

BJPsych Open: a summary of growth and vision for my second innings as editor-in-chief.

As my second 5-year term as its editor-in-chief begins, it is important to review what BJPsych Open has accomplished, its areas of growth and what should be our future vision for the Journal. The keyword throughout this editorial is growth, with emphasis on growth in quality, for meaningful growth can only exist with increased quality. The original remit remains the correct long-term direction for the Journal, with the important modifier 'relevance' added to ensure quality - a general psychiatric journal with high-quality, methodologically rigorous and relevant publications, with relevance to the advancement of clinical care, patient outcomes, the scientific literature, research and policy. During this second term, I desire to expand the editorial board to fill expertise and diversity gaps; increase editorials and commentaries highlighting specific articles and timely events with psychiatric themes; focus on thematic series driven by the editorial board; and address under-represented topics.

Narrative review of the COVID-19, healthcare and healthcarers thematic series.

This review covers the thematic series of 22 papers selected from among manuscripts published by BJPsych Open concerning coronavirus disease 2019 (COVID-19) and healthcare. We report nine papers that cover concepts and epidemiology relating to the public and patients. We review 11 papers about the impact of COVID-19 on healthcare services and their staff in 15 countries. Two papers consider the psychosocial impact on staff working in mental health services in the UK. Most papers report cross-sectional analyses of data collected from convenience samples by self-reported surveys conducted at single times. They have limitations of generalisability, do not enable conclusions about diagnosis or causality, and many are likely to have attendant bias and noise. BJPsych Open published these papers to meet requirements for early indications of the mental health impact of COVID-19 on the public and on healthcare staff. They claim high prevalence of symptoms of anxiety, depression and post-traumatic stress. We contrast these findings with selected reports of studies with different methodologies published elsewhere. We emphasise the need for longitudinal clinical studies with refined sampling and methodological rigour. We identify several longitudinal research programmes; two in this series. We advocate tuning advice offered about caring for the public and healthcare staff to the realities of their circumstances and their perceptions of need in the context of findings from further longitudinal studies. We draw attention to the importance of the social, relationship and environmental circumstances of the public and healthcare staff in order to understand their distress and their risks of developing mental health disorders.

Antiepileptic drugs in the treatment of psychiatric disorders.

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

Gabapentin-induced sexual dysfunction.

Sexual dysfunction is a key adverse effect leading to medication noncompliance. Psychotropic drugs associated with sexual dysfunction include antiepileptic drugs, antidepressants, and antipsychotics. Gabapentin, frequently used off-label to treat psychiatric and pain disorders, has previously been reported to cause sexual dysfunction at a minimum total daily dose of 900 mg. This report addresses dose-dependent gabapentin-induced sexual dysfunction reaching total sexual dysfunction (loss of libido, anejaculation, anorgasmia, and impotence) at a total daily dose of only 300 mg.

Activation of suicidal ideation with adjunctive rufinamide in bipolar disorder.

Antiepileptic drugs are effective psychotropics, especially for bipolar disorder, which leads to their use off-label in treatment-refractory cases. A recent publication suggests that rufinamide may be beneficial adjunctively for bipolar disorder with comorbid psychopathology. This report addresses two negative cases with significant psychiatric adverse effects: increased depression, agitation, and activation of suicidal ideation. These findings suggest that adjunctive rufinamide may lead to increased suicidal ideation in patients with treatment-refractory bipolar disorder. Secondary to the course of severe bipolar disorder, rufinamide cannot be specifically implicated; however, clinicians should be aware of this potential significant adverse effect and monitor high-risk patients. Further studies are required to address rufinamide treatment efficacy and severity of adverse effects in patients with bipolar disorder.

Off-label gabapentin masking ictal triphasic waves: case analysis of neuropsychiatric and electrographic correlates.

Antiepileptic drugs (AEDs) are frequently used off-label for the treatment of psychiatric, pain, and other neurological disorders. Off-label AED use may confound the diagnosis for acute neuropsychiatric changes associated with delirium by fortuitously treating, or partially treating, underlying seizure disorders while masking ictal electrographic patterns on EEGs. Standard video/EEG monitoring includes weaning from AEDs to maximize ictal activity and better determine seizure focus. We report a case of off-label gabapentin use masking ictal electrographic activity, the neuropsychiatric and electrographic consequences of discontinuing gabapentin, and the therapeutic response when gabapentin was re-initiated and titrated to a total daily dose greater than that at time of admission. Weaning from AEDs with concurrent video/EEG monitoring is an important diagnostic tool in these complex cases.

Arsenic trioxide and olanzapine co-administration: case analysis.

QTc prolongation is associated with arsenic trioxide (ATO) treatment of acute promyelocytic leukemia (APL). Olanzapine was safely co-administered with ATO to treat co-morbid psychiatric diagnoses. It is important to closely monitor for drug-drug interactions and cumulative drug adverse effects in patients receiving oncology agents and psychotropics. Further research is indicated to determine risk/benefit profiles of psychotropics co-administered with ATO. In light of current limited data, co-administration of psychotropics with ATO should be reported presenting both instances wherein no interactions are noted and those with adverse effects.

Let us do better: learning lessons for recovery of healthcare professionals during and after COVID-19.

The COVID-19 pandemic emphasises the need to rethink and restructure the culture of healthcare organisations if we are to ensure the long-term well-being and mental health of healthcare provider organisations and their staff. In this paper, we recognise the high levels of stress and distress among staff of healthcare services before the COVID-19 pandemic began. We identify lessons for care of healthcare staff and illustrate the paths by which support mobilises and later deteriorates. Although this paper focuses on NHS staff in the UK, we contend that similar effects are likely in most healthcare systems.