In recent years, the growing numbers of patients seeking care for a wide range of psychiatric illnesses in the primary care setting has resulted in an increase in the number of psychotropic medications prescribed. Along with the increased utilization of psychotropic medications, considerable variability is noted in the prescribing patterns of primary care providers and psychiatrists. Because psychiatric patients also suffer from a number of additional medical comorbidities, the increased utilization of psychotropic medications presents an elevated risk of clinically significant drug interactions in these patients. While life-threatening drug interactions are rare, clinically significant drug interactions impacting drug response or appearance of serious adverse drug reactions have been documented and can impact long-term outcomes. Additionally, the impact of genetic variability on the psychotropic drug’s pharmacodynamics and/or pharmacokinetics may further complicate drug therapy. Increased awareness of clinically relevant psychotropic drug interactions can aid clinicians to achieve optimal therapeutic outcomes in patients in the primary care setting.
psychotropic; drug-drug interaction; primary care; antidepressant; antipsychotic; mood stabilizer; cytochrome P450 (CYP450); pharmacogenetic
The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.
Eating disorders; Empirically supported treatment; Dissemination; Implementation; Scalable training
After decades of defining which behavioral treatments are effective for treating addictions, the focus has shifted to exploring how these treatments work, how best to disseminate and implement them in the community, and what underlying factors can be manipulated in order to increase the rates of treatment success. These pursuits have led to advances in our understanding of the mechanisms of treatment effects, the incorporation of technology into the delivery of current treatments and development of novel applications to support relapse prevention, as well as the inclusion of neurocognitive approaches to target the automatic and higher-order processes underlying addictive behaviors. Although such advances have the promise of leading to better treatments for more individuals, there is still much work required for these promises to be realized. The following review will highlight some of these recent developments and provide a glimpse into the future of behavioral treatments.
Behavioral treatment; Substance use disorders; Mechanisms; Evidenced-based therapy; Contingency management; Cognitive behavioral therapy; Brief interventions; Mindfulness-based relapse prevention; Technology-based interventions; Neuroscience-based interventions; Neurocognitive function; Cognitive enhancement
The importance of biomarkers to many branches of medicine is illustrated by their utility in diagnosis and monitoring treatment response and outcome. There is much enthusiasm in the field of mood disorders on the emergence of clinically relevant biomarkers with several potential targets. While there are generally accepted criteria to establish a biomarker, such approaches are premature for our field as we acquire evidence on the most relevant candidates. A number of components of the inflammatory pathway are supported by published data together with an increasing focus on brain derived neurotrophic factors (BDNF). These factors may have measurable impacts on endothelial function which may be particularly amenable to study in clinical samples. The adolescent population is a key focus since identifying biomarkers before the onset of comorbid medical conditions and which may help direct early intervention seem especially promising. A systematic approach to biomarker development in mood disorders is clearly warranted.
Bipolar disorder; biomarkers; inflammation; inflammatory; neurotrophic; brain-derived neurotrophic factor; cardiovascular; endothelium; endothelial function
A recent publication focused on biomarkers of future suicidal behaviors identifies several genes expressed in high-risk states among four samples. We discuss the implications of this study as well as the current state of research regarding biomarkers of suicidal behavior.
suicidal behavior; prediction; biomarkers
In contrast to the association of insomnia with mental health, its association with physical health has remained largely unexplored until recently. Based on findings that insomnia with objective short sleep duration is associated with activation of both limbs of the stress system and other indices of physiological hyperarousal, which should affect adversely physical and mental health, we have recently demonstrated that this insomnia phenotype is associated with a significant risk of cardiometabolic and neurocognitive morbidity and mortality. In contrast, insomnia with normal sleep duration is associated with sleep misperception and cognitive-emotional arousal but not with signs of physiological hyperarousal or cardiometabolic or neurocognitive morbidity. Interestingly, both insomnia phenotypes are associated with mental health, although most likely through different pathophysiological mechanisms. We propose that objective measures of sleep duration may become part of the routine evaluation and diagnosis of insomnia and that these two insomnia phenotypes may respond differentially to biological vs. psychological treatments.
Cardiometabolic morbidity; Insomnia; Mortality; Neurocognitive impairment; Physiological hyperarousal; Polysomnography; Poor sleep; Psychiatric morbidity; Short sleep duration; Sleep disorders; Psychiatry
Recent reports of antipsychotic medication use in pediatric populations describe
large increases in rates of use. Much interest in the increasing use has focused on
potentially inappropriate prescribing for non FDA-approved uses and use amongst youth with
no mental health diagnosis. Different studies of antipsychotic use have used different
time periods, geographic and insurance populations of youth, and aggregations of
diagnoses. We review recent estimates of use and comment on the similarities and
dissimilarities in rates of use. We also report new data obtained on 11 Health Maintenance
Organizations that are members of the Mental Health Research Network in order to update
and extend the knowledge base on use by diagnostic indication. Results indicate that most
use in pediatric populations is for disruptive behaviors and not psychotic disorders.
Differences in estimates are likely a function of differences in methodology; however,
there is remarkable consistency in estimates of use by diagnosis.
Antipsychotics; Children; Adolescents; Medicaid; Mental Health Research Network; Off-label; MarketScan; IMS Health; NAMCS; NDTI; NCS-A
Bereavement is a common experience in adults age 60 and older. Loss of a loved one usually leads to acute grief characterized by yearning and longing, decreased interest in ongoing activities, and frequent thoughts of the deceased. For most, acute grief naturally evolves into a state of integrated grief, where the bereaved is able to reengage with everyday activities and find interest or pleasure. About 7% of bereaved older adults, however, will develop the mental health condition of Complicated Grief (CG). In CG, the movement from acute to integrated grief is derailed, and grief symptoms remain severe and impairing. This article reviews recent publications on the diagnosis of CG, risk factors for the condition, and evidenced-based treatments for CG. Greater attention to complicated grief detection and treatment in older adults is needed.
Complicated grief; Bereavement; Older adults; Grief; Loss; Attachment theory; Symptoms; Treatment; Psychiatry
Over two-thirds of the 11.4 million cancer survivors in the United States can expect long-term survival, with many others living with cancer as a chronic disease controlled by ongoing therapy. Behavioral co-morbidities often arise during treatment and persist long-term to complicate survival and reduce quality of life. This review focuses on depression and insomnia with an emphasis on understanding the role of cancer-specific factors and their contribution to the prevalence of these behavioral co-morbidities in cancer patients following cancer diagnosis and treatment. The clinical significance of depression and insomnia for cancer patients is further stressed by epidemiological observations that link depression and insomnia to cancer morbidity and mortality risk.
Depression; Insomnia; Cancer; Sleep disturbance; Inflammation; Fatigue; Anxiety; Depressive symptoms; Major depression; Psychiatry
Stimulant–related disorders (SRD) continue to be an important public health problem for which there are presently no approved pharmacotherapies. Although behavioral interventions provide some benefit response varies. The development of novel and effective pharmacotherapies continues to be a research priority. Understanding neural mechanisms critical to the action of stimulants has helped reveal several potential pharmacotherapies that have already shown promise in controlled clinical trials. Common to some of these medications is the ability to reverse neural deficits in individuals with SRD. Results from thoroughly conducted clinical trials continue to broaden our knowledge increasing the possibility of soon developing effective pharmacotherapies for SRD.
Pharmacotherapy; Cocaine; Methamphetamine; Amphetamine; Stimulants; Substance use disorders; Stimulant use disorder; Substance related disorders; Amphetamine type substance use disorder; Dependence; Addiction; Dopamine; Norepinephrine; Clinical trial
The large number of individuals with substance use disorders involved in the nation’s criminal justice system (CJS) represents a unique opportunity, as well as challenges, in addressing the dual concerns of public safety and public health. Unfortunately, a low proportion of those who could benefit from treatment actually receive it while involved in the CJS. This article presents a review of recent research on the effectiveness of major substance abuse treatment interventions used at different possible linkage points during criminal justice case processing, including diversion, jail, prison, and community supervision. This is followed by a discussion of key research and practice issues, including low rates of treatment access and under-utilization of medication-assisted treatment. Concluding comments discuss principles of effective treatment for offenders and identify key gaps in research and practice that need to be addressed to improve and expand provision of effective treatment for offenders.
Criminal justice; Drug treatment; Substance abuse; Offenders; Implementation; Psychiatry
Alcoholism has a substantial heritability yet the detection of specific genetic influences has largely proved elusive. The strongest findings are with genes encoding alcohol metabolizing enzymes. A few candidate genes such as GABRA2 have shown robust associations with alcoholism. Moreover, it has become apparent that variants in stress-related genes such as CRHR1, may only confer risk in individuals exposed to trauma, particularly in early life. Over the past decade there have been tremendous advances in large scale SNP genotyping technologies allowing for genome-wide associations studies (GWAS). As a result, it is now recognized that genetic risk for alcoholism is likely to be due to common variants in very many genes, each of small effect, although rare variants with large effects might also play a role. This has resulted in a paradigm shift away from gene centric studies towards analyses of gene interactions and gene networks within biologically relevant pathways.
Alcohol use disorders; ALDH2; ADH1B; GABRA2; GABRG1; AUTS2; SGIP1; 5-HTTLPR; HTR2B; HTR3B; HTR3A; CRHR1; MAOA; CHD13; Childhood trauma; Gene–environment interactions; Flushing response; Addictions array; GWAS; Exome sequencing; RNA-Seq; GSA; COGA; NESARC; Pharmacogenetics
Therapists and patients enjoy and benefit from interventions that use electronic games (EG) in health care and mental health settings, with a variety of diagnoses and therapeutic goals. We reviewed the use of electronic games designed specifically for a therapeutic purpose, electronic games for psychotherapy (EGP), also called serious games, and commercially produced games used as an adjunct to psychotherapy, electronic games for entertainment (EGE). Recent research on the benefits of EG in rehabilitation settings, EGP, and EGE indicates that electronic methods are often equivalent to more traditional treatments and may be more enjoyable or acceptable, at least to some consumers. Methodological concerns include the lack of randomized controlled trials (RCT) for many applications. Suggestions are offered for using EG in therapeutic practice.
Psychotherapy; Electronic games; Serious games; Cognitive behavior therapy; Group therapy
Online mental health support forums are becoming increasingly popular and there is evidence that they are useful: particularly for providing anonymous support and filling information gaps. However, there are also very real concerns about negative outcomes for users. One online mental health service, Big White Wall, manages these risks and supports its members through the provision of 24 hour professional moderation. Comparison of Big White Wall’s member population with the population of one London borough shows a diverse user group, but members are more likely to be female, and aged 25 to 34, or unemployed.
Social media; Online social networking tools; Online self help forums; Online communication; Bipolar disorders; Depression; Online therapy; Suicide; Self-harm; Pro-anorexia
Insomnia is a prevalent disorder that greatly impacts military personnel, especially those deployed in support of combat efforts. Deployment-related stressors like combat exposure, mild traumatic brain injury (mTBI) irregular sleep-wake schedules, and adjustment to the return home all contribute to insomnia. However, insomnia can also exacerbate the deployment experience and is a risk factor for traumatic stress reactions such as PTSD, depression, and suicide. Military personnel with mTBI are significantly impacted by insomnia; the majority experience sleep disruption and this can impede recovery and rehabilitation. As more service members return home from deployment, treatment is vital to reduce the impact of insomnia. Preliminary outcome data, showing positive results for reduction of sleep disruption, has been found with treatments such as combined cognitive behavioral treatment of insomnia (CBTI) and imagery rehearsal therapy (IRT), preference-based interventions, as well as efforts to broadly disseminate CBTI. The recent literature on the impact and treatment of deployment-related insomnia is reviewed.
insomnia; comorbid insomnia; military personnel; veterans; PTSD; depression; anxiety; traumatic brain injury; suicide; psychotherapy; pharmacotherapy; sleep disorders; psychiatry
The eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) are severe psychiatric disorders with high mortality. Our knowledge about the neurobiology of eating disorders is very limited, and the question remains whether alterations in brain structure or function in eating disorders are state related, remnants of the illness or premorbid traits. The brain reward system is a relatively well-characterized brain circuitry that plays a central role in the drive to eat and individuals with current or past eating disorders showed alterations in those pathways compared to controls. Here we propose that structural and functional alterations in the insula and frontal cortex, including orbitofrontal and cingulate regions, areas that contribute to reward and anxiety processing, could predispose to developing an eating disorder and that adaptive changes in those circuits in response to malnutrition or repeated binge eating and purging could further promote illness behavior, hinder recovery and contribute to relapse.
Eating disorders; ED; Anorexia nervosa; AN; Bulimia nervosa; BN; Brain imaging; Reward; Anxiety; Circuitry; State; Trait; Dopamine; DSM-5; Psychiatry
Patients with co-morbidity and multi-morbidity have worse outcomes and greater healthcare needs. Co-morbid depression and other long-term conditions present health services with challenges in delivering effective care for patients. We provide some recent evidence from the literature to support the need for collaborative care, illustrated by practical examples of how to deliver a collaborative/integrated care continuum by presenting data collected between 2011 and 2012 from a London Borough clinical improvement programme that compared co-morbid diagnosis of depression and other long-term conditions and Accident and Emergency use. We have provided some practical steps for developing collaborative care within primary care and suggest that primary care family practices should adopt closer collaboration with other services in order to improve clinical outcomes and cost-effectiveness.
Collaborative care; Integrated care; Long-term medical conditions (LTC); Depression; Co-morbidity; Complexity
Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has well-described rapid antidepressant effects in clinical studies of individuals with treatment-resistant major depressive disorder (MDD). Preclinical studies investigating the effects of ketamine on brain-derived neurotrophic factor (BDNF) and on sleep slow wave activity (SWA) support its use as a prototype for investigating the neuroplastic mechanisms presumably involved in the mechanism of rapidly acting antidepressants. This review discusses human EEG slow wave sleep parameters and plasma BDNF as central and peripheral surrogate markers of plasticity, and their use in assessing ketamine’s effects. Acutely, ketamine elevates BDNF levels, as well as early night SWA and high-amplitude slow waves; each of these measures correlates with change in mood in depressed patients who respond to ketamine. The slow wave effects are limited to the first night post-infusion, suggesting that their increase is part of an early cascade of events triggering improved mood. Increased total sleep and decreased waking occur during the first and second night post infusion, suggesting that these measures are associated with the enduring treatment response observed with ketamine.
Ketamine; NMDA antagonist; Sleep; Major depressive disorder; MDD; Synaptic plasticity; Slow wave sleep; Slow wave activity; SWA; AMPA; Mood; Rapid antidepressant response; Neurotrophic factors; Brain-derived neurotrophic factor; BDNF; Treatment-resistant depression; Bipolar depression; Sleep disorders; Psychiatry
Depression and cognitive disorders, including dementia and mild cognitive impairment, are common in the elderly. Depression is also a common feature of cognitive impairment although the symptoms of depression in cognitive impairment differ from depression without cognitive impairment. Pre-morbid depression approximately doubles the risk of subsequent dementia. There are two predominant, though not mutually exclusive, constructs linking pre-morbid depression to subsequent cognitive impairment: Alzheimer’s pathology and the vascular depression hypothesis. When evaluating a patient with depression and cognitive impairment, it is important to obtain caregiver input and to evaluate for alternative etiologies for depressive symptoms such as delirium. We recommend a sequential approach to the treatment of depression in dementia patients: (1) a period of watchful waiting for milder symptoms, (2) psychosocial treatment program, (3) a medication trial for more severe symptoms or failure of psychosocial interventions, and (4) possible ECT for refractory symptoms.
Dementia; Depression; Alzheimer’s disease; AD; Mild cognitive impairment; MCI; Neuropsychiatric symptoms; Genetics; Neuroimaging; Neurotrophins; Pharmacologic treatments; Electroconvulsive therapy; ECT; Geriatric disorders; Psychiatry
Depressive disorders are among the most common ailments affecting humankind and some of the world’s leading causes of medical disability. Despite being common, disabling and a major public health problem, the etiology of depression is unknown. Indeed, investigators have suggested that the causes of depression are multiple and multi-factorial. With these considerations in mind, in this article we examine the hypothesis that our inability to identify the causes of depressive disorders is because depression is a nonspecific epiphenomenon of brain injury or insult arising through multiple pathways.
Depression; Depressive symptoms; Comorbid psychiatric disorders; Comorbid neurological and medical disorders; Neurobiology of depression; Brain injury; Risk factors; Treatment; Mood disorders; Psychiatry
Insomnia has been established as a risk factor for depression and mental illness for decades, but a growing body of evidence has recently exposed insomnia to be an independent risk factor for suicide that encompasses all age ranges. This discovery has invigorated investigation to elucidate the relationship between insomnia and suicide, and over 20 studies reinforcing this association in adults have been published since 2010 alone. This article analyzes relevant research and emphasizes studies published within the last three years with the intent of proposing theoretical mechanisms explaining the link between suicide and insomnia. These mechanisms may then be used as targets for future investigation of treatment.
Sleep; Depression; Suicide; Risk factors; Insomnia; Hopelessness; Nightmares; Mechanisms; Dysfunctional belief about sleep; Decision making; Serotonin; Hyperarousal; Circadian rhythm of suicide; Psychiatry
Mental health law; Schizophrenia; Organic brain disorders; Decision making; Safety; Psychiatry
Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims under healthcare reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.
Mental health; Co-occurring conditions; Primary care; PCP; Integrated care; Collaborative care; Chronic Care Model; CCM; Accountable care organization; ACO; Patient centered medical home; Screening; Diagnosis; Treatment; Access; Mental health services; Psychiatry; Bipolar disorder; Mood disorder; Substance abuse disorder; Anxiety disorder; Serious mental illness
Cyclical mood disorders characterized by shifting affective states include bipolar disorder, seasonal affective disorder, and premenstrual syndrome/premenstrual dysphoric disorder. In this article, we explore the relationship between these disorders and bring the reader up to date on the advances made in the past year in understanding the relationship between bipolar disorder, seasonality, and premenstrual symptoms.
Bipolar disorder; Seasonality; Seasonal affective disorder; Women's health; Premenstrual syndrome; Premenstrual dysphoric disorder; Melatonin
Guidelines regarding the treatment of depression during pregnancy were recently published by the American Psychiatric Association and the American College of Obstetricians and Gynecologists. We provide a commentary on these guidelines.
Depression; Pregnancy; Treatment; Guidelines