This review of the relationship between idiopathic hypersomnia and psychiatric disorders describes considerations in recognizing and managing complaints of excessive daytime sleepiness (EDS) in patients in psychiatric cl...This review of the relationship between idiopathic hypersomnia and psychiatric disorders describes considerations in recognizing and managing complaints of excessive daytime sleepiness (EDS) in patients in psychiatric clinical practice. Terms including "idiopathic hypersomnia" and "psychiatric" were used to search PubMed and Embase for English-language publications of human studies from inception to July 2024. Articles were manually screened for relevance to idiopathic hypersomnia pathophysiology, diagnosis, and treatment and EDS in psychiatric populations. Reference lists of identified articles were manually searched for additional relevant publications. Formal data charting was not performed. A total of 119 articles were included. Idiopathic hypersomnia is a central sleep disorder with the primary complaint of EDS, diagnosed prevalence of 0.037%, and estimated population prevalence up to 1.5%. Other prominent symptoms include sleep inertia, long sleep time, autonomic nervous system dysfunction, brain fog, and cognitive complaints. A high proportion of patients with idiopathic hypersomnia experience psychiatric comorbidities, including mood disorders and attention-deficit/hyperactivity disorder. Assessing individuals with psychiatric disorders and complaints of hypersomnolence can pose diagnostic challenges. Diagnosis and treatment may be complicated by possible exacerbation of EDS by psychiatric medications and, conversely, exacerbation of psychiatric symptoms by idiopathic hypersomnia treatments. Psychiatric clinicians are more likely to encounter patients with idiopathic hypersomnia than would be expected given its overall prevalence due to increased rate of psychiatric symptom comorbidity in this population. Recognizing and managing idiopathic hypersomnia for individuals with psychiatric conditions may lead to improvements in treatment outcome for patients.
The associations between peripheral vestibular disorders (PVDs)-specifically Meniere's disease, benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and unspecified PVD-and dementia risk are unclear. By usi...The associations between peripheral vestibular disorders (PVDs)-specifically Meniere's disease, benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and unspecified PVD-and dementia risk are unclear. By using data from the Taiwan National Health Insurance Research Database, this study included 70,363 patients aged ≥45 years with PVD between 1998 and 2011. An age-matched control group of 70,363 individuals without PVD was also established. All the included participants were followed up from the time of enrollment until the end of 2013 to assess the risk of dementia-related conditions, including Alzheimer's disease (AD), vascular dementia, and unspecified dementia. Cox proportional hazards regression models, adjusted for demographic characteristics and psychiatric comorbidities, revealed that patients with PVD exhibited a significantly elevated risk of any form of dementia during the follow-up period (hazard ratio [HR] = 1.83, 95% CI, 1.69-1.97) compared with the control group. Notably, patients with BPPV exhibited the highest risk of AD (HR = 3.14, 95% CI, 2.35-4.19), followed by Meniere's disease (HR= 2.79, 95% CI, 2.17-3.59) and vestibular neuritis (HR = 2.66, 95% CI, 2.11-3.35). PVDs are a risk factor for dementia, regardless of psychiatric comorbidities. Further research is warranted to elucidate the pathophysiological mechanisms underlying the association between PVDs and dementia.
Ketamine is an increasingly popular tool for the treatment of psychiatric disorders. Initially available in controlled studies at academic institutions, it is now being offered widely in the community, but little is know...Ketamine is an increasingly popular tool for the treatment of psychiatric disorders. Initially available in controlled studies at academic institutions, it is now being offered widely in the community, but little is known about how treatment is actually being delivered and if there are undetermined safety concerns. The aim of this study is to assess ketamine prescribing practices among clinics across the United States. An online survey was sent to all community-based ketamine clinics with publicly available email addresses collected from 4 ketamine clinic databases (n = 484) between September and November 2023. Public ketamine clinic websites (n = 473) were also reviewed for information regarding the credentials of prescribers in June 2024. A total of 126 (26% response rate) of the clinics responded to the survey request, and 119 were included in analyses. All included respondents (100%) report utilizing ketamine for treatment-resistant depression, with many also prescribing ketamine for treatment naive (72.3%), bipolar (78.9%), and subclinical depression (59.7%) in addition to nondepressive conditions at significant rates. Over 80% of clinics utilize maintenance ketamine treatment, with a substantial portion doing so for prolonged periods. A variety of ketamine formulations are regularly prescribed, and over 40% of clinics provide ketamine for at-home use. Based on website review, fewer than 30% of ketamine clinics reviewed are run by psychiatric physicians and over 25% are run by nonphysician providers. There is significant variability in ketamine treatment in the community including indications for therapy, duration of treatment courses, formulation of ketamine prescribed, and setting of use. There is a need for increased oversight and more specific practice guidelines to ensure ketamine is being used safely, appropriately, and effectively.
Adolescents with a history of depression are at a high risk of recurrent suicidal ideation (SI) and attempts. To enhance risk prediction, we examined the association of individual residual symptoms of depression to suici...Adolescents with a history of depression are at a high risk of recurrent suicidal ideation (SI) and attempts. To enhance risk prediction, we examined the association of individual residual symptoms of depression to suicidal events (suicide attempts, emergency room visits, and inpatient hospitalization) 6 months after discharge from treatment. A retrospective post hoc analysis of patients aged 12-18 years examined depression symptoms at admission and discharge. Patients in an intensive treatment program (December 2013-September 2022) received psychosocial and medication management. The Quick Inventory of Depressive Symptomatology, Adolescent Version, assessed depressive symptoms at entry and discharge (n 1,029), and suicidal events postdischarge were tracked (n 736). Analysis of variance analyzed symptom severity changes, and logistic regression used residual symptoms and controls (age, sex, previous attempt, and nonsuicidal self-injury) to predict suicidal events. Sad mood, view of self, and SI improved the most, while mood and sleep disturbance were most prevalent at discharge. Sleep disturbance (odds ratio [OR] = 2.09, 95% CI, 1.24-3.53, < .01) and SI (OR = 2.22, 95% CI, 1.26-3.90, < .01) were the strongest predictors of hospitalization, and, together with anhedonia (OR = 1.40, 95% CI, 1.02-1.93, < .05), they consistently predicted suicidal events during follow-up. Residual sleep disturbance, SI, and anhedonia after treatment indicated risk post discharge and might inform continuity of care planning. These findings encourage further research about the relationships between specific residual symptoms and suicidal events.
Flanagan JC, Nietert PJ, McCrady BS
… +4 more, Sellers S, Yates-Johnson A, Giff ST, Forkus SR
J Clin Psychiatry
· 2025 May · PMID 40392716
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This study examined the efficacy of intranasal oxytocin (40 IU), compared to matching placebo (saline), when combined with Alcohol Behavioral Couple Therapy (ABCT) for the treatment of alcohol use disorder (AUD). This 1...This study examined the efficacy of intranasal oxytocin (40 IU), compared to matching placebo (saline), when combined with Alcohol Behavioral Couple Therapy (ABCT) for the treatment of alcohol use disorder (AUD). This 12-week clinical trial (2018-2024) utilized a double-blind, randomized, placebo-controlled design. Enrollment occurred from May 2019 to April 2023. Participants were romantic couples (N = 96 dyads; n = 49 oxytocin, n = 47 placebo) consisting of an identified patient (IP) with current AUD per and their partner. Dyads in which both partners had AUD were eligible, and both partners in each dyad were randomized to the same drug condition (ie, placebo or oxytocin). Participants were observed in their medication self-administration 30 minutes prior to ABCT therapy sessions. Primary outcome measures were alcohol consumption (percent days drinking and percent days heavy drinking; Time Line Follow-Back) and relationship functioning (Dyadic Adjustment Scale-Short Form). All IPs and 50% of partners met diagnostic criteria for AUD; 62 IPs (64.5%) met criteria for severe AUD. Findings from the intent-to-treat analyses indicate that IPs and partners in both conditions evidenced substantial improvements in alcohol consumption and alcohol problem severity but not relationship functioning. No group differences emerged in alcohol consumption, alcohol problem severity, or relationship functioning at end of treatment. Participants completed an average of 10.2 ABCT sessions (SD = 3.5). There were no group differences in the number of medication doses administered or adverse events. Oxytocin was safe and tolerable but did not provide additional benefit beyond ABCT at the end of treatment. Alternative strategies are necessary to understand oxytocin's potential to facilitate different domains of AUD recovery. ClinicalTrials.gov identifier: NCT03046836.
Greene AL, Levin-Aspenson HF, Feltman S
… +7 more, Long S, Moore M, Ruggero C, Clouston SAP, Bromet EJ, Luft BJ, Kotov R
J Clin Psychiatry
· 2025 May · PMID 40392715
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Posttraumatic stress disorder (PTSD) is defined by the assumption that qualifying traumatic events lead to a syndrome distinct from other internalizing disorders, while stressful life events play a prominent role in etio...Posttraumatic stress disorder (PTSD) is defined by the assumption that qualifying traumatic events lead to a syndrome distinct from other internalizing disorders, while stressful life events play a prominent role in etiologic theories of major depressive disorder (MDD). We examined whether the environmental etiology of PTSD and MDD are distinct by evaluating the relative contributions of traumatic and stressful life events to both conditions. Harmful alcohol use and physical limitations served as noninternalizing comparators expected to show weaker associations with environmental factors. Longitudinal cohort study of World Trade Center disaster responders who completed annual assessments of mental health and physical functioning from July 1, 2002, to December 31, 2020. Psychiatric diagnoses were ascertained in clinical interviews. Multivariate regression and multilevel modeling quantified the percentage of variance in psychopathology and physical limitations attributable to trauma versus life stress. 11,153 responders (mean age on September 11, 2001: 37.5 years; 91% male) completed 61,244 visits. The combined environmental effect of 9/11-trauma and life stress on PTSD and MDD was nearly identical (14.3% and 14.8% of between person variability), but much weaker for alcohol use and physical limitations (0.8% and 9.1%). Life stress explained the most variance in all diagnoses and symptoms across longitudinal and cross-sectional analytic strategies. In the longest study to date coexamining the environmental etiology of PTSD and MDD, trauma and life stress contributed to both conditions. Considering a spectrum of exposures from stressful life events to trauma and integrating knowledge across internalizing conditions may advance understanding and treatment of stress related psychopathology.
Evidence-based psychotherapies (EBPs) have revolutionized posttraumatic stress disorder (PTSD) treatment, but research suggests more limited engagement and effectiveness in naturalistic settings, relative to randomized c...Evidence-based psychotherapies (EBPs) have revolutionized posttraumatic stress disorder (PTSD) treatment, but research suggests more limited engagement and effectiveness in naturalistic settings, relative to randomized controlled trials. Some clinics therefore offer additional evidence-informed options (eg, Skills Training in Affective and Interpersonal Regulation, Acceptance and Commitment Therapy, and Mindfulness Based Stress Reduction), but little research has compared outcomes within a naturalistic setting. We completed a retrospective chart review of 480 Veterans presenting to a trauma-focused clinic within a Veterans Affairs Medical Center during 2019. All variables were extracted from the VA medical record. We used logistic or linear regression models, χ, and analysis of variance to examine treatment outcomes differences. In the year following intake, 71.87% (n = 345) engaged with treatment, and 45.42% (n = 218) received an adequate dose of at least 1 treatment; of those who engaged with treatment, 63.19% received an adequate dose of at least 1 treatment. Veterans attended an average of 8.40 sessions and 1.39 episodes of care. At the person level rates of engagement and receipt of an adequate dose did not differ by treatment type (odds ratio [OR] = 1.52, .17; OR= 1.52, .17, respectively). However, those who planned to and/or received at least 1 EBP attended a significantly greater number of total sessions (11.82) relative to those that planned to and/or received evidence-informed psychotherapy (EIP; 7.31; 1.69, .04). Within episodes of care rates of engagement did not differ by treatment type (OR = 1.39, = .14). However, those who planned to and/or received EBP were more likely to receive an adequate dose of treatment (OR = 1.44, = .04) and attended a significantly greater number of sessions per episode (7.60), relative to EIP (6.00). These data highlight differences in treatment engagement and receipt of an adequate dose of treatment based on intervention-level factors within an active PTSD specialty clinic, which can aid decision-making for patients and providers. Future research is needed to investigate predictors of treatment engagement and outcomes.
Hundreds of genes and more than a hundred environmental exposures have been identified as potential causes, mediators, or markers of risk for autism spectrum disorder (ASD). The findings for the environmental exposures,...Hundreds of genes and more than a hundred environmental exposures have been identified as potential causes, mediators, or markers of risk for autism spectrum disorder (ASD). The findings for the environmental exposures, almost all occurring during pregnancy, have emerged from regression analyses in observational studies. The risk estimates are most often presented as odds ratios (ORs), sometimes as hazard ratios (HRs), and rarely as relative risks. This article uses gestational exposure to antidepressant drugs and risk of ASD in offspring as a background to explain how estimates of ASD risk in observational studies are commonly interpreted and why and when the usual interpretations are wrong, often very wrong. The article provides discussions on crude and adjusted estimates, ORs and HRs, individual studies and meta-analyses, strategies that help address confounding by unmeasured and unknown variables, and a detailed discussion on the imprecision of the numerical value of the adjusted estimate. The article explains how the value of an OR is not set in stone; different procedures and approaches in analysis of the same data result in different OR values. The article also explains how to evaluate an individual patient's risk when multiple risk factors are present that may or may not be independent of each other. Finally, the article suggests the presence of an elephant in the room: risk factors that, though independent, may saturate mechanisms that mediate the outcome; so, when simultaneously present, their individual ORs may suggest falsely lower values of risk. This suggestion could explain why ASD is uncommon in the population although the risk factors for ASD are common and many. It is important to be aware of the issues considered in this article when attempting to understand the field, counsel patients, communicate research findings to peers and the public, and frame policy.
Antidepressants are commonly prescribed, yet understanding of consequences for cardiovascular disease (CVD) risk is less well-developed. We examined associations of antidepressants (selective serotonin reuptake inhibitor...Antidepressants are commonly prescribed, yet understanding of consequences for cardiovascular disease (CVD) risk is less well-developed. We examined associations of antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], other antidepressants) with incident CVD in women Veterans, a population with a high psychiatric and CVD risk burden. Using Veterans Health Administration (VHA) electronic health records, we identified women Veterans who were VHA patients from January 1, 2000, to December 31, 2019. Exclusion criteria included <12 months of baseline data before index visit, prior CVD or antidepressant prescription, and no encounters after index visit. Antidepressant prescriptions were documented in pharmacy data. Our primary outcome was an incident CVD composite, comprising first-onset ischemic heart disease, stroke, atrial fibrillation/flutter, heart failure/ cardiomyopathy, and pulmonary hypertension based on diagnostic codes. Women Veterans (N = 609,546) had a mean age of 41.3 years. During mean follow-up of 8.8 years, 40.1% of women were prescribed SSRIs, 18.2% SNRIs, and 38.6% other antidepressants; 9.2% developed CVD. Marginal structural modeling was used to de-confound associations of antidepressants with incident CVD, accounting for demographics, VHA engagement, traditional CVD risk factors, and psychiatric disorders. SSRIs, SNRIs, and other antidepressants (vs no antidepressants) were associated with lower incidence of the CVD composite, as well as ischemic heart disease and stroke (relative risk: 0.27-0.76). Additionally, the inverse association between antidepressants and CVD was larger for women with major depressive disorder, posttraumatic stress disorder, and anxiety disorders. As antidepressants are widely prescribed in the VHA and beyond, these results are encouraging for patients receiving this care.
To provide recommendations regarding the critical elements of the assessment package in treatment-resistant depression (TRD) consultation programs. This is a complementary manuscript to Part I, which discusses practical...To provide recommendations regarding the critical elements of the assessment package in treatment-resistant depression (TRD) consultation programs. This is a complementary manuscript to Part I, which discusses practical and logistical considerations for developing and sustaining a subspecialized TRD consultation program. A group of 12 clinicians, researchers, administrators, and patient advocates from the National Network of Depression Centers (NNDC) TRD Task Group. The recommendations are based on expert opinion. This consensus statement reflects the effort of the NNDC's TRD Task Group to reach agreement on a set of principles that those interested in establishing new consultation programs could use to guide their effort and a set of recommendations that could serve as a basis for future empirical work. Each member of the NNDC TRD Task Group provided a written description of the procedures used at their home institution, which were used during a day-long forum to achieve consensus on recommendations for each component of a TRD consultation program. Subgroups were formed to draft recommendations, and points of disagreement were resolved at subsequent meetings of the full task group. We describe consensus recommendations regarding the goals of a TRD consultation, which include establishing the primary diagnosis and comorbidities, clarifying medical and psychiatric symptoms, identifying goals, documenting treatment history, identifying treatment barriers, and developing actionable treatment recommendations. We detail important components of the consultation evaluation process, the assessment tools to consider in establishing a TRD consultation program, and the qualifications of providers.
Efficacious treatments for binge-eating disorder (BED) have been identified, but research is lacking regarding patients' treatment preferences and their effects on outcomes. We investigated the frequency and correlates o...Efficacious treatments for binge-eating disorder (BED) have been identified, but research is lacking regarding patients' treatment preferences and their effects on outcomes. We investigated the frequency and correlates of patients' preferences for 2 distinct BED treatments-cognitive behavioral therapy (CBT) and lisdexamfetamine (LDX)-and whether preferences predicted and/or moderated outcomes. In a randomized controlled trial (performed March 2019 to September 2023) testing CBT and LDX for - defined BED, 102 participants indicated their preference after treatments were described and prior to beginning treatment. Treatment was randomly assigned (not influenced by preferences). Independent assessors, blinded to treatments and to patients' treatment preferences, performed outcome assessments. 43.1% (44/102) preferred LDX, 23.5% (24/102) preferred CBT, and 33.3% (34/102) reported no preference. Treatment preference was not significantly associated with any sociodemographic or baseline clinical characteristics. Logistic regression models (for binge-eating remission and attaining ≥5% weight loss) and mixed models (for changes in binge-eating frequency, weight, eating disorder psychopathology, and depression) testing main effects of treatments, main effects of treatment preferences, and their interaction effects converged. No significant interaction effects between treatment and treatment preferences were observed. In this study comparing CBT and LDX treatments for BED in patients with obesity, participants' preferences for treatments were not associated with their sociodemographic or clinical characteristics and did not moderate treatment outcomes of these 2 effective interventions. Implications for clinical practice and future research are discussed. ClinicalTrials.gov identifier: NCT03924193.
Atopic dermatitis (AD) is associated with an increased risk of mental illness. However, few studies have explored the association between AD and suicidal risk. This study aimed to investigate the risk of suicide attempts...Atopic dermatitis (AD) is associated with an increased risk of mental illness. However, few studies have explored the association between AD and suicidal risk. This study aimed to investigate the risk of suicide attempts in patients with AD. Between 1997-2013, 5,169 patients with AD and 20,676 controls (1:4) matched according to age, sex, socioeconomic status, and selected comorbidities were enrolled from the Taiwan's National Health Insurance Research Database to analyze the risk of suicide attempt. Individuals with AD were found to have an elevated risk of suicide attempts, with an adjusted hazard ratio of 3.44 (95% CI, 1.83-6.46), compared to the control group. In the stratification analysis, the risk of suicide remained significantly higher in patients with AD of younger age, female sex, and those with cumulative systemic corticosteroid use for <30 days. Dermatologists must recognize the potential increased suicidal risk in patients with AD, especially in vulnerable groups and those with certain comorbidities. Furthermore, patients with mild AD did not have a reduced suicidal risk.
To compare the effectiveness of vortioxetine versus escitalopram and sertraline as a treatment in individuals with major depressive disorder (MDD) and post-COVID syndrome (PCS). This is a prospective, open-label, compar...To compare the effectiveness of vortioxetine versus escitalopram and sertraline as a treatment in individuals with major depressive disorder (MDD) and post-COVID syndrome (PCS). This is a prospective, open-label, comparative effectiveness study in individuals with new-onset MDD as PCS outcome. The study was carried out in 1 clinical site. Individuals who had a history of confirmed SARS-CoV 2 infection, who met World Health Organization-defined criteria for PCS, and who met new-onset of MDD criteria according to were included. Participants that were eligible were assigned to receive vortioxetine at 10-20 mg/d, escitalopram 10-20 mg/d, or sertraline 50-200 mg/d over 8 weeks. The primary and secondary outcomes were changes from baseline to end point in Digital Symbol Substitution Test (DSST) and Montgomery-Asberg Depression Rating Scale (MADRS) or Patient Reported Outcome Measurement Information System Fatigue Short Form 7a (PROMIS 7a), respectively. Data were collected during January 2022 and December 2023. 140 participants were assigned to received vortioxetine (n = 70), escitalopram (n = 36), or sertraline (n = 34). Participants assigned to vortioxetine exhibited significant changes in DSST scores from baseline to end point compared to escitalopram or sertraline (least squares [LS] mean differences, 8.25; 95% CI, 6.25-10.25; < .001; LS mean differences, 8.00; 95% CI, 5.95-10.06; < .001, respectively). Participants in the vortioxetine treatment group reported significantly greater changes in total MADRS scores from baseline to end point compared to escitalopram or sertraline (LS mean differences, -4.06; 95% CI, -4.92 to -3.20; < .001; LS mean differences, -3.94; 95% CI, -4.83 to -3.06; < .001, respectively). Vortioxetine has a significant procognitive effect. Antidepressant effects and improvement in fatigue symptoms (PROMIS 7a) also were observed.
This pilot randomized controlled trial (RCT) examined the feasibility of study procedures and acceptability of 1-day cognitive behavioral therapy (CBT)-based workshops for postpartum depression (PPD) delivered by nonspec...This pilot randomized controlled trial (RCT) examined the feasibility of study procedures and acceptability of 1-day cognitive behavioral therapy (CBT)-based workshops for postpartum depression (PPD) delivered by nonspecialist public health nurses (PHNs) and explored the potential effects of the intervention on PPD and anxiety to inform a future, full-scale RCT. Birthing parents ≥18 years old with an infant <12 months old, living in Ontario, Canada, with an Edinburgh Postnatal Depression Scale (EPDS) score ≥10 were recruited between March 18 and May 25, 2022, and randomly assigned to receive the 1-day CBT-based workshop plus treatment as usual (TAU; experimental group) or TAU alone (control group). Feasibility objectives (recruitment, retention, intervention attendance) were described using descriptive statistics, and treatment effects were assessed at enrollment and 3 and 9 months post-intervention. 119 participants were enrolled in under 3 months, 85% in the experimental group attended their workshop, and 84% of participants completed the study. While the study was not powered to detect differences between experimental and control groups, the experimental group reported larger reductions in depression at 3 ( = .11) and 9 months ( = .045) postworkshop. Experimental group participants also reported greater reductions in anxiety at 3 ( < .01) and 9 months ( = .14) postworkshop than control participants. Recruiting and retaining participants in an RCT of PHN-delivered 1-day CBT-based workshops is feasible. Pilot results suggest that workshops may lead to improvements in PPD up to 9 months postworkshop. As this pilot study was not powered to detect differences in clinical outcomes, these findings warrant exploration in a full scale RCT. ClinicalTrials.gov identifier: NCT05314361.