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Journal: Journal of psychiatric practice

31

Major depressive disorder (MDD) is a source of great disease burden, due in part to the limited accessibility and effectiveness of current treatments. Although current treatments are efficacious in a segment of the population with MDD, there is a clear need for alternative and augmentation treatment strategies. Exercise is one such alternative treatment option. Research has shown exercise to be efficacious as both a stand-alone and an augmentation therapy. As a result, exercise is now included in the American Psychiatric Association’s treatment recommendations. The purpose of this article is to provide clinicians with a knowledge base to prescribe exercise to their patients. The authors describe the evidence supporting the use of exercise in the treatment of MDD, provide evidence-based recommendations for prescribing exercise, and address practical considerations related to prescribing exercise in real-world treatment settings. (Journal of Psychiatric Practice 2013;19:204-212).

Concepts: Life expectancy, Alternative medicine, Major depressive disorder, Dysthymia, Mental status examination, Medical prescription, Disease burden, American Psychiatric Association

27

Sluggish cognitive tempo (SCT) refers to an impairment of attention in hypoactive-appearing individuals that first presents in childhood. At this time, it exists only as a research entity that has yet to debut in official diagnostic taxonomies. However, it seems likely that a constellation of characteristic features of SCT may form the criteria for a newly defined childhood disorder in the foreseeable future, provided limitations in the extant findings can be addressed by future research. Most clinicians who assess and treat cases of attentiondeficit/hyperactivity disorder (ADHD) have likely seen and treated someone who falls within the parameters for SCT. This article outlines the history of SCT and reviews the current understanding of the disorder, how it is distinguishable from and similar to other attention disorders, and what future directions research and treatment may take. Based on this review and their clinical experience, the authors conjecture that SCT is probably distinct from ADHD rather than being an ADHD subtype, although there is notable overlap with the ADHD predominantly inattentive and combined presentations.

Concepts: Attention, Educational psychology, Attention-deficit hyperactivity disorder, ADHD predominantly inattentive, Methylphenidate, Sluggish cognitive tempo, Attention disorders

6

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that involves a combination of emotional and physical symptoms that result in significant functional impairment. Because of the debilitating nature of PMDD, multiple treatment options have been considered. This review provides a comprehensive overview of these therapeutic regimens to help health care professionals provide adequate treatment for PMDD and premenstrual syndrome. The treatments that are reviewed are organized into the following categories: psychiatric, anovulatory, supplements, herbal, nonpharmacological, and other. Selective serotonin reuptake inhibitors have been established as the first-line treatment for PMDD. Although luteal phase or continuous dosing can be used, additional research is needed to more thoroughly compare the efficacies and differential symptom response of continuous, semi-intermittent, luteal phase, and symptoms-onset dosing. The psychiatric medications venlafaxine, duloxetine, alprazolam, and buspirone have also been found to be useful treatments for PMDD. Various anovulatory-related treatments have demonstrated efficacy; however, the use of some of these treatments remains limited due to potential side effects and/or the availability of cheaper alternatives. Although a variety of supplement and herbal-related treatments have been proposed, with some warranting further research, at this time only calcium supplementation has demonstrated a consistent therapeutic benefit. In conclusion, serotoninergic antidepressants have been established as the first-line treatment option for PMDD; however, there are a variety of additional treatment options that should be considered if a patient fails to achieve an adequate therapeutic response with a selective serotonin reuptake inhibitor.

Concepts: Antidepressant, Selective serotonin reuptake inhibitor, Sertraline, Tricyclic antidepressant, Reuptake inhibitor, Fluoxetine, Premenstrual dysphoric disorder, Premenstrual syndrome

4

Early detection of psychotic disorders is now recognized as vital in reducing dysfunction, morbidity, and mortality. However, making the diagnosis of a psychotic disorder, especially earlier in the course of disease, can be challenging, and an incorrect diagnosis of a psychotic disorder may also have significant consequences. We therefore, conducted a retroactive chart review of 78 patients referred to a specialty early psychosis consultation clinic to examine the role of specialty clinics in clarifying the diagnosis of early psychosis, especially potential schizophrenia. Of the 78 patients, 43 (55%) had a primary diagnosis at referral of a schizophrenia spectrum disorder. The primary diagnosis in the consultation clinic was different in 22 (51%) of these 43 cases, and 18 (42%) of these patients were not diagnosed with any form of primary psychotic disorder. These patients were more likely to report anxiety and less likely to report thought disorder than patients with a consultation diagnosis of schizophrenia or schizoaffective disorder. Clinicians may therefore overdiagnose schizophrenia, demonstrating the value of second opinions from clinics specializing in the diagnosis of recent-onset psychosis.

4

Although benzodiazepines (BZDs) are commonly used in the treatment of posttraumatic stress disorder (PTSD), no systematic review or meta-analysis has specifically examined this treatment. The goal of this study was to analyze and summarize evidence concerning the efficacy of BZDs in treating PTSD.

Concepts: Complex post-traumatic stress disorder, Posttraumatic stress disorder, Stress

3

In clinical trials, each specific inclusion and exclusion criterion eliminates a percentage of the potentially eligible population from trial participation and thus increases the time and effort needed for enrollment in a study. Drug developers often do not have data on how these criteria affect the pool of potentially eligible subjects for their trials and, hence, they cannot factor in the impact of these criteria when designing a study and planning the time needed to complete it. Consequently, drug developers often have ambitious timelines that are unrealistic and can lead to actions that may interfere with the ability to separate the efficacy of drug versus placebo. To investigate the effects of inclusion and exclusion criteria on study enrollment, the authors quantified the effects of the inclusion and exclusion criteria commonly used in antidepressant registration trials (ARTs) by applying these criteria to the population treated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. In essence, the STAR*D study population was used as a surrogate for the general population of individuals with major depressive disorder. The effect of each criterion commonly used in ARTs was assessed in terms of the percentage of the STAR*D population that would have been excluded individually and collectively (ie, when all criteria were applied at once). For continuous criteria such as age and severity of depression, the resulting effects have been presented graphically. Collectively, the typical inclusion and exclusion criteria used in ARTs would have eliminated at least 82% of the STAR*D population. This result means that more than 5 times the number of subjects would have to be screened to find a population that would meet the typical inclusion and exclusion criteria for an ART, directly determining the screening effort required in terms of both resources and time. Thus, developers of antidepressant drugs can use the data from this study to plan the recruitment effort required and to weigh any potential benefit of each criterion alone and in aggregate versus their cost in terms of recruitment support and time. These data also graphically illustrate for prescribers how restrictive the population likely to be enrolled in ARTs is relative to the patients whom they treat with such medications.

Concepts: Effectiveness, Selective serotonin reuptake inhibitor, Sertraline

2

Several companies offer pharmacogenetic testing for psychiatry on the basis of the claim that the outcome of drug selection is better when guided by such testing than when such testing is not used. This column examines the results of the GeneSight Psychotropic Test which groups various antidepressants and antipsychotics into 3 bins: green (“use as directed”), yellow (“use with caution”), and red (“use with increased caution and more frequent monitoring”). The authors examined how frequently the same drugs appeared in these different bins in 19 patients. They found that of the 22 antidepressants evaluated, 2 were virtually always (>90%) in the green bin: desvenlafaxine and levomilnacipran; and 8 were almost never (≤10.5%) in the green bin: citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, and sertraline. Of the 16 antipsychotics evaluated, they found that 4 were virtually always (>90%) in the green bin: asenapine, lurasidone, paliperidone, and ziprasidone; and 2 were almost never (≤10.5%) in the green bin: chlorpromazine and thioridazine. What was common among those drugs almost always in the green bin versus those almost never in the green bin were newer versus older marketed drugs and those not dependent versus dependent on oxidative metabolism for their clearance. The authors concluded that the results of this pharmacogenetic testing could be predicted on the basis of knowledge of the pharmacology of the drugs, particularly whether their clearance was dependent on oxidative drug metabolism.

2

As a result of the prescription opioid epidemic in the United States, there has been an increasing need for effective treatment interventions, both pharmacological and nonpharmacological. Buprenorphine has emerged as a critical component of the treatment of opioid use disorder, yet its adoption has not been without some concerns. This article first reviews the pharmacology, clinical use, and US legislative action related to buprenorphine, followed by a discussion of the misuse and diversion of buprenorphine in the United States as well as internationally. We then explore the impact of buprenorphine abuse as well as discussing strategies for its reduction, including changes in policy, prescription and pharmacy monitoring, and continuing medical education for guiding and improving clinical practice.

Concepts: Pharmacology, Medicine, United States, Opioid, Morphine, Drug development, Pharmaceutical drug, Pharmacognosy

1

The exploration of possible therapeutic benefits of hallucinogenic substances has undergone a revitalization in the past decade. This literature review investigated the published literature regarding the psychotherapeutic uses of hallucinogens in psychiatric disorders. The results showed that a variety of substances have been evaluated in the treatment of psychiatric disorders, including ayahuasca, ibogaine, ketamine, lysergic acid diethylamide, 3,4-methylenedioxymethamphetamine, and psilocybin. The conditions treated ranged from depression to autism, with the largest volume of research dedicated to substance use disorders. The majority of studies that were reviewed demonstrated significant associations with improvement in the conditions investigated. However, it was difficult to draw definitive conclusions as most studies suffered from small sample sizes, inconsistent measures, and poor study design. To properly assess the risks and potential benefits of hallucinogens in psychiatric treatment, there is a need for well designed, standardized studies that demonstrate the impact of hallucinogenic substances on psychiatric conditions.

1

Human trafficking is an outrageous human rights violation with potentially devastating consequences to individuals and the public health. Victims are often underrecognized and there are few guidelines for how best to identify, care for, and safely reintegrate victims back into the community. The purpose of this paper is to propose a multifaceted, interdisciplinary, and interprofessional guideline for providing care and services to human trafficking victims. Databases such as PubMed and PsycINFO were searched for papers outlining human trafficking programs with a primary psychiatric focus. No integrated care models that provide decisional guidelines at different points of intervention for human trafficking patients and that highlight the important role of psychiatric consultation were found. Psychiatrists and psychologists are pivotal to an integrated care approach in health care settings. The provision of such a comprehensive and integrated model of care should facilitate the identification of victims, promote their recovery, and reduce the possibility of retraumatization.

Concepts: Health care, Psychology, Medicine, Health, Human rights, Psychiatry, Mental health professional, Human trafficking