Combining Asian and American pedagogy to improve clinical psychopharmacology practice.

As the world becomes increasingly interconnected, psychiatrists across geographical regions and from various international organizations need to collaborate to promote global health and wellness. A necessary step is for nations of the world to develop combined teaching initiatives and curricula to ensure best practices are shared globally. In no field of medicine is this more pressing than in psychiatry - especially psychopharmacology given the recent advances in the field. This paper highlights the need to work collaboratively in developing teaching curricula in psychopharmacology in order to incorporate pedagogy and content from international partners-here from Asia and America.

Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness.

BACKGROUND: Given the relative lack of psychiatric information and data on the perpetrators of US mass shootings, the aim of our study was to understand who these "mass shooters" were and whether they had a psychiatric illness. If so, were they competently diagnosed, and if so, were they treated with appropriate medication for their diagnoses before the violence? METHODS: Because a prospective study of diagnosis and treatment could not, for obvious reasons, be carried out, we designed a retrospective, observational study of mass shooters, defined as those who killed 4 or more people with firearms between 1982 and 2012 or who killed 3 or more people with firearms between 2013 and 2019 in the United States. We used the Mother Jones database-a database of 115 persons identified as committing a mass shooting in the United States between January 1982 and September 2019. In the vast majority of the incidents identified in the database, the perpetrator died either during or shortly after the crime, leaving little reliable information about their history-especially psychiatric history. We focused on the 35 mass shooters who survived and for which legal proceedings were instituted because these cases presented the most reliable psychiatric information. For each of these 35 mass shootings, we interviewed forensic psychiatrists and forensic psychologists who examined the perpetrator after the crime and/or collected the testimony and reports by psychiatrist(s) at trial or in the postconviction proceedings contained in the court record. In addition, we reviewed available information from the court proceedings, public records, a videotaped interview of assailant by law enforcement, social media postings of the assailant, and writings of the assailant. After collecting the clinical information from multiple sources on each case to make a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis, we also completed a Sheehan Diagnostic Scale. After this, 20 additional cases where the assailant died at the crime were randomly selected form the remaining 80, to determine whether there were differences in psychiatric diagnoses and treatment between such assailants and those who survived. RESULTS: Twenty-eight of 35 cases in which the assailant survived had a psychiatric diagnosis-18 with schizophrenia, 3 with bipolar I disorders, 2 with delusional disorders, persecutory type, 2 with personality disorders (1 paranoid and 1 borderline), 2 with substance-related disorders without other psychiatric diagnoses, and 1 with posttraumatic stress disorder. Four had no psychiatric diagnosis, and in 3, we did not have enough information to make a diagnosis.Of 15 of 20 cases in which the assailant died, 8 had schizophrenia. None of those diagnosed with psychiatric illnesses were treated with medication. CONCLUSIONS: A significant proportion of mass shooters experienced unmedicated and untreated psychiatric disorder.

Persistent Barriers to the Use of Long-Acting Injectable Antipsychotics for the Treatment of Schizophrenia.

PURPOSE/BACKGROUND: One of the major challenges in the treatment of schizophrenia is nonadherence, defined as the failure to take medications as prescribed. Nonadherence is a strong predictor of symptom relapse, hospital readmission, and poorer long-term outcome. Although long-acting injectable antipsychotics (LAIs) have been found to be superior to their oral analogs at reducing relapse in large-scale meta-analyses, their prevalence seldom exceeds 30% even in populations with a history of nonadherence. We review multiple barriers to the use of LAI utilization and suggest strategies to address them. METHODS/PROCEDURES: We searched for the following terms: long-acting injectable/depot antipsychotics, schizophrenia, barriers, and attitude/perception in both the PubMed search index and Google scholar from 1995 to 2018. A total of 329 studies were selected, of which data from 13 were reviewed for this article. Only peer-reviewed studies, randomized controlled trials, systematic reviews, and meta-analyses that describe barriers to using LAIs were included. FINDINGS/RESULTS: Several barriers to using LAIs were identified. These are organized into 3 overarching categories: those related to the clinician; those related to the patient; and systems barriers. Clinician factors include the perception of LAIs as coercive, fears of not being able to control the dose, as well as current practice patterns and guidelines. Patient factors include perception of the injection as painful or intrusive, general lack of knowledge, and a sense of coerciveness. For each identified barrier, we propose potential solutions. IMPLICATIONS/CONCLUSIONS: We identified multiple barriers to using LAIs in patients with schizophrenia. Specific strategies are suggested for overcoming each of these barriers.

The problem of medical-psychiatric illness in the homeless and its occurrence in the midst of a viral pandemic: A commentary.

This article has the purpose of examining the problem of getting help for the medical-psychiatric-substance use group of "homeless" people on the streets of our cities, who refuse treatment. The problem has gradually worsened since closure of state hospitals and subsequent lack of community resources. It has been stalemated, in part, by advocates, who argue for personal autonomy and freedom rather than involuntary diagnosis and treatment over the life of these people. It has reached a crisis situation secondary to such potential patients being imprisoned and/or sick with COVID-19 being potential health and legal threats. We review A) the nature of the problem, B) the current social-legal availability of treatment and long-term management (or lack of one) in the context of societal rejection of these potential patients, and C) suggest what might be done, locally and nationally. Mandating scientifically-based medical orders to citizens regardless of personal freedom - are now being implemented to manage the COVID-19 pandemic. We argue for creating a similar med-psych short- and long-term system as a new approach to help this group. They are now mostly being ignored "to die on the streets."

Update on integrative treatment of psychiatric symptoms and disorders in athletes.

Primary objective: In this review, we detail the issues and disorders athletes present with, guidelines for making diagnostic formulations and treatment goals, and strategies for delivering integrated treatment attuned to the athlete and their team and/or sport. In addition, we highlight special issues associated with athletes and their families. Reasoning: Data suggests athletes experience comprable incidence and prevalence rates to the general population of psychiatric disorders. The mental and physical demands placed on athletes are unique and may increase their susceptibility to certain mental health problems. The current literature regarding integrative interventions in athletes is sparse and largely anecdotal. We provide a summary of the scientific evidence from a literature review conducted by the IOC Consensus Committee on Mental Health in Elite Athletes, reviews and expert clinical strategies recommended by the authors of four books on sports psychiatry written since 2012, and our own review of the literature related to psychotherapy with elite and non-elite- athletes. Main outcomes and results: At the moment there are no randomized controlled trials assessing the use of psychotherapy or medication for mental illness in athletes to guide treatment. Controlled studies examining psychological interventions in collegiate athletes have demonstrated improvements in mental health symptomology. Although these studies were limited to collegiate athletes they assist in providing a foundation for elite athletes as well. For the assessment and management of the mental health needs of athletes' to be on a par with their physical needs, more high-quality scientific epidemiological and treatment intervention studies are needed. Conclusions: Development of specific models of psychiatric intervention for athletes with significant psychopathology and impairment appears to be warranted. These interventions should include individual, family/marital, and group psychotherapy with or without medication using evidence-based treatments.

Are Patients With Schizophrenia Better Off With Lifetime Antipsychotic Medication?: Replication of a Naturalistic, Long-Term, Follow-Up Study of Antipsychotic Treatment.

PURPOSE/BACKGROUND: The question of whether people with schizophrenia should be treated with antipsychotics for life has been debated for decades. We recently reported results of 2 retrospective long-term naturalistic studies examining the association of medication adherence and global outcomes in different demographic samples. In both, we found that patients with a history of better adherence to antipsychotic medication had better quality of life outcomes. Using similar methodology, here we present such associations for a very different sample-patients with chronic schizophrenia with a long past history of antipsychotic treatment that had been treated for 19 to 53 years in a Veterans Affairs clinic. METHODS: This is a retrospective, naturalistic, longitudinal 19- to 53-year (mean average, 33.5 years) lifetime follow-up of a consecutive series of patients with schizophrenia, who had at least 8 years of antipsychotic treatment. Lifetime data were collected on (1) their medication adherence, (2) long-term global outcome, and (3) life satisfaction. Outcomes were rated by 2 different clinicians, one with information on medication adherence (nonblind rater) and one without (blind rater). Linear regression models, adjusted for age, family support, substance use disorder, race, marital status, and number of years in treatment were used to estimate the association between adherence and each outcome. RESULTS: A total of 20 patients were assessed. Medication adherence was positively associated with the blind clinician's rating of global outcome (P = 0.049) and the Global Assessment of Functioning (P = 0.021). In the nonblinded clinician's rating, medication adherence was positively related to global outcome (P = 0.001) and to the patient's report of life satisfaction (P = 0.028). IMPLICATIONS/CONCLUSIONS: This replication study, together with our previous 2 studies, is consistent with the recommendation for continuous, long-term treatment for chronic schizophrenia over many years of a patient's lifetime unless medically contraindicated.

The Crisis in Psychiatric Hospital Care: Changing the Model to Continuous, Integrative Behavioral Health Care.

Inpatient psychiatric hospital services, as they currently exist, have little to no evidence base. Deficits in the current system represent a critical missed opportunity to improve the trajectory of patients' lives and long-term outcomes. The authors posit that a fresh approach to hospitalization is needed, one that incorporates distinct, measurable goals tied to a comprehensive, individualized treatment plan tailored to address a patient's lifetime course of illness. A structured approach can ultimately improve care quality and continuity by allowing for rigorous testing of each aspect of the assessment and care provision process, improving patient outcomes and care engagement while shortening average lengths of hospital stays, and accelerating the movement of care to cost-effective, need-specific settings. In an effort to move the field toward establishing a systematic, evidence-based protocol for hospital-based psychiatric care, the authors describe a new model, called the S.E.T.U.P. approach.

Exploring characteristics associated with first benzodiazepine prescription in patients with affective disorders and related diagnoses.

OBJECTIVE: In patients with affective disorders, benzodiazepines (BZDs) are frequently administered at the onset, sometimes inappropriately. We sought to identify clinical variables associated with first BZD prescription in a large sample of patients with affective disorders. METHODS: Four hundred sixty patients with mood or anxiety disorders attending different psychiatric services were assessed comparing those who received BZD as first treatment (BZD w/) and those who did not (BZD w/o). RESULTS: More than one third (35.7%) of the total sample had received BZDs as first prescription. In relation to mood disorders, BZD w/ subjects more frequently (a) had not a psychiatrist as first therapist, (b) had anxious symptoms at onset, (c) had adjustment disorder as first diagnosis, (d) were treated as outpatients. In relation to specific diagnoses, (a) personal decision of treatment for major depressive disorder, (b) outpatient status for bipolar disorder and (c) longer duration of untreated illness for adjustment disorder were more frequently associated with first BZD prescription. For anxiety disorders, the presence of stressful life events and the diagnoses of panic disorder or specific phobias were more frequently observed in BZD w/ patients. CONCLUSION: Patients with affective disorders frequently received BZDs as first prescription with significant differences between and within mood and anxiety disorders.

Mental health in elite athletes: International Olympic Committee consensus statement (2019).

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Psychotherapy for mental health symptoms and disorders in elite athletes: a narrative review.

BACKGROUND: Athletes, like non-athletes, suffer from mental health symptoms and disorders that affect their lives and their performance. Psychotherapy, either as the sole treatment or combined with other non-pharmacological and pharmacological strategies, is a pivotal component of management of mental health symptoms and disorders in elite athletes. Psychotherapy takes the form of individual, couples/family or group therapy and should address athlete-specific issues while being embraced as normative by athletes and their core stakeholders. MAIN FINDINGS: This narrative review summarises controlled and non-controlled research on psychotherapy for elite athletes with mental health symptoms and disorders. In summary, treatment is similar to that of non-athletes-although with attention to issues that are athlete-specific. Challenges associated with psychotherapy with elite athletes are discussed, including diagnostic issues, deterrents to help-seeking and expectations about services. We describe certain personality characteristics sometimes associated with elite athletes, including narcissism and aggression, which could make psychotherapy with this population more challenging. The literature regarding psychotherapeutic interventions in elite athletes is sparse and largely anecdotal.