Addressing the Increasing Mental Health Distress and Mental Illness Among Young Adults in the United States.

ABSTRACT: Recent surveys show rising numbers of young people who report anxiety and depression. Although much attention has focused on mental health of adolescent youth, less attention has been paid to young people as they transition into adulthood. Multiple factors may have contributed to this steady increase: greater exposure to social media, information, and distressing news via personal electronic devices; increased concerns regarding social determinants of health and climate change; and changing social norms due to increased mental health literacy and reduced stigma. The COVID-19 pandemic may have temporarily exacerbated symptoms and impacted treatment availability. Strategies to mitigate causal factors for depression and anxiety in young adults may include education and skills training for cognitive, behavioral, and social coping strategies, as well as healthier use of technology and social media. Policies must support the availability of health insurance and treatment, and clinicians can adapt interventions to encompass the specific concerns and needs of young adults.

Structural Racism and Psychiatric Practice: A Call for Sustained Change.

ABSTRACT: Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.

Psychiatry in the Time of COVID: Credibility, Uncertainty, and Self-Reflection.

ABSTRACT: Public trust in the credibility of medicine and physicians has been severely tested amid the COVID-19 pandemic and growing sociopolitical fissures in the United States. Physicians are being asked to be ambassadors to the public of scientific information. Psychiatrists have an opportunity to help the public understand and accept a "new normal" during a time of such uncertainty. Using a case example, we review the impact of uncertainty and fear on scientific and medical credibility. Although the pandemic provides an opportunity for systemic change, the consequences of any change remain unknown. To help patients navigate the uncertainty, we conclude by offering four guidelines to clinicians: the public has little interest in understanding the scientific method; we need to acknowledge that we do not have all the answers; credibility and trustworthiness are linked to our ability to be trusted, believable messengers; and we can retain scientific credibility while acknowledging uncertainty.

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19.

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

The Opioid Epidemic and Psychiatry: The Time for Action Is Now.

The number of people with opioid use disorder and the number of overdose deaths in the United States have increased dramatically over the past 20 years. U.S. Congress passed the SUPPORT for Patients and Communities Act, which was signed into law in 2018, authorizing almost $8 billion to address the crisis. As experts in the treatment of central nervous systems disorders, psychiatrists can play a leading role in expanding treatment for people with opioid use disorder and in advocating for policy changes to support community treatment for this group.

How the DSM Is Used in Clinical Practice.

Despite widespread use, how clinicians use the DSM in psychiatric practice is not well understood. Recognizing public and professional attitudes toward the DSM are integral to future DSM development, to assess a commonly held assumption such as that the DSM is used primarily for coding, and to assess its clinical utility. A convenience sample of Psychiatric Times readers was surveyed to assess the DSM's use in clinical practice. A total of 394 behavioral health care practitioners fully completed the online survey. Results suggest that the DSM, beyond administrative and billing use, is used for communication with health care providers, for teaching diagnoses to trainees, and, importantly, as an educational tool to inform patients and caregivers alike.

Adaptation in Delivering Integrated Care: The Tension Between Care and Evidence-Based Practice.

Clinical practice is assumed to be informed and supported by evidence-based clinical research. Nonetheless, clinical practice often deviates from the research evidence base, sometimes leading and sometimes lagging. Two examples from integrated care in mental health care (care for serious mental illness and collaborative mental health care in primary care settings) illustrate the natural space and therefore tension between evidence and implementation that needs to be better understood. Using the tools and perspectives of both examples, the authors present a framework for the connected relationship between practice and research that is founded on measurement and uses iterative adaptation guided by oversight of and feedback from the stakeholders in this process.

Why We Need to Enhance Suicide Postvention: Evaluating a Survey of Psychiatrists' Behaviors after the Suicide of a Patient.

Suicide prevention efforts are increasing to enhance capabilities and better understand risk factors and etiologies. Postvention, or how clinicians manage the postsuicide aftermath, strengthens suicide prevention, destigmatizes the tragedy, operationalizes the confusing aftermath, and promotes caregiver recovery. However, studies regarding its efficacy are minimal. The Psychopathology Committee of the Group for the Advancement for Psychiatry surveyed a convenience sample of psychiatrists to better understand postvention activities. Ninety psychiatrists completed the survey; they were predominantly men (72%) with an average of 24.6 years of experience (SD, 16.7 years). Most had contact with the patient's family within 6 months of the suicide, and most psychiatrists sought some form of support. Few psychiatrists used a suicide postvention procedure or toolkit (9%). No psychiatrists stopped clinical practice after a patient suicide, although 10% stopped accepting patients they deemed at risk of suicide. Postvention efforts, therefore, should be improved to better address survivor care.

Rational protection of subjects in research and quality improvement activities.

This Open Forum illuminates shortcomings with the basis for determining degree of oversight of health services research and quality improvement activities. Using a federally regulated definition of research rather than a direct appraisal of risk to patients can misallocate effort from activities with higher risk for patients to those with lower risk. The case of the Johns Hopkins multicenter study of central line safety checklists in intensive care units is cited. Definitions of research promulgated by the Office of Human Research Protection are reviewed, and an alternative model based on patient risk is proposed. Suggestions for how quality improvement work fits into the larger paradigm of research are made.

Implementing standardized assessments in clinical care: now's the time.

In this Open Forum the Committee on Psychopathology within the Group for the Advancement of Psychiatry (GAP) strongly encourages clinicians and health systems to implement standardized assessments of patients' outcomes for mental disorders, particularly disorders such as depression. The GAP committee describes how calls for the regular use of standardized scales in clinical settings naturally follow from the development and dissemination of treatment guidelines. It discusses the challenges involved in implementing routine outcome measures in clinical settings and explains why the advantages of measurement-based care make addressing these challenges worthwhile. Finally, the committee makes practical suggestions for clinicians and systems attempting to implement routine outcome measures in their clinics.

Psychiatrists and primary caring: what are our boundaries of responsibility?

This column provides a framework for considering the extent of psychiatrists' responsibility for patients' medical conditions. Psychiatrists have the greatest responsibility for medical conditions that occur as a result of their own actions. Next on the continuum of responsibility is psychiatrists' obligation to remain alert for medical conditions that can cause, trigger, or exacerbate psychiatric conditions or interfere with treatment. Another potential responsibility is for preventive monitoring, screening, and education for medical conditions that disproportionately affect psychiatric patients. Characteristics of the setting, practitioner, and patient that affect how such responsibilities are fulfilled are also discussed.

Topiramate as a therapy for chronic posttraumatic stress disorder.

Since the original publication of open-label suggestions of efficacy of adjunctive and monotherapy topiramate as a novel therapy for chronic posttraumatic stress disorder, three small, double-blind, placebo-controlled clinical trials conducted as pilot trials have been made public. The results of these studies, including efficacy, termination rates, and adverse effects resulting in termination are reviewed critically, including methodological limitations to interpretation of the findings. One study finds separation from placebo over 12 weeks for a reduction in total CAPS scores with a large effect size (d=1.63); a second finds significant benefit for re-experiencing but not total CAPS scores; and a third finds numerical superiority for topiramate but no significant benefit for any score reduction. Several problems, including unexpectedly high dropout rates in one study, limit the generalizability of these findings, but overall there is a signal of potential efficacy that warrants more adequately powered future clinical trials.

Prospective open-label study of add-on and monotherapy topiramate in civilians with chronic nonhallucinatory posttraumatic stress disorder.

BACKGROUND: In order to confirm therapeutic effects of topiramate on posttraumatic stress disorder (PTSD) observed in a prior study, a new prospective, open-label study was conducted to examine acute responses in chronic, nonhallucinatory PTSD. METHODS: Thirty-three consecutive newly recruited civilian adult outpatients (mean age 46 years, 85% female) with DSM-IV-diagnosed chronic PTSD, excluding those with concurrent auditory or visual hallucinations, received topiramate either as monotherapy (n = 5) or augmentation (n = 28). The primary measure was a change in the PTSD Checklist-Civilian Version (PCL-C) score from baseline to 4 weeks, with response defined as a >/= 30% reduction of PTSD symptoms. RESULTS: For those taking the PCL-C at both baseline and week 4 (n = 30), total symptoms declined by 49% at week 4 (paired t-test, P < 0.001) with similar subscale reductions for reexperiencing, avoidance/numbing, and hyperarousal symptoms. The response rate at week 4 was 77%. Age, sex, bipolar comorbidity, age at onset of PTSD, duration of symptoms, severity of baseline PCL-C score, and monotherapy versus add-on medication administration did not predict reduction in PTSD symptoms. Median time to full response was 9 days and median dosage was 50 mg/day. CONCLUSIONS: Promising open-label findings in a new sample converge with findings of a previous study. The use of topiramate for treatment of chronic PTSD, at least in civilians, warrants controlled clinical trials.

New drug development for post-traumatic stress disorder.

US FDA approval of two serotonin-selective reuptake inhibitor (SSRI) agents for post-traumatic stress disorder (PTSD) has created new opportunities for drug development. This follows many years of exploring the potential utility of several classes of psychotropic agents for this very common, yet under-recognized and under-treated disorder. This review examines some of the basic neurobiological abnormalities observed in PTSD and summarizes open and controlled drug trials for major classes of medications, including SSRIs, other antidepressants, atypical neuroleptics, noradrenergic modulators and anticonvulsants, while critically evaluating the extent of effectiveness of these agents and reviewing unmet gaps in therapeutic need.

Open-label topiramate as primary or adjunctive therapy in chronic civilian posttraumatic stress disorder: a preliminary report.

BACKGROUND: The hypothesis that exposure to traumatic events may sensitize or kindle limbic nuclei has led to efforts to treat posttraumatic stress disorder (PTSD) with anticonvulsants. Based on the kindling hypothesis of PTSD, this open-label study assesses clinical response to topiramate as a potential treatment for DSM-IV PTSD. METHOD: A naturalistic data review was conducted of medical records of all adult outpatients (9 men. 26 women symptomatic for a mean +/- SD of 18 +/- 15 years with DSM-IV chronic civilian PTSD) treated with topiramate, 12.5 to 500 mg/day, as add-on (N = 28) or monotherapy (N = 7). The last 17 patients completed the PTSD Checklist-Civilian Version (PCL-C) before treatment and at week 4. Dosage titration started at 12.5 to 25 mg/day and increased in 25- to 50-mg increments every 3 to 4 days until a therapeutic response was achieved or the drug was no longer tolerated. The mean duration of treatment was 33 weeks (range, 1-119 weeks). RESULTS: Topiramate decreased nightmares in 79% (19/24) and flashbacks in 86% (30/35) of patients, with full suppression of nightmares in 50% and of intrusions in 54% of patients with these symptoms. Nightmares or intrusions partially improved in a median of 4 days (mean = 11 +/- 13 days) and were fully absent in a median of 8 days (mean = 35 +/- 49 days). Response was seen in 95% of partial responders at a dosage of 75 mg/day or less, and in 91% of full responders at a dosage of 100 mg/day or less. Mean reductions in PCL-C score from baseline to week 4 were highly significant (baseline score = 60 vs. week 4 score = 39, p < .001), with similar reductions in reexperiencing, avoidance, and hyperarousal criteria symptoms. Thirteen patients discontinued for various reasons during the > 2-year study period. Except for a single instance of acute secondary narrow-angle glaucoma, there were no serious side effects. CONCLUSION: Topiramate appeared effective as add-on or monotherapy for chronic PTSD. It demonstrated a rapid onset of action and minimally serious, dose-related side effects without the development of tolerance. Double-blind studies are indicated.

Treatment of the nonpsychotic chronic patient: a problem of interactive fit.

Nonpsychotic chronic adult patients are troublesome, not only because of their psychosocial dysfunction, cognitive and affective impairments, and behavioral problems, but also because they fail the expectations and values of health care providers. The concept of interactive fit is proposed to facilitate the therapeutic process between patient and provider. Stages of treatment are described, together with guidelines for clinicians.