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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
Lithium may decrease self-harm in patients with bipolar disorder (August 2016)
Self-harm causes substantial morbidity in bipolar disorder, and patients who self-harm have an increased risk of suicide. Lithium may reduce the risk of self-harm. A recent study used electronic health records from a nationally representative sample from the United Kingdom to identify over 6000 patients with bipolar disorder who received maintenance monotherapy with lithium, valproate, olanzapine, or quetiapine . Self-harm included any nonfatal act of self-injury, regardless of suicidal intent. Patients were matched on observed potential confounders such as history of prior self-harm, sex, and comorbid disorders. Self-harm rates were lower with lithium, compared with valproate, olanzapine, or quetiapine. There was no difference in the rate of self-harm among valproate, olanzapine, or quetiapine. Lithium is one of our preferred options for maintenance therapy for patients with bipolar disorder. (See "Bipolar disorder in adults: Choosing maintenance treatment", section on 'Reduced risk of suicide'.)
CHILD AND ADOLESCENT PSYCHIATRY
Childhood factors predicting persistence of ADHD into adulthood (November 2016)
Child/adolescent attention-deficit/hyperactivity disorder (ADHD) persists into adulthood in approximately 40 to 60 percent of cases. In a longitudinal study of 453 children with ADHD, multivariate analysis found that initial ADHD symptom severity, co-occurring disorders, and parental mental health problems predicted the persistence of ADHD symptoms on follow-up assessment as adults (mean age of 25 years) . Childhood IQ, socioeconomic status, parental education, and parent-child relationships showed no associations with adult ADHD symptom persistence. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Course'.)
Effectiveness of antidepressants for pediatric unipolar major depression (August 2016)
Antidepressant medications are often used to treat moderately to severely ill children with unipolar major depression. For children and adolescents with acute depressive disorders, first-line pharmacotherapy is typically fluoxetine. There are several randomized trials comparing antidepressant medications with placebo, but there are few head-to-head comparison trials. In a recent meta-analysis of 34 trials comparing one antidepressant with placebo or another active drug for the acute treatment of major depressive disorder in children and adolescents, fluoxetine, sertraline, and escitalopram were statistically more efficacious than placebo . In addition, paroxetine was superior to clomipramine and fluoxetine was superior to nortriptyline. In a network meta-analysis subsequently performed to compare and rank antidepressants for the acute treatment of major depressive disorder, only fluoxetine was better than placebo. In comparison with other antidepressants, fluoxetine was significantly more effective than nortriptyline. Important limitations of the network meta-analysis include risk of bias within individual studies, lack of power and generalizability, and potential selective reporting. (See "Pediatric unipolar depression and pharmacotherapy: Choosing a medication", section on 'All antidepressants'.)
Continuation treatment with electroconvulsive therapy plus pharmacotherapy for remitted late-life depression (August 2016)
Electroconvulsive therapy (ECT) is often more effective for unipolar major depression than pharmacotherapy and psychotherapy, particularly for late-life depression. Although continuation treatment for patients who remit with ECT typically consists of pharmacotherapy, ECT plus pharmacotherapy is superior to pharmacotherapy alone. In one study, older adults with unipolar major depression were acutely treated with ECT plus venlafaxine; those who remitted (n = 120) were randomly assigned to six months of open-label continuation treatment with ECT plus pharmacotherapy (continuation venlafaxine plus lithium) or pharmacotherapy alone . Continuation ECT consisted of four weekly treatments following randomization and subsequent treatments as warranted by symptoms. Depression rating scale scores were lower with ECT plus pharmacotherapy than pharmacotherapy alone. There was no difference between the two groups in global cognitive functioning at baseline and post-ECT. Continuation ECT plus pharmacotherapy can benefit patients with late-life depression who initially respond to acute treatment with ECT plus pharmacotherapy. (See "Overview of electroconvulsive therapy (ECT) for adults", section on 'Efficacy'.)
FEEDING AND EATING DISORDERS
Olanzapine for anorexia nervosa (January 2017)
Many patients with anorexia nervosa decline or do not respond to first-line treatment with nutritional rehabilitation (refeeding) and psychotherapy. For these patients, olanzapine has often been used as add-on treatment, despite low-quality evidence for its efficacy. Increased support for this approach was demonstrated by the preliminary findings from a large randomized trial (n = 152) that compared olanzapine with placebo and found a modest advantage with olanzapine, such that weight gain with active drug exceeded weight gain with placebo by approximately one pound per month . (See "Anorexia nervosa in adults: Pharmacotherapy", section on 'Olanzapine'.)
Age of symptom onset and diagnosis of adult ADHD (September 2016)
Attention deficit hyperactivity disorder (ADHD) is conceptualized as a disorder with childhood onset that persists in adulthood. DSM-5 diagnostic criteria for adult ADHD require the presence of several symptoms prior to age 12 years. Multiple recent studies, however, have challenged this understanding of the disorder. One of them, a longitudinal cohort study, followed all children born in Pelotas, Brazil in 1993 up to the ages of 18 or 19 years . Three hundred ninety-three of the 5249 children were diagnosed with ADHD at age 11 and 492 were diagnosed with ADHD at age 18 or 19 years. Only 60 children with ADHD continued to have ADHD as young adults (17.2 percent) and only 60 young adults with ADHD had the disorder in childhood (12.6 percent). The requirement of childhood onset for the diagnosis of adult ADHD is controversial and may be reexamined as further data become available. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Course'.)
PSYCHIATRIC CONSEQUENCES OF MEDICAL CONDITIONS
Antipsychotics for delirium in terminally ill patients (January 2017)
The benefit of antipsychotics for management of delirium in terminally ill patients has been called into question by a randomized trial in which 247 inpatients of a hospice or palliative care service with mild to moderately severe delirium were assigned to oral risperidone, haloperidol, or placebo every 12 hours for 72 hours . All patients received individualized supportive care. Patients who received antipsychotics had more severe delirium, worse delirium-associated distress scores, more use of midazolam, more extrapyramidal effects, and worse short-term survival. In our view, this study does not justify abandoning the use of antipsychotics for severely agitated delirious patients but points to the importance of reversing precipitating causes, providing best supportive care for symptomatic distress associated with delirium, and the need for additional research on the use of antipsychotics. (See "Overview of managing common non-pain symptoms in palliative care", section on 'Treatment'.)
Abnormal glucose homeostasis in unmedicated schizophrenia (February 2017)
Hyperglycemia in patients with schizophrenia is principally thought of as a side effect of antipsychotic medications. However, in a meta-analysis of case-control studies comparing glucose homeostasis in antipsychotic-naïve individuals with first-episode schizophrenia versus healthy controls, patients with schizophrenia had higher fasting plasma glucose and insulin levels, lower glucose tolerance, and greater insulin resistance compared with controls, indicating altered glucose homeostasis from illness onset . Glycosylated hemoglobin did not differ between groups. Prospective studies are needed to determine whether the alterations are intrinsic to schizophrenia versus a result of factors associated with the disorder, such as a more sedentary lifestyle. (See "Schizophrenia: Clinical manifestations, course, assessment, and diagnosis", section on 'Metabolic disturbances'.)
Pharmacotherapy for antipsychotic-induced akathisia in schizophrenia (October 2016)
Benzodiazepines, beta blockers, and the anticholinergic drug benztropine are believed to be comparably effective in the treatment of akathisia in schizophrenia patients, based upon limited data from small clinical trials. Until recently, we favored benzodiazepines for first line treatment of akathisia. Earlier in 2016, however, a large retrospective analysis of claims and mortality data reported an increased mortality risk associated with benzodiazepine use in patients with schizophrenia . Subsequently, a dose-related relationship between cumulative benzodiazepine use and increased mortality was found in a national registry study of over 20,000 Swedish adults with schizophrenia . Although the study designs do not allow causality to be determined, based upon these findings, we now suggest that a beta blocker, such as propranolol, be used as first-line treatment for akathisia. Benzodiazepines remain an option, particularly in patients who do not respond to a beta blocker or benztropine. (See "Pharmacotherapy for schizophrenia: Side effect management", section on 'Akathisia'.)
Adjunctive antidepressant treatment in patients with schizophrenia (September 2016)
Approximately one in four patients with schizophrenia will experience a major depressive episode in their lifetime. Identification and management of depression requires exclusion of other clinical entities with overlapping presentations, such as negative symptoms of schizophrenia or antipsychotic drug-induced extrapyramidal symptoms. Previous systematic reviews have reported mixed effects of adjunctive antidepressants in schizophrenia patients; the clinical trials have multiple methodological limitations. A recent systematic review and meta-analysis, the largest to date, found that adjunctive antidepressant treatment compared with placebo or no adjunctive treatment in antipsychotic-treated schizophrenia patients led to reductions in depressive, negative, and overall symptoms without increasing psychotic symptoms . Beyond the typical antidepressant side effects, no differences in adverse events were seen between groups. The findings support antidepressant treatment of apparent depression in schizophrenia, particularly after optimization of antipsychotic medication management. (See "Depression in schizophrenia", section on 'Pharmacotherapy for major depressive disorder'.)
SOMATIC SYMPTOM AND RELATED DISORDERS
Treatment for somatic symptom disorder (November 2016)
Somatic symptom disorder (SSD) is characterized by at least one distressing somatic symptom and excessive thoughts, feelings, or behaviors associated with somatic symptoms or related health concerns, whereas illness anxiety disorder (IAD) is characterized by high levels of anxiety about health without or with only mild somatic symptoms. Cognitive-behavioral therapy (CBT) is effective for these conditions. In a 12-week trial, 130 patients with SSD or IAD (86 percent had SSD) were randomly assigned to CBT or a waiting list control group . Compared with the control group, there was significant improvement in health anxiety measures with CBT, and the benefit of CBT was maintained at the six-month follow-up assessment. (See "Somatization: Treatment and prognosis", section on 'Cognitive behavioral therapy'.)
Interactive web-based CBT for chronic insomnia (January 2017)
Cognitive behavioral therapy (CBT) is an effective treatment of chronic insomnia, but access to trained practitioners can be limited. In a randomized trial of 303 adults recruited via the internet, a six-week interactive web-based CBT program resulted in greater improvement in subjective sleep measures than internet patient education alone, and benefits were sustained at one year . Thus, internet-based CBT programs may be an alternative to in-person delivery for motivated, technology-savvy individuals. (See "Treatment of insomnia", section on 'Cognitive behavioral therapy'.)
Psychotropic medication and violent reoffending after prison release (November 2016)
The prevalence of severe mental illness has been estimated at 15 to 25 percent of people in US prisons. Assuring mental health care continuity in the community for people on release from prison may prevent subsequent incarceration. In a cohort study of released prisoners in Sweden, rates of violent reoffending were lower during periods when people received psychotropic medications (antipsychotics, psychostimulants, and/or drugs to treat substance use disorder) compared with periods when they were not medicated . Assuring mental health care continuity in the community for people on release from prison may prevent subsequent incarceration. (See "Clinical care of incarcerated adults", section on 'Psychiatric disorders'.)
Use of adjunctive antidepressants for treating complicated grief with comorbid depression (August 2016)
Complicated grief is a distinct syndrome that often occurs in bereaved individuals and is characterized by maladaptive thoughts, dysfunctional behaviors, and poorly regulated emotions. The best treatment for complicated grief is psychotherapy that is specific for complicated grief (complicated grief therapy, CGT). Antidepressants are frequently prescribed as an adjunctive therapy. Although adjunctive antidepressants do not appear to mitigate symptoms of complicated grief, they can improve comorbid unipolar major depression, which is common. In a recent trial, 395 adults with complicated grief were randomly assigned to citalopram alone, placebo alone, CGT plus citalopram, or CGT plus placebo . As expected, more patients responded to CGT plus placebo than placebo alone. The addition of citalopram did not significantly improve complicated grief outcomes. However, improvement of depressive symptoms was greater with citalopram. Thus, in patients with complicated grief and depressive symptoms, the addition of citalopram may be helpful. (See "Complicated grief in adults: Treatment", section on 'Other options'.)
Cognitive-behavioral therapy and other psychotherapies for prevention of recurrent self-harm (August 2016)
Self-harm is defined as an intentional act of self-injury, regardless of suicidal intent, and is a growing problem that consumes considerable hospital resources. Psychotherapy is typically used to manage patients who self-harm, and a recent study establishes that specific psychotherapies can be beneficial. A meta-analysis of 10 randomized trials compared cognitive-behavioral therapy (CBT) or problem solving therapy with usual care in >2200 patients with an episode of self-harm who were followed for up to 12 months . Repetition of self-harm was less likely to occur with CBT/problem solving therapy than usual care (odds ratio 0.80). In addition, improvement of depression, including hopelessness and suicidal ideation, was greater with active treatment. The review also included a meta-analysis of three randomized trials that compared dialectical behavior therapy with usual care in patients with an episode of self-harm; the frequency of self-harm decreased more with dialectical behavior therapy. (See "Suicidal ideation and behavior in adults", section on 'Psychotherapy'.)
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