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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.
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'.)
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'.)
MEDICAL CONSEQUENCES OF PSYCHIATRIC DISORDERS
Amygdalar activity and cardiovascular events (March 2017)
In a retrospective study of patients who underwent positron emission tomography/computerized tomography and were followed for a median of four years, increased resting metabolic activity in the amygdala was associated with an increased risk of cardiovascular events such as myocardial infarction, stroke, and unstable angina . A separate cross-sectional study showed that perceived stress was positively associated with amygdalar activity and arterial inflammation. These studies further add to the evidence that chronic emotional stress is associated with an increased risk of cardiovascular disease, and the mechanism that underlies this association may involve neural circuits that include the amygdala. (See "Psychosocial factors in acute myocardial infarction", section on 'Central nervous system dysfunction'.)
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
Psychiatric comorbidities in patients with narcolepsy (March 2017)
Small studies have found an increased rate of depression in patients with narcolepsy, but the risk of other psychiatric comorbidities has not been well established. In a population-based case-control study that included 9312 adults with narcolepsy and more than 45,000 age- and gender-matched controls, a broad range of psychiatric disorders were more common in patients with narcolepsy; the most prevalent were depressive disorders and anxiety, which were three to four times more common than in controls . Thus, recognition and treatment of psychiatric disorders is an important component of the care of patients with narcolepsy. (See "Clinical features and diagnosis of narcolepsy in adults", section on 'Other features'.)
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'.)
Antipsychotic drugs and risk of falls and fracture (March 2017)
In a large, population-based sample of Finnish people with Alzheimer disease, new users of antipsychotic medication had an increased risk of hip fractures from the first days of use . Subsequent to multiple similar reports in patients with varied disorders, the US Food and Drug Administration (FDA) issued a warning that antipsychotic drugs may cause falls and fractures as a result of somnolence, postural hypotension, and/or motor and sensory instability, and recommended that a fall risk assessment be completed when initiating antipsychotic treatment and recurrently for patients continuing on long-term antipsychotics. (See "Second-generation antipsychotic medications: Pharmacology, administration, and side effects", section on 'Falls'.)
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'.)
SUBSTANCE USE DISORDERS
Heroin and fentanyl may drive rise in opioid overdose deaths (February 2017)
Mortality rates from drug overdoses involving methadone declined in 2015 in the United States, while drug overdoses involving heroin and synthetic opioids other than methadone increased sharply . The rise in overdoses from synthetic opioids was likely driven by illicitly manufactured fentanyl, a highly potent opioid used to "cut" heroin. (See "Prevention of lethal opioid overdose in the community", section on 'Epidemiology of overdose'.)
AASM guideline on pharmacotherapy for chronic insomnia in adults (March 2017)
The American Academy of Sleep Medicine (AASM) has released a new clinical practice guideline on the pharmacologic treatment of chronic insomnia in adults . The guideline reviews evidence of effectiveness for a variety of medications (including benzodiazepines, nonbenzodiazepine hypnotics, ramelteon, doxepin, and suvorexant) and notes limitations and potential biases to the evidence, leading to low confidence in the overall estimation of risk-to-benefit ratio. The potential short-term benefits of pharmacologic therapy need to be balanced with the risk of side effects and dependence with long-term use. We continue to prefer behavioral therapy, rather than pharmacotherapy, as an initial treatment approach in most patients. (See "Treatment of insomnia in adults", section on 'Choice of an agent'.)
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 in adults", 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'.)
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- Attia E. Who is Willing to Take Olanzapine and Why? An Initial Look at Outpatient Participants in an Olanzapine vs Placebo Trial for Anorexia Nervosa. Presented at the XXII Annual Meeting of the Eating Disorders Research Society, New York, NY, October 29, 2016.
- Tawakol A, Ishai A, Takx RA, et al. Relation between resting amygdalar activity and cardiovascular events: a longitudinal and cohort study. Lancet 2017; 389:834.
- Caye A, Rocha TB, Anselmi L, et al. Attention-Deficit/Hyperactivity Disorder Trajectories From Childhood to Young Adulthood: Evidence From a Birth Cohort Supporting a Late-Onset Syndrome. JAMA Psychiatry 2016; 73:705.
- Ruoff CM, Reaven NL, Funk SE, et al. High Rates of Psychiatric Comorbidity in Narcolepsy: Findings From the Burden of Narcolepsy Disease (BOND) Study of 9,312 Patients in the United States. J Clin Psychiatry 2017; 78:171.
- Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:34.
- Koponen M, Taipale H, Lavikainen P, et al. Antipsychotic Use and the Risk of Hip Fracture Among Community-Dwelling Persons With Alzheimer's Disease. J Clin Psychiatry 2017.
- Pillinger T, Beck K, Gobjila C, et al. Impaired Glucose Homeostasis in First-Episode Schizophrenia: A Systematic Review and Meta-analysis. JAMA Psychiatry 2017.
- Fontanella CA, Campo JV, Phillips GS, et al. Benzodiazepine use and risk of mortality among patients with schizophrenia: a retrospective longitudinal study. J Clin Psychiatry 2016; 77:661.
- Tiihonen J, Mittendorfer-Rutz E, Torniainen M, et al. Mortality and Cumulative Exposure to Antipsychotics, Antidepressants, and Benzodiazepines in Patients With Schizophrenia: An Observational Follow-Up Study. Am J Psychiatry 2016; 173:600.
- Helfer B, Samara MT, Huhn M, et al. Efficacy and Safety of Antidepressants Added to Antipsychotics for Schizophrenia: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016; 173:876.
- Hedman E, Axelsson E, Andersson E, et al. Exposure-based cognitive-behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: randomised controlled trial. Br J Psychiatry 2016; 209:407.
- Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2016; 65:1445.
- Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2017; 13:307.
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- Chang Z, Lichtenstein P, Långström N, et al. Association Between Prescription of Major Psychotropic Medications and Violent Reoffending After Prison Release. JAMA 2016; 316:1798.