Dr. David Unwin, a family physician in England, has been treating patients with low carb diets since 2012. He is offering this online course that will cover very practical tips for doctors, like how to effectively discuss the low-carb lifestyle with patients, how to handle medications, safety, patient motivation, etc. 

Transcript for Video #10 is HERE
The full course can be found: HERE

SOURCE: DocGuide - JAMA Psychiatry 
DATE: February 2018

Importance
Duration of untreated psychosis (DUP) has been associated with poor outcomes in schizophrenia, but the mechanism responsible for this association is not known.
Objectives
To determine whether hippocampal volume loss occurs during the initial 8 weeks of antipsychotic treatment and whether it is associated with DUP, and to examine molecular biomarkers in association with hippocampal volume loss and DUP.
Design, Setting, and Participants
A naturalistic longitudinal study with matched healthy controls was conducted at Shanghai Mental Health Center. Between March 5, 2013, and October 8, 2014, 71 medication-naive individuals with nonaffective first-episode psychosis (FEP) and 73 age- and sex-matched healthy controls were recruited. After approximately 8 weeks, 31 participants with FEP and 32 controls were reassessed.
Exposures
The participants with FEP were treated according to standard clinical practice with second-generation antipsychotics.
Main Outcomes and Measures
Hippocampal volumetric integrity (HVI) (an automated estimate of the parenchymal fraction in a standardized hippocampal volume of interest), DUP, 13 peripheral molecular biomarkers, and 14 single-nucleotide polymorphisms from 12 candidate genes were determined.
Results
The full sample consisted of 71 individuals with FEP (39 women and 32 men; mean [SD] age, 25.2 [7.7]years) and 73 healthy controls (40 women and 33 men; mean [SD] age, 23.9 [6.4]years). Baseline median left HVI was lower in the FEP group (n = 57) compared with the controls (n = 54) (0.9275 vs 0.9512; difference in point estimate, -0.020 [95% CI, -0.029 to -0.010]; P = .001). During approximately 8 weeks of antipsychotic treatment, left HVI decreased in 24 participants with FEP at a median annualized rate of -.03791 (-4.1% annualized change from baseline) compared with an increase of 0.00115 (0.13% annualized change from baseline) in 31 controls (difference in point estimate, -0.0424 [95% CI, -0.0707 to -0.0164]; P = .001). The change in left HVI was inversely associated with DUP (r = -0.61; P = .002). Similar results were found for right HVI, although the association between change in right HVI and DUP did not achieve statistical significance (r = -0.35; P = .10). Exploratory analyses restricted to the left HVI revealed an association between left HVI and markers of inflammation, oxidative stress, brain-derived neurotrophic factor, glial injury, and markers reflecting dopaminergic and glutamatergic transmission.
Conclusions and Relevance
An association between longer DUP and accelerated hippocampal atrophy during initial treatment suggests that psychosis may have persistent, possibly deleterious, effects on brain structure. Additional studies are needed to replicate these exploratory findings of molecular mechanisms by which untreated psychosis may affect hippocampal volume and to determine whether these effects account for the known association between longer DUP and poor outcome.

SOURCE:  JAMA
DATE: February 28, 2018

Key Points
Question  
What are the incidence of and trends in gender-affirming surgery over time in the United States?
Findings  
In this population-based study of 37 827 gender-affirming surgical encounters, genital surgery increased over time and most patients undergoing these procedures were self-payers. The number of patients seeking these procedures who were covered by Medicare or Medicaid increased from 2012 to 2014 by 3-fold.
Meaning  
As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them.

Recently, as I've been exploring the role of an individual's diet in Integrated Psychiatry, I've seen a growing body of research to support the use of a Ketogenic-style diet to enhance brain functioning and help people achieve a healthy weight. There is additional research, which theorizes such a diet could be helpful for a number of mental health conditions from ADHD and depression to Alzheimer's Disease.

Just a few of the articles I've been looking at: 

• Article: Long-term effects of a ketogenic diet in obese patients 
• Article: The neuroprotective properties of calorie restriction, the ketogenic diet, and ketone bodies
• Article: Dietary ketosis enhances memory in mild cognitive impairment​
• Article: The antidepressant properties of the ketogenic diet​

SOURCE: JAMA
DATE: ​February 28, 2018

Key Points
​Question  
What is the comparative effectiveness of pharmacologic treatments in the prevention of rehospitalization in bipolar disorder?
Findings  
In this Finnish nationwide cohort study of 18 018 patients, lithium use was associated with the lowest risk of rehospitalization because of mental or somatic disorder. The risk of rehospitalization was about 30% lower during treatment with long-acting injections compared with treatment with their oral counterparts.
Meaning  
In bipolar disorder, lithium should remain the first line of treatment, and long-acting injections might offer a safe, effective option for patients in whom lithium is not suitable.

Dr. David Unwin, a family physician in England, has been treating patients with low carb diets since 2012. He is offering this online course that will cover very practical tips for doctors, like how to effectively discuss the low-carb lifestyle with patients, how to handle medications, safety, patient motivation, etc. 

Transcript for Video #8 is HERE
The full course can be found: HERE

SOURCE: JAMA

Association of Increased Chronicity of Depression With HIV Appointment Attendance, Treatment Failure, and Mortality Among HIV-Infected Adults in the United States

​​Key Points
Question 
For adults living with HIV, is the percentage of time spent with depression associated with appointment attendance, treatment failure, and mortality?

Finding 
In this large, multisite clinical cohort study, a greater time spent with depression was associated in a dose-response fashion with higher risk of missing appointments for HIV primary care, higher risk of detectable viral load, and higher mortality rates.

Meaning 
Although entirely eliminating depression is impractical, even shortening the duration of depressive episodes (eg, through integration of improved screening and evidence-based depression treatment into HIV care) may have important HIV-related benefits.

Recently, as I've been exploring the role of an individual's diet in Integrated Psychiatry, I've seen a growing body of research to support the use of a Ketogenic-style diet to enhance brain functioning and help people achieve a healthy weight. There is additional research, which theorizes such a diet could be helpful for a number of mental health conditions from ADHD and depression to Alzheimer's Disease.

Just a few of the articles I've been looking at: 

• Article: Long-term effects of a ketogenic diet in obese patients 
• Article: The neuroprotective properties of calorie restriction, the ketogenic diet, and ketone bodies
• Article: Dietary ketosis enhances memory in mild cognitive impairment​
• Article: The antidepressant properties of the ketogenic diet​

 ​

Title: Treatment agreement, adherence and outcome in cognitive behavioral therapy for insomnia
Source: Journal of Consulting and Clinical Psychology
​
Reduced adherence to psychological therapies is associated with poorer treatment outcomes in insomnia and has been identified as a barrier to treatment. Adherence to CBT can be examined using a number of different measures, nevertheless, assessing adherence can be difficult in clinical settings. Using clinical trial data, Dong and colleagues evaluated therapist ratings of patient adherence and agreement with the Adherence to Behavioural Strategies (ABS) coding grid - a measure of adherence to sleep diaries. Associations between treatment adherence, agreement and CBT outcomes were also examined. Therapist ratings of adherence were found to be positively associated with higher global ABS scores and predicted reductions in insomnia symptoms. Patient agreement with the treatment was also found to predict reductions in insomnia symptoms from pre-treatment to 6-months follow-up. Similarly, therapist-rated patient agreement, adherence and global ABS scores were predictive of insomnia remission at post-treatment, and therapist-rated adherence was the only predictor of remission at 6-months. Findings suggest therapist monitoring of patient adherence may be a simple way of determining adherence and highlights the importance of monitoring patients throughout therapy. 

Title: Insomnia - perchance a dream? Results from a NREM/REM sleep awakening study in good sleepers and patients with insomnia. 
Source: Sleep

Unlike normal sleepers, patients with insomnia can display discrepancies between objective and self-reported estimations of sleep duration. Hyperarousal, the tendency for insomnia patients to present with increased physiological activation, may help provide an explanation for this common clinical feature. Feige and colleagues suggest microarousals experienced during REM sleep may account for subjective-objective discrepancies. Arousal thresholds were examined to understand the impact of awakenings on sleep perception in both insomnia patients (n=27) and matched normal sleepers (n=27). All underwent polysomnography over four nights, and experienced three awakenings from either Stage 2 or REM sleep on nights three and four. Results suggest waking thresholds did not differentiate between groups, however, insomnia patients reported more instances of being awake when woken from REM than normal sleepers. Reports were similar during Stage 2 sleep for both groups. Furthermore, emotionally negative mentation experienced during REM sleep was significantly stronger in insomnia patients. Thus, altered subjective reports of sleep may be associated with microarousals during REM sleep in insomnia patients.

​Title: Are sleep disturbances causally linked to the presence and severity of psychotic-like, dissociative and hypomanic experiences in non-clinical populations? A systematic review.
Source: Neuroscience and Biobehavioral Reviews

Sleep disturbance may predict the occurrence of psychiatric symptoms in both clinical and non-clinical populations, however previous systematic reviews have focused only on clinical samples. Barton and colleagues aim to examine the relationship between sleep disturbance and psychotic symptoms (paranoia, delusions, hallucinations, positive and negative schizotypy), dissociation and hypomania in non-clinical populations. They found that all experiences examined were associated with some degree of sleep disturbance. Insomnia was universally associated with all psychotic, dissociative and hypomanic experiences and parasomnias correlated with psychotic experiences. Nightmare distress was associated with hypomania and psychotic symptoms with small-to-large effects; and evening chronotype was associated with dissociation and hypomania. Although many of the reviewed studies were cross-sectional, there was partial evidence of a causal link between sleep disturbance and psychotic and dissociative experiences, however effect sizes varied. This review hints at a potential causal link between sleep disturbance and psychotic symptoms in non-clinical individuals and highlights the need for future research in this area.

​

SOURCE: DocGuide 

BACKGROUND AND PURPOSE
Intravenous thrombolysis (IVT) improves outcomes after acute ischemic stroke but is underused in certain patient populations. Mental illness is pervasive in the United States, and patients with comorbid psychiatric disease experience inequities in treatment for a range of conditions. We aimed to determine whether comorbid psychiatric disease is associated with differences in IVT use in acute ischemic stroke.
METHODS
Acute ischemic stroke admissions between 2007 and 2011 were identified in the Nationwide Inpatient Sample. Psychiatric disease was defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes for secondary diagnoses of schizophrenia or other psychoses, bipolar disorder, depression, or anxiety. Using logistic regression, we tested the association between IVT and psychiatric disease, controlling for demographic, clinical, and hospital factors.
RESULTS
Of the 325 009 ischemic stroke cases meeting inclusion criteria, 12.8% had any of the specified psychiatric comorbidities. IVT was used in 3.6% of those with, and 4.4% of those without, psychiatric disease (P<0.001). Presence of any psychiatric disease was associated with lower odds of receiving IVT (adjusted odds ratio, 0.80; 95% confidence interval, 0.76-0.85). When psychiatric diagnoses were analyzed separately individuals with schizophrenia or other psychoses, anxiety, or depression each had significantly lower odds of IVT compared to individuals without psychiatric disease.
CONCLUSIONS
Acute ischemic stroke patients with comorbid psychiatric disease have significantly lower odds of IVT. Understanding barriers to IVT use in such patients may help in developing interventions to increase access to evidence-based stroke care.

REFERENCES
Bongiorno D, Daumit G, Gottesman R, Faigle R; Stroke (Jan 2018)

Recently, as I've been exploring the role of an individual's diet in Integrated Psychiatry, I've seen a growing body of research to support the use of a Ketogenic-style diet to enhance brain functioning and help people achieve a healthy weight. There is additional research, which theorizes such a diet could be helpful for a number of mental health conditions from ADHD and depression to Alzheimer's Disease.

Just a few of the articles I've been looking at: 

• Article: Long-term effects of a ketogenic diet in obese patients 
• Article: The neuroprotective properties of calorie restriction, the ketogenic diet, and ketone bodies
• Article: Dietary ketosis enhances memory in mild cognitive impairment​
• Article: The antidepressant properties of the ketogenic diet​

 

Dr. David Unwin, a family physician in England, has been treating patients with low carb diets since 2012. He is offering this online course that will cover very practical tips for doctors, like how to effectively discuss the low-carb lifestyle with patients, how to handle medications, safety, patient motivation, etc. ​

SOURCE: JAMA

Key Points
Question 
What is the association between long-term school performance and prenatal exposure to valproate sodium and other antiepileptic drugs?

Findings 
In this population-based cohort study including 479 027 children, 1865 children were exposed to different antiepileptic drugs in pregnancy. Prenatal exposure to valproate was associated with impaired school performance in both primary and lower secondary schooling compared with children unexposed to antiepileptic drugs and children exposed to lamotrigine.

Meaning 
Prenatal valproate exposure may be associated with long-term impairment of school performance.

This form was born out of frustration.  Frustration with the unfathomable mess that electronic prescribing systems create when you are try to create a clean and tidy med list for a patient's records.  There is rarely a spot in the record for trials, unless you make one and that only helps a patient so much.

​So - I created a printout that patients can take away with them and complete, so that we can have an informed discussion about past trials that results in something other than me pulling my hair out. 

SOURCE: Psychopharmacology Institute 
AUTHOR: ​Sandra A. Jacobson, M.D.

Geriatric Psychopharmacology: How Pharmacokinetic and Pharmacodynamic Changes Affect Prescribing

In terms of pharmacokinetic changes, aging slows hepatic metabolism. However, liver function tests are poorly correlated with drug metabolizing activity.

Normal aging does not affect glucuronidation reactions, but it does affect oxidation reactions. Psychotropics metabolized by glucuronidation are preferred in the elderly.

Pharmacodynamic changes include reduction of M1 signal transduction, among other alterations. This makes elderly patients more sensitive to anticholinergic effects.

First, pharmacokinetics. Think for a minute about how an oral drug works. It has to get into the bloodstream by absorption. It has to get to the brain by distribution. It has to have some effect at the level of the receptor. And then it has to be cleared from the body either by direct elimination or more commonly by metabolism and then elimination.