Annals of Clinical Psychiatry

DSM-5 introduced the anxious distress specifier in recognition of the significance of anxiety in patients who are depressed. Studies have supported the validity of the specifier in patients with major depressive disorder (MDD). In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the validity of the specifier in patients with bipolar depression.

Forty-nine patients with a principal diagnosis of bipolar depression and 369 with MDD were evaluated with semi-structured diagnostic interviews, including the DSM-5 Anxious Distress Specifier Interview (DADSI). The patients were rated on measures of depression, anxiety, and irritability, and completed self-report measures.

The majority of patients with bipolar depression met the DSM-5 anxious distress specifier, no different than the frequency in patients with MDD. The DADSI was significantly correlated with other measures of anxiety, and more highly correlated with other measures of anxiety than with measures of depression and irritability. Patients with panic and generalized anxiety disorder scored higher on the DADSI than patients without an anxiety disorder.

The results of our study indicate that anxious distress is common in patients with bipolar depression and support the validity of the DSM-5 anxious distress specifier.

Patients who drop out of clinical trials examining posttraumatic stress disorder (PTSD) may have different characteristics than patients who continue. These characteristics have never been examined in prior PTSD and attrition trials. Our goal was to examine how demographic and clinical characteristics of patients with PTSD impact attrition in a randomized controlled trial.

A total of 18 participants were recruited. Data were collected through questionnaires to assess PTSD, depression, and mood disorders. Fisher's exact test was used to examine the association of various categorical demographic and clinical variables with dropout. A Wilcoxon rank sum test was used to examine differences in medians.

The median total PTSD Checklist for DSM-5 score was 38 for patients who dropped out and 53 for those who did not. The depression scale total was also lower for the dropout group (7 vs 15). The insomnia index was lower for those who did not remain in the study (15 vs 21).

Posttraumatic stress disorder symptoms, depression, and insomnia were less severe in patients who dropped out compared with those who did not. Larger studies are needed to further examine these findings. This study could help guide future recruitment efforts for clinical trials examining PTSD.

Borderline personality disorder (BPD) and substance use disorder (SUD) frequently co-occur. Although some research has investigated the factors related to this comorbidity, few have isolated the effects of SUD on a BPD diagnosis.

Patients presenting for treatment were assessed with the Structured Clinical Interview for DSM-IV, the BPD module of the Structured Interview for DSM-IV Personality, the Difficulties in Emotion Regulation Scale (DERS), and the Five Facet Mindfulness Questionnaire (FFMQ). Analyses were conducted to determine how individuals diagnosed with BPD differ from individuals diagnosed with BPD and SUD.

Among the BPD diagnostic criteria, patients with comorbid BPD and SUD endorsed impulsivity at higher rates, and patients with only BPD more frequently endorsed frantic efforts to avoid real or imagined abandonment. The 2 groups were not distinguished by scores on the DERS, although the comorbid group reported higher FFMQ scores, specifically on the acting with awareness subscale.

Borderline personality disorder is fundamentally based on emotion dysregulation. Substance use and efforts to avoid abandonment are both forms of maladaptive coping that stem from this dysregulation, and individuals with BPD may tend to rely on one or the other. Future studies should continue to evaluate these clinical features across diverse groups.

Despite the prevalence of comorbid late-life treatment-resistant depression (LLTRD) and insomnia in older adults, there is a gap in the literature describing patient factors, such as patients’ beliefs about their illnesses and preferences for treatment, that can facilitate recovery. Therefore, we explored the perceptions and treatment preferences of older veterans with LLTRD and insomnia.

Semi-structured interviews were completed with 11 older veterans. A thematic analysis of the interviews was conducted.

Four main themes were identified: 1. Insomnia and medical problems were considered to be significant contributors to depression, which was defined by low mood and anhedonia; 2. "Overthinking'’ was thought to be a cause of insomnia; 3. Participants’ preference for psychotherapy was driven by their past experiences with therapy; and 4. Participants viewed patient education as a facilitator for compliance.

Older veterans with LLTRD and insomnia have a preference for behavioral interventions. However, they lack knowledge about available treatment options, such as behavioral interventions for sleep that can improve both their sleep and mood while being a good fit with their illness narratives, such as "overthinking." There is a need for patient education, which should be offered early and often during treatment.

Debilitating symptoms of schizophrenia often persist after sustained treatment with atypical antipsychotics. To date, clozapine has been the most effective of the atypical antipsychotics; however, negative symptoms may persist, indicating a critical need to develop augmenting treatment approaches.

A retrospective chart review evaluated outcomes for 5 young adult inpatients with treatment-resistant schizophrenia who were prescribed off-label oxytocin (OT; 10 IU/sublingual, 1 time per day, to 20 IU/sublingual, 3 times per day) after their therapeutic response to clozapine plateaued (dose range: 200 to 600 mg). The augmented treatment was well tolerated and continued for at least 1 year after discharge from the hospital, with continued outpatient follow-up by the treating psychiatrist. Evaluation included the Positive and Negative Syndrome Scale and clinical review based on both self and parent/guardian reports.

The augmentation of clozapine with sublingual OT in young adults with treatment-resistant schizophrenia appeared to reduce negative symptoms, maintain lowered positive symptoms, and increase occupational and social functioning (eg, return to work or school), as noted by family members.

Future controlled, prospective studies should investigate the possibility that OT can significantly reduce negative symptoms of chronic psychotic illnesses that are inadequately responsive to clozapine or other antipsychotic medications alone.

Previous research shows that mindfulness and emotion regulation (ER) are highly related to each other. Preliminary evidence in small clinical populations show that ER may partially account for the relationship between mindfulness and depressive symptoms. The present study aimed to investigate which diagnostic categories were associated with depressive symptoms after controlling for ER in a heterogeneous sample of treatment-seeking patients.

A large sample of psychiatric outpatients (N = 911) completed the Structured Clinical Interview for DSM-IV (SCID), Five Facet Mindfulness Questionnaire (FFMQ), Difficulties in Emotion Regulation Scale (DERS), and Clinically Useful Depression Outcome Scale (CUDOS). Partial correlations were conducted to evaluate to what degree the relationship between depression scores and facets of mindfulness were accounted for by ER scores.

When controlling for baseline mindfulness, the relationship between emotion dysregulation and depression symptoms remained significant for all data points; however, when controlling for baseline emotion dysregulation, the association between mindfulness and depression was not significant in the majority of cases. Nonjudging was most resistant to this result.

Although mindfulness is negatively associated with depressive symptoms, this association may be better accounted for by emotion dysregulation.

Psychiatric disorders are the most common cause of suicide attempts. Some studies have shown there is a relationship between low vitamin D levels and psychiatric disorders. In this study, we examined the relationship between suicidal behavior and vitamin D levels in adolescents.

This study included 215 patients who presented to the pediatric emergency department due to a suicide attempt (patient group) and 200 healthy individuals (control group). Demographic and clinical features of both groups were recorded, and serum vitamin D, calcium, and phosphorus levels were measured. The groups were compared in terms of these factors. All data were analyzed using the SPSS 20.0 (SPSS Inc., Illinois, USA) software program.

The mean vitamin D level was 19.4 ± 10 ng/mL in the control group and 12.3 ± 6 ng/mL in the patient group (t = 8.8 and P = .01). The mean serum total calcium level was 9.9 ± 0.3 mg/dL in the control group and 9.4 ± 0.5 mg/dL in the patient group (P < .01).

Vitamin D deficiency, which is a treatable condition, may be one of the causes of suicidal behavior in adolescents. Therefore, we believe that physicians who treat adolescents should consider vitamin D levels in routine examinations.

Benzodiazepines are currently the most commonly prescribed medication for the treatment of anxiety in older adults, although there is a dearth of good-quality data on this subject. The aim of this review was to systematically review studies examining the efficacy and tolerability of benzodiazepines for the treatment of anxiety disorders among older adults.

The authors conducted a systematic review, searching PubMed, Ovid MEDLINE, Ovid Embase, Web of Science, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. All searches were limitedto English-language articles. The quality of each study was appraised using criteria developed by the Centre for Evidence-Based Medicine for randomized controlled trials.

A total of 8,785 citations were retrieved and pooled in EndNote and de-duplicated to 3,753. This set was uploaded to Covidence for screening. Two separate screeners (AG and SAF) evaluated the titles, abstracts, and full text of the eligible articles. Five studies met the inclusion criteria. Across all studies, benzodiazepines were associated with decreased anxiety at the end of the study period. The limited tolerability data show mild adverse effects from the benzodiazepines studied. Limitations of the trials included limited data on the long-term use of benzodiazepines for anxiety and a preponderance of trials examining generalized anxiety disorder, with relatively less data on other anxiety disorders.

Benzodiazepines are effective for treating anxiety disorders in late life, at least in the short term, but more data is needed to establish tolerability and their long-term benefits.

Behavioral and psychological symptoms of dementia (BPSD) are challenging to recognize and treat effectively. Despite very effective nonpharmacologic strategies, there are cases where severe BPSD may require biological intervention. The purpose of this review was to clarify safe and evidence-based use of pharmacological agents based on available clinical trial evidence.

A structured search strategy was used in PubMed, Embase, and Psyclnfo to obtain the most relevant data regarding treatment of BPSD in patients with any-cause dementia.

We screened 1,442 English-language abstracts. Following initial screening, we had 184 unique references to review. A secondary search of these and review articles gave a total of 117 to tabulate and discuss. We categorized the results based on the following classifications: antidepressants, first-generation antipsychotics, second-generation antipsychotics, anticonvulsants/mood stabilizers, sedatives, stimulants, steroid therapies, other medications, other medication strategies, and medication withdrawal.

The judicious use of pharmacotherapy does seem to be appropriate in select cases where behavioral and psychological interventions have been partially effective or where symptoms confer imminent risk of harm.