The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Ketamine for unipolar depression: A systematic review of efficacy and safety

BackgroundUnipolar depression is a prevalent mental health disorder with persistent, treatment-resistant symptoms. Traditional antidepressants take weeks to show effects, underscoring the need for faster alternatives. Ketamine, originally an anaesthetic, has emerged as a rapid-acting antidepressant.ObjectiveThis systematic review evaluates ketamine's efficacy and safety in unipolar depression.MethodsA literature search (January 2000-May 2024) in PubMed, PsycINFO, and Cochrane Library included RCTs, CCTs, systematic reviews, meta-analyses, and observational studies on ketamine or esketamine in formally diagnosed individuals. Study characteristics, interventions, outcomes, and adverse events were analyzed, with quality and bias assessments.ResultsAcross 44 studies, ketamine significantly reduced depressive symptoms and suicidal ideation within hours, particularly in treatment-resistant cases, with effects lasting up to 1 week. Common side effects included transient dissociation, elevated blood pressure, nausea, and dizziness, while long-term safety remains uncertain.ConclusionsKetamine shows promise as a rapid antidepressant for treatment-resistant unipolar depression. However, long-term safety and optimal treatment protocols require further research. Careful clinical integration with monitoring is recommended.

Systematic Umbrella Review and Meta-Meta Analysis: Effectiveness of Physical Activity in Improving Depression and Anxiety in Children and Adolescents

OBJECTIVE

Depression and anxiety are prevalent and rising in children and adolescents, prompting interest in exercise as a potential therapeutic intervention. The aim of this systematic umbrella review and meta-meta-analysis was to evaluate the effects of exercise on depression and anxiety symptoms in children and adolescents and identify the most promising exercise-based approaches.

METHOD

This systematic umbrella review was preregistered (PROSPERO ID: CRD42024533558) and followed PRISMA and PRIOR guidelines. A search of 11 databases identified systematic reviews and meta-analyses of randomised controlled trials (RCTs) evaluating the effects of exercise (aerobic, resistance, mind-body exercise) on depression and anxiety symptoms in children and adolescents. Risk of bias was assessed using the AMSTAR-2 tool and certainty of evidence was assessed using GRADE. Meta-analyses were conducted to combine effect sizes, using random effects models. Subgroup analyses were performed to examine participant and intervention characteristics.

RESULTS

Twenty-one systematic reviews (n=375 RCTs, n=38,117 participants aged 5-18 years) were included. Participants had various clinical conditions including depression, psychosocial disorders, obesity, cancer, as well as healthy individuals. The pooled analysis found moderate effect sizes favouring exercise for symptoms of depression (SMD = -0.45 [95% CI, -0.59 to -0.31], I2 = 71.37%, p<0.01, 180 RCTs, n=34,490 participants) and anxiety (SMD = -0.39 [95% CI, -0.61 to -0.17], I2 = 68.1%, p<0.01, n=55 RCTs, n=24,797 participants). Mixed exercise modes and moderate-intensity exercise had the largest effects on depression, while resistance exercise was most effective for symptoms of anxiety. Interventions that were <12 weeks were more effective for depression compared with ≥12-week interventions. Benefits were generally consistent across populations. The certainty of evidence was moderate for depression and low to moderate for anxiety.

CONCLUSION

This meta-meta-analysis finds that exercise reduces depression and anxiety symptoms in children and adolescents. These results suggest that structured exercise programs should be considered as part of comprehensive care approaches.

Pramipexole Augmentation for Treatment-Resistant Unipolar Depression Not Responding to Aripiprazole Augmentation: An Observational Study

BACKGROUND

At least 50% of patients with treatment-resistant depression (TRD) fail to respond to antidepressant augmentation with aripiprazole (AA), currently the augmentation strategy with the best evidence of efficacy. The present observational study investigated whether pramipexole augmentation (PA) might be useful for patients who failed AA.

METHODS

We compared the short- and long-term effectiveness and safety of PA in 81 consecutively recruited unipolar patients with TRD, 58 (71.6%) not previously treated with AA (UAA) and 23 (28.4%) who previously failed AA (FAA).

RESULTS

The FAA and UAA groups did not differ significantly in terms of remission, response, improvement, and general functioning at 12 and 24 weeks and in terms of freedom from relapse at 12 and 24 months. The response rates at 24 weeks were 69.6% (n = 16) and 77.6% (n = 45), and the remission rates were 60.9% (n = 14) and 74.1% (n = 43), respectively. The rates of sustained response at 24 months were 72.7% (n = 8) and 84.2% (n = 16), respectively. The 2 groups did not differ significantly on safety outcomes (acceptability, tolerability, suicidality and suicide attempts) in the short and long term.

CONCLUSIONS

Our study showed that the off-label use of PA may be a promising treatment for patients with unipolar TRD who had previously failed respond to AA. The present findings are preliminary and should be interpreted with caution due to study limitations, including the flexibility of the add-on schedule and the small sample size of patients followed up for 12 and 24 months, and need to be confirmed in larger studies.

Extracellular vesicles derived from mesenchymal stem cells alleviate depressive-like behavior in a rat model of chronic stress

Depression is a prevalent chronic psychiatric disorder with a growing impact on global health. Current treatments often fail to achieve full remission, highlighting the need for alternative therapeutic strategies. Mesenchymal stem cells (MSCs) have attracted significant interest for their therapeutic potential in neuropsychiatric disorders, primarily due to their capacity to target neuroinflammation. This study aimed to investigate if extracellular vesicles derived from human umbilical MSCs (hucMSCs) promote behavioral beneficial actions in a rat model of chronic unpredictable mild stress (CUMS). We show that a single dose of hucMSCs or their derived EVs (hucMSC-EVs) via the tail vein alleviated depressive-like behavior in rats, reduced markers of neuroinflammation, reduced pro-inflammatory cytokines (IL-1β and TNF-α), and increased the number and dendritic complexity of DCX-positive cells in the dentate gyrus. Proteomic analysis of EVs revealed the presence of proteins involved in modulation of inflammatory processes and cell activation. Our study demonstrates EVs derived from hucMSCs can effectively mitigate depressive symptoms by modulating neuroinflammatory pathways and enhancing neurogenesis. These findings support further exploration of MSC-derived EVs as a novel therapeutic option for neuropsychiatric disorders.

Chronic health conditions and disability are prevalent among community users of a digital mental health service: a scoping survey

Objectives: Digital interventions can offer accessible and scalable treatment for chronic conditions, though often focus separately on physical or mental health. People accessing digital health services may live with multiple conditions or experience overlapping symptoms. This study aimed to describe the breadth and characteristics of chronic health conditions and self-reported disability among routine users of a digital mental health service, and to examine related motivations to engage with digital mental health interventions.

Methods: A cross-sectional survey of adults registered with a digital mental health service in the Australian community (THIS WAY UP) was conducted. Participant demography, chronic health conditions, self-reported disability and motivations for accessing digital treatment were collected and analyzed descriptively.

Results: 366 participants responded (77% female, mean age 50 ± 15 years). 71.6% of participants (242/338) reported ≥1 chronic health condition and one-third reported multimorbidity (112/338, 33.1%). Chronic pain, musculoskeletal and connective tissue disorders were most common. 26.9% of respondents (90/334) reported a disability, most commonly physical disabilities. 95% of those with chronic conditions reported negative mental health effects and 46% reported heightened interest in digital mental health treatments because of their condition. Primary motivations for digital service use were receiving a recommendation from a health professional and service accessibility.

Discussion: People who access digital mental health services in routine care report high rates of heterogenous chronic illness and related disability. There is interest in accessible digital treatments to support mental health at scale among people who live with varied chronic conditions and disabilities.

Association between sedentary behavior, depressive symptoms, and the risk of all-cause and cause-specific mortality among U.S. cancer survivors

BACKGROUND

Sedentary behavior and depressive symptoms are commonly observed in cancer survivors. However, the combined impact of these factors on the mortality outcomes of cancer survivors remains unknown.

METHODS

Cancer survivors from the National Health and Nutrition Examination Survey (NHANES) (2007-2018) were selected. Multivariate-adjusted Cox regression analyses were employed to examine the intendent and joint prognostic effects of sedentary behavior and depressive symptoms on the mortality outcomes of cancer survivors.

RESULTS

A total of 2,460 US adult cancer survivors (men = 1,143 and women = 1,317) were included. Severe sedentary behavior (≥ 8 h/day) was linked to higher all-cause [hazard ratio (HR) = 1.68, 95% confidence interval (CI): 1.36-2.09, p < 0.001] and noncancer mortality (HR = 1.80, 95% CI: 1.35-2.40, p < 0.001) in cancer survivors. Each additional hour of sedentary time increased the risk of all-cause (HR = 1.05, 95% CI: 1.02-1.08, p < 0.001) and noncancer mortality (HR = 1.07, 95% CI: 1.04-1.11, p < 0.001). Depressive symptoms (PHQ-9 ≥ 5) were also associated with higher all-cause (HR = 1.22, 95% CI: 1.01-1.48, p = 0.040) and noncancer mortality (HR = 1.27, 95% CI: 1.01-1.61, p = 0.045). In the joint analysis, cancer survivors with both depressive symptoms and severe sedentary behavior had the highest risk of all-cause mortality (HR = 2.06, 95% CI: 1.47-2.88, p < 0.001). Survivors with no depressive symptoms but severe sedentary behavior also had a higher risk (HR = 1.44, 95% CI: 1.10-1.88, p = 0.008). Additionally, the combination of depressive symptoms and severe sedentary behavior increased risks of cancer-specific (HR = 1.56, 95% CI: 1.04-2.34, p = 0.001), noncancer (HR = 1.86, 95% CI: 1.34-2.57, p < 0.001), and CMD-related mortality (HR = 1.74, 95% CI: 1.04-2.93, p = 0.037). In subgroup analysis, cancer survivors with endocrine-related and gastrointestinal cancers were more sensitive to these effects.

CONCLUSION

Our study highlighted the importance of considering both sedentary behavior and mental health in making effective long-term follow-up recommendations for cancer survivors.

Efficacy and safety of each class of sleep medication for major depressive disorder with insomnia symptoms: A systematic review and meta-analysis of double-blind randomized controlled trials

Combination therapy with antidepressants and sleep medications is a promising candidate treatment for major depressive disorder (MDD) with insomnia. This systematic review and meta-analysis examined the efficacy and safety of combination therapy with antidepressants and sleep medication for treating MDD with insomnia compared to antidepressant monotherapy by sleep medication class (benzodiazepine, Z-drug, melatonin receptor agonist, and orexin receptor antagonist). This study was preregistered with PROSPERO (CRD42025636571). PubMed, CENTRAL, and Embase were searched for double-blind randomized controlled trials published until June 2024, resulting in eight eligible studies (1945 participants; eszopiclone = 4, zolpidem = 2, triazolam = 1, ramelteon = 1). Meta-analyses were performed based on six trials of Z-drugs. Compared with antidepressant monotherapy, combination therapy with antidepressants and Z-drugs resulted in higher remission rates from depressive symptoms (risk ratio: 1.25, 95% confidence interval [CI]: 1.08-1.45, P = 0.003), greater improvement in depressive symptoms (standardized mean difference [SMD]: 0.17, 95% CI: 0.01-0.33, P = 0.04) and insomnia symptoms (SMD: 0.43, 95% CI: 0.28-0.59, P < 0.001) in the short-term (within 12 weeks), with no difference in safety outcomes except for dizziness. Combination therapy with antidepressants and Z-drugs may be more useful for MDD with insomnia symptoms than antidepressant monotherapy in the short term. However, this study did not evaluate the benefits and harms of long-term adjunctive Z-drug therapy. Further long-term studies are needed to draw definitive conclusions regarding the efficacy and safety of combination therapy with antidepressants and Z-drugs. Moreover, further research is warranted to assess whether the findings of this study are applicable to other sleep medication classes.

Health behaviour interventions to improve mental health outcomes for students in the university setting: a systematic review of randomised controlled trials

BACKGROUND

University students incur significantly elevated levels of stress compared to the general population and their non-student counterparts. Health risk behaviours are important modifiable determinants for the onset and aggravation of various mental health disorders, in which, university students generally exhibit poor engagement. Thus, this study aims to determine the efficacy of health behaviour interventions in relation to change in health behaviour and mental health outcomes, the impact of interventions (i.e., penetration, fidelity, and implementation), intervention characteristics associated with improved outcomes (efficacy) and the economic evaluation of interventions.

METHODS

Six electronic databases were searched for randomised controlled trials (RCT) published from the 1st January 2012 to 11th July 2023. Eligible RCTs included university students, evaluated behavioural interventions targeting health behaviours (i.e. dietary intake, physical activity, sedentary behaviour, alcohol use, substance use, smoking, and sleep) and reported a change in both health behaviour and mental health outcomes.

RESULTS

Twenty-two RCTs met the study inclusion criteria. Overall, only seven studies were effective in improving both health behaviour and mental health outcomes, with most (n = 4) focused on improving sleep behaviours. Insufficient evidence was found regarding intervention impact, intervention characteristics associated with improved outcomes and the economic evaluation of interventions to guide future implementation of health behaviour interventions in universities due to inadequate reporting of outcomes.

CONCLUSIONS

There is limited evidence regarding the efficacy of health behaviour interventions in improving both health behaviour and mental health outcomes. There is also insufficient evidence regarding intervention impact, intervention characteristics associated with improved outcomes and economic evaluation to guide the implementation of these interventions in the university setting.

A naturalistic analysis of rTMS treatment outcomes for major depressive disorder in West Australian youth

Objective

Repetitive transcranial magnetic stimulation (rTMS) is an effective, evidence-based treatment for major depressive disorder (MDD) in adults and is publicly funded in Australia. However, there is limited data as to its efficacy and safety in treating MDD in adolescent and youth populations.

Methods

This retrospective report examined routinely collected data of 46 outpatients aged 17 to 25 years old, who received rTMS treatment for MDD in a private TMS clinic. Primary outcomes measures were the Montgomery-Asberg Depression Rating Scale (MADRS) and the depression subscale of the 21-item Depression, Anxiety and Stress Scale (DASS-21). Secondary measures included the anxiety and stress sub-scales of the DASS-21, a measure of Quality of Life (QoL) Enjoyment and Satisfaction Questionnaire, and the Cognitive Failures Questionnaire (CFQ).

Results

A 4-7-week course of rTMS significantly reduce symptoms of self-reported depression (42.5% response) and clinician-assessed depression (40.7% response). Both anxiety and stress significantly reduced across the course of rTMS treatment and significant improvements to QoL and self-reported cognition were observed. Reported side effects following rTMS in youth included a mild headache and fatigue.

Conclusions

The findings of this naturalistic report suggest that an acute course of rTMS is safe and effective - resulting in similar response rates in adolescent and youth patients as reported in adults. Future large-scale, randomized, and sham-controlled trials are needed to consolidate and add to these findings.

The impact of aerobic exercise on depression in young people: A meta regression and meta-analysis

OBJECTIVE

This systematic review aimed to 1) update the existing evidence on the antidepressant effects of aerobic exercise (AE) in youth. 2) Investigate any potential dose‒response relationships between AE interventions and depressive symptom reduction. 3) Provide evidence-based insights to inform future research and clinical depression treatment.

METHODS

Employing the PRISMA and PERSiST guidelines, a comprehensive search across nine databases (Web of Science, PubMed, Scopus, PsycINFO, SportDiscus, CINAHL, Medline, Embase, and CNKI) yielded a total of 782 relevant studies. Following rigorous selection criteria, 26 eligible studies (comprising 22 different samples) were included in the analysis, featuring a combined sample size of 1308 participants. The meta-analysis was conducted via R.

RESULTS

AE notably decreased depressive symptoms among youth [g = -0.92; 95% CI (-1.16, -0.69); p < 0.01]. Significant dose‒response relationships were observed across age groups [β = -0.06; 95% CI (-0.12, 0.00), p < 0.05], the intensity [β = -0.03; 95% CI (-0.06, 0.00); p < 0.05], and the duration ^ 2 [β = 0.001, 95% CI (0.001, 0.002), p < 0.05] of the AE intervention.

CONCLUSIONS

Aerobic exercise interventions can effectively alleviate depressive symptoms in youth. A moderate-intensity AE program, lasting 25-40 min and conducted three times a week for 9-15 weeks, can increase alleviation of depression.

Pharmacotherapy in Comorbid Bipolar Disorder and Post-Traumatic Stress Disorder From the STEP-BD Cohort

INTRODUCTION

Post-traumatic stress disorder (PTSD) is more prevalent in those with bipolar disorder (BD) than in the general population, with rates of PTSD as high as 55% in some BD cohorts. Despite this, little research explores the effects of pharmacotherapy treatments in those with comorbid BD and PTSD. This study aims to explore patterns of pharmacotherapy use at baseline and their impact on symptoms in individuals with BD alone and comorbid BD and PTSD.

METHODS

The Systematic Treatment Enhancement Program for BD (STEP-BD) cohort was utilised to examine and compare BD symptoms and pharmacotherapy treatments between those with BD alone (n = 3393) and those with comorbid BD and PTSD (n = 304). We conducted regression models to compare those with and without comorbid PTSD. Models included measures of depression, mania, functioning and quality of life over 24 months of the STEP-BD study. We included baseline pharmacotherapies (lithium, valproate, antidepressants, antipsychotics and benzodiazepines) as predictor outcome variables in all models.

RESULTS

At baseline, reported use of lithium was lower in the comorbid BD and PTSD group, while the use of antidepressants, antipsychotics and benzodiazepines was significantly higher in the comorbid BD and PTSD than in the BD alone group. Benzodiazepine use was associated with a small improvement in depression symptom scores and poorer quality of life in those with comorbid BD and PTSD. Lastly, those with comorbid PTSD experienced higher levels of mania and depression symptoms and lower functioning and quality of life compared to BD alone, irrespective of pharmacotherapy treatment.

CONCLUSION

Clinical trial participants with BD and PTSD reported worse symptoms and outcomes across 24 months of the STEP-BD study compared to those without comorbid PTSD, regardless of baseline medication use. These results highlight the importance of considering comorbidity in the treatment of mental health conditions, specifically BD, and the need for further exploration of effective treatment options.

Response to Intermittent Theta Burst Stimulation in Treatment-Resistant Depression: Comparison of Patients With and Without History of Electroconvulsive Therapy in the Current Depressive Episode

INTRODUCTION

Intermittent theta burst stimulation (iTBS) is a novel form of repetitive transcranial magnetic stimulation (rTMS) conducted in patients with treatment-resistant depression (TRD). In this retrospective naturalistic study, we investigated the outcome of iTBS in treatment-resistant depression patients with (ECT+) and without (ECT-) history of electroconvulsive therapy (ECT) in their current depressive episode, as well as among previous ECT responders and nonresponders.

METHODS

We included 66 inpatients (57.6% women; mean age, 52.7 years) at a German University Department of Psychiatry. A binary logistic regression model was utilized to investigate the impact of ECT treatment history on response to iTBS.

RESULTS

Overall response rate was 51.5%. History of ECT in the current episode was present in 47% of patients. In the regression model, history of ECT in the current episode was associated with significantly worse response to iTBS (odds ratio, 0.252; 95% confidence interval, 0.085-0.743; P = 0.013), whereas other disease- and treatment-related covariates had no significant impact on treatment outcome. In the ECT+ group, ECT nonresponders showed a significantly worse outcome of iTBS than ECT responders. Overall rate of treatment discontinuations was 3%.

CONCLUSIONS

In this study, iTBS was most effective in patients without history of ECT in the current episode. Previous ECT responders had better outcome following iTBS than ECT nonresponders. Hence, patients with ECT response, who had to discontinue ECT due to side effects or complications, may be considered suitable candidates to be switched to iTBS.

Discovery of Herbal Remedies and Key Components for Major Depressive Disorder Through Biased Random Walk Analysis on a Multiscale Network

Major depressive disorder (MDD) is a widespread psychiatric condition with substantial socioeconomic impacts, yet single-target pharmacotherapies often yield responses. To address its multifactorial nature, this study employed a multiscale network analysis of herbs, their active components, and MDD-associated protein targets. Using a biased random walk with restart, we calculated interactions between disease-related and herb-derived targets, identifying herbs highly correlated with MDD. Enrichment analysis further revealed key signaling pathways, including oxidative stress, neuroinflammation, and hormone metabolism, underlying these herbs' therapeutic effects. We identified Ephedrae herba, Glehniae radix, Euryales semen, and Campsitis flos as promising candidates, each containing multiple bioactive compounds (such as ephedrine, psoralen, xanthine, and ursolic acid) that modulate critical processes like oxidation-reduction, inflammatory cytokine regulation, and transcriptional control. Network visualization showed how these herbs collectively target both shared and distinct pathways, supporting a synergistic, multi-target therapeutic strategy. This approach underscores the significance of network-based methodologies in addressing complex disorders such as MDD, where focusing on a single target may overlook synergistic interactions. By integrating diverse molecular data, this study provides a systematic framework for identifying novel interventions. Future experimental validation will be crucial to confirm these predictions and facilitate the translation of findings into effective MDD therapies.

Assessing the efficacy of metacognitive therapy as monotherapy or adjunctive treatment in patient suffering from major depression and dysthimia: A comprehensive review of clinical trials

BACKGROUND

Depression is one of the most widespread diseases worldwide, with the highest rates of disability. Considering its chronic course, over the years several treatment options have been developed and validated, however still with high relapse rates. Therefore, in recent years, the so-called third wave psychotherapies have been developed for the treatment of psychiatric disorders. Among these, the Metacognitive therapy (MCT) has proven to be effective in treating depression. The aim of this review is to evaluate the efficacy of MCT as monotherapy or adjunctive treatment in reducing depressive symptoms in patients suffering from major depression or dysthymia.

METHODS

From bibliographic research in PubMed until December 2023, we retrieved 12 original studies meeting our research criteria.

RESULTS

The total sample of patients undergoing metacognitive therapy (MCT) included 376 individuals, while the control groups comprised 300 subjects, with a gender ratio of the participants of 0.48 %. The results show that metacognitive therapy is an effective approach in reducing depressive symptoms in patients with a diagnosis of depression or dysthymia when used as add-on therapy, with an efficacy comparable to CBT and superior to pharmacotherapy and as monotherapy, with an efficacy comparable to therapy with antidepressants compared to the control group and compared to cognitive-behavioral therapy with higher rates of reduction of depressive symptoms after treatment and at six months. Preliminary data also indicate its efficacy in terms of reduction of depressive symptoms in elderly people, suggesting its possible use in this population.

LIMITATIONS

The methodological heterogeneity in terms of treatment protocols of MCT and treatment control as well as the clinical heterogeneity of the sample employed may have limited the generalizability of the results.

CONCLUSIONS

The results suggest that the use of MCT, both as monotherapy and as an add-on treatment, is a valid therapeutic option for major depression, even at the later stages. However, further studies are needed for deeper our comprehension of the efficacy of MCT in depression.

Efficacy of a Blended Low-Intensity Internet-Delivered Psychological Program in Patients With Multimorbidity in Primary Care: Randomized Controlled Trial

BACKGROUND

Multimorbidity is a highly prevalent phenomenon whose presence causes a profound physical, psychological, and economic impact. It hinders help seeking, diagnosis, quality of care, and adherence to treatment, and it poses a significant dilemma for present-day health care systems.

OBJECTIVE

This study aimed to assess the effectiveness of improved treatment as usual (iTAU) combined with a blended low-intensity psychological intervention delivered using information and communication technologies for the treatment of multimorbidity (depression and type 2 diabetes or low back pain) in primary care settings.

METHODS

A 2-armed, parallel-group, superiority randomized controlled trial was designed for this study. Participants diagnosed with depression and either type 2 diabetes or low back pain (n=183) were randomized to "intervention + iTAU" (combining a face-to-face intervention with a supporting web-based program) or "iTAU" alone. The main outcome consisted of a standardized composite score to consider (1) severity of depressive symptoms and (2a) diabetes control or (2b) pain intensity and physical disability 3 months after the end of treatment as the primary end point. Differences between the groups were estimated using mixed effects linear regression models, and mediation evaluations were conducted using path analyses to evaluate the potential mechanistic role of positive and negative affectivity and openness to the future.

RESULTS

At 3-month follow-up, the intervention + iTAU group (vs iTAU) exhibited greater reductions in composite multimorbidity score (B=-0.34, 95% CI -0.64 to -0.04; Hedges g=0.39) as well as in depression and negative affect and improvements in perceived health, positive affect, and openness to the future. Similar positive effects were observed after the intervention, including improvements in physical disability. No significant differences were found in glycosylated hemoglobin, pain intensity, or disability at 3-month follow-up (P=.60; P=.79; and P=.43, respectively). Path analyses revealed that the intervention had a significant impact on the primary outcome, mediated by both positive and negative affect (positive affect: indirect effect=-0.15, bootstrapped 95% CI -0.28 to -0.03; negative affect: indirect effect=-0.14, bootstrapped 95% CI -0.28 to -0.02).

CONCLUSIONS

This study supports the efficacy of a low-intensity psychological intervention applied in a blended format on multimorbidity in primary care. It justifies the exploration of the conceptualization of depression in type 2 diabetes as well as the analysis of the implementation of such interventions in routine clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/S12888-019-2037-3.

Efficacy of brain stimulation therapies across psychiatric, movement, and cognitive disorders: an umbrella review synthesizing meta-analyses of randomized controlled trials

BACKGROUND

Brain stimulation therapy (BST) has significant potential in treating psychiatric, movement, and cognitive disorders. Given the high prevalence of comorbidities among these disorders, we conducted an umbrella review to comprehensively assess the efficacy of BSTs in treating the core symptoms across these three categories of disorders.

METHODS

We systematically searched for meta-analyses and network meta-analyses of randomized controlled trials with sham controls up to September 25, 2024, from databases including PubMed, PsycINFO, Embase, and the Cochrane Library. Our primary outcome was improvements in core symptoms. We evaluated quality using 11 criteria. We calculated pooled effect estimates for core symptoms based on the largest meta-analyses, then conducted sensitivity and subgroup analyses, and assessed heterogeneity, publication bias, and small-study effects. Finally, we synthesized effect sizes from all meta-analyses to provide a comprehensive overview of BSTs' efficacy. PROSPERO registration: CRD42023439090.

FINDINGS

We included 198 articles with 108,377 patients evaluating 14 BSTs across 21 disorders. The largest meta-analysis showed a moderate standardized mean difference (SMD) of 0.56 (95% CI: 0.49, 0.64; I2 = 70%). Subgroup analyses revealed significant SMDs for psychiatric disorders (0.60; 95% CI: 0.49, 0.71; I2 = 66%), movement disorders (0.56; 95% CI: 0.42, 0.69; I2 = 79%), and cognitive disorders (0.46; 95% CI: 0.32, 0.61; I2 = 48%). SMDs were 0.44 (95% CI: 0.23, 0.65; I2 = 70%) for follow-up ≤1 month and 0.69 (95% CI: 0.43, 0.94; I2 = 84%) for follow-up >1 month. Compared to other conditions, BSTs show better therapeutic effects in treating depression, post-traumatic stress disorder, obsessive-compulsive disorder, pain, fibromyalgia, and post-stroke motor recovery.

INTERPRETATION

This review explored the potential of BSTs for comorbidities of the three disorders from a disorder-specific perspective, providing a roadmap for their clinical application and future research.

FUNDING

This work was supported by the Anhui Natural Science Foundation (2023AH040086), Key Laboratory of Philosophy and Social Science of Anhui Province on Adolescent Mental Health and Crisis Intelligence Intervention (SYS2023B08), and the Joint Funds of the National Natural Science Foundation of China (U23A20424).

Early use of long-acting injectable antipsychotics in bipolar disorder type I: An expert consensus

INTRODUCTION

Long-acting injectable antipsychotics (LAIs) are not routinely offered to patients living with bipolar disorder type I (BP-I), despite widespread evidence that supports their benefits over oral antipsychotics, particularly in early disease.

METHODS

A round-table meeting of psychiatrists convened to discuss barriers and opportunities and provide consensus recommendations around the early use of LAIs for BP-I.

RESULTS

LAIs are rarely prescribed to treat BP-I unless a patient has severe symptoms, sub-optimal adherence to oral antipsychotics, or has experienced multiple relapses. Beyond country-specific accessibility issues (e.g., healthcare infrastructure and availability/approval status), primary barriers to the effective use of LAIs were identified as attitudinal and knowledge/experience-based. Direct discussions between healthcare providers and patients about treatment preferences may not occur due to a preconceived notion that patients prefer oral antipsychotics. Moreover, as LAIs have historically been limited to the treatment of schizophrenia and the most severe cases of BP-I, healthcare providers might be unaware of the benefits LAIs provide in the overall management of BP-I. Improved treatment adherence associated with LAIs compared to oral antipsychotics may support improved outcomes for patients (e.g., reduced relapse and hospitalization). Involvement of all stakeholders (healthcare providers, patients, and their supporters) participating in the patient journey is critical in early and shared decision-making processes. Clinical and database studies could potentially bridge knowledge gaps to facilitate acceptance of LAIs.

CONCLUSION

This review discusses the benefits of LAIs in the management of BP-I and identifies barriers to use, while providing expert consensus recommendations for potential solutions to support informed treatment decision-making.

Trends in hypnotic drug use in depression 2007-2017: A Swedish population-based study

Insomnia is a common feature of depression; however, depression treatment guidelines provide limited recommendations regarding hypnotic drugs. Few studies have thoroughly investigated the use of hypnotic drugs in depression. In this cohort study using national Swedish registers, we included all patients ≥18 years with incident unipolar depression during 2007-2017. Patients were followed for 3 years, noting the annual and quarterly prevalence of hypnotic drug use from prescription fills. Prevalence ratios (PR) comparing 2017 to 2007 were calculated with 95% confidence intervals (CI). A total of 222,077 patients with depression were included (mean age 41 years, 59% women). In the year following diagnosis, 44.1% used any hypnotic drug in 2017, compared with 46.7% in 2007 (PR 0.94, 95% CI 0.92-0.97). The most commonly used drugs were Z-drugs (zopiclone, zolpidem, and zaleplon) with a prevalence of 27.6% in 2017 and 35.6% in 2007 (PR 0.78, 95% CI 0.75-0.80). Melatonin use increased sharply to 12.0% in 2017 from 0.4% in 2007 (PR 28.9, 95% CI 23.5-35.7). Hypnotic drug use was most prevalent in the first two quarters after diagnosis; however, after 3 years, the quarterly prevalence was still 19.2%. Hypnotics were more common among women, older patients, those with somatic comorbidities, more severe depression, or a history of suicide attempt. Evidence from this large register-based study demonstrates that hypnotics were used to a large extent in depression in Sweden 2007-2017. Z-drugs use declined and melatonin use increased dramatically. Hypnotic drug use remained high even 3 years after diagnosis.

Transcranial Magnetic Stimulation in Pregnancy: Efficacy, Safety, and Future Implications for Perinatal Mental Health Care

INTRODUCTION

Repetitive transcranial magnetic stimulation (TMS) has gained interest as a treatment for major depressive disorder (MDD). However, the literature on its efficacy and safety for pregnant patients with MDD is limited. This article reviews and appraises available studies on TMS in pregnant women with MDD.

METHODS

We reviewed randomized controlled trials and open-label studies on TMS in pregnant women with MDD.

RESULTS

Studies indicate that TMS is a safe and effective treatment for MDD during pregnancy, showing significant reductions in depression scores and increased response and remission rates compared to sham TMS. TMS was well tolerated with minimal side effects.

CONCLUSION

Larger, multicenter trials are needed to develop evidence-based protocols for TMS use in pregnancy.

Mostly harmless? Clinical practice guidelines need further consideration of psychotherapy adverse effects

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines on mood disorders recommend psychotherapy as foundational care for patients with acute depression with minimal discussion of any potential adverse effects. Randomised controlled trial evidence on psychotherapy adverse effects is limited. This is problematic because clinicians must balance the benefits of treatment against the harms, and clinical decisions become skewed without data on adverse effects. We suggest that clinical practice guidelines should be more guarded about recommending psychotherapy and add consensus statements on adverse effects for informed consent and clinical decision-making.

Deprescribing antidepressants for depression - what is the evidence for and against?

OBJECTIVE

Recent guidelines suggest that the overall quantity and duration of antidepressant prescriptions should be reduced. In this paper, we comment on the evidence both for and against this view.

METHODS

We critically review the arguments proposed by proponents of antidepressant deprescribing in the context of the evidence-base for the treatment of depression.

RESULTS

Proponents of deprescribing do not address the substantive issues of whether inappropriate prescribing has been demonstrated, and when prescribing is needed. Their arguments for deprescribing are rebutted in this context.

CONCLUSIONS

Whether or not to deprescribe antidepressant medication needs to take into consideration the risk-benefit profile of the decision, the responsibility for which needs to be shared and based on the context of the patient's depression, their preferences, experiences and perspectives.

Reflection on the RANZCP position on the adverse effects of psychotherapy

OBJECTIVE

In this perspective, we investigate how the Royal Australian and New Zealand College of Psychiatrists' (RANZCP) position statement on psychotherapy takes the potential for adverse effects into account.

CONCLUSIONS

Psychotherapy has two critical outcomes - efficacy and adverse effects. Evidence-based psychotherapy is significantly more effective than care-as-usual for about one in 10 psychotherapy patients. However, a similar proportion also reports adverse effects. Despite this, the RANZCP position statement on psychotherapy focuses on efficacy with minimal discussion of the adverse effects. This is an oversight because psychiatrists have legal and ethical obligations to consider the adverse effects as well as the benefits of any treatment. We therefore reflect on the RANZCP's six recommendations in light of the adverse effects of psychotherapy.

French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN) guidelines for the management of patients with partially responsive depression and treatment-resistant depression: Update 2024

INTRODUCTION

The purpose of this update is to add newly approved nomenclatures and treatments as well as treatments yet to be approved in major depressive disorder, thus expanding the discussions on the integration of resistance factors into the clinical approach.

METHODS

Unlike the first consensus guidelines based on the RAND/UCLA Appropriateness Method, the French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) developed an update of these guidelines for the management of partially responsive depression (PRD) and treatment-resistant depression (TRD). The expert guidelines combine scientific evidence and expert clinicians' opinions to produce recommendations for PRD and TRD.

RESULTS

The recommendations addressed three areas judged as essential for updating the previous 2019 AFPBN guidelines for the management of patients with TRD: (1) the identification of risk factors associated with TRD, (2) the therapeutic management of patients with PRD and TRD, and (3) the indications, the modalities of use and the monitoring of recent glutamate receptor modulating agents (esketamine and ketamine).

CONCLUSION

These consensus-based guidelines make it possible to build bridges between the available empirical literature and clinical practice, with a highlight on the 'real world' of the clinical practice, supported by a pragmatic approach centred on the experience of specialised prescribers in TRD.

Setting of initiation and factors associated with antidepressant use on entry to long-term care facilities

AIMS

Antidepressant use increases around long-term care facility (LTCF) entry, and initiation during hospitalizations may contribute to this. This study characterized the care setting (i.e., community-based, hospital or LTCF) where antidepressants were initiated and determined associated resident characteristics.

METHODS

A cross-sectional study including non-Indigenous individuals aged 65-105 years who entered LTCFs in two Australian states during 2015-2019, and were dispensed an antidepressant within 2 months, was conducted. Care settings (community-based, hospital or LTCF) were determined from linked LTCF records, and hospitalizations ≤30 days before LTCF entry. Pharmaceutical claims before and after LTCF entry were screened to determine antidepressant initiation. Multivariate multinomial logistic regression estimated adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for resident characteristics associated with care settings of antidepressant initiation.

RESULTS

This study included 34 525 residents from 1046 LTCFs. Overall, 27 160 (78.7%) commenced antidepressants prior to entry, 2552 (7.4%) in hospital and 4813 (13.9%) in LTCFs. Mirtazapine constituted 44.8% (n = 1143) of antidepressants initiated in hospitals and 39.5% (n = 1902) in LTCFs. Residents who were aged ≥90 years were more likely to start an antidepressant in the LTCF compared to community-based settings (aOR = 1.97, 95% CI 1.74-2.23). Residents recently using a psychotropic were more likely to start an antidepressant in community-based settings before LTCF entry, compared to a hospital or LTCF.

CONCLUSIONS

Individuals receiving antidepressants during transition to LTCFs are often already taking antidepressants prior to entry. Future interventions to optimize antidepressant use in LTCFs should consider setting, recency and indication for antidepressant initiation, and ongoing monitoring for safety.

The risks of adverse events with mirtazapine for adults with major depressive disorder: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Mirtazapine is used to treat depression worldwide, and the effects of mirtazapine on depression rating scales are well-known. Our primary objective was to assess the risks of adverse events with mirtazapine for major depressive disorder.

METHODS

We searched relevant sources from inception to 7 March 2024 for randomised clinical trials comparing mirtazapine versus placebo in adults with major depressive disorder. The primary outcomes were suicides or suicide attempts, serious adverse events, and non-serious adverse events. Data were synthesised using meta-analysis and Trial Sequential Analysis.

RESULTS

We included 17 trials randomising 2,131 participants to mirtazapine versus placebo. All results were at high risk of bias, and the certainty of the evidence was very low. The included trials assessed outcomes at a maximum of 12 weeks after randomisation. Meta-analysis and Trial Sequential Analysis showed insufficient information to determine the effects of mirtazapine on the risks of suicides or suicide attempts and serious adverse events. Meta-analyses showed that mirtazapine increased the risks of somnolence, weight gain, dry mouth, dizziness, and increased appetite but decreased the risk of headaches.

CONCLUSIONS

There is a lack of evidence on the effects of mirtazapine on suicides and serious adverse events. Mirtazapine increases the risks of somnolence, weight gain, dry mouth, dizziness, and increased appetite. Mirtazapine might decrease the risk of headaches. The long-term effects of mirtazapine are unknown.

PROSPERO ID

CRD42022315395.

Broad-Spectrum Micronutrients or Antidepressants for Antenatal Depression: Effect on Maternal and Infant Birth Outcomes in an Observational Secondary Analysis of NUTRIMUM

PURPOSE/BACKGROUND

One-fifth of women experience antenatal depression. Untreated antenatal depression is associated with increased risk of adverse birth outcomes. This study investigated the effect of broad-spectrum micronutrients (BSM; vitamins and minerals), used to treat antenatal depression (NUTRIMUM trial), on birth outcomes.

METHODS/PROCEDURES

Birth outcomes of 129 mother-infant pairs were obtained from hospital medical records or personal health records for home births. Pairs from NUTRIMUM exposed to ≥8 weeks of BSM antenatally (MN; n = 55) were compared to pairs exposed to antidepressants antenatally (MED; n = 20) and a reference group (REF; n = 54) of pairs not exposed to trial BSM or antidepressants.

FINDINGS/RESULTS

Groups were comparable on demographic variables. At study entry, MN and MED had depression scores in the moderate range, statistically higher than REF (nonclinical range). MN and REF did not differ significantly for gestational age, preterm births, infant size, or infant resuscitation. There were significantly lower rates of postpartum hemorrhage in MN relative to REF (7.7% vs 30%; RR = 0.26, 95% CI [0.08-0.84]). Gestational age at birth was higher for MN (39.5 weeks) than MED (38.5 weeks; d = 0.67, 95% CI [0.15-1.20], P = 0.03) as well as infant birth length (52.2 vs 50.0 cm; d = 0.77, 95% CI [0.21-1.33], P = 0.02), and rates of infant resuscitation were lower (14.5% vs 45%; RR = 0.33, 95% CI [0.15-0.73]). Days of BSM exposure was positively associated with birth weight ( r = 0.32, P = 0.008) and length ( r = 0.25, P = 0.04).

IMPLICATIONS/CONCLUSIONS

Micronutrients used to alleviate antenatal depression may mitigate negative effects of depression on birth outcomes and showed more favorable birth outcomes compared with antidepressants.

Is Engagement in Physical Activity Related to Its Perceived Mental Health Benefits Among People With Depression and Anxiety? A Population-Scale Survey Study

OBJECTIVE

To examine the prevalence of awareness of PA (physical activity) benefits among those with mental disorders and explore how this is related to actual PA levels in this population.

METHODS

We queried data from the Health Information National Trends Survey 2019. A sample of 1,139 adults with self-reported depression and anxiety (61% female; mean age of 52.5 years) was analyzed. Multivariable logistic regression was employed to investigate the association between awareness that PA benefits mental health and respondents' levels of PA.

RESULTS

Of the entire sample, a total of 904 individuals (80.9%) endorsed awareness that PA helps reduce symptoms of depression and anxiety. In multivariable analysis, awareness that PA improves mental health was significantly associated with greater odds of being less sedentary (OR 2.31; P = 0.025) and meeting national recommendations for weekly physical activity (OR 2.35; P = 0.046).

CONCLUSION

Overall, findings from this nationally representative survey data indicates that about 4 in 5 adults living with depression and anxiety in the United States endorsed awareness of the mental health benefits of PA. Furthermore, we found that the awareness of these benefits is related to PA engagement.

Bipolar disorders: an update on critical aspects

Bipolar disorders are chronic psychiatric conditions characterized by recurrent episodes of mania and depression. Affecting over 1% of the global population, these disorders contribute significantly to disability and mortality, often due to suicide and cardiovascular disease. Diagnostic challenges arise from symptom overlap with unipolar depression, frequently leading to delays. Bipolar disorders are driven by complex genetic, neurobiological, and environmental factors and are commonly accompanied by psychiatric and medical comorbidities, further complicating diagnosis and treatment. Standard management strategies include mood stabilizers, antipsychotics, and selective use of antidepressants, complemented by psychosocial interventions like cognitive-behavioral therapy and psychoeducation, which are vital for relapse prevention. Despite recent advancements, the management of bipolar disorders remains challenging, constrained by clinical variability, an absence of specific biomarkers, and differences in approved treatments and treatment guidelines across regions. Emerging research underscores the potential of precision psychiatry and digital health tools to enhance diagnosis and treatment. Nonetheless, critical gaps persist, particularly in implementing equitable care worldwide. This review offers a comprehensive update on bipolar disorders, examining clinical presentation, early diagnosis, pathogenesis, therapeutic strategies, and future perspectives to guide clinicians and researchers in addressing these ongoing challenges in research and clinical practice.

Funding

None.

The efficacy of exercise interventions on depressive symptoms and cognitive function in adults with depression: An umbrella review

OBJECTIVE

This umbrella review aims to consolidate the evidence concerning the influence of exercise on depressive symptoms and cognitive performance in adults diagnosed with depression.

METHODS

An umbrella review of systematic reviews with meta-analyses investigating the effect of exercise on depression and cognition was performed. Databases (PubMed, Cochrane Library, Web of Science, Embase) were searched from inception until February 2024 for reviews of randomized controlled trials. Overlap within included reviews was assessed using the corrected covered area method (CCA). A random effects model was used to calculate overall pooled effect size with sub-analyses.

RESULTS

This study included 27 reviews, encompassing 190 experiments. In patients with depression, compared to the control group, exercise demonstrated a moderate effect size in reducing depressive symptoms (SMD = -0.67; SE = 0.04; p < 0.0001), with a Number Needed to Treat (NNT) of 2.78. When analyses were limited to data from studies with a low risk of bias, the effect on depressive symptoms was smaller (SMD = -0.38; SE = 0.07; p < 0.0001; NNT = 4.72). Exercise had a small effect on cognitive functions (SMD = 0.12; SE = 0.03; p < 0.0001), with an NNT for cognitive function treatment of 14.79.

CONCLUSIONS

All forms of exercise benefit patients with depression. However, for optimal intervention outcomes, it is essential to customize the intensity and type of exercise according to the specific characteristics of the patient's depressive symptoms and cognitive functions. It is recommended to implement a phased treatment approach for patients based on the intensity of exercise.

Behavioral Emotion Regulation Strategies and Symptoms of Psychological Distress Among Turkish University Students

The purpose of this study was to examine the association between behavioral emotion regulation strategies and symptoms of depression, anxiety, and stress among Turkish university students. Participants consisted of 633 students continuing their university education in two different universities in Türkiye. Participants completed a data collection tool comprising a Sociodemographic Information Form, the Behavioral Emotion Regulation Questionnaire, and the Depression Anxiety Stress Scales-21. Data were analyzed using descriptive statistics, Pearson's product-moment correlation coefficient analysis, and multivariate multiple regression analysis. The results of this study revealed that seeking distraction was negatively associated with symptoms of depression, anxiety, and stress, whereas withdrawal, seeking social support, and ignoring were positively associated with symptoms of depression, anxiety, and stress among university students. Additionally, actively approaching was negatively associated with depressive symptoms. Overall, the findings demonstrate that university students who use maladaptive behavioral emotion regulation strategies (e.g., withdrawal, ignoring) tend to have higher levels of psychological distress, whereas university students who use adaptive emotion regulation strategies (e.g., distraction) tend to have lower levels of psychological distress. However, contrary to expectations, seeking social support was positively associated with symptoms of psychological distress. Given the paucity of research on the relationship between behavioral emotion regulation strategies and psychological distress in the Turkish cultural context, this study may contribute to identifying both universal and culturally specific strategies associated with depressive, anxiety, and stress symptoms among Turkish university students.

Rates of colorectal cancer diagnosis and mortality in people with severe mental illness: results from Australia's National Bowel Cancer Screening Programme

AIMS

Studies show that people with severe mental illness (SMI) have a greater risk of dying from colorectal cancer (CRC). These studies mostly predate the introduction of national bowel cancer screening programmes (NBCSPs) and it is unknown if these have reduced disparity in CRC-related mortality for people with SMI.

METHODS

We compared mortality rates following CRC diagnosis at colonoscopy between a nationally representative sample of people with and without SMI who participated in Australia's NBCSP. Participation was defined as the return of a valid immunochemical faecal occult blood test (iFOBT). We also compared mortality rates between people with SMI who did and did not participate in the NBCSP. SMI was defined as receiving two or more Pharmaceutical Benefits Scheme prescriptions for second-generation antipsychotics or lithium.

RESULTS

Amongst NBCSP participants, the incidence of CRC in the SMI cohort was lower than in the controls (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.61-0.98). In spite of this, their all-cause mortality rate was 1.84 times higher (95% CI 1.12-3.03), although there was only weak evidence of a difference in CRC-specific mortality (HR 1.82; 95% CI 0.93-3.57). People with SMI who participated in the NBCSP had better all-cause survival than those who were invited to participate but did not return a valid iFOBT (HR 0.67, 95% CI 0.50-0.88). The benefit of participation was strongest for males with SMI and included improved all-cause and CRC-specific survival.

CONCLUSIONS

Participation in the NBCSP may be associated with improved survival following a CRC diagnosis for people with SMI, especially males, although they still experienced greater mortality than the general population. Approaches to improving CRC outcomes in people with SMI should include targeted screening, and increased awareness about the benefits or participation.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (Trial ID: ACTRN12620000781943).

Psychosocial functioning and its influencing factors in patients with depression post-remission: Implications for assessment and interventions

BACKGROUND

Enhancing psychosocial functioning is crucial for reducing relapse in depression, but methods for monitoring and recovery are unclear.

METHOD

A 1-year follow-up study assessed psychosocial functioning in 182 patients with remitted depression at baseline (T0) as well as at 1, 2, 6, 9, and 12 months post-remission (T1-T5). Using generalized estimating equations (GEE) and multiple linear regression (MLR), we analyzed the impact of changes in psychosocial functioning on relapse/recurrence risk, and assessed the influence of various factors.

RESULTS

An increase in psychosocial functioning significantly lowered relapse/recurrence odds by 54.2 %, averaging a risk reduction of 3.1 %. GEE analyses indicated subjective depressive symptoms (β = -0.315) most significantly impacted psychosocial functioning, followed by social support (β = 0.236), positive coping (β = 0.225), and negative automatic thoughts (β = -0.183). Negative coping and expressed emotion exhibited non-significant effects. MLR revealed that the impact of negative automatic thoughts was most significant at initial remission, but the relative importance of residual subjective depressive symptoms, positive coping, and social support on psychosocial functioning remained stable over time.

LIMITATIONS

Predetermined follow-up assessments may not fully capture psychosocial functioning at relapse/recurrence, and the inclusion of factors might not be sufficiently comprehensive.

CONCLUSIONS

Recovery of psychosocial functioning significantly reduces relapse risk in post-remission patients with depression more than residual subjective depressive symptoms. The degree of influence of factors on psychosocial functioning can change with the length of remission time.

Participation in the National Bowel Cancer Screening Program by people with severe mental illness, Australia, 2006-2019: a national data linkage study

OBJECTIVE

To compare rates of participation in the National Bowel Cancer Screening Program (NBCSP) and follow-up for people with severe mental illness with those for people without severe mental illness or not prescribed antidepressants.

STUDY DESIGN

Retrospective cohort study; analysis of de-identified linked NBCSP, Pharmaceutical Benefits Scheme (PBS), and Medicare Benefits Schedule (MBS) data.

SETTING

Australia, 2006-2019.

PARTICIPANTS

People aged 50-74 years (NBCSP-eligible) with severe mental illness, defined as those dispensed two or more prescriptions for second generation antipsychotics or for lithium (PBS data), and a random sample of people aged 50-74 years eligible for Medicare-subsidised services but never prescribed psychotropic medications (antipsychotics, lithium, antidepressants).

MAIN OUTCOME MEASURES

NBCSP participation (returned faecal occult blood test sample), valid test result, positive test result, and follow-up colonoscopy rates.

RESULTS

A total of 119 475 people with severe mental illness and 1 090 574 control group people were included in our analyses. The proportion of women was larger in the severe mental illness group (51.3%) than the control group (48.7%), as were the proportions who lived in inner regional areas (23.5% v 19.1%) or in areas in the lowest socio-economic quintile (21.8% v 14.7%). The NBCSP participation rate was lower among people with severe mental illness (adjusted incidence rate ratio [IRR], 0.70; 95% confidence interval [CI], 0.69-0.84). The proportion of valid test results was smaller for people with severe mental illness (95.9% v 98.7%; adjusted IRR, 0.97; 95% CI, 0.96-0.99), and the positive test result proportion larger (12.3% v 6.6%; adjusted IRR, 2.01; 95% CI, 1.94-2.09). The proportion of positive test results followed by colonoscopy was smaller for people with severe mental illness (71.7% v 82.6%; adjusted IRR, 0.88; 95% CI, 0.85-0.92).

CONCLUSIONS

People with severe mental illness were less likely to participate in the NBCSP or to undergo colonoscopy after a positive test result than other Australians. These differences may contribute to higher colorectal cancer mortality among people with severe mental illness. The contributions of differences in cancer stage at diagnosis and subsequent treatment to higher colorectal cancer mortality require further study.

Self-Induced Mania Methods and Motivations Reported in Online Forums: Observational Qualitative Study

BACKGROUND

In bipolar disorder (BD), mania may be self-induced by manipulation of specific precipitants, as reported in case studies. Another potential source of information on the self-induction of mania is the online postings of users with lived experience of mania.

OBJECTIVE

The primary aim of this study is to examine the range of methods used to self-induce mania or hypomania described by users of online forums with self-reported BD. Second, we summarize the motivations of users to engage in these behaviors.

METHODS

We conducted an observational study of online forum posts that discussed self-induction of mania or hypomania, either in the posters themselves or observed firsthand in others. Posts were identified using Google advanced search operators, then extracted and coded for content in NVivo (version 12 for Mac; QSR International). A total of 44 online forum threads were identified discussing self-induced mania (n=25) or hypomania (n=19). These forums contained 585 posts by 405 usernames, of which 126 usernames discussed methods for self-induction across 327 posts (number of methods per username: median 2, IQR 1-4; range 1-11).

RESULTS

In total, 36 methods were grouped by the authors. The most frequently reported were sleep reduction (n=50), caffeine (n=37), and cessation of medication (n=27). Twenty-six usernames reported their motivation to self-induce mania or hypomania; almost three-quarters (n=19) reported a desire to end a depressive episode. Almost a third of usernames (118/405) explicitly discouraged other forum users from self-inducing mania or hypomania.

CONCLUSIONS

Online forums provide an additional and valuable source of information about triggers for mania that may inform relapse prevention in BD. The online forum conversations investigated were generally responsible and included cautionary advice not to pursue these methods.

Mapping review of register-based cohort studies of bipolar disorder

OBJECTIVES

Register-based cohorts allow us to better understand bipolar disorder over a life course. They are inclusive and their long-term data collection provides a longer scope than most clinical trials. This mapping review provides an overview of register-based cohort studies of bipolar disorder to inform researchers of the strengths and limitations to this body of research and identify gaps for future research.

METHODS

A systematic search was performed of Medline, EMBASE, and PsycINFO databases. Cohort studies were included if they focused on bipolar disorder and had a minimum of 1 year of longitudinal data. Studies needed to be from databases that monitor the whole state or national population. A descriptive analysis of the studies' populations and methodology provides an overview of this field of study and identifies evidence gaps.

RESULTS

A hundred and forty-six studies were included. The majority were from databases in Taiwan (n = 63), Denmark (n = 38), Sweden (n = 23), and Finland (n = 11). Forty-eight studies focused on aetiological questions. Sixty prognostic studies identified cohorts with bipolar disorder and described the impact of the illness by considering comorbidity, prescribing patterns, social functioning, and mortality. Thirty-six treatment studies focused on the efficacy and adverse effects of pharmaceuticals and ECT. No studies focused on psychological treatments.

CONCLUSION

Bipolar disorder research should include register-based cohorts with greater geopolitical and cultural diversity. Custodians of health registers should consider how non-pharmaceutical interventions such as psychotherapy are captured. Register-based cohorts investigating treatments of bipolar disorder should consider long-term social outcomes alongside the usual clinical outcomes.

Side Effects of Psychotropic Medications Experienced by a Community Sample of People Living With Severe and Persistent Mental Illness

BACKGROUND

Psychotropic medications are a common treatment modality for people living with severe and persistent mental illness (SPMI). While effective in reducing relapse and hospitalisation, psychotropic medications cause numerous side effects, varying in nature and severity. Identification and management of side effects is crucial in the ongoing management of SPMI.

OBJECTIVE

To characterise the side effects of psychotropic medications, experienced by a sample of consumers living with SPMI, using a validated tool.

SETTING AND PARTICIPANTS

Consumers with SPMI living in the community were recruited from all 25 community pharmacies across four Australian regions, which were allocated to the intervention arm of the Bridging the Gap between Physical and Mental Illness (PharMIbridge) randomised controlled trial (RCT).

MAIN OUTCOME MEASURES

Responses to the My Medicines & Me Questionnaire (M3Q).

RESULTS

Consumers (n = 156) most frequently reported side effects in the categories of sleep-related side effects (80.8%, n = 126), mood-related side effects (75.6%, n = 118) and weight and appetite changes (60.3%, n = 107). Daytime somnolence was the most reported individual side effect (68.6%, n = 107). Mood-related side effects were ranked as the most bothersome, followed by sleep-related side effects and weight and appetite changes. More than one-quarter (29.5%, n = 46) of consumers reported choosing not to take their medications due to side effects. Consumers more frequently told family and friends about the side effects rather than healthcare professionals.

CONCLUSIONS

An overwhelming majority of consumers experienced at least one side effect attributed to their psychotropic medication, with many experiencing multiple. These findings highlight the critical need to regularly engage with consumers to discuss, identify and manage side effects to treatment burden, reduce risk of non-adherence and improve their treatment experience.

PATIENT OR PUBLIC CONTRIBUTION

The PharMIbridge RCT included a training programme and intervention service that was co-designed and co-delivered with people with lived experience of mental illness. The research team, expert advisory panel and mentors who supported the delivery and implementation of the training and intervention included participants who have lived experience of mental illness or caring for someone with mental illness.

TRIAL REGISTRATION

ANZCTR12620000577910.

Emotional Response to Various Exercise Types in Patients With Mental Disorders

Objectives This study examined the relationship between different types of exercise bouts and emotional responses in patients with mental disorders. Methods This study utilized an acute pre-/post-interventional design. Patients participated in six types of exercises: yoga, strength training, dual-task exercises, aerobic exercises, multicomponent exercises, and dance. These sessions were conducted for 60 minutes per day, once a week, from June 2018 to February 2019. Emotional states, including pleasantness, relaxation, and anxiety, were evaluated using the Mood Check List-Short Form 2 before and after each session. Results Twenty-four patients with mental disorders, including mood disorders, schizophrenia, and other conditions, aged 20-77 years, participated in a total of 272 sessions across six exercise types. Significant emotional changes were observed before and after the exercises, with an increase in pleasant feelings and a decrease in unpleasant feelings for all exercise types except the dual-task exercises. Yoga, in particular, showed large effect sizes for emotional changes, ranging from 0.65 to 0.72. Conclusions Yoga was found to enhance pleasantness and relaxation while reducing anxiety, whereas dual-task exercises appeared less effective in providing these benefits. These findings can help inform the selection of effective exercise methods for patients with mental disorders.

Pharmacotherapy and electroconvulsive therapy prescription for women with depressive and anxiety disorders in a psychiatric mother-baby unit

OBJECTIVE

The purpose of this study was to understand the pharmacotherapy and electroconvulsive therapy (ECT) prescription of women with depression and anxiety admitted to an Australian inpatient psychiatric mother-baby unit (MBU) and compare prescription to national clinical practice guidelines.

METHOD

A retrospective audit was conducted on women diagnosed with depression or anxiety admitted to a public psychiatric inpatient MBU from March 2017 to July 2019. Data was captured at three time points to assess demographic, clinical and pharmacotherapy treatment characteristics. Descriptive statistics were completed.

RESULTS

Of the 74 women, 57 women had depression, with 73% prescribed Selective Serotonin Reuptake Inhibitors (SSRIs) and 14% provided ECT during admission. For women with anxiety (n = 17), 23% were prescribed a benzodiazepine with concurrent antidepressant prescription. SSRI prescription increased, with other antidepressant prescription up trending through admission. Atypical antipsychotic prescription was increased initially and trended downwards at discharge.

CONCLUSIONS

This study explored the therapeutic armamentarium employed for the treatment of mothers admitted to an inpatient psychiatric MBU with depression and anxiety. The results point to the intricate prescribing practices in a naturalistic setting and highlight that prescribing practices were in line with national guidelines.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Lost in translation? Qualitative interviews with Australian psychedelic-assisted therapy trial clinicians

BACKGROUND

Policy changes in Australia mean that psychedelic-assisted therapy (PAT) is now available to consumers outside of clinical trials. Yet, the regulatory frameworks guiding the practice of PAT are underdeveloped, and the evidence base for guiding clinical practice is diverse and emerging, resulting in anticipated challenges in translation to community practice. Mental health clinicians who have experience delivering PAT in clinical trials are likely to be at the forefront of community practice and training, and influential in discussions about implementation. Yet little is known of their perspectives, preferences, and practices associated with the implementation of PAT.

METHOD

Interviews with 11 clinicians working on clinical trials of PAT were thematically analysed.

RESULTS

Four themes were identified, describing the therapeutic frames that interviewees used to understand PAT and shaped their views on its interface with the mental health system: (1) therapeutic eclecticism, (2) enhanced reflexivity for PAT providers, (3) legitimisation of extra-medical perspectives in mental health, and (4) what might be lost in translation?

CONCLUSION

We argue that clinicians' perspectives on PAT are reflective of existing tensions between a medical model of mental health care and other psychosocial, relational models. Therapists' ideals for the delivery of PAT can be conceptualised as a sort of 'enhanced care' approach, but workforce development and economic constraints are likely to challenge the accessible and impactful translation of this vision.

Practical Psychosocial Management for Patients With Bipolar Disorder

The broad acceptance of evidence-based psychosocial interventions as adjuncts to pharmacotherapy for bipolar disorder has been inhibited by the extensive training, supervision, and fidelity requirements of these approaches. Interventions that emphasize evidence-based strategies drawn from these modalities-rather than the full manualized protocols-may broaden the availability of psychotherapy for patients with bipolar disorder. In this article, psychosocial risk factors relevant to the course of bipolar disorder (stressful life events that disrupt social rhythms, lack of social support, family criticism and conflict, and lack of illness awareness or literacy) are reviewed, along with evidence-based psychosocial interventions (e.g., interpersonal and social rhythm therapy, cognitive-behavioral therapy, family-focused therapy, and group psychoeducation) to address these risk factors. The results of a component network meta-analysis of randomized psychotherapy trials in bipolar disorder are discussed. Manualized psychoeducation protocols-especially those that encourage active skill practice and mood monitoring in a family or group format-were found to be more effective, compared with individual psychoeducation or routine care, in reducing 1-year recurrence rates. Cognitive restructuring, regulation of daily and nightly routines, and communication skills training were core components associated with stabilization of depressive symptoms. The authors describe a novel psychoeducational approach-practical psychosocial management (PPM)-that integrates these core strategies into the personalized care of patients with bipolar disorder to reduce recurrences and enhance mood stability. PPM is designed to be implemented, without time-intensive training and oversight, by physician or nonphysician clinicians. Evaluating the efficacy and coverage of PPM will require implementation trials in community settings.

Randomised control trial indicates micronutrient supplementation may support a more robust maternal microbiome for women with antenatal depression during pregnancy

BACKGROUND AND AIMS

We investigated the effects of high dose dietary micronutrient supplementation or placebo on the human gut microbiome in pregnant women who had moderate symptoms of antenatal depression. There is a significant absence of well-controlled clinical studies that have investigated the dynamic changes of the microbiome during pregnancy and the relationship among diet, microbiome and antenatal depression. This research is among the first to provide an insight into this area of research.

METHODS

This 12 - week study followed a standard double blinded randomised placebo-controlled trial (RCT) design with either high dose micronutrients or active placebo. Matching stool microbiome samples and mood data were obtained at baseline and post-treatment, from participants between 12 and 24 weeks gestation. Stool microbiome samples from 33 participants (17 in the placebo and 16 in the treatment group) were assessed using 16s rRNA sequencing. Data preparation and statistical analysis was predominantly performed using the QIIME2 bioinformatic software tools for 16s rRNA analysis.

RESULTS

Microbiome community structure became increasingly heterogenous with decreased diversity during the course of the study, which was represented by significant changes in alpha and beta diversity. This effect appeared to be mitigated by micronutrient administration. There were less substantial changes at the genus level, where Coprococcus decreased in relative abundance in response to micronutrient administration. We also observed that a higher abundance of Coprococcus and higher alpha diversity correlated with higher antenatal depression scores.

CONCLUSIONS

Micronutrient treatment appeared to support a more diverse (alpha diversity) and stable (beta diversity) microbiome during pregnancy. This may aid in maintaining a more resilient or adaptable microbial community, which would help protect against decreases or fluctuations that are observed during pregnancy.

Efficacy and safety of lumateperone for bipolar depression and schizophrenia: a systematic review and meta-analysis

This study aimed to evaluate the efficacy and safety of lumateperone in treating bipolar disorder and schizophrenia. A comprehensive literature search was conducted across multiple databases and websites from inception to July 16, 2024, to identify both published and unpublished randomized controlled trials (RCTs). Meta-analyses were performed using random-effects or fixed-effects models depending on statistical heterogeneity. Relative risks (RRs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs) were used to summarize the effects. Out of 931 records screened, 7 RCTs (four focusing on bipolar depression and 3 on schizophrenia) were eligible for inclusion. Lumateperone was efficacious in reducing depressive symptoms in bipolar depression (SMDs = -0.36, 95% CI: -.59 to -.13). In treating schizophrenia, lumateperone exhibited a lower combined SMD of -0.14 (95% CI: -.27 to 0, P = .051, I² = 49.6%), showing no significant difference from the placebo group, although the P-value approached significance. The lumateperone group showed significantly higher response rates compared with placebo in both bipolar depression (RRs = 1.27, 95% CI = 1.07 to 1.51) and schizophrenia (RRs = 1.44, 95% CI = 1.12 to 1.86). Common treatment-emergent adverse events included somnolence, dry mouth, dizziness, nausea, and headache (RRs = 1.30 to 3.29). Importantly, lumateperone did not significantly increase extrapyramidal symptoms (EPS, RRs = 1.46, 95% CI = .84 to 2.53). Lumateperone is effective in treating bipolar depression but does not significantly reduce symptom severity in schizophrenia. It has a favorable safety and tolerability profile. However, caution is warranted in interpreting these findings due to the limited number of studies included.

Patterns of medicine use in the year prior to death by suicide: an Australian population-based case series study

Background

Prescribed medicines are commonly used to treat mental health conditions but are also often implicated in suicide death by poisoning. This was a descriptive study quantifying changes in dispensing and initiation of antidepressants, benzodiazepines, and antipsychotics in the year prior to death by suicide.

Methods

In this Australian population-based case series, we used national coronial data linked with dispensing claims for all people ≥10 years who died by suicide (2013-2019). Our primary outcome was change in aggregate weekly medicine dispensing the year before death, quantified using piecewise linear regression stratified by cause of death (medicine poisoning vs other causes). Our secondary outcome was change in medicine initiation rates. This study was performed between June 2021 and July 2023.

Findings

Our study included 14,207 people (24% female, median age 44  years). In the year prior to death, we observed higher rates of nervous system medicine use in people who died by medicine poisoning compared with those that did not: antidepressants (62.4% vs 42.9%), benzodiazepines (51.4% vs 29.0%), antipsychotics (25.6% vs 17.1%), opioids (43.8% vs 23.4%). For benzodiazepines, among people who died by medicine poisoning the slope (rate of increase) changed from 0.18 (95% CI -0.01, 0.37) to 4.12 (95% CI 0.98, 7.26) dispensings per 1000 people per week at 8 weeks prior to death. Among people who died of other causes, the slope changed from 0.18 (95% CI 0.14, 0.22) to 2.41 (95% CI 1.90, 2.91) also at 8 weeks prior to death. For antidepressants, among people who died of medicine poisoning we observed no change in the slope. Among people who died of other causes, the slope increased from 0.18 (95% CI 0.09, 0.28) to 1.68 (95% CI 1.20, 2.15) at 14 weeks prior to death.

Interpretation

Dispensing of antidepressants and benzodiazepines increased more rapidly closer to date of death, regardless of medicine involvement in death. This suggests these changes may reflect worsening symptoms or increased help seeking and that the method of death by suicide may be due to greater means access. However, findings need to be interpreted with caution as our analyses were performed on aggregate data and may not reflect person-level changes.

Funding

This study is funded by a grant from the Australian National Health and Medical Research Council (NHMRC) and the Translational Australian Clinical Toxicology Research (TACT) Group.

Active components and mechanisms of action of psychological interventions in bipolar disorder: A systematic literature review

OBJECTIVE

The efficacy of psychological interventions for bipolar disorder (BD) is well established, but much remains unknown about how change occurs. The primary objective of this exploratory study was to audit what is known about active components and mechanisms of action of psychological interventions for BD.

METHOD

We conducted a systematic review (PROSPERO CRD42022323276). Two independent reviewers screened references from four databases and extracted data from eligible studies.

RESULTS

We included four component studies, six studies with mediation analyses and 26 studies presenting subjective experiences of how psychological interventions bring change. Ten mediators were examined across six studies, with only one putative mediator, medication adherence, tested in more than one study. Some initial support for mediation of varied outcomes by control over thoughts, positive non-verbal behaviour, self-esteem, post-trauma growth and medication adherence. Some preliminary support was found in two components, human support and IPT. Studies exploring participant experiences of therapeutic change enumerated a range of potential active components, mechanisms of action and contextual factors potentially warranting investigation in future research. However, the evidence base for active components and mechanisms of action in psychological interventions for BD is unsatisfactory. Findings were inconsistent, studies homogenous with significant methodological limitations and statistical approaches failed to meet quality criteria.

CONCLUSIONS

Preliminary identification of potential components and mechanisms via qualitative analyses and the insights emerging from this review will inform future research aimed at investigating how psychological interventions work in BD.