This newsletter includes a brief overview of some topics discussed at the 2022 APA Annual Meeting, as well as some valuable pearls to apply in clinical practice.
We also share practical tips for using psychotropics in patients with hepatic issues, key points from a presentation on psychosis and schizophrenia in children and adolescents, and our practical research summaries (Quick Takes).
Insights From the 2022 APA Annual Meeting
The APA Annual Meeting resumed its annual in-person meeting in New Orleans, LA, after 2 years interrupted by the pandemic. This year’s central theme was on social determinants of mental health.
These last 2 years have highlighted the significant influence of social stressors on mental health. The latest research on the effects of the pandemic reflected interesting data on how social factors affect the presentation and course of mental illness. Because of this, experts agree on emphasizing the inclusion of social factors in everyday clinical practice, although they recognize efforts must be made to incentivize the busy mental healthcare worker to take this into account.
We covered the meeting and summed up the following key points for you:
The Psychopharmacology Algorithm Project: 2021 Update on Posttraumatic Stress Disorder
- Paroxetine and sertraline are the only FDA-approved medications for PTSD. However, they have a small size effect.
- The evidence suggests trying prazosin before an SSRI, particularly if patients have sleep disturbances.
An Overview of Bipolar Mixed States and Managing Medication Side Effects
- Mixed episodes have a worse prognosis than pure manic and depressive episodes.
- Functional recovery can take up to 12 weeks, although symptoms can be resolved earlier.
- The evidence suggests not using antidepressants in patients with bipolar disorders.
Current Trends in Suicide Research and Prevention
- Disclosure and dialogue can reduce the stigma of mental illnesses.
- Language matters when discussing suicide; it is best to avoid phrases like “commit suicide” and instead use the phrase “died by suicide.”
- Asking about suicidal thoughts does not harm patients.
Clinical Update on Managing Schizophrenia: Drugs and Other Treatments
- Long-term exposure to prolactin-increasing antipsychotics is significantly associated with increased odds of breast cancer. Consider prolactin-sparing antipsychotics in women.
- Lumateperone has a good side-effect profile. Its efficacy has not been well established yet; however, it seems like a promising medication.
- The combination of olanzapine and samidorphan was associated with less weight gain from olanzapine.
The Development of an Antidepressant Stepped Treatment Algorithm Application
- According to the STAR*D results, the response rate to antidepressants might decrease after 2 trials.
- This algorithm proposes focusing on mood response and assessing it every 2 weeks; if there is not enough response, switch or augment treatment every 4 weeks.
- With this accelerated sequential antidepressant protocol (ASAP), in 12 weeks, you would have performed 3 clinical trials, reducing the risk of no response.
Efficacy and Pitfalls of Real-World Long-Term Ketamine/Esketamine Therapy
- Intranasal esketamine is usually covered by insurance but only for MDD. IV ketamine is usually not covered.
- There are no head-to-head trials comparing the efficacy of IV ketamine with intranasal esketamine for depression. However, in some studies, there is a signal that IV ketamine is more efficacious than intranasal esketamine.
- Consider an alternative treatment if patients do not get better after 3 infusions.
2022 APA Medical Marijuana Debate
- There is not enough evidence on the efficacy of CBD for anxiety disorders, PTSD, MDD, and cannabis use disorder.
- MDD can increase the risk of cannabis use disorder.
- Withdrawal symptoms of cannabis use disorder overlap with MDD symptoms. Sometimes, patients report that cannabis helps them with depressive symptoms; however, they might only be sidestepping withdrawal symptoms.
Use of Psychotropics in Patients With Hepatic Issues, With Jonathan M. Meyer, M.D.
In this interview, Dr. Jonathan Meyer discusses practical considerations when prescribing psychotropic medications for patients with hepatic issues. He emphasizes the use of the Child-Pugh Score in determining how hepatic impairment can affect drug metabolism and the need for subsequent dosing adjustments. He also clarifies dosing considerations for specific medications in patients with hepatic issues.
Interview highlights include the following:
- Plasma levels of clozapine can be greatly affected by CYP1A2 inhibition and should be monitored in instances such as changes in smoking status or the presence of CYP1A2 inhibitors.
- Although valproate can cause elevated liver function tests, most patients will not need to discontinue valproate, as these elevations rarely impact hepatic metabolism to a significant degree.
Learn more and earn 0.5 CME credits here.
Psychosis and Schizophrenia in Children and Adolescents
In this presentation, Dr. David Rosenberg discusses psychosis and schizophrenia in children and adolescents, including unique features, differential diagnoses, and the importance of assessing psychotic symptoms in childhood. He reviews treatment considerations for this particular population, with a primary focus on the use of antipsychotics and psychosocial interventions. Additionally, he provides clinical insights and a vignette to illustrate the challenges of using antipsychotics in children.
Treatment of Psychosis and Schizophrenia in Children and Adolescents: Antipsychotic Dosing, Monitoring, and Side Effects
- Antipsychotic medication is the primary treatment for schizophrenia spectrum disorders in children and adolescents.
- SGAs are the first-line treatment due to their lower risk of EPS.
- The lower risk of EPS with SGAs needs to be balanced against the increased risk of metabolic side effects.
- Due to the serious metabolic side effects, baseline and follow-up monitoring need to be performed.
Learn more and earn 1.5 CME credits here.
Quick Takes: Informing Your Practice
Study of Mirtazapine for Agitated Behaviors in Dementia (SYMBAD)
- The first line of management for agitation in dementia is a full assessment to identify any potentially modifiable causes of the behavior.
- In all but the most urgent of situations, the next line is nonpharmacologic treatment because such approaches have been shown to be at least as effective as drug treatment.
- Mirtazapine was no better than placebo, and 7 deaths among 102 patients raised concerns about safety. Learn more.
Demographic and Clinical Characteristics of Patients Who Recommence Clozapine Following Therapy Interruptions
- In Western Australia clozapine clinics, only 30% of patients stick with clozapine without ever stopping. Among those who stopped, 50% resumed—most in the first month and 80% within a year. Learn more.
Listen to or read the full volume, and earn 0.5 CME credits here.
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