Authors:

Authors: Scott Simpson, MD, MPH, FACLP, Department of Behavioral Health Services, Denver Health, CO; Ryan Loh, PhD, Department of Behavioral Health Services, Denver Health, CO; Maximilliam Cabrera, MD, Department of Behavioral Health Services, Denver Health, CO; Megan Cahn, PhD, MPH, University of Colorado Anschutz Medical Campus, Aurora, CO; Anne Gross, MD, Department of Psychiatry, Oregon Health Sciences University, Portland, OR; Allison Hadley, MD, Department of Psychiatry, Oregon Health Sciences University, Portland, OR; Ryan Lawrence, MD, Department of Psychiatry, Columbia University Medical Center, New York City, NY.

Research: When to Discharge and When to Voluntary or Compulsory Hospitalize? Factors associated with treatment decision after self-harm

Authors: Laurent Michaud, MD, et al.

Abstract: Clinicians assessing suicidal patients in emergency departments must decide whether to admit the patient to a psychiatric ward with voluntary or compulsory hospitalization, or to discharge him/her as an outpatient. Using data from all patients admitted to four Swiss emergency departments between 2016 and 2019, this study identifies predictors of this decision among a large sample of self-harm patients.

Legislation on this topic greatly varies between countries. In Switzerland, the Civil Code allows compulsory hospitalization as a measure of deprivation of liberty for assistance purposes thus: A person suffering from a mental disorder or mental disability or serious neglect (the patient) may be committed to an appropriate institution if the required treatment or care cannot be provided otherwise. The burden that the person concerned represents for his relatives and for third parties as well as their protection are taken into consideration.

The decision for a voluntary/compulsory hospitalization is critical as outpatient and inpatient treatments are very different. “While hospitalization offers the highest intensity of care and may thus be considered as protective,” say the authors, “as shown by some health-services research it may also favor a regressive process—and other authors question its usefulness in preventing suicide. Furthermore, although compulsory admissions are frequently decided when a highly suicidal patient does not accept hospitalization, it may increase the risk of further suicide attempts and is associated with stigma and other negative outcomes.”

Compulsory admissions may induce fright and distress in patients, contribute to post-traumatic stress disorder, alter patients’ confidence in care, and reduce their satisfaction with treatment. These phenomena may also influence future decisions to seek care.

Importance: This research gives insight into the factors that should be considered when deciding whether to involuntarily hospitalize a patient.

Availability: Published in Psychiatry Research

Research: Latent profile analysis for classification of psychosomatic symptoms in perimenopausal women

Authors: Na Yeon Kim (resident of the Chung-Ang University Hospital, Seoul, Republic of Korea), et al.

Abstract: More than 80% of perimenopausal women experience various physical and neuropsychiatric symptoms due to changes in female hormones—such as hot flashes, night sweats, vaginal dryness, urogenital atrophy, impaired memory, heart discomfort, physical and mental fatigue, sexual problems, joint and muscle discomfort, sleep disturbances, depressive symptoms, and anxiety.

However, accurate evaluation and treatment of menopausal symptoms are lacking due to limited evidence regarding customized treatment for each symptom type, say the authors.

“Clearly, distinguishing whether these symptoms are physical symptoms caused by biological hormonal changes, psychological symptoms experienced by middle-aged people, or psychosomatic symptoms associated with a psychological condition affecting the occurrence of physical symptoms is difficult,” say the authors.

This study identified and clustered psychosomatic symptoms in 1,060 Korean perimenopausal women and investigated the characteristics of each cluster type.

Psychosomatic symptoms were classified into four categories along with groups corresponding to differences in demographic factors, such as the presence of a partner, income, age, fertility, and previous psychiatric history.

Importance: Despite the high prevalence and social costs of menopause, only 30% of women who experience menopausal symptoms visit hospitals. Even if they visit a hospital, there are significant differences in interventions because of the lack of common clinical guidelines. Moreover, physical treatments such as hormone therapy alone are not sufficient to improve all menopausal symptoms.

Although there are many possible non-pharmacological interventions, such as exercise, diet control, cognitive behavior therapy, Kegel exercises, bladder training, and meditation, data to verify the effectiveness of each treatment are lacking. In addition, there is a lack of evidence regarding adequate treatment selection for each symptom type and customized treatment for patient characteristics. Therefore, maximizing the treatment effect by clustering menopausal symptom types and providing customized interventions are necessary.

Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)

Research: Brain Wellness ‘Spas’—Anticipating the Off-label Promotion of Psychedelics

Authors: Anna Wexler, PhD, et al.

Abstract: Psychedelic drugs have re-emerged as a promising adjunct to psychotherapy for various mental health indications. Clinical studies indicate 3,4-methylenedioxymethamphetamine (MDMA) is both efficacious and well tolerated in the treatment of post-traumatic stress disorder. Psilocybin—naturally found in mushrooms—appears to be efficacious in treating depression.

The US Food and Drug Administration (FDA) has designated both as breakthrough therapies, fast-tracking them for approval. Commercial interest has surged, with dozens of companies investing in psychedelic drug development in what is predicted to be a multibillion-dollar market.

“If and when psychedelics are approved by the FDA, they will almost certainly be used not just for their approved indication(s) but for off-label ones as well,” say the authors. When supported by evidence, they say, off-label use can benefit patients by increasing access to safe treatments.

But, in this comment piece, the authors raise concerns about ethical and legal issues related to the public promotion and advertisement of psychedelics for off-label indications against a background of an already-burgeoning landscape of private neurotherapy and brain wellness clinics that promote off-label use of psychiatric drugs and medical devices.

For example, more than 100 clinics in the US advertise the use of transcranial magnetic stimulation for off-label indications; “some of the advertised indications have a weaker body of evidence supporting efficacy than others,” say the authors.

Hundreds of other clinics offer alternative neurotherapies that lack a strong evidence base, such as neurofeedback, for both clinical indications as well as for ‘cognitive enhancement.’ Furthermore, off-label ketamine use is promoted by clinics for various clinical indications as well as for ‘wellness’ and ‘inner exploration.’

Many of these same clinics are poised to begin offering psychedelics if and when they garner FDA approval.

Importance: “With high public enthusiasm, extremely bullish investors, and hundreds of newly established brain wellness clinics, all the pieces are now in place for expansive off-label promotion and use of psychedelics to quickly mushroom beyond what is safe,” say the authors.

“While off-label use may be a useful way to provide access to promising treatments, it must be done responsibly and with an eye toward future evidence-based advancements in medical science; regulators, policy makers, and health authorities must carefully examine and create guardrails for the promotion and off-label use of psychedelics.”

Availability: Published by JAMA Network