Publications by authors named "Amir Garakani"

60 Publications

Commentary: Treatment-resistant Depression: Considerations Related to ECT and Ketamine.

Authors:
Amir Garakani

J Psychiatr Pract 2021 Nov 5;27(6):496-497. Epub 2021 Nov 5.

GARAKANI: Department of Psychiatry and Behavioral Health, Greenwich Hospital, Greenwich, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT.

Treatment-resistant depression (TRD) may be responsive to interventions beyond antidepressants including brain stimulation such as electroconvulsive therapy (ECT) or to ketamine or esketamine, the latter of which is approved for TRD in an intranasal form. The 3 cases presented in this issue deal with an array of clinical considerations in treating patients with TRD, including the use of ECT in a patient with a history of liver transplantation, the use of heated yoga in a patient nonresponsive to ECT, and intranasal ketamine abuse in a patient with comorbid migraines. Gunther and colleagues described the case of a 73-year-old man who presented with a major depressive episode with psychotic features not responsive to medications 26 years after liver transplantation. Despite his past transplant and antirejection medications, the patient was cleared for ECT and received 9 bitemporal treatments with good response. Sakurai and colleagues reported the case of a 28-year-old woman with chronic TRD and multiple previous ECT treatments who had only a partial response to several antidepressants and maintenance ECT. She was evaluated and treated with a course of twice-weekly 90-minute heated yoga and experienced a remission of her depression. Finally, Rivas-Grajales and colleagues described a 52-year-old woman with recurrent TRD and chronic migraines who was receiving 2 antidepressants and migraine medication, who presented emergently with agitation and paranoia in the context of receiving intranasal ketamine from multiple providers, suggesting a pattern of misuse. Her symptoms abated despite her refusal of prescribed antipsychotics. These 3 cases highlight different challenges and complexities in treating patients with TRD. While ECT remains safe and effective, even in cases of organ transplantation, there is potential for the development of nonpharmacologic adjunctive treatments, such as heated yoga (which is under randomized study). And while eskatamine is an approved treatment for TRD, screening and ongoing monitoring is important to prevent misuse or abuse.
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http://dx.doi.org/10.1097/PRA.0000000000000593DOI Listing
November 2021

Commentary: Psychiatric Presentations of Nonpsychiatric Illness or Treatment.

Authors:
Amir Garakani

J Psychiatr Pract 2021 09 16;27(5):404-405. Epub 2021 Sep 16.

GARAKANI: Department of Psychiatry and Behavioral Health, Greenwich Hospital, Greenwich, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT.

Patients presenting with psychiatric symptoms, even in cases where there is no clear psychiatric history, are often labeled as having "psychogenic" symptoms or a psychosomatic reaction, and a tendency does exist to mislabel and/or misdiagnose certain patients in medical settings. The 3 cases presented in this issue of the Journal provide examples of patients presenting with psychotic or manic symptoms in the context of an underlying nonpsychiatric medical disorder. Kim and colleagues describe the case of a 65-year-old man with no psychiatric history who presented with acute visual hallucinations 1 day after starting omeprazole for gastroesophageal reflux. The visual hallucinations resolved immediately after the medication was stopped. Fipps and Rainey describe the case of a 74-year-old man with chronic generalized anxiety who presented with severe panic and suicidal thinking as well as refractory nausea that were unresponsive to benzodiazepine treatment and to a taper of the benzodiazepine. This patient was later found to have a subdural hematoma that was causing what had at first been suspected to be psychogenic nausea. Finally, Das and Brasseux present the case of a 23-year-old man hospitalized from jail who presented with manic symptoms; this patient was found to have had a traumatic brain injury 2 months earlier and, on brain imaging, was also found to have had a perinatal brain injury. The patient responded to mood stabilizers and the off-label use of memantine for his cognitive deficits. These 3 cases highlight the importance of obtaining a comprehensive neurological and medical history and, if indicated, workup, in cases involving patients with atypical presentations or nonresponse to traditional treatments.
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http://dx.doi.org/10.1097/PRA.0000000000000577DOI Listing
September 2021

Selective Serotonin Reuptake Inhibitors: How Long Is Long Enough?

J Psychiatr Pract 2021 09 16;27(5):361-371. Epub 2021 Sep 16.

Selective serotonin reuptake inhibitors (SSRIs) are among the most commonly prescribed medications. They are among the first-line medications for several chronic or relapsing-remitting psychiatric conditions, including major depressive disorder and anxiety disorders. The advantages of SSRI use include ease of titration and their tolerability and safety profile. Guidelines for the short-term use of SSRIs are widely available, but there is no well-organized guidance on how and whether to maintain a patient on SSRIs for the long-term. In this article, we discuss the benefits and possible adverse consequences of long-term SSRI use, as well as clinical practice considerations when using SSRIs chronically. The major benefit of long-term SSRI use is relapse prevention. The current literature suggests that the general health risks of long-term SSRI use are low; however, further research, particularly in special populations including youth and the elderly, is needed. Long-term SSRI use increases the risk of tachyphylaxis and discontinuation syndrome. Recognizing that many patients may remain on SSRIs for many years, there are several factors that prescribers should consider if they choose to use an SSRI when initiating treatment and during long-term monitoring. The decision to continue or to discontinue an SSRI should be an active one, involving both the patient and prescriber, and should be revisited periodically. Patients who remain on SSRIs for the long-term should also have periodic monitoring to reassess the risk-benefit ratio of remaining on the SSRI, as well as to assess the safety, tolerability, and efficacy of the medication.
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http://dx.doi.org/10.1097/PRA.0000000000000578DOI Listing
September 2021

Guest Editorial: Going Back to My Country.

Authors:
Amir Garakani

J Psychiatr Pract 2021 09 16;27(5):343-345. Epub 2021 Sep 16.

Department of Psychiatry and Behavioral Health, Greenwich Hospital, Greenwich, CT, and Department of Psychiatry, Yale School of Medicine, New Haven, CT.

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http://dx.doi.org/10.1097/PRA.0000000000000571DOI Listing
September 2021

Intensive Dialectical Behavior Treatment for Individuals With Borderline Personality Disorder With and Without Substance Use Disorders.

Front Psychol 2021 23;12:629842. Epub 2021 Aug 23.

Yale School of Medicine, New Haven, CT, United States.

Treatment of borderline personality disorder (BPD) with comorbid substance use disorder can be challenging due to symptom overlap and limited assessment methods. Preliminary evidence has shown promising effectiveness of dialectical behavioral therapy (DBT) for BPD with comorbid substance use disorders. The current study compared the benefits of a 28-day transitional DBT treatment program for individuals with BPD with and without substance use disorders through evaluating the changes in coping skills, generalized anxiety, and depression symptom scales at admission and discharge. A total of 76 patients were split into two groups: Group 1 consisted of individuals with BPD without substance use disorders ( = 41), and Group 2 involved individuals with BPD and a substance use disorder (SUD) ( = 35). A univariate general linear model showed significant differences between the two groups in improvement of coping skills and depressive symptoms. After a 28-day transitional DBT treatment program there were significant decreases from severe to moderate depression scores in both groups. Our findings support the effectiveness of DBT treatment in patients with comorbid BPD and SUD.
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http://dx.doi.org/10.3389/fpsyg.2021.629842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8419465PMC
August 2021

Impact of Childhood Trauma Histories Versus Recent Trauma Symptoms on Affective Lability in Adult Bipolar Disorder.

J Clin Psychiatry 2021 08 17;82(5). Epub 2021 Aug 17.

Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.

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http://dx.doi.org/10.4088/JCP.21br13912DOI Listing
August 2021

Commentary: Diagnostic and Treatment Issues in Psychosis.

Authors:
Amir Garakani

J Psychiatr Pract 2021 07 28;27(4):338-339. Epub 2021 Jul 28.

GARAKANI: Department of Psychiatry and Behavioral Health, Greenwich Hospital, Greenwich, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT.

The 3 cases presented in this issue highlight challenges in evaluating and treating patients with psychotic symptoms. The first case involved the rare but debilitating condition of periodic catatonia, the second case involved the use of intranasal oxytocin to augment an antipsychotic for a patient with worsening psychotic symptoms (and a prior diagnosis of schizophrenia) in the postpartum period, and the third case involved auto-enucleation (often referred to as "Oedipism"), a violent form of self-mutilation, in a patient presenting with first-episode schizophrenia. These case reports reinforce the need to consider a wide differential diagnosis before initiating treatment. Understanding the broad spectrum with which psychotic symptoms can present, or rare presentations of more common conditions, can help clarify the diagnosis and guide treatment, and hopefully help prevent or reduce future self-harm or violence, psychotic episodes, and hospitalizations.
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http://dx.doi.org/10.1097/PRA.0000000000000562DOI Listing
July 2021

Clinical and imaging outcomes after intrathecal injection of umbilical cord tissue mesenchymal stem cells in cerebral palsy: a randomized double-blind sham-controlled clinical trial.

Stem Cell Res Ther 2021 08 6;12(1):439. Epub 2021 Aug 6.

Pediatrics Center of Excellence, Department of Pediatric Neurology, Children's Medical Center, Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Background: This study assessed the safety and efficacy of intrathecal injection of umbilical cord tissue mesenchymal stem cells (UCT-MSC) in individuals with cerebral palsy (CP). The diffusion tensor imaging (DTI) was performed to evaluate the alterations in white-matter integrity.

Methods: Participants (4-14 years old) with spastic CP were assigned in 1:1 ratio to receive either UCT-MSC or sham procedure. Single-dose (2 × 10) cells were administered in the experimental group. Small needle pricks to the lower back were performed in the sham-control arm. All individuals were sedated to prevent awareness. The primary endpoints were the mean changes in gross motor function measure (GMFM)-66 from baseline to 12 months after procedures. The mean changes in the modified Ashworth scale (MAS), pediatric evaluation of disability inventory (PEDI), and CP quality of life (CP-QoL) were also assessed. Secondary endpoints were the mean changes in fractional anisotropy (FA) and mean diffusivity (MD) of corticospinal tract (CST) and posterior thalamic radiation (PTR).

Results: There were 36 participants in each group. The mean GMFM-66 scores after 12 months of intervention were significantly higher in the UCT-MSC group compared to baseline (10.65; 95%CI 5.39, 15.91) and control (β 8.07; 95%CI 1.62, 14.52; Cohen's d 0.92). The increase was also seen in total PEDI scores (vs baseline 8.53; 95%CI 4.98, 12.08; vs control: β 6.87; 95%CI 1.52, 12.21; Cohen's d 0.70). The mean change in MAS scores after 12 months of cell injection reduced compared to baseline (-1.0; 95%CI -1.31, -0.69) and control (β -0.72; 95%CI -1.18, -0.26; Cohen's d 0.76). Regarding CP-QoL, mean changes in domains including friends and family, participation in activities, and communication were higher than the control group with a large effect size. The DTI analysis in the experimental group showed that mean FA increased (CST 0.032; 95%CI 0.02, 0.03. PTR 0.024; 95%CI 0.020, 0.028) and MD decreased (CST -0.035 × 10; 95%CI -0.04 × 10, -0.02 × 10. PTR -0.045 × 10; 95%CI -0.05 × 10, -0.03 × 10); compared to baseline. The mean changes were significantly higher than the control group.

Conclusions: The UCT-MSC transplantation was safe and may improve the clinical and imaging outcomes.

Trial Registration: The study was registered with ClinicalTrials.gov ( NCT03795974 ).
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http://dx.doi.org/10.1186/s13287-021-02513-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343813PMC
August 2021

Gaming to relieve tension or anxiety and associations with health functioning, substance use and physical violence in high school students.

J Psychiatr Res 2021 08 27;140:461-467. Epub 2021 May 27.

Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06510, United States; The Connecticut Council on Problem Gambling, Wethersfield, CT, 06109, United States; The Connecticut Mental Health Center, New Haven, CT, 06519, United States; Department of Neuroscience and Child Study Center, Yale School of Medicine, New Haven, CT, 06510, United States. Electronic address:

Gaming is popular among youth and gaming disorders have been introduced recently into psychiatric nomenclature systems. Motivations underlying gaming may include involvement to reduce negative emotional states and thus may link to psychiatric and overall health. Thus, the extent to which adolescents engage in gaming to relieve anxiety warrants additional investigation. Data from 2005 Connecticut high-school students were used to examine how adolescents who reported gaming to relieve tension or anxiety differed from those who reported gaming but not to relieve tension or anxiety on measures of demographics, academic performance, general health, extracurricular activities, dysphoria/depression symptoms, substance use, and aggressive or violent behaviors. Chi-square analyses and binomial and multinomial logistic regression models were conducted. Gaming to relieve anxiety was more prevalent in boys and Hispanic and Asian adolescents and associated with less extracurricular involvement, poorer academic performance, increased cigarette and other drug use, problematic internet use, and depression. Participants with gaming to relieve tension or anxiety were also more likely to report weapon-carrying, missing school because they felt unsafe, having been threatened with a weapon, having engaged in physical fights, and having experienced injuries from fights. As gaming to relieve anxiety was related to mental-health- and functioning-related measures, additional research is needed to examine the precise natures of these relationships and to translate the information into improved intervention strategies.
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http://dx.doi.org/10.1016/j.jpsychires.2021.05.055DOI Listing
August 2021

The mediating effects of quality of life, depression, and generalized anxiety on perceived barriers to employment success for people diagnosed with Neurofibromatosis Type 1.

Orphanet J Rare Dis 2021 05 21;16(1):234. Epub 2021 May 21.

Department of Psychiatry, Yale School of Medicine, 300 George Street, New Haven, CT, 06510, USA.

Background: Neurofibromatosis Type 1 (NF1) is a genetic disorder that presents with physical symptoms that can negatively impact numerous areas of one's life, including occupational and psychological functioning, with decreased quality of life compared to a normative population. The purpose of the current study was to explore differences in the impact of psychological factors (anxiety and depression), quality of life and employment hope on barriers to successful employment between those with NF1 and matched controls.

Methods: A total of 212 individuals were stratified into two groups (NF1 and matched controls) using a cross-sectional design that collected a one-time response.

Results: A mediation analysis in which total barriers to successful employment on the differences between groups with quality of life, anxiety and depression as the mediators, and levels of employment hope as the co-variates were examined. The results confirmed a direct (.001) and indirect (< .001) relationship between barriers to successful employment with NF1 to matched controls, and with quality of life, anxiety, and depression.

Conclusions: The current findings indicate that the barriers to successful employment for individuals with NF1 impact their quality of life, anxiety, and depression more than that of the matched controls. Poorer barriers of employment observed amongst people with a genetic disease can impact mental health and quality of life.
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http://dx.doi.org/10.1186/s13023-021-01866-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138923PMC
May 2021

Commentary: Diagnostic Challenges in Evaluating Adolescents.

Authors:
Amir Garakani

J Psychiatr Pract 2021 05 5;27(3):239-240. Epub 2021 May 5.

GARAKANI: Silver Hill Hospital, New Canaan, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT; and Icahn School of Medicine at Mount Sinai, New York, NY.

Three cases presented in this issue highlight diagnostic challenges in evaluating adolescents, in particular those with a constellation of symptoms that includes hallucinations. These cases raise the question of the accuracy of patient reports and the importance of further exploring symptoms before rushing to a diagnosis or treatment. The first case involved an 18-year-old female patient with Cotard syndrome. She had the syndrome's typical delusions and hallucinations, but her case was unusual because this syndrome is more common in adults and usually involves prominent mood symptoms. The second case involved a 14-year-old girl with depressive symptoms, suicidal ideas, and auditory and visual hallucinations, as well as sexually predatory behavior. This case was unusual in that girls and women are less commonly sexual predators although such behavior is more common among survivors of sexual abuse, as was the case with this patient. The authors believe that the patient's "hallucinations" were more likely related to posttraumatic stress disorder and dissociation. The third case involved a 16-year-old girl diagnosed with schizophrenia and treated with antipsychotics based merely on her report of "visions" of demons but absent any auditory hallucinations, delusions, or thought disorder. The authors, consulting on the case, identified more prominent depression, anxiety, and trauma-related symptoms as a result of school bullying and concluded that the patient did not have schizophrenia. Only the patient in the first of these 3 cases actually met the criteria for a psychotic disorder and warranted medication treatment. These cases highlight the importance of a full differential diagnosis in evaluating adolescent patients presenting with what appear to be psychotic symptoms to avoid the harm that can occur in terms of stigma and unnecessary treatment with the risk of side effects from antipsychotic medications when an incorrect diagnosis is made.
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http://dx.doi.org/10.1097/PRA.0000000000000553DOI Listing
May 2021

Editorial: Pharmacotherapy of Anxiety Disorders: Promises and Pitfalls.

Front Psychiatry 2021 18;12:662963. Epub 2021 Mar 18.

Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

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http://dx.doi.org/10.3389/fpsyt.2021.662963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012478PMC
March 2021

Neurological manifestations as the predictors of severity and mortality in hospitalized individuals with COVID-19: a multicenter prospective clinical study.

BMC Neurol 2021 Mar 16;21(1):116. Epub 2021 Mar 16.

Department of Neurology, Skull Base Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Backgrounds: The reports of neurological symptoms are increasing in cases with coronavirus disease 2019 (COVID-19). This multi-center prospective study was conducted to determine the incidence of neurological manifestations in hospitalized cases with COVID-19 and assess these symptoms as the predictors of severity and death.

Methods: Hospitalized males and females with COVID-19 who aged over 18 years were included in the study. They were examined by two neurologists at the time of admission. All survived cases were followed for 8 weeks after discharge and 16 weeks if their symptoms had no improvements.

Results: We included 873 participants. Of eligible cases, 122 individuals (13.97%) died during hospitalization. The most common non-neurological manifestations were fever (81.1%), cough (76.1%), fatigue (36.1%), and shortness of breath (27.6%). Aging, male gender, co-morbidity, smoking, hemoptysis, chest tightness, and shortness of breath were associated with increased odds of severe cases and/or mortality. There were 561 (64.3%) cases with smell and taste dysfunctions (hyposmia: 58.6%; anosmia: 41.4%; dysguesia: 100%). They were more common among females (69.7%) and non-smokers (66.7%). Hyposmia/anosmia and dysgeusia were found to be associated with reduced odds of severe cases and mortality. Myalgia (24.8%), headaches (12.6%), and dizziness (11.9%) were other common neurological symptoms. Headaches had negative correlation with severity and death due to COVID-19 but myalgia and dizziness were not associated. The cerebrovascular events (n = 10) and status epilepticus (n = 1) were other neurological findings. The partial or full recovery of smell and taste dysfunctions was found in 95.2% after 8 weeks and 97.3% after 16 weeks. The parosmia (30.9%) and phantosmia (9.0%) were also reported during 8 weeks of follow-up. Five cases with mild headaches and 5 cases with myalgia were reported after 16 weeks of discharge. The demyelinating myelitis (n = 1) and Guillain-Barré syndrome (n = 1) were also found during follow-up.

Conclusion: Neurological symptoms were found to be prevalent among individuals with COVID-19 disease and should not be under-estimated during the current pandemic outbreak.
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http://dx.doi.org/10.1186/s12883-021-02152-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7960879PMC
March 2021

Commentary on 2 Cases of Neuropsychiatric Symptoms Occurring in Association With COVID-19.

Authors:
Amir Garakani

J Psychiatr Pract 2021 03 5;27(2):145-146. Epub 2021 Mar 5.

GARAKANI: Silver Hill Hospital, New Canaan, CT; Department of Psychiatry, Yale University School of Medicine, New Haven, CT; and Icahn School of Medicine at Mount Sinai, New York, NY.

Two cases are presented involving neuropsychiatric symptoms occurring in the context of coronavirus disease 2019 (COVID-19) infections. The first case involved a middle-age man with no known psychiatric history who presented with acute psychotic symptoms (delusions, hallucinations, disorganization) after recovery from a recent respiratory illness. This patient tested positive for COVID-19 on admission. The patient's symptoms were not consistent with delirium and testing did not suggest a neurological etiology. The patient's psychosis eventually resolved 6 weeks after its abrupt onset with treatment with antipsychotic medication. The second case involved a 44-year-old man with a history of depression and psychotic symptoms who presented after a serious suicide attempt and tested positive for COVID-19 on admission. The patient had subsequent negative tests while on the inpatient psychiatric unit before again testing positive later in his admission. The patient's positive COVID-19 tests appeared to coincide with exacerbations in his mood symptoms, which led to the suicide attempt and psychotic episode that initially caused his admission. This patient was successfully treated with clozapine. In both of these cases, the question arose as to whether there was a link between the COVID-19 infections and the neuropsychiatric symptoms. Growing evidence suggests that severe neuropsychiatric sequelae can develop after COVID-19 infection.
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http://dx.doi.org/10.1097/PRA.0000000000000527DOI Listing
March 2021

The prevalence of post-traumatic stress disorder related symptoms in Coronavirus outbreaks: A systematic-review and meta-analysis.

J Affect Disord 2021 03 2;282:527-538. Epub 2021 Jan 2.

Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: Infectious disease outbreaks affect physical and mental health of humans worldwide. Studies showed that the prevalence of post-traumatic stress disorder (PTSD) symptoms increased in these conditions. This systematic-review and meta-analysis aimed to assess the prevalence of PTSD related symptoms in coronavirus outbreaks.

Methods: Systematic search of literature was conducted in Scopus, Embase, PubMed, and Web of Science. Google Scholar and Grey literature including conference proceedings were also checked. Published articles from November 1, 2012 until May 18, 2020 were searched. Subgroup analysis, meta-regression and sensitivity analysis were also conducted to assess heterogeneity.

Results: We found 38 articles with 19,428 individuals met the eligibility criteria. Of these papers, 35 studies were included in meta-analysis. The prevalence of PTSD symptoms was estimated to be about 18% (95%CI: 15% to 20%). These symptoms were more frequent in cohort studies (29%) compared to cross-sectional (15%) and case-control (11%) studies. Prevalence rates of PTSD symptoms in MERS (36%) outbreaks were higher than SARS (18%) and COVID-19 (9%) outbreaks. Meta-regression showed that the geographical location of study was the source of heterogeneity (R: 19.8%, P-value: 0.003). Meta-analysis reported that about three in every ten survivors of coronavirus infection, about two in every ten healthcare workers, and about one in every ten individuals of general population experienced PTSD symptoms in outbreaks.

Limitations: PTSD cannot be objectively assessed and this can lead to information bias of included studies.

Conclusion: PTSD symptoms are shown to be common in coronavirus outbreaks. Mental care should be, therefore, considered in the present COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.jad.2020.12.188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831964PMC
March 2021

Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options.

Front Psychiatry 2020 23;11:595584. Epub 2020 Dec 23.

Clinical Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, United States.

Anxiety disorders are the most prevalent psychiatric disorders and a leading cause of disability. While there continues to be expansive research in posttraumatic stress disorder (PTSD), depression and schizophrenia, there is a relative dearth of novel medications under investigation for anxiety disorders. This review's first aim is to summarize current pharmacological treatments (both approved and off-label) for panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and specific phobias (SP), including selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), azapirones (e.g., buspirone), mixed antidepressants (e.g., mirtazapine), antipsychotics, antihistamines (e.g., hydroxyzine), alpha- and beta-adrenergic medications (e.g., propranolol, clonidine), and GABAergic medications (benzodiazepines, pregabalin, and gabapentin). Posttraumatic stress disorder and obsessive-compulsive disorder are excluded from this review. Second, we will review novel pharmacotherapeutic agents under investigation for the treatment of anxiety disorders in adults. The pathways and neurotransmitters reviewed include serotonergic agents, glutamate modulators, GABAergic medications, neuropeptides, neurosteroids, alpha- and beta-adrenergic agents, cannabinoids, and natural remedies. The outcome of the review reveals a lack of randomized double-blind placebo- controlled trials for anxiety disorders and few studies comparing novel treatments to existing anxiolytic agents. Although there are some recent randomized controlled trials for novel agents including neuropeptides, glutamatergic agents (such as ketamine and d-cycloserine), and cannabinoids (including cannabidiol) primarily in GAD or SAD, these trials have largely been negative, with only some promise for kava and PH94B (an inhaled neurosteroid). Overall, the progression of current and future psychopharmacology research in anxiety disorders suggests that there needs to be further expansion in research of these novel pathways and larger-scale studies of promising agents with positive results from smaller trials.
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http://dx.doi.org/10.3389/fpsyt.2020.595584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786299PMC
December 2020

Commentary on "A New Onset of Mania in a 49-Year-Old Man: An Interesting Case of Wilson Disease".

Authors:
Amir Garakani

J Psychiatr Pract 2020 11;26(6):510-517

GARAKANI: Director of Education, Silver Hill Hospital, New Canaan, CT; Assistant Professor (Adjunct) of Psychiatry, Yale University School of Medicine, New Haven, CT; and Assistant Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY.

Wilson disease is a rare copper metabolism disorder that generally occurs in individuals between 5 and 35 years of age. Common clinical manifestations are hepatic, neurological, and psychiatric symptoms. Roughly, 4% of all cases occur in patients over 40 years of age and, among these patients, the presenting symptoms are generally neuropsychiatric, which often leads to misdiagnosis as a primary psychiatric disorder and a delay in correct diagnosis. This report presents the case of a 49-year-old man with no formal psychiatric history who presented with a new onset of mania. We outline the distinctive characteristics that appeared inconsistent with a primary psychiatric disorder and pointed toward secondary mania. Despite low serum ceruloplasmin, the absence of brain abnormalities more typical of Wilson disease on magnetic resonance imaging led a neurology consultant to advise that the diagnosis was likely primarily psychiatric. Due to atypical components of the patient's presentation, such as his late age of onset for bipolar disorder and acute cognitive decline, the psychiatric team advocated for further diagnostic workup. The subsequent evaluation confirmed Wilson disease based on specific ophthalmological and hepatic abnormalities and further copper studies. In addition, once diagnosed, the management of Wilson disease involves distinct clinical considerations given patients' presumed vulnerability to neurological side effects. This case illustrates the role psychiatric providers play in advocating for diagnostic workup in patients with atypical presentations of primary psychiatric disorders and the distinct diagnostic and treatment considerations associated with Wilson disease.
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http://dx.doi.org/10.1097/PRA.0000000000000507DOI Listing
November 2020

Commentary on "A New Onset of Mania in a 49-Year-Old Man: An Interesting Case of Wilson Disease".

Authors:
Amir Garakani

J Psychiatr Pract 2020 11;26(6):510-517

GARAKANI: Director of Education, Silver Hill Hospital, New Canaan, CT; Assistant Professor (Adjunct) of Psychiatry, Yale University School of Medicine, New Haven, CT; and Assistant Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY.

Wilson disease is a rare copper metabolism disorder that generally occurs in individuals between 5 and 35 years of age. Common clinical manifestations are hepatic, neurological, and psychiatric symptoms. Roughly, 4% of all cases occur in patients over 40 years of age and, among these patients, the presenting symptoms are generally neuropsychiatric, which often leads to misdiagnosis as a primary psychiatric disorder and a delay in correct diagnosis. This report presents the case of a 49-year-old man with no formal psychiatric history who presented with a new onset of mania. We outline the distinctive characteristics that appeared inconsistent with a primary psychiatric disorder and pointed toward secondary mania. Despite low serum ceruloplasmin, the absence of brain abnormalities more typical of Wilson disease on magnetic resonance imaging led a neurology consultant to advise that the diagnosis was likely primarily psychiatric. Due to atypical components of the patient's presentation, such as his late age of onset for bipolar disorder and acute cognitive decline, the psychiatric team advocated for further diagnostic workup. The subsequent evaluation confirmed Wilson disease based on specific ophthalmological and hepatic abnormalities and further copper studies. In addition, once diagnosed, the management of Wilson disease involves distinct clinical considerations given patients' presumed vulnerability to neurological side effects. This case illustrates the role psychiatric providers play in advocating for diagnostic workup in patients with atypical presentations of primary psychiatric disorders and the distinct diagnostic and treatment considerations associated with Wilson disease.
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http://dx.doi.org/10.1097/PRA.0000000000000507DOI Listing
November 2020

Commentary on "Window to His World: Using a Patient's YouTube Channel to Help Diagnose Chronic Mania".

Authors:
Amir Garakani

J Psychiatr Pract 2020 07;26(4):324-328

GARAKANI: Director of Education, Silver Hill Hospital, New Canaan, CT; Assistant Professor (Adjunct) of Psychiatry, Yale University School of Medicine, New Haven, CT; and Assistant Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY.

Although chronic mania has been investigated, with several case reports and systematic retrospective cohort studies in the literature, it not a widely recognized entity. No specific definition for chronic mania is provided in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Furthermore, it is challenging to identify patients with chronic mania unless they come to the attention of the legal or medical system. We present the case of a manic patient who was hospitalized and subsequently found to have a YouTube channel that he had been using to promote his self-invented religion for over 2 years. Consent was obtained from the patient to review this YouTube channel for collateral information. From these videos, the patient was seen to be chronically circumstantial in his thought processes, grandiose in his ideas, highly energetic, distractible, preoccupied with religion, and talking with elaborate and rapid speech. A significant improvement in his symptoms was observed after administration of oral risperidone, with his scores on the Young Mania Rating Scale and Brief Psychiatric Rating Scale also showing improvement. To our knowledge, this is the first case in the literature in which an online video-sharing service was used longitudinally to facilitate diagnosis of a mental illness. We suggest that technology has great potential to improve our diagnostic tools, especially for disorders such as chronic mania the diagnosis of which relies primarily on self-report and collateral information.
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http://dx.doi.org/10.1097/PRA.0000000000000480DOI Listing
July 2020

Gaming and Gaming Disorder: A Mediation Model Gender, Salience, Age of Gaming Onset, and Time Spent Gaming.

Cyberpsychol Behav Soc Netw 2020 Sep 10;23(9):647-651. Epub 2020 Jul 10.

Nottingham Trent University, Nottingham, United Kingdom.

Females in empirically based peer-reviewed studies of Internet gaming disorder (IGD) are underrepresented, despite evidence that there are only minor gender disparities present in online gaming. Moreover, few studies have specifically evaluated adult gender effects, within a formal diagnosis of IGD, and behavioral motivation, as defined by the reinforcing behavioral function. A mediation analysis evaluated the relationship between gender, behavioral motivation, and the diagnostic features in online gaming among adults to understand the impact of motivation on videogame playing. This study interviewed 304 adults (aged >18 years) in which 178 identified as female. Participants completed the Video Game Functional Assessment-Revised (VGFA-R) and the 20-item Internet Gaming Disorder Test (IGDT-20) through an online survey. Results showed that number of hours played per week, and subfactors of the VGFA-R differed between gender, indicating that the function and the maintaining of videogame play are essential in evaluating videogame addiction. These findings support and extend the literature's limited findings concerning gender and online gaming.
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http://dx.doi.org/10.1089/cyber.2019.0445DOI Listing
September 2020

Chronic Pain, Mood Disorders and Substance Use: Outcomes of Interdisciplinary Care in a Residential Psychiatric Hospital.

J Pain Res 2020 24;13:1515-1523. Epub 2020 Jun 24.

Yale Child Study Center, Yale University School of Medicine, Yale University, New Haven, CT, USA.

Purpose: The objective is to report outcomes of an interdisciplinary group-based residential chronic pain recovery program (CPRC), located in a private non-profit psychiatric hospital. The chronic pain program was aimed at treatment and engagement in self-care of both pain and co-occurring disorders in a residential facility that also offered treatment for specific psychiatric disorders.

Patients And Methods: A retrospective chart review was conducted that included a convenience sample of 131 patients admitted from March 2012 through August 2017 who completed treatment. An interdisciplinary team of professionals provided psycho-behavioral therapy, movement therapies and medication management. Patients completed a battery of psycho-social and demographic questionnaires on admission and before discharge of the program.

Results: Significant differences were noted in pain severity, pain interference, depression and anxiety (p<.01) between admission and discharge, and the Chronic Pain Coping Inventory demonstrated significant differences in guarding (p <.001), asking (p =.018), exercise (p <.001), relaxation (p <.001), and pacing (p=.024). Of patients using opioids on admission, at discharge, 37% had tapered and remained off all opioids, 43% were using buprenorphine for opioid use disorder, and 20% continued on analgesic opioids.

Conclusion: Treatment was associated with reductions in pain severity and interference, in anxiety and in depression as well as improvements in pain coping. Additionally, there was a reduction in reliance on opioids for pain relief.
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http://dx.doi.org/10.2147/JPR.S250568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322115PMC
June 2020

The effects of augmenting clozapine with oxytocin in schizophrenia: An initial case series.

Ann Clin Psychiatry 2020 05;32(2):90-96

Silver Hill Hospital, New Canaan, CT 06840 USA. E-MAIL:

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

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

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

Conclusions: Future controlled, prospective studies should investigate the possibility that OT can significantly reduce negative symptoms of chronic psychotic illnesses that are inadequately responsive to clozapine or other antipsychotic medications alone.
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May 2020

Impact of depressive symptoms on self-perceived severity of autonomic dysfunction in multiple system atrophy: relevance for patient-reported outcomes in clinical trials.

Clin Auton Res 2020 06 3;30(3):215-221. Epub 2020 Apr 3.

Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Ave, Suite 9Q, New York, NY, 10016, USA.

Purpose: To assess the relationship between depressive symptoms and self-perceived severity of autonomic dysfunction in patients with multiple system atrophy (MSA).

Methods: Cross-sectional evaluation of patients with MSA who underwent autonomic testing, Unified MSA Rating Scale (UMSARS)-1 and -2, rating of the presence and severity of depressive symptoms (Zung scale), quality of life (SF-36), body vigilance, anxiety (Spielberger's anxiety scale), severity of autonomic dysfunction with the Composite Autonomic Symptoms Score (COMPASS-31), and severity of orthostatic hypotension (OH) symptoms with the Orthostatic Hypotension Questionnaire (OHQ).

Results: Fifty-eight patients (32 women) with probable MSA (aged 61.8 ± 8.6 years; disease duration 4.3 ± 2.1 years) were studied. Forty patients (69%) had symptoms of depression in the Zung scale. Age, disease duration, and motor disability were similar in those with and without symptoms of depression. Despite a similar orthostatic blood pressure fall, the severity of orthostatic symptoms was higher in patients with symptoms of depression (p = 0.004). Depression scores were associated with higher burden of autonomic symptoms (R = 0.401, p = 0.02), specifically with the COMPASS-31 items related to orthostatic intolerance (R = 0.337, p = 0.045), and with the OHQ (R = 0.529; p < 0.001). A multivariable regression model including age, sex, UMSARS, and drop in systolic blood pressure upon head-up tilt as covariates showed that the burden of depressive symptoms was independently associated with the OHQ score: for every 1-unit increase in the Zung depression score, there was a 1.181-point increase in the total OHQ score.

Conclusions: In patients with MSA, depressive symptoms worsen the perceived severity of autonomic symptoms in general and orthostatic hypotension in particular. Our findings have implications for clinical trial design.
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http://dx.doi.org/10.1007/s10286-020-00681-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7341538PMC
June 2020

Parsing the effects of comorbid adult ADHD and substance misuse on affective lability in bipolar disorder.

J Affect Disord 2020 04 22;266:338-340. Epub 2020 Jan 22.

Department of Psychiatry, Icahn School of Medicine at Mount Sinai, NY, United States. Electronic address:

Introduction: Attentional deficits, substance misuse, and affective lability are all common features among adults with bipolar disorder, but little research has attempted to parse their inter-relationships.

Methods: Using standardized scales and semi-structured interviews, we evaluated adult ADHD features and affective lability in 113 dually-diagnosed mood/substance use disorder inpatients (mean age 32.6 years, 63% female) drawn from one private suburban academically affiliated inpatient treatment program.

Results: 24% of bipolar subjects had above-threshold ADHD screens. Affective Lability Scale (ALS) total and subscores were significantly associated with ADHD scores (univariate r's ranging from 0.38-0.63). ALS total and most subscale scores were significantly higher among bipolar subjects having above- (versus below-) threshold ADHD ratings. Linear regressions to predict affective lability revealed significant partial correlations between bipolar diagnoses and ALS total, depression, elation, and anger subscores, while controlling for significant effects from ADHD comorbidity. Inclusion of current substances of abuse did not change goodness-of-fit.

Limitations: Subjects were drawn from a single private institution, potentially limiting generalizability.

Conclusions: Comorbid ADHD appears to moderate multiple domains of affective lability in bipolar disorder inpatients, independent of current substance misuse.
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http://dx.doi.org/10.1016/j.jad.2020.01.087DOI Listing
April 2020

Pharmacogenomic Testing in Psychiatry: Ready for Primetime?

J Nerv Ment Dis 2020 02;208(2):127-130

Faculty of Health Sciences, Western University of Health Sciences, Pomona, California.

Pharmacogenomic testing in clinical psychiatry has grown at an accelerated pace in the last few years and is poised to grow even further. Despite robust evidence lacking regarding efficacy in clinical use, there continues to be growing interest to use it to make treatment decisions. We intend this article to be a primer for a clinician wishing to understand the biological bases, evidence for benefits, and pitfalls in clinical decision-making. Using clinical vignettes, we elucidate these headings in addition to providing a perspective on current relevance, what can be communicated to patients, and future research directions. Overall, the evidence for pharmacogenomic testing in psychiatry demonstrates strong analytical validity, modest clinical validity, and virtually no evidence to support clinical use. There is definitely a need for more double-blinded randomized controlled trials to assess the use of pharmacogenomic testing in clinical decision-making and care, and until this is done, they could perhaps have an adjunct role in clinical decision-making but minimal use in leading the initial treatment plan.
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http://dx.doi.org/10.1097/NMD.0000000000001107DOI Listing
February 2020

Retrospective Chart Review of Voluntary Admissions to an Inpatient Psychiatric Hospital in New York City: A Demographic Breakdown.

Community Ment Health J 2020 04 25;56(3):448-455. Epub 2019 Oct 25.

Yale School of Medicine, New Haven, CT, USA.

The current paper evaluates psychiatric needs of voluntary admissions in a large urban psychiatric hospital through a retrospective chart review, as this research is limited within the United States. A total of 581 voluntary adult psychiatric admission charts were reviewed. Continuous variables were evaluated using an ANOVA while associations between variables were examined by an unadjusted Pearson correlation coefficient a stepwise linear regression analysis. Men were significantly more likely to have a past admission for psychiatric services (p = .016), suicidal ideation (p < .001) and test positive for substances (p < .001) than women, and were more likely to be unemployed, homeless and without insurance. Women were more likely to have a past suicide attempt and a depressive disorder. A significant relationship between gender and rationale for seeking voluntary admission (p < .001) was found. This study offers understanding of male and female voluntary admissions, and a foundation for improving treatment interventions to reduce recurrent readmissions.
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http://dx.doi.org/10.1007/s10597-019-00498-2DOI Listing
April 2020

Patient Requests for Discharge from Voluntary Psychiatric Hospitalization: a Chart Review.

Psychiatr Q 2019 12;90(4):849-859

Silver Hill Hospital, 208 Valley Road, New Canaan, CT, 06840, USA.

The purpose of this study was to examine the rate of 72-hour letters (written requests for discharge, with 72 hours indicating the time the hospital has to discharge or seek retention) placed by voluntary psychiatric inpatients at a New York City hospital and determine whether there are factors contributing to the rates of discharge requests. Charts from all voluntary psychiatric hospitalizations during the calendar year 2007 were retrospectively reviewed. Included were all single voluntary admissions by adults (age 18 years and older) to the hospital. A confirmatory factor analysis (CFA) was conducted with the following factors: urine toxicology, cigarette use on admission, suicidal ideation upon presentation, employment, past inpatient psychiatric admission, and admission day. A linear regression was used to evaluate the relationship between discharge requests and these factors. Of the total sample (N = 581), 119 (20.5%) patients submitted 72-hour letters. The stepwise linear regression analysis confirmed a positive relationship between letter placement and admission day (M = 3.5, SD = 1.7), unemployment (M = 4.7, SD = 2.1), suicidal ideation (M = .5, SD = .5), positive urine toxicology (M = .47, SD = .5), previous psychiatric hospitalization (M = .7, SD = .5) and cigarette usage (M = .5, SD.5) R = .043, (6, 461) = 3.42, p = .003). These specific variables accounted for 55.6% of likelihood of a patient submitting a 72-hour letter. Several factors, related to substance and tobacco use, employment, and recurrent use of inpatient services, likely contribute to requests for early discharge. Addressing these factors may help improve inpatient care, reduce costs and improve patient outcomes in the long term.
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http://dx.doi.org/10.1007/s11126-019-09671-yDOI Listing
December 2019

Hyponatremia Associated With Tramadol in a Patient With Alcohol Use Disorder and Anxiety Taking Desvenlafaxine.

Authors:
Amir Garakani

Prim Care Companion CNS Disord 2018 Dec 13;20(6). Epub 2018 Dec 13.

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http://dx.doi.org/10.4088/PCC.18l02316DOI Listing
December 2018

Opinions Regarding Benzodiazepine Teaching and Prescribing Among Trainees in Psychiatry.

Acad Psychiatry 2018 Apr 6;42(2):297-303. Epub 2017 Jul 6.

Northwell Health, Lenox Hill Hospital, New York, NY, USA.

Objectives: Benzodiazepines are widely prescribed for a variety of symptoms and illnesses. There has been limited investigation on the training psychiatry residents receive regarding benzodiazepine prescribing. This study surveyed US psychiatric trainees about their didactic and clinical experience with benzodiazepines, investigating how experience with benzodiazepines may shape trainees' opinions and likelihood to prescribe.

Methods: The 14-question online survey was distributed to residents and fellows at US training programs through an invitation from their training directors.

Results: Of 466 programs contacted, with an estimated 1345 trainees, a total of 97 programs (20.8%) and 424 trainees (31.5%) responded. The analyses focused only on the 342 general psychiatry trainees who responded. Most trainees reported having formal didactics on benzodiazepines, and earlier training was correlated with higher trainee quality of instruction assessments (p < 0.01). Most trainees rated their instructors as Above or Well Above Average. Trainees cited the observation and opinion of supervisors as the two most important factors affecting likelihood of future benzodiazepine prescribing. Trainees commonly reported pressure from patients to prescribe benzodiazepines but were split on perceived pressure from supervisors about prescribing and whether a bias exists against prescribing at their program or in general.

Conclusion: The survey indicated that psychiatry trainees generally feel adequately trained through didactic and clinical experience with benzodiazepines. Trainees perceived pressure by patients to prescribe benzodiazepines, but generally felt comfortable in managing benzodiazepine usage. Psychiatry attendings' opinions on benzodiazepines most impacted trainees. Influences on trainees' prescribing patterns are important variables that can impact future benzodiazepine prescribing.
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http://dx.doi.org/10.1007/s40596-017-0750-0DOI Listing
April 2018
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