Keeping Our Balance ,

Psychotic Symptoms Predict Suicidal Behavior Postdischarge in High Risk Psychiatric Inpatients Background: Psychotic disorders, as well as psychotic symptoms, are associated with a greater lifetime risk of suicidal behavior (SB). It is not known, however, whether psychotic symptoms are independent predictors for short-term SB. Methods: Data were collected from 201 psychiatric inpatients at Mount Sinai Beth Israel Hospital. Self-reported psychotic symptoms were assessed using the Brief Symptom Inventory (BSI). Postdischarge SB defined as an aborted, interrupted, or actual suicide attempt was assessed using the Columbia-Suicide Severity Rating Scale (C-SSRS), during the 4 to 8 weeks following discharge from an inpatient psychiatric unit (n=127, 63% retention). Logistic regressions were performed to assess the relationships between psychotic symptoms and SB, controlling for primary psychiatric disorders. Results: Self-reported psychotic symptoms were associated with subsequent postdischarge SB. There was no significant difference between the SB versus no SB groups on the basis of primary psychiatric disorder. Self-reported psychotic symptoms remained an independent and significant predictor of postdischarge SB when the analysis controlled for primary psychiatric disorder. Conclusions: These results suggest that psychotic symptoms are a dimensional predictor of near-term postdischarge SB and are a necessary component of suicide risk assessment during inpatient hospitalization, independent of psychiatric diagnosis.

Motives for Illicit Drug Use Among Individuals With Body Dysmorphic Disorder Drug use disorders (DUDs) are highly prevalent in body dysmorphic disorder (BDD), but motives for illicit drug use in BDD have not yet been explored. This study examined motives for drug use and clinical correlates of drug use motives in a sample of individuals with BDD and lifetime drug use, using the Drug Use Motives Questionnaire and 3 additional body image–specific drug use motives. As predicted, the Drug Use Motives Questionnaire coping motive was positively associated with attempted suicide and a lifetime DUD. All 3 body image–specific motives for drug use were also significantly associated with a lifetime DUD. In addition, they were the only variables that were significantly associated with greater severity of BDD. These results build on previous evidence suggesting that coping motives are related to problematic substance use and suicide attempts in BDD.

Psychological Function, Iyengar Yoga, and Coherent Breathing: A Randomized Controlled Dosing Study Background: Evidence suggests that yoga may be an effective treatment for major depressive disorder (MDD). Studies evaluating the “dosing” of yoga treatment and efficacy for MDD are needed. The goal of this study was to assess the effects of an intervention combining Iyengar yoga and coherent breathing in participants with MDD and determine the optimal intervention dose. Methods: Thirty-two participants (18 to 65 y of age) diagnosed with MDD were randomized to a high-dose group (HDG) or a low-dose group (LDG) of yoga and coherent breathing for 12 weeks. The HDG (n=15) involved three 90-minute yoga classes and four 30-minute homework sessions per week. The LDG (n=15) involved two 90-minute yoga classes and three 30-minute homework sessions per week. Participants were evaluated at baseline, week 4, week 8, and week 12 with the following instruments: Positivity Self-Test, Spielberger State Anxiety Inventory, Patient Health Questionnaire-9, Pittsburgh Sleep Quality Index, and Exercise-induced Feeling Inventory. Data were analyzed using intent-to-treat methods. Results: Significant improvements in all outcome measures were found for both groups, with acute and cumulative benefits. Although the HDG showed greater improvements on all scales, between-group differences did not reach significance, possibly due to lack of power because of the small sample size. Cumulative yoga minutes were correlated with improvement in outcome measures. Limitation: This dosing study did not include a non-yoga control. Conclusions: Improvement in psychological symptoms correlated with cumulative yoga practice. Both interventions reduced symptoms of depression and anxiety and increased feelings of positivity. The time commitment for yoga practice needs to be weighed against benefits when designing yoga interventions.

Feasibility and Acceptability of a Lifestyle Intervention For Individuals With Bipolar Disorder Individuals with bipolar disorder are at greater risk for cardiovascular disease and are less likely to adhere to lifestyle interventions than the general population. To decrease cardiovascular risk and improve adherence to lifestyle interventions, we developed the Nutrition Exercise and Wellness Treatment (NEW Tx). NEW Tx is an 18-session, 20-week cognitive behavioral therapy–based treatment comprising 3 modules: Nutrition, Exercise, and Wellness. To evaluate the feasibility and acceptability of this intervention as well as predictors of treatment satisfaction and expectations, 38 adult outpatients with bipolar disorder were randomized to either NEW Tx or a waitlist control condition. There was no statistically significant difference in dropout rates between the groups (26.3% in NEW Tx, 31.6% in the control condition). In the NEW Tx condition, participants attended a mean of 66.7% of sessions and reported moderate to high satisfaction. There were no study-related adverse events. We also found that expectations, but not perceived credibility (or believability), of NEW Tx (as measured by the Credibility/Expectancy Questionnaire) at baseline predicted treatment satisfaction (as measured by the Care Satisfaction Questionnaire) posttreatment. Manic symptoms at baseline predicted treatment satisfaction, and marital status predicted one’s expectations of lifestyle interventions. Data suggest that NEW Tx is a feasible and acceptable intervention for individuals with bipolar disorder and that further research is warranted to explore potential moderators of treatment expectations and credibility in this clinical population.

Drug-Drug Interactions (DDIs) in Psychiatric Practice, Part 7: Relative Receptor Binding Affinity as a Way of Understanding the Differential Pharmacology of Currently Available Antipsychotics This column is the seventh in a series exploring drug-drug interactions (DDIs) with a special emphasis on psychiatric medications. The first 3 columns in this DDI series discussed why patients being treated with psychiatric medications are at increased risk for taking multiple medications and thus experiencing DDIs, how to recognize such DDIs, strategies for avoiding and/or minimizing adverse outcomes from such DDIs, and pharmacokinetic considerations concerning DDIs in psychiatric practice. The fourth and fifth columns in this series presented a pair of parallel tables, one of which outlined the primary, known mechanism(s) of action of all commonly used psychiatric medications and one of which summarized major types of pharmacodynamic DDIs based on mechanism of action. Clinicians can use these 2 tables together to predict pharmacodynamically mediated DDIs. The sixth column discussed key pharmacodynamic interactions involving ethanol, opioids, and monoamine oxidase inhibitors. That column focused particularly on hypertensive crises and serotonin syndrome with monoamine oxidase inhibitors and also DDIs involving psychiatric medications with adverse effects on the cardiovascular system and on the central nervous system. This seventh column in this series presents the concept of relative receptor binding and includes a table summarizing the relative receptor binding affinity of commonly used antipsychotic medications, including all of the newer agents as well as some of the older agents such as haloperidol. The overall goal of this series of columns is to present a simple way of conceptualizing neuropsychiatric medications in terms of their pharmacodynamics and pharmacokinetics to allow prescribers to take these facts into consideration when they need to use ≥2 drugs in combination to optimally treat a patient.

Psychotherapy in Psychiatry: Fighting Alternative Facts In the Canadian province of Ontario, the Ministry of Health and Long-Term Care is proposing to impose arbitrary limits on access to psychotherapy provided by physicians. This column presents and debunks 3 myths associated with this ill-conceived proposal: (1) that long-term psychotherapy costs the health care system too much money, making it necessary for the government to curb this spending; (2) that long-term psychotherapy is a non–evidence-based treatment being needlessly spent on the worried well; and (3) that we need to focus on quick treatments, not long ones.

Welfare Checks and Therapeutic Risk Management In clinical practice, welfare checks have become a fairly common aspect of suicide prevention. At the same time, the medical literature provides almost no guidance to inform clinicians under what circumstances welfare checks should be requested, how best to go about placing those requests, or how to document decision-making related to this important subject. Literature searches spanning both PubMed and Google Scholar failed to yield any applicable results. Performed correctly, welfare checks have the potential to be life-saving interventions for persons in suicidal crises. Performed incorrectly, welfare checks may become an overly defensive practice that damages therapeutic relationships, violates patients’ rights, and consumes important and limited community resources. The need for thoughtful guidance to assist clinicians in navigating these difficult clinical scenarios is long overdue. This column, the second in a 2-part series, offers an approach to welfare checks informed by the tenets of therapeutic risk management.

Synchrony Between Bipolar Mood Cycles and Lunar Tidal Cycles Ended After Initiation of Light Treatment and Treatment of Hypothyroidism According to a recent report, mood cycles in a group of patients with rapid cycling bipolar disorder oscillated in synchrony with lunar gravimetric tides. Mood switches in a 67-year-old woman with rapid cycling bipolar II disorder on lithium maintenance treatment were assessed with a χ2 periodogram and a χ2 analysis of the mood switches in relation to the lunar tidal cycle. During a period when she was treated with nortriptyline and her thyroid-stimulating hormone levels were elevated, her mood switches had a significant (P<0.05) 29- to 30-day periodicity, and the χ2 analysis showed that the switches were distributed nonrandomly in relation to the spring-neap lunar tidal cycle (P<0.0001); 14 of 15 switches occurred within 2 days of the spring tides. After nortriptyline was discontinued, thyroid-stimulating hormone levels were normalized with treatment with levothyroxine, and consistent bright light treatment was started, the synchrony between mood cycles and lunar cycles disappeared, and rapid cycling eventually stopped. The possibility that lunar mood cycling is sometimes contingent on antidepressant treatment, decreased thyroid function, and certain types of light-dark cycles needs to be considered in future research on lunar tidal influences on the course of bipolar illness.

Commentary on “Synchrony Between Bipolar Mood Cycles and Lunar Tidal Cycles Ended After Initiation of Light Treatment and Treatment of Hypothyroidism” According to a recent report, mood cycles in a group of patients with rapid cycling bipolar disorder oscillated in synchrony with lunar gravimetric tides. Mood switches in a 67-year-old woman with rapid cycling bipolar II disorder on lithium maintenance treatment were assessed with a χ2 periodogram and a χ2 analysis of the mood switches in relation to the lunar tidal cycle. During a period when she was treated with nortriptyline and her thyroid-stimulating hormone levels were elevated, her mood switches had a significant (P<0.05) 29- to 30-day periodicity, and the χ2 analysis showed that the switches were distributed nonrandomly in relation to the spring-neap lunar tidal cycle (P<0.0001); 14 of 15 switches occurred within 2 days of the spring tides. After nortriptyline was discontinued, thyroid-stimulating hormone levels were normalized with treatment with levothyroxine, and consistent bright light treatment was started, the synchrony between mood cycles and lunar cycles disappeared, and rapid cycling eventually stopped. The possibility that lunar mood cycling is sometimes contingent on antidepressant treatment, decreased thyroid function, and certain types of light-dark cycles needs to be considered in future research on lunar tidal influences on the course of bipolar illness.