What's new in psychiatry

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

CHILD AND ADOLESCENT PSYCHIATRY

Bright light therapy for adolescents with unipolar major depression (April 2024)

Although bright light therapy is a standard treatment for seasonal affective disorder, the benefit for nonseasonal depression is not established. A recent four-week randomized trial compared adjunctive morning bright light therapy with placebo red light in 224 adolescent inpatients with major depression who were receiving multimodal usual care [1]. Improvements in depressive symptoms were comparable in both groups. However, the results may not be generalizable to outpatients, who receive less intense treatment than inpatients. Adjunctive bright light therapy for nonseasonal major depression in adolescent outpatients is reasonable, based upon its tolerability and safety, as well as positive studies in adults. (See "Overview of prevention and treatment for pediatric depression", section on 'Adjunctive interventions'.)

Antidepressant-induced mania in children (February 2024)

Pediatric unipolar depression is often treated with antidepressants, but the risk of inducing mania or hypomania is uncertain. In a 52-week registry study of children and adolescents with unipolar depression who either received antidepressants (eg, fluoxetine or sertraline) or did not, incident mania/hypomania by week 12 was comparable [2]. However, by week 52, incident mania/hypomania had occurred more often in those who received antidepressants. We recommend that as part of monitoring, clinicians assess patients for treatment-emergent mania or hypomania. (See "Pediatric unipolar depression and pharmacotherapy: General principles", section on 'Antidepressant-induced mania'.)

Dialectical behavior therapy for adolescents with bipolar disorder (January 2024)

Several trials have demonstrated that dialectical behavior therapy can reduce suicide attempts in youth who are suicidal, but most excluded patients with bipolar disorder. A recent randomized trial in adolescents with bipolar disorder who all received pharmacotherapy found fewer suicide attempts over one year follow-up among those who received adjunctive dialectical behavior therapy rather than usual psychotherapy [3]. Although multiple psychotherapies are reasonable for youth with bipolar disorder, we suggest dialectical behavior therapy for those at increased risk of suicide (eg, lifetime history of suicide attempt). (See "Pediatric bipolar disorder: Efficacy and core elements of adjunctive psychotherapy", section on 'Dialectical behavior therapy'.)

NEUROCOGNITIVE DISORDERS

Adult-onset ADHD and dementia (December 2023)

Individuals with adult-onset attention deficit hyperactivity disorder (ADHD) may have difficulties compensating for deficits from neurodegenerative or cerebrovascular processes, but any association with dementia has been inconsistent. In a prospective study including over 100,000 adults without ADHD or dementia at baseline, those who were subsequently diagnosed with adult-onset ADHD were more likely to receive a diagnosis of dementia (adjusted relative risk 2.8) [4]. Whether symptoms that resulted in the ADHD diagnosis were early or prodromal dementia symptoms is uncertain; nevertheless, these findings suggest that caregivers be alert for signs of dementia in individuals with adult-onset ADHD. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, clinical features, assessment, and diagnosis", section on 'Comorbidity'.)

DEPRESSIVE DISORDERS

Dexmedetomidine and postpartum depression (April 2024)

Dexmedetomidine is an anesthetic that is also used to treat acute psychotic or manic agitation. In a randomized trial of 338 individuals who were undergoing elective cesarean delivery and screened positive for antenatal depression, adding dexmedetomidine to standard patient-controlled intravenous analgesia reduced subsequent rates of depression at 42 days postpartum (11 versus 30 percent with standard analgesia plus saline placebo) [5]. However, the study sample represents a relatively small portion of the population at risk for postpartum depression, and the drug remains an investigational approach until additional data confirm its benefit. (See "Postpartum unipolar depression: Prevention", section on 'Investigational interventions'.)

Perinatal depression and mortality (March 2024)

Perinatal depression is associated with an increased risk of death. An analysis of a national register from Sweden compared outcomes among individuals with and without a diagnosis of depression during pregnancy or postpartum, matched by age and year of delivery [6]. After controlling for potential confounding factors, all-cause mortality was greater in those with perinatal depression over 18 years of follow-up; the increased risk was largely driven by suicide. These results confirm previous data on the risks of perinatal depression and support our practice of screening for depression during pregnancy and postpartum. Services to ensure follow-up for diagnosis and treatment should accompany screening efforts. (See "Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and diagnosis", section on 'All cause'.)

Exercise for treating depression (March 2024)

Evidence supports moderate to vigorous aerobic exercise for treating depression; however, the efficacy of other types of physical activity is less clear. A recent network meta-analysis of 218 randomized trials suggests that even light to moderate physical activity can improve depression [7]. Walking or jogging, dance, yoga, strength training, and tai chi significantly reduced depressive symptoms compared with active controls, and the magnitude of the effects was similar to those with standard treatments (ie, cognitive behavioral therapy or antidepressant treatment). Although the quality of evidence from most trials was low, these results support specific activity options for patients with depression who cannot engage in aerobic exercise. (See "Major depressive disorder in adults: Treatment with supplemental interventions", section on 'Type, intensity, and frequency'.)

NEURODEVELOPMENTAL DISORDERS

Pharmacotherapy for ADHD and mortality risk (April 2024)

Attention deficit hyperactivity disorder (ADHD) is associated with higher mortality than in the general population; whether treatment modifies that risk is unclear. In an observational study of nearly 149,000 individuals with ADHD in Sweden (mean age 17 years), initiation of medication within three months of diagnosis was associated with lower all-cause mortality (hazard ratio [HR] 0.79) as well as lower mortality from unnatural causes (eg, suicide, unintentional injury, and accidental poisoning; HR 0.75) over the ensuing two years [8]. While the study could not control for unmeasured confounders that may have impacted mortality risk (eg, lifestyle factors, social support), these data generally lend further support for pharmacotherapy of ADHD. (See "Attention deficit hyperactivity disorder in adults: Treatment overview", section on 'Benefits of stimulant treatment'.)

SUBSTANCE USE DISORDERS

Initiation of medications for alcohol use disorder during hospitalizations (May 2024)

Medications for the management of alcohol use disorder are effective but underutilized. Hospitalization may be an opportune time to initiate them. In an observational study of over 6700 individuals hospitalized at least once for alcohol-related disorders, initiation of medications for alcohol use disorder at discharge was associated with a 42 percent lower rate of all-cause death, emergency department visits, and readmission at 30 days and a 51 percent lower rate of alcohol-related emergency visits or hospitalization [9]. These findings support efforts to initiate medications for alcohol use disorder at hospital discharge. (See "Alcohol use disorder: Pharmacologic management", section on 'Patients hospitalized for alcohol-related disorder'.)

Hepatitis C virus antiviral treatment for patients with opioid use disorder (May 2024)

Despite concerns about adherence to antiviral therapy among individuals with opioid use disorder, hepatitis C virus (HCV) treatment can be highly successful in this population, particularly in nontraditional care settings. In a cluster-randomized trial that included 600 individuals with chronic HCV infection who were engaged in an opioid treatment program, provision of antiviral therapy through the program, directed by an HCV specialist over telemedicine, increased rates of antiviral initiation (92 versus 40 percent) and sustained virologic response (85 versus 30 percent) compared with traditional referral to a specialist clinic for treatment [10]. These data highlight the impact of reducing barriers to care for individuals with opioid use disorder and support our recommendation to treat all patients for chronic HCV, regardless of active drug use. (See "Patient evaluation and selection for antiviral therapy for chronic hepatitis C virus infection", section on 'Active drug use'.)

Congenital anomaly risk with methadone or buprenorphine exposure (April 2024)

Data regarding the teratogenic risk of medications for opioid use disorder (MOUD) are limited. In a population-based study comparing over 9500 pregnancies exposed to buprenorphine in the first trimester with nearly 3900 methadone-exposed pregnancies, buprenorphine use was associated with a lower overall risk of congenital anomalies (5 versus 6 percent) [11]. Although the analysis adjusted for multiple potential confounding factors, unmeasured confounders may explain some of the observed associations. We base the choice of buprenorphine versus methadone for MOUD on other factors (table 1). (See "Opioid use disorder: Pharmacotherapy with methadone and buprenorphine during pregnancy", section on 'Risk of structural anomalies'.)

Delta-8 tetrahydrocannabinol use by United States adolescents (March 2024)

Delta-8 tetrahydrocannabinol (THC) is typically a minor cannabinoid found in cannabis, but can also be synthesized. It is increasingly found in United States (US) cannabis products, often marketed as low delta-9 THC. A survey of US twelfth graders in 2023 found that 11 percent reported using delta-8 THC within the past 12 months, compared with 30 percent reporting marijuana use [12]. Delta-8 THC use was lower in states with cannabis legalization (8 versus 14 percent) or delta-8 THC regulation (6 versus 14 percent). These findings suggest that delta-8 THC is a public health concern in adolescents, particularly in states that do not regulate it and have not legalized marijuana for adult use. (See "Cannabis (marijuana): Acute intoxication", section on 'Cannabis formulations'.)

Mortality risk in alcohol-associated liver disease (January 2024)

Few studies have reported the long-term outcomes of patients with alcohol-associated liver disease (ALD). In a national registry study including over 23,000 patients with ALD diagnosed at median age 58 years, 67 percent died during >100,000 person-years of follow-up and liver disease was the primary cause of death in 45 percent [13]. The 5- and 10-year mortality rates due to liver disease were 26 and 31 percent, respectively. These data emphasize the importance of treating patients with alcohol use disorder and may inform strategies to prevent liver-related mortality in those with ALD. (See "Management of alcohol-associated steatosis and alcohol-associated cirrhosis", section on 'Mortality'.)

OTHER PSYCHIATRY

Solriamfetol for ADHD in adults (January 2024)

Stimulants are typically first-line pharmacotherapy for attention deficit hypersensitivity disorder (ADHD) in adults but may be poorly tolerated and suboptimally effective in some patients. Solriamfetol, a selective dopamine/norepinephrine reuptake inhibitor used to treat narcolepsy, may be an effective alternative. In a trial of adults with ADHD, six weeks of solriamfetol resulted in higher rates of being "much improved" or "very much improved" (45 versus 6 percent) and higher rates of remission (24 versus 3 percent) compared with placebo [14]. While the treatment group had more adverse effects overall (ie, decreased appetite, insomnia, cardiovascular), all side effects related to treatment medication were mild or moderate in severity. Further trials are needed to determine the role of solriamfetol in adult ADHD treatment. (See "Attention deficit hyperactivity disorder in adults: Treatment overview", section on 'Treatments with limited supporting data in adult ADHD'.)