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

Exercise in children and adolescents with depression (February 2023)

Prescribing exercise for depression in adults is supported by multiple trials. Physical activity also appears to benefit children and adolescents with depression. In a meta-analysis of 21 studies of more than 2400 youths (mostly randomized trials), a variety of aerobic exercise programs (generally prescribed as monotherapy) were associated with moderately improved depressive symptoms compared with usual care or no treatment [1]. However, after a mean follow-up of 21 weeks, improvement of depressive symptoms in the two groups was comparable. For children and adolescents with unipolar major depression, we suggest physical exercise as an adjunct treatment along with pharmacotherapy and/or psychotherapy. (See "Overview of prevention and treatment for pediatric depression", section on 'Adjunctive exercise'.)

Risk of drug overdose in young people prescribed benzodiazepines for sleep disorders (December 2022)

Prescription database studies indicate that benzodiazepines are commonly prescribed for insomnia, despite risks and the availability of safer options. In a recent cohort study in the United States that included over 90,000 children and young adults (age 10 to 29 years) with a sleep disorder who were prescribed a new insomnia medication, benzodiazepines were associated with increased risk of drug overdose in the next six months compared with alternative insomnia medications (trazodone, hydroxyzine, zolpidem, zaleplon, eszopiclone) [2]. Risk was highest among individuals who had also received an opioid prescription in the preceding three months. We do not prescribe benzodiazepines for insomnia in patients taking opioids or in those with a substance use disorder. (See "Pharmacotherapy for insomnia in adults", section on 'Shared warnings and precautions'.)

Screening for anxiety in children and adolescents (December 2022)

Anxiety in children and adolescents interferes with social, emotional, and academic development. The United States Preventive Services Task Force (USPSTF) now recommends screening for anxiety in all individuals aged 8 to 18 years old [3]. This updated recommendation is supported by a meta-analysis that included 39 studies with 6065 subjects in that age range and showed moderate accuracy of screening tools and moderate benefit of treatment on symptom response and disease remission [4]. The harms associated with screening and subsequent treatment were minimal. Our approach is consistent with these recommendations. We use the Screen for Child Anxiety-Related Emotional Disorders (SCARED) tool, which is available in the public domain. (See "Anxiety disorders in children and adolescents: Assessment and diagnosis", section on 'Screening'.)

DEPRESSIVE DISORDERS

Adjunctive therapy for treatment-resistant, late-life depression (March 2023)

For late-life depression that does not respond to initial treatment with an antidepressant, potential options include augmentation of the initial antidepressant with a second agent and switching antidepressants. In a 10-week randomized trial in more than 400 patients older than 60 years with treatment-resistant depression, improvements in psychological well-being were slightly greater with add-on aripiprazole than switching to bupropion [5]. However, akathisia, fatigue, and weight gain appeared to be greater with aripiprazole. For treatment-resistant depression in the general population, we generally suggest adjunctive treatment with a second drug, such as aripiprazole, rather than switching antidepressants; these data suggest a similar approach may be appropriate for late-life depression, although side effects may be limiting. (See "Diagnosis and management of late-life unipolar depression", section on 'Aripiprazole'.)

Psilocybin for treatment-resistant depression (January 2023)

Although the psychedelic psilocybin is a Schedule I controlled substance in the United States (no accepted medical use; high potential for abuse), small trials have suggested that it may be useful for treatment-resistant depression. In a recent randomized trial of 158 patients with unipolar major depression who had not responded to at least two antidepressants, the rate of symptom improvement at three weeks was higher with one 25 mg dose of psilocybin compared with a control 1 mg dose [6]. However, during 12 weeks of follow-up, there were two incidents of suicidal ideation, two incidents of nonsuicidal self-injury, and three incidents of suicidal behavior in the 25 mg group. In the 1 mg group, there was one incident of nonsuicidal self-injury. Larger and longer trials are necessary to establish the efficacy and safety of psilocybin. (See "Unipolar depression in adults: Management of highly resistant (refractory) depression", section on 'Drug therapies'.)

Psychotic depression and mortality (January 2023)

Mortality is greater with unipolar major depression than in the general population. In addition, the risk of death is even higher in psychotic depression. An 18-year national registry study found that first-episode psychotic depression was associated with a 40 percent higher all-cause mortality risk compared with severe nonpsychotic depression [7]. These findings support prompt treatment and relatively close monitoring of psychotic depression. (See "Unipolar major depression with psychotic features: Maintenance treatment and course of illness", section on 'Mortality'.)

PSYCHOTIC DISORDERS

Sublingual dexmedetomidine for agitation in patients with schizophrenia (February 2023)

In 2022, the US Food and Drug Administration approved the sublingual form of dexmedetomidine for mild to moderate agitation in individuals with schizophrenia; the trial supporting the approval was recently published. Among 380 participants with schizophrenia, those randomly assigned to dexmedetomidine (180 or 120 mcg) had greater improvements in symptoms of agitation at two hours compared with placebo; improvements were apparent at 20 and 30 minutes [8]. Adverse effects, mainly somnolence, dry mouth, and dizziness, were more common with dexmedetomidine (37 to 40 versus 15 percent). The sublingual formulation avoids the need for intramuscular medication administration and thus potentially improves the patient experience and allows for broader use in psychiatric settings. (See "Psychosis in adults: Initial management", section on 'Psychiatric symptoms'.)

SUBSTANCE USE DISORDERS

Removal of X-waiver requirement to prescribe buprenorphine for opioid use disorder (February 2023)

Previously, in order to prescribe buprenorphine for opioid use disorder (OUD) in the United States, clinicians had to apply for a federally required DATA Waiver (X-Waiver). In January 2023, the Consolidated Appropriations Act of 2023 removed this requirement and allowed clinicians with schedule III authority on their Drug Enforcement Administration (DEA) registration to prescribe buprenorphine for OUD treatment if permitted by applicable state law [9]. We believe this change will encourage buprenorphine prescribing and thus prevent opioid overdose. (See "Acute opioid intoxication in adults", section on 'Prevention of recurrent opioid overdose'.)

Psilocybin for alcohol use disorder (October 2022)

When combined with psychotherapy, psilocybin appears to be effective for alcohol use disorder. In a trial, 95 subjects who were receiving 12 weeks of cognitive behavioral and motivational enhancement therapy were randomly assigned to two day-long medication sessions with either psilocybin or diphenhydramine [10]. Over the 32-week follow-up period, subjects in the psilocybin group reported a lower proportion of days they drank heavily (10 versus 24 percent) and fewer mean drinks per day (1.2 versus 2.3). There were no serious adverse events in either group. Although psilocybin is classified a Schedule I controlled substance in the United States (no accepted medical use and high potential for abuse), these data suggest that further evaluation of psilocybin for alcohol use disorder management may be warranted. (See "Alcohol use disorder: Pharmacologic management", section on 'Agents with limited empirical support'.)

OTHER PSYCHIATRY

Complications of physician burnout (September 2022)

Physician burnout appears to adversely affect career engagement and patient care. A meta-analysis that included 170 observational studies with >230,000 physician participants found that physicians with burnout were more than three times as likely to be dissatisfied with their career, regret their career choice, and think about leaving their job [11]. In addition, physicians with burnout were twice as likely to be involved in patient safety incidents, have low professionalism, and to receive low patient satisfaction ratings. Interventions to mitigate burnout should be implemented. (See "Unipolar depression in adults: Assessment and diagnosis", section on 'Burnout'.)