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
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) [1]. 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 [2]. 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 [3]. 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
Pharmacogenetic testing in treatment-resistant depression (August 2022)
Although preliminary evidence suggests that pharmacogenetic tests may be useful for selecting an antidepressant in treatment-resistant depression, their clinical utility remains unknown. As an example, a 24-week, open-label randomized trial in nearly 2000 patients with treatment-resistant unipolar major depression compared pharmacogenetic testing with usual care to guide selection of a new antidepressant [4]. The testing examined genes that affect antidepressant metabolism and mechanism of action. Remission at week 12 was greater with testing-guided care, but the clinical effect was small, and remission rates in the two groups were nearly identical at week 24. As suggested by this study, using pharmacogenetic testing to guide management of treatment-resistant depression is not standard practice because it does not consistently lead to improved clinical outcomes. (See "Unipolar depression in adults: Choosing treatment for resistant depression", section on 'Antidepressants'.)
PSYCHIATRIC CONSEQUENCES OF MEDICAL CONDITIONS
Psychiatric disorders following recovery from COVID-19 (May 2022, Modified September 2022)
Patients who recover from acute COVID-19 are at increased risk for psychiatric disorders, although the risk for some of these disorders may decrease over time. In a large retrospective study, incident psychiatric disorders, including anxiety, depressive, posttraumatic stress, sleep, and substance use disorders, occurred more frequently in patients who survived COVID-19 than in patients without a history of COVID-19 (hazard ratio 1.5) [5]. In another retrospective study of over 1.2 million patients with a history of COVID-19, the risk of psychopathology in the first six months following infection was greater than that among matched controls with a different respiratory infection [6]. However, after another three months, the excess risk of anxiety disorders, insomnia, and mood disorders had diminished. By contrast, a history of COVID-19 was associated with a higher risk of cognitive impairment and psychotic disorders during the entire two-year follow-up period. Patients with COVID-19 can be reassured that eventually the risk of some psychiatric sequelae is no greater than that with other respiratory infections, but some patients with certain post-COVID-19 psychiatric disorders may require psychotherapy and/or pharmacotherapy. (See "COVID-19: Psychiatric illness", section on 'Patients with COVID-19'.)
PSYCHOTIC DISORDERS
Noninvasive brain stimulation for negative symptoms in schizophrenia (August 2022)
Negative symptoms of schizophrenia worsen functional outcomes and quality of life, but effective therapeutic options are limited. In a network meta-analysis of 48 randomized trials comparing various non-invasive brain stimulation (NIBS) protocols with sham treatments among over 2200 subjects with schizophrenia, excitatory protocols over the left dorsolateral prefrontal cortex were associated with the greatest reductions in negative symptoms [7]. These included high-definition transcranial noise stimulation, intermittent theta burst stimulation, transcranial direct current stimulation, and high-frequency repetitive transcranial magnetic stimulation. While certain NIBS protocols may improve negative symptoms, further comparative trials to define the most effective protocols are warranted. (See "Psychosis in adults: Initial management", section on 'Negative symptoms'.)
SUBSTANCE USE DISORDERS
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 [8]. 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'.)
Trends in medical cannabis program enrollment in the United States (July 2022)
In the United States, state-dependent legalization of medical cannabis has increased cannabis availability, although eligibility varies by state. An observational study of 26 state medical cannabis registries reported an overall 4.5-fold increase in enrollments in medical cannabis programs between 2016 and 2020 [9]. All states without legalized recreational cannabis had increases in enrollment, whereas five of seven states with legalized recreational cannabis had decreases. Over the same time period, use of cannabis for conditions or symptoms without substantive evidence of a benefit increased from 15 to 32 percent. Research to inform appropriate indications for medical cannabis and uniform policies are needed to optimize medical cannabis provision. (See "Cannabis use: Epidemiology, pharmacology, comorbidities, and adverse effects", section on 'Medico-legal context'.)
TRAUMA - AND STRESSOR-RELATED DISORDERS
PTSD and cognitive decline (August 2022)
Posttraumatic stress disorder (PTSD) is associated with memory and attentional impairment; however, an association with cognitive decline has not been established. In a prospective study of over 12,000 females (mean age 61 years) with prior trauma, a high number of PTSD symptoms was associated with greater declines in learning, working memory, psychomotor skills, and attention over 24 months [10]. Adjusting for behavioral health factors (eg, smoking, alcohol use, physical activity, diet) or comorbid medical conditions did not change the association. Further investigation of the mechanisms underlying this association is needed, but these findings suggest a potential role for early cognitive screening in individuals with PTSD. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis", section on 'Course and complications'.)
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'.)
Neurostimulation for attention deficit hyperactivity disorder in adults (September 2022)
Nonpharmacologic interventions for attention deficit hyperactivity disorder (ADHD), such as transcranial direct current stimulation (tDCS), are attractive management approaches, as medication discontinuation from adverse effects or suboptimal response is common. In a randomized trial of 64 adults with ADHD who were not taking stimulants, 28 sessions of daily home-based tDCS to the right dorsolateral prefrontal cortex resulted in lower mean scores on measures of inattention (19 versus 24 out of 36 points) and higher rates of substantial reduction in inattention (34 versus 6 percent) compared with sham tDCS [12]. Mild adverse effects (eg, headache, skin redness) were more common in the active tDCS group. Given that tDCS appears to be a safe, well-tolerated, noninvasive treatment for inattention in adults with ADHD, further studies to identify the optimal intensity, duration, and number of sessions are warranted. (See "Management of attention deficit hyperactivity disorder in adults", section on 'Treatments with limited supporting data in adult ADHD'.)
