One of the main changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was the separation of Stress Related Disorders from the Anxiety chapter. This separation paves the way to examine the unique characteristics of posttraumatic stress disorder (PTSD) (ie, identifiable onset, memory processes, etc) and related neural mechanisms. The time that elapses between the traumatic event and the manifestation of the disorder may also be addressed as the “golden hours,” or the window of opportunity in which critical processes take place and relevant interventions may be administrated.

We review the attributes of inhibited and uninhibited infant temperaments, and their developmental trajectories into early adulthood. Inborn individual differences in infants' propensity to respond to novel people and objects are associated with persistent differences in the responsivity of the amygdala to novelty, as measured with functional magnetic resonance imaging, after more than 20 years of development. Because an inhibited temperament is a risk factor for developing later psychiatric disorders, particularly generalized social anxiety disorder, temperamental differences are confounds in neuroimaging and genetic studies. Longitudinal studies are a unique tool for understanding the developmental and temperamental risk factors for psychiatric disorder.

With the widespread use of atypical antipsychotics over the past several years, adverse metabolic effects have emerged as the most serious medical consequences of pharmacotherapy with some of these agents. Initially, weight gain and obesity were observed (especially with clozapine and olanzapine), but subsequently, type 2 diabetes and dyslipidemia became apparent as well. Further, many reports suggest that sudden and severe (occasionally fatal) diabetes ketoacidosis (DKA) can emerge during treatment with some atypical antipsychotics, even in the absence of adiposity. A marked increase of serum lipids (especially triglycerides) has also been reported, to varying degrees, with different atypicals. This article reviews the data regarding metabolic dysfunction in patients with psychosis (schizophrenia and bipolar disorder). Populations with psychosis have a 2–3-fold higher prevalence of diabetes even before treatment with any antipsychotics, suggesting a possible genetic linkage or comorbidity; this was confirmed with glucose regulation studies in schizophrenia and mania. The induction of type 2 diabetes with atypicals has further increased the prevalence of noninsulin-dependent diabetes from about 6%–8% to 11%–15% according to recent studies, and even higher rates of subclinical hyperglycemia. Serious weight gain (eg, 26–29 lbs after 1 year of clozapine or olanzapine treatment) is an important risk factor, but sudden DKA has now been reported in patients with minimal weight gain, suggesting alternative mechanisms, such as insulin resistance, as a direct effect of some atypicals. Psychiatrists can reduce the risk of metabolic disorders in schizophrenia and bipolar disorder by avoiding the use of certain atypicals as first-line treatment in patients with a personal or family history of diabetes, obesity, and hyperlipidemias. Regulatory agencies in some countries have already taken action in this regard.

Patients experiencing a first psychotic episode or early stages of psychosis present with key diagnostic issues for clinicians. At the time of first-episode psychosis presentation, it is crucial that clinicians select the most effective treatment option as immediate intervention offers the best chance for containing the illness. Functional impairment occurs most rapidly at the early stage of illness, and such impairment can influence the patient's future prognosis, alter the level of necessary treatment, and affect morbidity. Although research has shown a decrease in brain gray matter as well as signs of functional impairment in those who develop psychosis, many of these patients remain untreated for extended periods of time and do not visit a clinician due to fear of stigma, a failure to recognize the problem, or complexities of their care system. Prior studies have shown that untreated psychosis results in worse outcome for patients compared to psychosis that is treated earlier in the course of illness. There is a range of treatment options for psychosis, including use of first-generation or second-generation antipsychotic medication. Clinicians should note that both medication types are associated with certain side effects, such as tardive dyskinesia and weight gain, respectively. For all antipsychotics, doses should be lower for patients with a first psychotic episode than for patients with chronic psychosis. Finally, clinicians must consider that patients may present with various comorbidities, such as substance abuse, that also may affect treatment.

This expert roundtable supplement will address the diagnosis and treatment selection for first-episode psychosis as well as comorbidities related to the condition. The use of first- or second-generation antipsychotics for psychosis treatment, dosing guidelines, and the antipsychotic side-effect profile will also be addressed.

Background: This analysis evaluated the effects of the serotonin-norepinephrine reuptake inhibitor, desvenlafaxine (administered as desvenlafaxine succinate), on anxiety symptoms associated with depression.

Methods: Data were pooled from 9 randomized, placebo-controlled, double-blind, 8 week studies of desvenlafaxine (50-400 mg/day, fixed or flexible dose) in patients with major depressive disorder (MDD), without a primary anxiety diagnosis. Changes from baseline in scores on the anxiety/somatization factor of the 17-item Hamilton Rating Scale for Depression (HAM-D17) and on the Covi Anxiety Scale at the final evaluation (last observation carried forward) were compared between desvenlafaxine and placebo groups using analysis of covariance.

Results: In the overall data set (intent to treat n=2,913 [desvenlafaxine, n=1,805; placebo, n=1,108]), desvenlafaxine was associated with significantly greater reductions compared with placebo in scores on the HAM-D17 anxiety/somatization factor (-3.41 vs -2.92, P<.001) and Covi Anxiety Scale (-1.35 vs -1.04, P<.001). In the subset of fixed-dose studies, significant differences were observed for all dose groups on the HAM-D17 anxiety/somatization factor (P≤.OH), and for the 50, 100, and 200 mg/day dose groups on the Covi Anxiety Scale (all P≤.015 vs placebo).

Conclusions: Desvenlafaxine was associated with significantly greater improvement in anxiety symptoms compared with placebo in patients with MDD.

This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patient's current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patient's level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.

Lithium is a unique drug. In more than 60 years of observation, it showed its multiple important clinical properties in treating mania, stabilizing mood alterations, preventing suicide and protecting from neurodegeneration. It was also the most extensively studied drug in psychiatry. Nevertheless, it is generally underprescribed. Specifically, lithium is virtually not considered in the treatment of patients affected by mixed affective states. Lithium is not suggested for the acute treatment of mixed affective states and is considered to be less effective than other mood stabilizers in the long-term management of these patients. The main reason why lithium has no indication for mixed states is the “lack of evidence.” Actually, there are several reasons to consider lithium as an effective treatment in patients with mixed affective states.

Introduction: Body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD) have several similarities and are included among the obsessive-compulsive spectrum of disorders. However, the content of preoccupations and level of insight of BDD patients differ from OCD patients.

Objective: To compare the level of insight regarding obsessive-compulsive symptoms (OCS) and other clinical features in OCD patients with and without comorbid BDD.

Methods: We evaluated 103 OCD patients (n=25, comorbid BDD), according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria using the Structured Clinical Interview for DSM-IV, the Yale-Brown Obsessive-Compulsive Scale, the University of São Paulo Sensory Phenomena Scale, the Beck Depression and Anxiety Inventories, and the Brown Assessment of Beliefs Scale.

Results: The study groups differed significantly on several clinical features, including level of insight. A worse level of insight regarding OCS was independently associated with the presence of comorbid BDD. Lower educational level, more psychiatric comorbidities, presence of somatic and hoarding obsessions, and presence of intrusive images were associated with BDD comorbidity, even after adjusting for possible confounders.

Conclusion: The presence of BDD in OCD patients is associated with poorer insight into obsessional beliefs and higher morbidity, reflected by lower educational levels and higher number of psychiatric comorbid disorders in general.

Exploring space is one of the most attractive goals that humanity ever set, notwithstanding, there are some psychological and psychopathological risks that should be considered. Several studies identified some possible hazards of space travels and related physical and psychological consequences on astronauts. If some psychological reactions are obviously inherent to the characteristics of the spaceships (habitability, confinement, psychological, and interpersonal relationships), other (disturbances of sleep-wake cycle, personality changes, depression, anxiety, apathy, psychosomatic symptoms, neurovestibular problems, alterations in cognitive function, and sensory perception) represent a clear warning of possible central nervous system (CNS) alterations, possibly due to microgravity and cosmic radiation. Such conditions and eventual CNS changes might compromise the success of missions and the ability to cope with unexpected events and may lead to individual and long-term impairments. Therefore, further studies are needed, perhaps, requiring the birth of a novel branch of psychology/psychiatry that should not only consider the risks related to space exploration, but the implementation of targeted strategies to prevent them.

There is an urgent need to improve the clinical management of major depressive disorder (MDD), which has become increasingly prevalent over the past two decades. Several gaps and challenges in the awareness, detection, treatment, and monitoring of MDD remain to be addressed. Digital health technologies have demonstrated utility in relation to various health conditions, including MDD. Factors related to the COVID-19 pandemic have accelerated the development of telemedicine, mobile medical apps, and virtual reality apps and have continued to introduce new possibilities across mental health care. Growing access to and acceptance of digital health technologies present opportunities to expand the scope of care and to close gaps in the management of MDD. Digital health technology is rapidly evolving the options for nonclinical support and clinical care for patients with MDD. Iterative efforts to validate and optimize such digital health technologies, including digital therapeutics and digital biomarkers, continue to improve access to and quality of personalized detection, treatment, and monitoring of MDD. The aim of this review is to highlight the existing gaps and challenges in depression management and discuss the current and future landscape of digital health technology as it applies to the challenges faced by patients with MDD and their healthcare providers.

The relationship between criminogenic risk and mental illness in justice involved persons with mental illness is complex and poorly understood by clinicians, researchers, administrators, and policy makers alike. Historically, when providing services to justice involved persons with mental illness, clinicians have emphasized mental health recovery (eg, psychiatric rehabilitation) at the exclusion of treatments targeted at criminogenic risk. More recently, however, researchers have demonstrated with great clarity that criminogenic risk not only contributes but is likely the leading factor in the criminal behavior committed by persons with mental illness. Yet, we still do not know the nature of this criminogenic-mental illness relationship, how this relationship impacts treatment needs, and of ultimate concern, what this relationship means in terms of individual and societal outcomes. In this paper we briefly define criminogenic risk and the research that demonstrates the role of criminogenic risk in criminal justice involvement of persons with mental illness. We also review prevalence rates of persons with mental illness justice involvement, and then discuss important factors to be considered when assessing risk to include both criminogenic and mental illness risk. We conclude this paper by reviewing treatment and management strategies for persons with mental illness that are criminal justice involved particularly reviewing and building off the recommendations put forth by Bartholomew & Morgan.

We describe a retrospective case series of three patients, two with bipolar depression and one with unipolar depression. Pramipexole is a Food and Drug Administration-approved antiparkinsonian agent, which, when used to augment antidepressants, would be considered an off-label use and should be discussed with the patient. These patients had robust responses to pramipexole augmentation of their treatment regimen. All three patients had been taking an atypical antipsychotic. The depressive symptoms were evaluated using the Hamilton Rating Scale for Depression.

The lack of predictive biomarkers for therapeutic responses to schizophrenia leads clinical procedures to be decided without taking into account the subjects’ neuroanatomical features, a consideration, which could help in identifying specific pharmacological treatments for the remission of symptoms. Magnetic resonance imaging (MRI) is a technique widely used for radiological diagnosis and produces 3-dimensional images in excellent anatomical detail, and with a great capacity to differentiate soft tissue. Various MRI techniques of the human brain have emerged as a result of research, enabling structural tests that may help to in consolidate previous findings and lead to the discovery of new patterns of abnormality in schizophrenia. A literature review was undertaken to assess the superior temporal gyrus (STG) as a possible biomarker in schizophrenia with the use of voxel-based morphometry of the brain using MRI. Many findings in studies of schizophrenia using MRI have been inconclusive and, in some cases, conflicting, although interesting results have been obtained when attempting to correlate neuroimaging changes with aspects of clinical features and prognosis of the disease. The individuals affected by this mental illness appear to have smaller STG volumes when compared to healthy controls and also to subjects with a diagnosis of first-episode affective psychosis or groups of individuals at high risk of psychosis. However, the wide variety of definitions surrounding the STG found in a number of studies is a contributing factor to the lack of correlation between brain abnormalities and clinical symptoms. For instance, disagreements have arisen due to studies using regions of interest to analyze the STG whereas other studies prioritize the analysis of only STG subregions or specific supratemporal plane regions. It is necessary to standardize the nomenclature of the areas to be studied in the future, as this will enable more consistent results, allowing higher clinical and morphological correlations.

In this article, we examined evidence for the acute treatment of depression in bipolar I disorder, focusing on double-blind, placebo-controlled studies with a definite primary outcome measure and published in peer review journals. Quetiapine and olanzapine/fluoxetine are currently approved by the FDA for the treatment of bipolar depression, and a number of additional agents (including other atypical antipsychotics, mood stabilizers, antidepressants, and novel compounds) have been studied with varying degrees of efficacy. The medication with the most evidence for efficacy in bipolar depression is quetiapine, with five studies showing positive efficacy compared to placebo. In contrast, five studies of lamotrigine were negative, although meta-analyses of the pooled have found some treatment effects. Two studies of olanzapine and olanzapine/fluoxetine and three small studies of divalproex showed significant efficacy in treating bipolar depression. Two studies of aripiprazole found no differences compared to placebo. Early research on lithium in bipolar depression had significant methodological flaws, and only one study of lithium met our primary search criteria. To better understand the role of antidepressants, we also examined studies of antidepressants as adjunctive treatment of bipolar depression in participants taking mood stabilizers or atypical antipsychotics. These studies reported mixed results for a variety of antidepressants, but the majority found no differences compared to placebo. Other studies of adjunctive treatment were also discussed. There has been one positive adjunctive study each of lamotrigine, omega-3 fatty acids, modafinil, and armodafinil, while there was one negative trial each of omega-3 fatty acids, ziprasidone, and levetiracetam.

Faye is a 44-year-old woman who presented complaining of tension. She felt tense in her muscles, her whole body felt “on edge,” and she was unable to relax or to fall asleep easily. The tension was not only physical but also mental, she experienced anxiety on and off throughout the day, had multiple worries, and often felt irritable. Ever since she could remember, she had been somewhat highly strung, but in her thirties she took a more stressful job, and there were often times when the physical symptoms became more intense and even interfered with her work function. During these periods of increased anxiety, she resorted to using benzodiazepine tablets prescribed by her primary care physician for poor sleep.