Delirium is associated with lower quality of life, increased healthcare costs, longer hospitalizations, and worse prognosis when detected in patients who are already confronted with a severe and invalidating disease, like the major neurocognitive disorder (MND). In order to identify the most evidence-based interventions that could be included in case management for patients with both delirium and MND, this narrative review explored three electronic databases (Pubmed, Cochrane, and Web of Science/Clarivate) for primary and secondary sources dedicated to this topic. All papers published in English between the inception of each database and September 2024 were screened for relevant data on pharmacological and non-pharmacological therapies targeting delirium. The results supported the use of a multicomponent approach as the first line of treatment, mitigating the precipitating factors, and only as a second line, the use of pharmacological instruments. There is a lack of validated therapies targeting specifically the delirium superimposed on MND, most of the recommendations being extrapolated from studies with delirium in the general population or in elderly patients with different organic diseases. Further studies are required to investigate the specifics of delirium in patients with MND and potential strategies focused on neurobiological mechanisms instead of just clinical manifestations.
Clinical research is the cornerstone of the progress recorded in psychiatry in the last six decades, or of what is called the psychopharmacological revolution. Regardless of the stage of clinical research, there are sensitive ethical and legal aspects that may appear during this process, and such challenges have to be acknowledged in order to preserve its scientific value, integrity, and centered-on-the-patient-wellbeing core principles. Also, adequate strategies focused on preventing the risk of ethical misconduct and litigation have to be found to avoid a loss of trust in the results of clinical research, to protect vulnerable populations from abuse, and to ensure a legally stable environment for investigators. In order to explore these practical problems, a narrative review was performed through a search in PubMed and Google Scholar databases. The main ethical risks detected in clinical research were related to errors in the methodology of obtaining informed consent, monitoring the participant's safety during the clinical trial, and falsifying collected data. Several famous cases of ethical misconduct were found and analyzed, and methods to decrease the risk of the re-appearance of such problems have been listed. In conclusion, this review is an invitation to explore the complexity of the methodology of clinical research and its ethical and legal risks, as well as to find new ways to mitigate the possibility of such risks related to the research process.
Erectile dysfunction (ED) has an intricate pathogenesis, with organic and psychosocial factors contributing to the shaping of its clinical manifestations and functional impairment. ED disrupts not only an individual’s sexual life but may also contribute to impairments of self-esteem, social functioning, quality of life, overall well-being, mood, etc. The assessment process and therapeutic interventions should be adequate to the specific profile of each patient, therefore an interdisciplinary approach is usually recommended, in order to find the vulnerability factors, recent triggers, psychiatric and organic comorbidities or causes, and elements that contribute to maintaining the sexual dysfunction, such as lifestyle factors, interpersonal conflicts, or inadequate sexual education. This narrative review explores the evidence-based approaches to structured psychiatric, psychological, and therapeutical assessment in patients with ED, and the most validated psychosocial treatments available. The results support the use of recognized diagnostic criteria within DSM-5TR and ICD-11, together with structured instruments (scales, questionnaires, and inventories), in a multidisciplinary approach. The cognitive model and cognitive-emotional model of ED support the initiation of cognitive-behavioral therapy in these patients. Other interventions, like the PLISSIT model, sexual therapy, couple therapy, and sexual-focused psychoeducation are also supported by evidence. In conclusion, ED requires a combined, psychiatric, psychologic, psychotherapeutic, and organic-oriented assessment, with the purpose of tailoring the treatment to the patient’s particularities.
The assessment of coping mechanisms in patients diagnosed with oncological diseases is essential for mental health specialists, who have to design the most appropriate case management strategy for comorbid mood disorders, anxiety disorders, adjustment disorders, and other psychiatric conditions that may be detected in this vulnerable population. The adequate treatment of these disorders is important for the preservation of mental health status, quality of life, and overall functionality in patients diagnosed with cancer. Coping mechanisms modulate the vulnerability toward psychiatric disorders, but they also have an impact on treatment adherence, which is an important factor correlating with prognosis. Appraisal-focused, problem-focused, emotion-focused, and occupation-focused coping represent the most well-defined strategies patients use when confronted with a stressful life situation, like a diagnosis with potentially vital consequences. Maladaptive coping strategies may also be identified in these patients, e.g., withdrawal from reality, including complete or partial denial of the disease, substance abuse, behavioral addictions, refusal of the recommended treatment, etc. The psychotherapeutic approach in patients with oncological diseases should include an initial evaluation of the coping strategies used either currently or in the past stressful conditions, an assessment of all the psychosocial resources the patients have (e.,g., support group, professional insertion, hobbies), and screening for mood and anxiety disorders that may have been triggered by the cancer diagnosis. Consequently, within the psychotherapeutic framework, a trained specialist can enhance the role of adaptive coping strategies and highlight the disadvantages of dysfunctional ones. This process may possess a favorable impact on treatment adherence, mental health status, and quality of life in patients with cancer.
Nutritional interventions in the field of psychiatry have been explored more intensively in the last two decades, but definitive conclusions based on the retrieved data in the literature about the efficacy of this therapeutic approach are difficult to formulate. This observation has multiple explanations, e.g., these therapeutic interventions are very heterogenous, cohort studies usually enroll different psychiatric populations or healthy subjects with minor psychiatric symptoms, nutritional supplements or special diets are commonly recommended as add-ons to the pharmacological interventions (thus making it difficult to differentiate the impact of each therapy on the outcomes), placebo-controlled randomized studies are still very few, etc. Therefore, a narrative review focused on the main challenges reported during the research in the field of nutritional psychiatry (NP) may be useful for clinicians interested in strategies to augment the efficacy of pharmacological treatments or to find new solutions with low risk of adverse events in patients with organic comorbidities or multiple concomitant medications. Data about the efficacy and tolerability of nutritional interventions explored for psychiatric disorders were searched in four electronic databases (PubMed, Cochrane, Clarivate/Web of Science, and EMBASE). Omega-3 polyunsaturated fatty acids supplementation, healthy diet interventions, folate and vitamin B12, S-adenosyl-L-methionine, N-acetyl cysteine, vitamin B1 and B6, vitamin D, minerals, psychobiotics, inositol, and herbal products were the main interventions identified, and their demonstrated efficacy was quite heterogenous, while their tolerability and safety were good. Therefore, NP is a domain of research that may benefit from more good-quality and longer-duration trials, in order to verify the effectiveness of such augmentation strategies to the already validated treatments.
The conundrum of post-psychotic depression (PPD) is still present in the psychiatric literature, for more than a century since it was first described by Mayer-Gross. After a short existence in the DSM-IV and ICD-10, this nosological construct was excluded from newer versions of the mental disorders classifications. Therefore, an exploratory analysis of the PPD concept was considered useful both from clinical and theoretical perspectives. There is a high prevalence of depressive symptoms in patients with schizophrenia spectrum disorders (SSD) and, although not all of them represent cases of PPD, they are considered risk factors for suicide. The arguments and contra-arguments for/against PPD were reviewed, and the potential pharmacological interventions for this disorder were analyzed. The explored evidence indicates that PPD is worth further investigation, and in order to differentiate it from schizoaffective disorder, negative symptoms of SSD, or depressive manifestations within the acute psychotic episodes, clearly defined criteria should be found. The use of validated scales, like the Calgary Depression Scale for Schizophrenia and the InterSePT Scale for Suicidal Thinking, is recommended for the initial assessment of depression and suicidal risk in patients with SSD, but also for their monitoring during the acute and maintenance phases. Besides the administration of combined, antidepressant and antipsychotic treatment, the use of clozapine, and the recommendation to initiate treatment for SSD with atypical antipsychotics whenever possible, there is a dearth of studies exploring specific interventions for PPD. Future studies are expected to address the validity of the nosological construct of PPD and the most adequate therapeutic and prophylactic interventions in patients with SSD.
During the COVID-19 pandemic, neuropsychiatric disorders have been diagnosed both in the acute phase, and in the aftermath of this disease. Inpatients, as well as outpatients recently diagnosed with mild, moderate or severe forms of Coronavirus infection have reported neuropsychiatric manifestations with variable duration, symptoms that could be directly or indirectly related to the viral pathogenic agent. Patients who are recovering from the acute phase of COVID-19 also may exhibit various psychopathological manifestations, during the so-called “post-COVID-19 syndrome” or “long COVID-19 syndrome”. Explanations regarding the onset of this type of clinical manifestations and the SARS-CoV-2 infection are extremely diverse, ranging from biological factors (e.g., direct central nervous system viral activity, cerebral hypo- oxygenation, high level of inflammatory response) to psycho-social stressors (e.g., isolation, fear of death, anxiety related to possible somatic complications or sequelae). Objectives: The primary objective of this article was to analyze psychiatric manifestations in patients with acute COVID-19 disease and in patients during post-COVID-19 phase. The secondary objective was to propose a conceptual framework for the evaluation and treatment of these patients. Methods: Patients included in this analysis were screened positive for COVID-19 infection in the last 6 months before their first psychiatric examination. These patients were further evaluated to detect any personal history of psychiatric disorders, somatic comorbidities, or significant concomitant pharmacological treatments. Specific scales for the measurement of symptoms severity and functional impairment were administered in all patients. Results: Five patients were included in this analysis, one during the acute phase of COVID-19 infection, and four patients were evaluated after the complete remission of this disease. Hyperactive delirium, mild neurocognitive disorder, major depressive episode, panic disorder with agoraphobia, or acute psychotic disorder were the main diagnoses in these patients. All patients received adequate treatment and they were monitored using psychological scales until symptoms remission or stabilisation. Conclusions: Psychosocial stressors, neurobiological changes, systemic inflammatory reaction, and individual vulnerability factors may contribute to a diathesis- stress model for psychiatric disorders onset within the acute phase or after the remission of acute manifestations in COVID- 19-diagnosed patients.
A unique approach to the treatment of posttraumatic stress disorder (PTSD) is difficult to support, because of the complexity and heterogeneity of this pathology. Multiple evidence-based guidelines for PTSD treatment exist, elaborated by prestigious institutions around the world, but a certain level of the inconsistency of their recommendations appears when these sources are compared with each other. Therefore, a review of current guidelines and extraction of the most supported by evidence recommendations is considered important for clinical practice, due to the need to approach such complex cases as PTSD-diagnosed patients in a stepwise manner. Structured monitoring of the clinical status during the treatment is also an important and rather neglected aspect of the case management in PTSD, and the necessity of follow-up visits for efficacy and tolerability should be taken into consideration. Psychotherapy (especially cognitive- behavioral oriented therapies and eye movement desensitization and reprocessing therapy) is supported by evidence as a first-line approach, as well as certain antidepressants, like the selective serotonin reuptake inhibitors and venlafaxine. Many second-line pharmacological agents and psychotherapies are also available, but there is an obvious need for more pragmatic trials with PTSD patients.
Matching drugs with anxiolytic properties- but without the potential of inducing dependence or abuse- with clinical manifestations of various affective disorders is a very important challenge for psychiatrists. Although the first line of pharmacologic treatment for anxiety disorders remains antidepressants with serotoninergic properties, calcium channel alpha-2-delta ligands are adjuvant agents which could be useful for augmenting antidepressant agents’ clinical effects. Unfortunately, calcium channel alpha-2-delta ligands efficacy and tolerability are not very well known, due to a lack of large scale, randomized, placebo-controlled trials focused on psychiatric disorders. Data regarding pregabalin and gabapentin pharmacology and clinical effects are reviewed and conclusions with pragmatically impact based on the discovered evidence are formulated accordingly.
