Psychopharmacology Conference Offers New Research, Prescribing Tips

Psychiatric TimesVol 39, Issue 12

Check out the best clinical pearls from the 2022 Neuroscience Education Institute (NEI) Congress!

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The 2022 Neuroscience Education Institute (NEI) Congress, a psychopharmacology conference for mental health clinicians, provided clinical updates and reviews on several important topics in psychiatry. Held November 9 to 12 in Colorado Springs, Colorado, the conference was attended virtually and in person. If you were unable to attend, do not worry—Psychiatric Times™ has you covered.

Motivational Interviewing Benefits Patients With Schizophrenia

“Patients aren’t going to do things unless there is something that motivates them,” Amber Hoberg, MSN, APRN, PMHNP-BC, said during a presentation at the 2022 NEI Congress in November. In the presentation, Hoberg and Leslie Citrome, MD, MPH, discussed how motivational interviewing (MI) lets patients with schizophrenia and their families share in the decision-making process of determining treatment goals and helps clinicians communicate with patients in an empathetic manner that encourages adherence.

Citrome and Hoberg acknowledged that there are barriers to positive outcomes for both patients and clinicians. Barriers for patients include communication difficulties, cognitive and other adverse events associated with treatment, and stigma of schizophrenia. Barriers for clinicians include underestimation of the importance of the therapeutic relationship, conveyance of hopelessness to the patient, and lack of interest in the patient’s life goals and other issues that are important to the patient.

“We need to address these barriers in a systematic way,” said Citrome, who is a clinical professor in the New York Medical College Department of Psychiatry in Valhalla. Citrome and Hoberg also shared that, according to research, 91% of patients with serious mental illness want to be involved in decisions about their care; 67% of treatment decisions involving oral antipsychotics were made without the input of either the patient or their care partner; and long-acting injectables (LAIs) were not discussed with 50% of patients who were taking oral antipsychotics, but more than half of patients agreed to start LAIs after discussing them with their clinician. According to Citrome and Hoberg, this demonstrates the importance of building the therapeutic alliance through shared decision-making.

“This is very important when you’re talking to any patient with mental illness, but particularly schizophrenia patients because they want to trust you and part of that trusting thing is developing that relationship with your patients,” said Hoberg, who is a nurse practitioner with Morning Star Family Medicine in Floresville, Texas.

Citrome and Hoberg stated that MI is a very important tool for clinicians, particularly when working with patients with schizophrenia and other serious mental illnesses. Defined as a collaborative conversation style for strengthening the patient’s motivation and commitment to change, MI “is really part of modern medicine today,” Citrome said, adding that “it means we do something with someone—not for or to them.”

“The whole goal of motivational interviewing is to help the patients change” Hoberg said. “Ambivalence is normal with patients, but what we’re trying to do is get them to that other side, using their ability to set their goals and make those decisions for themselves.”

Citrome and Hoberg shared that clinicians can effectively incorporate MI into their work with patients by asking open-ended questions and using reflective listening’s acronym RULE, which suggests clinicians:

  • resist making too many suggestions,
  • understand the patient’s motivation,
  • listen with a patient-centered empathetic approach, and
  • empower the patient.

Open-ended questions and an empathetic approach are vital to positive outcomes, according to Citrome and Hoberg. “The way we’re counseling can either increase or decrease the effectiveness of what we’re doing with our patients,” Hoberg said. “You want to think of it like knobs on a radio. If you’re being very punitive, very confrontational, very negative in your approach, your patients are going to turn you off, and they’re really not going to want to listen, and their barriers and their walls are going to go up. But if we use open-ended questions, we start to listen to our patients and we reflect back what we’re hearing. The knob is going to be turned up and they’re really willing to engage with you and have that motivation to change.”

Citrome and Hoberg also shared 5 questions for clinicians to consider when incorporating MI into their work with patients:

1. Why would you want to make this change?

2. How might you go about it in order to succeed?

3. What are the 3 best reasons to do it?

4. How important is it for you to make this change, and why?

5. What do you think you will do?

“The most important thing you can do is ask open-ended questions,” Hoberg concluded.—EAO

Exploring the Major Differences in Presentation and Management of Bipolar I and II

“Unfortunately, in the great majority of people, both bipolar I disorder and bipolar II disorder—especially bipolar II disorder—are not detected in a timely fashion,” said Roger S. McIntyre, MD, FRCPC, who discussed the major differences between bipolar I and bipolar II disorder in a presentation at the 2022 NEI Congress in November. The aim of the presentation was to identify differences in the clinical presentation and diagnostic criteria associated with each disorder and to determine the most effective pharmacologic treatments for each one.

According to McIntyre, head of the Mood Disorders Psychopharmacology Unit and a professor of psychiatry and pharmacology at the University Health Network in Toronto, Canada, misdiagnosis and underdiagnosis are very common in patients with bipolar I and II disorders, as these patients are often diagnosed with other disorders such as depression and schizophrenia. McIntyre also holds additional professorships at Guangzhou Medical University in China; Korea University College of Medicine in Seoul; SUNY Upstate Medical University in Syracuse, New York; and the University of California School of Medicine in Riverside.

“When they come to our office, patients often present with low-grade depression and anxiety. They can’t sleep, they can’t focus, and often they come to us as well with a sense of no purpose and functional impairment,” McIntyre told conference attendees, noting that depression in particular may be an adverse event or comorbidity that can lead to misdiagnoses.

“The more the patient presents with depression, the more likely we are to miss the diagnosis because major depressive disorder [MDD] is all depression, bipolar II disorder is very much depression, and bipolar I is also predominant depression but less than bipolar II,” added McIntyre, who also is chair and executive director of the Brain and Cognition Discovery Foundation and director and chair of the Depression and Bipolar Support Alliance Scientific Advisory Board.

Bipolar disorder has the highest rates of comorbidity, according to McIntyre, with bipolar I being closer genetically to schizophrenia and bipolar II being closer genetically to MDD. Childhood trauma can also influence onset and presentation of both types of bipolar disorder. Generally, the greater the degree of trauma, the earlier the age of onset will occur and the greater the earlier severity of presentation. Trauma also can contribute to additional comorbidities such as substance use, higher rates of suicide, and cognitive impairment. In terms of cognitive impairment, McIntyre stated that the more episodes of illness a patient experiences, the higher the quantitative reduction in brain volume.

To avoid common misdiagnoses, McIntyre suggested that clinicians be aware of the 4 A’s: anxiety, agitation, anger/irritability, and attention-deficit/hyperactivity disorder (ADHD). “When a patient comes to my office, and they’re depressed, and the patient says to me, ‘Dr McIntyre, I am depressed. My life sucks and I’ve got anxiety. I’ve got agitation. I’m angry as hell, and I’ve got ADHD. I need Adderall’…this indicates to me that this [patient] could have hypomania and mixed features as they’re described in the DSM to represent hypomanic symptoms when someone’s depressed,” McIntyre said.

McIntyre also provided an updated list of medications approved by the US Food & Drug Administration (FDA) that are reportedly efficacious across the phases of bipolar disorder. FDA-approved medications for acute bipolar depression include cariprazine, lumateperone (Caplyta), lurasidone (Latuda), and quetiapine (Seroquel). FDA-approved medications for acute mania include lithium, carbamazepine, aripiprazole, and olanzapine samidorphan (Lybalvi). And for maintenance, FDA-approved medications include asenapine, lamotrigine, quetiapine (adjunctive), and risperidone (long-acting injectable; Risperdal).—EAO

A Heavy Burden: Bipolar Disorder and Obesity

What effects does obesity have on patients with bipolar disorder? Results from a new study were highlighted at a poster presentation at the 2022 NEI Congress.1

Michael J. Doane, PhD, and colleagues collected data from the 2016 and 2020 US National Health and Wellness Surveys to examine the relationships between obesity and clinical, humanistic, and economic outcomes among patients who self-reported a diagnosis of bipolar I disorder (BDI). As part of the retrospective, cross-sectional analysis, participants (N=1853) were categorized as underweight or normal weight if their BMI was less than 25 kg/m2, overweight if their BMI was between 25 and 30 kg/m2, and obese if their BMI was at least 30 kg/m2. The study was sponsored by Alkermes, Inc.

Doane et al used the 36-item Short Form Version 2 and EuroQol EQ-5D health surveys to measure participants’ health-related quality of life. The Work Productivity and Activity Impairment Questionnaire was used to measure work productivity and absenteeism as well as work and activity impairment. The investigators also leveraged the Medical Expenditure Panel Survey and US Bureau of Labor statistics to ascertain direct and indirect costs.

The mean age of all participants was 34.1 years, with patients in underweight/normal grouping tending to be younger than their peers in the overweight and obese groups. There were more women (65%) among the participants, and women were fairly evenly distributed among the BMI groups. Similarly, more than half (62%) of participants were white. Less than half of the participants were married (45%). The overall mean for being employed was 46%, and the percentage decreased as BMI increased. More than half of the patients who were overweight or obese were trying to lose weight and had exercised in the past month.

In addition to having the highest rates of high blood pressure, increased cholesterol, and type 2 diabetes, participants who were categorized as obese were more likely to have asthma, cancer, osteoarthritis, sleep apnea, and other comorbidities. They also reported the highest levels of activity impairment as well as the highest number of hospitalizations and emergency department visits in the previous 6 months. Interestingly, when compared with the obesity group, the underweight/normal weight group had slightly higher levels of absenteeism (37.1 vs 36.4), and overall work impairment (64.3 vs 64.2). Not surprisingly, the highest direct and indirect costs were found in the obesity group.

Doane et al acknowledged that individuals with BDI have an increased risk of obesity compared with the general population, which may be due to genetic, lifestyle, and treatment-related factors (ie, weight liability of medications used to treat BDI).

“[The] study results highlight important clinical, humanistic, and economic burdens associated with obesity in adults living with BD-I,” the researchers concluded. “These outcomes are important to consider in terms of a holistic treatment approach.”—HAD

Do you have tips for your colleagues on how to address obesity in patients with BDI? Share your stories with us at PTEditor@mjhlifesciences.com.

Reference

1. Doane MJ, Thompson J, Jauregui A, et al. Clinical, economic, and humanistic outcomes associated with obesity among adults with bipolar I disorder: analysis of National Health and Wellness Survey data. Poster presented at: 2022 NEI Congress. November 3-6, 2022; Colorado Springs, CO.


Delusional Hypergeusia: A Case Report

Investigators from Smell & Taste Treatment and Research Foundation reported an intriguing encounter of delusional hypergeusia in their poster presented at the 2022 NEI Congress.1

The case involved a 62-year-old woman whose symptoms developed after exposure to a solvent. She reported to the emergency department with bifrontal headaches, diffuse weakness, and fatigue. She also noted hallucinated smells and tastes. For instance, she initially felt the ambient aroma was replaced by the solvent aroma. As time progressed, the symptoms intensified, with the patient reporting that it felt like “soap was blown into [my] nostril.” Cologne exposure left her short of breath; and the taste and smell of coffee were replaced by a chemical taste and smell. She also reported panic attacks, and she said her throat and ears closed after watching food commercials.

Upon evaluation in the emergency department, the patient’s blood pressure was 189/90 and pulse was 100. The patient displayed sad mood with congruent affect; she was hyperverbal, loud, circumstantial, and irritable with pressured speech. She appeared disheveled with racing thoughts. Neuropsychiatric testing was performed with some abnormal results. The Go-No-Go Test resulted in abnormal score of 2/6, and she scored 17 (abnormal) on the Center for Neurological Studies Lability Scale. Results of the Clock Drawing Test were normal with a score of 4.

Gustatory and olfaction testing also were completed. The Alcohol Sniff Test and Odor Discrimination/Memory Test were indicative of hyposmia, whereas the Retronasal Smell Index showed signs of anosmia. Waterless Empirical Taste Test and Propylthiouracil Disc showed scores were considered normogeusia.

The researchers explained that perceived delusional hyperosmia and hypergeusia may be endogenous or exogenous (ie, medically or environmentally induced). “This may represent a variant of the 2-factor hypothesis of delusions whereby a distorted sensory perception is then misrepresented in a delusion,” they concluded.

Although delusional and subjective hyperosmia have received increased attention as a result of the COVID-19 pandemic, the researchers noted reports of delusional hypergeusia have not been previously published.—HAD

Reference

1. Kalita S, Birwatkar D, Sundar A, Hirsch AR. Too sweet to eat: delusional hypergeusia. Poster presented at: 2022 NEI Congress. November 3-6, 2022; Colorado Springs, CO.


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