OBJECTIVE:A variety of diseases can cause both psychosis and myelin changes that manifest as white matter hyperintensities on T2-weighted magnetic resonance imaging of the brain. Although many of the acquired conditions relevant to this discussion are widely recognized by psychiatrists and other physicians, a number of lesser-known rare genetic disorders also deserve consideration in this context. As such, this review sought to summarize the phenotypic features, brain imaging abnormalities, and approach to diagnosing the most common leukodystrophies and other genetic leukoencephalopathies that can cause psychosis. METHODS:This is a narrative review. The most common leukodystrophies that can cause both psychosis and white matter hyperintensities are first reviewed, followed by a variety of other rarer leukodystrophies and related genetic disorders. Suggestive clinical features, workup recommendations, and potential clinical implications are subsequently discussed. RESULTS:Although the psychotic symptoms that occur in these disorders might phenomenologically resemble those typical of schizophrenia, the identification of any "red flag" neurological features, idiosyncratic medical comorbidities, additional brain imaging abnormalities, parental consanguinity, or a mendelian pattern of inheritance, should prompt consideration for an underlying genetic explanation. Making a correct diagnosis in this context is critical, given the numerous potential clinical implications, including with respect to treatment decisions. CONCLUSION:While psychiatrists are not expected to be experts in this area, at a minimum they should have a basic familiarity with the genetic disorders that are most likely to cause both psychosis and white matter hyperintensities, given the relatively frequent occurrence of this clinical scenario.
OBJECTIVE:Neurocognitive disorders (NCDs), which include delirium, major and mild NCDs such as Alzheimer's disease (AD), and other forms of dementia, constitute a significant and growing public health burden, affecting tens of millions of individuals worldwide. This systematic review aims to examine the medications approved by the United States Food and Drug Administration (FDA) for NCDs from 2008 to 2024, as well as those in the pipeline in Phase III, and to describe the mechanism of action, clinical indications, dosing, evidence for efficacy, and adverse effects. METHODS:We searched the literature using the PubMed database for studies published from January 1, 2008, to December 31, 2024, focusing on FDA-approved psychiatric medications and Phase III pipeline medications, using the keywords "neurocognitive" OR "dementia" OR "Alzheimer*" AND "psychopharm*" OR "medic*" OR "pharm*." Two reviewers performed an independent assessment of the resulting publications and reached a consensus on the eligible studies to include in the systematic review. RESULTS:From 2008 to 2024, the FDA approved eight medications for major and mild NCDs, including monoclonal antibodies, acetylcholinesterase inhibitors, N-methyl-D-aspartate (NMDA) receptor antagonists, and an atypical antipsychotic. Additionally, we identified 22 pipeline medications currently in Phase III clinical trials for NCDs as of December 31, 2024, including biologics and neuroprotective agents, among others. No medications for delirium were FDA-approved or in Phase III, although agents for a variety of encephalopathies have been developed. CONCLUSION:Significant advancements in the pharmacological management of NCDs have been made during this period, including developing disease-modifying therapies for AD. However, available medications primarily provide symptomatic relief, and challenges persist in the implementation of disease-modifying treatments due to adverse effects and high costs of care. The pipeline of Phase III clinical trials includes many emerging agents with novel mechanisms of action, and ongoing trials will prove essential to confirm the efficacy and safety of these therapies.
Decision-making capacity (DMC) is a core element of ethical and effective clinical care, ensuring that patients can understand, appreciate, reason through, and communicate informed choices about treatment. Accurate assessment of DMC is essential in psychiatric settings, where serious mental illness (SMI) may affect cognition, insight, or judgment, yet does not inherently imply incapacity. This paper examines how implicit, racial, and cognitive biases can influence DMC evaluations and contribute to disparities, particularly for Black and Hispanic patients with SMI. Diagnostic overshadowing, assumptions about insight, and misinterpretation of culturally influenced communication may lead to incorrect determinations of incapacity and undermine patient autonomy. Evidence indicates that while cognitive impairment is a significant contributor to reduced DMC, many individuals with SMI retain the ability to make reasoned treatment decisions. Standardized tools-such as the MacArthur Competence Assessment Tool and related instruments-can improve reliability and mitigate subjective judgment, though current measures lack explicit integration of cultural and racial considerations. This paper highlights strategies to reduce bias in DMC assessments, including clinician education, development of culturally informed protocols, interdisciplinary decision-making, and expanded access to advocacy resources. These efforts support equitable, accurate, and ethically grounded evaluation of patient capacity across diverse clinical populations.
BACKGROUND:Cognitive Assessment Tool for Pediatric Clinical Research (CAT-PCR) is a new brief nonverbal test battery validated in a Zambian school-aged population. CAT-PCR involves the standardized administration of two tests, WAVES and SYMBOLS. CAT-PCR provides measures of visuomotor processing (VMP) and visuographomotor constructional processing (VGCP). The psychometric properties of CAT-PCR were evaluated in a field trial complemented with an ancillary test-retest study. RESULTS:Four-hundred-twenty children, aged 5 to 17 years, 51.2 percent female, speaking Bemba (81.1%), English (72.6 %), Nyanja (22.8%), Tonga (1.9%), and Lozi (1.2%), were recruited at multiple Zambian clinical sites and schools. Children able to speak one, two, and three or more languages composed 23.5, 10.0, and 66.5 percent of participants, respectively. CAT-PCR detected differences in cognitive performance between two comparable subgroups of children with or without conditions associated with increased risk for cognitive impairment. The poorer health group composition reflected a spectrum of conditions such as chronic neurologic or medical diseases (ie, epilepsy, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], recurrent malaria, sickle cell disease, and other cardiac and metabolic conditions) or prolonged exposure to psychosocial stress and deprivation. The reliability was satisfactory. The intraclass correlation coefficient (95% confidence interval) at test-retest at 48 hours (n=86) was 0.85 (0.78, 0.91) for VGCP Index and 0.84 (0.76, 0.90) for VMP Index. CONCLUSION:Study findings support the reliability, validity, and utility of CAT-PCR measures in evaluating the effect of health-related risks on the child's cognitive functioning and development. Further research should address the validity of CAT-PCR in response prediction, monitoring, and evaluation of health-promoting interventions.
OBJECTIVE:Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with a wide range of neurological symptoms and neuropsychiatric conditions. SARS-CoV-2 shows various degrees of neurotropism. SARS-CoV-2 primarily targets respiratory and gastrointestinal tracts; however, it can affect other organs. Neurological and neuropsychological manifestations of COVID-19 have been reported. Several mechanisms are involved in these manifestations in COVID-19. Therefore, the present narrative review will take account of mechanisms underlying the neurological and neuropsychological manifestations in COVID-19. METHODS:A literature search for relevant articles in different databases was made with a focus on recent publications for this narrative review. RESULTS:Inflammation and thrombosis have been suggested to be mechanisms contributing to these manifestations. Also, renin-angiotensin system (RAS), transmembrane serine protease 2 (TMPRSS2), cathepsin B and L, furin, neuropilin-1 (NRP1), and sterile alpha motif and HD domain-containing protein 1 (SAMHD1) have been proposed to be involved in pathogenesis of SARS-CoV-2. Moreover, cluster of differentiation 147 (CD147) and dipeptidyl peptidase 4 (DPP4) have been suggested to have a role in SARS-CoV-2 entry into the central nervous system (CNS). CONCLUSION:Further investigation on the underlying mechanisms leading to SARS-CoV-2-associated neurological and neuropsychological manifestations is pivotal. Insights into these mechanisms will help the treatment strategies for patients with COVID-19 and such manifestations.
This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other healthcare professionals so "clinician" is used to indicate all treatment team members.
Parenting is the fundamental parent-child relationship process that impacts their lives. To better understand how adolescents perceive their parents' attitudes and behaviors, it is important to adapt, translate, and validate the perceived parenting style questionnaire in Pakistani culture. Therefore, the study was carried out by using International Test Commission (ITC) protocols. In initial steps, forward and backward translation was carried out, and language equivalence was tested on a sample of 30 bilingual participants. In the final stages, reliability analysis was carried out and followed by confirmatory factor analysis (CFA). Furthermore, construct validity was estimated through a structural equation model (SEM). The process comprised a convenient sampling technique to approach a sample size of 456 adolescents aged 13 to 17 years from nine districts of Punjab, Pakistan. The results of the item correlation showed a highly significant connection between the items of the Perceived Parenting Style Scale (PPSS). Cronbach's alpha index was significantly high (r=0.93). According to CFA, the model fits accurately, as all values are approximately equivalent to the model's ideal values. Moreover, PPSQ showed sound psychometric properties and emerged as a reliable and valid tool for measuring perceived parenting styles.
BACKGROUND:Anecdotal reports of psychosis emerging in the context of artificial intelligence (AI) chatbot use have been increasingly reported in the media. However, it remains unclear to what extent these cases represent the induction of new-onset psychosis versus the exacerbation of pre-existing psychopathology. We report a case of new-onset psychosis in the setting of AI chatbot use. CASE PRESENTATION:A 26-year-old woman with no previous history of psychosis or mania developed delusional beliefs about establishing communication with her deceased brother through an AI chatbot. This occurred in the setting of prescription stimulant use for the treatment of attention-deficit hyperactivity disorder (ADHD), recent sleep deprivation, and immersive use of the chatbot. Review of her chatlogs revealed that the chatbot validated, reinforced, and encouraged her delusional thinking, with reassurances that "You're not crazy." Following hospitalization and antipsychotic medication for agitated psychosis, her delusional beliefs resolved. However, three months later, her psychosis recurred after she stopped antipsychotic therapy, restarted prescription stimulants, and continued immersive use of AI chatbots so that she required brief rehospitalization. CONCLUSION:This case provides evidence that new-onset psychosis in the form of delusional thinking can emerge in the setting of immersive AI chatbot use. Although multiple pre-existing risk factors may be associated with psychosis proneness, the sycophancy of AI chatbots together with AI chatbot immersion and deification on the part of users may represent particular red flags for the emergence of AI-associated psychosis.
Delusional parasitosis is a psychiatric disorder in which one experiences persistent, false delusions of being infected by parasites or other organisms. Symptoms include formication, pruritis, and self-inflicted cutaneous manifestations. In this article, we discuss the complicated case of a 45-year-old male patient with history of Crohn's disease, opioid use disorder, and post-traumatic stress disorder to highlight key concepts of the disease. The clinical presentation often leads to a broad differential diagnosis, which can complicate and delay treatment.
Cultural concepts of distress, previously referred to as culture-bound syndromes, are psychiatric conditions influenced by cultural beliefs, history, and social norms. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, these syndromes manifest as culturally specific expressions of psychosocial distress, though there is a lack of formal diagnostic criteria. This article explores three cultural concepts of distress, koro, Dhat, and latah syndromes, through fictional case vignettes to illustrate their clinical presentation, underlying psychiatric associations, and potential management strategies. Each syndrome and case contain unique factors of psychosocial distress and highlights necessary considerations with avenues for improved patient care.
A small proportion of people are exceptionally sensitive to slights from others, and they might then heap shame upon themselves and even consider suicide. Often, however, these patients might also have a "gift" that their sensitivity to feelings concurrently provides them. They might be especially able to accurately infer the more subtle, underlying feelings of others and with this capacity connect with them in ways that most other persons cannot. However, these individuals might have no idea that their sensitivity is the strength that it is. They might regard their sensitivity as only a liability. Viewing this trait as an asset can change how they see themselves and, therefore, their quality of life. This article will address how therapists can reduce these patients' sense of liability and enhance their ability to make maximal use of their sensitivity.
OBJECTIVE:The aim of this study was to measure levels of ethical awareness and burnout among mental health professionals, while also investigating the relationship between age, ethical awareness, and burnout. Additionally, the study aimed to compare the exhaustion level between mental health professionals working in public and private sectors. METHODS:A correlational study was conducted in Lahore, Pakistan. Data was collected using the Santa Clara Ethics Scale and the Counselor's Burnout Inventory from 319 mental health professionals with at least two years of experience. The analysis of the collected data was carried out using SPSS version 23. RESULTS:The mean±standard deviation levels of ethical awareness and burnout were found to be 31.4±4.46 and 48.4±13.91, respectively. Ethical awareness was positively correlated with age and negatively correlated with dimensions of burnout (exhaustion, incompetence, negative work environment, devaluing clients, and personal life deterioration) and overall burnout. There were significant positive correlations among these burnout factors. Furthermore, mental health professionals in the public sector exhibited significantly higher levels of exhaustion than those working in private sector. CONCLUSION:This study underscores the significant association between age, ethical awareness, and burnout in mental health professionals and urges tailored interventions that enhance the ability to make ethical decisions while minimizing the risk of burnout, especially among early-career mental health professionals and professionals working in the public sector.
This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other healthcare professionals so "clinician" is used to indicate all treatment team members.
OBJECTIVE:Cannabis use and chronic diseases have both been associated with impaired cognitive ability. The current study will explore their independent and co-occurring effects on cognitive difficulty concentrating, remembering, or making decisions on the population level. METHODS:This study used a probability sample of United States (US) adults aged 18 years or older from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), a telephone-administered survey. The cross-sectional survey collects data from a representative sample regarding health-related risk behaviors, chronic health conditions, and use of preventive services. RESULTS:The study sample consisted of 94,918 participants in the BRFSS survey that completed the optional module on cannabis use. The prevalence of having difficulty concentrating, remembering, or making decisions was 12.7 percent (standard error [SE]: 0.21%), prevalence of monthly cannabis use was 14.9 percent (SE: 0.24%), that of daily cannabis use was 7.4 percent (SE: 0.18%), and prevalence of any chronic medical condition was 59.2 percent (SE: 0.32%). The prevalence of having difficulty concentrating, remembering, or making decisions was higher for those with a chronic medical condition (17.6% [SE: 0.31%] vs. 5.7% [SE: 0.25%], Rao-Scott p<0.0001). Such difficulty was also higher for those who used cannabis monthly (24.4% [SE: 0.731%] vs. 10.7% [SE: 0.21%], Rao-Scott p<0.0001) or daily (29.1% [SE: 1.12%] vs. 11.4% [SE: 0.21%], Rao-Scott p<0.0001). Greater cognitive difficulty for those with a chronic medical condition was accentuated by cannabis use; daily cannabis (vs. nonuse) was associated with 145-percent higher prevalence of cognitive difficulty and monthly cannabis use (vs. nonuse) was associated with 76-percent higher prevalence of cognitive difficulty. For those without a chronic medical condition, the prevalence of cognitive difficulty was 183- and 97-percent higher in daily and monthly cannabis users (vs. nonusers), respectively. CONCLUSION:In the general population, having a chronic medical condition significantly increased cognitive difficulty concentrating, remembering, or making decisions. Cannabis use (particularly daily use) significantly increased cognitive difficulty for people with each chronic condition included in this study. The greater cognitive difficulty with cannabis use was less pronounced in individuals with chronic conditions with higher difficulty at the outset, such as depression.
Patients with concussion often receive insufficient and/or ineffective diagnostic workups. A limiting factor for prompt and accurate diagnosis is the scarcity of practical and effective concussion diagnostics that can be used by private-practice physicians. This gap in the diagnostic process can delay the implementation of crucial interventions. The absence of an affirmative concussion diagnosis leaves patients with few options when follow-up treatment would otherwise be indicated, potentially leading to worsening symptoms, prolonged recovery, and a higher likelihood of developing long-term complications. Neurophysiological assessments such as electroencephalography (EEG) and event-related potentials (ERPs) offer an opportunity for an objective evaluation of brain deficits that can occur after a concussion. By detecting abnormalities in brain patterns that are often associated with concussive injuries, these tests can help provide timely diagnosis and treatment of the disorder, thus reducing the likelihood of chronification of post-concussive symptoms. We reviewed a battery of neurophysiological assessments that have been scientifically validated to detect the pathophysiological effects of concussion and can be performed in office settings by nonspecialist technicians. These assessments are designed to help with diagnosis and prognosis of concussion, while also being accessible and practical to administer for private-practice physicians who can incorporate them into routine evaluations of patients with traumatic brain injury (TBI). The implementation of neurophysiological tools in primary care and outpatient settings has the potential to bridge the gap between symptom presentation and definitive diagnosis, thus mitigating the risk for long-term adverse outcomes.
This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other healthcare professionals so "clinician" is used to indicate all treatment team members.
OBJECTIVE:Psychiatric inpatients often require complex medication regimens due to the refractory nature of their serious mental illness (SMI) and the high prevalence of medical comorbidities. Among the many inherent issues associated with these regimens are the potential pharmacodynamic drug interactions resulting in an increased risk of QTc prolongation and the potential sequelae, Torsades de Pointes (TdP). This study builds on previous research that demonstrated the utility of the MedSafety Scan (MSS) clinical decision support (CDS) tool by establishing theoretical evidence from patients with SMI but did not provide objective data to validate its use in this population. This has left prescribers questioning whether the MSS CDS tool is capable of accurately guiding prescribing decisions in this vulnerable patient population. Therefore, the objective of this study was to assess the degree of correlation between psychiatric patients' QTc intervals and their MSS-calculated TdP risk scores to objectively validate the predictive impact and clinical value of the MSS tool in psychiatric inpatients for the purpose of informing safe prescribing. METHODS:A retrospective analysis was conducted to assess the relationship between participants' MSS TdP risk scores and their QTc Δ, defined as the difference between participants' measured QTc intervals and sex-specific QTc prolongation thresholds (female individuals: 470ms; male individuals: 450ms). The MSS TdP risk score is calculated based on patient demographic data, medical diagnoses, serum electrolyte values, and medications. Data from 251 subjects were extracted from an adult inpatient psychiatric facility's electronic medical record system from February 1, 2018, through November 30, 2023. Inpatients with a documented electrocardiogram during the study period were eligible for inclusion, and the exclusion criterion was having a Criminal Procedure Law (CPL) designation. Data were analyzed using a one-way analysis of variance (ANOVA) with alpha set to 0.01. RESULTS:The data from the ANOVA that compared participants' QTc Δ to MSS TdP risk score were found to be significant (p<0.01). CONCLUSION:This study showed that the MSS CDS tool accurately reflected the relationship between our psychiatric inpatients' measured QTc intervals and their predicted MSS TdP risk scores, which objectively validated the predictive impact and clinical utility of this tool in our psychiatric population. Prescribers can use this tool to mitigate QTc prolongation risk for patients without underlying, unknown congenital risk; therefore, this can be an important course of action in treating psychiatric patients, given their predisposition to decreased lifespans and their increased risk of QTc prolongation due to SMI-related proarrhythmic factors. The MSS tool is an open-source, web-based CDS tool that provides comprehensive analyses of TdP risk, drug interactions, and duplicate therapies, and produces a detailed patient-specific report that allows for documentation of management plans. These features prove MSS to be a valuable tool for psychiatric inpatient clinicians to establish an initial basic clinical impression to advise need for additional comprehensive medical follow-up, cardiology consultation, or pharmacotherapeutic modifications.
Treatment-resistant depression (TRD) is major depression that has not responded to at least two trials of antidepressants. The STAR-D study highlighted the necessity of multiple treatment steps to achieve remission, with each step decreasing the likelihood of success and increasing relapse risk, underscoring the complexity of TRD treatment and the need for personalized approaches. Transcranial magnetic stimulation (TMS) is a noninvasive technique using magnetic fields to stimulate brain nerve cells, targeting the dorsolateral prefrontal cortex, that is effective in many patients with depression. However, for patients with TRD who fail TMS, no standard of care exists. Intranasal esketamine, a noncompetitive N-methyl-D-aspartic acid (NMDA) receptor antagonist, is approved for adults with TRD or major depressive disorder with suicidal thoughts. We present a case series of five patients with TRD who failed TMS and subsequently responded to intranasal esketamine. Response, defined as a 50-percent symptom reduction, was monitored using Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI), and Generalized Anxiety Disorder-7 (GAD-7) scores. After 16 treatment sessions, all patients achieved a treatment response per PHQ-9 and BDI scores; 80 percent achieved complete remission per PHQ-9, and 60 percent per BDI. Additionally, 80 percent of patients showed a treatment response on GAD-7 scores. This case series supports further investigation into esketamine for patients with TRD who are unresponsive to TMS.
