Manhattan Psychiatric Center

<title>Abstract</title> <bold>Background:</bold> Treatment-resistant schizophrenia is the occurrence of delusions or hallucinations despite two antipsychotic drug attempts. Clozapine, an FDA-approved atypical antipsychotic, is reserved for such a case due to its efficacy but is handicapped by a wide array of side effects like sedation, agranulocytosis, seizures, metabolic syndrome, and neuroleptic malignant syndrome. Interestingly, clozapine has also been associated with the development or worsening of obsessive-compulsive symptoms (OCS) in up to 38.2% of patients, purportedly a byproduct of its serotonin 5-HT2A and 5-HT2C receptor antagonism. By comparison, tic-like vocalizations on clozapine are utterly rare and maybe underreported. <bold>Case presentation:</bold> We report the case of a 39-year-old man with treatment-resistant schizophrenia and psychogenic polydipsia who exhibited tic-like vocalizations and compulsive behavior upon clozapine initiation and dose escalation. Despite initial therapeutic response, the patient evolved with chronic OCS and vocalization, necessitating adjunctive antipsychotic therapy (Aripiprazole) and close behavioral monitoring. Comprehensive assessment excluded organic causes. Unfortunately, treatment with aripiprazole showed no improvement, and he is being monitored on Clozapine. <bold>Conclusion:</bold> This report underscores the importance of early detection and tailored treatment of rare neuropsychiatric side effects such as clozapine-induced vocal tics. Clinicians must remain vigilant for such signs to optimize therapeutic benefits in treatment-resistant schizophrenia. Regular screening with rating scales is recommended. Treatments like aripiprazole have shown significant OCS improvement, while adjuncts such as valproic acid, often combined with dose reduction, have also been explored.

Older age is a major risk factor for many neurocognitive disorders like Alzheimer's disease. While there are limited treatment options for improving memory in this population, research has shown that special psychotherapeutic modalities like Cognitive Remediation Therapy (CRT), especially when coupled with psychosocial and vocational rehabilitation(PSR and VCR respectively), benefit older adults. This study examines the availability of these services in US mental health (MH) facilities serving older adults and compares the characteristics of the facilities providing these services. Our study includes 1216 MH facilities using the 2022 National Substance Use and Mental Health Services Survey (N-SUMHSS) data from the Substance Abuse and Mental Health Services Administration (SAMHSA). Descriptive statistics were used to determine availabilities, while multivariable logistic regression was used to compare facilities that offer the services compared to those that do not. Of the total facilities included, 78 (6%), 634 (52%), and 381 (31%) offered CRT, PSR, and VCR respectively. Facilities that provided only MH services compared to those providing substance use and MH services, those that offer special services for veterans, and special Alzheimer's programs compared to those that do notwere more likely to have CRT services. MH facilities that provide supplemental employment services, housing services and recovery housing were more likely to offer PSR and VCR compared to those that do not. Compared to facilities in Midwest states, facilities in East South-Central were less likely to offer PSR and VCR. This study highlights the relative unavailability of CRT, indicating a need for more interest in evidence-based nonpharmacological treatment options for cognitive decline in the aging population.

Treatment-resistant depression (TRD) is a significant challenge in psychiatric practice, affecting a substantial proportion of patients with major depressive disorder (MDD). Traditional treatment modalities often fall short, necessitating the exploration of alternative therapies. This literature review examines the combined use of Transcranial Magnetic Stimulation (TMS) and ketamine in treating TRD. The objectiveof this study is toevaluate the efficacy, safety, and potential synergies of combining TMS and ketamine in the treatment of TRD. A comprehensive literature search was conducted using PubMed and Google Scholar databases from 2014 to 2024. The search terms included combinations of "Transcranial Magnetic Stimulation," "Ketamine," "Depression," "Major Depressive Disorder," "Treatment-Resistant Depression," and "Combination." After screening for relevance and applying inclusion and exclusion criteria, six studies were selected for review, including three case reports, a retrospective study, a pilot study, and a review study. The selected studies demonstrated that the combination of TMS and ketamine resulted in substantial and sustained improvement in depressive symptoms for patients with TRD. Case reports and retrospective studies highlighted significant reductions in depression severity and improvements in psychosocial functioning. The combination therapy showed a higher efficacy compared to monotherapies of either TMS or ketamine alone. Notably, adverse effects were generally mild and transient, with no severe adverse events reported in most studies. In conclusion, the combination of TMS and ketamine presents a promising treatment modality for patients with TRD, offering significant improvements in depressive symptoms and better outcomes compared to traditional monotherapies. However, the heterogeneity in study designs and small sample sizes underline the need for larger, randomized controlled trials to establish standardized protocols and further validate these findings.

Abstract BackgroundValbenazine is a once-daily VMAT2 inhibitor approved for the treatment of tardive dyskinesia (TD), a persistent and potentially disabling movement disorder associated with prolonged exposure to antipsychotics, antiemetics, and other dopamine receptor blocking agents. The efficacy, safety, and tolerability of valbenazine has been established in several phase 3 trials, including a long-term study (KINECT 4 [NCT02405091]) in which participants received open-label valbenazine (40 or 80 mg) for 48 weeks. Post hoc analyses of KINECT 4 data were conducted to assess patterns of treatment response.MethodsData from KINECT 4 treatment completers (participants who reached the Week 48 visit and had the longest duration of treatment) were analyzed post hoc. TD was assessed using the Abnormal Involuntary Movement Scale (AIMS) total score (sum of items 1–7, as rated by the study investigator), the Clinical Global Impression of Change-Tardive Dyskinesia (CGI-TD), and the Patient Global Impression of Change (PGIC). Analyses were conducted at Week 8 (first study visit after the valbenazine dose-optimization period) and Week 48 using the following definitions of response: ≥50% and ≥70% improvement from baseline in AIMS total score; rating of “much improved” or “very much improved” (score ≤2) on the CGI-TD and PGIC.ResultsOf the 167 participants who entered KINECT 4, 103 (62%) were treatment completers and included for analysis. Of these 103 participants, 39% and 86% met the ≥50% AIMS response threshold at Weeks 8 and 48, respectively. The percentages of participants who met the highly rigorous AIMS ≥70% response threshold at Weeks 8 and 48 were 17% and 52%, respectively. Of the 40 participants with AIMS ≥50% total score improvement at Week 8, 95% also met this threshold at Week 48 (“sustained response”). Of the 63 participants with &lt;50% AIMS improvement at Week 8, 81% achieved the ≥50% response threshold by end of treatment at Week 48. The proportion of participants meeting the threshold for CGI-TD response also increased over time, from 50% at Week 8 to 92% at Week 48. PGIC results were similar, with response rates of 53% and 88% at Weeks 8 and 48, respectively.ConclusionsPost hoc analyses of data from a 48-week, open-label study of once-daily valbenazine showed that the proportion of participants meeting rigorous treatment response thresholds increased over time. By the end of treatment at Week 48, &gt;80% of participants demonstrated robust improvements in TD, as assessed using the AIMS (≥50% improvement), CGI-TD (score ≤2), and PGIC (score ≤2).FundingNeurocrine Biosciences, Inc.

not included.

International medical graduate (IMG) is a term used to describe individuals who have completed their undergraduate medical education outside of the United States in schools not accredited by the Liaison Committee on Medical Education. These trainees may face substantial obstacles in learning psychiatry and other fields of medicine even as they bring many assets to the field. In this chapter, we describe the nature of academic medicine and the challenges and opportunities that IMGs face on the basis of our experience and from our particular personal histories. Traditionally, academic medicine’s mission in the United States has been threefold: teaching, research, and service. Academic medicine is an approach, a state of mind, and a way of practicing medicine. In our experience, IMGs have to overcome obstacles including absence of a role model, employment setting, type of residency program, and discrimination. To succeed in academic medicine, IMGs should be proactive and volunteer, polish presentation and public speaking skills, engage in publishing and other scholarly activities, find a mentor, become a member of professional organizations, manage complex academic relationships, and develop cultural competence. Developing and succeeding in an academic career, although challenging, is often fun, enriching, and deeply gratifying.

Cognitive deficits are a prominent feature of many psychiatric disorders and are predictors of decreased functioning, quality of life, and treatment response. Cognitive remediation focuses on improving cognitive skills through repeated practice and strategy learning. In people with schizophrenia, cognitive remediation is associated with improvements in cognition and psychosocial functions. This article provides an overview of cognitive remediation and some considerations for developing a cognitive remediation service in a treatment setting.