Psychiatrists frequently incorporate strategies learned in their psychotherapy training into medication visits. This final installment in a 4-part series focuses on the integration of pharmacotherapy and cognitive-behavioral therapy (CBT), which is the most extensively studied form of psychotherapy for depressive and anxiety disorders. Evidence supporting the value of combined treatment (as compared with pharmacotherapy alone) is strong, but these data come almost exclusively from studies in which the 2 components of treatment were delivered by separate providers. Data are sorely lacking for the integrated approach described in this paper. We hope that the apparent face validity of this approach is evident and helps to foster a new generation of pragmatic research addressing issues that are truly relevant to the contemporary practice of psychiatric medicine, including the possibility that it is more cost-effective when a single provider delivers both modalities.

Suicide among older adults is a critical yet often overlooked public health concern, with this population exhibiting the highest suicide rates globally. This article explores the multifaceted factors contributing to suicide in older adults, including depression, loneliness, chronic illness, financial stress, and a loss of purpose. It also addresses challenges in identifying and preventing suicide, such as stigma, limited access to mental health services, and misclassification of cases. Current prevention strategies, including screening tools like the Geriatric Depression Scale, integrated care models, and community-based interventions, are discussed alongside ethical debates surrounding autonomy in end-of-life decisions. The article highlights critical research gaps in understanding how various social, cultural, and economic factors intersect to influence suicide risk in older adults. It underscores the need for longitudinal studies and culturally tailored interventions, particularly leveraging telehealth solutions to improve access to care. Recommendations for primary care physicians include enhancing suicide risk screening, fostering collaboration with mental health specialists, and leveraging community resources to reduce isolation. By adopting a comprehensive and collaborative approach, health care providers, researchers, and policymakers can address the unique needs of this vulnerable population and work toward reducing suicide rates among older adults.

We present divergent experiences of 2 patients who participated in a clinical trial of psilocybin-assisted cognitive behavioral therapy for major depressive disorder. Both patients participated in an open trial involving 2 drug administration sessions separated by one month (10 and 25 mg, respectively) along with 12 sessions of cognitive behavioral therapy. The first of the 2 patients had powerful and beneficial experiences on psilocybin that led to immediate and sustained antidepressant effects over the 7-month study. The second participant reported significant challenges with psilocybin and minimal to no antidepressant effects following the drug administration. We present the clinicians’ experiences who treated both patients. Finally, we theorize and discuss areas of future research to elucidate how psilocybin can yield the greatest psychiatric benefit, the conditions within the patient that can lead to (or inhibit) psychiatric benefit, and the psychosocial environment that can best facilitate psilocybin therapy.

The ethical complexity within psychiatric evaluations of decision-making capacity (DMC) often involves more than determining whether a patient retains DMC. Some psychiatrists propose that DMC evaluation may be requested due to distress regarding additional ethical dilemmas, even when capacitation status is not questioned. The present study quantitatively illustrates this additional ethical complexity and provides greater transparency regarding additional areas that may require psychiatric facilitation of care when consulted for the evaluation of DMC. A total of 145 DMC evaluation case encounters were retrospectively analyzed for the presence of 27 total additional ethical context factors. Factor prevalence and number of factors per case were calculated. Cooccurrence of ethical context factors was determined through Fisher exact test pairwise comparisons. Almost all cases (93.1%) featured ≥1 additional ethical context factor (range = 0 to 13 factors/case). The most common factors included inpatient treatment refusal or nonadherence (34.5%), leaving against medical advice (26.2%), concerns about nonadherence to outpatient treatment (25.7%), surrogate determination (22.1%), palliative care and hospice consideration (20.7%), and disposition conflict (20.7%). Several ethical context factors demonstrated significant pairwise cooccurrence, many of which involved mandatory reporting of abuse and neglect. Clinical scenarios encountered in DMC evaluations often contain ethical complexities beyond clarifying capacitation status. Often, consultation with psychiatrists to evaluate DMC may reflect the underlying desire for management of additional ethical context factors. The unique skillset of consultation liaison psychiatrists can help both patients and medical teams navigate these complicated clinical trajectories. Screening for additional ethical context factors in DMC evaluations may enable the facilitation of optimal care.

This article presents a case demonstrating that multiple medication use can begin on the first outpatient visit if the prescriber makes multiple psychiatric diagnoses and then feels the need to treat each diagnosis with a different central nervous system active medication labeled for each indication. This approach poses potential problems. First, a single drug or perhaps 2 drugs, in this case, may have been sufficient as initial and perhaps final treatment. Second, the prescriber cannot tell which drug(s) is/are producing either a beneficial or an adverse effect. This approach may stem from prescribers thinking that if they have made a diagnosis then they need to treat it with a drug labeled for or clinically used to treat that indication rather than taking a more conservative approach. However, such an approach adversely affects the ability to determine cause-and-effect relationships and hence adversely affects the ability to determine the best way to revise the treatment going forward.

Catatonia is a neuropsychiatric syndrome affecting movement, emotion, speech, and behavior, which commonly occurs secondary to medical or psychiatric disorders and with comorbid illnesses. We report the case of an 18-year-old male with a history of depression, anxiety, attention-deficit/hyperactivity disorder, polysubstance use, and previous suicide attempts who presented to the hospital from a residential eating disorders treatment facility, due to psychomotor slowing. The patient scored 3 or lower on the Bush-Francis Catatonia Rating Scale (BFCRS), but he showed marked improvement following 2mg of intravenous lorazepam. The patient was referred for ECT, experienced dramatic improvement, and was discharged at his baseline functioning. His discharge diagnosis was catatonic syndrome secondary to severe melancholic depression. Catatonia may present a diagnostic challenge as no single catatonia screener captures all possible phenotypes. The patient consistently scored low on the BFCRS but he had a clear response to standard-of-care catatonia treatment. Psychomotor slowing is common in catatonia but is not designated as a catatonic feature in either the DSM-5 or the BFCRS. This case also presented diagnostic complexity as the patient initially presented with malnutrition and concern about a possible eating disorder. This report highlights that diagnosing catatonia is challenging, particularly in the context of medical complexity, and that there are discrepancies between diagnostic tools. When suspicion of catatonia is high, despite low individual screening scores, clinicians may consider alternative screening instruments or empiric treatment.

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is one of the most commonly used instruments for assessing and quantifying the presence and severity of obsessive-compulsive disorder (OCD) symptoms. Both the interview and self-report (SR) versions of the original Y-BOCS have demonstrated good psychometrics. However, areas for revision were noted regarding the measure's severity ceiling and a "resistance to obsessions" item that did not perform adequately in psychometric testing and was not consistent with theoretical models of OCD. The Y-BOCS-II was thereby created to address these concerns. While the interview has demonstrated strong psychometrics, psychometric evaluation of the self-report version is currently nonexistent. In a sample of 63 adult patients seeking outpatient treatment for OCD (66.7% female, 77.8% white, and 17.5% Hispanic or Latine), we examined the psychometric properties of the Y-BOCS-II-SR, including the level of agreement with the Y-BOCS-II items, subscales, and severity qualifiers, as well as its internal consistency, and its convergent validity with measures of OCD, functional impairment, and quality of life. As expected, the Y-BOCS-II-SR demonstrated strong psychometric properties and expected overlap with responses obtained using the Y-BOCS-II. The findings provide strong initial support for the psychometric properties of the Y-BOCS-II-SR and suggest that it is an efficient and effective option to measure OCD severity.