Authors: Felix Coid, MBChB, BSc, et al.

Abstract: Catatonia is a serious neuropsychiatric disorder associated with considerable morbidity and mortality. Despite growing interest in the disorder and the field’s advancing understanding, a gap between research and clinical practice persists. This is particularly problematic as prompt recognition is essential to optimal management and improving outcomes.

The authors present an educational review of 10 common myths regarding the recognition, etiology, phenotype and management of catatonia. They address each myth using an evidence-based approach. Considerations include the broad age range affected by catatonia, the fact that patients with catatonia often have preserved awareness of their surroundings, and the importance of using validated catatonia screening instruments for reliable identification.

By addressing myths, they aim to reduce the gap between evidence and clinical practice to ultimately improve care and clinical outcomes.

“The prompt recognition and management of catatonia, particularly in the early stages with close clinical monitoring, is vital to prevent complications and treat the condition effectively,” say the authors. “Many clinicians do not recognise the signs and symptoms of catatonia. Takács’ survey from a sample of Hungarian psychiatrists revealed almost 50% incorrectly identified signs and symptoms of catatonia and 76.5% had encountered fewer than 10 cases of catatonia across their whole career

“Additionally, Wortzel’s study reported that participants correctly answered only 55% of test questions and 69% of the Bush Francis Catatonia Rating scale items on a standardised patient exam. Improved education in the field of catatonia for both clinicians and non-clinicians is urgently needed.”

Importance: Catatonia can result in poor clinical outcomes and higher rates of mortality if left untreated, yet it remains widely underdiagnosed. This review highlights the many common myths that likely result in the under-recognition and mismanagement of the condition.

Availability: Pre-publication in the Journal of the Academy of Consultation Liaison Psychiatry (JACLP).

Author: Justine Petersen, PhD student, et al.

Abstract: In this the first review on physical activity in borderline personality disorder, 21 studies were reviewed covering various and distinct physical activity modalities. Rationales highlight physical activity’s potential to improve psychological aspects.

People with borderline personality disorder—affecting 1-2% of the US population and up to 20% of individuals undergoing mental health treatment —face a reduced life expectancy of 14–27 years, primarily due to suicide and cardiovascular-related issues. The studies reviewed here included 229 participants, primarily female, and covered six physical activity modalities: structured exercise; yoga; dance movement therapy; outdoor modalities; sports; and body awareness and psychomotor therapies.

Rationales for incorporating physical activity were: improving patient care; fostering emotional regulation; promoting mental health; regulating maladaptive behaviors; enhancing social skills; protecting physical health; and reclaiming embodiment; as well as fostering emotional regulation, the most prominent.

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The current standard of care for individuals with borderline personality disorder primarily relies on specialized psychotherapies, such as dialectical behavior therapy and mentalization-based therapy. While effective, these interventions are resource-intensive, requiring specialized expertise and significant financial investment, say the authors. “Moreover, they are often hospital-based and time-limited, potentially limiting their capacity to promote social inclusion, improve daily functioning, and address somatic health risks. Considering the high prevalence of physical inactivity among individuals with borderline personality disorder there is a pressing need for targeted interventions that improve physical health outcomes and overall wellbeing.”

Regular physical activity is widely recognized as a cornerstone of health promotion, playing a vital role in preventing and managing various physical and mental health conditions, while also contributing to a reduction in overall mortality, according to earlier research quoted in the review.

Engaging in physical activity reduces the risk of cardiovascular diseases, metabolic syndrome, stroke, diabetes, and certain cancers through mechanisms such as improved weight management, enhanced insulin sensitivity, strengthened cardiovascular and bone health, reduced inflammation, and a bolstered immune system.

In populations with mental illness, physical activity has been shown to mitigate stress, anxiety, and depression, while also improving sleep quality in non-clinical populations. Furthermore, research on the psychological effects of physical activity has demonstrated improvements in emotion regulation by decreasing negative affect and enhancing positive cognitive processes, thereby supporting overall wellbeing and quality of life. Evidence also supports the role of physical activity in alleviating symptoms and enhancing health outcomes in conditions such as major depressive disorder, anxiety disorders, PTSD and schizophrenia.

Conversely, say the authors, the use of physical activity in managing borderline personality disorder remains an underexplored and fragmented field.

Importance: This review highlights the promising but fragmented research on physical activity interventions for borderline personality disorder, with a primary emphasis on psychological aspects. Notable gaps include limited attention to somatic comorbidities and the lack of consistent outcome measures.

Availability: Published by Psychiatry Research.

Authors: Hong Luo, PhD, et al, School of Basic Medicine, Hubei University of Arts and Science.

Abstract: This study evaluates the short-, medium-, and long-term efficacy of psychoeducation-based programs on internalized stigma in patients with schizophrenia. Subgroup analyses were conducted to identify the relationship between critical moderator variables and short-term efficacy of psychoeducation-based programs.

The study finds that psychoeducation-based programs essentially reduce internalized stigma with a large effect size in patients with schizophrenia for short-term efficacy, but lack the maintenance of therapeutic effects in follow-up periods for both medium- and long-term efficacy.

Sample size, dosage, duration, length per session, data analysis techniques for handling missing data, and type of control group might be the critical moderator variables of psychoeducation-based programs on internalized stigma in short-term efficacy.

Importance: Trials examining the efficacy of psychoeducation-based programs in reducing internalized stigma in patients with schizophrenia have mainly focused on short-term efficacy, with the effects of specific potential moderators unclear. Hence, the authors set out to fill in these gaps.

Patients with schizophrenia are at high risk of experiencing and internalizing stigma throughout their lives. Internalized stigma involves adopting negative public stereotypes, endorsing these beliefs, and subsequently applying them to oneself—resulting in harmful outcomes including beliefs, labeling, responses, consequences, and vulnerability to future disorders. Such patients are at a higher risk of social prejudice and internalized stigma compared to those with other psychiatric disorders.

This review confirms evidence that in short term efficacy, psychoeducation-based programs have the potential to reduce internalized stigma in these patients.

Availability: Published by Psychiatry Research.

Authors: Anne Knorr, BA, et al.

Abstract: Highlights of this study are:

• 34% voluntarily receive emergency department care 24-hours after a suicide attempt.
• Those attempting suicide by poisoning are more likely to seek help afterwards.
• Those with borderline personality disorder are more likely to get help post attempt.
• Those with bipolar disorder are less likely to seek help after a suicide attempt.
• Those in a romantic relationship are less likely to seek help after a suicide attempt.

“There is a critical need to identify proximal factors associated with help-seeking following a suicide attempt,” say the authors. “Many individuals receive emergency department care following a suicide attempt, however, little is known about factors distinguishing individuals who present to the emergency department voluntarily (i.e., play an active role in presentation through their own action to obtain help or through requesting help) and those who do not (i.e., brought to the emergency department due to no action of their own) following a suicide attempt.

“Results can inform suicide prevention initiatives to promote help-seeking immediately following a suicide attempt, a critical period that may represent the last opportunity for self-intervention prior to the occurrence of lasting serious injury or death by suicide,” say the authors.

Importance: Rising rates of suicidal ideation, suicide attempt, and death by suicide highlight the need to better understand the facilitation of help-seeking. Only 30% to 50% of those with a history of suicidal thoughts and behaviors seek formal help from health care and mental health professionals. 49% to 68% seek informal help from family and friends in the month before a suicide attempt.

Given that in the year prior to suicide an estimated 83% of individuals attend a health care appointment, a predominant referral source for mental health care, the opportunity for intervention likely plays a limited influence on formal help-seeking.

Elucidating factors that contribute to help-seeking following a suicide attempt is crucial for developing effective interventions to prevent suicide.

Availability: Published by Psychiatry Research.

Authors: Judith Restrepo, MD, et al.

Abstract: Current experience with the management of clozapine in patients needing solid organ transplant (SOT) is sparse.

Clozapine is an essential antipsychotic for many patients with treatment-resistant schizophrenia that cannot be replaced by other antipsychotics without the risk of psychotic relapse. However, clozapine is associated with many side-effects, including neutropenia, that may interact with immunosuppressive therapies during organ transplantation.

The authors reviewed literature about clozapine use during SOT and a retrospective case review using natural language processing of the Partners Research Patient Data Registry to identify individuals over 18 who had taken clozapine at any time and been evaluated for, or undergone, SOT. They identified 15 patients who met this criterion.

Three patients underwent renal transplant while remaining on clozapine and one patient started clozapine after renal transplant, all without complication.

The authors also include an illustrative case report to summarize their direct experience of continuing clozapine through lung transplant, highlighting the first known case in this population.

They provide clinical guidance for management of clozapine and associated side-effects during SOT. Proactive consultation with psychiatry, they say, may avoid abrupt cessation of clozapine, which can result in severe clozapine withdrawal, and increase the number of patients on clozapine considered for SOT.

Importance: Clozapine is an atypical antipsychotic medication that is highly effective for treatment-resistant schizophrenia and bipolar disorder. Continuing clozapine safely in the face of complex medical conditions or procedures like SOT poses a dilemma for clinicians given clozapine’s extensive side-effect profile, including bone marrow suppression and neutropenia.

Concern for these side-effects is increased when combined with immunosuppressant medications required in transplant. Additionally, there is no consensus guidance in managing clozapine, or literature examining the impact of other complex side-effects of clozapine, including constipation, sialorrhea, and seizure, during SOT.

Serious considerations regarding dose adjustment of clozapine after transplant are needed given the growing body of evidence highlighting elevated clozapine levels at the time of critical illness as well as an expectation of increased levels of clozapine related to cytochrome P450 interactions with antifungal medications.

Availability: Published by the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).

Authors: Valerio Ricci, MD, et al.

Abstract: Cannabis use is associated with psychotic disorder onset and exacerbation. This study examines how continued cannabis use affects depressive symptoms, psychotic symptoms, and suicidal behaviors following cannabis-induced first-episode psychosis (FEP).

Sixty-five participants (aged 16-50) with FEP were recruited from psychiatric inpatient facilities in northern Italy. Participants were categorized into two groups: non-cannabis users and cannabis users, based on substance use during the nine-month follow-up. Twenty-one participants (32.3%) were lost to follow-up, with a final sample of 44 subjects. Assessments were conducted at baseline, three months, and nine months.

Cannabis users exhibited persistently higher depression and suicidality scores than non-cannabis users throughout follow-up, with significant differences at both three months and nine months. Positive psychotic symptoms improved in both groups, though cannabis users showed slower recovery and higher relapse rates.

Importance: Continued cannabis use adversely affects depressive and psychotic symptoms and suicidality in FEP patients, while cannabis cessation is associated with improved clinical outcomes. Continued use is associated with treatment-resistant depressive symptoms even when psychotic symptoms improve, highlighting the need for integrated clinical approaches.

Availability: Published by The American Journal on Addictions.