D-Cycloserine: A Novel Pharmacological Agent for Treating Anxiety Spectrum Disorders Katherine Ma... more D-Cycloserine: A Novel Pharmacological Agent for Treating Anxiety Spectrum Disorders Katherine Martin, M.D. Melanie Sisti, M.D. 12 A Novel Project in Student Education Snehal Bhatt, M.D. Heather Grigo, M.D. Anthony Tobia, M.D. Barbara Palmeri, M.D. 6 clickable The following is an interview with William Carpenter, Jr., M.D., on “Psychotic Disorders and DSM-V,” conducted by Maju Koola, M.D. Dr. Carpenter is a Professor of Psychiatry and Pharmacology at the University of Maryland School of Medicine, Director of the Maryland Psychiatric Research Center, and Editor-in-Chief of Schizophrenia Bulletin. Dr. Carpenter is also a member of the APA DSM-V Task Force and Chair of the APA DSM-V Psychotic Disorders Work Group. Dr. Koola is a third-year psychiatry resident at the University of New Mexico, Albuquerque, and this month’s Issue Editor. An Interview with William Carpenter, Jr., M.D.
Psychology and Behavioral Science International Journal, 2017
Objective: Movies have long been utilized to highlight varied areas in the field of psychiatry. W... more Objective: Movies have long been utilized to highlight varied areas in the field of psychiatry. We have previously described a course [1] that teaches psychopathy to psychiatry residents based on the horror genre. Methods: Course directors subsequently created a medical student elective (SCREAM) that serves as a steering committee for the residents's course. As art imitates life, the primary focus of SCREAM is to enhance residents' didactics by incorporating media inspired by true stories. Such teaching not only takes advantage of the strengths of fictional case studies [1], but also appreciates that the films are often inspired by actual events. Results: This paper reviews three historical events that occurred 100 years apart and relates them to both the movies they inspired and their relevance to the field of psychiatry. Conclusions: Courses that use media to teach are found to be engaging and are an innovative way to educate future physicians.
Mr. W, age 26, has a history of alcohol abuse and presents with new-onset altered mental status, ... more Mr. W, age 26, has a history of alcohol abuse and presents with new-onset altered mental status, weakness, increasing lethargy, and jaundice. How would you manage him? [CASE] Confused and weak Mr. W, age 26, is brought to the emergency department (ED) by his parents for intermittent confusion, weakness, and increasing lethargy over the past 4 days. He is jaundiced with mild abdominal pain, nausea, and vomiting. Mr. W has a history of alcohol use disorder, drinking as much as 1 L of vodka a day. Six months ago, he was hospitalized for alcoholic hepatitis and severe hyponatremia. In the ED, Mr. W is awake, alert, and oriented to person, place, and time. Vital signs are: pulse 89 beats per minute; blood pressure, 117/50 mm Hg; respirations, 15 breaths per minute; and temperature, 98.5[degrees]F. Physical examination is notable for scleral icterus, jaundice, tender hepatomegaly, and asterixis. Mr. W is not taking any medications. He reports that his most recent drink was the day before;...
The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently b... more The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently been developed, has led to a lack of information on assessment and treatment of its variable behavioral manifestations. In this article, we discuss four challenging cases of anti-NMDAR encephalitis, focusing on the importance of a multidisciplinary approach to identification and management of the disorder and the necessity of close collaboration in the acute hospital setting for management of the behavioral symptoms. The cases we discuss highlight some of the medication and non-pharmacologic treatment strategies which may facilitate management of psychiatric symptoms, both while the medical work-up is ongoing and after the diagnosis has been confirmed.
Purpose To explore the feasibility and impact of a brief mindfulness training for medical student... more Purpose To explore the feasibility and impact of a brief mindfulness training for medical students and to learn about the perceptions, expectations, and problems associated with mindfulness practices in the context of medicine and medical education. Method Forty-one medical students were randomized into either an introductory mindfulness class only or an introductory mindfulness class plus an 8-week mindfulness meditation course. Quantitative and qualitative data were collected from both groups after the introductory class and again after the full course. Qualitative data was subject to close iterative reading as part of a grounded-theory-guided content analysis, generating a list of codes which were then assigned to statements and arranged into overarching themes. Results Mindfulness and awareness were negatively correlated with stress and depression. Students who took the full mindfulness course emerged with a greater familiarity with and willingness to utilize mindfulness modalities. There was no significant difference on wellness outcomes between the introductory-course-only group and the full-mindfulness-course group. Thematic analysis revealed student aspirations for a mindfulness alternative in medicine and medical education but also a recognition of the challenges inherent in applying such an alternative. Conclusion A mindfulness course for medical students is feasible and has potential as a wellness and educational initiative. Shorter duration mindfulness interventions may increase accessibility without significantly reducing benefit. Interpretation of overarching themes derived from the grounded theory analysis illuminates the subject of mindfulness for medical students from the perspective of students themselves.
Antipsychotics and Their Effects Schizophrenia is a chronic mental illness requiring long-term th... more Antipsychotics and Their Effects Schizophrenia is a chronic mental illness requiring long-term therapy with antipsychotic drugs often in combination with anticholinergic medication to reduce extrapyramidal side effects [1,7]. The anticholinergic medications may induce characteristic side-effects including decreased salivation, increased heart rate, dilated pupils, difficulty urinating, and constipation [1,8]. One symp
Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 2016
Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder an... more Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with c-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.
Abstract Introduction Most veterans receive health care in the civilian sector, where the complex... more Abstract Introduction Most veterans receive health care in the civilian sector, where the complexities of delivering care to them require interprofessional teams that include other veterans. Recogn...
Films have long entertained people and affected their attitudes regarding a multitude of issues i... more Films have long entertained people and affected their attitudes regarding a multitude of issues including mental illness. Over the decades, movies have depicted various aspects of psychiatry ranging from acculturation to the patient-therapist relationship. This paper summarizes a case formulation of the film, Sinister, and demonstrates how introducing a trivial modification to the plot could transform the film into a teaching didactic on the Dissociative Disorders
Journal of Communication Disorders, Deaf Studies & Hearing Aids, 2015
The DSM-5 has revised criteria for the diagnosis of the developmental disorders. The DSM-5 has el... more The DSM-5 has revised criteria for the diagnosis of the developmental disorders. The DSM-5 has eliminated Asperger's Disorder and created the umbrella title, Autism Spectrum Disorder (ASD). At Rutgers Robert Wood Johnson Medical School, residents in training learn about the latest revisions of the DSM through media. The character, Sheldon Cooper, from The Big Bang Theory meets criteria in the DSM-IV for Asperger's Disorder. By assessing Sheldon's behavior across several episodes, the viewer can reevaluate Sheldon considering the new criteria. When Sheldon Cooper is used as a model, a patient with a DSM-IV diagnosis of Asperger's would now be diagnosed in the DSM-5 with ASD, level 1 severity, without accompanying intellectual impairment, without accompanying language impairment.
Objectives: Co-occurring social anxiety in patients with schizophrenia is common and often severe... more Objectives: Co-occurring social anxiety in patients with schizophrenia is common and often severe. Pharmacologic agents with serotonin receptor 1A agonist properties such as aripiprazole are believed to be effective anxiolytic drugs. This open-label study tested the hypothesis that a switchover to aripiprazole would reduce the severity of social anxiety in patients, who have schizophrenia with co-occurring social anxiety, treated with neuroleptic medications. Study Design: Eligible consenting outpatients meeting the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for schizophrenia or schizoaffective disorder with co-occurring social anxiety symptoms completed baseline assessments, after which their neuroleptic medication was gradually cross-titrated over to a maximum of 30 mg of aripiprazole orally per day. Patients who completed the 2-month short-term study had the option to continue for 10 more months in the extension phase of the study. Complete baseline assessments were performed after 1, 2, 4, 6, 9, and 12 months. The study hypothesized that a switchover to aripiprazole would significantly improve social anxiety symptoms and quality of life ratings in the short term and that treatment continuation would help maintain and strengthen those effects, as assessed on the Liebowitz Social Anxiety and Sheehan Disability scales and on preselected specific global items of the Lehman Quality of Life Interview. Results: Sixteen patients were enrolled in the short-term study, and 10 of them entered the extension phase study. Last observation carried forward analysis showed significant improvements from baseline to the end of month 2 and from baseline to the end of month 12 in social anxiety scores (Liebowitz Social Anxiety Scale total, avoidance, and anxiety), social disability scores (Sheehan Disability Scale total, work, social life, and family), and in the Lehman Quality of Life Interview overall function, average life in general, and emotional well-being scores and psychosis (Positive and Negative Syndrome Scale total) scores. Conclusions: These findings suggest that the switchover to aripiprazole effectively improved social anxiety, psychosis, and quality of life in patients with schizophrenia who were treated with neuroleptic medications. These improvements occurred within the first 8 weeks of treatment and persisted when treatment was continued for up to 1 year. Further studies are warranted to replicate these findings in controlled trials.
Introduction: The goal of pharmacologic intervention is therapeutic outcome — maximal efficacy wi... more Introduction: The goal of pharmacologic intervention is therapeutic outcome — maximal efficacy with minimal adverse effects. In treating bipolar disorder, this may be complicated by comorbidities and/or adjunctive medications required to address adverse effects. Optimal rational polypharmacy may maximize therapeutic outcome yet could create ethical issues in competitive sports. The World Anti-Doping Code (WADC) and yearly published World Anti-Doping Agency Prohibited List are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. This paper presents three hypothetical examples (ADHD / lithiumtremor / pain) wherein unintended Prohibited List contravention would result in doping violation disqualifications without approved Therapeutic Use Exemptions (TUEs). Method: Hypothetical case analyses with literature review. Results: Comorbid ADHD — the Prohibited List precludes psychostimulants (methylphenidate / am...
Hypercalcemia is known to cause neuropsychiatric dysfunction including mood and cognitive changes... more Hypercalcemia is known to cause neuropsychiatric dysfunction including mood and cognitive changes and rarely, acute psychosis. High calcium levels can be a catalyst for neuronal demise, possibly due to glutaminergic excitotoxicity and dopaminergic and serotonergic dysfunction. While restoration of normal calcium levels or removal of a parathyroid adenoma has been shown to rapidly resolve neuropsychiatric symptoms, there have been rare reported cases of primary hyperparathyroid-related hypercalcemia with persistent symptoms of psychosis. In this case report, we will describe a patient with no past psychiatric history presenting with a protracted course of delirium and psychosis after a removal of a parathyroid adenoma which had caused prolonged exposure to hypercalcemia. The patient’s psychosis was unresponsive to psychotropic medication and required inpatient psychiatric care after medical clearance. Per medical records, before the patient was ultimately lost to follow-up, she conti...
D-Cycloserine: A Novel Pharmacological Agent for Treating Anxiety Spectrum Disorders Katherine Ma... more D-Cycloserine: A Novel Pharmacological Agent for Treating Anxiety Spectrum Disorders Katherine Martin, M.D. Melanie Sisti, M.D. 12 A Novel Project in Student Education Snehal Bhatt, M.D. Heather Grigo, M.D. Anthony Tobia, M.D. Barbara Palmeri, M.D. 6 clickable The following is an interview with William Carpenter, Jr., M.D., on “Psychotic Disorders and DSM-V,” conducted by Maju Koola, M.D. Dr. Carpenter is a Professor of Psychiatry and Pharmacology at the University of Maryland School of Medicine, Director of the Maryland Psychiatric Research Center, and Editor-in-Chief of Schizophrenia Bulletin. Dr. Carpenter is also a member of the APA DSM-V Task Force and Chair of the APA DSM-V Psychotic Disorders Work Group. Dr. Koola is a third-year psychiatry resident at the University of New Mexico, Albuquerque, and this month’s Issue Editor. An Interview with William Carpenter, Jr., M.D.
Psychology and Behavioral Science International Journal, 2017
Objective: Movies have long been utilized to highlight varied areas in the field of psychiatry. W... more Objective: Movies have long been utilized to highlight varied areas in the field of psychiatry. We have previously described a course [1] that teaches psychopathy to psychiatry residents based on the horror genre. Methods: Course directors subsequently created a medical student elective (SCREAM) that serves as a steering committee for the residents's course. As art imitates life, the primary focus of SCREAM is to enhance residents' didactics by incorporating media inspired by true stories. Such teaching not only takes advantage of the strengths of fictional case studies [1], but also appreciates that the films are often inspired by actual events. Results: This paper reviews three historical events that occurred 100 years apart and relates them to both the movies they inspired and their relevance to the field of psychiatry. Conclusions: Courses that use media to teach are found to be engaging and are an innovative way to educate future physicians.
Mr. W, age 26, has a history of alcohol abuse and presents with new-onset altered mental status, ... more Mr. W, age 26, has a history of alcohol abuse and presents with new-onset altered mental status, weakness, increasing lethargy, and jaundice. How would you manage him? [CASE] Confused and weak Mr. W, age 26, is brought to the emergency department (ED) by his parents for intermittent confusion, weakness, and increasing lethargy over the past 4 days. He is jaundiced with mild abdominal pain, nausea, and vomiting. Mr. W has a history of alcohol use disorder, drinking as much as 1 L of vodka a day. Six months ago, he was hospitalized for alcoholic hepatitis and severe hyponatremia. In the ED, Mr. W is awake, alert, and oriented to person, place, and time. Vital signs are: pulse 89 beats per minute; blood pressure, 117/50 mm Hg; respirations, 15 breaths per minute; and temperature, 98.5[degrees]F. Physical examination is notable for scleral icterus, jaundice, tender hepatomegaly, and asterixis. Mr. W is not taking any medications. He reports that his most recent drink was the day before;...
The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently b... more The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently been developed, has led to a lack of information on assessment and treatment of its variable behavioral manifestations. In this article, we discuss four challenging cases of anti-NMDAR encephalitis, focusing on the importance of a multidisciplinary approach to identification and management of the disorder and the necessity of close collaboration in the acute hospital setting for management of the behavioral symptoms. The cases we discuss highlight some of the medication and non-pharmacologic treatment strategies which may facilitate management of psychiatric symptoms, both while the medical work-up is ongoing and after the diagnosis has been confirmed.
Purpose To explore the feasibility and impact of a brief mindfulness training for medical student... more Purpose To explore the feasibility and impact of a brief mindfulness training for medical students and to learn about the perceptions, expectations, and problems associated with mindfulness practices in the context of medicine and medical education. Method Forty-one medical students were randomized into either an introductory mindfulness class only or an introductory mindfulness class plus an 8-week mindfulness meditation course. Quantitative and qualitative data were collected from both groups after the introductory class and again after the full course. Qualitative data was subject to close iterative reading as part of a grounded-theory-guided content analysis, generating a list of codes which were then assigned to statements and arranged into overarching themes. Results Mindfulness and awareness were negatively correlated with stress and depression. Students who took the full mindfulness course emerged with a greater familiarity with and willingness to utilize mindfulness modalities. There was no significant difference on wellness outcomes between the introductory-course-only group and the full-mindfulness-course group. Thematic analysis revealed student aspirations for a mindfulness alternative in medicine and medical education but also a recognition of the challenges inherent in applying such an alternative. Conclusion A mindfulness course for medical students is feasible and has potential as a wellness and educational initiative. Shorter duration mindfulness interventions may increase accessibility without significantly reducing benefit. Interpretation of overarching themes derived from the grounded theory analysis illuminates the subject of mindfulness for medical students from the perspective of students themselves.
Antipsychotics and Their Effects Schizophrenia is a chronic mental illness requiring long-term th... more Antipsychotics and Their Effects Schizophrenia is a chronic mental illness requiring long-term therapy with antipsychotic drugs often in combination with anticholinergic medication to reduce extrapyramidal side effects [1,7]. The anticholinergic medications may induce characteristic side-effects including decreased salivation, increased heart rate, dilated pupils, difficulty urinating, and constipation [1,8]. One symp
Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 2016
Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder an... more Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with c-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.
Abstract Introduction Most veterans receive health care in the civilian sector, where the complex... more Abstract Introduction Most veterans receive health care in the civilian sector, where the complexities of delivering care to them require interprofessional teams that include other veterans. Recogn...
Films have long entertained people and affected their attitudes regarding a multitude of issues i... more Films have long entertained people and affected their attitudes regarding a multitude of issues including mental illness. Over the decades, movies have depicted various aspects of psychiatry ranging from acculturation to the patient-therapist relationship. This paper summarizes a case formulation of the film, Sinister, and demonstrates how introducing a trivial modification to the plot could transform the film into a teaching didactic on the Dissociative Disorders
Journal of Communication Disorders, Deaf Studies & Hearing Aids, 2015
The DSM-5 has revised criteria for the diagnosis of the developmental disorders. The DSM-5 has el... more The DSM-5 has revised criteria for the diagnosis of the developmental disorders. The DSM-5 has eliminated Asperger's Disorder and created the umbrella title, Autism Spectrum Disorder (ASD). At Rutgers Robert Wood Johnson Medical School, residents in training learn about the latest revisions of the DSM through media. The character, Sheldon Cooper, from The Big Bang Theory meets criteria in the DSM-IV for Asperger's Disorder. By assessing Sheldon's behavior across several episodes, the viewer can reevaluate Sheldon considering the new criteria. When Sheldon Cooper is used as a model, a patient with a DSM-IV diagnosis of Asperger's would now be diagnosed in the DSM-5 with ASD, level 1 severity, without accompanying intellectual impairment, without accompanying language impairment.
Objectives: Co-occurring social anxiety in patients with schizophrenia is common and often severe... more Objectives: Co-occurring social anxiety in patients with schizophrenia is common and often severe. Pharmacologic agents with serotonin receptor 1A agonist properties such as aripiprazole are believed to be effective anxiolytic drugs. This open-label study tested the hypothesis that a switchover to aripiprazole would reduce the severity of social anxiety in patients, who have schizophrenia with co-occurring social anxiety, treated with neuroleptic medications. Study Design: Eligible consenting outpatients meeting the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for schizophrenia or schizoaffective disorder with co-occurring social anxiety symptoms completed baseline assessments, after which their neuroleptic medication was gradually cross-titrated over to a maximum of 30 mg of aripiprazole orally per day. Patients who completed the 2-month short-term study had the option to continue for 10 more months in the extension phase of the study. Complete baseline assessments were performed after 1, 2, 4, 6, 9, and 12 months. The study hypothesized that a switchover to aripiprazole would significantly improve social anxiety symptoms and quality of life ratings in the short term and that treatment continuation would help maintain and strengthen those effects, as assessed on the Liebowitz Social Anxiety and Sheehan Disability scales and on preselected specific global items of the Lehman Quality of Life Interview. Results: Sixteen patients were enrolled in the short-term study, and 10 of them entered the extension phase study. Last observation carried forward analysis showed significant improvements from baseline to the end of month 2 and from baseline to the end of month 12 in social anxiety scores (Liebowitz Social Anxiety Scale total, avoidance, and anxiety), social disability scores (Sheehan Disability Scale total, work, social life, and family), and in the Lehman Quality of Life Interview overall function, average life in general, and emotional well-being scores and psychosis (Positive and Negative Syndrome Scale total) scores. Conclusions: These findings suggest that the switchover to aripiprazole effectively improved social anxiety, psychosis, and quality of life in patients with schizophrenia who were treated with neuroleptic medications. These improvements occurred within the first 8 weeks of treatment and persisted when treatment was continued for up to 1 year. Further studies are warranted to replicate these findings in controlled trials.
Introduction: The goal of pharmacologic intervention is therapeutic outcome — maximal efficacy wi... more Introduction: The goal of pharmacologic intervention is therapeutic outcome — maximal efficacy with minimal adverse effects. In treating bipolar disorder, this may be complicated by comorbidities and/or adjunctive medications required to address adverse effects. Optimal rational polypharmacy may maximize therapeutic outcome yet could create ethical issues in competitive sports. The World Anti-Doping Code (WADC) and yearly published World Anti-Doping Agency Prohibited List are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. This paper presents three hypothetical examples (ADHD / lithiumtremor / pain) wherein unintended Prohibited List contravention would result in doping violation disqualifications without approved Therapeutic Use Exemptions (TUEs). Method: Hypothetical case analyses with literature review. Results: Comorbid ADHD — the Prohibited List precludes psychostimulants (methylphenidate / am...
Hypercalcemia is known to cause neuropsychiatric dysfunction including mood and cognitive changes... more Hypercalcemia is known to cause neuropsychiatric dysfunction including mood and cognitive changes and rarely, acute psychosis. High calcium levels can be a catalyst for neuronal demise, possibly due to glutaminergic excitotoxicity and dopaminergic and serotonergic dysfunction. While restoration of normal calcium levels or removal of a parathyroid adenoma has been shown to rapidly resolve neuropsychiatric symptoms, there have been rare reported cases of primary hyperparathyroid-related hypercalcemia with persistent symptoms of psychosis. In this case report, we will describe a patient with no past psychiatric history presenting with a protracted course of delirium and psychosis after a removal of a parathyroid adenoma which had caused prolonged exposure to hypercalcemia. The patient’s psychosis was unresponsive to psychotropic medication and required inpatient psychiatric care after medical clearance. Per medical records, before the patient was ultimately lost to follow-up, she conti...
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