Wednesday, May 27, 2015

Children's Suicide Rates Reflect Racial Differences


Between 1993 and 2012, 657 children in the United States died by suicide, the 11th leading cause of death among children aged 5 to 11 years. While the overall suicide rate did not change significantly over that time (from 1.18 to 1.09 per million), there were notable differences between white and black children.

“Among white children, the suicide rate decreased significantly during the study period (incident rate ratio = 0.86), whereas for black children there was a significant increase in the suicide rate (incident rate ratio = 1.27),” wrote epidemiologist Jeffrey Bridge, Ph.D., a principal investigator at the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio, and colleagues in JAMA Pediatrics.

Those differences were largely driven by a significant decrease in suicide rates among white boys (from 1.96 per million to 1.31 per million) and a significant increase among black boys (from 1.78 to 3.47 per million). Hanging/suffocation accounted for 78 percent of all suicides.

The authors speculated on several possible explanations of this disparity in outcomes—black youth may be exposed to more violence or traumatic stress, for instance—but could not say for certain what caused the observed difference in suicide rates.

“[F]uture steps should include ongoing surveillance to monitor these emerging trends and research to identify risk, protective, and precipitating factors associated with suicide in elementary school–aged children to frame targets for early detection and culturally informed interventions,” they concluded.

For more in Psychiatric News about children and suicide, see: "CBT for Child Anxiety May Confer Long-Term Protection From Suicidality."

--aml   (Image: pio3/Shutterstock.com)

Tuesday, May 26, 2015

Citicoline Appears to Reduce Cocaine Use in Patients With Bipolar Disorder, Study Finds


Citicoline reduced cocaine use and was well tolerated by patients with bipolar disorder, according to a report published May 22 in AJP in Advance. However, because the treatment effects diminished over time, the authors of the study suggest citicoline may work best as an acute treatment while other interventions are initiated.

For the study by E. Sherwood Brown, M.D., Ph.D., a professor of psychiatry at the University of Texas Southwestern Medical Center, and colleagues, 130 outpatients with bipolar I disorder and cocaine dependence received citicoline or placebo for 12 weeks. (Citicoline is sold as a prescription drug in Japan and Europe and over the counter as a dietary supplement in the United States. It has a mild side effect profile, is relatively inexpensive, and has no known drug-drug interactions, according to the researchers.) Assessments of mood, based on the Inventory of Depressive Symptomatology–Self Report, the Hamilton Depression Rating Scale, and the Young Mania Rating Scale, were performed weekly, and urine drug screens were conducted three times per week.

While no between-group differences in mood symptoms or side effects were observed, the researchers found that there was a significant treatment group and group-by-time effect (whether or not missing urine screens were imputed as cocaine positive).

“The effects of citicoline in reducing cocaine use appeared to occur quickly and tended to decline during the study,” the authors write. “These findings suggest that citicoline might be most effectively used in an acute treatment to reduce cocaine use in inpatient settings while other treatments are initiated rather than as a long-term monotherapy.”

For more on strategies to reduce cocaine use, see the Psychiatric News article "Cocaine Vaccination Isn't Science Fiction Anymore."

Friday, May 22, 2015

FDA Approves New Three-Month Long-Acting Antipsychotic Invega Trinza


The FDA has approved Invega Trinza (paliperidone palmitate), a long-acting atypical antipsychotic intended to treat schizophrenia, from Janssen Pharmaceuticals Inc.

The approval of the injectable antipsychotic, which remains active in the body for three months, was based on results from a two-year maintenance trial with 506 patients diagnosed with schizophrenia. The analysis, published March 29 in JAMA Psychiatry, showed that patients who were administered Invega Trinza were statistically less likely to relapse than those who were administered placebo. The most common adverse effects of the medication included injection-site reactions, weight gain, upper respiratory tract infections, and extrapyramidal symptoms.

The newly approved antipsychotic will come with a boxed warning stating that it is not approved for patients with dementia-related psychosis and that use of the drug may increase the risk for death in elderly patients with dementia.

Before patients can begin taking Invega Trinza, they must first show tolerability to Janssen's Invega Sustenna, a one-month form of paliperidone palmitate, for at least four months.

Invega Trinza was approved under the FDA's priority review process, a fast track for drugs thought to represent a significant advance in medical care. It is being marketed by Janssen.

For more information about psychotropic medications in the pipeline, see the Psychiatric News article "Candidates, Innovation Missing From Psychotropic Drug Pipeline."

Thursday, May 21, 2015

Experts Discuss Mental llness, Risk for Violence, and Gun Ownership


An evidence-based assessment of dangerousness—not mental illness, per se—should guide public policies regarding restrictions on gun ownership, Jeffrey Swanson, Ph.D. (left), of Duke University School of Medicine said during the "Do Firearm Restrictions Prevent Suicide and Violence in People With Serious Mental Illness?" workshop at the APA annual meeting in Toronto. He was joined by Joshua Horwitz, executive director of the Educational Fund to Stop Gun Violence.

Swanson, a professor of psychiatry and behavioral science, presented evidence showing that while there are instances when those with a serious mental illness are at increased risk of violence, serious mental illness, on its own, contributes very little to overall violence towards others. (Mental illness alone carries a far greater risk for suicide.)

For instance, he showed data from a survey of public behavioral health system psychiatric outpatients with serious mental illness in five U.S. sites demonstrating that the risk of violence rose significantly when in combination with substance abuse, early victimization, and/or exposure to violence in one's current social environment.

Swanson offered these following principles to guide public policy regarding restricting access to firearms:

  • Prioritize contemporaneous risk assessment based on evidence of behaviors that correlate with violence and self-harm at specific times, not mental illness or treatment history per se as a category of exclusion;

  • Preempt existing gun access, rather than simply thwarting a new gun purchase by a dangerous person;

  • Provide legal due process for deprivation of gun rights;

  • Preserve confidential therapeutic relationships;

  • Prevent the unpredictable through universal background checks, but also by reducing the social determinants of violence and investing in improved access to mental health and substance abuse services.

For more information on gun policy and mental illness, see the Psychiatric News article "Capitol Hill Gets Straight Story On Gun Violence, Mental Illness" and the Psychiatric Services article "Gun Policy and Serious Mental Illness: Priorities for Future Research and Policy."

(Image: Mark Moran)

Wednesday, May 20, 2015

Understanding the Motivations of Cheating Athletes Can Guide Treatment


“Deflategate” may be the word of the day in the sports world, but it is neither the first nor the last example of athletes cheating to gain an edge on competitors. Winning is everything to many athletes, no matter the cost to their integrity and health.

Cheating in sports likely falls into one of the four B’s: Betting, Bribery, Battery, and Banned substances, said Thomas Newmark, M.D., a professor of psychiatry at the Rowan School of Medicine, at APA’s 2015 annual meeting in Toronto today. He gave an overview of infamous sports scandals in cheating, ranging from cyclist Lance Armstrong’s use of performance enhancement drugs to the ice skater Tanya Harding’s planned assault on fellow competitor Nancy Kerrigan at the Olympic trials in 1991. Newmark discussed that underlying motives behind some cheating scenarios are the gaining of fame, extreme financial incentives, success, and acceptance, or, in the case of collegiate athletes, grades and maintaining eligibility.

Psychiatrists can step in and help athletes caught cheating by educating them about the error of their ways or helping them cope with the stress of dealing with a suspension or the end of a career, said Eric Morse, M.D., a sports psychiatrist who works with professional, college, and youth athletes and teams. Ironically, sometimes it is the psychiatrist who is pressured to cheat—to provide a medical diagnosis that helps a college athlete drop a course he is failing or “legalize” a banned medication with a back-dated prescription.

Dan Begel, M.D., a cofounder of the International Society for Sport Psychiatry, discussed that athletes with personality disorders such as narcissistic, borderline, or antisocial personalities are at higher risk of cheating behaviors. “Understanding the deeper motivations of such athletes can drive treatment,” said Begel. “It is important to explore childhood and family and cultural dynamics to develop a treatment plan.”

Therapy tools highlighted during the session to treat athletes included cognitive-behavioral therapy, family therapy, dynamic therapy, and supporting therapy. The experts emphasized that the key role of psychiatrists in sports medicine is to educate athletes about cheating, help them not to cheat again, and help with the consequential stress of being caught—which could result in a loss of identity for the player.

Ira Glick, M.D., professor emeritus of psychiatry and behavioral sciences at the Stanford University School of Medicine, said that a personal, family, and cultural history of the athlete are good starting points for therapy.

“Cognitive-behavioral therapy, family therapy, dynamic therapy, or supportive therapy can help,” said Glick. “Often the elite athlete may feel a sense of entitlement that needs to be addressed.”

For more on how sports can inform therapy, see Psychiatric News article “Why Sports Evoke Passion, for Better or Worse.”

(Image: Peter Weber/Shutterstock.com)

Tuesday, May 19, 2015

NIDA Director Calls for Humane Response to Addiction as a Brain Disorder


“If we as psychiatrists can embrace addiction as a disease of the brain that disrupts the systems that allow people to exert self-control, we can reduce the stigma that surrounds this disorder—for insurance companies and the wider public—and help to eliminate the shame and suffering that accompany the addict who experiences relapse after relapse after relapse.”

That was the message that Nora Volkow, M.D., (left) director of the National Institute on Drug Abuse, brought to APA members at the 59th Convocation of Distinguished Fellows at APA’s 2015 annual meeting in Toronto Monday evening.

Volkow opened her speech with a moving and emotional story of how she learned of her grandfather’s lifetime of chronic alcoholism and suicide; he had died when she was a girl of 6 in Mexico, but Volkow’s mother did not reveal the truth of her grandfather’s addiction and death until many years later, when her mother was dying and after Volkow had already achieved distinction as an addiction expert.

It was a dramatic illustration of the despair experienced by people who have an addiction and continue to engage in a behavior that they may know is destroying them—a phenomenon that Volkow has devoted her career to understanding. She gave a brief overview of her own research and the evolution of addiction science, describing how it was once believed that addiction was a disorder of hyperactive reward centers in the brain—that addicts sought out drugs or alcohol because they were especially sensitive to the pleasure-inducing effects of dopamine.

But Volkow explained that in recent years research has revealed just the opposite: that addicts are actually less sensitive to the effects of dopamine. They seek out drugs because of the very potency with which they can increase dopamine in the brain, often at the expense of other pleasurable natural stimulants that do not increase dopamine so dramatically. And it is the neurobiological reflection of the phenomenon of “diminishing effects” that addicts typically report clinically: they require more and more of the drug to get a similar effect.

"This was completely counterintuitive," Volkow said.

Moreover, she emphasized that addiction to drugs disrupts multiple systems in the brain—not simply reward centers—that govern the ability to plan, anticipate, and change behavior in response to changing circumstances. Volkow said it is this phenomenon that accounts for the “craving” experienced by addicts and alcoholics in response to environmental triggers—often leading to what she characterized in the account of her grandfather’s death as that “one last moment of self-hatred.”

(Image: David Hathcox)

Monday, May 18, 2015

ABMS Executive Defends Importance of MOC Part 4 in Assembly Address


"I absolutely believe we should keep the performance-in-practice component of Maintenance of Certification (MOC)," said American Board of Medical Specialties (ABMS) President and Chief Executive Lois Margaret Nora, M.D., J.D., during a special address to the APA Assembly Sunday morning at APA’s 2015 annual meeting in Toronto. However, Nora did note that the MOC process itself and the Part 4 performance-in-practice component (also referred to as "Improvement in Medical Practice") needs to be improved and refined.

According to Nora, the ABMS plans to respond to physician concerns over Part 4 by a "relaxation" of requirements and an expansion of activities that count toward fulfilment of performance in practice. "With the appropriate flexibility, I believe that performance in practice will be embraced by physicians," Nora said. ("Performance in practice" refers to a requirement that physicians build into their routine practice the capacity to assess their performance continually against guidelines for best practices and make improvements to meet those guidelines.)

Up to now it has been a chilly embrace. In an interview with Psychiatric News last year, Larry Faulkner, M.D., president of the American Board of Psychiatry and Neurology (ABPN), explained that the "the performance-in-practice issue is a controversial and difficult one. … It boils down to a quality-improvement process. In general, physicians are going to have to demonstrate that they have looked at their practices and identified issues that need to be improved."

But Part 4 has been the object of widespread physician concern and even anger. At the March meeting of the APA Board of Trustees, the Board voted to write a letter to Faulkner requesting that ABPN advocate to the ABMS that Part 4 be eliminated. (ABPN operates under criteria established by the ABMS).

The letter was the result of a motion, spurred by the Assembly Executive Committee and made at the Board of Trustees meeting in March, reflecting concerns over the limited evidence base for Part 4. Also at its March meeting, the Board established a joint Board-Assembly work group to evaluate the broad issue of MOC in psychiatry and its relationship to maintenance of state licensure and requirements of other accrediting bodies.

Note: Just prior to the start of APA's annual meeting, the ABPN announced that the feedback module in Part 4 will become optional as of January 1, 2016. The Part 4 Clinical Module component (chart review) will remain a requirement, and additional approved activities are now available on ABPN’s website. This change is in compliance with current MOC standards as mandated by the ABMS.

For more on APA’s efforts to eliminate Part 4 of MOC program, see the Psychiatric News article “APA Urges ABPN to Advocate for Elimination of MOC Part 4.”

(Image: David Hathcox)

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