Depression in Early Pregnancy Linked to Gestational Diabetes, Postpartum Depression

Depression early in pregnancy appears to increase the risk for gestational diabetes, which in turn increases the risk for postpartum depression, according to a report appearing online in Diabetologia.

Stephanie Hinkle, Ph.D., and colleagues at the National Institute of Child Health and Human Development assessed longitudinal associations between depression early in pregnancy and the risk for gestational diabetes (GDM), as well as GDM and subsequent risk of postpartum depression. They analysed data from the prospective National Institute of Child Health and Human Development Fetal Growth Studies-Singleton cohort (2009–2013), which had been collected at 12 U.S. clinical centers.

The sample consisted of 2,477 pregnant women without psychiatric disorders, diabetes, or other chronic conditions before pregnancy. Depression was assessed in the first (8–13 gestational weeks) and second (16–22 weeks) trimesters and at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale.

Comparing the highest and lowest quartiles of first-trimester depression scores, the researchers found that the scores from the highest quartile were associated with a significant 1.72-fold increased risk for GDM after adjusting for confounding factors; the second-trimester results were similar. The risk was stronger and significant in both trimesters among nonobese women, and women with persistently high depression scores in both trimesters had the greatest risk of GDM.

The researches then matched 162 women with GDM and healthy controls and followed them up at 6 weeks postpartum. Postpartum depression was defined as a depressive symptom score of 10 or greater or antidepressant medicine use after delivery.

They found that GDM was associated with an adjusted 4.62-fold increased risk of subsequent postpartum depression.

“Our data suggest that screening early in pregnancy may be particularly important even among women without a history of mental health conditions,” the researchers wrote. “In addition, women with GDM may require closer monitoring postpartum given their elevated risk of postpartum depression. Taken together, our work extends previous data supporting depression and glucose intolerance as comorbid conditions among nonpregnant individuals to women during pregnancy and postpartum, a critical time window for the health and well-being of both women and their offspring.”

For related information see the Psychiatric News article "Link Seen Between Mental Disorders, Diabetes in New Study."

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Review Reveals Complex Association Between Hypnotic Medications and Suicidality

Modern hypnotic medications are associated with suicidality, but the association may often be confounded by the presence of mental illness. Moreover, many hypnotic-associated suicides have also involved use of other sedatives or alcohol. Finally, hypnotic-associated suicide may also occur specifically at times of peak drug effect—an occurrence that might be mitigated by judicious prescription and use of hypnotic medications.

Those are among the complex findings around the association of hypnotic medications and risk of suicide from a review of literature and Food and Drug Administration (FDA) adverse-event reports published in AJP in Advance. The review also includes a list of 10 recommendations for safe prescribing of hypnotics.

Insomnia is associated with increased risk for suicide, and the FDA has mandated that warnings regarding suicide be included in the prescribing information for hypnotic medications. The researchers found that toxicology studies from the United States and elsewhere show that modern hypnotics have frequently been taken before death by suicide, although the hypnotics are often taken in combination with other sedatives or alcohol. At the same time, death is possible when hypnotics are used as a single agent for self-poisoning, and examples of this were found for flurazepam, temazepam, triazolam, and zolpidem.

Retrospective case series have consistently shown that hypnotic users are overrepresented among suicide victims, with odds ratios in the range of 2 to 3, but these studies have been unable to disentangle the confounding effect of treatment for mental illness.

Importantly, published case reports and FDA adverse-event reports show that some suicidal behaviors and suicide deaths occur during a period of confusion, amnesia, hallucination, or paranoia in the first few hours after ingestion of a hypnotic—that is, suicide is linked to hypnotic-induced parasomnia during the time of peak drug effect, according to the review.

“The principal new contribution of this review is the clarification regarding the timing of suicide risk related to ingestion of hypnotics,” the authors stated. “Under specific conditions, hypnotics may induce or exacerbate suicidality by altering consciousness or disinhibition at the time of peak drug effect and at the same time may reduce or prevent suicidal ideation in persons with insomnia and mental illness after appropriate drug metabolism.”

For related information, see the Psychiatric News article “Novel Suicide-Prevention Treatment Targets Poor Sleep.”

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Depressed Patients May Be At Highest Risk of Suicide Following Hospital Discharge

Patients recently discharged from psychiatric hospitals for the treatment of depressive disorders and bipolar disorder may be at the greatest short-term risk of suicide, particularly if they appear to have had little contact with the health care system for months before their hospitalization, according to a study published today in JAMA Psychiatry.

“Knowledge of which mental disorders … put adults at highest short-term risk for suicide after psychiatric hospital discharge might shed light on the mechanisms of acute risk for suicide and guide interventions to prevent suicide,” lead author Mark Olfson, M.D. (pictured left), of Columbia University Medical Center and colleagues wrote.

Olfson and colleagues used Medicaid claims data from January 1, 2001, to December 31, 2007, to examine suicide risk during the first 90 days after inpatient hospital discharge for adults aged 18 to 64 with a diagnosis of a mental disorder (depressive disorder, bipolar disorder, schizophrenia, substance use disorder, and other mental disorders). This risk was then compared with the short-term suicide risk of inpatients with a diagnosis that was not a mental disorder. A total of 370 deaths from suicide took place during the study period.

Based on an analysis of more than 1.8 million people—including 770,642 adults with mental disorders—the authors found that short-term suicide rates in the groups of adults with depressive disorder (235.1 per 100,000 person-years), bipolar disorder (216.0 per 100,000 person-years), schizophrenia (168.3 per 100,000 person-years), substance use disorder (116.5 per 100 000 person-years), and other mental disorders (160.4 per 100,000 person-years) were higher than the rates in the inpatients who were not diagnosed with a mental disorder (11.6 per 100,000 person-years) or the U.S. general population (14.2 per 100,000 person-years).

Additional analyses showed that the 90-day rate of suicide was nearly twice as high for men as women. Psychiatric inpatients who did not receive any outpatient health care in the six months prior to hospitalization were also found to be at increased risk of suicide.

“These patterns suggest that complex psychopathologic diagnoses with prominent depressive features, especially among adults who are not strongly tied into a system of care, may pose a particularly high risk,” the authors wrote. “As with many studies of completed suicide, however, the low absolute risk for suicide limits the predictive power of models based on clinical variables. These constraints highlight the critical challenge of predicting suicide among recently discharged inpatients based on readily discernible clinical characteristics.”

In a related editorial, Merete Nordentoft, D.M.Sc., and colleagues wrote, “Psychiatric patients should not be considered cured at the time of discharge. They are still ill, many of their symptoms continue, treatment is ongoing, and their need for care remains. ... It is, therefore, very important to carefully plan and initiate referrals for aftercare. Ideally, outpatient treatment should be introduced before discharge, so that the patient is familiar with the persons who will care for them after discharge.”

For related information, see the Psychiatric News article “Two-Part Assessment May Help Predict Suicidal Behavior, Study Finds.”

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Patients With Alcohol Dependence Who Like Sweets May Respond Better to Naltrexone

Individuals with alcohol dependence who like sweets may be more likely to respond positively to treatment with naltrexone, according to a report in JAMA Psychiatry.

Determining whether a patient has a “sweet-liking (SL) phenotype” and/or a high level of craving for alcohol may represent practical tools clinicians can use when deciding whether to prescribe naltrexone for alcohol dependence, lead author James C. Garbutt, M.D., of the Department of Psychiatry at the University of North Carolina, and colleagues wrote.

The researchers randomized 80 patients with alcohol dependence to naltrexone hydrochloride (50 mg/daily) or placebo for 12 weeks. Both groups of patients were tested to determine whether they fell into the sweet-liking or sweet-disliking (SDL) phenotype. Participants’ sensitivity and response to sweet taste was tested using five concentrations of sucrose presented in five separate blocks for a total of 25 tastings. Participants were categorized as having an SL phenotype if they rated the highest concentration of sucrose as the most pleasurable.

They found naltrexone resulted in 4.8 fewer heavy drinking days over placebo (an effect that was not statistically significant), but the SL phenotype moderated the effect of naltrexone on heavy drinking—those with the SL phenotype had 6.1 fewer heavy drinking days and 10.0 more days of abstinence. They also found that high craving for alcohol at baseline moderated the effect of naltrexone on heavy drinking, with 7.1 fewer heavy drinking days among those with high craving. 

The combination of the SL phenotype and high craving was associated with the strongest response to naltrexone, with 17.1 fewer heavy drinking days and 28.8 more abstinent days compared with placebo.

“The results of the present trial support the hypothesis that the SL phenotype is a moderator of the response to naltrexone in alcohol dependence and that this effect is most apparent in the presence of a high subjective craving for alcohol,” Garbutt and colleagues wrote. “If these findings are confirmed, an assessment of the SL/SDL phenotype could be clinically useful. The phenotype shows good stability and reproducibility; is simple, safe, and inexpensive to assess; and could evolve as a simple tool to help clinicians with medication decisions.”

For related information on treating alcohol use disorder, see the Psychiatric News article “An Underutilized, Evidence-Based Treatment for Alcohol Use Disorder” by Cornel N. Stanciu, M.D. 

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Study Highlights How Children at High Risk of Suicide May Differ From Adolescents

Although suicide in elementary school–age children (aged 5 to 11) is rare, little is known about the factors precipitating suicide in this age group. A study published today in Pediatrics suggests that children who died by suicide were more likely to have been diagnosed with attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD) than early adolescents (aged 12 to 14) who died by suicide. 

“These findings raise questions about impulsive responding to psychosocial adversity in younger suicide decedents, and they suggest a need for both common and developmentally specific suicide prevention strategies during the elementary school–aged and early adolescent years,” Arielle Sheftall, Ph.D., of Ohio State University and colleagues wrote.

The researchers analyzed suicide data recorded in the National Violent Death Reporting System from 2003 to 2012 in 17 U.S. states and compared individual characteristics and precipitating circumstances of suicide in children aged 5 to 11 to those aged 12 to 14.

About one-third of the children and young adolescents were recorded in the system as having had a current mental health problem, but while depression—a well-known risk factor for suicide—was the most common diagnosis among adolescents (65.6%), young children who died by suicide were most likely to have ADD or ADHD (59.3%).

“Assuming the diagnoses are accurate, this result would suggest that suicide in young children may be more related to impulsive behavior, a hypothesis that warrants further research,” David Fassler, M.D., a child and adolescent psychiatrist and professor at the University of Vermont College of Medicine, told Psychiatric News.

“[S]uch research could have important implications for suicide prevention efforts in childhood and potentially diminish the relevance of traditional strategies focused primarily on identifying and treating depression as a means of mitigating suicide risk,” the study authors wrote.

Other characteristics that were more common in younger children who died by suicide were being male, black, suicide by hanging/strangulation/suffocation, and having died at home.

Fassler noted that because suicide is relatively rare in young children, it can be a challenging population to study. “Despite significant methodological challenges, the study represents an important contribution to the literature on suicide in young children and adolescents,” he said.

For a related story on suicide, see the Psychiatric News article “U.S. Experiences Uptick In Rates of Suicide.”

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Collaborative Care Lessens Sports Concussion Symptoms

A small study of 49 adolescent patients with persistent postconcussive symptoms indicates that they may benefit from collaborative care that includes cognitive-behavioral therapy, case management, and psychopharmacological consultation, according to a study in the October issue of Pediatrics.

To better represent real-world conditions, patients were recruited at least a month after their concussion occurred. They were randomized to receive the intervention or usual care managed by a concussion specialist, wrote Carolyn McCarty, Ph.D., a research associate professor of pediatrics and adjunct research associate professor of psychology at the University of Washington in Seattle, and colleagues.

The intervention arm used the services of a care manager, a CBT interventionist, a pediatrician, and a supervising psychiatrist, who could draw on the expertise of another psychiatrist who specialized in pediatric psychopharmacology.

Evaluated at six months after baseline, only 13 percent of intervention patients reported high levels of postconcussive symptoms compared with 41.7 percent of control patients. About 78 percent of intervention patients had a greater than 50 percent reduction in depressive symptoms, compared with 45.8 percent of patients in the usual care group. There were no significant differences in anxiety symptoms.

“Larger-scale randomized clinical trials are needed in this understudied and critical aspect of adolescent medicine,” concluded the researchers. “Our findings prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion.”

For more in Psychiatric News about postconcussion care, see “Baseline Somatization May Predict Sports-Related Concussion Recovery.”

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Addressing Psychosocial Variables May Improve Care for Patients With Mental Illness, Diabetes

There is limited research on how to best match medically complex patients who have serious mental illness with the right treatments. A study published today in Psychiatric Services in Advance describes how considering psychosocial variables such as a patient’s social support, self-efficacy, and attitude regarding possible treatment outcomes could help to guide care for patients with serious mental illness and diabetes.

Researchers from the Case Western University School of Medicine analyzed baseline data from 200 individuals with serious mental illness (including schizophrenia, schizoaffective disorder, bipolar disorder, or major depression) and comorbid diabetes involved in a study comparing a self-management intervention versus treatment as usual. As part of the trial, participants were asked questions about their symptoms as well as their perception of social support, perception of their ability to manage their conditions, and outcome expectancy related to treatment.

The analysis revealed two conceptually distinct subgroups of patients within the study. Patients with the most severe depression had “less confidence that they could manage both their psychiatric illness and diabetes, had lower expectations for treatment, and had lower perceived social support. This group scored significantly worse on measures of psychiatric symptom severity, general functioning, and diabetes control compared with the other group,” according to the authors.

“Consideration of all of these factors can personalize care for specific challenges and strengths among patients with comorbid serious mental illness and diabetes and may inform treatment approaches that can advance care for this vulnerable group of individuals,” they concluded.

For related information, see the Psychiatric News article “Bipolar Patients More Likely to Take Medications for Comorbid Conditions.”

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