Risk of Heart Disease Quadruples in Women Hospitalized for Bulimia

The risk of cardiovascular disease skyrockets for women who have been hospitalized for bulimia nervosa, a study in JAMA Psychiatry reports. The risk is greatest in the first two years after hospitalization and remains high for another three years before disappearing at the 10-year mark.

“Our findings suggest that women with a history of bulimia nervosa should be informed of an increased risk of cardiovascular disease and death in the first decade after the index admission for bulimia,” wrote Rasmi M. Tith, R.D., M.P.H., of the University of Waterloo in Ontario and colleagues. “These women may benefit from screening for prevention and treatment of cardiovascular risk factors.”

The study followed more than 416,000 women for up to 12 years from 2006 to 2018. Of the patients, 818 were hospitalized for bulimia, and the rest were hospitalized for pregnancy-related events such as delivery of a live or stillborn infant, abortion, or pregnancy outside the uterus (ectopic pregnancy). The average age of the women at hospitalization was 28 years.

“The comparison group was representative of most women in the province … because 99% of deliveries and a significant proportion of other pregnancy events occur in hospitals,” the researchers wrote.

Compared with women who had been hospitalized for pregnancy-related events, women who had been hospitalized for bulimia had nearly 22 times the risk of heart attack within two years of hospitalization and more than 14 times the risk at five years. Over the entire follow-up, they had more than four times the risk of any cardiovascular disease, including six times the risk of heart attack, seven times the risk of ischemic heart disease (heart problems caused by narrowed heart arteries), and seven times the risk of atherosclerosis. They also had five times the risk of death. Those who had multiple hospitalizations for bulimia had a higher risk of cardiovascular disease and death than those who had been hospitalized only once.

The researchers noted that bulimia has been associated with metabolic changes such as changes in lipids that may affect the risk of cardiovascular disease. They added that bulimia may cause endocrine abnormalities such as low estrogen levels, which may also increase cardiovascular risk.

“Although more studies are needed, the findings from the present study suggest that bulimia nervosa, especially bulimia that requires multiple hospitalizations for treatment, may be associated with a range of cardiovascular disorders,” the researchers concluded. “Bulimia nervosa may be an important contributor to premature cardiovascular disease in women.”

For related information, see the Psychiatric News article “Brief Update and Review on Treating Eating Disorders.”

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Transcranial Direct Current Stimulation May Effectively Treat Negative Schizophrenia Symptoms

Transcranial direct current stimulation (tDCS) appears to be an effective and safe add-on treatment for ameliorating negative symptoms in schizophrenia, such as loss of interest in everyday activities and emotional withdrawal, according to a study published yesterday in JAMA Psychiatry. This noninvasive therapy delivers weak, direct currents into the brain via electrodes placed on the scalp.

“There is an unmet clinical need for the treatment of negative symptoms in schizophrenia,” wrote Leandro da Costa Lane Valiengo, M.D., Ph.D., of the Instituto Nacional de Biomarcadores em Neuropsiquiatria Faculdade de Medicina in São Paulo, Brazil, and colleagues. “[G]iven its acceptability, tolerability, and short treatment protocol, tDCS could be evaluated as an add-on intervention for patients with schizophrenia with negative symptoms in outpatient settings.”

The double-blind, placebo-controlled, randomized trial took place from September 2014 to March 2018 in two São Paulo outpatient clinics. The 100 participants aged 18 to 55 were all diagnosed with schizophrenia using the Portuguese version of DSM-IV, had Positive and Negative Syndrome Scale (PANSS) negative symptom scores of 20 or more, and had stable positive and negative symptoms for four weeks or more. Participants received tDCS in twice-daily, 20-minute sessions over five consecutive days. A sham group went through the same procedure without receiving tDCS. A total of 95 patients completed the trial.

The participants’ symptoms were assessed at baseline, five days, two weeks, four weeks, six weeks, and 12 weeks after the treatment began. After 12 weeks, there was a 4.5-point improvement in the mean PANSS negative symptoms subscale score for patients who received tDCS, compared with a 1.8-point improvement in the sham group. Forty percent of those in the tDCS group achieved treatment response (a 20% or greater improvement in negative symptoms), compared with only 4% in the sham group. The participants had no serious adverse effects, such as acute psychosis or hospitalization, though those who received tDCS reported a burning sensation over the scalp.

“Our findings encourage the use and optimization of this technique in patients with psychotic disorders,” the authors concluded.

For related information, see the American Journal of Psychiatry article “Low-Intensity Transcranial Current Stimulation in Psychiatry.”

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APA Celebrates 175th Anniversary Today

APA is 175 years old today.

On October 16, 1844, 13 superintendents of U.S. institutions for people with mental illness came together in Philadelphia for a four-day meeting that led to the creation of the Association of Medical Superintendents of American Institutions for the Insane. In 1892, the Association’s name was changed to the American Medico-Psychological Association, and in 1921 it became the American Psychiatric Association.

“APA’s founders were determined to provide their patients with psychosocial care in a humane environment,” said APA President Bruce Schwartz, M.D. “They gathered to talk about the common challenges they faced and to advance treatments to improve the lives of their patients. In the 175 years since, APA and its members have worked to promote the highest quality of care for individuals with mental illness and substance use disorders.”

Over the past 175 years, APA has advanced the field of psychiatry by promoting research, advocating at the federal and state levels for equitable treatment of people with mental illness and substance use disorders, standing up for the rights of people with mental illness in the courts, and educating the public about mental illness and the effectiveness of treatment. Documents and other resources related to APA’s rich history are preserved in the Melvin Sabshin, M.D. Library & Archives at APA headquarters in Washington, D.C.

Highlights of APA’s history include the following:

• In 1917 the American Medico-Psychological Association, working with the National Committee for Mental Hygiene, created a formal system for classifying mental illnesses. This would later become the Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952. Further revisions, most recently in 2013 with DSM-5, reflect significant scientific advances in understanding and diagnosing mental illness.
• Throughout the 1970s and 1980s APA was instrumental in confronting the former Soviet Union over its use of psychiatric hospitals to detain political dissidents; APA has also advocated for civil rights of people with mental illness in Chile, Cuba, South Africa, and China.
• In 1981 American Psychiatric Publishing Inc., APA’s publishing company, was created to produce books, journals, and multimedia to provide cutting-edge information to medical students, residents, and practicing psychiatrists. (APA members may access the American Journal of Psychiatry from its beginnings as the American Journal of Insanity in 1844.)
• In 1992 APA created the American Psychiatric Association Foundation to advance mental health through educational programs in schools, workplaces, correctional institutions, and the broader community.
• In 2008 Congress passed the Mental Health Parity and Addiction Equity Act, requiring insurers to provide coverage for treatment of mental illness and substance use disorders on the same par as that provided for general medical and surgical treatments. APA was a leading advocate for this legislation and has continued to work on ensuring the law’s enforcement.

APA kicked off celebrating its 175th anniversary during its Annual Meeting earlier this year in San Francisco. The year of commemoration concludes at the organization’s next Annual Meeting in Philadelphia in April 2020.

“We are proud to recognize our rich and deep history,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “By exploring our past, we can see how far we have come as a medical organization and the great potential we have moving forward.”

For information on APA’s founding, see the Psychiatric News article “APA’s Origins Reflected Enlightened Thinking About Care for People With Mental Illness.”

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Suicide Attempts by Black Adolescents Rising, Report Suggests

Between 1991 and 2017, the rate of black adolescents who reported attempting suicide rose, according to a report published Monday in Pediatrics. This trend was not seen in adolescents who identified as white, Hispanic, Asian American or Pacific Islander, or being of multiple races.

“Examining trends in suicidal ideation and behaviors over time by sex and race and ethnicity allows us to determine where to focus prevention and intervention efforts,” wrote Michael A. Lindsey, Ph.D., M.S.W., M.P.H., of New York University and colleagues.

Lindsey and colleagues analyzed data from the Youth Risk Behavior Survey (YRBS)—a national survey administered to high schoolers across the United States—from 1991 through 2017. As part of this survey, youth were asked to report suicidal thoughts and behaviors; such questions included the following: “During the past 12 months, did you make a plan about how you would attempt suicide?”; “During the past 12 months, how many times did you actually attempt suicide?”; and “Did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?”

The sample included 198,540 high school students. During the study period, the weighted overall prevalence rates of suicidal ideation, plan, attempt, and injury by attempt were 18.8%, 14.7%, 7.9%, and 2.5%, respectively, Lindsey and colleagues reported. While the analysis revealed that the rates of suicidal ideation and suicide plans by the adolescents trended downward over time across all sex and racial and ethnic groups, black adolescents experienced an increase in rates of suicide attempts.

Additional analysis revealed that self-reported suicide attempts increased at an accelerating rate in black girls (even as suicide attempts among adolescent girls overall declined), and there was a significant increase in injuries from self-reported suicide attempts in black boys.

“[O]ver time, black youth have experienced an increase in suicide attempts, which is the most prominent risk factor associated with suicide deaths,” Lindsey and colleagues wrote. They suggested that this finding may be related to disparities in access to mental health treatment and social factors disproportionately experienced by black youth, such as racial discrimination.

“Despite the recent increases in rates of suicide, black adolescents continue to have a lower suicide rate than white adolescents,” noted Benjamin N. Shain, M.D., Ph.D., of the University of Chicago in an accompanying commentary. Nonetheless, he wrote, “the increases in rates of suicide and suicide attempts by black adolescents are concerning and should influence prevention and intervention efforts. Future research should be aimed at delineating the reasons for the increases and suggesting approaches useful for clinicians, schools, and leaders in charge of health care and social policy.”

For related information, see the Psychiatric News article “Mental Health Needs of Blacks Not Being Met, Says APA President.”

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Candidates for APA's 2020 Election Announced

The APA Nominating Committee, chaired by immediate past President Altha Stewart, M.D., reports the following slate of candidates for APA’s 2020 election. This slate is considered public, but not official, until the Board of Trustees approves it at its December 2019 meeting.



President-Elect
David C. Henderson, M.D.
Henry A. Nasrallah, M.D.
Vivian B. Pender, M.D.

Treasurer
Ann Marie T. Sullivan, M.D.
Richard F. Summers, M.D.

Trustee-At-Large
Frank Clark, M.D.
Mark Komrad, M.D.
Michele Reid, M.D.

Area 2 Trustee
James P. Kelleher, M.D., M.B.A.
Glenn A. Martin, M.D.

Area 5 Trustee
Jenny Boyer, M.D., Ph.D., J.D.
Philip L. Scurria, M.D.

Resident-Fellow Member Trustee-Elect
Mariam Aboukar, D.O.
Aatif Mansoor, M.D.
Sanya Virani, M.D., M.P.H.

The deadline for candidates who wish to run by petition is November 15. All candidates and their supporters are encouraged to review APA’s Election Guidelines. Candidates’ photos and the addresses of their personal websites will be published in the December 20 issue of Psychiatric News.

APA voting members may cast their ballots from January 2 to January 31, 2020. For more election information, please visit the Election section of APA’s website or email election@psych.org.

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Changes in Depressive Symptoms at Two-Week Treatment Mark May Predict 12-Week Remission Outcomes

Whether patients with major depressive disorder show improvement (or lack thereof) at the end of their second week on an antidepressant medication may predict whether they will ultimately achieve remission at the end of 12 weeks, a study published in Psychiatric Research & Clinical Practice found.

“For any antidepressant medication trial, it is important to identify as early as possible whether the patient is likely to achieve remission …,” wrote Paul B. Hicks, M.D., Ph.D., of Texas A&M College of Medicine and colleagues. “The present study bolsters the proposed use of the lack of early improvement as a predictor of failure to achieve remission with the current medication.”

The researchers conducted a secondary analysis of data from the Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) study, which involved 1,552 veterans aged 18 and older whose major depressive disorder was unresponsive to at least one course of antidepressant treatment. The study participants were randomly assigned to one of three medication treatment groups: augmentation with bupropion sustained release, augmentation with aripiprazole, or switch to a different antidepressant. The dosage remained relatively constant throughout the trial, though the researchers allowed adjustments to doses as early as the end of the first week. The researchers evaluated participants at baseline and at the end of weeks 1, 2, 4, 6, 8, 10, and 12.

Early improvement was defined as a drop from the baseline depression severity score of 20% or more, as measured by the Quick Inventory of Depressive Symptomatology-Clinician Rated (QIDS-C), within the first two weeks of the treatment modification. The researchers then calculated positive and negative predictive values by evaluating whether the participants showed early improvement by the end of the second week and whether they then achieved remission by the end of week 12. The values were determined by categorizing participant outcomes based on whether the patient had a true positive (they showed early improvement and achieved remission), false positive (they showed early improvement but did not achieve remission), true negative (they neither achieved early improvement nor remission), and false negative (they did not show early improvement but achieved remission).

The researchers found that early improvement in patients resulted in a positive predictive value of 38.2% and a negative predictive value of 92.6%; the latter means that if the patient does not show improvement by the end of the second week on a medication, the chance of achieving remission at the end of the 12th week is less than 8%. “The odds of achieving remission, response, and greater than minimal improvement was higher among individuals who exhibited early improvement,” the authors wrote.

They noted, however, that it is also important to analyze the characteristics of the patients who did not experience early improvement but did ultimately achieve remission by the end of the 12 weeks. Those patients were more likely to have lower baseline scores, fewer adverse childhood experiences, lower baseline Beck Anxiety Inventory Score, lower Columbia-Suicide Severity Rating Scale scores, and a higher baseline quality of life.

“A lack of early improvement at the end of week 2 of antidepressant therapy can be used to inform clinical decisions on the likelihood of nonremission of depression during the subsequent 10 weeks, even when dosage optimization is incomplete,” the authors concluded.

For related information, see the American Journal of Psychiatry article “General Predictors and Moderators of Depression Remission: A VAST-D Report.”

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Bacterial Infection in Pregnancy Linked to Psychosis in Offspring as Adults

Children of mothers who contract a bacterial infection such as pneumonia during pregnancy are significantly more likely to have a psychotic disorder in adulthood compared with those not exposed to infection in utero, according to a report in AJP in Advance.

The risk of psychosis in adulthood is even greater when pregnant women have an infection that impacts multiple body systems such as sepsis and is especially high for males.

Lead author Younga H. Lee, Ph.D., of Brown University and colleagues said more research with larger sample sizes could help uncover how gestational bacterial infection may directly or indirectly cause adult psychosis. “If replicated, our findings would also call for public health and clinical efforts that focus on preventing and managing bacterial infection in pregnant women,” they wrote.

Lee and colleagues analyzed data on 15,421 live births between 1959 and 1966 in Boston and Providence, R.I., as part of the Collaborative Perinatal Project (now known as the New England Family Study). Information about exposure to bacterial infection was recorded during perinatal visits beginning at the time of registration for prenatal care, at intervals of four weeks during the first seven months of pregnancy, every two weeks at 8 months, and every week thereafter until birth.

Of 15,421 cohort mothers in the sample, 3,499 (23%) had bacterial infection; of these, 3,191 (21%) had localized infections, 399 (3%) had multisystemic infections, and 91 (<1%) had both. Localized bacterial infections included tuberculosis (n=8); pneumonia (n=83); syphilis (n=66); gonorrhea (n=15); and kidney, ureter, and bladder infections (n=1,203); and vaginitis (N=2,136).

A total of 116 offspring were diagnosed with a psychotic disorder in adulthood.

Offspring of mothers who experienced a multisystemic infection were almost three times as likely to have a psychotic disorder in adulthood compared with those whose mothers experienced no infection. Offspring of mothers who had any kind of infection during pregnancy—localized or multisystemic—were 1.8 times as likely to have a psychotic disorder as those whose mothers had no infection.

The risk was especially high for males; male offspring of mothers who experienced a multisystemic infection during pregnancy had a five times greater risk of psychosis than males whose mothers did not have infection, and nearly three times the risk of psychosis when mothers had had any kind of bacterial infection.

A large body of research has implicated viral infections during pregnancy in psychosis among offspring; the new AJP study extends that work to bacterial infections. “These findings could be an important first step to motivating large-scale national register-based investigation” of the role of both viral and bacterial infections in psychosis, the researchers wrote.

For related information, see the Psychiatric News article “Maternal Infection, Later Childhood Infection Linked to Psychosis in Offspring.”

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