Escitalopram Linked to Significant Improvement of Mother’s Depression and Child’s Symptoms

Previous studies have shown that when symptoms of a depressed mother remit after treatment, her offspring’s psychiatric symptoms are decreased. A study published today in AJP in Advance may shed light on some antidepressant treatment options that could lead to this domino effect.

Myrna Weissman, Ph.D., a professor of psychiatry and chief of the division of clinical and genetic epidemiology at New York State Psychiatric Institute, analyzed 76 depressed mothers and 135 offspring—aged 7 to 17—to compare which antidepressants taken by mothers would eventually lead to less psychiatric symptoms in offspring. Maternal participants were given either escitalopram, bupropion, or the combination of the two for 12 weeks. Offspring psychiatric symptoms were assessed prior to maternal initiation of therapy and at study endpoint.

Though maternal subjects in all three groups were able to achieve remission, escitalopram alone was found to be associated with statistically significant improvement in mothers' depression and subsequent improvements in offspring's psychiatric symptoms, whereas treatment with bupropion and combined bupropion and escitalopram therapy did not. In addition, mothers in the escitalopram cohort were more likely to report improvement in their ability to listen and talk to their children over the 12-weeks than mothers administered bupropion or combined therapy. Children of the escitolapram group reported their mother to be more caring after treatment.

These findings "highlight the importance of active treatment of depressed mothers, which may help them and their children," the researchers noted. "Personalizing the treatment of depressed mothers may be enhanced by assessing parental behavior and monitoring the impact on children.” The researchers concluded that antidepressants that also reduce symptoms of anxiety and irritability—like escitalopram—may be necessary to properly assess the impact of the parent’s remission on the well-being of their offspring.

(Photo Courtesey of National Institutes of Health)

More Psychiatric Care for Minorities Could Mean Substantial Savings to Health System, Study Finds

Reducing disparities in mental health care access for racial and ethnic minorities would lead to subsequent reductions in some general medical expenditures for the same populations, said Benjamin Lê Cook, Ph.D., M.P.H., a senior scientist at the Center for Multicultural Mental Health Research and an instructor at the Harvard Medical School, and colleagues in the study "The Costs and Benefits of Reducing Racial-Ethnic Disparities in Mental Health Care" published in Psychiatric Services in Advance.

The researchers looked at data on 6,206 people with mental illness from the 2004-2010 Medical Expenditure Panel Survey. Relative to whites, African Americans and Latinos who received outpatient mental health care in one year spent less on inpatient and emergency general medical care the following year. Latinos receiving mental health care in year 1 spent less than others on inpatient general medical care in year 2. In addition, Latinos taking psychotropic drugs in year 1 showed reductions in inpatient general medical care.

The U.S. health care system would need to provide additional care to approximately 1.3 million blacks and 1.1 million Latinos with probable mental illness to eliminate disparities, wrote the researchers. “For blacks and Latinos, the potential savings in inpatient general medical expenditure are substantial (as much as $1 billion), providing preliminary evidence of a ‘business case’ for reducing disparities in mental health care access.

For more in Psychiatric News about the effect of racial and ethnic disparities in mental health, see the article "Satcher Outlines Roadmap to Reducing Health Disparities."

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Duration of First Psychosis Found Longer in U.S. Community Settings

Patients experiencing a first-episode psychosis and treated at community based clinics had longer duration of psychosis (DUP) than has been reported for those treated at academic medical centers, according to the study “Duration of Untreated Psychosis at Community Treatment Centers in the United States,” published online in Psychiatric Services.

Researchers with the National Institute of Mental Health (NIMH) Early Treatment Program (ETP)—which is part of an NIMH initiative called Recovery After an Initial Schizophrenia Episode (RAISE)—examined DUP among persons receiving care in community mental health centers in the United States. Longer DUP has been found to be associated with poorer long-term trajectory of illness and poorer overall functioning.

Participating in the study were 404 individuals (ages 15–40) who presented for treatment for first-episode psychosis at 34 nonacademic clinics in 21 states.

The median duration of psychosis was 74 weeks, and 68 percent of patients had a DUP of greater than six months. DUP was significantly shorter for participants living in northern states compared with those from midwestern and southern states. No differences in DUP were observed for rural, suburban, or urban location or for insurance status.

The correlates of longer DUP included earlier age at first psychotic symptoms, substance use disorder, positive and general symptom severity, poorer functioning, and referral from outpatient treatment settings.

“This study reported longer DUP than studies conducted in academic settings but found similar correlates of DUP,” the researchers stated. “Reducing DUP in the United States will require examination of factors in treatment delay in local service settings and targeted strategies for closing gaps in pathways to specialty first-episode psychosis care.”

For more information, see the Psychiatric News article “Benefits Persist Decade After Early Psychosis Intervention.”

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Some Symptoms of Mild Dementia May Predict Progression to Severe Dementia, Early Death

Specific neuropsychiatric symptoms are associated with shorter survival time from mild Alzheimer’s dementia to severe dementia and/or death, according to a report appearing online in AJP in Advance titled “Neuropsychiatric Symptoms as Predictors of Progression to Severe Alzheimer’s Dementia and Death: The Cache County Dementia Progression Study.”

Constantine Lyketsos, M.D., of Johns Hopkins University School of Medicine, and colleagues used data from the Cache County Dementia Progression Study, a longitudinal study of dementia progression in incident cases of dementia, to examine the link between clinically significant neuropsychiatric symptoms in mild Alzheimer’s dementia and progression to severe dementia or death.

Three hundred thirty-five patients with incident Alzheimer’s dementia were studied. Sixty-eight (20 percent) developed severe dementia over the follow-up period.

To identify potentially predictive neuropsychiatric symptoms, the researchers used the 10-item Neuropsychiatric Inventory, a structured interview that provides a systematic assessment of the 10 neuropsychiatric symptom domains: delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/euphoria, apathy/indifference, disinhibition, irritability/lability, and aberrant motor behavior.

They found that psychosis, agitation/aggression, and any one clinically significant neuropsychiatric symptom were associated with more rapid progression to severe dementia. Psychosis, affective symptoms, agitation/aggression, mildly symptomatic neuropsychiatric symptoms, and clinically significant neuropsychiatric symptoms were associated with earlier death.

“The treatment of specific neuropsychiatric symptoms in early dementia should be examined for its potential to delay time to severe dementia or death,” researchers wrote.

For more information, see the Psychiatric News article “DICE Rolls to New Approach for Treating Dementia Symptoms.”

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FDA Approves Mobile App for Evaluating Traumatic Brain Injury

A new app will soon be available to help clinicians diagnose traumatic brain injury in as little as five minutes in almost any setting, including environments of combat.

The app, called the Defense Automated Neurobehavioral Assessment (DANA), runs on multiple mobile platforms and was recently granted U.S. Food and Drug Administration (FDA) approval. “It's like a brain thermometer,” stated Lt. Col. Chessley Atchison, a program manager for the Combat Casualty Care Research Program of the U.S. Army Medical Research and Materiel Command (USAMRMC). “And once we get it right, we’re going to put it fairly far forward in the field.”

According to the USAMRMC, DANA operates much like a video game. Service members will undergo a baseline series of on-screen exercises during which both their speed and accuracy are recorded. Those who may have had a serious head injury will then participate in a series of both cognitive efficiency tests and self-administered questionnaires. Afterward, a clinician will review the results, comparing them with the results of the baseline exercises. The combination of the app's cognitive and psychological components allows for insight into the prevalence of symptoms related to both traumatic brain injury and posttraumatic stress disorder, USAMRMC said in a press statement.

USAMRMC stated that once DANA is fully validated for battlefield use, it may be used to help assess fitness for duty. The app is currently being tested on tablet devices.

For more information on diagnosing traumatic brain injury, see the Psychiatric News article "I Can’t Think Clearly: Diagnosing Traumatic Brain Injury with DSM-5."

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Telephone Consultation Improves Care of Children's Mental Health in Primary Care, Study Finds

Pediatric primary care providers in Massachusetts reported a dramatic improvement in their ability to meet their patients' psychiatric needs because of a project to provide telephone child psychiatry consultations and specialized care coordination to primary care providers.

The Massachusetts Child Psychiatry Access Project is described in a report in Health Affairs, by John Strauss, M.D., director for special projects at Massachusetts Behavioral Health Partnership, a ValueOptions company in Boston, and Barry Sarvet, M.D., chief of child psychiatry and vice chair of the Department of Psychiatry at Baystate Health in Springfield.

Beginning as a pilot project at the University of Massachusetts, the project received legislative approval in June 2004 to be administered by the Massachusetts Behavioral Health Partnership. The project consists of six regional hubs, each with one full-time-equivalent child psychiatrist, licensed therapist, and care coordinator. Collectively, the hubs are available to over 95 percent of the children in Massachusetts. In fiscal year 2013 the Massachusetts Child Psychiatry Access Project served 10,553 children.

“Access to behavioral health care for children is essential to achieving good health care outcomes,” Strauss and Sarvet said. "Pediatric primary care providers have an essential role to play in identifying and treating behavioral health problems in children. However, they lack adequate training and resources and thus have generally been unable to meet children’s need for behavioral health care.....Telephone child psychiatry consultation programs for pediatric primary care providers, many modeled after the Massachusetts project, have spread across the United States."

The website for the Massachusetts Child Psychiatry Access Project is here. For information about a similar project in New York, see the Psychiatric News article, "New York Child Psychiatry Divisions Fill Gap in Collaborative Care Model."

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Physicians, Patients Not Getting Full Information on Antipsychotic Drugs

Elements of package inserts for second-generation antipsychotic medications aimed at both physicians and patients for use in affective illness “may belie scientific data regarding the neuropsychiatric risks of these drugs,” according to Frederick Jacobsen, M.D., M.P.H., a clinical professor of psychiatry and behavioral sciences at the George Washington University School of Medicine and Health Sciences.

This oversight has significant public health implications, given the increasingly broad prescription of these drugs for mood-related disorders and for off-label uses, wrote Jacobsen in the February issue of the American Journal of Public Health. He reviewed online package inserts for 10 second-generation antipsychotics. Advertisements for the drugs also inaccurately suggest reversibility of chronic neurotoxicty, he wrote.

“Inspection of SGA package inserts ‘Patient Counseling Information’ sections … omit tardive syndromes and other long-term neuropsychiatric side effects," Jacobsen wrote. "These surprising omissions are accompanied by a shift of responsibility for identifying or monitoring long-term neurotoxicity from physician to patient: 7 of 10 SGA package inserts included ‘Medication Guides’ (for patients) that mentioned abnormal movements as potential side effects. Three of these ‘Medication Guides’ instruct patients to ‘notify the prescribing physician if such movements are noticed.’ ”

The lack of appropriate patient counseling may be tied to the brevity of clinical trials (6 to 12 weeks) used for FDA approval compared to the chronic duration of clinical use.

“Patients deserve better information and education regarding the long-term side effects,” said Jacobsen. “Long-term efficacy and safety outcomes, including side effects, of SGAs in affective illness—and in off-label uses (anxiety, sleep, children, elderly, and so on)—need to be documented in meaningful long-term trials corresponding to the realities of clinical practice.”

For more in Psychiatric News on the benefits and risks of the use antipsychotic medications, see “First- and Second-Generation Antipsychotics Compared in Federal Agency Monograph.”

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