Thursday, January 19, 2017

History of Depression, Gestational Diabetes May Increase Risk of Postpartum Depression


A nationwide study that included more than 700,000 women in Sweden has found that gestational diabetes raises the risk of postpartum depression (PPD) in first-time mothers. In women who had a history of depression, pre-gestational diabetes was also a moderate risk factor for PPD.

These and other findings of the study may help to shed light on the relationship between depression and other pre- and perinatal PPD risk factors, the study authors said.

Michael Silverman, Ph.D., an assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai and colleagues examined more than a dozen risk factors for PPD—such as gestational age at delivery, mode of delivery, and birth weight—and their association with PPD in women with and without a history of depression.

As they described Wednesday in the journal Depression and Anxiety, the researchers found that women with a history of depression were more than 20 times more likely to experience PPD than mothers without a previous clinical diagnosis of depression—a risk that was slightly increased if the mother also had pre-gestational diabetes or a preterm delivery (delivery at 32 to 36 weeks’ gestation).

Preterm delivery at 32 weeks’ gestation or earlier, instrument-assisted or cesarean delivery, and younger age (24 or younger) increased PPD risk in women without a history of depression. Giving birth after age 35 was associated with PPD risk in all women regardless of depression history.

“[F]or the first time, we show how maternal and obstetric risk factors for PPD may differ between new mothers with and without a history of depression,” the authors wrote. Based on the differences in risks they observed, the authors suggested that there may be different causal pathways of PPD in women with and without a history of depression

For related information, see the Psychiatric News article “Determining Onset Timing of Postpartum Depression May Lead to Improvements in Treatment.”

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Wednesday, January 18, 2017

Modafinil May Help Improve Memory in Patients With Remitted Depression


Cognitive dysfunction is known to be a core symptom of depression that tends to persist even after mood improves. A study published in Biological Psychiatry suggests that modafinil—a wake-promoting agent approved to treat patients with narcolepsy—might be able to help patients with remitted depression who are experiencing cognitive deficits.

Past studies have highlighted the cognitive-enhancing effects of modafinil in patients with schizophrenia and attention-deficit/hyperactivity disorder as well as healthy controls, but few have looked at the potential of the medication to treat cognitive deficits in patients with remitted depression.

For the current study, Barbara Sahakian, Ph.D., of the University of Cambridge and colleagues recruited patients in remission from depression (score of less than 12 on the Montgomery–Asberg Depression Rating Scale for at least two months). A total of 60 patients (48 were taking antidepressants) were evaluated using the Cambridge Neuropsychological Test Automated Battery, which includes tests of episodic memory, working memory, planning, and attention. One week after baseline evaluation of cognitive function, patients were randomized to receive either a single dose of modafinil (200 mg) or placebo, followed by another round of cognitive tests two hours after treatment.

The researchers found that the modafinil group significantly outperformed the placebo group on episodic memory and working memory tests. There were no differences between the groups in regards to improvements in planning and attention.

Although none of the study participants reported significant adverse events during the testing or 24 hours after the study, two patients taking modafinil reported sleep disturbances on the night of the study session.

“Cognitive deficits in remitted depression have detrimental effects on life functioning and pose a risk for relapse,” the authors wrote. “Modafinil may have potential as a therapeutic agent to help remitted depressed patients with persistent cognitive difficulties.”

For related information, see the Psychiatric News article “Is Modafinil a ‘Smart’ Choice to Treat Cognitive Problems in Psychiatric Disorders?

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Tuesday, January 17, 2017

Federal Confidentiality Rule Updated Regarding Substance Use Treatment


Federal regulations regarding the confidentiality of patient records on treatment for alcohol and other substance use disorders have been updated to account for the evolution of integrated care and other changes. The update appears in the form of a final rule that will be published tomorrow in the Federal Register

The rule “will further enhance health services research, integrated treatment, quality assurance, and health information exchange activities while at the same time safeguarding the essential privacy rights of people seeking treatment for substance use disorders,” said Kana Enomoto, deputy assistant secretary of the Department of Health and Human Services. She oversees the Substance Abuse and Mental Health Services Administration (SAMHSA). 

The previous regulations governing the confidentiality of substance use disorder records (referred to as "42 CFR Part 2”) were promulgated in 1975 to protect the confidentiality of patients receiving services for alcohol and other substance use disorders through programs that receive federal assistance. In February 2016, SAMHSA issued a notice of proposed rulemaking intended to adjust the regulations to reflect changes in the health care delivery system—especially the development of integrated care networks that depend on shared information—and permit appropriate research and data exchange activities.

Major provisions in the final rule include the following:
  • SAMHSA will allow any lawful holder of patient identifying information to disclose Part 2 patient identifying information to qualified personnel for purposes of conducting scientific research if the researcher meets certain regulatory requirements. SAMHSA also permits data linkages to enable researchers to link to datasets from data repositories holding Part 2 data if certain regulatory requirements are met. These will enable more needed research on substance use disorders.
  • SAMHSA will allow a patient to consent to disclosing their information using a general designation to individuals and/or entities (such as “my treating providers”) in certain circumstances. This change is intended to allow patients to benefit from integrated health care systems while retaining patient choice, confidentiality, and privacy; patients do not have to agree to such disclosures.
  • SAMHSA has added a requirement allowing patients who have agreed to the general disclosure designation the option of receiving a list of entities to whom their information has been disclosed.
  • SAMHSA has made changes that outline the audit or evaluation procedures necessary to meet the requirements of a CMS-regulated accountable care organization or similar CMS-regulated organizations. This change will ensure CMS-regulated entities can perform necessary audit and evaluations activities, including financial and quality assurance functions critical to accountable care organizations and other health care organizations.
  • The final rule addresses both paper and electronic documentation.
APA staff are analyzing the final rule. A report on the final rule and APA’s analysis will appear in a future issue of Psychiatric News. For information about confidentiality in mental health treatment, see the Psychiatric News article “Confidentiality: When Does It Give Way to Other Ethical Imperatives?

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Friday, January 13, 2017

Antidepressants May Increase Risk of Hip Fractures in Older Adults


Older adults taking antidepressants—particularly those with Alzheimer’s disease (AD)—appear to be at a greater risk of hip fracture than older adults not taking the medications, according to a report in the International Journal of Geriatric Psychiatry.

“Antidepressant use is associated with an increased risk of incident hip fracture among older persons with and without AD,” the study authors wrote. “Thus, if the antidepressant treatment is necessary, other risk factors for falling should be carefully considered.”

For the study, researchers from the University of Eastern Finland compared the health outcomes of 50,491 community-dwelling adults who were diagnosed with AD (mean age 80) and 100,982 age- and sex-matched controls without an AD diagnosis documented in national registers over a four-year period.

A total of 22.4% of the people with AD and 9.9% of persons without AD started taking antidepressants during the study period. (The most frequently initiated antidepressants included selective serotonin reuptake inhibitors, mirtazapine, and selective noradrenaline reuptake inhibitors.) 

During antidepressant use, the age-adjusted rate of hip fractures per 100 person-years was 3.01 among persons with AD and 2.28 among persons without AD. Antidepressant use was associated with an increased risk of hip fracture among persons with and without AD (adjusted hazard ratio [HR]=1.61; HR=2.71, respectively) compared with nonuse. This increased risk remained even after adjusting for use of antipsychotics, benzodiazepines, and other psychotropic drugs during the follow-up period.

“In our study, the adjusted hazard ratio was higher among persons without AD than in persons with AD. However, we found age-adjusted event rate for hip fracture per 100 person-years during antidepressant use was higher among persons with AD compared with persons without AD, which indicates the vulnerability of persons with AD.”

Additional analysis revealed that the risk of hip fracture was highest at the beginning of antidepressant use (1 to 30 days) in people with AD and without AD (HR=3.30; HR=3.92, respectively), but remained throughout the follow-up.

For related information, see the Psychiatric Services article “Antidepressant Prescribing in Primary Care to Older Adults Without Major Depression.” 

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Thursday, January 12, 2017

Activity in Amygdala May Predict Risk of Later Cardiovascular Events


Higher emotional stress as measured by resting activity of the amygdala is associated with greater risk of subsequent cardiovascular disease events, according to a study published yesterday in The Lancet. The findings “provide novel insights into the mechanism through which emotional stressors can lead to cardiovascular disease,” the authors stated.

Researchers examined data originally derived from cancer screening imaging studies of 293 patients to analyze amygdalar and bone-marrow activity, as well as arterial inflammation, reported lead author Ahmed Tawakol, M.D., an associate professor of medicine at Massachusetts General Hospital and Harvard Medical School.

During the median follow-up at 3.7 years, 22 patients reported having experienced a cardiovascular disease event—including heart attacks, strokes, angina, or other events. Each increase of one standard deviation in resting amygdalar activity predicted a 1.6 increased risk of a cardiovascular event. The results were significant even after adjustment for established cardiovascular risk factors.

Greater amygdalar activity was also associated with increased bone marrow activity, which the authors said led to increased arterial inflammation followed by cardiovascular disease events.

“[T]he brain’s salience network, bone marrow, and arterial inflammation together form an axis that could accelerate the development of cardiovascular disease,” concluded Tawakol and colleagues. “Furthermore, our findings raise the possibility that efforts to attenuate psychosocial stress could produce benefits that extend beyond an improved sense of psychological wellbeing, and could beneficially impact the atherosclerotic milieu.”

For more in Psychiatric News about the connection between heart disease and psychiatric illness, see “Can Collaborative Care Really Help Patients With Depression and Diabetes or Heart Disease.”

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Tuesday, January 10, 2017

AJP Recognized for Outstanding Publication of Research That Informs Clinical Practice


Two prestigious institutions have recognized the American Journal of Psychiatry (AJP) for publication of outstanding research that informs and improves clinicians’ practice of psychiatry by enhancing assessment of patients or improving treatment options.

New England Journal of Medicine (NEJM) Journal Watch Psychiatry and the Brain and Behavior Research Foundation have each recognized its top 10 choices for research studies published in 2016. Two AJP articles were selected by NEJM Journal Watch Psychiatry, and three were selected by the Brain and Behavior Research Foundation. For both lists, AJP had the most number of listed publications.

“Providing reliable, up-to-date information for clinicians and their patients is the most important role of the American Journal of Psychiatry,” said AJP Editor Robert Freedman, M.D. “Therefore, the Editorial Board, our authors, and I take special pride in receiving top recognition this year from both NEJM Journal Watch Psychiatry and the Brain and Behavior Research Foundation for bringing our readers the highest quality information that can guide their practice now and in the future.”

These are the two reports selected by NEJM Journal Watch Psychiatry:

The Brain and Behavior Research Foundation selected these reports:

More information about these studies will appear in a future issue of Psychiatric News.


(Image: American Journal of Psychiatry)

Monday, January 9, 2017

Patients With Depression, Panic Disorder May Experience More Side Effects on Antidepressants


Patients with chronic depression and panic disorder appear to experience more side effects from antidepressants than those without panic disorder, according to a study in the Journal of Clinical Psychiatry.

“These results have clinical importance, as side effects vary in their tolerability, need for clinical management, and effects on attrition and outcome,” Stewart Shankman, Ph.D., of the University of Illinois at Chicago and colleagues wrote. “Thus, ability to predict which side effects will more likely occur matters for adequate pharmacological management.”

The researchers analyzed data collected as part of the Research Evaluating the Value of Augmenting Medication with Psychotherapy (REVAMP) trial, during which patients with chronic depression were openly assigned to antidepressants for 12 weeks. Every two weeks, patients were asked to evaluate antidepressant side effects using the Patient-Rated Inventory of Side Effects (PRISE) and the Frequency, Intensity, and Burden of Side Effects Rating (FIBSER); depressive symptoms were also evaluated every two weeks, using the Hamilton Depression Rating Scale (HDRS).  

For the current study, Shankman and colleagues examined the associations between comorbid panic disorder, social phobia, and generalized anxiety disorder (GAD) and patient reports of side effects in eight categories: gastrointestinal, cardiovascular, dermatologic, neurologic, eye/ear, genitourinary, sleep, and sexual functioning. Of the 808 patients in the study, 85 had a lifetime diagnosis of panic disorder, 123 had a lifetime diagnosis of social phobia, and 85 had a lifetime diagnosis of GAD; 711 patients (88%) reported at least one medication side effect over the course of the 12-week trial. 

The researchers found that a diagnosis of comorbid panic disorder was positively associated with self-reported gastrointestinal, cardiovascular, neurologic, and genitourinary medication side effects—an association that was not seen in patients with GAD and social phobia. Additional analysis revealed that panic disorder significantly moderated the association between the frequency and severity of side effects and the course of depressive symptoms.

“That side effects and depressive symptoms were more strongly correlated for patients with panic disorder than for those without has important clinical implications,” the authors wrote. “Clinicians treating chronically depressed individuals should pay particular attention to gastrointestinal, cardiac, neurological, and genitourinary side effects reported by patients with comorbid panic disorder and perhaps adjust the treatment accordingly. [C]linicians may want to consider treating these patients’ panic disorder (or at least heightened interoceptive awareness) concurrent with the antidepressant treatment.

For related information, see the Psychiatric News article “Study to Answer What Comes Next When MDD Patients Don’t Respond.” 

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