Wednesday, December 24, 2014

Long-Term Study Assesses Fetal Alcohol Syndrome Outcomes in Adults


A Swedish population study finds that that many of the educational, employment, health, and other outcomes for 79 adults diagnosed as children with fetal alcohol syndrome (FAS) were different from those of a matched comparison group of 3,160 people, said Jenny Rangmar, Ph.L, a doctoral candidate at Gothenburg University, and colleagues in the January Pediatrics.

For instance, the FAS group (average age, 32) were more likely to have received a disability pension (31 percent vs. 3 percent), to have received special education (25 percent vs. 2 percent), and to have higher hospital admission rates for psychiatric disorders (33 percent vs. 5 percent).

However, rates of criminal conviction were slightly but not significantly higher for the FAS group and were actually lower than a subset of the comparison group that had been placed in state care. Of those who did receive special education, about 60 percent completed high school, suggesting some disabilities “may be ameliorated by protective factors like special education and assistance in school.” Finally, 49 percent of FAS subjects were employed, although probably in lower-paying jobs than their peers, the researchers noted.

These results may have been influenced by an early diagnosis of FAS, providing “a protective effect because it may give children benefit from appropriate services,” said Rangmar and colleagues.

To read more about studies of fetal exposure to substances of abuse, see the Psychiatric News article “How Do Abused Drugs Affect Fetus, Newborn?

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Tuesday, December 23, 2014

CBT For Children With Anxiety May Confer Long-Term Suicide Prevention Benefit, Study Suggests


Successful cognitive-behavioral therapy (CBT) for childhood anxiety disorder may confer long-term benefits for suicide prevention, according to a report in the Journal of the Academy of Child and Adolescent Psychiatry.

Evidence for an independent relationship between anxiety and suicidality has been mixed. Researchers from the Center for Mental Health Policy and Services Research at the University of Pennsylvania Perelman School of Medicine examined the relationship between response to treatment for an anxiety disorder in childhood and suicidal ideation, plans, and attempts at a follow-up interval of seven to 19 years. In the study, 66 adults were assessed, having completed CBT treatment for anxiety as children. Information regarding suicidality at follow-up was obtained via the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview and the Beck Depression Inventory.

The follow-up data indicated that participants who responded favorably to CBT during childhood were less likely to endorse lifetime, past-month, and past-two-week suicidal ideation than were treatment nonresponders. This was consistent across self-report and interview-report of suicidal ideation.

“Results suggest more chronic and enduring patterns of suicidal ideation among those with anxiety in childhood that is not successfully treated,” the researchers stated. “This study adds to the literature that suggests successful CBT for childhood anxiety confers long-term benefits and underscores the importance of the identification and evidence-based treatment of youth anxiety.”

For more on research into suicide prevention, see the Psychiatric News article, "Novel Suicide-Prevention Treatment Targets Poor Sleep."

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Monday, December 22, 2014

Benzodiazepine Prescriptions High Among the Elderly, Study Finds


A new surveillance study has found that benzodiazepine usage increases with age, with nearly 9 percent of adults aged 65 to 80 filling a benzodiazepine prescription in 2008, compared with around 7 percent of adults 51 to 64, 5 percent of adults aged 36 to 50, and less than 3 percent of adults aged 18 to 35.

Adults over 65 were also more likely to have a long-term prescription for a benzodiazepine and were more likely to have their prescription written by a nonpsychiatrist; psychiatrists wrote less than 6 percent of benzodiazepine prescriptions for those aged 65 to 80.

These findings were published in JAMA Psychiatry on December 17.

Benzodiazepines can be effective in the short-term for treating anxiety or insomnia, but their risk of dependence and adverse effects such as cognitive impairment and loss of balance has led to expert recommendations to limit their use, especially in elderly people.

“It was alarming to find the highest rates of benzodiazepine use among the group with the highest risks,” said study author Michael Schoenbaum, Ph.D., of the Office of Science Policy, Planning, and Evaluation at the National Institute of Mental Health. “Given that safer, effective options are available for anxiety and insomnia, it’s hard to make a clinical argument for these results.”

Schoenbaum proposed that clinicians should restart a dialogue on the usage of benzodiazepines in the elderly, though a commentary accompanying the study suggested even stronger changes.

“It may be time to act, perhaps first by restricting the prescription of benzodiazepines to psychiatrists. In the study, psychiatrists seemed to prescribe them properly. The next step is to consider them the same as other dangerous addictive substances and put them on a tight dispensation schedule using limited-duration prescriptions with no refills,” the commentary authors wrote.

To read about the potential cognitive harm of benzodiazepine use, see the Psychiatric News article "Long-Term Use of Benzodiazepines May Be Linked to Alzheimer’s.

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Friday, December 19, 2014

Hyperactivity of Caudate Nucleus May Be An Underlying Factor of OCD Symptoms, Study Finds


A study published in today’s American Journal of Psychiatry suggests that misfiring of the brain’s control system for habits may be a reason for compulsions in obsessive-compulsive disorder (OCD).

Researchers in the departments of psychiatry and psychocology at Cambridge Behavioural and Clinical Neuroscience Institute and New York University performed MRI scans on the brains of 70 people, with and without OCD, to determine whether an association existed between symptoms of OCD and abnormal brain activation in the caudate nucleus, a structure in the basal ganglia that must fire correctly for one to control their habits. While receiving scans, the patients were asked to press a pedal, a part of a pedal pressing behavioral test, to avoid shock to the wrist. In the final stage of testing, the shock block was removed to assess whether the pedal-pressing behaviors of the patients could be discontinued.

The researchers found that patients with OCD were less capable of stopping their pedal-pressing habits than the control group. In addition, individuals in the OCD cohort were more likely to have hyperactivation in the caudate nucleus, compared with those without OCD.

The study’s lead author, Claire Gillian, Ph.D., a professor of psychology at the New York University, stated that the findings may not be specific to OCD and that in fact habits may underpin symptoms of many psychiatric conditions. “There are a range of human behaviors that are now considered examples of compulsivity, including drug and alcohol abuse and binge eating. What all these behaviors have in common is the loss of top-down control, perhaps due to miscommunication between regions that control our habits and those such as the prefrontal cortex that normally help control volitional behavior. As compulsive behaviors become more ingrained over time, our intentions play less and less of a role in what we actually do,” she concluded.

To read about other studies investigating possible pathophysiologies of OCD, see the Psychiatric News article “Study Looks at Association Between OCD, Schizophrenia.”

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Thursday, December 18, 2014

Preliminary Study Shows Primary Care Provider Training Can Improve Prescribing for Children


A New York state initiative to provide psychiatric consultation to pediatric primary care providers about prescribing psychotropic medication shows promise for enhancing providers' comfort with prescribing, according to the report “Detection and Treatment of Mental Health Issues by Pediatric PCPs in New York State: An Evaluation of Project TEACH” published online in Psychiatric Services in Advance.

Researchers in the Department of Child and Adolescent Psychiatry at New York University School of Medicine and colleagues at other institutions evaluated Project TEACH (PT), a statewide training and consultation program for pediatric primary care providers (PCPs) on identification and treatment of mental health conditions. The project is part of a collaboration between the REACH Institute (Resource for Advancing Children’s Health) and five academic departments of psychiatry. The curriculum consists of 15 hours of in-person training, a tool kit, and Web-based learning tools, along with a six-month distance learning program that includes 12 one-hour consultation calls with child psychiatrists.

Researchers compared an intervention group of 176 PCPs who volunteered for PT training with a stratified random sample of 200 PCPs who did not receive PT training. Data on prescription practices, diagnoses, and follow-up care were from New York State Medicaid files for youths seen by the trained and untrained PCPs. They found that the percentage of children prescribed psychotropic medication increased after PT training (from 9% to 12%), a larger increase than in the untrained group (from 4% to 5%).

“Our findings suggest potential benefits of training PCPs to identify and treat children’s mental health conditions," the researchers said. "Provider training and consultation may be a meaningful way to help reduce the number of children who do not receive treatment for mental health conditions, but further research is necessary to determine whether this type of model will be useful as the responsibility for mental health care and outcomes shifts under health care reform.”

For more about this program, see the Psychiatric News article, "New York Child Psychiatry Divisions Fill Gap in Collaborative Care Model."

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Wednesday, December 17, 2014

Health Coaching Intervention Effective for Obesity in Those With Serious Mental Illness, Study Finds


A health coaching intervention for obesity appears to be effective in achieving and sustaining clinically significant reductions in cardiovascular risk for overweight and obese individuals with serious mental illness.

That’s the finding of a replication trial of the In SHAPE program in the report “Pragmatic Replication Trial of Health Promotion Coaching for Obesity in Serious Mental Illness and Maintenance of Outcomes,” published in AJP in Advance.

In SHAPE is a 12-month program consisting of individual weekly meetings in the community with a health-promotion coach, a fitness club (YMCA) membership, and nutrition education adapted for people with serious mental illness that was found in a previous study to contribute to clinically significant reduction in cardiovascular risk in overweight or obese adults with serious mental illness.

In the new study, Stephen Bartels, M.D., of the Department of Psychiatry and the Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth and colleagues randomly assigned 210 individuals with serious mental illness and a body mass index greater than 25 receiving services in three community mental health organizations either to the 12-month In SHAPE program or to fitness club membership alone. The primary outcome measures were weight and cardiorespiratory fitness (as measured with the 6-minute walk test) assessed at baseline and at 3, 6, 9, 12, and 18 months.

At 12 months, the In SHAPE group had greater reduction in weight and improved fitness compared with the fitness club membership group. Primary outcomes were maintained at 18 months. Approximately half of the In SHAPE group achieved clinically significant cardiovascular risk reduction, defined by a weight loss greater than 5 percent or an increase of greater than 50 meters on the 6-minute walk test.

“By comparing In SHAPE to an active comparison condition (a fitness club membership), we were able to test the specific contribution of having a health-promotion coach,” the researchers stated. “Having a health-promotion coach was associated with more than two-and-a-half times the mean amount of fitness club attendance, which in turn was associated with greater weight loss and improved fitness.”

For more on this subject, see the Psychiatric News article, "Health Mentors Prove Valuable For Those With Serious Mental Illness."


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Tuesday, December 16, 2014

Senator Blocks Passage of Veterans' Suicide Prevention Bill


The legislative battle went down to the wire, but a lone recalcitrant senator ultimately blocked passage of a bill to help reduce suicides among veterans by enabling the Veterans Health Administration (VHA) to hire more psychiatrists. APA, veterans’ service organizations, and the Department of Veterans Affairs had strongly backed the Clay Hunt Suicide Prevention for American Veterans Act, which the House of Representatives approved unanimously last week.

The Senate vote was blocked by a “hold” placed on the bill by retiring Sen. Tom Coburn (R-Okla.), who objected to the allegedly dysfunctional management of the VHA. A hold permits a single senator to block a vote on the Senate floor.

In reply, Sen. Richard Blumenthal (D-Conn.) noted that the act included provisions for annual evaluations of the VHA’s mental health care and suicide prevention programs, in addition to encouraging recruitment of “not less than 10” psychiatrists per year into the VHA in part through use of a medical school loan repayment program. Psychiatrists entering the program would agree to a minimum of two years of service with the VHA in return for a $30,000 per year loan repayment.

There is hope for passage early next year, however. “Veterans groups have assurances from Senators John McCain (R-Ariz.) and Richard Burr (R-N.C.) for a quick reintroduction in January,” said Lizbet Boroughs, deputy director of APA’s Department of Government Relations. “A bipartisan group of 20 senators currently supports the bill, and Representatives Jeff Miller (R-Fla.) and Tim Walz (D-Minn.) will act quickly on the House side, as well.”

For more in Psychiatric News about psychiatrists and mental health care in the VHA, see the article “Psychiatrists’ Pay to Rise at Veterans Health Administration.”

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