Wednesday, August 26, 2015

Military Women Are at No Greater Risk of Developing PTSD Than Men


While past research on gender differences in the onset of posttraumatic stress disorder (PTSD) among U.S. veterans has been mixed, a recent study by the departments of Defense and Veterans Affairs suggests that women in the military are at no greater risk of developing PTSD than their male counterparts who experience similar traumatic events.

The study included more than 2,300 pairs of men and women in the military who were matched based on an array of variables—including combat exposure, alcohol misuse, depression, and sexual assault—and surveyed on PTSD symptoms over an average time span of seven years (from 2001 to 2008). All participants had been deployed at least once to Iraq or Afghanistan and did not show signs of PTSD at the study’s initiation. Outcome measures included a positive screen for PTSD and symptom severity scores measured by the PTSD Patient Checklist-Civilian Version.

The results, published in the Journal of Psychiatric Research, showed that 6.7 percent of women and 6.1 percent of men developed PTSD — a difference that was not statistically significant. There was also no difference in the severity of PTSD symptoms among men and women who developed the disorder.

“This study supports the positive direction being taken by the expansion of women's occupations into combat arms roles, and suggests continued support from the [Department of Defense] for women seeking occupational equality in the military setting,” the researchers noted. They concluded that the current findings support the notion that gender alone is not an indicator of PTSD risk.

To read more about the efforts to treat PTSD in military personnel, see the Psychiatric News article “Military Turns to Collaborative Care to Treat PTSD, Depression.”

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Tuesday, August 25, 2015

Outreach Care Management, Self-Management Improves Outcomes for Patients With Depression


A program that combined outreach care management and self-management skills for people with chronic or recurrent depressive symptoms was more effective than treatment as usual in reducing depressive symptoms and major depressive episodes, according to a study published last week in Psychiatric Services in Advance.

Researchers from the Group Health Research Institute in Seattle recruited 302 participants ages 18 and older with chronic depression or recurrent episodes of depression from five primary care clinics in the Seattle area. Participants were randomly assigned to treatment as usual or a self-management support service consisting of depression self-management training, recovery coaching, and care coordination.

The 18-month intervention included regular telephone or in-person contacts with a care manager and a structured group program. As part of the group program, participants met weekly for ten weeks, twice a month for two months, and then once a month for maintenance of progress. The meetings were co-led by a care manager and a trained peer specialist.

Repeated-measures estimates of the long-term effect of the intervention versus usual care (average of the six-, 12-, and 18-month outcomes adjusted for age, gender, and site) indicated that intervention participants had less severe symptoms, higher recovery scores, and were less likely to be depressed.

“A systematic program of care management and group self-management support is a worthy addition to outpatient care for patients with chronic depressive symptoms,” the study authors wrote. “By combining elements of the chronic care model and the recovery model in a single program, the program successfully integrated the management strengths of the chronic care model with the sense of optimism and well-being provided by a care management approach.”

For related information, see the Psychiatric News article “Integrated Care Book Offers ‘How-To’ Advice for Psychiatrists.

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Monday, August 24, 2015

Suicidal Thoughts, Attempts Are Higher in Patients With Migraine, Comorbid Fibromyalgia


People who have migraines and fibromyalgia have a higher rate of suicidal thoughts or attempts than those with migraines alone, according to a study published online Friday in Neurology.

For the study, researchers surveyed over 1,300 adult migraine patients who had attended a specialty headache clinic. Around 10% of these patients reported also having fibromyalgia, and among this subset 58.3% of patients reported suicidal ideation and 17.6% reported suicide attempts. In migraine patients who did not report fibromyalgia, the rates for ideation and attempt were 24.1% and 5.7%, respectively.

Patients with migraines and fibromyalgia also reported a higher frequency of headaches, more headache-related disability, poorer sleep quality, and more depression and anxiety symptoms than those with migraines only.

The authors noted that since all the participants in the study went to a headache clinic, their symptoms and discomfort may be higher than the average population, so the findings may not be applicable to everyone. However, they recommended that future studies explore the relationship between suicide risk and other pain conditions to see if there is some unique effect of combined migraine and fibromyalgia or if the risks are due to increased pain in general.

To read more about the effective management of people with chronic pain conditions, see the FOCUS article "A Review of Chronic Noncancer Pain: Epidemiology, Assessment, Treatment, and Future Needs."

(Image: Monkey Business Images/Shutterstock)

Friday, August 21, 2015

Study Identifies Effective Weight Loss, Smoking Interventions for People With SMI


Four interventions—metformin and behavioral strategies for weight loss and bupropion and varenicline for smoking reduction—were found to be effective in people living with serious mental illness, according to a review in Schizophrenia Bulletin.

People with serious mental illness (SMI) have mortality rates two to three times higher than that of the overall U.S. population. The prevalence of cardiovascular risk factors, such as obesity and diabetes mellitus, and other conditions, such as HIV/AIDS, are particularly heightened in this group.

Based on the recommendations of a National Institute of Mental Health (NIMH) stakeholder meeting, researchers from Johns Hopkins University and NIMH conducted a comprehensive review examining the strength of the evidence surrounding interventions to address major medical conditions and health-risk behaviors among persons with SMI. A total of 108 randomized, controlled trials and observational studies testing interventions to address medical conditions and risk behaviors among persons with schizophrenia and bipolar disorder between January 2000 and June 2014 were included.

The authors found that well-designed behavioral interventions and metformin were beneficial for weight loss, and bupropion and varenicline reduced tobacco smoking among people with serious mental illness. However, the strength of the evidence was low for most other interventions reviewed.

“Future studies should test long-term interventions to cardiovascular risk factors and health-risk behaviors,” the researchers stated. “In addition, future research should study implementation strategies to effectively translate efficacious interventions into real-world settings.”

For more information, see the Psychiatric News article “What Can Psychiatrists Do for People With SMI?

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Thursday, August 20, 2015

Appeals Court Decision Could Push Enforcement of MH Parity Law


The U.S. Court of Appeals for the Second Circuit ruled today that a lawsuit against UnitedHealth Group and subsidiaries, including United Behavioral Health, for violation of the federal parity law can go forward, dismissing objections raised on appeal by United.

The court’s ruling will allow a suit brought by the New York State Psychiatric Association (NYSPA) against United to go forward in the U.S. District Court for the Southern District of New York. The ruling also establishes at least two points that may be important in future claims against insurers.

First, it recognized that NYSPA could represent its members and their patients in pressing a claim under the Mental Health Parity and Addiction Equity Act (MHPAEA) through “associational standing.” (Both APA and the AMA filed amicus briefs on behalf of NYSPA emphasizing that associations have traditionally been permitted to represent their members’ interest in litigation that is consistent with the mission of the association and that physicians are permitted to represent the interest of their patients.) Second, it recognized that United could be sued even when it acted not as the insurer but as the administrator of a self-insured plan. This means that the carriers are at risk under MHPAEA whenever they exercise discretion in the administration of benefits and employees do not have to sue their employer (as United argued) to recover benefits.

APA President RenĂ©e Binder, M.D., commented, “Today’s decision gives professional organizations, such as APA and NYSPA, the right, on behalf of its members and their patients, to sue for mental health parity violations, which is important because patients are often unable to speak out for themselves. This ruling gives us hope that the Mental Health Parity Act of 2008 will now be enforced.”>

Seth Stein, J.D., executive director of NYSPA, hailed the court’s decision as a victory for NYSPA members and their patients. “NYSPA pursued this lawsuit to help enforce federal parity rules," he told Psychiatric News. “We are pleased that the court agreed that NYSPA had standing at this point in the litigation to represent the interests of our members and their patients, particularly where we believe that health plans are violating federal parity laws and interfering with access to care for the treatment of mental illness. The decision of the court regarding the ability to sue plan administrators is particularly important because it removes a technicality that plan administrators might raise to avoid being responsible when they make determinations that run afoul of federal parity laws.”

The original lawsuit was brought by NYSPA and several individual patients, a member psychiatrist, and a psychologist in March 2013 alleging that UnitedHealth Group and subsidiaries, including United Behavioral Health, systematically violated the federal parity law and the Affordable Care Act. NYSPA joined the suit on behalf of its members and their patients. At that time, Stein told Psychiatric News that the district branch had fielded numerous complaints from its members about denial of mental health and substance use treatment by United (Psychiatric News, April 5, 2013).

In his blog on APA's website, APA Medical Director and CEO Saul Levin, M.D., M.P.A., wrote, "APA is working tirelessly to advance parity. ... We’ve brought greater attention to parity at the U.S. Department of Labor, to state attorneys general, and to major employers – and we are finding many people are interested to help." Read the entire message.

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Wednesday, August 19, 2015

FDA Approves First Treatment for Hypoactive Sexual Desire Disorder in Women


Yesterday, the Food and Drug Administration approved Addyi (flibanserin) to treat acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. The medication is the first FDA-approved treatment for sexual desire disorders in men or women.

“The problems associated with low sexual desire are commonly seen in psychiatric practice and may be comorbid with many psychiatric disorders, especially anxiety and mood disorders,” said Robert Segraves, Ph.D., M.S., a professor emeritus of psychiatry at Case Western Reserve University and a member of the Sexual and Gender Identity Disorders Work Group for DSM-5. “For the first time, an approved medication can be prescribed for this disorder.”

The approval of the Addyi—a serotonin 1A receptor agonist and serotonin 2A receptor antagonist—was based on data from three 24-week randomized, double-blind, placebo-controlled trials in approximately 2,400 premenopausal women with acquired, generalized HSDD. The average age of the trial participants was 36 years, with an average duration of HSDD of approximately five years. The participants took either an oral 100 mg dose of Addyi or placebo at bedtime.

Across the three trials, women taking Addyi were 10% more likely to report at follow-up meaningful improvements in past-month sexual event satisfaction or sexual desires than women being treated with placebo. On average, treatment with Addyi increased the number of satisfying sexual events by 0.5 to 1 additional event per month over placebo. The most common adverse reactions associated with the use of Addyi included dizziness, somnolence, and dry mouth. The mechanism by which Addyi improves sexual desires is currently unknown.

Addyi was approved also with a Boxed Warning to highlight the risk of severe hypotension and loss of consciousness (syncope) in patients who drink alcohol during treatment with Addyi and in those who use moderate to strong CYP3A4 inhibitors that interfere with the breakdown of the medication. The newly approved drug is also contraindicated for those with liver disease.

Because of the increased risk of severe hypotension and syncope due to the interaction between Addyi and alcohol, the FDA is requiring all prescribers of Addyi to enroll and complete training in a risk evaluation and mitigation strategy (REMS), which includes elements to assure safe use. Certified prescribers must counsel patients using a Patient-Provider Agreement Form about the increased risk of severe hypotension and syncope and about the importance of not drinking alcohol during treatment with Addyi. Only REMS-certified pharmacies will be allowed to dispense Addyi from a certified prescriber.

For more information on Addyi, see the FDA press announcement here. To read more about Sexual and Gender Identity Disorders, see the Psychiatric News article Layperson’s Guide to DSM-5 Describes Sexual Disorders, Gender Dysphoria.

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Tuesday, August 18, 2015

Black, White Seniors With Depression Respond Similarly to Venlafaxine


Despite greater comorbidity and less prior exposure to antidepressant treatment and psychotherapy, older African Americans appear to be no more likely to discontinue venlafaxine treatment and experience a rate of remission from depression that is comparable to white seniors, according to a study appearing online in Psychiatric Services in Advance.

The results suggest that with appropriate pharmacotherapy embedded in good supportive care it is possible to mitigate the well-established disparity in antidepressant outcomes between older black and white adults, according to the study authors.

Researchers from several institutions analyzed data from the initial phase of a NIMH-sponsored multicenter trial (Pittsburgh, St. Louis, and Toronto) called “Incomplete Response in Late-Life Depression: Getting to Remission” (IRL-GREY). In the initial phase of IRL-GREY, a total of 47 black and 412 white adults aged 60 or older were treated with open-label venlafaxine extended-release for 12 to 14 weeks.

Venlafaxine extended-release was initiated at 37.5 mg per day and titrated to a target dose of 150 mg per day. At the end of week six, non-remitters had their dose increased further to a target dose of up to 300 mg per day. Throughout the study, pharmacotherapy was embedded in a model of depression care management including supportive clinical care focusing on psychoeducation about depression and its treatment, depressive symptoms, suicidal ideation, countermeasures for medication adverse effects, and treatment adherence.

Baseline depression severity, depression duration, age at onset, and recurrence history did not differ between groups; however, black participants had greater baseline general medical comorbidity, worse physical health–related quality of life, and poorer cognitive function compared with white participants. White participants were also more likely to have received an adequate trial of antidepressant and psychotherapy before study entry.

Despite the differences between the two groups, the study authors found that black and white participants had similar final doses of venlafaxine and similar rates of attrition and remission.

“Our findings suggest that with adequate treatment it is possible to mitigate the disparity in antidepressant outcomes between older black and white adults,” the researchers stated. “With appropriate pharmacotherapy embedded in good supportive care, black and white older adults with major depressive disorder can do equally well.”

For related information, see the Psychiatric News article “No Racial Differences Found in Effectiveness of Psychotherapy for Depression.”

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