Friday, August 26, 2016

U.S. Surgeon General Asks Physicians to Pledge Commitment to Stop Opioid Epidemic

In a letter sent to 2.3 million physicians and other health care professionals across the country on Thursday, the U.S. Surgeon General asked them to pledge their support of a national movement to reverse the opioid epidemic in the United States.

“Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly—almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed,” wrote Surgeon General Vivek Murthy, M.D., M.B.A. “Now, nearly 2 million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C.”

The letter—which Murthy noted marks the first sent from his office to health professionals to address a public health crisis—is part of the Surgeon General’s TurnTheTide Campaign, a national effort to raise awareness about those affected by opioid use disorder, successful treatment programs, and the challenges that remain in communities hardest hit by the epidemic.

Murthy asked health care professionals to commit to addressing the growing problem of prescription opioid abuse through several actions:

  • Learn how best to treat pain safely and effectively. (The letter directs professionals to a pocket guide based on CDC Opioid Prescribing Guidelines.)
  • Screen patients for opioid use disorder and provide or connect them with evidence-based treatment.
  • Speak openly about the fact that addiction is a chronic illness that requires treatment.

“I know solving this problem will not be easy. We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic,” Murthy wrote.

To read more and pledge your support of the Surgeon General’s campaign to end the opioid epidemic and access APA training and other resources on opioid use disorder, click here.

For related information, see the Psychiatric News article “Residents Can Help to Curb the Current Opioid Epidemic” by Rachel Katz, M.D.

Thursday, August 25, 2016

Metformin May Curb Weight Gain in Youth Taking Antipsychotics for Autism

Although atypical antipsychotic medications can help to reduce irritability and agitation in youth with autism spectrum disorder (ASD), these medications are known to cause weight gain and may increase risk of diabetes. A small trial published online yesterday in JAMA Psychiatry suggests that metformin, a drug used for treatment of type 2 diabetes, may decrease weight gain in children with ASD.

Evdokia Anagnostou, M.D., a senior clinician scientist at the Bloorview Research Institute in Toronto, and colleagues randomly assigned 61 young people (aged 6 to 17) with ASD to receive metformin or placebo for 16 weeks. (All of the study participants had been taking a stable dose of an atypical antipsychotic for at least one month and had documented weight gain since starting on the medication.) Children aged 6 to 9 received metformin or matching placebo titrated up to 500 mg twice daily; those 10 to 17 received 850 mg twice daily. The primary outcome measure was change from baseline to week 16 in body mass index (BMI) z scores. 

“Metformin was superior to placebo in reducing weight gain associated with atypical antipsychotics,” the researchers reported. “No significant differences were noted in changes of any of the metabolic variables studied.” Overall, metformin was well tolerated, but the authors noted youth taking metformin experienced a higher percentage of treatment days with gastrointestinal adverse events during the 16-week trial.

“Anagnostou et al. have made a significant contribution to the literature and provided clinicians with an effective approach to consider for managing weight gain in youths with ASD treated with atypical antipsychotics,” wrote Christopher McDougle, M.D., director of the Lurie Center for Autism at Massachusetts General Hospital in Lexington, Massachusetts, in an accompanying editorial. “In addition to more studies of this approach, alternative strategies that warrant investigation include the co-administration of topiramate, monotherapy with ziprasidone, and undoubtedly others.”

For more in Psychiatric News about the side effects of antipsychotics in young people, see “Exposure to Antipsychotics May Increase Risk of Type 2 Diabetes in Youth.”

(Image: forestpath/Shutterstock)

Wednesday, August 24, 2016

New Model Found Useful for Predicting Alcohol Use in Youth

A study published in AJP Advance shows that combining data from demographic interviews with data from neuropsychological and neuroimaging tests may be useful for predicting adolescents who may be at risk of initiating alcohol use by age 18.

“Previous findings have suggested that a mix of social, psychological, and biological mechanisms contribute to alcohol use during adolescence,” wrote the study authors, a team a behavioral scientists and psychiatric researchers. Neuropsychological and neuroimaging data may provide quantification of underlying behavioral mechanisms of risk for substance use and better help identify at-risk adolescent before they initiate such use.

The study involved 137 substance-naïve adolescents aged 12 to 14. Participants' demographic information was obtained at baseline through interview. Neuropsychological testing at baseline was administered to evaluate the neurocognitive function; structural magnetic resonance imaging (sMRI) and functional magnetic resonance imaging (fMRI) were used to assess brain structure. Information on participants' substance use, assessed by the Customary Drinking and Drug Use Record, was updated every six months by telephone interview until the end of the study. 

The results showed that by age 18, 70 adolescents (51%) initiated moderate to heavy alcohol use, and 67 remained nonusers. The combined data model was found to be 74% accurate in predicting such outcomes. In comparison, the demographic model had an accuracy rate of 62%, and the demographic and neuropsychological model, 69%.

In addition, the study identified 34 predictors that contributed to alcohol use by age 18, including being male, higher socioeconomic status, early dating, more externalizing behaviors, worse executive functioning, and thinner cortices, and less brain activation in diffusely distributed regions of the brain. 

"The results provide evidence that multimodal neuroimaging data, as well as neuropsychological testing, can be used to generate predictions of future behaviors with [possibly] significantly better accuracy than demographic information alone," the authors wrote. "Understanding neurocognitive factors that predate substance use initiation is crucial to specifying the consequences of substance use on brain development, as well as identifying at-risk youths and potential targets of preventive efforts." 


Tuesday, August 23, 2016

FDA Approves Devices for Assessing Cognitive Function After Brain Injury

Two devices for assessing cognitive function immediately following a suspected brain injury or concussion were approved for marketing by the Food and Drug Administration (FDA) yesterday.

The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and ImPACT Pediatric are the first medical devices permitted for marketing that are intended to assess cognitive function following a possible concussion, according to the FDA. They are intended as part of the medical evaluation that doctors perform to assess signs and symptoms of a head injury.

“These devices provide a useful new tool to aid in the evaluation of patients experiencing possible signs of a concussion, but clinicians should not rely on these tests alone to rule out a concussion or determine whether an injured player should return to a game,” said Carlos Peña, Ph.D., M.S., director of the Division of Neurological and Physical Medicine Devices at the FDA’s Center for Devices and Radiological Health, in a statement announcing the approval.

ImPACT software runs on a desktop or laptop and is intended for use with those aged 12 to 59, while the ImPACT Pediatric runs on an iPad and is designed for children aged 5 to 11. 

ImPACT and ImPACT Pediatric are not intended to diagnose concussions or determine appropriate treatments. Instead, they are meant to test cognitive skills such as word memory, reaction time, and word recognition, all of which could be affected by a head injury. The results are compared with an age-matched control database or to a patient’s pre-injury baseline scores if available.

Only licensed health care professionals should perform the test analysis and interpret the results.

The FDA reviewed ImPACT through its de novo classification process, a regulatory pathway for novel, low- to-moderate-risk medical devices that are first of a kind and for which there are special and general controls to provide a reasonable assurance of safety and effectiveness of the devices. The assessment tools are manufactured by ImPACT Applications in Pittsburgh, Pennsylvania.

For related information, see the Psychiatric News article "Computer-Based Tool Can Offer Rapid Screening After TBI."

(Image: stockdevil/

Monday, August 22, 2016

New Scoring System May Improve Reliability of PMDD Diagnosis

Premenstrual dysphoric disorder (PMDD)—which was added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—is a debilitating condition characterized by the emergence of mood and emotional symptoms in the luteal phase of the menstrual cycle.

This condition is difficult to diagnose, however, because doing so prospectively requires the evaluation of daily symptom ratings and their fluctuations over a two-month period. As such, many clinicians make decisions through a retrospective analysis of a patient’s symptoms, which is known to be prone to false positives, according to the authors.

A study published in AJP in Advance has proposed a new approach termed the Carolina Premenstrual Assessment Scoring System (C-PASS). Through this computerized procedure, clinicians can enter patient-provided ratings on a spreadsheet that determines a PMDD diagnosis based on a standardized thresholds. 

The study authors compared the C-PASS diagnoses of 200 women who had submitted their symptom ratings each week with those of an expert clinician who also reviewed prospectively and found a 94.5% agreement between the two (11 disagreements).

“The current C-PASS materials may be immediately useful clinically,” the study authors concluded. “However, additional development is needed to digitize data collection and streamline the diagnostic process for clinical application.”


Friday, August 19, 2016

Probiotics Alone May Be Unlikely to Reduce Risk of Depression, Report Finds

Past reports suggest the consumption of foods containing probiotics, such as yogurt, may lead to health benefits, including lower fasting glucose and blood pressure levels. Do probiotics also lower the risk of depression?

According to a large cross-sectional study published today in the Journal of Neuropsychiatry and Clinical Neurosciences, the answer appears to be no. 

Researchers from the Department of Epidemiology at Janssen Research and Development in Titusville, New Jersey, assessed 18,019 adults who participated in the National Health and Nutrition Examination Survey (NHANES). As part of this survey, participants were asked to estimate the types and amounts of foods and beverages consumed during the 24-hour period prior to the interview. Depression was measured with the Patient Health Questionnaire (PHQ-9). (Participants were classified as having moderate or more severe depressive symptoms if PHQ-9 scores were 10 or greater and a score of 5 or greater was used to classify subjects with mild to more severe depressive symptoms.)

About 14% of the participants reported consuming probiotics, primarily through their diet. When making an unadjusted comparison, the probiotic users did have about half the odds of depression as non-users (odds ratio of 0.58); however, this did not factor in that people in the probiotic group were more likely to be white, older, women, healthier, and to have higher family income.

When the analysis was adjusted, the association between probiotic exposure and depression disappeared, irrespective of how depression was defined. Excluding the small subset of people who took probiotics via supplements also did not affect the results.

“These findings suggest that it is not the probiotic exposure itself, but the attributes of subjects who consume probiotics, which lessen the odds of depression,” the authors wrote. “Although these data can provide insight, information on usual dietary practices collected over time would be expected to provide a stronger indication of associations between dietary factors and health outcomes.”

For related information, see the Psychiatric News article “Food May Be a Tool to Consider When Helping Psychiatric Patients,” by Drew Ramsey, M.D.

(Image: iStock/gzorgz)

Thursday, August 18, 2016

Antipsychotic Use Early in Pregnancy Does Not Appear to Increase Risk of Birth Defects

With the possible exception of risperidone, taking antipsychotics early in pregnancy does not appear to significantly increase the risk of newborns having birth defects, a study published yesterday in JAMA Psychiatry reports. According to the study authors, more research is needed to understand the small increase in risk for malformations associated with risperidone.

To examine the risk for congenital defects associated with first-trimester exposure to different antipsychotics, Krista Huybrechts, M.S., Ph.D., of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues analyzed a nationwide sample of over 1.3 million pregnant women enrolled in Medicaid. Exposure to antipsychotics was defined as filling at least one prescription during the first 90 days of pregnancy, and congenital malformations overall and cardiac malformations were assessed during the first 90 days after delivery.

Among the 1,341,715 pregnancies included in the study cohort, 9,258 women (0.69%) filled a prescription for an atypical antipsychotic during the first trimester, and 733 women (0.05%) filled a prescription for a typical antipsychotic. The most frequently used atypical antipsychotic was quetiapine, followed by aripiprazole, risperidone, olanzapine, and ziprasidone.

The authors found that overall, 32.7 per 1,000 infants not exposed to antipsychotics were diagnosed with congenital malformations compared with 44.5 per 1,000 infants exposed to atypical antipsychotics and 38.2 per 1,000 infants exposed to typical antipsychotics. 

While unadjusted analyses suggested an increased risk of birth defects with atypical antipsychotics (relative risk [RR], 1.36) but not for typical antipsychotics (RR, 1.17), after controlling for potential confounding by mental and physical comorbid conditions and their associated behaviors, these relative risks fell to 1.05 and 0.90 for atypical antipsychotic and typical antipsychotic exposure, respectively. Additional analysis revealed that women taking risperidone were 26% more likely than women not taking antipsychotics to give birth to an infant with a birth defect.

“The small increase in absolute risk and RR for malformations observed with risperidone should be interpreted with caution because no apparent biological mechanism can readily explain this outcome, and the possibility of a chance finding cannot be ruled out,” the authors wrote. “This finding should therefore be interpreted as a potential safety signal that will require follow-up in other studies.

Reflecting on the findings in a related editorial, Katherine Wisner, M.D., M.S., and colleagues wrote, “The sophisticated pharmacoepidemiologic methodology comprehensively tackles the major challenge in observational studies, that is, confounding by underlying disease factors that are (like the APs [antipsychotics]) potentially associated with pregnancy outcomes. The task is to separate the effect of two exposures (APs and psychiatric disease) on the reproductive outcomes. The finding that “associations between AP exposure and birth defects were attenuated after adjustment for confounding ... implies that these variables, rather than AP exposure, account for much of the effect on congenital malformations.”

For related information on weighing the risks and benefits of medications when treating pregnant women, see the Psychiatric News article “Yes or No: Prescribing Antidepressants to Pregnant Patients” by Jennifer L. Payne, M.D.

(Image: iStock/nattrass)


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