Autistic Traits Associated With Elevated Depression in Youth Aged 10 to 18

At age 10, children with autism spectrum disorder (ASD) and those with high levels of autistic traits have more depressive symptoms than children in the general population, reports a study published in JAMA Psychiatry. These elevated depressive symptoms persist in the children until they are 18 and are significantly influenced by bullying.

“[F]urther research into the role of traumatic experiences, such as bullying, and the utility of interventions to reduce bullying or address its adverse effects could have the potential to reduce the burden of depression in this population,” wrote lead author Dheeraj Rai, Ph.D., of the University of Bristol and colleagues. 

For this study, Rai and colleagues assessed data from the Avon Longitudinal Study of Parents and Children (ALPSAC), which tracked over 15,000 children born in the Bristol area between 1990 and 1992 and their parents until the children turned 18. As part of ALSPAC, investigators conducted periodic clinical assessments and had parents and children complete self-report questionnaires for a range of behavioral issues, including ASD and depression.

The final dataset for the study included 8,087 children. Of this group, 96 children were diagnosed with ASD, 546 had social communication impairments, 526 had problems with speech coherence, 419 displayed repetitive behaviors, and 801 had poor social temperament.

Children with ASD or any of the four autistic traits had higher depressive symptom scores than the general population at age 10, as assessed by the Short Mood and Feelings Questionnaire (SMFQ). The SMFQ scores continued to rise over time, though by age 18 only those with social communication impairments had a significantly higher rate of diagnosed depression than the youth in the general population (1.68 times the risk).

At age 10, the children with ASD and autistic traits who reported being bullied had the highest average SMFQ scores; likewise, youth with social communication impairments who reported being bullied in childhood or adolescence were more likely to have a diagnosis of depression at age 18.

“These findings add to the evidence highlighting a higher burden of depression and also suggest a potentially modifiable pathway, through bullying,” Rai and colleagues wrote. “However, gaps remain in our understanding of the measurement and phenomenology of depression in individuals with autism, which could be a priority for future research. Further work could also focus on improvements in psychological and pharmacological management of depression in ASD.”

To read more about this topic, see the Psychiatric News article, "Social Skills Therapy for ASD Shows Modest Benefits in Routine Settings."

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Highlights From APA’s 2018 Annual Meeting: Issue #1

Everett Sums Up State of Psychiatry in America and Where Profession Is Headed
One of the keys to psychiatry’s future is the development of innovative technologies that will reduce administrative burdens and improve patient care.

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Talking About Firearms With Patients Necessary, But Examine Your Beliefs First
When talking with patients about gun ownership and storage issues, proceed with respect and neutrality.

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APA Poll Finds Americans’ Anxiety Is Increasing, Especially About Health, Safety, and Finances
Many Americans are dealing with stress and anxiety in various areas of their lives, especially with regard to money and paying bills, finds an APA poll.

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Familial History of Psychiatric Disorders Key in Predicting Postpartum Risk
An AJP study reports that the risk of experiencing a postpartum psychiatric episode was highest when mothers had a first-degree relative with bipolar disorder.

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Online Support Shows Potential of Tech-Based MH Care, Insel Says
Online counseling networks show how simple technological approaches can reduce delays in care and build online help communities.

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Rapid Weight Gain, Decreased Insulin Sensitivity Found in Youth Taking SGAs for First Time

Within 12 weeks of starting treatment with low-dose aripiprazole, olanzapine, or risperidone, youth with disruptive behavioral disorders experienced significant increases in total body fat, according to a study published today in JAMA Psychiatry. The study also found that youth treated with these second-generation antipsychotics (SGAs) experienced decreases in insulin sensitivity over the 12-week period.

The findings point to the importance of continued monitoring for metabolic abnormalities when treating youth with antipsychotics.

For the study, Ginger E. Nicol, M.D., of the Department of Psychiatry at Washington University School of Medicine in St. Louis and colleagues recruited antipsychotic-naïve youth aged 6 to 18 with one or more psychiatric disorders and clinically significant aggression. A total of 144 youth were assigned to aripiprazole, olanzapine, or risperidone for 12 weeks. (According to the study authors, mean final antipsychotic doses were representative of pediatric practice patterns and below the doses typically used to treat psychosis: aripiprazole, 6.0 mg; olanzapine, 6.3 mg; risperidone, 1.0 mg.)

The authors used dual X-ray absorptiometry (DXA) and magnetic resonance imaging (MRI) scans to assess changes in total body fat and abdominal fat over the course of the trial. At baseline and 12 weeks, the youth also received an insulin sensitivity test and answered questions about their symptoms.

Although the youth experienced clinically and statistically significant improvements in irritability, aggression, and overall symptoms over the course of the study, the mean DXA percentage total body fat of the youth increased significantly during 12 weeks for all study treatments—1.66% for aripiprazole, 4.12% for olanzapine, and 1.18% for risperidone. Abdominal fat measured by MRI also “increased significantly in visceral and subcutaneous compartments, … [with] greater subcutaneous mean fat increase with olanzapine compared with risperidone and aripiprazole,” Nicol and colleagues wrote. The researchers also found insulin sensitivity decreased significantly from baseline in the pooled study sample.

“These findings confirm previous reports … which showed rapid-onset obesity and glucose dysregulation in children using SGA medications, as well as the greatest weight gain and adverse changes in glucose metabolism in those treated with olanzapine,” Marc De Hert, M.D., Ph.D., and Johan Detraux, M.Psy., of Katholieke Universiteit Leuven in Belgium wrote in an accompanying editorial. They emphasized the importance of routine weight, glucose, and lipid monitoring when prescribing antipsychotics to youth.

“Although no SGA regimen is absolutely free from metabolic consequences, preference should be given to an SGA drug with a low to moderate metabolic risk (thus avoiding olanzapine), and clinicians should aim for the shortest necessary treatment duration in the case of off-label use,” De Hert and Detraux concluded.

For related news, see the Psychiatric News article “Survey Finds Poor Compliance With Guidelines For Monitoring SGAs in Kids.”

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Psychiatrist Patrice Harris, M.D., M.A., Elected President-Elect of the AMA

APA member Patrice Harris, M.D., M.A., a former APA board member and AMA board member, was elected today as president-elect of the AMA during the AMA’s House of Delegates meeting in Chicago. 

“I believe our American Medical Association has well-crafted policy concerning the changing health care environment in this country,” Harris said in an address to the House following her election. “It will be my honor to represent our AMA in the venues where important issues will be debated. I am committed to preserving the central role of the physician-patient relationship in our healing art.”

Harris is the first African-American woman to hold the office.

Harris served on the AMA Board of Trustees beginning in 2011 and served as secretary for the 2014-2015 term and as chair of the board for the 2016-2017 term. As a practicing psychiatrist trained in child/adolescent and forensic psychiatry, she consults with both public and private organizations on health service delivery. She is also chair of the AMA Task Force to Reduce Opioid Abuse and is an adjunct assistant professor in the Department of Psychiatry and Behavioral Sciences at Emory University. 

“I’m elated that Dr. Harris has been elected president of the AMA,” said APA President Altha Stewart, M.D. “This is a great day for APA and for psychiatry. The APA Board of Trustees looks forward to continuing to work with her as both organizations collaborate to increase patient access to care and improve the practice of medicine.”

Harris previously served as the director of health services in Fulton County, Ga., and the head of the Fulton County Department of Behavioral Health and Developmental Disabilities. As chief health officer for Fulton County, she spearheaded efforts to integrate public health, behavioral health, and primary care. She is a past president of the Georgia Psychiatric Physicians Association.

“We are delighted to have a psychiatrist and a former APA Board of Trustees member leading the house of medicine as president-elect of the AMA,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Her election demonstrates how psychiatrists can be leaders in medicine. We look forward to working with Dr. Harris on continued advocacy for improving the quality of care and integrating psychiatry and mental health within medicine.”

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APA Calls on Administration to Defend Patient Protections in ACA

APA has strongly condemned the recent decision by the Department of Justice to not defend the patient protections provided in the Affordable Care Act (ACA) in the case Texas v United States.

Since the ACA took effect in 2013, the uninsured rate among nonelderly adults has dropped 40 percent (from 20.5% in 2013 to 12.2% in 2016), according to the Kaiser Family Foundation. The Justice Department’s decision opens the door for insurers to deny health care coverage to the 130 million individuals with preexisting conditions and allows insurers to raise the premiums for Americans with disabilities, senior citizens, and those who have a history of using more health care.

“We strongly condemn the Administration’s decision not to defend the patient protections provided in the Affordable Care Act, an established law of the land,” APA President Altha Stewart, M.D., said in a statement released Friday. “This is harmful to the health of Americans and is very short-sighted, considering the nation is in the midst of an opioid epidemic and a 30 percent rise in suicide rates. We call upon the administration to reverse this decision and defend the rights of our patients.”

APA also signed on to a similar statement released Saturday with five other medical organizations representing more than 560,000 physician and medical student members. It read, “We strongly urge the Department of Justice to reconsider its decision in Texas v United States and that we all seek policy solutions that increase access to affordable health care that provides all individuals, regardless of their gender, race, and health status, reasonable protections against discrimination in coverage and pricing.”

The Supreme Court had previously upheld the ACA’s individual mandate that required most people to carry minimum essential health insurance, but only in so far as it was a tax provision that yielded at least some revenue for the federal government. But because the Tax Cut Jobs Act eliminates the ACA’s tax/penalty provision of the individual mandate starting in 2019, the Justice Department determined that it will no longer be constitutional as of January 1, according to a memorandum filed June 7. Texas, along with 19 other states, had filed a federal lawsuit in February challenging the individual mandate and other patient protections in the law.

The Justice Department did not uphold the ACA’s “guaranteed issue” and “community rating” provisions. These provisions required insurance companies to provide coverage to those with preexisting conditions and provide the same premiums regardless of medical history.

The Department of Justice’s brief in the case is posted at https://www.justsecurity.org/wp-content/uploads/2018/06/ACA.Azar_.filing.pdf.

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APA Reacts to CDC Report on Uptick in Suicides Across United States

A report released yesterday by the CDC found suicides rates increased significantly in most states between 1999 and 2016, with 25 states experiencing increases of greater than 30%. The report also suggested that more than half of people who died by suicide did not have a known mental health condition.

“Suicide is a critical issue for all of us who work in health care,” APA President Altha Stewart, M.D., said in statement released today. “We know from other research that most people who die by suicide have mental health conditions, though they may not have been formally diagnosed or treated. People should know that suicide is preventable. Anyone contemplating suicide should know that help is available, and that there is no shame in seeking care for your mental health.”

The National Suicide Prevention Hotline is available 24 hours/7 days a week. For those seeking help, please call 1-800-273-8255.

“Suicide is rarely caused by any single factor, but rather, is determined by multiple factors,” including mental illness and prior suicide attempts, as well as social and economic problems, access to lethal means, and poor coping and problem-solving skills, lead author Deborah Stone, Sc.D., of the CDC and colleagues wrote. “Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning.”

Stone and colleagues used data from National Vital Statistics System to calculate national and state-level suicide rate estimates for people aged 10 and older from 1999 to 2016. Suicide rates increased in all states except Nevada, where the rate was consistently high (above 21 per 100,000 people) throughout the study period; the absolute increases in suicide rates ranged from 0.8 per 100,000 people in Delaware to 8.1 per 100,000 people in Wyoming.

The researchers also compared the characteristics of people who died by suicide, with and without known mental health conditions, in the 27 states with complete data in CDC’s National Violent Death Reporting System in 2015. Their analysis revealed that 54.0% of those who died by suicide did not have known mental health conditions (disorders and syndromes listed in DSM-5). While most of the people who died by suicide were male (76.8%) and non-Hispanic white (83.6%), those without known mental health conditions were more likely to be male (83.6% versus 68.8%) and belong to a racial/ethnic minority than those with known mental health conditions.

“Today's report on suicide reinforces the need to fund and enforce laws ensuring access to mental health services,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Early identification of mental illness is essential, and we are ready to work with Congress and other stakeholders to ensure that Americans can receive treatment when needed.”

For related information, see the Psychiatric News article “How to Reduce Risk of Suicide by Firearms,” by Liza Gold, M.D.

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Alcohol Use Intervention in ED Shows Promise in Reducing Dating Violence, Depression

A single motivational interviewing-based brief intervention used in the emergency department to curb underage drinking may also reduce short-term dating violence and depression, according to a study in the June issue of Pediatrics.

For this study, Quyen M. Ngo, Ph.D., of the University of Michigan Medical School and colleagues analyzed data collected as part of the U-Connect trial. A total of 836 adolescent patients in the emergency department (aged 14 to 20) who screened positive for risky drinking on the Alcohol Use Disorders Identification Test were randomly assigned to a computer-led brief intervention, a therapist-led brief intervention, or a control group that received “enhanced usual care” (staff reviewed a resource brochure with participants). 

In addition to assessing drinking behaviors at three-, six-, and 12-month follow-ups, the researchers asked the participants about exposure to dating violence (using the modified Conflict in Adolescent Dating Relationships Inventory) and symptoms of depression (using the Brief Symptom Inventory).

At three months, patients who received either computer or therapist brief intervention had a 15% lower incidence rate for depression. At six months, computer brief intervention resulted in a reduction of dating violence perpetration (48% lower than control) and depression symptoms (22% lower than control). At the 12-month follow-up, therapist-led brief intervention resulted in a significant reduction of dating violence perpetration (47% lower than that of the control group).

“Currently, no ED-based alcohol interventions have been tested that are also used to address multiple detrimental outcomes, including dating violence perpetration and depression symptoms,” Ngo and colleagues wrote. “Even when controlling for baseline alcohol consumption, we found that these are notable risk reductions, especially given that the intervention was not explicitly focused on dating violence or depression. … With our findings, we suggest that participating in an alcohol BI [brief intervention] may have a broader impact beyond alcohol consumption, including dating violence and depression secondary outcomes.”

For other information on alcohol use in adolescence, see the American Journal of Psychiatry article “Neural Predictors of Initiating Alcohol Use During Adolescence.”

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