Risk Calculator Predicts Youth Likely to Experience Recurrence of Bipolar Symptoms

It is possible to predict whether youth with a history of bipolar disorder will experience a recurrence of symptoms using a risk calculator that factors in patient characteristics commonly measured in clinical practice.

That’s the finding from a report that appears in the Journal of the American Academy of Child and Adolescent Psychiatry. “The risk calculator offers a potentially useful clinical and research tool to predict the individual progression of the illness and guide treatment,” wrote Boris Birmaher, M.D., of the University of Pittsburgh School of Medicine and colleagues.

The researchers created a bipolar relapse risk calculator that assessed 11 potential predictors of symptom recurrence, based on existing scientific literature. These predictors included a patient’s age and family history, severity of previous mood episode of illness, length of time of recovery since last mood episode, and more.

They used this risk calculator to assess 363 youth (mean age 13 years) with a history of bipolar disorder who were currently in recovery (defined as at least two months with no or minimal mood symptoms). The researchers evaluated any changes in the participants’ psychiatric symptoms on average every seven months for a median of 12.5 years.

Over the course of the study, approximately 80% of participants had at least one recurrence of depressive or manic symptoms and 60% had two or more recurrences. The risk calculator was able to predict which youth would experience a mood recurrence within six months or five years with 72% and 82% accuracy, respectively. The calculator was slightly better at predicting future hypomania compared with future depression. The most important factors in predicting recurrence of mood episodes were shorter periods of recovery, younger age at assessment, earlier mood onset, and history of more severe depression.

“A clinician could utilize the risk calculator … to predict the person-level risk for recurrences [whether depressive or hypomanic] at different points of time after recovery,” Birmaher and colleagues wrote. “This information can inform the management of individual patients and is valuable for the patients and their families to enhance their understanding of illness prognosis and become more involved in their treatment. For example, a high-risk score may indicate the need for more frequent follow-ups, and more intensive treatment to avoid recurrences.”

For related information, see the Psychiatric News article “Preventing and Treating Mood Disorders Starting in Childhood.”

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Transcranial Direct Current Stimulation Found to Improve Cognition in Patients With Depression

Both high and low doses of transcranial direct current stimulation (tDCS) may improve cognition in patients with depression, according to a study in Depression & Anxiety.

“Research has found that unipolar depression can reduce processing speed, decrease attention, and impede executive function, and that bipolar disorder can adversely affect working memory,” wrote Shawn M. McClintock, Ph.D., M.S.C.S., of UT Southwestern Medical Center and colleagues. Although previous studies have suggested that tDCS has antidepressant effects, less was known of the neurocognitive effects of the therapy.

This study enrolled 130 adults 18 and older with unipolar or bipolar depression who had been experiencing a major depressive episode for at least four weeks. The participants were randomized to receive 20 sessions (given on consecutive weekdays over four weeks) of either high-dose tDCS (2.5 mA for 30 minutes) or low-dose tDCS (0.034 mA for 30 minutes). Afterwards, all participants had the option to continue with four weeks of open-label, high-dose tDCS treatment.

At baseline, after four weeks, and after eight weeks, the researchers assessed participants’ mood as well as verbal learning, memory, selective attention, auditory attention, working memory, psychomotor processing speed, visuospatial attention, and verbal fluency.

Participants in the high- and low-dose tDCS groups experienced mood improvements over the eight-week period. “The study found across all patients and time, that there were improvements in verbal learning and memory, selective visual attention, auditory attention, and information processing speed in both the low- and high-dose tDCS conditions, which were independent of mood effects,” McClintock and colleagues wrote.

They concluded, “The tDCS associated neurocognitive effects require further investigation and replication, which is clinically important as such investigation could provide information to develop personalized tDCS therapeutic approaches to target specific cognitive functions and improve the utility and efficacy of this noninvasive neuromodulation treatment.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Noninvasive Brain Stimulation: Challenges and Opportunities for a New Clinical Specialty.”

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Youth Suicide Rates Higher in Areas With Greater Poverty, Study Finds

Youth suicide rates are higher in U.S. counties with elevated poverty rates, according to a study published today in JAMA Pediatrics. The association between suicide and county-level poverty was particularly prominent for suicides by firearms.

“As pediatric suicide rates in the United States continue to increase, understanding of the upstream contributors to pediatric suicide, including poverty-related factors, appears to be needed so that suicide prevention efforts can focus on the youths at highest risk,” wrote Jennifer Hoffmann, M.D., of the Ann & Robert H. Lurie Children’s Hospital of Chicago and colleagues.

For the study, the researchers analyzed 2007-2016 death certificate data for youth (aged five to 19) collected by the Centers for Disease Control and Prevention along with income data from the National Census Bureau. They found youth suicide rates were higher in counties with greater poverty. For example, compared with counties in which less than 5% of the population lived below the federal poverty level ($21,027 in annual household income for a family of four in 2007 and $24,339 in 2016), counties with poverty rates of 20% or more had 1.37 times as many suicides by youth each year.

The researchers then analyzed the three most common methods of suicide during the study period (firearms, poisoning, and suffocation). They found no association between the rate of suicide by suffocation or poisoning and poverty levels. Among firearm suicides, the suicide rate increased with increasing levels of poverty compared with the lowest levels of poverty.

“The independent association between county poverty concentration and pediatric suicide … should prompt research into potential mediators through which poverty might convey an elevated suicide risk,” Hoffman and colleagues wrote. “On a more societal level, strategies that combat poverty, such as increasing the minimum wage, may be part of a multipronged strategy to consider for reducing youth suicide.”

To read more on this topic, see the Psychiatric News article “Rise in Youth Suicide Rates Confounds Experts.”

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Buprenorphine Use for Treating OUD Rising, Except in Youth

The rate of buprenorphine use to treat opioid use disorder more than doubled between 2009 and 2018, according to a study in JAMA. However, this trend did not hold true for patients aged 15 to 24 years, in whom buprenorphine use declined.

Mark Olfson, M.D., M.P.H., of Columbia University and colleagues analyzed data from the IQVIA Real World Data: Longitudinal Prescription database to determine the number of buprenorphine prescriptions filled by people aged 15 to 80 years old between 2009 and 2018, excluding formulations that were not approved for treating opioid use disorder. The researchers defined a new episode of buprenorphine use as a prescription fill that took place at least 180 days after the last buprenorphine fill. The episode of buprenorphine use ended 30 days after a prescription fill ended and the patient did not obtain a refill or new prescription.

The annual rate of buprenorphine use episodes increased from 1.97 per 1,000 people in 2009 to 4.43 per 1,000 in 2018. The largest increase occurred in adults aged 35 to 44 years, from 2.41 episodes of use to 8.34 episodes of use per 1,000 people. However, buprenorphine use decreased in patients aged 15 to 24 years, from 1.76 to 1.40 episodes per year per 1,000 people. Patients in this age group who received buprenorphine prescriptions were also more likely to receive prescriptions for doses lower than the recommended dose of 16 mg/dl, and less likely to maintain their prescriptions for 180 days or more.

The “[f]indings suggest a widening treatment gap for young people and underscore the importance of improving buprenorphine treatment services for this age group,” the researchers wrote. They added that these changes took place during a period when young people had increasing rates of opioid-related overdose deaths.

For related information, see the Psychiatric News article “Most Youth With OUD Who Need Medication Treatment Do Not Receive It.”

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Adults in Pain More Likely to Use Cannabis Without Prescription, Study Finds

Adults who experience pain are more likely to use cannabis without a prescription and have cannabis use disorder than those without pain, according to a study published yesterday in AJP in Advance.

“These results suggest that, among adults with pain, frequent nonmedical cannabis use and cannabis use disorder are growing problems,” wrote Deborah S. Hasin, Ph.D., of the New York State Psychiatric Institute and colleagues. “[T]he need remains for other interventions to manage pain that do not incur risk of another substance use disorder (i.e., cannabis use disorder) as an adverse treatment outcome.”

Hasin and colleagues analyzed data from two national surveys of adults: the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions and the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. Both surveys used the Alcohol Use Disorder and Associated Disabilities Interview Schedule to assess substance use and substance use disorders. As part of these surveys, the respondents were asked about their use of cannabis without a prescription or other than prescribed (nonmedical use). Respondents were also asked to rate how much pain interfered with their “normal work” during the previous four weeks.

Between the 2001-2002 and 2012-2013 surveys, the prevalence of pain among U.S. adults increased from 19.3% to 20%. Pain was associated with significantly greater risk for any nonmedical cannabis use in both surveys.

The prevalence of frequent cannabis use (defined as use at least three times a week) did not differ by pain status in the 2001-2002 survey. But frequent cannabis use was significantly more prevalent in those with pain compared with those without pain in the 2012-2013 survey (5.03% compared to 3.45%).

Cannabis use disorder (defined as meeting DSM-IV criteria for cannabis dependence or abuse) was also more prevalent in respondents with pain compared with those without. In the 2012-2013 survey, the prevalence of cannabis use disorder was 4.18% in those with pain compared with 2.74% in those without.

“Extrapolating to the number of U.S. adults potentially affected, approximately 1.5 million more adults with pain were frequent nonmedical cannabis users in the 2012-2013 period than in the 2001-2002 period, and approximately 0.9 million more adults with pain had past year cannabis use disorder in the 2012-2013 period than in the 2001-2002 period,” the authors wrote.

“Psychiatrists and other mental health professionals treating patients with moderate to severe pain should be informed about the potential risks of cannabis, including cannabis use disorder, provide information about these risks to their patients, and monitor patients for signs and symptoms of cannabis use disorder,” they concluded.

For related information, see the Psychiatric News article “National Academies Issues Report on Health Effects of Cannabis.”

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Digital CBT Found Effective for Reducing Insomnia During Pregnancy

Digital cognitive-behavioral therapy (CBT) is a safe and effective approach for reducing insomnia symptoms in pregnant women, reports a study published today in JAMA Psychiatry.

“Although sleep disturbance during pregnancy may be viewed as normative and innocuous, research indicates that it is associated with an increased risk of adverse maternal outcomes, including depression and preterm birth,” wrote Jennifer Felder, Ph.D., of the University of California, San Francisco, and colleagues. “A digital CBT-I [CBT for insomnia] program may be of particular interest for pregnant women, who report a preference for mental health care that includes flexible options and for whom timely intervention may be particularly important.”

Felder and colleagues randomly assigned 208 women who were up to 28 weeks pregnant and had insomnia to receive either digital CBT-I or standard insomnia treatment for 10 weeks. The digital CBT-I program consisted of six weekly tutorials on topics including the following: proper sleep hygiene, relaxation techniques, and stimulus control (how to associate a bed as a cue for sleep). The CBT-I program provided automated reminders to complete each session and automated help based on a person’s progress. The participants also had access to a moderated online community and a library of sleep education materials. The women receiving standard care had access to treatments including prescription/over-the-counter sleep medications, herbal remedies, counseling, and/or peer support groups.

After 10 weeks, the women who received CBT-I reported significantly greater improvements in their insomnia symptoms compared with women receiving standard treatment. The average scores on the Insomnia Severity Index (ISI) of the women in the CBT-I group dropped 0.59 points every week, compared with 0.23 points a week for the standard-care group. Remission rates, defined as ISI scores of 7 or less, were significantly higher among those in the digital CBT-I group (44.0%) versus those in the standard treatment group (22.3%). Women receiving digital CBT-I also reported greater reductions in depressive symptom severity and anxiety symptom severity compared with women receiving standard treatment. Additionally, the benefits of CBT-I over standard care for insomnia, depression, and anxiety remained when the patients were re-assessed eight weeks later.

“Given the widespread nature of insomnia in pregnancy, the scalability of this intervention, its low-risk profile, and its demonstrated efficacy, digital CBT-I has great promise as a treatment for insomnia in pregnant women,” Felder and colleagues concluded.

To read more on this topic, see the Psychiatric News article “Online CBT for Insomnia Offers Long-Term Benefit.”

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Family Therapy May Delay Mood Episodes in Youth at High Risk of Bipolar Disorder

Family therapy focused on building communication and problem-solving skills may benefit youth at high risk of bipolar disorder, according to a report in JAMA Psychiatry. Specifically, the study found that youth with mood symptoms and a family history of bipolar disorder who participated in a four-month program with their parents (and, when possible, siblings) had longer periods between symptoms of depression, mania, hypomania, or mixed episodes (mood episodes) than those who participated in a program with less intensive family involvement.

Previous studies show that youth at highest risk of progressing to bipolar disorder early in life are those with mood symptoms and with a family history of the disorder. Still, there is “little agreement on what treatments are most effective in preventing symptom progression among high-risk children,” wrote David J. Miklowitz, Ph.D., of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues.

For the current study, Miklowitz and colleagues recruited 127 youth aged 9 to 17 years with major depressive disorder or unspecified (subthreshold) bipolar disorder, active mood symptoms, and at least one first- or second-degree relative with bipolar disorder I or II. The youth and their families were randomly assigned to one of two treatments over a four-month period: family-focused therapy or enhanced care. Youth and families assigned to family-focused therapy participated in 12 60-minute sessions of psychoeducation, communication-enhancement training (which the authors described as “practicing active listening or expressing positive or negative feelings”), and problem-solving skills training. Youth and families assigned to enhanced care participated in three 60-minute family psychoeducation sessions a week; then only the youth participated in three monthly sessions on mood management.

The researchers evaluated the participants’ symptoms at the start of the study, every four months for the first year, and every six months for up to four years. Of the 127 youth who participated in the study, 75 had major depressive disorder and 52 had unspecified bipolar disorder.

Youth in the group that received family-focused therapy had longer intervals between mood episodes compared with youth in enhanced care. “Specifically, FFT [family-focused therapy] was associated with longer intervals to depressive episodes but did not differ from enhanced care in time to manic or hypomanic episodes, conversions to bipolar disorder, or symptom trajectories,” the authors noted.

“Delaying or preventing episodes of mood disorder may have enduring effects on psychosocial functioning for youth with high-risk syndromes, as well as among parents in terms of the considerable burden of caregiving for a young person with early-onset BD [bipolar disorder],” they concluded.

For related information, see the Psychiatric News article “Researchers Sum Up Current Knowledge of Bipolar Disorder, Call for More Study.”

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