Wednesday, February 22, 2017

Inadequate Gestational Weight Gain Linked to Nonaffective Psychosis In Offspring Later in Life

Extremely inadequate weight gain during pregnancy is associated with an increased risk in children later in life for nonaffective psychosis, even among an affluent and well-nourished population, according to a study published today in JAMA Psychiatry.

Previous research has shown prenatal exposure to starvation is associated with a twofold increased risk of nonaffective psychosis in children, so the study authors set out to investigate whether gestational weight gain throughout pregnancy and maternal body mass index (BMI) in early pregnancy were also associated with risk of nonaffective psychosis in offspring.

Renee Gardner, Ph.D., of the Karolinska Institutet, Stockholm, and colleagues used data from national health and population registries to follow up 526,042 individuals who were born in Sweden from 1982 through 1989. The individuals were tracked from age 13 to the end of 2011. Gestational weight gain of the mother was calculated as the difference in maternal weight between the first prenatal visit and delivery.

At the end of the study period, 2,910 offspring had an ICD-9 or ICD-10 diagnosis of nonaffective psychosis, which included 704 with narrowly defined schizophrenia.

Among the individuals with psychosis, 184 (6.32%) had mothers with extremely inadequate gestational weight gain (less than 17.6 pounds for mothers with normal BMI), compared with 23,627 (4.52%) individuals without psychosis. Outcomes were similar in analyses that adjusted for confounding factors such as maternal weight at baseline.

In the analysis measuring the impact of the maternal baseline BMI, a modest association was found between the risk of noneffective psychosis and maternal thinness (BMI >17.0 and <18.5) and class 2 obesity (BMI >35 and <40.0). 

While the authors suggested that malnutrition is a potential mediating factor, they pointed out that other factors may be involved. "Severely inadequate gestational weight gain may ... be indicative of an existing maternal medical condition, such as endrocrinologic disorders, malabsorption, anorexia nervosa, bulimia nervosa, or hyperemesis gravidarum," they wrote. "Insufficient weight gain can also occur in otherwise healthy individuals owing to insufficient medical guidance or by a drive to conform to societal (but not medical) standards of appropriate weight gain."

The researchers emphasized that more research is needed to understand the association between conditions that lead to insufficient maternal weight gain and the risk for nonaffective psychosis in children.

For related information on the role that fetal development plays in the risk for mental illness, see “Fetal Origins of Mental Health” in the American Journal of Psychiatry.


Tuesday, February 21, 2017

Teen Suicide Attempts Fell After Legalization of Same-Sex Marriage, Study Finds

Same-sex marriage laws appear to be associated with a reduction in the proportion of high school students reporting suicide attempts, according to a report published Monday in JAMA Pediatrics.

Researchers and psychiatrists who commented on the study for Psychiatric News say the report points to how social policy that reflects greater tolerance and reduced stigma may improve mental health.

Julia Raifman, Sc.D., of the Johns Hopkins Bloomberg School of Public Health and colleagues analyzed data on more than 700,000 public high school students who participated in the Youth Risk Behavior Surveillance System (YRBSS) from 1999 through 2015. The authors looked at changes in suicide attempts among the students before and after the implementation of state policies in 32 states permitting same-sex marriage and year-to-year changes in suicide attempts in 15 states without such policies. A secondary analysis examined how same sex-marriage laws affected suicide attempts among high school students who self-identified as belonging to a “sexual minority.”

Same-sex marriage policies were associated with a 0.6 percentage point reduction in suicide attempts—equivalent to a 7% decline in the proportion of all high school students reporting a suicide attempt within the past year. Among students who identified as belonging to a sexual minority, the absolute decrease in suicide was 4.0 percentage points—equivalent to a 14% relative decline in the proportion of adolescents who were sexual minorities reporting suicide attempts in the past year.

Marshall Forstein, M.D. (pictured above), president of the APA Assembly Caucus of Lesbian, Gay, Bisexual, Transgender and Questioning/Queer Psychiatrists, said he believes marriage-equality laws are a marker for a host of social factors that create a more tolerant atmosphere for sexual minority youth, which, in turn, can help to diminish stigma and reduce the risk of suicide. “Marriage equality is a proxy for many changes in attitudes that create a matrix of social support for LGBT young people,” he said. “Increasing social tolerance creates the environment for increasing self-esteem.”

Brian Hurley, M.D., representative to the AMA Section Council on Psychiatry from GLMA: Health Professionals Advancing LGBT Equality, agreed. He noted that while most LGBT people are not suicidal, the study demonstrates the important role of sexual identity in mental health outcomes. “[O]ne implication of the study for individual psychiatrists is that speaking to patients about their sexual identity is a relevant part of a safety assessment and is clinically important,” he said.  

For related information, see the Psychiatric News article “Clinician Insight Can Help Meet MH Care Needs of LGBT People.”

Friday, February 17, 2017

U.S. Appeals Court Upholds Doctors Right to Ask Patients About Gun Ownership

The 11th U.S. Circuit Court of Appeals yesterday upheld a lower federal court ruling against Florida’s Firearms Owners Privacy Act, which sought to restrict discussions by physicians and other medical professionals about firearm safety.

The 2011 law included penalties for physicians who routinely asked patients and their families if they owned firearms. The Florida chapter of the American Academy of Pediatrics (AAP), other medical groups, and six individual physicians challenged the law as a violation of the First Amendment right to free speech.

“We are pleased with the 11th Circuit’s common-sense decision, which allows physicians the right to counsel families on firearms ownership and storage,” said Madeline Joseph, M.D., president of the Florida chapter of the AAP, in a statement.

APA, along with the AMA and numerous other medical groups, filed an amicus brief supporting the pediatricians, stating that discussion of gun safety is a legitimate public health concern and the law violates physician and patient First Amendment rights.

“Careful history-taking about firearm access is the cornerstone of risk assessment in vulnerable patients,” said Marvin Swartz, M.D., a professor of psychiatry and behavioral sciences at Duke University and chair of APA’s Committee on Judicial Action. “This long-awaited ruling from the Florida appeals court defends the free speech physicians must exercise to appropriately care for their patients and preserves the privacy of the physician-patient relationship without the unwarranted intrusion of a political agenda.”

The decision is likely to be appealed.

For more on APA’s role in Wollschlaeger et al., versus Governor, State of Florida, see the Psychiatric News article “APA Weighs In on Cases Where Law Intersects With Psychiatry.”

(Image: iStock/Peter Hermes Furian)

Thursday, February 16, 2017

Addressing Substance Use Early in Psychosis May Be Key to Better Outcomes

Substance use—known to be common in people with psychosis—is associated with poorer outcomes, including more severe psychopathology, higher relapse rates, and lower life expectancy. While previous studies have suggested discontinuing substance use early in the course of illness can improve symptoms and function, most of these were short-term trials. 

A study in Schizophrenia Bulletin that tracked the relationship between substance use, early abstinence, and psychosis longitudinally over 10 years now suggests the detrimental effects of substance use on mental health may be reversed if the person quits early on.

A global team of researchers, led by a group in Norway, analyzed data from a long-term study of people enrolled at one of four Scandinavian health care sectors. From this population, the researchers identified 301 patients with first-episode psychosis. These patients were followed up at three months and then again one, two, five, and 10 years later. 

Of these 301 patients, 266 could be classified into one of four groups based on their patterns of substance use in the first two years after diagnosis: persistent users (n=43), episodic users (n=38), stop-users (stopped substance use within two years after diagnosis, n=34), and nonusers (n=141).

After 10 years, stop-users had similar symptom profiles as nonusers, and both groups had fewer symptoms than episodic or persistent users. In fact, while persistent users had Positive and Negative Syndrome Scale negative scores that increased over the 10-year period, the negative scores of stop-users decreased over time.

“Our results, showing improvement in negative symptoms with cessation of substance use, are of interest as these are symptoms difficult to treat with antipsychotics. In addition, these symptoms are closely linked to daily and social functioning and quality of life.” the authors concluded. “The fact that harm can be substantially minimized with early discontinuation gives a hopeful message for patients who struggle with addiction and psychosis.”

For related information, see the Psychiatric Services article “Substance Use Disorder Among People With First-Episode Psychosis: A Systematic Review of Course and Treatment” and the Focus article “Substance Use Disorders and Schizophrenia.”

(Image: iStock/squaredpixels)

Wednesday, February 15, 2017

Meta-Analysis Reveals Several Predictors of MDD, PTSD Following TBI

A history of pre-injury depression and shorter period of amnesia following injury are just two of several factors that may predict whether a person with traumatic brain injury (TBI) is likely to later develop major depressive disorder (MDD) or posttraumatic stress disorder (PTSD), according to a meta-analysis published Tuesday in The Journal of Neuropsychiatry and Clinical Neurosciences.

“This knowledge could be used to flag patients who might benefit from additional monitoring or (preventive) therapeutic interventions, which have shown to be effective in people at risk for MDD and PTSD,” Suzanne Polinder, Ph.D., of Erasmus Medical Center in The Netherlands and colleagues wrote.

Polinder and colleagues systematically reviewed the literature on predictors and multivariable models for MDD and PTSD after TBI. A total of 26 observational studies were found. Participants in the studies were civilian adults at least 16 years of age who sustained TBI.

The researchers found that MDD following TBI was associated with female gender, preinjury depression, post-injury unemployment, and lower brain volume. Individuals who experienced PTSD following TBI were more likely to have shorter periods of posttraumatic amnesia and memory of the traumatic event. They were also more likely to have early posttraumatic symptoms.

The researchers noted that some of the studies included in the analysis had methodological problems and more research is needed to confirm the predictors of MDD and PTSD after TBI. “The results of this systematic review imply that there is still limited knowledge regarding which patients develop MDD and PTSD after TBI,” they wrote.

“Physicians could be extra aware regarding female patients with a preinjury history of depression and postinjury unemployment or psychiatric symptoms. Also, a reduction in brain volume might indicate a risk of developing MDD postinjury. Furthermore, patients with a shorter [amnesia after the trauma], with a clear memory of the traumatic event, and with early posttraumatic symptoms might be at higher risk of developing PTSD post-TBI,” they concluded.

For related information, see the Psychiatric News article “Sertraline May Help Prevent Depression Following Traumatic Brain Injury.”

(Image: iStock/wildpixel)

Tuesday, February 14, 2017

APA Announces Winners of 2017 Election

APA’s Committee of Tellers has approved the following results of APA’s 2017 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting March 4-5.

Altha J. Stewart, M.D.

Philip R. Muskin, M.D., M.A.

Minority/Underrepresented Representative (M/UR) Trustee
Ramaswamy Viswanathan, M.D., D.M.Sc.

Area 2 Trustee
Vivian B. Pender, M.D.

Area 5 Trustee
Jenny Boyer, M.D., Ph.D., J.D.

Resident-Fellow Member Trustee-Elect
Tanuja Gandhi, M.D.

Complete results of the election will be reported in the March 3 issue of Psychiatric News.

Monday, February 13, 2017

CNS Polypharmacy in Seniors Doubled From 2004 to 2013, Study Finds

Between 2004 and 2013, the number of Americans 65 and older who took three or more central nervous system (CNS) medications doubled, according to a study published today in JAMA Internal Medicine. In nearly half of these cases, the seniors—who were taking antidepressants, antipsychotics, painkillers, and/or sleep aids—did not appear to have a mental health or pain diagnosis.

The findings suggest that despite concerns over the risks of CNS polypharmacy, some older patients continue to be prescribed multiple CNS medications at once.

Donovan Maust, M.D., a geriatric psychiatrist at the University of Michigan Medical School in Ann Arbor, and colleagues analyzed data on patients 65 or older from the 2004 through 2013 National Ambulatory Medical Care Survey (NAMCS), which included 97,910 patients.

They found that annual polypharmacy visits by seniors rose from 0.6% in 2004 to 1.4% in 2013. Applied to the entire U.S. senior population, this translates to an increase from 1.5 million annual doctor visits to 3.68 million annual doctor visits involving CNS polypharmacy. The sharpest rise in CNS polypharmacy occurred among seniors living in rural areas, where mental health specialists are rare. The rate of rural polypharmacy visits tripled during the study period, and rural patients accounted for 16.6% of all CNS polypharmacy visits in 2013.

“Because of limited access to specialty care and a preference to receive treatment in primary care settings, it is unsurprising that mental health treatment has expanded in nonpsychiatric settings,” the researchers wrote. “The growth in polypharmacy in rural settings, where access to specialty mental health or pain care is particularly limited, is part of this broader trend.”

For related information, see the Psychiatric Services study “Antidepressant Prescribing in Primary Care to Older Adults Without Major Depression,” also by Donovan Maust, M.D., and colleagues.

(Image: Richard Lyons/Shutterstock)


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