Friday, March 23, 2018

Individuals With Aggression-Related Diagnoses Are More Likely to Have Had Mild Head Injuries

Clinicians evaluating individuals with intermittent explosive disorder or self-directed aggression should be sure to ask them about a history of head injury, concluded a study published earlier this month in the Journal of Neuropsychiatry and Clinical Neurosciences.

Individuals with intermittent explosive disorder, as well as people with a history of suicidal or self-injurious behavior, were found to be twice as likely to have a history of mild traumatic brain injury (mTBI) than those with other psychiatric disorders or healthy controls, according data from a study by Emil F. Coccaro, M.D., of the University of Chicago and Caterina Mosti, Ph.D., of Drexel University.

Mild TBI is highly prevalent, with more than 1.3 million injuries occurring in the United States each year. Additionally, some 15% of returning military service personnel are estimated to have sustained an mTBI. Since many people who experience mild head injury do not seek medical treatment, this is likely a significant underestimation, the authors wrote. While the resulting cognitive, physical, and emotional consequences typically resolve within three months of the injury, a growing body of research suggests that 10% to 31% of those with mTBI injuries suffer lingering physical symptoms and mood disturbances.

To explore the relationship between history of mTBI and aggression, the researchers interviewed 1,634 physically healthy adults (this group included 695 participants with intermittent explosive disorder, 486 participants with a current/lifetime diagnosis of a psychiatric disorder that was not intermittent explosive disorder, and 453 with no psychiatric disorder). During these interviews, study participants were asked to report any history of mTBI (defined as a blow to the head associated with mild neurological symptoms including any of the following: dizziness, disorientation, memory difficulties lasting less than 24 hours, or loss of consciousness of less than 30 minutes). The participants were also asked questions about aggressive and impulsive behaviors.

Among patients who had a mTBI, 11% had no evidence of psychiatric disorder, 12% had a psychiatric or personality disorder (other than bipolar or schizophrenia/psychotic disorders), and 24% had intermittent explosive disorder. About 25% of those with mTBI had suicidal and/or self-injurious behavior. Participants reporting two or more loss of consciousness episodes had the highest aggression scores of all groups.

“On the basis of these data alone, we cannot say whether the presence of high trait impulsivity and aggression led IED [intermittent explosive disorder] participants to be in circumstances that increase risk for mTBI or whether history of mTBI altered the brains of mTBI participants, leading to an increase in aggressive and impulsive behavior post-mTBI,” the authors wrote. “That said, impulsive-aggressive behaviors are present from very early life, and individuals with this temperament are likely to place themselves in circumstances associated with bodily injury, including mTBI.”

For related information on aggression following TBI, see the Psychiatric News article “Amantadine May Reduce Aggression in TBI Patients.”

(Image: Olimpik/Shutterstock)

Thursday, March 22, 2018

Review Examines Evidence to Support Use of Prenatal Supplements to Prevent Mental Illness

Previous studies suggest that certain prenatal supplements can enhance fetal brain development, but less is known about whether these supplements decrease the subsequent risk of mental illness in offspring. A review published Wednesday in AJP in Advance suggests that while prenatal nutrients may offer some protective mental health benefits to the offspring, there are some health risks.

AJP Editor Robert Freedman, M.D., of the University of Colorado School of Medicine and colleagues conducted a literature search for human studies that included the keyword “micronutrients” combined with “pregnancy” or “fetal development” that were published between 1990 and 2017. Thirty-five human studies and trials of individual nutrients were identified that included reports on subsequent child behavior, emotion, or cognition in one or more articles. Freedman and colleagues identified four supplements as a result of this literature review: folic acid, omega-3 fatty acids, phosphatidylcholine, and vitamins D and A.

Key findings of the review included the following:

  • Folic acid and phosphatidylcholine supplements appear to reduce social and emotional problems in young children that are associated with later mental illness. More research is needed to establish whether these supplements can reduce the risk of psychiatric disorders such as schizophrenia.
  • Vitamin A and D supplements appear to decrease the risk for schizophrenia and autism. However, at higher doses these vitamins can be toxic to both mother and child. The authors wrote, “Supplementation should not be greater than the amount in standard multivitamins.” (The daily recommendation in the United States for vitamin D is 600 IU for pregnant women and 400 IU for infants.)
  • Omega-3 fatty acid supplements during pregnancy appear to increase the risk for schizophrenia and attention-deficit/hyperactivity disorder (ADHD) symptoms; however, other studies show that omega-3 supplements can substantially reduce the risk of premature birth, which is also a risk factor for ADHD.

Freedman and colleagues noted that more research is needed to understand the relationship between prenatal nutrients and mental health of offspring; of the 35 studies they analyzed for the review, only five were randomized, controlled clinical studies. “To obtain [substantive] evidence for any nutrient will require new research agendas that emphasize prenatal clinical trials of interventions, early biomarkers of their effectiveness developed in translational models, and then longer-term follow-up through childhood developmental stages into adulthood,” the authors wrote.

“In the absence of definitive evidence, parents currently planning pregnancy now have difficult decisions about nutrient supplements,” the authors continued. “The mother is unlikely to receive fully effective levels of the currently studied nutrients from diet alone. Adverse effects of supplements are few at the doses studied, but it would be premature to conclude that they are nonexistent. Conversely, there is only one opportunity in each child’s life for intervention to enhance fetal brain development and protect the child against developmental risks that arise in this period.”

To read more about this topic, see the Psychiatric News article “Long Career Studying Choline Leads to Public Health Payoff.”

(Image: pio3/Shutterstock)

Wednesday, March 21, 2018

Study Offers Clues About Neural Biomarkers of Resilience to Depression

While numerous studies have examined risk factors for the transmission of familial depression, fewer have explored the factors that might protect individuals from developing this disorder. A report published today in JAMA Psychiatry suggests adolescent girls who appear resilient to depression may have greater connectivity in brain networks known to play a key role in the processing and regulation of emotion, motivation, and self-awareness.

For this longitudinal study, Adina S. Fischer, M.D., Ph.D., of Stanford University and colleagues conducted clinical and behavioral assessments every 18 months on a group of girls from age 9 to 18. Half of the girls had a mother who had recurrent major depressive disorder (MDD) episodes during her daughter’s lifetime (high risk); the other half had mothers with no history of depression (low risk). Approximately six years after the start of the study, adolescents in the high-risk and low-risk groups received a resting-state functional magnetic resonance imaging (fMRI) scan.

Fischer and colleagues compared data from the fMRI scans of 20 adolescents in the high-risk group who did not develop MDD (resilient) with 20 in the high-risk group who developed MDD (converted) and 25 adolescents in the low-risk group who did not develop depression (control).

Compared with adolescents who developed depression and those in the control group, adolescents in the resilient group had greater connectivity between the amygdala and prefrontal cortex—two regions known to be involved with emotion processing and regulation. Resilient adolescents also had greater connectivity between regions of the executive control network (implicated in explicit emotion regulation, including cognitive reappraisal and impulse control) than did adolescents who developed depression and the control peers. Both high-risk groups (resilient and converted) differed from controls in salience network connectivity, with the strongest salience network connectivity in the converted group. (The salience network is implicated in self-awareness and integrating stimuli.)

“Our findings suggest that high-risk adolescent females in the resilient group have greater ‘top-down’ control over emotions and behavior than do high-risk adolescent females who develop depression. … [T]his provides a possible mechanism and target through which therapeutic interventions aimed at strengthening these connections could increase resilience in high-risk populations.”

In an accompanying editorial, Scott A. Langenecker, Ph.D., and colleagues at the University of Illinois at Chicago wrote, “The work of Fischer and colleagues provides an important foundation for studying neurobiological factors, such as functional connectivity, that may reflect resilience for daughters of depressed mothers. … This type of work ultimately increases our understanding of promotive factors that can be strengthened, existing techniques that facilitate resilience, and the ways in which these techniques might be improved and more widely disseminated.”

For related information on resilience to psychiatric disorders, see the American Journal of Psychiatry article “The Role of Intrinsic Brain Functional Connectivity in Vulnerability and Resilience to Bipolar Disorder.”

(Image: iStock/Henrik5000)

Tuesday, March 20, 2018

Survivors of Self-Harm at High Risk of Repeat, Suicide Over Following Year

Teenagers and young adults who deliberately hurt themselves are at markedly increased risk of suicide within one year, especially if the original self-harm incident involved violent methods such as using firearms, according to a report published Monday in Pediatrics.

According to lead author Mark Olfson, M.D., M.P.H. (pictured left), and colleagues, the results speak to the need for urgent clinical attention to young people who self-harm. “Clinical priority should be given to ensuring the safety of young people after self-harm, which may include treating underlying psychiatric disorders, restricting access to lethal means, fortifying psychosocial supports, and close monitoring for emerging suicidal symptoms,” they wrote.

Olfson and colleagues analyzed a cohort of 32,395 Medicaid patients aged 12 to 24 who had been diagnosed with deliberate self-harm. The cohort was followed from their index self-harm until the end of a 365-day follow-up period, date of death, or end of available data, whichever came first. The primary outcomes of interest were repeat, nonfatal self-harm and suicide.

Within a year after the initial self-harming incident, teenagers and young adults were at 26.7 times higher risk of suicide than those in the general population matched for age, sex, or race and/or ethnicity. Approximately 17% of the self-harm patients (n=5,545) had another incident of non-fatal self-harm during the follow-up year.

For self-harm patients who initially used firearms, the risk of suicide during the following year was 35 times greater than for those who harmed themselves by nonviolent means. Additionally, the odds of suicide were more than five times higher for American Indian and Alaskan native patients than for white non-Hispanic patients.

“For high-risk young people with access to firearms, distributing trigger locks and urging family members to store firearms away from the patient’s home can be a lifesaving precautionary measure,” Olfson and colleagues wrote.

For more information on self-harm, see the Psychiatric News article “Upping Our Game to Prevent Suicide,” by APA President Anita Everett, M.D., and the Psychiatric Services article “Denial of Suicide Attempt Among Hospitalized Survivors of a Self-Inflicted Gunshot Wound.”


Monday, March 19, 2018

Childhood TBI Increases Risk of ADHD for Several Years

Traumatic brain injury (TBI) during early childhood is known to increase the risk of developing attention-deficit/hyperactivity disorder (ADHD) in the first two years following the injury; this is known as secondary ADHD (SADHD). A study published today in JAMA Pediatrics now shows that the risk for SADHD can extend for at least seven years after the TBI.

These findings “suggest that physicians and other clinicians should continue to be vigilant in monitoring attention problems in patients with a history of brain injury, even if it has been a number of years since the injury, the injury was moderate in nature, or the patient experienced a predominantly positive recovery,” wrote Megan Narad, Ph.D., of Cincinnati Children’s Hospital Medical Center and colleagues. This vigilance will aid in more timely identification of SADHD cases, the authors continued, which could reduce the functional impairments these children may face.

Narad and her team enrolled 187 children between the ages of 3 and 7 who were hospitalized overnight with either a TBI (81 children) or an orthopedic injury  (106 children; the control group). All participants were periodically assessed for SADHD until they reached middle school. The final assessments took place an average of 6.8 years after the initial injury.

Of the 187 children, 48 (25.7%) met the researchers’ definition of SADHD by the study’s end. These included 13 children with severe TBI at enrollment, 6 with moderate TBI, 13 with complicated mild TBI, and 16 with an orthopedic injury. Almost half of the children with TBI who later developed SADHD (15 of 32) did so more than one year after their injury.

An analysis of these outcomes revealed a 3.62-fold increased risk of SADHD among children with severe TBI compared with children with an orthopedic injury. Children with mild or moderate TBI had about a 1.7-fold increased risk of SADHD, but these data were not statistically significant. The authors also found that among children with TBI, family dysfunction was associated with a statistically significant 4.24-fold increased risk of SADHD.

“Findings about the association of family functioning with the development of attention problems after TBI also support previous research highlighting the importance of allocating resources to the injured child’s family throughout recovery,” Narad and colleagues concluded. “Assessing family functioning, identifying families at risk, and developing programs to promote healthy family functioning to foster positive outcomes should be integrated into clinical practice when working with patients and families with a history of TBI.”

To read more about TBI, see the Psychiatric News article “FDA Clears the Way for First Blood Test to Evaluate Head Injuries.


Friday, March 16, 2018

Adolescents With Mental Health Conditions More Likely to Transition to Long-Term Opioid Therapy, Study Finds

Adolescents with preexisting mental health conditions may be more likely than their peers to transition from a first opioid prescription to long-term opioid therapy, according to a study published this week in JAMA Pediatrics.

“Given the limited support for the efficacy of opioid therapy for chronic pain among youths, research is needed to understand potential adverse effects of LTOT [long-term opioid therapy] among adolescents as well as the role that preexisting mental health conditions may play in harmful outcomes,” lead author Patrick D. Quinn, Ph.D., of Indiana University and colleagues wrote.

For the study, Quinn and colleagues analyzed data from the 2003-2014 Truven Health MarketScan Commercial Claims and Encounters (MarketScan) databases of commercial health care insurance claims. The researchers identified a cohort of more than 1.2 million adolescents aged 14 to 18 who received opioids for the first time during this period. The researchers then tracked this group from their first prescription until their first disenrollment or December 31, 2014 (whichever occurred first), to examine subsequent long-term opioid therapy (defined as more than 90 days’ supply within a six-month window having no gaps in supply of more than 32 days).

Associations between preexisting mental health conditions and treatments and any opioid receipt were examined by comparing adolescents who received any opioid analgesic with those who did not matched on sex, calendar year and years of age of first enrollment, and months of enrollment.

The authors found that 3.0 per 1,000 opioid recipients transitioned to long-term opioid therapy within three years of fulfilling an initial opioid prescription. “Although adolescents with a wide range of preexisting mental health conditions and treatments were modestly more likely than adolescents without those conditions or treatments to receive an initial opioid, the former had substantially higher rates of subsequent transitioning to LTOT [long-term opioid therapy],” the authors wrote. 

“There is a clear need for mental health assessment among adolescents being considered for opioid therapy. Such an assessment may help inform decision making regarding pain treatment as well as illuminate the possible value of concomitant mental health interventions,” they concluded.

In an accompanying editorial, Michael J. Mason, Ph.D., of the University of Tennessee, Knoxville, wrote, “These findings are important clinically and provide a foundation for future research to test the efficacy and potential adverse effects of long-term opioid therapy for adolescents with and without comorbid diagnoses. This research has highlighted the need to address comorbidity by addressing the accompanying risk and protective factors—a challenging task but one that would provide immediate translational guidance for pediatric practitioners.” 

For related information, see the Psychiatric News article “Many Prescription Opioids Go to Adults With Depression, Anxiety.”
(Image: iStock/monkeybusinessimages)

Thursday, March 15, 2018

Nondisclosure of Suicidal Intent Following Gunshot Wound Presents Barrier to Care, Study Finds

Some survivors of self-inflicted gunshot wounds falsely deny their injuries are a result of a suicide attempt. According to a study published today in Psychiatric Services in Advance, these patients are far less likely to receive inpatient psychiatric care following their injury than those who disclose suicidal intent.

The results highlight the importance of increased assessment, intervention, and psychoeducation for survivors of self-inflicted gunshot wounds, particularly while they are hospitalized on medical floors, wrote Michael Matthew McClay, M.S., of Western Kentucky University, Stephen S. O'Connor, Ph.D., of the University of Louisville, and colleagues. Because survivors of suicide attempts are at high risk of recurrence, correctly identifying these individuals is critical so treatment and prevention efforts can ensue, wrote the authors.

About 44,000 people die by suicide every year in the United States, making it the 10th most common cause of death. Suicide attempts occur at an even greater rate and result in more than 316,000 hospital admissions and $51 billion in combined costs of medical care and loss of work each year, the authors wrote.

The researchers examined electronic medical record data from 128 survivors of self-inflicted gunshot wounds at a trauma center in Tennessee; more than 25% of these patients were known to have made a prior suicide attempt.

Overall, 71% of the survivors of self-inflicted gunshot wounds disclosed that it was a suicide attempt, and 29% denied it. Of patients who denied the suicide attempt, about 40% (16 patients) were flagged during a psychiatric consultation as presenting under circumstances suspicious of a suicide attempt. Suicide attempt was suspected in some cases due to reports from witnesses or conflicting stories by the patients regarding the circumstances of their injury, for instance.

Patients who denied their suicide attempt were more than 10 times more likely to be discharged to home than to inpatient care, compared with patients who disclosed an attempt, the study found.

“Within acute care center settings, the desire to avoid inpatient psychiatric hospitalization and documentation in the medical record may be barriers to reporting that a self-inflicted gunshot wound was intentional,” the researchers wrote. “[T]he results indicate a need for further reflection on ways in which usual care in health systems (such as inpatient hospitalization) may present a barrier for eliciting honest reports from suicide attempt survivors due to a fear of hospitalization.”

For related information, see the book Gun Violence and Mental Illness, co-edited by Liza Gold, M.D., and Robert I. Simon, M.D.

(Image: iStock/robypangy)


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