Monday, February 8, 2016

Adults Diagnosed With Concussion May Be at Heightened Long-Term Risk of Suicide

Adults who have been diagnosed with a concussion may be at a heightened long-term risk of suicide, reports a study published today in the Canadian Medical Association Journal. According to the authors, the findings suggest that a history of concussion may be relevant when assessing a patient's suicide risk.

Donald Redelmeier, M.D., of Sunnybrook Health Sciences Centre in Toronto and colleagues examined 235,110 records of patients in Ontario who had a concussion between 1992 and 2012. During the follow-up period, 667 suicides occurred, equivalent to 31 deaths per 100,000 patients annually—three times the population norm.

Weekend concussions (considered more likely to be caused by recreational injuries) were associated with a one-third further increased risk of suicide compared with weekday concussions (considered more likely to be caused by occupational injuries). For people with a prior suicide attempt, a psychiatric or substance use disorder, or multiple concussions, this risk was even higher; however, even individuals who met none of these criteria still had double the long-term suicide risk following a concussion.

“[C]oncussions are rarely deemed relevant for consideration by psychiatrists or other physicians when eliciting a patient’s history,” the authors wrote. “Greater attention to the long-term implications of a concussion in community settings might save lives because deaths from suicide can be prevented.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Suicide and Chronic Traumatic Encephalopathy.”

(Image: Triff/Shutterstock)

Friday, February 5, 2016

Study Finds Chronic Viral Infections May Contribute to Cognitive Decline

Some chronic viral infections such as herpes could contribute to subtle cognitive deterioration in otherwise healthy older adults, according to a study published in Alzheimer Disease and Associated Disorders.

While previous work had found an association between cognitive problems and viruses, this study offers temporal evidence to suggest infections may contribute to cognitive decline down the road.

Over a period of five years, researchers from the University of Pittsburgh School of Medicine (UPMC) and Johns Hopkins University annually assessed cognitive function (attention, memory, language, and more) in 1,000 adults 65 years and older. At study entry, nonfasting blood samples were obtained and assayed for exposure to cytomegalovirus (CMV), Herpes Simplex virus 1 and 2 (HSV-1, HSV-2), and Toxoplasma gondii (TOX).

The team found that baseline antibody levels for HSV-2 were significantly associated with baseline cognitive scores, while CMV, HSV-2, and TOX (though not HSV-1) were significantly associated with greater cognitive decline over the five-year period—independent of other age-related variables.

“This is important from a public health perspective, as these infections are very common and several options for prevention and treatment are available,” Mary Ganguli, M.D., M.P.H., a professor of psychiatry at UPMC, said in a press statement. “As we learn more about the role that infectious agents play in the brain, we might develop new prevention strategies for cognitive impairment.”

To read more about the potential role of infection in mental health, see the Psychiatric News article “Researchers Consider Infection as One Cause of Depression.”

(Image: Spectral-Design/Shutterstock)

Thursday, February 4, 2016

APA Urges Members to Support Reclassification of ECT Devices

Five years after it last broached the matter, the Food and Drug Administration (FDA) is again proposing to reclassify electroconvulsive therapy (ECT) from a Class III (high risk) medical device to Class II (low risk). APA supports this change.

Opposition from anti-psychiatry groups was blamed for the FDA's maintaining the Class III status in 2011. Opponents to reclassification argued then that ECT causes memory problems, cognitive impairment, and other adverse effects. Supporters noted that current ECT practices, using anesthesia and muscle relaxants, significantly reduce those effects.

The FDA in a recent Federal Register notice acknowledged some side effects but concluded: “FDA believes that in the specified patient population, and with the application of general and special controls as described in this document, the probable benefit to health from use of the device outweighs the probable injury or illness from such use.”

APA urges psychiatrists to contribute their comments to the FDA in favor of the reclassification. A template form letter has been prepared that provides talking points. The FDA’s draft guidance on the proposed reclassification and a link to post comments can be accessed here. The FDA must receive comments by March 28.

“[I]t is so important for psychiatrists to take the lead in expressing their views in regard to the role that ECT plays in clinical practice and in the treatment of major depressive disorder,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., and APA President RenĂ©e Binder, M.D., in a blog post. “For appropriate patients, ECT has been a lifesaver. It has given them an opportunity for a normal, functional life.”

For more in Psychiatric News about the previous attempt to reclassify ECT, see “FDA Advisory Panel Favors ECT in High-Risk Category.”

Wednesday, February 3, 2016

Veterans With Prior Suicidal Thoughts Rate Emergency Department Intervention Highly

Veterans who received training in coping skills before leaving the emergency department (ED) following a suicide-related concern and follow-up calls weekly until they entered outpatient treatment reported that the program was helpful in preventing further suicidal behavior and fostering treatment engagement, according to a study published Monday in Psychiatric Services in Advance.

Patients discharged from EDs following suicide attempts often fail to connect with follow-up care or experience significant delays between ED discharge and outpatient treatment. The literature suggests that up to 50% of these individuals fail to seek recommended follow-up care, and among those who do seek treatment, approximately 40% discontinue treatment within three months.

In an effort to improve treatment engagement and reduce the risk of suicide attempts in veterans after their first contact with the ED, a team of researchers developed the SAFE VET intervention, a two-part intervention that teaches individuals who present in EDs coping strategies prior to leaving the ED and engages patients weekly by phone until their first outpatient treatment appointment. A previous study found SAFE VET enhanced treatment engagement. In the current study, Barbara Stanley, Ph.D., of Columbia University and colleagues asked a sample of 100 veterans who participated in SAFE VET to rate the acceptability, usefulness, and helpfulness of the intervention.

Most participants found the SAFE VET intervention to be useful in mitigating suicide risk (93%) and in increasing the likelihood of attending follow-up mental health appointments (77%). The overwhelming majority (99%) said they found the SAFE VET intervention very acceptable, reporting that they would recommend it to a friend in crisis. Participants also rated the program’s ability to assist them in identifying professional support (46%) and having “someone check in regularly” (75%) as being the most helpful components of the program.

“This intervention was designed to fill a crucial gap in the current system of care,” the study authors noted. The authors cautioned that “although the combined intervention was found to be both acceptable and helpful,” further studies are needed to assess whether the results would be the same in EDs outside the VA system.

For related information, see the Psychiatric News article “Study Points to Risk Factors Predictive of Suicide After Emergency Visit.”

(Image: Straight 8 Photography/Shutterstock)

Tuesday, February 2, 2016

Renaming Psychiatric Medications May Lead to Improved Patient Care, Recovery

Classifying psychiatric medications by their pharmacology and mode of neurobiological action as opposed to the clinical indication for which they were first discovered may help to improve patient care and recovery, according to an international group of psychopharmacologists.

“The current nomenclature reflects a system of classification that has not received any attention for decades,” said psychiatrist David Kupfer, M.D. (pictured left), who was the chair of the DSM-5 Task Force. “Neuroscience and the science of pharmacology have advanced enormously, but our nomenclature is a thing of the past.”

A recent Psychiatric News article describes a new international initiative under way called Neuroscience-based Nomenclature (NbN)—which aims to develop a nomenclature that reflects contemporary neuroscientific knowledge—and a proposal for an updated neuropsychopharmacological nomenclature. Kupfer is one of a 10-member task force spearheading the initiative, and APA President-elect Maria Oquendo, M.D., is a member of a North American working group of the NbN.

“Referring to drugs based on the condition that they were first discovered to address presents several problems,” Oquendo told Psychiatric News. “Most importantly, it is at odds with what happens in a clinical encounter. Many psychiatrists have likely had conversations with patients who want to know why they are being prescribed an antidepressant for anxiety or an antiepileptic for a mood disorder. It is possible that this confusion can result in problems with adherence.”

Oquendo noted that in other fields of medicine, drugs are increasingly classified according to their target receptors, enzymes, ion channels, and other biologically precise targets.

“One of the best weapons we have against stigma is to reinforce the idea that psychiatric conditions are biological in nature,” Oquendo said. “A reconsideration of nomenclature would be a powerful tool in this effort.”

Oquendo and Kupfer will present a presidential symposium on the subject at APA’s 2016 Annual Meeting in Atlanta.

For more on the proposal to replace indication-based titles for psychiatric medications with a nomenclature based on pharmacology and neurobiological action, see the full Psychiatric News article “Psychopharmacologists Seek New Nomenclature for Psychiatric Drugs.”

Monday, February 1, 2016

Study Highlights Value of Investing in Intensive, Early Care for Psychosis

Analysis of the Recovery After Initial Schizophrenia Episode (RAISE) trial has found that coordinated specialty care for young people with first-episode psychosis may be more cost-effective than typical community care, according to a study appearing today in Schizophrenia Bulletin.

An earlier report on the NIMH-funded RAISE Early Treatment Program found that patients who receive NAVIGATE, a type of coordinated specialty care, “experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school” compared with controls.

In the current study, Robert Rosenheck, M.D., a professor of psychiatry and public health at Yale University, and colleagues analyzed data from the RAISE program to compare the cost-effectiveness of the NAVIGATE (NAV) intervention package (n=223) with that of standard community care (n=181) over 2 years.

The researchers found that there were no significant differences during the 2-year follow-up period in inpatient service use, with 14% greater mental health or medical surgical days among NAV patients. However, NAV patients received 6.5 (35%) more mental health outpatient visits per 6-month period than community care patients; they also received more clinical, rehabilitation, and family treatment visits, but fewer peer support visits than those in community care. Those additional care visits, plus use of newer medications and increased training for clinicians, contributed to a 27% increase in cost over usual community care, the researchers noted.

The incremental cost-effectiveness ratio was $12,081/Quality of Life Scale (QLS-SD), with a .94 probability that NAV was more cost-effective than community care at $40,000/QLS-SD. When converted to monetized Quality Adjusted Life Years, NAV benefits exceeded costs, especially at future generic drug prices.

“[T]hese additional expenses have now been shown to be worth the investment in improving individuals’ health and functioning,” Robert Heinssen, Ph.D., director of the Division of Services and Intervention Research at NIMH, said in a press release.

For more information, see the Psychiatric News article “Psychosocial Treatments Found Effective for Early Psychosis” and the Psychiatric Services article “The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components.”

(Image: hxdbzxy/Shutterstock)

Friday, January 29, 2016

Metformin May Normalize Antipsychotic-Induced Lipid Imbalance in People With Schizophrenia

Patients with schizophrenia who take antipsychotics commonly experience serious adverse metabolic effects including dyslipidemia—a condition characterized by abnormally high levels of total cholesterol, low-density lipoprotein cholesterol (LDL-C), or triglycerides, as well as abnormally low levels of high-density lipoprotein cholesterol (HDL-C). A study published this week in Molecular Psychiatry now suggests that the type 2 diabetes medication metformin may be able to help normalize lipid levels in this patient population.

Although there is evidence to suggest metformin decreases triglycerides and LDL-C in patients with diabetes, it was unknown whether the medication would offer similar benefits to schizophrenia patients with antipsychotic-induced dyslipidemia who have weight gain and/or have developed insulin resistance after antipsychotic treatment.

A team of researchers from the United States and China pooled data from two randomized, placebo-controlled trials, including 201 schizophrenia patients aged 18 to 40 who had experienced dyslipidemia within the first year of being treated with one of four antipsychotics: clozapine, olanzapine, risperidone, or sulpiride. The patients were randomly assigned to take 500 mg of metformin or placebo twice a day for six months. (Participants who were taking an antipsychotic at the time of trial start remained on the medication until the trial’s completion.)

After 24 weeks of treatment, 25.3% of patients in the metformin group had dyslipidemia (defined by LDL-C greater than or equal to 3.37 mmol/L) compared with 64.8% in the placebo group. In contrast, 54.2% of the patients in the placebo group who had a normal LDL-C levels at baseline developed dyslipidemia over the course of the trial compared with 14.3% taking metformin.

“Metformin treatment had [a] significant effect on not only controlling weight gain, insulin, and insulin resistance, … but also significantly improving the altered level of lipids, including LDL-C, HDL-C, total cholesterol, and triglycerides in blood,” the authors wrote. The findings suggest “that the addition of metformin to antipsychotics is a potential treatment to attenuate dyslipidemia in patients with schizophrenia,” they concluded.

For related information, see the Psychiatric News article “Coding for Coverage for Lipid Testing.”

(Image: CLIPAREA l Custom media/Shutterstock)


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