Thursday, October 30, 2014

Traumatic Brain Injury in Older Adults May Increase Dementia Risk, Study Suggests

A study published this week in JAMA Neurology suggests that traumatic brain injury (TBI) may be associated with an increased risk for dementia in older adults.

Researchers from the University of California, San Francisco, examined health records of approximately 52,000 adults aged 55 and older diagnosed with a traumatic injury to compare risks for dementia between those who have experienced TBI and those with non-TBI-related trauma (defined as fractures excluding the head and neck).

The analysis showed that 8.9 percent of the participants with a history of TBI developed dementia, compared with 5.9 percent of those with traumatic injury to areas other than the head or neck. Data also showed that moderate to severe TBI was associated with an increased risk for dementia in those aged 55 or older, while mild TBI was associated with an increased risk for participants who were aged 65 or older.

In an accompanying editorial, Steven DeKosky, M.D., director of the Alzheimer's Disease Research Center at University of Pittsburgh and a professor of psychiatry, commended the researchers for using a very large database to examine dementia risk following significant trauma. The findings from the research, noted DeKosky, "will enable us to ask important questions, evolve new or more informed queries, and both lead and complement the translational questions that are before us." He concluded that because dementia is both a global problem and a pathological conundrum, the complementary use of big data and basic neuroscience analyses may offer the most promise in learning more about the overlap of TBI and cognitive decline.

To read more about TBI and its associated psychiatric sequelae, see the Psychiatric News article, "Traumatic Brain Injury: Why Psychiatrists Matter." For information about issues in the assessment and treatment of TBI, see Management of Adults With Traumatic Brain Injury from American Psychiatric Publishing.

(Image: Lightspring/

Wednesday, October 29, 2014

Home Visits Bring Multiple Benefits to American-Indian Teen Mothers

A home-visiting program directed at teenage American-Indian mothers reduced maternal risks and improved their children’s behavior but also helped the high-school-educated workers who carried out the intervention.

"American Indian adolescents...have the highest rates of teen pregnancy, substance use, suicide, and dropping out of school of any racial or ethnic group in the country," said lead researcher Allison Barlow, M.P.H., Ph.D. (photo above), associate director of the Johns Hopkins Center for Indian Health, and colleagues, in the study "Paraprofessional-Delivered Home-Visiting Intervention for American Indian Teen Mothers and Children..." published in AJP in Advance.

The home visitors—called family health workers—were young women recruited from the same Apache and Navajo reservations in Arizona as the teen mothers and so understood their language and culture. In the study, all 322 patients received "optimized standard care," including transportation to clinic visits, information on child care, and referrals to local services. The study's goal was "to evaluate the intervention’s effects on parental competence (parenting knowledge, locus of control, stress, and behaviors) and maternal behavioral problems that impede effective parenting through early childhood.... Secondary aims were to evaluate intervention effects on early childhood emotional and behavioral outcomes."

Mothers randomized to the intervention group also received the Family Spirit program, including training in observing their babies, interpreting their cries, reading to them, and developing routines. Home visits began during pregnancy and continued until the child was 36 months old. Intervention-group mothers demonstrated more parenting knowledge, less substance use, and lower scores of depression and externalizing problems. Their children also had fewer externalizing and internalizing problems and dysregulation.

The family health workers also benefited from the program. "After they were trained by Hopkins, not one is unemployed," said Barlow in an interview. "They are either in school or working in health-related jobs."

(Image: Johns Hopkins University)

Tuesday, October 28, 2014

Clozapine Monotherapy More Cost-Effective Than Antipsychotic Polypharmacy, Study Shows

Treatment with clozapine alone instead of antipsychotic polypharmacy for treatment-resistant schizophrenia is associated with reduced disease-specific emergency department use and with reduced disease-specific and all-cause health care costs, according to the study “Outcomes of Medicaid Beneficiaries With Schizophrenia Receiving Clozapine Only or Antipsychotic Combinations” published in Psychiatric Services in Advance.

Researchers at the University of Texas Health Science Center at San Antonio used data from the Medicaid MarketScan database to study disease-specific and all-cause hospitalization, emergency department use, and Medicaid payments among nonelderly Medicaid beneficiaries with schizophrenia who were treated with either second-generation polypharmacy or clozapine monotherapy.

A total of 479 patients were treated with clozapine monotherapy, and 2,440 were treated with antipsychotic polypharmacy containing antipsychotics other than clozapine. After controlling for baseline differences in comorbidity, patients treated with clozapine monotherapy were less likely than those treated with antipsychotic polypharmacy to have mental-disorder–related use of the emergency department or schizophrenia-related use of the emergency department in the 12-month period following initiation of treatment.

Also, total Medicaid payments for the clozapine-monotherapy group were significantly lower across all categories, with all-cause costs reduced on average by $21,233, mental-disorder–related costs reduced by $17,457, and schizophrenia-related costs reduced by $10,582.

Deanna Kelly, Pharm.D., a professor of psychiatry at the University of Maryland School of Medicine, who reviewed the report for Psychiatric News, said that clozapine has been shown to be the most effective antipsychotic and  that much more effort should be focused on maximizing its use.

She added that the cost findings in the study are especially important. “If payers get involved and begin encouraging use of clozapine, it could cause a paradigm shift in our field,” Kelly said. “This study may be a good first step toward creating that shift.”

For related information on treating treatment-resistant schizophrenia, see the Psychiatric News article "Schizophrenia Symptoms Reduced By Combination of ECT and Clozapine."

(Image: Andrii Kondiuk/

Monday, October 27, 2014

Cocoa-derived Flavanols Can Improve Memory and Cognition, Study Finds

A daily dose of flavanols—antioxidants found in foods like tea and cocoa—helped improve the memory and cognitive brain function of middle-aged adults, reports a new study published in Nature Neuroscience.

A team led by researchers at Columbia University Medical Center randomly assigned 37 healthy volunteers aged 50 to 69 to receive either a high-flavanol (900 mg) or a low-flavanol (10 mg) cocoa drink, developed by candymaker Mars Inc., once a day for three months. Each participant also was given a brain scan and cognitive tests before and after the study; the scan involved using functional magnetic resonance imaging (fMRI) to measure blood volume in the dentate gyrus, a region of the hippocampus associated with age-related memory decline.

After three months, the researchers found noticeable improvements in both the health of the dentate gyrus and cognitive test performance among those who consumed the high-flavanol drink. As lead author Scott Small, M.D., of Columbia University explained, “If a participant had the memory of a typical 60-year-old at the beginning of the study, after three months that person on average had the memory of a typical 30- or 40-year-old.”

While this was a well-controlled clinical study, the authors noted that the results will need to be replicated in a larger population. They also cautioned that matching the flavanol doses used in the study means eating lots more chocolate than people reasonably can—and that most commercial chocolate has flavanols removed during processing anyway and will thus not produce similar effects.

In addition to providing the flavanol drink, Mars Inc. partially supported the study. Additional funding was provided by the National Institutes of Health, the James S. McDonnell Foundation, and the McKnight Brain Research Foundation.

To read more about the dentate gyrus and age-related memory loss, see the Psychiatric News article “Kandel Details Brain’s Role in Growth and Loss of Memory.”

Friday, October 24, 2014

Child Psychiatrists Discuss Impact of Marijuana Legalization

With legislation loosening restrictions on marijuana use becoming more prevalent in the U.S., researchers are investigating how its commercialization can impact society, especially youth.

Yesterday, at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers from the University of Colorado School of Medicine presented comparative studies on the trends in cannabis use among adolescents and negative consequences associated with such use among individuals during the pre- and post-commercialization eras of medical marijuana in Colorado.

The first study, presented by Christian Hopfer, M.D. (pictured above), an associate professor of psychiatry, showed that of 560 adolescents being treated for polysubstance use disorder from 2007 to 2013, those who entered treatment after 2009 (after commercialization of medical marijuana) were more likely to have higher amounts of delta-9-tetrahydrocabnnabinol—an active ingredient in marijuana—in their urine and more polysubstance use at admission, compared with individuals who accessed treatment for polysubstance abuse during the pre-commercialization era. In a study lead by Stacy Salomonsen-Sautel, Ph.D., a postdoctoral fellow, data showed that commercialization of medicinal marijuana in Colorado also correlated with an increase in fatal motor vehicle crashes among drivers aged 16 and older who tested positive for marijuana use, whereas no change was seen among this category of drivers living in states without laws legalizing sale of marijuana for medical purposes.
"Commercialization of marijuana is definitely in process throughout the nation,” Hopfer pointed out. “There is a lot of capital going towards this substance…[as well as] efforts to remarket it as a more ‘upscale’ product." During an interview with Psychiatric News, Hopfer stressed that because marijuana legalization and commercialization are bound to have a substantial impact on society, it is crucial for parents, adolescents, and psychiatrists to educate themselves on the “policy changes regarding marijuana, the pharmacology of marijuana, and the effects of marijuana on adolescent development and safety."
To read more about youth and marijuana use, see the Psychiatric News articles "Research Review Prompts NIDA Warning About Marijuana Use" and "Marijuana Legalization and Young Brains: Time for Serious Study."
(Image: Psychiatric News/Vabren Watts)

Thursday, October 23, 2014

Psychiatrists Urged to Increase Awareness of Domestic Violence

October is National Domestic Violence Awareness Month, focusing national attention on a problem for which physicians and other health care workers—including psychiatrists—may be first responders. Psychiatrist Gail Robinson, M.D., points out that domestic violence can include physical, sexual, emotional, and verbal assault (including denigrating language and blaming the partner) and violence against objects such as punching the wall beside the partner. Robinson, who is APA’s minority and underrepresented trustee, is at the University of Toronto as director of the Women’s Mental Health Program, senior psychiatrist of the University Health Network, and a professor of psychiatry.

Robinson said risk factors for being a victim of domestic violence include observing violence between parents in the home when young; having attitudes that accept violence and gender inequality; and experiencing marital conflict or disruption. “Substance abuse and low self-esteem have been noted as increasing vulnerability to domestic violence; however, they may be a consequence of the violence rather than a cause of the violence,” she said. “Physically there may be outward signs of violence, such as bruises or fractures. If a woman is pregnant—violence continues to occur during pregnancy, often directed to the women’s abdomen—there may be at increased risk of miscarriage, premature deliveries, or small-for-date babies.”

Robinson’s advice to clinicians: “Always ask about the presence of conflict in the family when taking a history, as women find it difficult to report unless they get the sense that they will be heard and not ignored or blamed. Having pamphlets or posters about domestic violence in the waiting room can provide an atmosphere that encourages women to report. It is important for the psychiatrist to have some practical information about safety measures such as domestic violence hotlines and where to go if the woman has to leave.

Domestic violence is not exclusively a problem between heterosexual couples. A recent study found that same-sex domestic violence affects one-quarter to nearly three-quarters of lesbian, gay, and bisexual individuals—figures that equal or exceed those for straight couples. “Domestic violence can occur in LGBT families with the same frequency as it does in straight ones,” said psychiatrist Jack Drescher, M.D., past president of the Group for the Advancement of Psychiatry. “Clinicians need to be alert to domestic violence presentations in their clinical practices and to understand what kind of interventions may be helpful to their patients and their families."

Expressing support for education and outreach efforts on domestic violence, APA President Paul Summergrad, M.D., stressed that, "Domestic violence can lead to serious health problems, including anxiety, depression, posttraumatic stress disorder, and substance abuse, as well as an increased likelihood of general medical problems such as headaches, chronic pain, and poor physical health. Domestic violence is not limited by economic status, race, national origin, religion, gender, or sexual orientation.... APA strongly advocates for prevention and better detection of domestic violence, improved treatment of victims and offenders, and expanded research into causes, consequences, and prevention.” APA has posted domestic violence resources at

APA's is holding its next #YourMH @twitter chat in observance of Domestic Violence Awareness Month. Join your APA colleagues in responding to questions and comments from the public on Friday, October 24, from noon to 1 p.m. ET. To join, use #YourMH (stands for "Your Mental Health"), @apapsychiatric, or #DVAM14. If you haven't created a Twitter account yet, click here to do so now. Here's your chance to share your knowledge and insights.

Wednesday, October 22, 2014

Forensic Psychiatrists Discuss Factors That Can Increase Violence Risk in Those With Mental Illness

Predicting violence among psychiatric patients “remains an inexact science,” a bit like predicting the weather, said forensic psychiatry experts Charles Scott, M.D., a professor of clinical psychiatry at the University of California, Davis, and Philip Resnick, M.D., a professor of psychiatry at Case Western Reserve University School of Medicine. While most people with mental illness are not violent, certain factors increase the risk of violence for people with psychosis or mood disorders, wrote Scott and Resnick in the October issue of CNS Spectrums.

“[I]ndividuals who suffer from persecutory delusions and negative affect are more likely to act on their delusions,” they said. Angry affect is a critical variable, especially when coupled with feelings of being spied upon, followed, plotted against, or being under external control. They pointed out as well that depression may be a risk factor when accompanied by a recent history of violence and/or alcohol use. Active manic symptoms are also associated with increased risk of engaging in a violent crime, but mostly when associated with comorbid substance abuse.

Scott and Resnick suggest using structured risk assessments to help gather appropriate data and reviewing research findings to identify violence-related risk factors associated with psychotic and mood disorder symptoms. “Like a good weather forecaster, the clinician does not state with certainty that an event will occur,” they concluded. “Instead, he or she estimates the likelihood that a future event will occur.

For more in Psychiatric News about assessment of risk for violence, see the article, “Experts Discuss Factors That May Lead to Violence Among Mentally Ill People.”

(Image: Lisa F. Young/


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