Friday, July 29, 2016

Psychiatrist Joshua Gordon, M.D., Appointed Director of NIMH

The National Institutes of Health (NIH) announced yesterday the selection of Joshua A. Gordon, M.D., Ph.D., an associate professor of psychiatry at Columbia University Medical Center and research psychiatrist at the New York State Psychiatric Institute, to serve as the director of the National Institute of Mental Health (NIMH). 

Gordon is expected to assume his new post in September. He will replace Acting Director Bruce Cuthbert, Ph.D.

“I am personally delighted with Dr. Gordon’s appointment as director of NIMH,” APA President Maria A. Oquendo, M.D., a professor of psychiatry and vice chair for education at Columbia University Medical Center, told Psychiatric News. "Having worked closely with him over the years, I can attest to the fact that in addition to being a scientist of the highest caliber, he has an open-mindedness, fairness, and thoughtfulness that are rare indeed. I look forward to seeing the wonderful things Dr. Gordon will do. For our part, APA will continue to pursue staunch advocacy for mental health research funding, the most effective path toward improving the lives of our patients.

Gordon joins NIMH with an extensive research background that focuses on the analysis of neural activity in genetic mouse models that have mutations of relevance to psychiatric diseases such as schizophrenia, anxiety disorders, and depression. His research involves an integrative neuroscience perspective and is performed across multiple levels of analysis, with an aim to understanding how a given disease mutation leads to a particular behavior.

Gordon’s work has been recognized by several prestigious awards, including the Brain and Behavior Research Foundation–NARSAD Young Investigator Award, Rising Star Award from the International Mental Health Research Organization, A.E. Bennett Research Award from the Society of Biological Psychiatry, and Daniel H. Efron Research Award from the American College of Neuropsychopharmacology. 

(Photo courtesy of NIMH)

Thursday, July 28, 2016

No Response to Lurasidone at 2 Weeks? Study Suggests Dose Escalation May Help

Despite the fact that early nonresponse to antipsychotic therapy in patients with schizophrenia is known to predict future poor response, there is limited evidence available to guide clinicians for addressing early nonresponse in this patient population. A study in the Journal of Clinical Psychiatry that examined nonresponse to a standard dose of lurasidone at two weeks suggests that escalating the dose of the medication early may lead to symptom improvements.

Antony Loebel, M.D., of Sunovion Pharmaceuticals Inc., and colleagues randomly assigned patients with acute schizophrenia (Positive and Negative Syndrome Scale [PANSS] total score equal to or greater than 80) to lurasidone 80 mg/d (n=199) or placebo (n=112) for two weeks. After two weeks of treatment with lurasidone 80 mg/d, the researchers classified 98 patients (49.5%) as early nonresponders (less than 20% improvement in PANSS total score) and re-randomized these patients to either continue treatment with lurasidone at 80 mg/d or lurasidone at 160 mg/d. 

In patients classified as early nonresponders at week 2, mean change from week 2 to week 6 in PANSS total score was significantly greater for patients whose lurasidone dose was increased to 160 mg/d compared with that for patients who continued receiving 80 mg/d (-16.6 versus -8.9). While a comparable magnitude of improvement was observed in Clinical Global Impression-Severity (CGI-S) score from week 2 to week 6 for early nonresponders re-randomized to lurasidone 160 mg/d versus 80 mg/d, the difference was not statistically significant. Treatment response (defined as equal or greater than 20% decrease in PANSS total score from study baseline to week 6) was demonstrated by 74.4% and 59.6% of early nonresponders re-randomized to lurasidone 160 mg/d and 80 mg/d, respectively. 

Early nonresponders whose dose was increased to lurasidone 160 mg/d reported a greater incidence of anxiety, abdominal discomfort, akathisia, insomnia, and somnolence compared with patients who continued on lurasidone 80 mg/d.

[T]he increased probability of response in early nonresponders after dose escalation to lurasidone 160 mg/d should be considered in the context of the risk-versus-benefit findings associated with this strategy,” the authors wrote. “These considerations include a modest increase in the frequency of certain adverse events and the clinical need to enhance the rate of response.”

William Carpenter, M.D., a professor of psychiatry at the University of Maryland School of Medicine and an expert on schizophrenia, told Psychiatric News that “the initial response predicting later outcome has been documented in several datasets, but the dose escalation benefit observed with lurasidone should not be generalized to other antipsychotic medications, where adverse effects may outweigh benefit. It is natural for clinicians to seek new options if you don't see a treatment response at two weeks, but there is scant evidence supporting common practices such as dose increase or addition of another drug.”

Added Carpenter, who was not involved in the study, “Clinicians who prescribe lurasidone should also consider if the real message of these findings is that they should start patients at 160 mg/day. And, if so, should the higher dose be reduced once remission is achieved?” 

This study was sponsored by Sunovion Pharmaceuticals Inc. 

Wednesday, July 27, 2016

Low Scores on Odor Identification Test May Predict Early-Stage Alzheimer’s Disease

At the 2016 Alzheimer’s Association International Conference yesterday, new evidence was presented suggesting that a low-cost smell identification test may be able to predict cognitive decline and the early onset of dementia in older adults.

Past studies have suggested that decreased ability to identify odors is a predictor of cognitive decline. The current study, led by researchers from the Columbia University Medical Center and New York State Psychiatric Institute, evaluated the usefulness of the 40-item University of Pennsylvania Smell Identification Test (UPSIT) in detecting the transition to dementia and cognitive decline. 

The researchers administered UPSIT to 397 older adults (average age of 80 years) from a multiethnic population in Manhattan, New York, who did not have dementia at the start of the study and were followed for four years. All participants received an MRI scan to measure the thickness of the entorhinal cortex, one of the first regions of the brain known to be affected by Alzheimer’s disease. Composite cognitive domain scores were derived from memory, language, and visual-spatial abilities.  

At the four-year follow-up, 12.6% of the participants had developed dementia, and 19.8% had signs of cognitive decline. Low UPSIT scores—indicative of a decreased ability to identify odors—and entorhinal cortical thinning were significantly associated with the transition to dementia after adjusting for age, education, gender, language of UPSIT administration (English or Spanish), functional status, and intracranial volume. Low UPSIT scores also predicted cognitive decline; entorhinal cortical thinning was not associated with cognitive decline.

“It’s clear that the science around biological measures in the detection of Alzheimer’s continues to gather pace and validation,” said Heather Snyder, Ph.D., director of medical and scientific operations of the Alzheimer’s Association, at a press conference that highlighted the study’s findings. “Using other biomarkers of Alzheimer’s disease to detect the disease at an earlier stage—which have the potential to be lower-cost and non-invasive—could lead to dramatic improvements in early detection and management of the disease.”

For more information, see the Psychiatric News article “Low Physical Activity in Early Adulthood Linked to Worse Midlife Cognition.”

Tuesday, July 26, 2016

Quetiapine Appears Effective as Monotherapy for PTSD, Study Shows

The atypical antipsychotic quetiapine appears to be effective as a single agent in the treatment of posttraumatic stress disorder (PTSD), according to a report in AJP in Advance.

Not all patients with PTSD respond to first-line antidepressant treatment, and current VA/Department of Defense guidelines recommend quetiapine and other antipsychotic medications as adjunctive treatments. Researchers from several VA centers and research institutions sought to determine the efficacy of quetiapine as monotherapy.

Eighty veterans meeting criteria for chronic PTSD were randomly assigned to treatment with either quetiapine or placebo tablets for 12 weeks. Quetiapine was initiated at a dose of 25 mg at bedtime and gradually titrated up to a minimum of 50 mg and maximum of 800 mg daily. The participants were evaluated at weeks 1, 2, 4, 8, and 12.

The primary outcome measure was the total Clinician-Administered PTSD Scale (CAPS) score. Secondary efficacy measures included the CAPS subscales, the Davidson Trauma Scale, the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impressions (CGI) scales for severity of illness and improvement, the Hamilton Depression Rating Scale (HAM-D), and the Hamilton Anxiety Rating Scale (HAM-A).

Patients in the quetiapine group experienced greater reductions in CAPS total, re-experiencing, and hyperarousal scores than those in the placebo group. (Scores on the CAPS avoidance/numbing subscale and the PANSS negative symptom subscale did not differ from those of the placebo group—a finding that is consistent with previous reviews of antipsychotics in the treatment of PTSD.) Patients taking quetiapine also experienced greater improvements in scores on the David Trauma Scale, CGI severity and improvement ratings, HAM-A, HAM-D, and PANSS positive symptom and general psychopathology subscale scores compared with the placebo group. 

“Our findings suggest that quetiapine as a single agent is effective in the treatment of PTSD and associated depression and anxiety symptoms,” they wrote. “The level of improvement observed with quetiapine suggests it may be superior for the treatment of PTSD over other antipsychotics, such as risperidone, which did not improve global PTSD symptoms in a large study with veterans.”

For related information, see the Psychiatric News article “Military Turns to Collaborative Care to Treat PTSD, Depression” and the Psychiatric Services article “Development and Validation of a Computerized-Adaptive Test for PTSD (P-CAT).”

(Image: iStock/Todd Headington)

Monday, July 25, 2016

Greater Pain Found to Increase Risk of Opioid Use Disorder

Researchers have long suspected that the level of pain experienced by a patient may increase his or her risk of developing an opioid use disorder. A study in AJP in Advance has for the first time taken a prospective look at this link, revealing a significant association between pain and prescription opioid use disorder at baseline and three years later.

Researchers at Columbia University and the National Institute on Drug Abuse analyzed data from a national sample of 34,653 adults who were surveyed three years apart. At each assessment, the participants were asked about their pain levels and prescription opioid use, as well as other substance use disorders, mood or anxiety disorders, and any family history of addiction or behavioral problems.

The researchers found that people with moderate or severe pain had a 41 percent higher risk of developing prescription opioid use disorders than those without, independent of demographics or other potential contributing factors. Males, younger adults (of either gender), and those with a family history of antisocial personality disorder were also found to be more likely to develop opioid use disorder.

There was no correlation for the inverse phenomenon; that is, people with an opioid disorder did not show any increased risk for developing chronic pain.

“Our findings highlight the need to provide evidence-based treatment for individuals in pain and to develop more effective nonopioid alternative treatments for those who do not respond to existing options,” the authors wrote. “From the clinical and preventive perspective, these clinical and demographic characteristics identify subgroups at increased risk who should be screened for pain and prescription opioid abuse.”

To read more about strategies to prevent opioid misuse, see the Psychiatric News column “Be Sure to Check the PDMP Before Prescribing Controlled Medications,” by Anna Lembke, M.D.

(Image: Paul Matthew Photography/Shutterstock)

Friday, July 22, 2016

Multiple Steps Are Needed to Reduce U.S. Firearm Suicides

What has proven effective at reducing the number of firearm suicides in other countries and what is possible to achieve in the United States may be quite different things, according to J. John Mann, M.D., a professor of psychiatry at Columbia University.

While studies in other countries have revealed that general restrictions against the ownership of guns lower firearm suicide rates, such legislation has “proven impossible to duplicate in the United States,” Mann and his colleague, Christina Michel, B.A., wrote online today in AJP in Advance. Instead, gun regulation efforts might better focus on restricting firearm access to people deemed at risk of harming themselves or others. 

However, as the authors noted, “[L]ess than 10 percent of the firearms used in suicides are purchased within two weeks of the suicide and the median interval between handgun purchase and suicide by the victim or another family member is 11 years, with the greatest risk in the first year after purchase.”

Mann and Michel described several ways gun violence restraining orders (which allow family members, significant others, and law enforcement personnel to formally request confiscation of firearms belonging to a person who may hurt himself or others), safer storage, smart-gun technology (which limits firearm access to the owner or permitted users), and firearm safety education campaigns for gun owners may help to lower firearm suicide rates. 

“All such initiatives must be accompanied by systematic evaluation of their effectiveness,” wrote Mann and Michel. “Ultimately, such program evaluation and lifting of the ban on federal funding of research on firearm violence will help improve efforts to reduce firearm suicide mortality.”

For related information, see the Psychiatric News column “Psychiatrists Have a Role to Play in Latest Gun Law Debates,” by APA President Maria A. Oquendo, M.D., and the Psychiatric News article “Violence Risk, Not Mental Illness, Should Guide Gun Access.”

(Image: iStock/DmyTo )

Thursday, July 21, 2016

Self-Report Symptom Scale May Predict Patients Most Likely to Experience Depressive Relapse

Despite achieving full remission from depression, it is estimated that nearly 15% of formerly depressed patients may relapse within six months. A study published in AJP in Advance now suggests a 12-item symptom-based tool may be able to predict those at greatest risk of depressive relapse.

Lewis Judd, M.D., of the University of California, San Diego, and colleagues examined the records of participants in the National Institute of Mental Health Collaborative Depression Study. (As part of the NIMH study, follow-up evaluations were regularly conducted and patients periodically completed the Symptom Checklist–90 [SCL-90] self-report.) 

The researchers analyzed the records of 188 patients with major depressive disorder who had at least one SCL-90 assessment after at least eight weeks of full remission from a depressive episode (defined as a value of 1 on the weekly psychiatric rating scale for all depressive conditions, recorded on Longitudinal Follow-Up Evaluation interviews). 

In about 1 in 7 occasions when 188 remitted subjects completed the SCL-90 (73 of 514 assessments), relapse followed within the ensuing 6 months. Analysis of these SCL-90 reports revealed a broad range of symptoms present at a moderate or worse level, including dysphoria, sleep disturbances, somatization, and having one’s feelings easily hurt. 

Further analysis revealed a set of 12 symptoms that most accurately predicted relapse within six months. The relapse rate was 5.8% when none of the 12 symptoms were present, 16.4% when one to five symptoms were present, 34.1% when six to nine symptoms were present, and 72.7% when 10 or more symptoms were present.

“A simple count of the number of symptoms (0 to 12) self-reported at a moderate or worse level of severity during the past week created a score that was highly related to the risk of relapse,” Judd and colleagues wrote.

This study demonstrates “it is possible to construct a brief self-report scale that can be used to ascertain an estimated risk of relapse for the individual patient,” the authors continued. “Such a person-level indicator can be used to tailor the follow-up schedule for each remitted patient based on his or her individually identified risk of relapse and potentially to initiate interventions in a more timely fashion when needed.”

For related information, see the Psychiatric News article “Integrating CBT, Pharmacotherapy May Prevent Relapse in MDD.”

(Image: iStock/DragonImages)


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