Tuesday, October 25, 2016

Early Identification Programs Show Urban Poor More Likely to Meet Psychosis Criteria

Individuals from deprived and urban communities appear most likely to meet criteria for first-episode psychosis (FEP) among those referred to early identification programs in the eastern region of England, according to an epidemiological analysis in AJP in Advance.

The findings could be used to inform the provision of effective early intervention services for psychosis in the United States and other areas where early identification is less established but gaining traction, according to researchers from several English institutions and agencies.

The researchers identified all new first-episode psychosis cases of individuals aged 16 to 35 years old presenting to early intervention psychosis services in the East of England. Importantly, they found that those most likely to meet criteria for FEP were poorer, younger males from deprived and densely populated neighborhoods. For instance, 68.7% of those between the ages of 16 and 25 met the criteria, compared with 31.3% of those over age 25. Additionally, 55.6% of referrals who met the criteria for FEP were either long-term unemployed or “long-term sick or disabled,” compared with 22.4% of those who were employed. And 52.1% resided in the neighborhoods with the highest population density.

The findings point to possible environmental factors that may influence the incidence of schizophrenia, but the researchers said it is difficult to rule out other possibly confounding influences, relevant to psychosis, that may aggregate among lower sociodemographic populations.

“Further longitudinal studies are required to disentangle the potential role of social causation from [other confounding factors],” the researchers wrote. “Although we could not establish causation directly, our results demonstrate that our most deprived and urban communities shoulder a disproportionate burden of psychosis morbidity at the population level. This should be used to inform the provision of effective early intervention services for psychosis.”

For related information see the Psychiatric News article “Psychosocial Treatments Found Effective for Early Psychosis.”

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Monday, October 24, 2016

Some Patients May Develop Adjustment Disorder Up to Year After Trauma

Although adjustment disorders—characterized by the development of emotional or behavioral symptoms within three months of a stressor—are considered to be relatively common, much remains unknown about the course of the disorder, its phenomenology, or its relationship to other disorders. A study published today in AJP in Advance suggests that some people may continue to develop adjustment disorder up to one year after a traumatic event.

The findings came from an analysis of over 800 injury survivors (aged 16 to 70) who had been hospitalized in trauma centers in Australia. Baseline data were collected prior to discharge from the hospital, which was on average seven days after injury, and follow-up data were collected at three months and 12 months after injury.

The authors found that the overall prevalence of adjustment disorder was 19% at three months and 16% at 12 months. While one-third of the patients with adjustment disorder at three months continued to experience symptoms at 12 months, the majority of patients with the disorder at 12 months were not diagnosed as having adjustment disorder at three months. Injury survivors that were diagnosed with adjustment disorder at three months were significantly more likely to meet criteria for another psychiatric condition at 12 months compared with those with no psychiatric disorder.

The most common symptoms reported among those with adjustment disorder were PTSD-associated symptoms including poor concentration, disturbed sleep, and irritability. 

“This study adds to the limited research evidence on adjustment disorder by demonstrating that the diagnosis identifies people who following a stressor experience distress/functioning impairment and who are at risk for developing more severe disorders,” Meaghan O’Donnell, Ph.D., and colleagues at the Phoenix Australia Centre for Posttraumatic Mental Health in Australia, wrote. “However, it challenges the current diagnosis by finding that (1) many people develop the disorder beyond the initial three months after the stressor and (2) it does not present with distinct anxiety or depressive symptoms but rather mixed features, with PTSD symptoms playing an important role. Considering the frequency with which this diagnosis is used by clinicians, it is imperative that more structured research is conducted so that robust diagnostic criteria can be established.”

To read more about this topic, see the Psychiatric News article “When Somebody Has an Adjustment Disorder” by Patricia Casey, M.D., and James Strain, M.D.

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Friday, October 21, 2016

Brief CBT Element Encourages Trauma Patients to Seek Psychotherapy

Therapeutic homework assignments derived from cognitive-behavior therapy (CBT) and delivered in routine care seem helpful in drawing trauma patients into psychotherapy or counseling, as well as reducing PTSD symptoms, said Doyanne Darnell, Ph.D., an acting assistant professor of psychiatry and behavioral sciences at the University of Washington, Seattle, and colleagues.

The researchers randomized 115 patients from a hospital trauma center to receive the CBT assignments (n=56) or usual care, Darnell reported in Psychiatric Services in Advance.

Patients also received some psychoeducation about symptoms and posttraumatic recovery, as well as anxiety and stress-reduction techniques. These were brief and could be rendered during routine care in the emergency department, hospital, or in outpatient medical follow-up appointments, or even by telephone.

“The elements were designed to help patients overcome behavioral avoidance patterns consequent to anxious avoidance, withdrawal, or functional impairments related to the injury,” wrote the researchers.

The researchers found that trauma patients who received the intervention were more likely (93%) than usual-care controls (10%) to get psychotherapy or counseling.

Furthermore, the analysis showed “a statistically significant and clinically meaningful association between CBT element homework completion and PTSD symptom reduction for intervention patients.”

Darnell and colleagues concluded that with further study, “readily deliverable CBT elements targeting PTSD and comorbidity” could be incorporated into American College of Surgeons guidelines in acute medical settings, just as universal screening for alcohol use disorder is today.

For more in Psychiatric News about early intervention for trauma victims, see “Early Intervention Offers Hope For Preventing PTSD.”

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Thursday, October 20, 2016

Why Isn't Naltrexone Used More Often for Alcohol Use Disorder?

Naltrexone, first approved for treatment of opioid addiction, is known to help some patients with alcohol use disorder (AUD) drink less. For instance, a 2014 meta-analysis in JAMA found it was associated with reduction in return to drinking and number of heavy drinking days. But clinicians who spoke with Psychiatric News say the medication is vastly underutilized in treatment of AUD. 

Charles O’Brien, M.D., Ph.D. (pictured at left), one of the original researchers on naltrexone for alcohol use disorder and chair of the DSM-5 Work Group on Substance Related Disorders, said there are several reasons naltrexone is underutilized: for example, many physicians are unfamiliar with the medication, and alcohol rehabilitation centers are not typically staffed by medical professionals. But the most important reason, he and others say, is the longstanding conviction—widely held among physicians as well as the general public—that alcoholism can be treated only by the 12-step recovery model.

“When I send a patient to a rehabilitation center, they follow the 12-step program," he said, adding that many counselors at such centers are likely to advise patients not to use medication.

John Renner, M.D., co-chair of APA’s Council on Addiction Psychiatry, agreed. “There is very good evidence showing that if you compare naltrexone to placebo you get much better sobriety,” he said. “But the general attitude in the recovery community is a very strong preference for a very early version of AA that is uncomfortable with medication.

“Doctors just aren’t used to thinking about pharmacotherapy for alcohol use disorder, and we have had difficulty getting buy-in from general physicians," he continued.

O’Brien and Renner both emphasized that there is no reason that clinicians can’t use naltrexone in conjunction with AA or any other psychosocial treatment, and that in fact it is always encouraged. “We always recommend cognitive-behavioral therapy and/or 12 step,” O’Brien told Psychiatric News.

For more in-depth coverage on this subject, see tomorrow’s issue of Psychiatric News PsychoPharm. For related information, see O’Brien’s 2015 article in the American Journal of Psychiatry titled “In Treating Alcohol Use Disorders, Why Not Use Evidence-Based Treatment?” An archive of webinars and other information about the Providers’ Clinical Support System for Medication Assisted Treatment is available on the APA website.

Wednesday, October 19, 2016

Folinic Acid May Improve Verbal Skills in Children With Autism Spectrum Disorder

High-dose folinic acid (a form of folate) may improve communication skills in children with autism spectrum disorder (ASD), reports a study published yesterday in Molecular Psychiatry.

For the study, Richard Frye, M.D., Ph.D., of the Arkansas Children’s Hospital and colleagues randomly assigned 48 children (aged 3 to 14 years) diagnosed with ASD and language impairment to receive either daily folinic acid (2 mg/kg, capped at 50 mg) or placebo for 12 weeks. Researchers used the CELF-preschool-2, CELF-4, and the Preschool Language Scale-5 instruments to measure changes in verbal communication.

At the end of the 12-week period, the children taking folinic acid showed significantly greater improvements in verbal communication than placebo (an average of 5.7 standardized points better). Several secondary measures such as daily living skills, stereotypic behaviors, and internalizing problems also improved more in the folinic acid groups.

Frye and colleagues also screened the children for the presence of antibodies to the folate receptor alpha (FRAAs) in the blood, which would indicate a dysfunction in the transport of folate from the blood to the brain. They found that children with positive FRAA results showed a particularly strong improvements in verbal communication when given folinic acid (about 7.3 standardized test points).

“This study suggests that FRAAs predict response to high-dose folinic acid treatment,” the authors wrote. “[F]uture studies will be needed to define factors that predict response to treatment, investigate optimal dosing and help understand whether other compounds could work synergistically with folinic acid.”

While no serious adverse events were reported by children in the folinic acid group, the authors did caution that “[s]ince ASD is likely a lifelong disorder the long-term adverse effect of any treatment is a concern. As folinic acid may increasingly become used to treat ASD in the future, short-term and long-term adverse effects should be studied in more detail to ensure safety.”

For related information, see the Psychiatric News article “Program Teaches Social Skills to Adolescents With Autism” and the American Journal of Psychiatry article “Neurometabolic Disorders: Potentially Treatable Abnormalities in Patients With Treatment-Refractory Depression and Suicidal Behavior.”

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Tuesday, October 18, 2016

People With OCD May Prefer Psychotherapy to Medications

Although it is well known that patient preferences for treatment can influence outcomes, few studies have explored treatment preferences among individuals with anxiety disorders such as obsessive-compulsive disorder (OCD). A study published yesterday in Psychiatric Services in Advance suggests that people with OCD may prefer psychotherapy to medications, both as a first-line therapy and augmenting agent.

A total of 216 adults who self-reported at least moderate OCD symptoms completed an online survey developed by researchers at Columbia University. The survey asked participants to choose their preferred evidence-based treatments, rate acceptability of novel treatments, and answer questions regarding their treatment history, current OCD symptoms and severity, and more.

The study participants reported a slightly higher preference for exposure and response prevention (EX/RP) therapy (55%) than serotonin reuptake inhibitors (SRIs, 45%) as a first-line treatment. Additional analysis revealed that those who preferred SRIs were in treatment at the time of the survey, were receiving SRIs as their treatment, and reported a positive experience with treatment overall and with medications.

Participants significantly preferred EX/RP (68%) to antipsychotic medications (31%) when used to augment SRI response. Compared with those who preferred antipsychotics, those who preferred EX/RP were younger, more likely to be female, and more likely to be taking benzodiazepines. 

Among novel OCD treatments, behavioral interventions (such as acceptance and commitment therapy and Kundalini yoga) were rated as more acceptable than medical procedures (deep brain stimulation and gamma knife surgery).

“Our findings highlight the importance of patient-level characteristics, beliefs about treatment, and past experience as factors that influence preferences for OCD treatment,” the authors wrote. “Given EX/RP’s efficacy, both as monotherapy and as a strategy to augment SRI response, and our finding that individuals preferred EX/RP whether or not they were taking SRIs, efforts to increase access to this treatment are warranted.

To read more on the topic of OCD treatments, see the Psychiatric News article “Antidepressants May Inhibit D-Cycloserine From Improving Symptoms in People With OCD.”

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Monday, October 17, 2016

Study Suggests Association Between SSRIs in Pregnancy, Speech Disorders in Offspring

A study published last week in JAMA Psychiatry suggests that children born to women who took selective serotonin reuptake inhibitors (SSRIs) during pregnancy may be at an elevated risk of speech and language disorders. While experts say the study raises important questions, more research is needed to determine whether exposure to SSRIs confers greater risk than untreated depression during pregnancy over the long term.

For the study, Alan S. Brown, M.D., M.P.H., director of the Unit in Birth Cohort Studies at the New York State Psychiatric Institute, tracked the incidence of speech/language, scholastic, and motor disorders from birth to 14 years in 56,000 children born in Finland between 1996 and 2010. 

The offspring were divided into three groups: 15,596 were in the SSRI-exposed group (mothers diagnosed as having depression-related psychiatric disorders with a history of purchasing SSRIs during pregnancy); 9,537 were in the unmedicated group (mothers diagnosed as having depression-related psychiatric disorders without a history of purchasing SSRIs during pregnancy); and 31,207 were in the unexposed group (mothers without a psychiatric diagnosis or a history of purchasing SSRIs). 

Over the study period, there was a total of 829, 187, and 285 instances of speech/language, scholastic, and motor disorders, respectively. The authors found that children in the SSRI-exposed group and the unmedicated group were at a significantly increased risk of speech/language disorders compared with those in the unexposed group.

Additional analysis revealed that children of mothers who purchased SSRIs at least twice during pregnancy had a 37% increased risk of speech/language disorders compared with offspring in the unmedicated group and a 63% increased risk compared with children in the unexposed group. There were no significant differences in the risk of the other disorders between offspring in the SSRI-exposed group and the unmedicated group.

“Overall the study is reassuring because there were no scholastic or motor associations, and the risk of language delay, if real, is very small,” Jennifer Payne, M.D., the director of the Women's Mood Disorders Center at Johns Hopkins School of Medicine, told Psychiatric News.

However, Payne noted that because the study did not control for severity of depression or postpartum depression, there is no way of knowing whether antidepressant exposure is actually associated with speech and language delays.

“Postpartum depression has long been known to affect language development and IQ in children,” she added.

“Brown et al have identified a very important research question, … but the current report does not answer whether exposure to SSRIs or untreated depression during pregnancy are in equipoise with respect to neurodevelopmental toxicity or if, over the long-term, one confers greater risk,” Lee Cohen, M.D., and Ruta Nonacs, M.D., Ph.D., of Massachusetts General Hospital wrote in a related editorial.

“Given the extent to which depression during pregnancy predicts risk for postpartum depression with its attendant morbidity, and in light of the robust data describing the adverse effects of maternal psychiatric morbidity on long-term child development, clinicians will need to broaden the conceptual framework used to evaluate relative risk of SSRI use during pregnancy as they navigate this clinical arena with patients making individual decisions to match patient wishes,” Cohen and Nonacs concluded.

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