Early Exposure to Football May Have Long-Term Behavioral Consequences

A neuropsychiatric assessment of former football players has found that those who began playing the sport before the age of 12 were more likely to report symptoms of depression and apathy decades later than those who started playing after they turned 12.

This association was independent of the players' current age, duration of football play, or history of learning disabilities, suggesting that age of first exposure to football is an independent risk factor for behavioral problems. The findings were published Tuesday in Translational Psychiatry.

This analysis included 214 former amateur (high school and college players) and professional football players who were part of an ongoing study called the Longitudinal Examination to Gather Evidence of Neurodegenerative Disease (LEGEND). As part of the LEGEND study, these players were asked to take a series of annual cognitive and mood tests, including the Brief Test of Adult Cognition by Telephone (BTACT), Behavior Rating Inventory of Executive Function-Adult Version, Center for Epidemiologic Studies Depression Scale, and the Apathy Evaluation Scale.

When the investigators, led by Robert Stern, Ph.D., of the Boston University Alzheimer’s Disease and Chronic Traumatic Encephalopathy Center, divided the group based on age of first exposure (AFE) to football, they found that players with an AFE <12 had about twice the odds of having worse scores on their executive function and apathy tests, and three times the odds of elevated depression scores. There were no significant effects on overall cognition as measured with BTACT. 

Stern and colleagues did caution that while there was a robust group-level difference, there was a wide range of scores at an individual level and many players with an AFE <12 were normal. 

The findings suggest that “[y]outh exposure to football may have long-term neurobehavioral consequences,” the authors wrote. “Future longitudinal studies that objectively monitor the clinical function of youth football players throughout life, including those who do not go on to play football at the high school, college, or professional level, are ultimately needed to understand the long-term neurological safety implications of youth tackle football.”

For related information, see the Psychiatric News article “Study Finds High Prevalence of CTE, Other Disorders in Former Football Players.”

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APA Calls for Rejection of Latest Republican Effort to Repeal ACA

APA is urging members to contact their U.S. senators and voice their opposition to the Graham-Cassidy bill—the latest effort by Republicans to repeal and replace the Affordable Care Act. The bill, which was drafted by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) and unveiled last week, appears to be gaining traction in the Senate. 

“This legislation … will lead to millions of Americans losing their health care coverage,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said Tuesday in a press release. “We are particularly concerned that this bill would make drastic cuts to the Medicaid program and roll back expansion, which has allowed 1.3 million Americans with serious mental illness and 2.8 million Americans with substance use disorder, to gain coverage for the first time. This bill harms our most vulnerable patients.”

Among its many proposals, the bill would allow states to change what qualifies as an essential health benefit, eliminating guaranteed coverage of substance use disorders and mental health treatment services. It would also stop the Affordable Care Act’s Medicaid expansion and cost-sharing subsidies and instead put that money into block grants that states could use to design their own health care systems.

“The APA is ready to work with members of both parties to craft a bipartisan solution that stabilizes the health insurance market and ensures Americans have access to quality, affordable health care,” Levin said.

Last week APA joined with five other medical specialty organizations representing more than 560,000 physicians in a letter to Senate Majority Leader Mitch McConnell and Minority Leader Charles Schumer to oppose the bill. The organizations noted that “a similar proposal was put forth by these two senators in July. Based on our analysis, the revised proposal may actually be worse than the original.”

The Republicans are up against a tight deadline of September 30 to secure the 50 votes needed to pass the measure using the budget reconciliation process. After this date, they would need 60 votes to pass the legislation. The Congressional Budget Office (CBO) on Monday announced that while it will aim to have a preliminary assessment of the Graham-Cassidy bill by early next week, it will not be able to provide point estimates of the bill’s effects on the deficit, health insurance coverage, or premiums for at least several weeks.

APA members are urged to call and email their senators today and register their opposition to the bill through a special portal on the APA website.

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Methylphenidate Found to Reduce Apathy in Patients With Mild Alzheimer’s Disease

Methylphenidate appears to improve apathy in patients with mild Alzheimer’s disease (AD), according to a study of community-dwelling veterans with mild AD published in AJP in Advance.

Prasad Padala, M.D., an associate director for clinical programs at the Geriatric Research Education and Clinical Center at the Central Arkansas Veterans Healthcare System, and colleagues also found that methylphenidate improved cognition, functional status, caregiver burden, Clinical Global Impression (CGI) scores, and depression.

Padala and colleagues randomized 60 community-dwelling male veterans with mild Alzheimer’s disease to methylphenidate or placebo. All participants were started on 5 mg of methylphenidate or a look-alike placebo twice daily and titrated to 10 mg twice daily at two weeks. The protocol allowed the study physician to decrease the dose if adverse events were reported. Otherwise, participants continued to take 10 mg twice daily until 12 weeks, at which time the dose was tapered to 5 mg twice daily for three days and stopped.

The primary outcome measure was the score on the clinician-reported Apathy Evaluation Scale (AES-C). The secondary outcome measures were scores on the Modified Mini-Mental State Examination and instruments evaluating cognition and function, including ability to carry out daily activities, and depression.

Padala and colleagues found significant differences over time for apathy in the methylphenidate group but not in the placebo group. After adjusting for baseline scores on the AES-C, they found that the methylphenidate group had significantly greater improvement than the placebo group at four weeks, and apathy continued to improve at eight weeks and 12 weeks. The behavioral and cognitive domains improved by eight weeks, and the emotional domain finally improved at 12 weeks. 

“These results suggest that improvement in the emotional domain may be mediated by improvements in the cognitive and behavioral domains,” Padala and colleagues wrote.

They added, “Although the ideal duration of treatment with methylphenidate is unknown, a case for longer duration can be made because the results of these studies were proportional to the duration of treatment, with the highest improvement in apathy and cognition noted with 12-week treatment. Longer duration studies need to be conducted to investigate if the improvement in apathy continues with the duration of treatment or if it plateaus at a certain point.”

For related information, see the Psychiatric News article “Kunadlini Yoga Found to Enhance Cognitive Functioning in Older Adults.”

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FDA Approves First App to Treat Substance Use Disorder

The Food and Drug Administration last week announced that it has approved the first mobile app to help treat individuals with substance use disorders (SUD). 

The app, known as Reset, uses cognitive-behavioral therapy and is intended to be used in combination with outpatient therapy to treat alcohol, cocaine, marijuana, and stimulant SUDs. The goal is to increase retention in outpatient therapy programs and promote abstinence from substance abuse. The app is not intended to be used for the treatment of opioid dependence, the FDA noted.

“This is an example of how innovative digital technologies can help provide patients access to additional tools during their treatment,” Carlos Peña, Ph.D., M.S., director of the Division of Neurological and Physical Medicine Devices in FDA’s Center for Devices and Radiological Health, said in a press release. 

The Reset app is indicated as a 12-week prescription-only adjunct treatment for patients with SUD who are not currently on opioid replacement therapy, who do not abuse alcohol solely, or who do not have an opioid use disorder. The product combines patient-facing interventions and assessments via a mobile app with clinician-facing dashboards and data analytics.

The FDA reviewed data from a multisite, unblinded 12-week clinical trial of 399 patients who received either standard treatment or standard treatment with the addition of a desktop-based version of Reset, which could be accessed at the clinic or at home. The data showed a statistically significant increase in adherence to abstinence for the patients with alcohol, cocaine, marijuana, and stimulant SUD in those who used Reset (40.3%) compared with the patients who did not (17.6%). The clinical trial did not demonstrate effectiveness of using Reset in patients reporting opioid use.

There were no reports of side effects associated with the device, according to data from the clinical studies.

With the FDA’s clearance of Reset, Pear Therapeutics (based in Boston and San Francisco), the developer of the technology, can now begin to market the app.

For related information, see the Psychiatric News article “APA to Provide Framework to Evaluate Mobile Health Apps.”

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Changes to ICD-10-CM Codes for DSM-5 Diagnoses Effective October 1

Revised 2018 ICD-10-CM codes, released by the National Center for Health Statistics (NCHS), are scheduled to take effect on October 1, 2017. The codes include new, updated, or deleted codes for diagnoses listed in ICD-10-CM, including some 65 codes related to mental health conditions listed in DSM-5. All practitioners and payers must use the codes.  

Coding updates are typically made to provide greater diagnostic specificity, which in turn impacts reimbursement levels.  

NCHS is a federal agency within the Centers for Disease Control and Prevention, which oversees the ICD-10-CM. The ICD-10 Coordination and Maintenance Committee, a federal committee co-chaired by a representative from NCHS and from the Centers for Medicare and Medicaid Services, approves proposed changes to ICD on a yearly basis. 

The coding changes that impact DSM-5 are posted on the APA website. The diagnoses are listed alongside two columns—one column listing the codes that were used through September 30, 2017, and the other column listing the new codes that will become effective October 1. Two versions of the table are provided—one listing the codes in numerical order and the other listing them in the order that they appear in DSM-5.

CBT Provides Long-Term Benefits for Pediatric Patients With OCD

Children and adolescents with obsessive-compulsive disorder (OCD) who respond to cognitive-behavioral therapy (CBT) appear to continue to experience benefits from the therapy even after their initial course of treatment ends, according to a study published Wednesday in the Journal of the American Academy of Child and Adolescent Psychiatry.

Other research has suggested that CBT for pediatric OCD is a durable therapy, but these studies had been limited by either small samples sizes or having CBT combined with other treatments. 

For the current trial, Per Hove Thomsen, D.M.Sc., of Aarhus University in Denmark and colleagues tracked one-year outcomes in 155 youth with OCD aged 7 to 17, whose symptoms improved (Children’s Yale-Brown Obsessive-Compulsive Scale [CY-BOCS] scores ≤15) after receiving 75-minute, manualized, exposure-based CBT once a week for 14 weeks. 

During the one-year follow-up, CBT booster sessions could be given at any time, if required, with a maximum of three sessions per six-month period. About 40% of the participants had at least one booster session during the first six months, and 15% received at least one booster CBT session during the second six months.

At the one-year mark, 142 of the 155 participants still had CY-BOCS scores ≤15, and 121 had CY-BOCS scores of ≤10 (OCD remission). Only 13 of the patients, or 8%, experienced a relapse.

On average, CY-BOCS total scores dropped by 1.72 points during the first year after terminating the initial treatment, with children’s scores lowering by 1.34 points and adolescent scores dropping by 2.08 points. The authors noted that the adolescent group had a higher average CY-BOCS at the start of the study, so that may have enabled a greater reduction one year later.

“Clinically, these results imply that it is important to regularly monitor patients during the first year after successful first-line CBT,” Thomsen and colleagues wrote. “[O]ffering booster sessions to selected patients during follow-up might further strengthen the long-term effect of CBT.” 

For related information, see the Psychiatric News article “Report Highlights Alternative Treatment Options for OCD.” 

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Increase in Suicide Attempts Appears Driven By Young Adults With Less Formal Education, Psychiatric Disorders

An overall increase in suicide attempts from 2004-2005 to 2012-2013 appears to have disproportionately affected younger adults with less formal education and those with antisocial personality disorder, anxiety disorders, depressive disorders, and a history of violence, according to a report published today in JAMA Psychiatry.

Borderline personality disorder (BPD) continues to be the disorder most associated with suicide attempt risk, but the percentage of individuals with BPD attempting suicide dropped during the period of analysis, possibly suggesting increased access to evidence-based treatments.

Lead author Mark Olfson, M.D., M.P.H. (pictured above), of Columbia University and colleagues noted that because attempted suicide is the greatest known risk factor for completed suicide, reducing suicide attempts is an important public health and clinical goal. “The trends revealed in the study support a clinical and public health focus on young, socioeconomically disadvantaged adults, especially those who have made previous suicide attempts and those who have common mood, anxiety, and personality disorders,” he told Psychiatric News.

Olfson and colleagues used data from the 2004-2005 wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and the 2012-2013 NESARC-III. These nationally representative surveys asked identical questions to 69,341 adults, aged 21 years and older, concerning the occurrence and timing of suicide attempts.

During the study period, the percentage of U.S. adults who reported making a recent suicide attempt increased from 0.62% in 2004-2005 to 0.79% in 2012-2013. In both surveys, most adults with recent suicide attempts were female (60.17% and 60.94% for the two periods, 2004-2005 and 2012-2013, respectively) and younger than 50 years (84.75% and 80.38%, respectively).

Statistical analysis showed significantly higher risk of suicide attempt among adults aged 21 to 34 years than among adults aged 65 and older; adults with no more than a high school education than among college graduates; and adults with antisocial personality disorder, a history of violent behavior, or a history of anxiety or depressive disorders than among adults without these conditions.

“Although we don’t understand all of the factors that are driving these trends, it may be that younger adults and adults with less education have been especially hard hit by the recent recession in terms of economic and psychological stress,” Olfson said. “Unemployed adults, those with less education, and adults with lower family incomes were all especially likely to report a recent suicide attempt.”

He called the decrease in the percentage of individuals with BPD reporting recent suicide attempt a bright spot in the study. In 2004-2005, 6.9% of adults with BPD made a suicide attempt compared with 4.57% in 2012-2013.

“This may be in part because more psychiatrists and other mental health professionals are being trained to deliver dialectical behavioral therapy,” Olfson said. 

For related information, see the Psychiatric News article “Netflix Drama About Teen Suicide Prompts Related Google Searches.”

(Image: courtesy Mark Olfson, M.D., M.P.H.)