Tuesday, July 7, 2015

Meta-Analysis Finds No Association Between Stimulants for ADHD and New, Worsening Tics


Psychostimulant use does not appear to be associated with an onset or worsening of tics in children with with attention-deficit/hyperactivity disorder (ADHD), according to a meta-analysis of studies appearing online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Clinical practice currently restricts the use of psychostimulant medications in children with tics or a family history of tics because of fear that tics will develop or worsen as a side effect of treatment. To examine the relationship between psychostimulant use and tics, researchers from several institutions conducted a PubMed search to identify all double-blind, randomized, placebo-controlled trials examining the efficacy of psychostimulant medications in the treatment of children with ADHD.

They identified 22 studies involving 2,385 children with ADHD for inclusion and used statistical analysis to examine the effects of stimulant type, dosage, duration of use, trial design, and mean age of participants on the measured risk of tics.

The analysis revealed that new onset tics or worsening of tic symptoms were commonly reported in both the psychostimulant and placebo groups, and the risk of new onset or worsening of tics associated with psychostimulant treatment was similar between the two groups. Moreover, type of psychostimulant, dose, and duration of psychostimulant treatment did not affect risk of new onset or worsening of tics.

“When new onset or worsening of tics occurs after the initiation of a psychostimulant medication, it is much more likely to be a result of coincidence than caused by the medication.” the authors wrote. “Using psychostimulant medications in children with ADHD and comorbid tics (or with a family history of tics) should be considered, especially when agents that target both ADHD and tic symptoms (e.g., alpha-2 agonists) have failed.”

For related information, see the Psychiatric News article “ADHD Genes Also Influence Social, Cognitive Behaviors.”

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Monday, July 6, 2015

CBT Reduces Insomnia in Patients With Co-Occurring Psychiatric Conditions


A form of cognitive-behavioral therapy especially developed to treat insomnia (CBT-I) was found to be effective in reducing insomnia symptoms and sleep disturbances, even in cases where the patient has a co-occurring problem such as a psychiatric disorder, according to a new analysis of medical literature published online today in JAMA Internal Medicine.

While a meta-analysis published last month demonstrated that CBT-I—a multicomponent treatment package that usually includes stimulus control, sleep restriction, and cognitive therapy—is a safe and effective treatment option for adults with chronic insomnia, the analysis excluded studies of insomnia comorbid with psychiatric and general medical conditions. For the current study, Jason Ong, Ph.D., of Rush University Medical Center, and colleagues included data from 37 studies and nearly 2,200 participants with insomnia as well as a range of medical conditions (such as depression, alcohol dependence, chronic pain, and cancer).

The researchers found that twice the percentage of patients who received CBT-I achieved remission from insomnia compared with patients in control or comparison groups (36% vs. 17%), and CBT-I improved most sleep parameters with the exception of total sleep time.

CBT-I was also associated with positive effects on the coexisting illness, though the benefits were more pronounced in people with psychiatric disorders compared with other medical problems. The authors suggested this correlation may occur because sleep may be more strongly associated with cognitive-emotional symptoms than physical symptoms.

For more information on sleep and psychiatric disorders, see the Psychiatric News article “Combining Insomnia, Depression Treatment May Improve Outcome” and the FOCUS article “Psychological and Behavioral Treatments for Insomnia,” which was part of an issue devoted to sleep disorders.

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Thursday, July 2, 2015

Study Finds Overall Uptick in Youth Prescribed Antipsychotics


From 2006 to 2010, antipsychotic use increased among U.S. adolescents and young adults but not in children 12 and under, according to a study published online Wednesday in JAMA Psychiatry.

Mark Olfson, M.D., M.P.H., a professor of clinical psychiatry at Columbia University, and colleagues retrieved data on antipsychotic prescriptions filled by or for young people (aged 1 to 24 years) in 2006, 2008, and 2010 from the IMS LifeLink LRx Longitudinal Prescription database, which includes about 60 percent of all retail pharmacies in the United States. The researchers then calculated the percentage of young people for whom one or more antipsychotic prescriptions were filled during the study year by sex and age group, and generalized the IMS prevalence to the entire U.S. population of young people, including those who did not fill a prescription.

The percentages of young people whose antipsychotic prescriptions were filled in 2006 and 2010, respectively, were 0.14% and 0.11% for younger children (1 to 6 years), 0.85% and 0.80% for older children (7 to 12 years), 1.10% and 1.19% for adolescents (13 to 18 years), and 0.69% and 0.84% for young adults (19 to 24 years). Further analysis of the 2010 data revealed that across all age groups, males were more likely than females to have filled their antipsychotic prescriptions; among young people treated with antipsychotics in 2010, receiving a prescription from a psychiatrist was less common among younger children (57.9%) than among other age groups (range, 70.4%-77.9%).

“In view of evidence of widespread antipsychotic prescribing outside of U.S. Food and Drug Administration–labeled indications and concerns regarding the adverse metabolic effects of second-generation antipsychotics, this decline [in the rate of antipsychotic use among children 12 and under] is a welcome development,” the authors wrote. “Nevertheless, age and sex antipsychotic use patterns suggest that much of the antipsychotic treatment of children and younger adolescents targets age-limited behavioral problems.”

When evaluating treatment options for the youngest children with disruptive behaviors, practice guidelines recommend that “consideration of antipsychotic medications should be limited to those who have severe, sustained, and intractable impairment in multiple settings or who pose safety risks,” the authors noted. They added that if such therapy is initiated, young patients should be continually reassessed to minimize treatment duration. However, as the authors pointed out, children treated with antipsychotics most commonly receive prescriptions from physicians who are not psychiatrists.

“Given the paucity of high-quality empirical evidence supporting the efficacy and safety of antipsychotic treatment in this age group, these treatment patterns raise potential safety concerns and underscore the importance of improving access for young children with severe mental health problems to high-quality, specialized child and adolescent mental health services,” they concluded.

For more on antipsychotic use among children and adolescents and practice guidelines, see the Psychiatric News article “Recent Rise in Youth on Antipsychotics Raises Concerns Among Experts.”



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Wednesday, July 1, 2015

Childhood Exposure to Violence Highly Prevalent


In the course of a year, four out of ten children experienced some exposure to violence, crime, or abuse, according to a survey of 4,000 young people published online in JAMA Pediatrics June 29.

The researchers analyzed data from the National Survey of Children’s Exposure to Violence (NatSCEV), which is conducted every three years. The most recent study took place in 2014 and asked children aged 0 to 17 (or their caregivers) about physical assault, sexual assault, child maltreatment, property crime, and witnessing violence.

“More than one-third of all youth (37.3%) experienced a physical assault during the study year, primarily at the hands of siblings and peers,” wrote David Finkelhor, Ph.D., a professor of sociology and director of the Crimes against Children Research Center at the University of New Hampshire in Durham, and colleagues. About 15% experienced maltreatment (physical or emotional abuse, neglect, or custodial interference); 6.5% had something stolen; and 24.5% witnessed family or community violence. Overall, 5% experienced a sexual offense; 16% of girls 14 to 17 reported a sexual offense and 4.6% a sexual assault or sexual abuse.

Most concerning to the authors was the fact that 41% of the young people surveyed had more than one direct experience of violence, crime, or abuse.

“Exposures to violence were interrelated in such a way that experiencing one type increased the likelihood of experiencing other types as well,” concluded Finkelhor and colleagues. “Every combination had a significant risk amplification.”

To learn about the association between childhood maltreatment and cognitive deficits, see the AJP study “Neural Correlates of Error Processing in Young PeopleWith a History of Severe Childhood Abuse: An fMRI Study.”

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Tuesday, June 30, 2015

PTSD Increases Heart Disease Risks in Women


Women who display four or more symptoms of post-traumatic stress disorder (PTSD) are more likely to have a heart attack or stroke compared with women who never experienced trauma, reports a recent study appearing in Circulation.

Researchers at Columbia University's Mailman School of Public Health and the Harvard T.H. Chan School of Public Health surveyed nearly 50,000 women participating in the Nurses' Health Study II. Trauma exposure and PTSD symptoms were assessed using the Brief Trauma Questionnaire and a PTSD screen.

While 80% of the women reported experiencing a traumatic event in their lives, more than half of this group (58%) reported no symptoms of PTSD. Participants reporting symptoms of PTSD were split evenly between those reporting four or more symptoms of the disorder and those reporting one to three symptoms.

Women who reported four or more symptoms of PTSD had a 60% higher risk of cardiovascular disease risk after adjusting for age, family history, and childhood factors compared with women with no trauma exposure. The researchers also found that trauma exposure alone increased risk for heart attack and stroke by 45%—an increased risk not seen in women who had been exposed to a trauma but reported one to three PTSD symptoms.

"PTSD is twice as common in women than in men, and women with PTSD are more likely to have severe and persistent symptoms," study author Karestan Koenen, Ph.D., of Columbia University said in a press release. "Likewise, women with cardiovascular disease are more likely to be hospitalized and die from a heart attack compared with men. For all these reasons, it's critical that we understand how PTSD contributes to cardiovascular disease in women."

To read about another potential health risk of PTSD in women, see the Psychiatric News article "PTSD Linked to Increased Risk for Type 2 Diabetes in Women."

(shutterstock/Sebastian Kaulitzki)

Monday, June 29, 2015

Long-Acting Injectable Risperidone Leads to Greater Adherence, Relapse Prevention in Patients With Schizophrenia


Patients with a recent first episode of schizophrenia who are treated with a long-acting injectable (LAI) formulation of the antipsychotic risperidone may experience lower rates of psychotic relapse and better control of psychotic symptoms than those treated with oral risperidone, according to a study published this week in JAMA Psychiatry.

For the study, Kenneth Subotnik, Ph.D., a research psychologist at the University of California, Los Angeles, and colleagues randomized 83 patients with recent-onset schizophrenia to receive LAI risperidone (25 mg every two weeks) or oral risperidone (2 mg daily) over a 12-month period. Furthermore, half of the patients in each group were simultaneously randomized to receive cognitive remediation (a cognitive training program of at least one hour a week) or healthy-behaviors training (weekly instruction in relaxation, healthy eating habits, and exercise).

The results showed that psychotic exacerbation and/or relapse rate was lower for the LAI risperidone group compared with the oral group (5% versus 33%), and LAI risperidone was significantly associated with lower levels of hallucinations and delusions throughout the follow-up period. The proportion of patients who required psychiatric hospitalization was significantly lower for LAI risperidone than for oral risperidone (5.0% versus 18.6%), and treatment with the LAI risperidone led to significantly better medication adherence.

The cognitive remediation and healthy-behaviors training groups did not differ significantly regarding psychotic relapse, psychotic symptom control, or hospitalization rates. There were no significant interactions between the two medications and the two psychosocial treatments.

"The superiority of long-acting injectable risperidone extends beyond preventing psychotic symptom return," the researchers noted. "Use of long-acting injectable risperidone in our first-episode patients also led to better maintenance of intracortical myelination as well as improved cognitive functioning," they wrote. "If this trifecta of improved psychotic symptom control, cognition, and intracortical myelination can be replicated in longer longitudinal studies of patients with a first episode of schizophrenia, it would suggest that the use of long-acting injectable antipsychotics early in schizophrenia can modify the trajectory of the disorder and lead to better long-term outcomes."

Thie study was supported by grants from the National Institute of Mental Health; supplementary funding and medication were provided by Janssen Scientific Affairs, LLC. Janssen is the manufacturer of LAI risperidone.

For more on long-acting, injectable antipsychotics, see the Psychiatric News article "Some Experts Urge More Use of Long-Acting, Injectable Antipsychotics."

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Friday, June 26, 2015

Supreme Court Rules Same-Sex Marriage Is a Constitutional Right


This morning the U.S. Supreme Court ruled in a 5-to-4 decision that states do not have the right to ban or outlaw same-sex unions—giving same-sex couples the right to legally marry in every state across the nation.

"In forming a marital union, two people become something greater than once they were,” wrote Justice Anthony Kennedy for the majority. "It would misunderstand these men and women to say they disrespect the idea of marriage," the ruling continued. "Their plea is that they do respect it, respect it so deeply that they seek to find its fulfillment for themselves. They ask for equal dignity in the eyes of the law. The Constitution grants them that right."

The ruling extending from the case Obergefell v. Hodges also mandates states to recognize a marriage between two people of the same sex when legally married in another state.

"Today’s ruling strikes a blow to inequality and discrimination throughout the nation, and that’s good for Americans’ mental health," said APA President RenĂ©e Binder, M.D. "APA has a long history of supporting the rights of same-sex couples, and we have long noted that there is no scientific or medical reason to deny these couples the right to marry. This decision is a landmark step in ensuring equality and happiness for every American."

APA joined a coalition of the nation’s top health care associations including the AMA, the American Academy of Pediatrics, and others in submitting an amicus brief in support of same-sex marriage.

“The claim that allowing sex-same couples to marry undermines the institution of marriage and harms children is inconsistent with the scientific evidence,” Binder said. “In fact, the evidence strongly supports the conclusion that homosexuality is a normal expression of human sexuality and that gay men and lesbians form stable, committed relationships equivalent to heterosexual couples.

“But this issue goes well beyond the scientific evidence,” said Binder. “It is about what is the right thing to do and the fact that everyone should be free from discrimination.”

Over the past several decades, APA has issued a number of position statements on antidiscrimination policies related to the LGBT community. Those positions were consolidated in a 2013 Position Statement on issues related to homosexuality.

“Today is a watershed moment for equal rights in America,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We at APA are proud that our country—after a long period of seeking equal rights—now sees that everyone has the constitutional right to marriage.”

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