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.

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) of the U.S. population of young people, including those who did not fill a prescription. 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 Renée 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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Thursday, June 25, 2015

Supreme Court Affirms Subsidies for ACA Tax Credits


The U.S. Supreme Court today upheld a key provision of the Affordable Care Act (ACA), permitting continued use of tax-credit subsidies to pay for health insurance premiums for low-income Americans.

Writing for the majority in a 6-to-3 decision, Chief Justice John Roberts rejected arguments positing a significant difference between state and federal insurance exchanges—a difference that would have eliminated the subsidies in the 34 states that did not have state exchanges.

“We are pleased that the Supreme Court upheld subsidies for more than six million people,” said APA President Renée Binder, M.D., in a statement. “Today’s decision means these Americans will continue to receive vital mental health benefits as guaranteed by the ACA. As the physician experts and leaders in mental health treatment, we know there can be no health care without mental health care.”

Acknowledging that there were “more than a few examples of inartful drafting” in the ACA, the court's majority nevertheless chose to look at the “broader structure of the Act” in holding for the government.

“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. … The combination of no tax credits and an ineffective coverage requirement could well push a State’s individual insurance market into a death spiral,” wrote Roberts. “It is implausible that Congress meant the Act to operate in this manner.”

“For many of our patients, expansion of the ACA has provided a crucial lifeline to access needed health care services, to better engage in treatment, and to experience not just recovery, but to be well again,” said Harsh K. Trivedi, M.D., M.B.A., the chair of APA’s Council on Healthcare Systems and Financing and vice chair for clinical affairs in the Department of Psychiatry at Vanderbilt University in Nashville, Tenn.

“We will continue to work with Congress, the Administration, and the medical community to ensure that mental illness and substance use disorders are treated the same as other illnesses as outlined in the ACA,” added APA CEO and Medical Director Saul Levin, M.D., M.P.A.

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Wednesday, June 24, 2015

Psychiatrists Join in Healing Efforts After Charleston Murders


Within days after a gunman murdered nine churchgoers at the Emanuel African Methodist Episcopal Church (left) in Charleston, S.C., on June 17, faculty members from the Medical University of South Carolina’s (MUSC) Department of Psychiatry and Behavioral Sciences were supporting recovery and resilience efforts as part of a unified community response.

South Carolina Psychiatric Association (SCPA) members, along with clinicians from Community Mental Health and the MUSC's National Crime Victims Center, supported the family assistance center coordinated by the Federal Bureau of Investigation to help those affected by the tragedy.

Various agencies continue to provide emotional and practical supports and referrals to the family and friends of the victims, said psychiatrist Edward Kantor, M.D., SCPA district branch disaster liaison and an associate professor and director of residency training at MUSC, in an interview.

The center was scheduled to close after three days, but has remained open for another week to accommodate family members coming from out of town, said Kantor.

The SCPA is also undertaking a broader needs assessment, in partnership with state and local partners, to look for concrete ways that psychiatry can support recovery efforts in the city and across the state, added David Beckert, M.D., an assistant professor of psychiatry at MUSC and SCPA vice president.

“Many families are affected, not just those in Charleston,” Beckert told Psychiatric News. “We are sifting through evidence-based material to help well people who are affected by the event but are not psychiatrically ill. They still need assistance in recovering.”

Kantor was impressed by the outpouring of unity and support in the city and state after the tragedy: “It feels like there is a genuine effort across the board to really come together in good faith to figure out how to move forward together.”

Edward Kantor, M.D., and David Beckert, M.D. are contributing authors to the American Psychiatric Publishing book Disaster Psychiatry: Readiness, Evaluation, and Treatment.


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