Study Finds High Prevalence of Prenatal Alcohol Exposure Disorders Among Patients of Chicago Clinic

Over 38 percent of the patients who attended a family medicine clinic in Chicago’s Southside had a neurodevelopmental disorder associated with prenatal alcohol exposure (ND-PAE).

While national surveys has estimated that disorders due to fetal alcohol exposure may affect 2% to 5% of individuals, this new report, published yesterday in Psychiatric Services in Advance, shows how pervasive this problem can get in certain communities.

The article assessed the records of 590 adult and 21 youth psychiatric patients--almost entirely African-American--who attended the Family Medicine Clinic at Jackson Park Hospital.

Of the 611 patients, 237 (226 adults and 11 children) had clinical profiles consistent with ND-PAE, now recognized as an emerging condition in DSM-V; in contrast, only 53 patients presented with a “classical” DSM-V neurodevelopmental disorder such as ADHD or autism. The higher ND-PAE prevalence among the child patients (57 percent) may suggest that this problem is becoming more pronounced, though the sample size was small.

“Fetal alcohol exposure is at the root of much of the violence, abuse, incarceration, special education, and poor adaptability that plague these underserved African-American communities,” said lead author Carl Bell, M.D., a clinical professor of psychiatry and public health at the University of Illinois School of Medicine. “Hopefully these results will bring more attention to the problem of ND-PAE, which is the most common preventable form of intellectual disability.”

To read more about the addition of ND-PAE to DSM-V, see the Psychiatric News viewpoint article, "New DSM Code Should Benefit Clinicians, Researchers."

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Study Finds That Anticholingeric Medications Increase Risk of Pneumonia

A study of 3,000 seniors has shown that medications with anticholinergic effects (those that block the neurotransmitter acetycholine) are associated with a higher risk of developing pneumonia.

Drugs that have anticholinergic properties treat a wide swath of conditions, many of which are common in older adults; these include asthma, COPD, gastrointestinal disorders, and bladder problems. Anticholinergic drugs are also important therapies for mental disorders; benzodiazepines and tricyclic antidepressants fall into this category.

A team from the Group Health Research Institute in Seattle examined health and pharmacy data from 1,039 cases of pneumonia that occurred among their older, immune, competent patients (65-94) as well as 2,000 healthy controls of the same age and gender composition.

They found that 59% of the pneumonia cases had one or more prescription fills of an anticholinergic 90 days or less before the diagnosis, compared with 35% of the healthy group. The pneumonia group also showed higher chronic anticholinergic use, with 53% of the patients having filled three or more prescriptions over the past year, compared with 36% of the controls.

Members of this research team had recently published another study demonstrating that extended use of anticholinergic medications might increase the risk for dementia in older adults. To learn more, see the Psychiatric News Alert “High Dose and Extended Use of Anticholinergic Drugs May Increase Risk for Dementia, Study Suggests.”

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Risk for Dying Young Increased With ADHD Diagnosis, Study Finds

Though previous research has shown an association between attention-deficit/hyperactivity disorder (ADHD) and mental illnesses that are likely to increase mortality such as oppositional defiant disorder and substance use disorder, it is unknown whether an ADHD diagnosis alone is capable of increasing risk for premature death.

Researchers from Aarhus University in Denmark conducted a study with approximately 2 million individuals born between 1981 and 2011 to investigate whether any association exists between an ADHD diagnosis and premature mortality. Health records of the subjects were analyzed from first birthday until 2013.

The results, published in Lancet, showed that of the 32,061 individuals with a diagnosis for ADHD, 107 died before the age of 33—a rate that is twice that for persons without the disorder, even after adjusting for factors that increase risk for premature death such as history of psychiatric disorders and employment status. In addition, the researchers found that individuals diagnosed at age 18 years or older were more than four times as likely to die early compared with those without ADHD at the same age. More than half of all deaths among those with ADHD were caused by automobile crashes and other accidents.

Timothy Wilens, M.D., chief of child and adolescent psychiatry at Massachusetts General Hospital for Children, told Psychiatric News that the study adds to the literature emphasizing the importance of properly diagnosing and treating ADHD. “While the risk of premature death in this age group remains low, the overall findings are a reminder for individuals with ADHD, their families, and practitioners that early identification and treatment of ADHD may help to improve overall long-term outcome including issues of safety. Moreover, individuals with ADHD must continue to be vigilant about the increased risk for addictions as well as mishaps related to driving."

More information about adult ADHD and its treatment can be found in the American Psychiatric Publishing book Understanding and Treating Adults With Attention-Deficit/Hyperactivity Disorder.

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Congressman and Senator Come Together to Discuss Forthcoming MH Legislation

A congressman and a senator working on parallel tracks for comprehensive mental health care reform made their bipartisan case in a Washington discussion today.

Rep. Tim Murphy (R-Pa.) said he plans to reintroduce his bipartisan Helping Families in Mental Health Crisis Act in March.

“We are going line by line, tweaking the bill now,” said Murphy, a psychologist, in a presentation organized by The Hill, a newspaper that covers national politics. “The legislation could move this year.”

Sen. Chris Murphy (D-Conn.) praised his House counterpart for the expertise and attention he has brought to a complicated issue and said he is working on a “substantially similar” bill in the Senate. (The two men are not related, they pointed out.)

Expanding the mental health workforce, reducing barriers to accessing care, increasing the number of inpatient psychiatric beds, integrating primary and mental health care, and solving reimbursement problems were all critical components of a comprehensive bill, both legislators agreed.

“We can pass comprehensive mental health reform,” said Sen. Murphy, whose home state was the site of the Sandy Hook school shooting in 2012. “I hope we don’t have another tragedy before we make common-sense changes in the mental health system.”

They expressed a willingness to work with both Democratic and Republican colleagues.

“There is no party loyalty on this issue,” said Rep. Murphy. “This is all about helping people and bringing the system into the 21^st century.”

For more in Psychiatric News about the progress of mental health legislation, see "Author of House Mental Health Bill Addresses APA Assembly."

Medical Groups Urge Steps to Cut Gun Violence

APA and seven other medical societies yesterday joined with the American Bar Association in a statement published in Annals of Internal Medicine that calls for a reduction in “the health and public health consequences of firearms.”

“Across the United States, physicians have firsthand experience with the effects of firearm-related injuries and deaths and the impact of such events on the lives of their patients,” said the statement. None of the recommendations contravened the Second Amendment, according to the American Bar Association.

In addition to APA, the other signatories were the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Emergency Physicians, the American Congress of Obstetricians and Gynecologists, the American College of Physicians, the American College of Surgeons, and the American Public Health Association.

The organizations specifically cautioned against the indiscriminate inclusion of “all persons with any mental or substance use disorder in a category of persons prohibited from purchasing firearms,” while supporting greater access to mental health treatment.

The statement also calls for more research into firearm violence and unintentional injury and elimination of laws that prohibit physicians from discussing gun ownership with patients.

"We believe that multidisciplinary, interprofessional collaboration is critical to bringing about meaningful changes to reduce the burden of firearm-related injuries and death on persons, families, communities, and society in general," the authors concluded.

For information in Psychiatric News about the APA Board of Trustees's recent statement on firearms, see "APA Board Urges Public-Health Approach to Gun Violence."

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Brief CBT Appears Effective in Reducing Suicide Risk in Military With Suicidal Ideation

Brief cognitive-behavioral therapy (CBT) appears to be effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt, according to the report "Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up" in AJP in Advance.

The study was conducted by M. David Rudd, Ph.D., of the National Center for Veterans Studies at the University of Memphis, and colleagues. The subjects were active-duty Army soldiers at Fort Carson, Colo., who had either attempted suicide or experienced suicidal ideation; they were randomly assigned to treatment as usual (N=76) or treatment as usual plus brief CBT (N=76).

Assessment of incidence of suicide attempts during the two-year follow-up period was conducted with the Suicide Attempt Self-Injury Interview. Statistical analysis was used to determine treatment efficacy with regard to incidence and time to suicide attempt, and differences in psychiatric symptoms were evaluated over time.

Thirty-one suicide attempts were made by 26 participants across both groups during the two-year follow-up, including two deaths by suicide (one in the brief CBT group and one in the treatment-as-usual group). Eight participants in brief CBT and 18 participants in treatment as usual made at least one suicide attempt during the two-year follow-up , which suggests that soldiers in brief CBT were approximately 60 percent less likely to make a suicide attempt during the follow-up period than soldiers in treatment as usual. There were no between-group differences in severity of psychiatric symptoms.

“It is noteworthy that the observed reduction in suicide attempts occurred despite minimal differences in symptom severity between groups over time, a finding that mirrors previous outcomes from dialectical-behavior therapy and cognitive therapy,” the researchers stated. “Given that the primary goal of brief CBT is emotion regulation and problem-solving-skills development as opposed to symptom reduction, this finding is not surprising and supports the assertion that suicidal thoughts and behaviors should be targeted as a unique treatment goal separate from psychiatric diagnosis and symptom severity.”

For more on this subject, see the Psychiatric News article “Army Learning Complex Factors Associated With Soldier Suicides.”

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IOM Proposes New Name, Diagnostic Criteria for Chronic Fatigue Syndrome

An Institute of Medicine (IOM) report has proposed new diagnostic criteria for chronic fatigue syndrome (CFS), as well as a new name that reinforces that this illness is a physiological, not psychological, problem.

The recommended new name is systemic exertion intolerance disease (SEID); the IOM committee that prepared the report believes this designation more accurately captures the central characteristics of this illness, which affects up to 2.5 million people but is frequently misdiagnosed or overlooked.

These central symptoms noted by the committee as diagnostic criteria are a substantial and persistent impairment in the ability to engage in pre-illness activity levels, unrefreshing sleep, and post-exertion malaise, where the effort of even a mild activity can trigger a collapse that can last for days. Besides these three characteristics, a patient must also have cognitive impairment and/or orthostatic intolerance for an SEID diagnosis.

The 15-member IOM expert committee developed the new report--Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness--after a comprehensive literature review and input from patient, advocacy, and research communities.

To read about other recent IOM reports of relevance to the psychiatric community, see the Psychiatric News articles “Mixed Reviews Follow IOM Report on Future of GME Financing” and “IOM Report Critical of Substance Abuse Care for Troops.”

(IOM)