Patients With OUD Who Receive Extended-Release Naltrexone May Be More Likely to Stay in Treatment

Naltrexone is a proven treatment for opioid use disorder (OUD), but its clinical usefulness, when taken orally, has been limited by poor adherence among patients, according to several studies. A study in AJP in Advance now suggests that patients with OUD may be twice as likely to stay in therapy if they receive monthly injections of extended-release naltrexone (XR-naltrexone) following opioid withdrawal compared with daily oral naltrexone.

“These study findings have immediate clinical relevance for treatment of opioid use disorder at a time when an opioid epidemic continues unabated in the United States,” wrote Maria Sullivan, M.D., Ph.D., of Columbia University and colleagues. “Given that postdetoxification outpatient treatment without pharmacotherapy yields poor completion rates, high (60%−90%) relapse rates, and heightened risk of overdose and death, XR-naltrexone may be a viable alternative to prevent relapse in patients seeking treatment for opioid use disorder who do not prefer an agonist approach [such as methadone or buprenorphine].”

Sullivan and colleagues enrolled 60 adults aged 18 to 60 who met DSM-IV criteria for opioid dependence in the study. All participants completed an inpatient medication-assisted opioid withdrawal program and were transitioned to naltrexone therapy. Thirty-two patients were randomly assigned to treatment with oral naltrexone (50 mg/day) and 28 were assigned to treatment with XR-naltrexone (380 mg per injection every four weeks) for 24 weeks.

All participants were asked to visit the clinic three times per week for the first two weeks and then twice weekly for the remainder of the 24-week study. During each clinic visit, the patients took a urine test, discussed any recent substance use, and received a behavioral therapy session. The goal of the behavioral therapy was to educate, motivate, and support patients through the process of opioid detoxification, naltrexone induction, and successful naltrexone maintenance. Therapy goals were reinforced with a reward system whereby patients could win gift vouchers after achieving goals or milestones.

After six months, 12 of the 28 (43%) patients receiving XR-naltrexone had dropped out of treatment, compared with 23 of 32 (72%) patients in the oral naltrexone group. There were no significant differences in side effects between the two groups, other than a higher rate of insomnia among patients taking oral naltrexone. There were nine serious adverse events, but only one was found to be related to medication: one patient receiving XR-naltrexone developed allergic hives and was removed from the study.

“These results support the use of XR-naltrexone combined with behavioral therapy as an effective treatment for patients seeking opioid withdrawal and nonagonist treatment for preventing relapse to opioid use disorder,” the researchers concluded.

To read more about naltrexone, see the Psychiatric News article “Low-Dose Naltrexone May Mitigate Severity of Opioid Withdrawal During Detox.”

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Giving Patients Choice of PTSD Treatment Yields Significant Benefit, Study Finds

Adults with posttraumatic stress disorder (PTSD) given a choice between sertraline or prolonged exposure therapy opted for prolonged exposure almost two to one; and while both treatments conferred significant benefits, prolonged exposure provided some advantage over sertraline, reports a study published today in AJP in Advance.

The study aimed to determine whether giving patients diagnosed with PTSD their choice of treatment would affect patient outcomes, wrote Lori A. Zoellner, Ph.D., of the Department of Psychology at the University of Washington and colleagues. According to the authors, the study was the first large-scale trial directly comparing the efficacy of sertraline and prolonged exposure therapy for PTSD.

Some 200 patients with PTSD watched videotaped treatment rationales for both treatments and then indicated a preference for either sertraline or prolonged exposure. They were then randomly assigned to having a choice between treatments or to no choice of treatment. Both groups received up to 10 weeks of acute treatment and up to 24 months of follow-up.

Participants showed a strong preference for prolonged exposure therapy over the medication: of 97 participants given a choice of treatment, 63% chose prolonged exposure therapy and 37% chose sertraline. Participants in the prolonged exposure group received 10 weekly, 90- to 120-minute sessions led by a therapist. Responders were offered continued sertraline up to 24 months or up to two prolonged exposure booster sessions during the follow-up period.

The primary outcome measure was interviewer-rated PTSD symptoms, as measured by the PSS-I—a 17-item interview that uses DSM-IV symptom criteria and yields a severity rating (range, 0–51) and a diagnosis (yes/no). Additional measures included several standard self-assessments for depression, anxiety, and disability.

Both treatment groups showed large gains that were maintained during the 24-month follow-up; however, patients treated with prolonged exposure were significantly more likely to lose their PTSD diagnosis.

The authors noted that patients who received their preferred treatment were more likely to complete treatment (73% vs. 49%), and were more likely to lose their PTSD diagnosis, achieve responder status, and have lower self-reported PTSD, depression, and anxiety symptoms.

“Notably, preference effects were as strong as, if not stronger than, treatment modality effects, which suggests that accommodating patients’ preferences in treating PTSD is as important as, if not more so, than the specific choice of an empirically supported treatment,” the researchers wrote. “Accommodating patient preferences … and developing strategies for enhancing patient buy-in are important next steps in facilitating access, initiation, adherence, and completion of empirically supported treatment for PTSD.”

For related information, see the Psychiatric News article “Propranolol Combined With Reactivation Therapy May Reduce PTSD Symptoms.”

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Several Symptoms May Point to Suboptimal Medication Adherence in Patients With Depression

Despite the proven efficacy of antidepressants, a significant number of patients with depression fail to take these medications as prescribed, which can increase the risk of depression relapse, hospitalization, and more. A study in Depression & Anxiety now suggests that patients with major depression who have more severe symptoms, suicidal thoughts, and/or report physical pain may be most likely to report not taking their medications as prescribed.

Carolina Baeza-Velasco, Ph.D., of the University of Paris Descartes and colleagues examined data extracted from hospital admissions at the Department of Emergency Psychiatry and Acute Care of the University Hospital of Montpellier, France, between May 2012 and July 2015. A total of 360 adults aged 18 to 77 who met DSM-IV criteria for a current major depression episode and filled out the Medication Adherence Rating Scale (MARS) questionnaire were included in the study.

The MARS questionnaire asks patients to answer yes or no to 10 questions/statements on medication adherence behavior, beliefs/attitudes about taking medication, and side effects of medication. The researchers divided the study participants into two groups according to how they responded to the four MARS questions on medication adherence behavior—the “optimal adherence group” and the “suboptimal adherence group.” Patients in the optimal adherence group responded no to all four questions, including “Do you ever forget to take your medication?” and “When you feel better, do you sometimes stop taking your medication?”. Of the 360 patients included in the study, 107 (29.7%) were found to be optimally adherent to their medication.

The researchers next compared the responses of patients in the two groups to questions regarding depressive symptoms and suicidal thoughts; history of abuse and/or neglect during childhood; physical pain intensity; and psychiatric history. The number of psychiatric hospitalizations, the score of depression severity, suicidal ideation, reports of negative side effects from medication, and pain were significantly higher in the patients in the suboptimal adherence group compared with those in the optimal adherence group. Patients in the suboptimal adherence group also had less favorable attitudes toward medication and were less likely to be married/living with a partner than patients in the optimal adherence group.

“These results suggest a vicious circle in which more vulnerable patients are less adherent to medication, which could worsen the clinical picture maintaining, in turn, low adherence,” the researchers concluded.

For related information, see the Psychiatric News article “Motivational Pharmacotherapy Can Improve Medication Adherence,” by Roberto Lewis-Fernández, M.D., of Columbia College of Physicians and Surgeons.

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Older Adults Who Engage in Self-Harm Are Often Not Referred to Mental Health Services, Study Finds

Most older adults who engage in self-harm are not referred to mental health services, according to the results of a study conducted in the United Kingdom. The findings, which were published in Lancet Psychiatry, suggest these patients are 20 times more likely to die from unnatural causes within a year compared with older adults who do not engage in self-harm.

“We have identified a group at high risk of premature unnatural death and identified areas of improvement for clinical management of older-aged adults in primary care,” wrote Catherine Morgan, M.D., of the University of Manchester, U.K., and colleagues. “Health care professionals should take the opportunity to consider the risk of self-harm when an older person consults with other health problems, especially when major physical illnesses and psychopathology are both present, to reduce the risk of an escalation in self-harming behaviour and associated mortality. “

Morgan and colleagues analyzed data from the UK Clinical Practice Research Datalink, which contains anonymous patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. They identified 4,124 adults aged 65 years and older with a self-harm episode recorded during calendar years 2001 to 2014. Of these episodes, 3,327 (80.7%) involved ingestion of drugs and 234 (5.7%) involved self-cutting.

For their analysis, the researchers focused on the 2,854 adults with at least 12 months of follow-up data. They examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. They compared the self-harm cohort with a group of similarly aged patients who did not engage in self-harm.

Within 12 months of their initial self-harm episode, just 335 (11.7%) of 2,854 older adults were referred to mental health services, 1,692 (59.3%) were prescribed an antidepressant, and, of these, 336 (11.8%) received a tricyclic antidepressant, which can be fatal when taken in overdose.

In the year after the first self-harm episode, 412 (14.4%) individuals had another self-harm episode, of whom 344 (83.5%) had one repeat episode and 68 (16.5%) had two or more episodes. A total of 908 (37.0%) deaths occurred in the self-harm cohort compared with 12,683 (25.9%) deaths in the comparison cohort, of which 54 (5.9%) were unnatural deaths and 36 (4.0%) were deaths by suicide in the self-harm cohort versus 275 (2.2%) unnatural deaths and 12 (<0.1%) deaths by suicide in the comparison cohort, the authors reported.

“After self-harm in an older adult, improvement of referral rates [to specialty mental health care] and consideration of possible alternative medication, with particular avoidance of TCAs [tricyclic antidepressants], might reduce the risk of escalating self-harm behavior and associated mortality risk,” the authors wrote.

For related information, see the American Journal of Psychiatry article “Suicide Following Deliberate Self-Harm.”

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Methylphenidate May Lead to Improvements in Youth With Disruptive Behavior Disorder, Study Suggests

Methylphenidate (MPH) may be a potential treatment option for youth with disruptive behavior disorder, suggests a study published in the Journal of the American Academy of Child & Adolescent Psychiatry.

Research has shown that youth with disruptive behavior disorder are less likely than others to anticipate the negative consequences of their behaviors, which may contribute to behavioral problems. Studies also show that people with disruptive behavior disorder tend to have lower activity in the amygdala—a brain region known to be involved in emotional learning, including fear response.

Koen Van Lith, M.D., of the Vrije Universiteit Amsterdam and colleagues tested whether MPH might increase amygdala activity in youth with disruptive behavior disorder, including oppositional defiant and/or conduct disorder. The researchers chose MPH since this medication is known to increase amygdala activity in children with attention-deficit/hyperactivity disorder.

Van Lith and colleagues conducted a clinical study of 42 boys aged 14 to 17 who were diagnosed with disruptive behavior disorder. The adolescents completed a fear-learning task (learning to associate a visual stimulus with a mild electric shock) 90 minutes after taking either a single dose of MPH (0.3 mg/kg to 0.4 mg/kg) or placebo. Twenty-one adolescents with no behavioral problems were also included as a comparison group; these participants were given no medication before testing. All the participants underwent functional MRI scanning while performing the fear-learning task to measure amygdala activity.

The adolescents with disruptive behavior disorder who took placebo had much lower amygdala activity during the fear-learning task compared with healthy controls. In contrast, the adolescents with disruptive behavior disorder who took MPH had amygdala activity that was similar to the adolescents with no behavioral problems.

“This is promising for MPH as a possible treatment option in DBD [disruptive behavior disorder],” Van Lith and colleagues wrote. “Because amygdala functioning is important for decision making and moral judgment, MPH might improve clinical outcomes, although future studies should establish whether increased amygdala function after MPH administration indeed improves behavioral outcomes.”

To read more about treating disruptive behaviors in youth, see the Psychiatric News article “Experts Search for Meds to Help Youth With DMDD.”

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Candidates Announced for APA's 2019 Election

The APA Nominating Committee, chaired by APA Immediate Past President Anita Everett, M.D., today announced the candidates for the Association's 2019 election.




President-Elect
Jeffrey Geller, M.D., M.P.H.
Philip Muskin, M.D., M.A.

Secretary
Jeffrey Akaka, M.D.
Sandra DeJong, M.D., M.Sc.
Ramaswamy Viswanathan, M.D., D.M.Sc.

Minority/Underrepresented (M/UR) Trustee
Rahn Bailey, M.D.
Robert Cabaj, M.D.

Area 3 Trustee
Kenneth Certa, M.D.
Barry Herman, M.D.
Roger Peele, M.D.

Area 6 Trustee
Barbara Weissman, M.D.
Melinda Young, M.D.

Resident-Fellow Member Trustee-Elect
Lisa Harding, M.D.
Daniel Hart, M.D.
Michael Mensah, M.D., M.P.H.

The deadline for candidates who wish to run by petition is November 15. All candidates and their supporters are encouraged to review APA's Election Guidelines. For more election information, please visit the Election section on APA's website or email election@psych.org.

The slate of candidates who have been nominated is considered public but not official until it is approved by the APA Board of Trustees at its December meeting. APA members may cast their ballots from January 2 to January 31, 2019.

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Heart Valve Surgery May Lead to Postoperative Cognitive Deficits

Patients who undergo heart valve surgery are at a heightened risk of cognitive decline in the first few months after surgery, suggests a paper published yesterday in the Journal of the American Geriatrics Association.

“Aortic valve surgery, which is performed more commonly in older adults, entails greater risk of early cognitive dysfunction within the first month after surgery than mitral valve surgery, but cognition in both groups appears to converge by six months,” wrote Mark Oldham, M.D., of the University of Rochester Medical Center and colleagues.

Oldham and colleagues conducted a meta-analysis of 12 clinical studies that had assessed the cognitive scores of adults before and after undergoing heart valve surgery. A total of 12 clinical studies, which included 450 patients who had early cognitive assessments (one week to one month after surgery) and 722 patients with intermediate assessments (two to six months after surgery), were included in the analysis. The researchers identified no studies that explored long-term cognitive changes after heart valve surgery, which they noted is a major research gap.

The analysis revealed that patients who underwent heart valve surgery experienced moderate cognitive decline in the first month after surgery that improved slightly by six months out. Patients who underwent mitral valve surgery experienced mild but progressive decline over six months, while those who underwent aortic valve surgery had greater early cognitive dysfunction, followed by partial recovery. The authors noted that patients receiving aortic valve surgery were about 11 years older on average, which could have influenced these outcomes.

“These findings call for further investigation aimed at refining risk stratification and prevention strategies in this group, in which cognitive vulnerability is widely underrecognized,” Oldham and colleagues concluded.

To read more about this topic, see the Psychiatric News article “Escitalopram May Reduce Risk of Heart Problems.”

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