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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Tuesday, June 23, 2015

Data Show Mental Illness Alone is Not a Risk for Gun Violence


Mental illness is not a risk for gun violence, according to a study appearing in Psychiatric Services in Advance. Prior violence and substance abuse may be better indicators of risk for subsequent violence, say researchers from several institutions.

The MacArthur Violence Risk Assessment Study followed a group of 1,136 patients who had been discharged from acute civil inpatient facilities at three U.S. sites between 1992 and 1995. This sample included English-speaking male and female patients who were between the ages of 18 and 40; were of white, African-American, or Hispanic background; and had a chart diagnosis of bipolar disorder, depressive disorder, schizophrenia or other psychotic disorder, substance use disorder, or personality disorder.

Three sources of information were used to ascertain the occurrence of violent acts in the community post discharge, including interviews with patients, interviews with persons identified by the patient as being knowledgeable about his or her life, and official sources of information (arrest and hospital records).

Of the 951 persons available for at least one follow-up, 23 (2%) committed acts of violence with a gun. These 23 people tended to have admission diagnoses of major depression (61%), alcohol abuse (74%), or drug abuse (52%). Three patients (13%) were diagnosed as having bipolar disorder, none were diagnosed as having schizophrenia, and three (13%) received other diagnoses. At the time of hospital admission, the 23 people who later went on to commit gun violence displayed symptoms of substance abuse (61%), suicidal threats (65%), hallucinations (22%), paranoia (13%), delusions (9%), and anxiety (9%).

While prior hospitalization rates among discharged patients who committed gun violence were comparable to those of the overall MacArthur sample in the study (78% and 73%, respectively), the prior arrest rate of discharged patients who later committed gun violence was almost twice as high as the prior arrest rate of the overall sample (89% and 49%, respectively).

“For the small group of people with mental illness who are at risk of committing gun violence, improved collaborations with the criminal justice system are clearly indicated,” the researchers stated. “However, directly targeting mental illness as the major driver of gun violence is misguided. ... Prior violence, substance use, and early trauma are more likely to contribute to subsequent violence than is mental illness per se. In this regard, the politically inspired haste to focus gun control efforts on people being treated for a mental illness, rather than on people with demonstrated indicators of violence risk, such as restraining orders related to domestic violence, seems particularly misdirected.”

For more on this subject, see the Psychiatric News article "Capitol Hill Gets Straight Story on Gun Violence, Mental Illness."

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Monday, June 22, 2015

Study Finds HIV Pre-Exposure Medication Does Not Increase Rate or Severity of Depression


A new clinical study reports that the HIV pre-exposure prophylaxis (PrEP) medication Truvada® (emtricitabine and tenofovir disoproxil fumarate, or FTC/TDF) does not increase the risk of depression in men and transgender women who have sex with men.

These findings are the result of further analysis of the 2,500-person iPrEx study, which found that Truvada was a safe and effective prophylaxis. During the trial, depression was reported as one of the most common side effects, and there was concern whether the medication might increase the risks of depressive symptoms and suicide in a vulnerable population.

The new analysis found that the overall number of people reporting depression-related adverse events did not differ between Truvada and placebo (127 vs. 105), nor did the total number of depression events (152 vs. 144). The rate of suicide ideation or attempt also did not differ statistically between Truvada and placebo.

While these findings are encouraging, the study authors did stress that the overall rates of depression or depression-related events were high in both groups. This could be a public health issue, as depression can lead to more risky sexual behaviors while lowering adherence to prophylactic medications.

“PrEP programs may provide infrastructure for increasing access to mental health services, enabling synergistic diagnoses, and management of co-morbidities,” the authors noted.

To read more about the risks of HIV among people with mental health disorders, see the Psychiatric News article “HIV in Mental Health Facilities Sometimes Gets too Little Attention.”

(shutterstock/alexskopje)

Friday, June 19, 2015

Ziprasidone May Be Effective as Adjunctive Therapy for Depression


For some patients who have undergone rounds of monotherapy for major depressive disorder (MDD), achieving remission may require the use of adjunctive treatment strategies. A study published Thursday in AJP in Advance shows that the atypical antipsychotic ziprasidone may serve as a potential strategy.

Researchers from the Massachusetts General Hospital Clinical Trails Network, the Mayo School of Medicine, and the University of Alabama-Birmingham School of Medicine conducted a multisite study to test the efficacy of adjunctive ziprasidone in 139 adults who remained symptomatic for nonpsychotic unipolar MDD after receiving treatment with the antidepressant escitalopram. The patients were divided into two groups: one group received escitalopram plus ziprasidone for eight weeks; the other received escitalopram plus placebo. The primary outcome measure was clinical response, defined as a reduction of at least 50% in score on the 17-item Hamilton Depression Rating Scale (HAM-D).

At eight weeks, the analysis showed that symptoms of depression were significantly more likely to have improved from baseline in the escitalopram plus ziprasidone group than the escitalopram plus placebo group. Improvements in symptoms of anxiety were also significantly greater in the escitalopram plus ziprasidone cohort than the escitalopram plus placebo cohort. Approximately 14% of the patients in the escitalopram plus ziprasidone group discontinued treatment because of intolerance compared with none in the escitalopram plus placebo group.

“These results suggest that, similar to other atypical antipsychotic agents, adjunctive ziprasidone can represent a useful treatment option for patients with major depressive disorder,” the researchers noted. Due to the rates of discontinuance for the escitalopram plus ziprasidone, the researchers emphasized that more studies testing different dosing regimens are merited.

To read more about the use of antipsychotics as an adjunctive therapy for treatment of MDD, see the Psychiatric News article “FDA Approves Antipsychotic to Treat Bipolar Depression.”

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