Friday, January 19, 2018

APA Voices Concerns About Broadening Religious-Based Exemptions in Health Care

APA today issued a statement expressing concerns that broadening religious exemptions for health care providers would allow them to discriminate and deny care because of a patient's gender identity, sexual orientation, or reproductive health decisions.

The statement comes one day after the Department of Health and Human Services announced the creation of the Conscience and Religious Freedom Division within the Office of Civil Rights. It will be responsible for handling complaints by health care workers who feel their beliefs conflict with the care they are being asked to provide.

“I am deeply concerned that our patients—many of whom already face unique health challenges—may now be denied care because of their providers’ personal beliefs. We know that discriminatory policies harm our patients’ mental health and well-being,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the statement. “Laws allowing religious refusals of care must avoid harming patients’ health or imposing another’s moral beliefs on patients.”

In a November 2017 letter from APA to HHS, Levin wrote, “The mission of DHHS is ‘to enhance and protect the health and well-being of all Americans,’ and we are concerned about any regulatory changes that would roll back protections to ensure all patients are treated with dignity and respect and have access to care without fear of discrimination.”

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Thursday, January 18, 2018

Catatonia Often Goes Undiagnosed, Untreated in General Hospitals

Physicians fail to diagnose the majority of cases of catatonia in a general hospital setting, which may result in suboptimal treatment for these patients, according to an article in the Journal of Neuropsychiatry and Clinical Neurosciences. However, psychiatric consultation can significantly decrease the odds of failure to diagnose the condition, the study found.

Diagnosing catatonia is challenging because it requires clinical suspicion and physical examination, according to researchers Joan Roig Llesuy, M.D., of New York University School of Medicine and colleagues. While catatonia is often reversible when treated with lorazepam and/or electroconvulsive therapy (ECT), its underrecognition and subsequent lack of treatment might lead to dangerous medical complications, the authors wrote.

Moreover, failure to recognize catatonia may lead to improper treatment with antipsychotics, which can increase the risk for developing malignant catatonic features or neuroleptic malignant syndrome. “Thus, awareness about catatonia for all clinicians is relevant to improve patient care,” the authors wrote.

The study involved a retrospective chart review of adult inpatients at the University of Chicago general hospital between 2011 and 2013. The presence of three or more keywords in the chart describing catatonia-related signs was used to flag cases for review. Of 133 cases found meeting DSM-5 criteria for catatonia, 79 (nearly 60%) were not diagnosed with the condition.

Additional analysis revealed that patients meeting DSM-5 criteria for catatonia who underwent a psychiatric consultation during the admission process were more than 44 times as likely to be correctly diagnosed with catatonia, compared with those who did not receive a consultation. Still, more than one-third of undiagnosed patients (37%) had received a psychiatry consult, supporting “the need for greater recognition of catatonia across disciplines,” the researchers wrote.

Physicians may be unaware of the cluster of signs and symptoms that constitute catatonia: the presence of grimacing, agitation, or echolalia symptoms was associated with a 4 to 6 times greater likelihood that the catatonia would go undiagnosed.

Regardless of diagnosis of catatonia, none of the 133 subjects received ECT. Also, no differences were found in the rate of lorazepam treatment between diagnosed or undiagnosed patients: half of those with catatonia did not receive lorazepam. However, the total dose of lorazepam was significantly lower in the undiagnosed group, who received 0.4 mg a day on average versus those diagnosed with catatonia, who received an average of 1.3 mg a day. High doses of lorazepam for several days or longer might be needed to treat catatonia effectively, the researchers wrote.

“Improving detecting and treatment of catatonia could help improve clinical outcomes of patients with this reversible syndrome in the general hospital,” concluded the authors.

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Suspected Delirium Predicts the Thoroughness of Catatonia Evaluation.”

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Wednesday, January 17, 2018

Depression May Increase Risk of Death Following Heart Procedure, Study Suggests

Older patients with depression may be at greater risk of death following a procedure to replace a damaged aortic valve of the heart, reports a study published today in JAMA Cardiology.

“The clinical implications of our findings support active screening for depression before and after aortic valve procedures to identify patients who may benefit from further psychiatric evaluation for the diagnosis and treatment of a depressive disorder,” wrote Jonathan Afilalo, M.D., M.Sc., of Jewish General Hospital, Montreal, and colleagues.

The study included patients who were at least 70 years of age with symptomatic aortic stenosis and who had undergone transcatheter or surgical aortic valve replacement. As part of a larger prospective cohort study, these patients completed a preprocedural assessment of frailty, disability, comorbidity, cognitive function, and mood. Depressive symptoms were assessed using the five-item Geriatric Depression Scale Short Form (GDS-SF) at baseline and follow-up at six and 12 months. The authors defined a GDS-SF score of at least 2 of 5 as indicative of clinically relevant depression.

Of the 1,035 patients (427 men and 608 women; mean age of 81.4 years) included in the analysis, 326 patients (31.5%) screened positive for depression. Compared with patients without depression, those with depression were more likely to have diabetes, chronic kidney disease, hypertension, chronic obstructive pulmonary disease, and/or cerebrovascular disease. Patients with depression were also more likely to be physically frail and to be cognitively impaired compared with those without depression.

After adjusting for clinical and geriatric confounders, the researchers found that baseline depression increased risk of death at one month (odds ratio [OR], 2.20) and at 12 months (OR, 1.532). Persistent depression—defined as baseline depression that remained six months after the procedure—was associated with a threefold increase in mortality at 12 months (OR, 2.98).

“Given the prognostic implications and diagnostic challenges, coordinated care involving cardiovascular and psychogeriatric specialists is indicated to provide optimal management to patients undergoing TAVR [transcatheter aortic valve replacement] and SAVR [surgical aortic valve replacement] who exhibit depressive symptoms,” the authors wrote.

For related information, see the Psychiatric News article “Can Collaborative Care Really Help Patients With Depression and Diabetes or Heart Disease?” by David Katzelnick, M.D., Rebecca Rossom, M.D., M.S., and Leif Solberg, M.D.

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Tuesday, January 16, 2018

Propranolol May Help Patients With PTSD

While exposure therapy is recognized as one of the best strategies for treating patients with posttraumatic stress disorder (PTSD), many continue to experience significant problems. A study published in AJP in Advance suggests that patients with PTSD who take propranolol (a noradrenergic beta-receptor blocker) prior to recalling their traumatic event may experience greater PTSD symptom reduction than those who do not take the medication.

“PTSD participants who actively recalled their traumatic event under the influence of propranolol once a week for up to six weeks showed a substantial decrease in symptom ratings compared with placebo,” wrote Alain Brunet, Ph.D., of McGill University and colleagues. “The decrease was evident from both the clinician’s and the participant’s perspective.”

Sixty adults diagnosed with long-standing PTSD were randomized to receive either propranolol or placebo 90 minutes before a brief memory reactivation session, once a week for six consecutive weeks. Patients in the treatment arm received 0.67 mg/kg of conventional (short-acting) propranolol, plus 1.0 mg/kg of long-acting propranolol. The patient-rated PTSD Checklist Specific (PCL-S) scale was administered at the beginning of each treatment session, before propranolol was administered. The Clinician-Administered PTSD Scale (CAPS) was used one week before and one week after the six-week trial.

Sixty minutes after ingesting the medication or placebo, the participants were asked to write a one-page trauma narrative in the present tense, first-person singular, focusing on the event’s most disturbing moments and including five or more bodily sensations drawn from a checklist. The participants were then asked to read the narrative aloud once to the therapist “as if they were back in the event.”

Patients in the propranolol and placebo groups had similar PCL-S and CAPS scores at baseline. At the posttreatment assessment, the scores had decreased in both groups, but the decreases were significantly greater in the propranolol group. At the six-month follow-up, the mean CAPS scores were 52.0 for the propranolol group and 69.2 for the placebo group. Mean PCL-S scores were 38.4 for the propranolol group and 69.0 for the placebo group.

“The effect sizes obtained for pre-reactivation propranolol in our study compare well to those obtained with the best evidence-based treatment for PTSD, namely, cognitive-behavioral therapy, as well as those obtained with the most recommended pharmacological treatment for PTSD, namely, SSRIs,” Brunet and colleagues wrote. “Should these results be replicated in further studies, propranolol blockade of reconsolidation [of traumatic memories] may become a new therapy for some patients with PTSD.”

For related information, see the Psychiatric News article “New Research Shows Multiple Genes May Be Associated With PTSD.”

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Friday, January 12, 2018

Escalating Symptoms of Anxiety May Point to Older Patients at Greatest Risk of Alzheimer’s

Older adults experiencing worsening anxiety may have higher levels of a protein fragment implicated in Alzheimer’s disease, according to a study published today in AJP in Advance.

Past studies have suggested depression and other neuropsychiatric symptoms may be predictors of Alzheimer’s progression during its “preclinical” phase—a period marked by the accumulation of brain deposits of fibrillar amyloid and pathological tau in a patient’s brain. 

In the current study, Nancy J. Donovan, M.D., of Brigham and Women’s Hospital and colleagues examined the association between brain amyloid beta and depression symptoms over time in cognitively normal, older adults.

A total of 270 participants aged 62 to 90 underwent baseline positron emission tomography (PET) scans to measure cortical aggregate amyloid beta and annual depression assessments with the 30-item Geriatric Depression Scale (GDS). The team calculated total GDS scores as well as scores for three GDS item clusters: apathy-anhedonia, dysphoria, and anxiety-concentration. These scores were examined over a span of five years.

“Rather than just looking at depression as a total score, we looked at specific symptoms such as anxiety,” Donovan said in a press release. “When compared to other symptoms of depression such as sadness or loss of interest, anxiety symptoms increased over time in those with higher amyloid beta levels in the brain.”

“These results suggest a direct or indirect association of elevated amyloid beta levels with worsening anxious-depressive symptoms and provide support for the hypothesis that emerging neuropsychiatric symptoms represent an early manifestation of preclinical Alzheimer’s disease,” the researchers wrote. “Further longitudinal follow-up is necessary to determine whether these escalating depressive symptoms give rise to clinical depression and/or MCI and dementia stages of Alzheimer’s disease over an extended period.”

For related information, see the Psychiatric News article “Alzheimer’s-Associated Protein Might Help Brain Fight Infections.”

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Thursday, January 11, 2018

Study Suggests Hormone Therapy May Reduce Risk of Depression During Menopause Transition

The risk of depression is known to increase among women as they enter the menopause transition and early postmenopausal period. A study published yesterday in JAMA Psychiatry found that perimenopausal and early postmenopausal women treated with estrogen plus progestin hormone therapy (HT) for 12 months were about half as likely to develop depression as women treated with placebo.

“The findings of this study confirm that perimenopausal and early postmenopausal women are at high risk for developing clinically significant depressive symptoms,” wrote Jennifer L. Gordon, Ph.D., of the University of Regina, Canada, and colleagues. “Health care professionals should be alert to the high risk for clinically significant depressive symptoms in this population.”

Gordon and colleagues randomly assigned 172 healthy perimenopausal and early menopausal women aged 45 to 60 years to either continuous transdermal estradiol (0.1 mg/d) plus oral micronized progesterone every two to three months or placebo. Depressive symptoms were assessed at seven visits throughout the year using the Center for Epidemiological Studies-Depression Scale (CES-D).

During the one-year study, women assigned to placebo were more likely than those assigned to the HT regimen to report clinically significant depressive symptoms, defined as a CES-D score of at least 16 (32% versus 17%). Women assigned to placebo were also more likely to have a higher mean CES-D score across the 12-month study compared with those receiving HT. Additional analysis revealed that women in the early stage of perimenopause were most likely to experience mood benefits from the HT regimen for prevention of depression, Gordon and colleagues reported. In fact, the mood-enhancing benefit of HT was not evident among women in the late menopause transition or postmenopausal women studied. The beneficial effect of HT was also more apparent in those with a greater number of stressful life events.

The authors noted that there were three severe adverse events requiring study termination and medical treatment: two cases of major depressive disorder in the placebo group and, in the HT group, one case of an acute deep vein thrombosis—a known risk of HT.

“We commend the authors for investigating the efficacy of a biologically rational strategy to prevent depressive symptoms in women at increased risk owing to reproductive stage using a randomized clinical trial design,” Hadine Joffe, M.D., M.Sc., of Brigham and Women’s Hospital, and Martha Hickey, M.D., of the University of Melbourne, Australia, wrote in a related editorial.

However, Joffe and Hickey cautioned, “Hormone therapy is U.S. Food and Drug Administration–approved for treatment of hot flashes and vaginal dryness, but not for treatment or prevention of mood disturbance. The recommendation by Gordon et al that HT be considered off-label for the prevention of depressive symptoms … is inconsistent with accumulating high-level evidence that HT should not be used for the prevention of chronic disease.”

For related information, see the Psychiatric News article “Discontinuing Hormone Therapy May Increase Risk of Depression in Some Women.”

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Wednesday, January 10, 2018

AJP Articles Make NEJM Journal Watch Psychiatry, BBRF’s Top 10 for 2017

The American Journal of Psychiatry has once again received recognition from New England Journal of Medicine (NEJM) Journal Watch Psychiatry and the Brain and Behavior Research Foundation (BBRF) for the publication of outstanding research in the past year that advances the clinical practice of psychiatry. Two AJP articles were named “top stories of 2017” by NEJM Journal Watch Psychiatry, and four were listed as representing “top advances and breakthroughs” by the Brain and Behavior Research Foundation.

One article—“Adjunctive Bright Light Therapy for Bipolar Depression: A Randomized Double-Blind Placebo-Controlled Trial,” by Dorothy K. Sit, M.D., et al.—appeared on both lists. As Sit and colleagues explained in the AJP article, there is a growing interest in nonpharmacological approaches to treat bipolar depression, after many medications used to treat the disorder have proven ineffective and/or produce adverse effects, including mood switching. The researchers discovered that exposing patients with bipolar depression on stable antimanic medications to midday bright white light led to reductions in their depression scores after six weeks compared with those in the control group. Importantly, no hypomania, dramatic mood switching, or serious side effects were observed during the study.

The other study named on NEJM Journal Watch Psychiatry’s Top 10 list was “KINECT 3: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Trial of Valbenazine for Tardive Dyskinesia,” by Robert A. Hauser, M.D., M.B.A., et al. This study found that once-daily treatment with valbenazine at 80 mg/day significantly improved the symptoms of tardive dyskinesia compared with placebo in a population of patients with schizophrenia, schizoaffective disorder, or a mood disorder. The medication was generally well tolerated, even among patients taking concomitant antipsychotics, and the psychiatric status of the patients remained stable throughout the trial.

In addition to the article by Sit and colleagues referenced above, the following studies were selected by BBRF in its list of the top advancements and breakthroughs by Foundation grantees in 2017 (in chronological order):

  • Effect of a Novel NMDA Receptor Modulator, Rapastinel (Formerly GLYX-13), in OCD: Proof of Concept,” by Carolyn I. Rodriguez, M.D., Ph.D., et al. In this small, open-label trial, Rodriguez and colleagues found that unmedicated patients with obsessive-compulsive disorder who received a single intravenous dose of rapastinel reported a drop in obsessive-compulsive, depression, and anxiety severity scores within 90 minutes of the infusion. The effects were short-lived, however, with no significant effects on symptoms seen one week later.

To see a list of the AJP articles that were recognized last year, click here.


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