Drugs, Suicide Among Leading Causes of Postpartum Death in California, Study Finds

Drug-related deaths are second only to deaths from obstetric complications among women in California who die within a year of giving birth, a study in the American Journal of Obstetrics and Gynecology has found. Suicide ranked seventh as a cause of death in this population.

Sidra Goldman-Mellor, Ph.D., of the University of California, Merced, and Claire E. Margerison, Ph.D., of Michigan State University analyzed the health records of more than 1 million women who delivered a living infant in California hospitals between 2010 and 2012. They found that in that period, 300 women died within a year of giving birth and that drug-related causes and suicide together were responsible for roughly 1 in 6 of those deaths. Other causes of death in the women included circulatory system disease, cancer, other unintentional injuries, and homicide.

Three-fourths of the women who died from drug-related causes or suicide had visited an emergency department (ED) or hospital at least once between giving birth and dying—a finding that suggests an opportunity for screening, Goldman-Mellor and Margerison wrote.

“This observation suggests that ED and hospital visits may serve as a point of identification of—and eventually, intervention [for]—women at risk for postpartum death. Although examining details of these visits was beyond the scope of this study, this finding warrants further exploration in other samples, including examining the nature of these interactions to identify predictors of maternal death and/or points of intervention,” they wrote.

The researchers also found that although black women had the highest overall rate of postpartum death, non-Hispanic white women and women whose delivery costs were covered by Medicaid or paid by the patient had an elevated risk of drug-related death or suicide.

In discussing the limitations of their study, the study authors stated that data from California may not apply to the entire nation and called for further research.

“An important first step would be further documentation of this problem across the U.S., which will require that all state Maternal Mortality Review Committees (MMRCs) categorize deaths due to drugs, suicide, and other non-obstetric causes as medical deaths that fall within the scope of their review, particularly in [the] wake of congressional legislation providing funding for all states to form MMRCs,” they wrote.

For related information, see the Psychiatric News article “Is Postpartum Depression a Unique Psychiatric Disorder?” and the Psychiatric Services article “Use of Text Messaging for Postpartum Depression Screening and Information Provision.”

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APA Member Patrice Harris, M.D., Inaugurated AMA’s 174th President

“We are no longer at a place where those with mental illness and addiction are hidden and ignored, but we are not yet at a place where mental disorders are viewed without stigma and truly integrated into health care,” said long-time APA member Patrice A. Harris, M.D., M.A., in her address last night after her inauguration as the AMA’s 174th president.

Harris, a former member of the APA Board of Trustees, was sworn in during a ceremony at the AMA’s House of Delegates meeting in Chicago. Administering the oath of office was Jack Resnick, M.D., chair of the AMA Board of Trustees.

Harris, who is the first African American woman president of the AMA, said during her address that diversity and inclusion are critical to closing the gap in health disparities and that a focus of her presidency will be on health equity and increasing the diversity of the physician workforce.

“We face big challenges in health care today, and the decisions we make now will move us forward in a future we help create,” she said. “We are no longer at a place where we can tolerate the disparities that plague communities of color, women, and the LGBTQ community. But we are not yet at a place where health equity is achieved in those communities.”

Harris also vowed to elevate mental health as a part of overall health and to increase the understanding of the impact of childhood trauma on health.

During her presidential year, Harris will continue to chair the AMA’s Task Force to Reduce Opioid Abuse, which she has chaired since its inception in 2014.

Harris served as director of health services in Fulton County, Ga., and head of the Fulton County Department of Behavioral Health and Developmental Disabilities. As chief health officer for Fulton County, she spearheaded efforts to integrate public health, behavioral health, and primary care.

First elected to the AMA Board of Trustees in 2011, she has held the executive offices of AMA board secretary and AMA board chair. In addition to her leadership of the opioid task force, Harris has been active on AMA task forces and committees dealing with such issues as health information technology, payment and delivery reform, and private contracting. She also chaired the influential AMA Council on Legislation and co-chaired the Women Physicians Congress.

She served as trustee-at-large on the APA Board of Trustees from 2001 to 2004. In addition, she was president of the Georgia Psychiatric Physicians Association and founding president of the Georgia Psychiatry Political Action Committee.

APA leaders hailed her election as an important indication of the strength of psychiatry within the House of Delegates. “We look forward to the opportunity to continuing to work with Dr. Harris on many issues, including further collaboration within the house of medicine to improve the quality of care for our patients,” said APA President Bruce Schwartz, M.D.

APA CEO and Medical Director Saul Levin, M.D., M.P.A., said, “We are honored and delighted to have a psychiatrist and long-time APA member leading the house of medicine as president of the AMA. Her work over the years at APA and the AMA will add value to her new role as the face of the AMA.”

For related information, see the Psychiatric News article “APA Member Patrice Harris Chosen AMA’s President-Elect.”

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Children Whose Parents Have SMI Face Greater Risk of Self-Harm, Somatic Illness, Death

Children who have a parent with a serious mental illness (SMI) are at a greater risk of physical illnesses and death, according to a report in Schizophrenia Bulletin, highlighting the need for greater support of these children by the mental health community.

“Genetic vulnerability and lifestyle could be playing a role in the children’s increased risk,” wrote Anne Ranning, Ph.D., of Copenhagen University Hospital and colleagues. “Children may adapt to parents’ behavioral disposition with regard, for instance, to physical activity, smoking habits, and dietary patterns. Moreover, it has been suggested that SMI might in some cases be linked to a dysfunction in the immune system, which may also affect the child’s risk of general medical illnesses.”

The researchers conducted a register-based nationwide study of more than 2 million children born in Denmark between 1982 and 2012. These children were followed until their first hospital visit for a somatic illness or until their death. The maximum age of the offspring at follow-up was 30 years. Outcomes for children with a parent with SMI (parent had been diagnosed with depression, bipolar disorder, or schizophrenia) were then compared with outcomes for children whose parents did not have SMI.

Having at least one parent with SMI was associated with a 17% increase in likelihood of hospital contact for physical illness and a 31% increase in mortality rate compared with children whose parents did not have SMI, Ranning and colleagues reported. Compared with children who did not have a parent with SMI, those whose mothers had depression had a 22% greater risk of a hospital visit for physical illness, while those whose mothers had bipolar disorder had more than double the risk of death. Furthermore, the authors found that children whose parents had SMI and comorbid substance abuse were at higher risk for somatic illness and death.

Children with parents with SMI were more likely to have a variety of conditions, including endocrine/metabolic diseases, infections, and injury, the researchers found. The greatest risk of injury among children with a parent with SMI was intentional self-harm.

“Due to their increased risk of mental disorders, the children of parents with mental illness constitute an at-risk population; hence, selective preventive interventions are widely recommended to shift expected trajectories toward mental illness and social adversity,” Ranning and colleagues wrote. They recommended interventions to reduce risk factors and promote resilience such as family therapy, parenting and problem-solving skills training, and emotional well-being skills training for children and parents.

For related information, see the Psychiatric Services article “Randomized Controlled Trial of an Internet-Based Educational Intervention for Mothers With Mental Illnesses: An 18-Month Follow-Up.”

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Esketamine Plus Antidepressant Maintenance Delays Relapse in Refractory Depression, Study Finds

In patients with treatment-resistant depression who responded to intranasal esketamine plus an antidepressant, maintaining that treatment regimen significantly reduced their risk of relapse, according to a study in JAMA Psychiatry. 

Previous studies have confirmed the short-term antidepressant efficacy of esketamine, which was recently approved by the Food and Drug Administration for treatment-resistant depression. (AJP in Advance in May published a study showing patients with treatment-resistant depression who took esketamine nasal spray plus a new oral antidepressant for 28 days experienced significant symptom improvements over those treated with placebo nasal spray plus a new oral antidepressant.) Still, little is known about the long-term effects of esketamine, according to Ella Daly, M.D., of Janssen Research and Development and colleagues. 

This recent study is part of SUSTAIN-1, a multi-phased, randomized, controlled trial designed to compare 56 mg or 84 mg of esketamine nasal spray plus an antidepressant versus placebo nasal spray plus an antidepressant in patients with treatment-resistant depression. 

Daly and colleagues enrolled 297 adults with depression who had achieved a stable response (n=121) or stable remission (n=176) with esketamine plus an oral antidepressant during the 16-week first phase of SUSTAIN-1. Stable response was defined as a minimum 50% reduction from baseline in the Montgomery-Åsberg Depression Rating Scale (MADRS) in the last two weeks of initial treatment. Stable remission was defined as a MADRS score of 12 or lower for at least three of the last four weeks of initial treatment. 

For the maintenance phase of the study, the participants were randomized to continue esketamine-antidepressant treatment or switched to an antidepressant plus placebo nasal spray. The participants remained in this phase until they had a depression relapse or withdrew from the study. Relapse was defined as a MADRS score of 22 or higher for two consecutive assessments or hospitalization for worsening depression, suicide attempt, suicide prevention or completed suicide, or another clinical event indicating relapse.

“Continued treatment with esketamine and antidepressant significantly delayed relapse compared with treatment with antidepressant and placebo,” Daly and colleagues wrote. Among patients who responded, 25.8% who continued esketamine and 57.6% who received placebo nasal spray experienced depression relapse. Among those who remitted, 26.7% in the esketamine group and 45.3% in the placebo group had a relapse. The authors calculated that esketamine reduced relapse risk by 51% among stable-response patients and by 70% among stable-remission patients. 

The researchers reported no new or unexpected safety findings. 

For related information, see the AJP in Advance article “Efficacy and Safety of Flexibly Dosed Esketamine Nasal Spray Combined With a Newly Initiated Oral Antidepressant in Treatment-Resistant Depression: A Randomized Double-Blind Active-Controlled Study.”

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APA Endorses New Parity Enforcement Legislation, Urges Speedy Passage

APA has endorsed the Mental Health Parity Compliance Act, a bipartisan bill introduced in the Senate today that would enhance the transparency and accountability of insurers’ coverage of mental and substance use disorders, in compliance with the federal parity law.

That law, the Mental Health Parity and Addiction Equity Act of 2008, requires health plans to cover mental and substance use disorders the same as other medical illnesses; however, there is a lack of oversight to ensure that patients are receiving equal coverage of psychiatric conditions under the law. Plans that are subject to the Employee Retirement Income Security Act of 1974 (ERISA), or self-funded employment plans, are outside the enforcement jurisdiction of state agencies. The new legislation, co-sponsored by Sen. Chris Murphy (D-Conn.) and Sen. Bill Cassidy (R-La.), will tighten parity enforcement of these ERISA plans.

“For too long insurers have neglected their responsibility to adequately provide coverage for patients with mental illness or substance use disorders,” said APA President Bruce Schwartz, M.D. “This bill will help to ensure those patients be treated like patients with any other illness and end this harmful discrimination.”

Insurers have used a variety of means to sidestep the parity law and reduce utilization of mental health services, including inadequate reimbursement rates for psychiatrists and mental health professionals and “skinny” networks; the latter refer to health insurance provider networks that have few mental health professionals available to treat patients. In some cases, health plans have been found to have “phantom networks” that may include physicians who are no longer accepting patients, have moved out of a geographic area, or are deceased.

“We wholeheartedly support this bill, and we urge the Senate and the House to take this up soon and pass it,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Our patients depend on insurance for their care.”

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Methylphenidate Remains Effective for ADHD After Two Years of Regular Use

There is a wealth of evidence that methylphenidate can improve attention-deficit/hyperactivity disorder (ADHD) symptoms in the short term, but there are limited data on the long-term benefits of this medication. According to a study in AJP in Advance, youth with ADHD who have taken methylphenidate for two or more years continue to benefit from methylphenidate when compared with peers who are temporarily taken off this medication.

Anne-Flore Matthijssen, M.Sc., of Groningen University in the Netherlands and colleagues enrolled 94 children and adolescents aged 8 to 18 who had been taking methylphenidate regularly for at least two years. The participants were randomly assigned to either continue their treatment or go on gradual discontinuation (three weeks of drug tapering followed by four weeks of placebo medication).

At the end of seven weeks, ADHD symptom scores (assessed with the investigator-rated ADHD Rating Scale) remained stable among children taking methylphenidate (from 21.4 to 21.9) but increased among those who discontinued the medication (from 19.6 to 24.7). Similar outcomes were seen when using a teacher-rated symptom assessment (Conners’ Teacher Rating Scale–Revised: Short Form).

The authors found that the benefits of continuing to take methylphenidate were superior among participants 13.8 years and younger; youth older than 13.8 years did not have significantly worse symptoms on average upon discontinuing their medication.

Matthijssen and colleagues cautioned that most eligible families they contacted declined to enroll their children. “[O]ur sample likely included an overrepresentation of families who suspected that the medication may not have been working well and therefore wanted to try going off medication,” the authors wrote. “Those who declined to participate may have felt more confident that the medication was helpful and may therefore have been unwilling to risk being assigned to the placebo condition.” This recruitment issue may partially explain why the differences between the methylphenidate and discontinuation groups was modest.

“Nevertheless, the fact that most participants in our study did not experience significant worsening after discontinuation of methylphenidate supports guideline recommendations to periodically assess whether there is a continued need for methylphenidate treatment, for example, by considering a temporary discontinuation of medication in clinical practice to prevent unnecessary long-term medication use,” the authors concluded.

For related information, see the Psychiatric News article “Noninvasive Electrical Stimulation Shown Effective for ADHD.”

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Taking Antidepressants After Age 60 May Increase Dementia Risk, Study Finds

People who take antidepressants after age 60 may face a greater risk of dementia than those who don’t take antidepressants, a study in the American Journal of Geriatric Psychiatry has found.

Arad Kodesh, M.D., of the University of Haifa in Israel and colleagues analyzed the health records of 71,515 people aged 60 years or older from Israel. As far back as 2002, the participants had no diagnosis of dementia or record of taking medications for dementia. No participants had taken an antidepressant in 2012. The researchers then followed the participants from May 2013 to October 2017.

During follow-up, 3,688 participants had received and filled prescriptions for an antidepressant for at least 60 days. Of those, 11% developed dementia. In contrast, only 2.6% of those who did not take antidepressants developed dementia. After adjusting for other conditions linked to dementia risk, the researchers found that the risk of dementia in those who took an antidepressant was 3.43 times greater than those who did not.

“This is a considerable increase in risk and may be compared to other risk factors for dementia that have around a 1.6-fold increased dementia risk, e.g., smoking, and BMI [body mass index],” Kodesh and colleagues wrote.

The researchers found the increased risk to be consistent across different classes of antidepressants, with two notable exceptions: Compared with those who did not take antidepressants, those who took amitriptyline had twice the risk of developing dementia, and those who took paroxetine had more than five times the risk.

In noting the limitations of their study, the researchers wrote that their results could “mimic the [known] association between depression and dementia rather than the effect of taking an antidepressant.”

Nonetheless, they emphasized the importance of careful prescribing in older patients.

“Clinicians, caregivers, and patients may wish to consider this potential negative consequence of antidepressant exposure with the objective of balancing the adverse events and symptomatic benefits of monotherapeutic antidepressant medication in old age,” they wrote.

For related information, see the Psychiatric News article “Percentage of Americans Taking Antidepressants Climbs.”

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