Study Sheds More Light on Risk of Death After MH Hospitalization

Previous studies have shown that people who are hospitalized for treatment of mental illness have an elevated risk of suicide in the first few months after their discharge. A study in Psychiatric Services in Advance now reports that this immediate postdischarge period carries a higher risk not only of suicide, but also of death from other causes such as overdoses, accidents, and injuries. In addition, the findings suggest important opportunities for prevention.

Ira R. Katz, M.D., Ph.D., of the Office of Mental Health and Suicide Prevention at the U.S. Department of Veterans Affairs (VA) and colleagues analyzed the records of 3,829 VA patients who died within a year of being discharged from inpatient mental health units in 2013 and 2014. They classified the deaths as either suicide, other external causes (accidental or undetermined), or natural causes. Natural causes included circulatory and lung diseases, cancer, infectious disease, and dementia.

The researchers found that suicide rates were higher in the first 30 and 90 days after discharge compared with the remaining nine months of the first year after discharge: 19.4% of deaths attributed to suicide occurred within 30 days of discharge, and 39.8% occurred within 90 days of discharge. They also found a disproportionate number of deaths from other external causes in the initial months after discharge, with 13% occurring within 30 days and 27.3% occurring within 90 days. A significant number of the early deaths due to external causes were classified as accidental or undetermined overdoses.

“The observation of increased mortality from nonsuicide external causes in the period closest to discharge, compared with the remainder of the year, may be related to the stresses of hospitalization and discharge, to residual symptoms of conditions that led to hospitalization, or to adverse effects of medications started in the hospital,” the researchers wrote. “Observations regarding the frequency of overdoses suggest that opportunities for prevention include ensuring that substance use disorders are addressed during hospitalization, including cases in which the admission is related to another condition.”

The researchers also noted the importance of recognizing the potential side effects of the medications patients take when they return home and counseling patients and their families accordingly.

For related information, see the Psychiatric News article “Psychiatric Patients at Highest Suicide Risk Following Hospital Discharge.”

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Low-Cost VR Intervention Found to Benefit Patients With Acrophobia

A rudimentary virtual reality (VR) intervention that uses cardboard goggles, a smartphone, and self-guided cognitive-behavioral therapy (CBT) via a mobile app can reduce acrophobia (fear of heights) symptoms, according to a study published yesterday in JAMA Psychiatry.

“[O]ur findings support the hypothesis that a fully self-guided app-based VR-CBT, which can be done at home at a fraction of the cost of existing evidence-based treatment options, strongly reduces acrophobia symptoms,” wrote Tara Donker, Ph.D., and colleagues at Vrije Universiteit in Amsterdam. “The current study adds to the development of innovative and scalable delivery methods of evidence-based treatments and underlines that new technologies have the potential to transform mental health care worldwide.”

Donker and colleagues enrolled 193 adults with acrophobia (scoring at least 45.45 on the Acrophobia Questionnaire [AQ]-Anxiety) to receive either the active VR treatment or be placed on a wait list. The smartphone-based VR program, known as ZeroPhobia, provides six animated game-like modules that incorporate CBT principles and techniques. ZeroPhobia was downloaded on the participants’ existing smartphones, and VR was simulated with $10 cardboard goggles. Participants could use the program at home or in another natural environment, but they had to complete all six modules within three weeks.

After three weeks, AQ-Anxiety scores dropped from an average of 68.62 to 39.55 in the ZeroPhobia group, compared with a drop from 67.91 to 60.41 in the wait-list group. The strong symptom improvements were maintained at a follow-up assessment three months later. Aside from some transient cases of cyber sickness (headaches and dizziness), the participants found the VR intervention to be tolerable and user friendly.

“One of the key strengths of the present study was its ecological validity because the intervention was conducted in the participants’ natural environments instead of a research laboratory,” Donker and colleagues wrote. “Furthermore, participants received no guidance when using the VR-CBT app or filling in assessments, thereby ruling out any influence of human contact.”

To read more about VR-based phobia therapies, see the Psychiatric News article, “Avatar-Guided VR Therapy for Fear of Heights Shows Promise.”

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FDA Approves First Medication Specifically for Postpartum Depression

Yesterday the U.S. Food and Drug Administration (FDA) approved Zulresso (brexanolone) for the treatment of postpartum depression (PPD). It is the first drug approved by the FDA specifically for PPD. PPD is believed to be caused by the rapid change in hormones immediately after giving birth and is estimated to affect 400,000 women annually.

“Postpartum depression is a serious condition that, when severe, can be life threatening. Women may experience thoughts about harming themselves or harming their child. Postpartum depression can also interfere with the maternal-infant bond,” said Tiffany Farchione, M.D., acting director of the Division of Psychiatry Products in the FDA's Center for Drug Evaluation and Research, in a press announcement.

Zulresso will be available only through a restricted program called the Zulresso REMS Program. Patients must be enrolled in the program prior to treatment with the medication. Only health care professionals in a certified health care facility may administer Zulresso.

Zulresso is given as a continuous intravenous infusion over a total of 60 hours (2.5 days). Patients must be monitored for potential side effects including excessive sedation or sudden loss of consciousness. They also must be accompanied by a caregiver or family member to assist them with child care during the infusion. Patients should not drive, operate machinery, or do other dangerous activities until feelings of sleepiness from the treatment have completely gone away. These requirements are addressed in a black-box warning about which patients must be counseled prior to treatment.

Zulresso, which modulates the GABA neurotransmitter, was evaluated by the FDA under Priority Review and designated as a Breakthrough Therapy in 2016. Efficacy was demonstrated in two phase 3 clinical studies in which participants were followed for four weeks after a 60-hour continuous infusion for changes in depressive symptoms. Greater symptom improvements compared with placebo were noted within 24 hours of the infusion and persisted through the end of the follow-up period.

Zulpresso is expected to be available in late June, and a single course of treatment will cost $34,000. Sage is also developing a similar PPD medication that can be taken daily in pill form.

For more information on PPD, see the Psychiatric News article, “APA Releases New Statement on Perinatal Disorders” and the Psychiatric Services article “Use of Text Messaging for Postpartum Depression Screening and Information Provision.”

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Attention Training Using Computers May Lessen Anxiety in Youth

Computer modules that help young people practice focusing their attention may improve symptoms in youth with treatment-resistant anxiety, according to a report in the Journal of the Academy of Child and Adolescent Psychiatry.

Adolescents who had previously been treated with cognitive-behavioral therapy (CBT) but still experienced anxiety showed significant reductions in symptom severity after they received treatment with either one of two training modules—Attention Bias Modification Treatment (ABMT) and Attention Control Training (ACT).

“These findings suggest that both attention-training protocols may increase attention control and thereby reduce anxiety,” wrote Jeremy W. Pettit, Ph.D., of the Florida International University, and colleagues.

Both modules involve showing simultaneous images of neutral and angry faces, followed by a symbol or probe (“<” or “>”) appearing in the location of one of the faces. Participants are instructed to indicate the orientation of the probe by clicking the left or right mouse button (left for “<”, right for “>”) using their dominant hand. The task tests the subjects' bias toward paying attention to a threatening or nonthreatening stimulus and requires them to repeatedly practice focusing their attention.

Sixty-four youths (34 boys, 30 girls) with an average age of 17 who continued to have anxiety after completing CBT were randomized to four weeks of twice weekly ABMT or ACT. The primary outcome was the score on the six-item version of the Pediatric Anxiety Rating Scale (PARS). The secondary outcome was the score on the Screen for Child Anxiety Related Emotional Disorders–Child and Parent versions (SCARED-C/P). The latter consists of 41 items on which youth and parents rate youth anxiety symptoms.

Scores on both measures were significantly better at four weeks and at two-month follow-up, with no significant differences between the two groups. At two-month follow-up, the primary anxiety disorder diagnostic recovery rate was 50% for ABMT and 65% for ACT.

“We found that both forms of attention training led to improvements in attention control,” said Pettit in comments to Psychiatric News. “Increases in attention control were associated with decreases in anxiety severity. We interpret these findings as indicating that attention training influences later-stage, strategic attentional processing, and improvements in strategic attentional processing are associated with reductions in anxiety.”

For related information, see the Psychiatric News article “ Peer Program Helps High Schoolers Handle Depression, Anxiety.”

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Study Suggests Factors Linked to Teens’ Suicide Attempts

About 12% of adolescents who had suicidal thoughts or engaged in self-harm at age 16 went on to attempt suicide by age 21, but the risk factors for transition differed from established thinking on the subject, according to a large, longitudinal study of adolescents in Lancet Psychiatry.

“Existing research suggests that many well-established risk factors for suicide (such as depression, hopelessness, and impulsivity) do not predict suicide attempts among adolescents who have suicidal thoughts or engage in nonsuicidal self-harm,” wrote Becky Mars, Ph.D., a research fellow in epidemiology in the Department of Population Health Sciences at the University of Bristol and an American Foundation for Suicide Prevention postdoctoral fellow, and colleagues. “Longitudinal studies investigating predictors of future suicide attempts in these high-risk groups are extremely scarce.”

Researchers examined the Avon Longitudinal Study of Parents and Children, a population-based birth cohort study in the United Kingdom, for participants’ answers on two self-report questionnaires on suicidal thoughts and self-harm completed at 16 and 21 years of age. At baseline, 456 adolescents reported suicidal thoughts, and 569 adolescents reported nonsuicidal self-harm. Researchers explored the associations between risk factors at baseline and future first-time suicide attempts through age 21. (Participants who reported attempting suicide at baseline were excluded to focus on predictors of first-time suicide attempts.)

Among participants with suicidal thoughts at age 16, the following factors strongly predicted a suicide attempt by age 21, all of which were associated with two to three times higher risk of suicide attempt:

• Nonsuicidal self-harm
• Cannabis use
• Other illicit drug use
• Higher levels of the personality type intellect/openness

Among participants with nonsuicidal self-harm at age 16, the following factors strongly predicted a suicide attempt by age 21, all of which were associated with twice the risk of a suicide attempt:

• Cannabis use
• Other illicit drug use
• Insufficient sleep

“It might appear surprising that we did not find evidence of an association for several well-established suicide risk factors, including depression symptoms, psychiatric disorder, suicidal plans, and impulsivity. However, our results are consistent with previous research that has suggested that these factors appear to be associated with suicide attempts … but are not involved in the transition,” the researchers wrote.

For related information, see the Psychiatric News article “Irritability in Childhood May Point to Teens at High Risk for Suicide” and the Psychiatric Services article “ ‘13 Reasons Why’: Viewing Patterns and Perceived Impact Among Youths at Risk of Suicide.”

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Trigeminal Nerve Stimulation May Be Effective for Children With ADHD

Trigeminal nerve stimulation (TNS) may be as effective in treating symptoms of attention deficit/hyperactivity disorder (ADHD) in children as nonstimulant medications, according to a study in the Journal of the American Academy of Child & Adolescent Psychiatry. During treatment with TNS, a small stimulator powered by a 9-volt battery delivers a low current to patients through adhesive patches on their foreheads while they sleep. The current stimulates parts of the brain that are involved in concentration and impulse control.

James J. McGough, M.D., of the Semal Institute for Neuroscience and Human Behavior and the David Geffen School of Medicine at UCLA, and colleagues compared active treatment with TNS to sham (fake) treatment in 56 children aged 8 to 12 years. The sham devices were identical in appearance to real ones but did not deliver active treatment. The children received 8 hours of active of sham TNS every night for four weeks.

The researchers used the ADHD Rating Scale (ADHD-RS) and the Clinical Global Impression-Improvement Scale (CGI-I), two common assessments for symptoms of ADHD, to track the children’s response to their assigned devices. They also measured activity in the children’s brains with electroencephalography (EEG) before the study began and at study’s end.

Children in both groups showed improvement during the first week. Improvement leveled off in the sham treatment group after that, but continued in the active TNS group through the fourth week, although at a slower pace.

“ADHD-RS response patterns suggest that the greatest degree of TNS-related improvement occurred during the first week, with additional improvement accruing with ongoing use. The week 4 medium-sized treatment effect is within the same range typically evidenced with nonstimulant ADHD medications,” the researchers wrote. “Weekly CGI-I ratings further indicate that response rates increase with sustained treatment, at least over four weeks.”

The researchers also saw positive changes in brain activity in the active treatment group’s EEG readings, a finding that the researchers said supports that TNS was responsible for the children’s improvement.

“The virtual lack of significant side effects should make [TNS]  a popular treatment choice for many patients with ADHD, particularly for parents who prefer to avoid psychotropic medication,” the researchers concluded.

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Response to PHQ Item May Predict Suicide Risk Among Patients With Psychosis

Answers to a specific questionnaire item about thoughts of self-harm strongly predicted which patients with a psychotic disorder would attempt suicide in the next 90 days, according to a study in the March Psychiatric Services.

Suicidal behavior is especially common among individuals with psychotic disorders: 1 in 20 die by suicide and more than 1 in 4 attempt suicide at some point, wrote Gregory E. Simon, M.D., M.P.H., of the Kaiser Permanente Washington Health Research Institute, and colleagues. “Our findings indicate that individuals with psychotic disorders provide clinically useful responses to simple self-report questions about thoughts of death or self-harm.”

Researchers studied electronic health records over more than six years from seven large integrated health systems in nine states to identify adults with a diagnosis of schizophrenia spectrum psychosis, schizoaffective disorder, or unspecified psychosis. They identified all outpatient visits during which these patients completed the nine-item Patient Health Questionnaire (PHQ-9) and tracked their suicide attempts or completed suicides for 30 days and 90 day after their visits. Altogether, the study sample included 33,000 visits by nearly 6,000 patients.

More than 1 in 10 outpatients with a psychotic disorder reported frequent thoughts of death or self-harm on PHQ-9 item 9, which asks “Over the past 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” Researchers found that responses to Item 9 was a strong predictor of a suicide attempt over the ensuing 90 days: nearly half of suicide attempts occurred among those who reported recent thoughts of death or self-harm at the sampled visit. Also, 59% of suicide attempts occurred among those reporting thoughts of death or self-harm at the index visit or any visit in the prior year.

The risk of suicide attempt within 90 days of an outpatient visit was 0.8% among the patients reporting no thoughts of death or self-harm and 3.5% among those reporting such thoughts “nearly every day.” A similar pattern was seen for suicide attempts within 30 days of the visits. Considering patients’ prior-year responses to item 9—not just the current response—improved detection of risk, researchers said.

Researchers said identification of suicide risk should not be limited to self-report questionnaires and information typically recorded in electronic health records. “Providers should also consider important social risk factors for suicidal behavior, such as job loss, bereavement, or relationship disruption.”

Researchers noted the gap between assessment and subsequent treatment of suicidal patients: “Endorsement of frequent thoughts of death or self-harm certainly indicates an increased risk of self-harm and a need for more detailed assessment and appropriate care planning. Of patients reporting thoughts of death or self-harm nearly every day, approximately 1 in 30 received care for self-harm or probable suicide attempt during the following 90 days.”

For more information, see the Psychiatric Services study: “Predicting Suicide Attempts and Suicide Deaths Following Outpatient Visits Using Electronic Health Records.”

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