Study Finds Extended-Release Venlafaxine Effective in Spinal Cord Injury Patients With Depression

Extended-release venlafaxine was well tolerated and appears to be an effective antidepressant for decreasing core symptoms of depression and improving disability related to spinal cord injury, according to a report in JAMA Psychiatry.

Researchers at the Department of Psychiatry at the University of Washington and from several other institutions randomized 133 participants who were being treated at spinal cord injury centers to either a 12-week trial of extended-release venlafaxine or placebo using a flexible-dose algorithm. Participants were aged 18 to 64, at least one month after spinal cord injury, and diagnosed with major depressive disorder or dysthymic disorder.

Main outcome measure was score on the Hamilton Depression Rating Scale (HAM-D 17-item version and Maier subscale, which focuses on core depression symptoms and excludes somatic symptoms) over 12 weeks, and on the Sheehan Disability Scale.

Statistical analyses showed a significant difference between the venlafaxine and placebo groups in improvement on the Maier subscale but not on the HAM-D. Participants receiving venlafaxine reported significantly less disability related to spinal cord injury on the Sheehan Disability Scale at 12 weeks compared with placebo. Blurred vision was the only significantly more common new or worsening adverse effect in the venlafaxine group compared with the placebo group.

“Depression is prevalent and associated with negative outcomes in individuals with spinal cord injury,” the researchers stated. “Antidepressants are used routinely to treat depression, yet no placebo-controlled trials have been published in this population to our knowledge…. Further research is needed to determine the optimal treatment and measurement approaches for depression in chronic spinal cord injury.”

For more information, see "The Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill," published by American Psychiatric Publishing.

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ADHD Drug Can Reduce Binge Eating, Preliminary Study Suggests

The attention-deficit/hyperactivity disorder (ADHD) medication lisdexamfetamine dimesylate (trade name Vyvanse) may help in the treatment of binge-eating disorder, according to new clinical research appearing in JAMA Psychiatry.

The study, which carried out both safety and efficacy analyses, found that 50 and 70 mg doses of Vyvanse helped more participants curtail their binges than placebo (a 30 mg dosage had no effect). Forty-two percent of those taking 50 mg of the drug and 50 percent taking 70 mg were able to avoid excess consumption for four weeks, compared with 21 percent of the placebo group.

Nearly 85 percent of participants taking the medication experienced some form of adverse event, though, compared with around 59 percent in the placebo group. Among these cases, none of the participants in the placebo group and three in the Vyvanse group were classified as having a serious adverse event; six discontinued because of side effects. The study authors stated that the safety profile was in line with the known effects of the drug in treating ADHD, including the potential changes in heart rate. Other researchers, however, have cautioned that more work, particularly studies of long-term usage, need to be carried out.

Binge-eating is a recently recognized psychiatric disorder, having been included as a distinct category for the first time in the fifth edition of APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The disorder is characterized by recurrent episodes of excessive food consumption accompanied by feelings of a lack of control.

This clinical trial was funded by Shire Development, LLC, the manufacturer of Vyvanse.

To learn more about the latest challenges and hope regarding eating disorders, see the Psychiatric News article “Expert Hopeful About Future of Treatment for Eating Disorders.”

One can also read about the current state of psychological and pharmacological treatments for eating disorders in the 5th edition of Gabbard’s Treatments of Psychiatric Disorders (chapters 30-32).

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Escitalopram Linked to Significant Improvement of Mother’s Depression and Child’s Symptoms

Previous studies have shown that when symptoms of a depressed mother remit after treatment, her offspring’s psychiatric symptoms are decreased. A study published today in AJP in Advance may shed light on some antidepressant treatment options that could lead to this domino effect.

Myrna Weissman, Ph.D., a professor of psychiatry and chief of the division of clinical and genetic epidemiology at New York State Psychiatric Institute, analyzed 76 depressed mothers and 135 offspring—aged 7 to 17—to compare which antidepressants taken by mothers would eventually lead to less psychiatric symptoms in offspring. Maternal participants were given either escitalopram, bupropion, or the combination of the two for 12 weeks. Offspring psychiatric symptoms were assessed prior to maternal initiation of therapy and at study endpoint.

Though maternal subjects in all three groups were able to achieve remission, escitalopram alone was found to be associated with statistically significant improvement in mothers' depression and subsequent improvements in offspring's psychiatric symptoms, whereas treatment with bupropion and combined bupropion and escitalopram therapy did not. In addition, mothers in the escitalopram cohort were more likely to report improvement in their ability to listen and talk to their children over the 12-weeks than mothers administered bupropion or combined therapy. Children of the escitolapram group reported their mother to be more caring after treatment.

These findings "highlight the importance of active treatment of depressed mothers, which may help them and their children," the researchers noted. "Personalizing the treatment of depressed mothers may be enhanced by assessing parental behavior and monitoring the impact on children.” The researchers concluded that antidepressants that also reduce symptoms of anxiety and irritability—like escitalopram—may be necessary to properly assess the impact of the parent’s remission on the well-being of their offspring.

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More Psychiatric Care for Minorities Could Mean Substantial Savings to Health System, Study Finds

Reducing disparities in mental health care access for racial and ethnic minorities would lead to subsequent reductions in some general medical expenditures for the same populations, said Benjamin Lê Cook, Ph.D., M.P.H., a senior scientist at the Center for Multicultural Mental Health Research and an instructor at the Harvard Medical School, and colleagues in the study "The Costs and Benefits of Reducing Racial-Ethnic Disparities in Mental Health Care" published in Psychiatric Services in Advance.

The researchers looked at data on 6,206 people with mental illness from the 2004-2010 Medical Expenditure Panel Survey. Relative to whites, African Americans and Latinos who received outpatient mental health care in one year spent less on inpatient and emergency general medical care the following year. Latinos receiving mental health care in year 1 spent less than others on inpatient general medical care in year 2. In addition, Latinos taking psychotropic drugs in year 1 showed reductions in inpatient general medical care.

The U.S. health care system would need to provide additional care to approximately 1.3 million blacks and 1.1 million Latinos with probable mental illness to eliminate disparities, wrote the researchers. “For blacks and Latinos, the potential savings in inpatient general medical expenditure are substantial (as much as $1 billion), providing preliminary evidence of a ‘business case’ for reducing disparities in mental health care access.

For more in Psychiatric News about the effect of racial and ethnic disparities in mental health, see the article "Satcher Outlines Roadmap to Reducing Health Disparities."

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Duration of First Psychosis Found Longer in U.S. Community Settings

Patients experiencing a first-episode psychosis and treated at community based clinics had longer duration of psychosis (DUP) than has been reported for those treated at academic medical centers, according to the study “Duration of Untreated Psychosis at Community Treatment Centers in the United States,” published online in Psychiatric Services.

Researchers with the National Institute of Mental Health (NIMH) Early Treatment Program (ETP)—which is part of an NIMH initiative called Recovery After an Initial Schizophrenia Episode (RAISE)—examined DUP among persons receiving care in community mental health centers in the United States. Longer DUP has been found to be associated with poorer long-term trajectory of illness and poorer overall functioning.

Participating in the study were 404 individuals (ages 15–40) who presented for treatment for first-episode psychosis at 34 nonacademic clinics in 21 states.

The median duration of psychosis was 74 weeks, and 68 percent of patients had a DUP of greater than six months. DUP was significantly shorter for participants living in northern states compared with those from midwestern and southern states. No differences in DUP were observed for rural, suburban, or urban location or for insurance status.

The correlates of longer DUP included earlier age at first psychotic symptoms, substance use disorder, positive and general symptom severity, poorer functioning, and referral from outpatient treatment settings.

“This study reported longer DUP than studies conducted in academic settings but found similar correlates of DUP,” the researchers stated. “Reducing DUP in the United States will require examination of factors in treatment delay in local service settings and targeted strategies for closing gaps in pathways to specialty first-episode psychosis care.”

For more information, see the Psychiatric News article “Benefits Persist Decade After Early Psychosis Intervention.”

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Some Symptoms of Mild Dementia May Predict Progression to Severe Dementia, Early Death

Specific neuropsychiatric symptoms are associated with shorter survival time from mild Alzheimer’s dementia to severe dementia and/or death, according to a report appearing online in AJP in Advance titled “Neuropsychiatric Symptoms as Predictors of Progression to Severe Alzheimer’s Dementia and Death: The Cache County Dementia Progression Study.”

Constantine Lyketsos, M.D., of Johns Hopkins University School of Medicine, and colleagues used data from the Cache County Dementia Progression Study, a longitudinal study of dementia progression in incident cases of dementia, to examine the link between clinically significant neuropsychiatric symptoms in mild Alzheimer’s dementia and progression to severe dementia or death.

Three hundred thirty-five patients with incident Alzheimer’s dementia were studied. Sixty-eight (20 percent) developed severe dementia over the follow-up period.

To identify potentially predictive neuropsychiatric symptoms, the researchers used the 10-item Neuropsychiatric Inventory, a structured interview that provides a systematic assessment of the 10 neuropsychiatric symptom domains: delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/euphoria, apathy/indifference, disinhibition, irritability/lability, and aberrant motor behavior.

They found that psychosis, agitation/aggression, and any one clinically significant neuropsychiatric symptom were associated with more rapid progression to severe dementia. Psychosis, affective symptoms, agitation/aggression, mildly symptomatic neuropsychiatric symptoms, and clinically significant neuropsychiatric symptoms were associated with earlier death.

“The treatment of specific neuropsychiatric symptoms in early dementia should be examined for its potential to delay time to severe dementia or death,” researchers wrote.

For more information, see the Psychiatric News article “DICE Rolls to New Approach for Treating Dementia Symptoms.”

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FDA Approves Mobile App for Evaluating Traumatic Brain Injury

A new app will soon be available to help clinicians diagnose traumatic brain injury in as little as five minutes in almost any setting, including environments of combat.

The app, called the Defense Automated Neurobehavioral Assessment (DANA), runs on multiple mobile platforms and was recently granted U.S. Food and Drug Administration (FDA) approval. “It's like a brain thermometer,” stated Lt. Col. Chessley Atchison, a program manager for the Combat Casualty Care Research Program of the U.S. Army Medical Research and Materiel Command (USAMRMC). “And once we get it right, we’re going to put it fairly far forward in the field.”

According to the USAMRMC, DANA operates much like a video game. Service members will undergo a baseline series of on-screen exercises during which both their speed and accuracy are recorded. Those who may have had a serious head injury will then participate in a series of both cognitive efficiency tests and self-administered questionnaires. Afterward, a clinician will review the results, comparing them with the results of the baseline exercises. The combination of the app's cognitive and psychological components allows for insight into the prevalence of symptoms related to both traumatic brain injury and posttraumatic stress disorder, USAMRMC said in a press statement.

USAMRMC stated that once DANA is fully validated for battlefield use, it may be used to help assess fitness for duty. The app is currently being tested on tablet devices.

For more information on diagnosing traumatic brain injury, see the Psychiatric News article "I Can’t Think Clearly: Diagnosing Traumatic Brain Injury with DSM-5."

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