Friday, February 16, 2018

APA Joins Other Physician Groups to Demand Action on Gun Violence

In the aftermath of Wednesday’s shooting that killed 17 students and staff members at Marjory Stoneman Douglas High School in Parkland, Fla., APA and four organizations representing 450,000 physicians and medical students called on President Donald Trump and Congress to take meaningful action against gun violence.

Joining with APA were the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American College of Physicians.

“Gun violence is a public health epidemic that is growing in frequency and lethality, and it is taking a toll on our patients,” the groups said in a statement released today. “We urge our national leaders to recognize in this moment what the medical community has long understood: we must treat this epidemic no differently than we would any other pervasive threat to public health. We must identify the causes and take evidence-based approaches to prevent future suffering.”

The groups have asked the president and Congress to take the following actions:
  • Label violence caused by the use of guns a national public health epidemic.
  • Fund appropriate research at the Centers for Disease Control and Prevention as part of the FY 2018 omnibus spending package.
  • Establish constitutionally appropriate restrictions on the manufacture and sale, for civilian use, of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.
While mass shootings attract much attention from the public and the media, the groups noted that current policies regarding access to guns in this country expose Americans daily to the risks of violent acts including suicide, homicide, and unintentional injury.

“The families of the victims in Parkland and all those whose lives have been impacted by daily acts of gun violence deserve more than our thoughts and prayers. They need action from the highest levels of our government to stop this epidemic of gun violence now,” the statement concluded.

(Image: iStock/izzzy71)

Thursday, February 15, 2018

FDA Approves First Blood Test to Detect Concussions

The Food and Drug Administration (FDA) on Wednesday approved the first blood test to evaluate mild TBI (mTBI) or concussion.

The test, called the Brain Trauma Indicator, works by measuring levels of two proteinsUCH-L1 (ubiquitin C-terminal hydrolase L1) and GFAP (glial fibrillary acidic protein). These proteins are released from the brain following a head injury and appear in the blood within hours of the injury.

“A blood-testing option for the evaluation of mTBI/concussion not only provides health care professionals with a new tool, but also sets the stage for a more modernized standard of care for testing of suspected cases,” FDA Commissioner Scott Gottlieb, M.D., said in a press release.

Health care professionals currently evaluate patients suspected of head injuries with the 15-point Glascow Coma Scale followed by a computed tomography (CT) scan of the head to detect intracranial lesions that may need follow-up care. More than 90% of patients presenting to the emergency department with mild TBI or concussion have a negative CT scan, according to Banyan Biomarkers, Inc., the developer of the Brain Trauma Indicator.

The FDA evaluated data from a multicenter, prospective clinical study of 1,947 individual blood samples from adults with suspected mTBI/concussion and reviewed the product’s performance by comparing mTBI/concussion blood tests results with CT scan results. According to the FDA, the Brain Trauma Indicator was able to predict the presence of intracranial lesions on a CT scan 97.5% of the time and those who did not have intracranial lesions on a CT scan 99.6% of the time.

“These findings indicate that the test can reliably predict the absence of intracranial lesions and that health care professionals can incorporate this tool into the standard of care for patients to rule out the need for a CT scan in at least one-third of patients who are suspected of having mTBI,” the agency noted in the press release. The results of the test are available within three to four hours.

For related information, see the Psychiatric News article “Blood Test May Detect Concussions Days Later.”

Wednesday, February 14, 2018

Antidepressants May Reduce Opioid Use in Patients With Comorbid Depression, Chronic Pain

Patients experiencing chronic pain and depression may be more likely to stop taking opioids if they adhere to their antidepressants, reports a study published in the British Journal of Psychiatry. Further analysis also suggests that halting opioid use contributes to improvements in depression.

“Depression can worsen pain and is common in patients who remain long-term prescription opioid users,” Jeffrey Scherrer, Ph.D., of the Saint Louis University School of Medicine said in a press release. “Effective depression treatment may break the mutually reinforcing opioid-depression relationship and increase the likelihood of successful opioid cessation.”

Scherrer and colleagues analyzed electronic medical records from the Veterans Health Administration for this study. They identified 2,821 patients who received antidepressants for a new diagnosis of depression following at least 90 days of opioid use for chronic pain (excluding cancer pain or HIV pain). Of this group, 1,077 of the patients were adherent to antidepressants (took at least 80% of their prescribed amount) and 1,744 were not.

The authors calculated that antidepressant adherence was associated with a 24% greater likelihood of opioid cessation; this association was not related to duration of opioid use, degree of pain, or number of other medical comorbidities.

An exploratory analysis of all four patient subgroups (adherent/nonadherent and opioid cessation/noncessation) revealed that patients who stopped using opioids—regardless of their adherence—showed greater improvements in their depressive symptoms. However, antidepressant adherent patients who stopped using opioids showed the greatest improvements.

While the authors cautioned more studies are needed to confirm these preliminary findings, they wrote “together, these results provide preliminary evidence that a reduction in depression may lead to OAU [opioid analgesic use] cessation … opioid taper paired with antidepressant medications could result in a faster reduction of depression symptoms and increase the likelihood of successful OAU cessation.”

To read more on this topic, see the Psychiatric News article “Many Prescription Opioids Go to Adults With Depression, Anxiety.”

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Tuesday, February 13, 2018

APA Commends Bipartisan Budget Deal for Health, MH Provisions

The bipartisan budget agreement passed last week by Congress won praise from APA for its inclusion of funding for many mental health, substance use, and criminal justice programs that will benefit millions of Americans living with serious mental and substance use disorders. APA had lobbied hard on many of these issues for months leading up to the vote.

Among the major provisions of the legislation is an extension of the Children’s Health Insurance Program through 2028, marking the longest reauthorization in the program’s history. CHIP is a federal-state partnership that provides comprehensive health insurance coverage for children whose families earn too much to qualify for Medicaid but not enough to afford private insurance. CHIP insures 9 million children, including 850,000 with serious behavioral or emotional disorders.

The budget agreement also provides the following:
  • $6 billion to help fight the nation’s opioid epidemic, primarily through state grants that expand substance abuse and mental health treatment. In addition, $2 billion has been earmarked over the next two years to support research at the National Institutes of Health, including its study of nonopioid pain therapies.
  • Two-year reauthorizations of funding for the community health centers; the National Health Service Corps, which provides student loan forgiveness to health professionals who work in rural or underserved areas; and the Teaching Health Center Graduate Medical Education Program. These all provide critical health-related resources to vulnerable communities.
  • Technical corrections related to the Medicare Access and CHIP Reauthorization Act (MACRA), which will help ease regulatory burdens faced by physicians.
  • Additional funding for Department of Veterans Affairs hospitals and clinics.
  • Funding that will improve access to telehealth services by Medicare Advantage enrollees.

“Through enhanced federal commitment to programs—stimulating the mental health workforce, furthering evidence-based practices, and advancing medical research—we can ensure the next generation of mental health professionals are well prepared to combat current and future health-related challenges,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., wrote in a letter to congressional leaders following the bill’s passage. “APA looks forward to continued collaboration to build and support robust systems of care, innovative programs, and a high-performing workforce to ensure the stability of our healthcare system now and for the future.”

Detailed information on the budget agreement will appear in the March 2 issue of Psychiatric News.

(Image: David Hathcox)

Monday, February 12, 2018

ABMS Online Survey Seeks Feedback From Physicians on MOC

Physicians are invited to provide feedback about Maintenance of Certification (MOC) requirements through an online survey being conducted by the American Board of Medical Specialties (ABMS).

The survey is part of an ABMS initiative titled “Continuing Board Certification: Vision for the Future.” The feedback from the survey, which members of the public and other stakeholders are also invited to take, will help identify key concerns regarding MOC and inform the work of ABMS’s new Vision for the Future Commission. The commission will use the survey results as part of a comprehensive assessment of continuous board certification to make it "meaningful to physicians and the patients they serve well into the next decade." The commission will submit a draft report for public comment in November; a final report will be submitted to the ABMS Board of Directors in February 2019.

According to an ABMS spokesperson, the survey will be live for another three to four weeks.

The 27-member commission is co-chaired by psychiatrist Christopher Colenda, M.D., M.P.H., president emeritus of the West Virginia University Health System (WVUHS). According to the ABMS website, the commission will “engage and gather the perspectives of those involved and affected by physician certification, including practicing physicians; advocates for patients and the public; state medical societies; specialty associations and societies; accreditors; credentialing organizations; health care delivery systems; experts in assessment, learning, and quality improvement; certifying boards; and other professional organizations.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., said the survey is an opportunity for APA members to register their concerns about MOC and its relevance to physicians and patient care. “APA leadership continues to be aware of the serious concerns many members have about the current structure of MOC and continuing board certification,” Levin said. “We wholeheartedly support the value of lifelong learning but believe that the process for professional self-regulation needs to be clinically relevant and not add to the administrative burdens with which many physicians are already wrestling.

“I encourage APA members to use the ABMS survey to share their experience and expertise and help mold the future direction of MOC and continuing board certification,” he said.

For more information, see the Psychiatric News article “Board Opposes Use of MOC Status to Penalize Physicians.”

Friday, February 9, 2018

APA Announces Winners of 2018 Election

APA’s Committee of Tellers has approved the following results of APA’s 2018 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting March 17-18.

Bruce J. Schwartz, M.D.

Gregory W. Dalack, M.D.

Richard F. Summers, M.D.

Early Career Psychiatrists Trustee-at-Large
Ayana Jordan, M.D., Ph.D.

Area 1 Trustee
Eric M. Plakun, M.D.

Area 4 Trustee
Cheryl D. Wills, M.D.

Area 7 Trustee
Annette M. Matthews, M.D.

Resident-Fellow Member Trustee-Elect
Rana Elmaghraby, M.D.

Complete results of the election will be reported in the March 2 issue of Psychiatric News.

Thursday, February 8, 2018

For Better or Worse: Risk of Alcohol Use Disorder Rises When Spouse is Diagnosed

A study of married couples in Sweden found that spouses strongly resemble one another in their risk for alcohol use disorder (AUD), with the way spouses interact with each other playing a strong causal role, according to a report published yesterday in JAMA Psychiatry.

Women in a first marriage with no history of AUD were nearly 14 times more likely to be diagnosed with AUD immediately after their husbands were diagnosed with AUD and about four times as likely after two years, compared with women who had no spousal exposure to AUD, according to Kenneth S. Kendler, M.D., at the Virginia Institute for Psychiatric and Behavioral Genetics and colleagues. Similarly, husbands with no history of AUD were more than nine times as likely to be diagnosed with AUD immediately after their wives were diagnosed, and about three times as likely after three years.

Researchers examined population, medical, pharmacy, and crime registries in Sweden to determine marital and AUD status, excluding married partners who did not reside together. First, they identified 8,562 married couples where neither had a history of AUD prior to marriage and one spouse developed AUD during the marriage. These couples were compared with individuals who did not reside with a spouse with an AUD. The researchers then studied 4,891 individuals with multiple marriages whose first spouse had no AUD diagnosis and second spouse did, or vice versa.

Researchers noted that individuals who remarried were more likely to move from having a spouse without AUD to a spouse with AUD than vice versa. When individuals moved from a marriage to a spouse with AUD to a spouse without the disorder, they cut their risk for AUD by half. By contrast, individuals who moved from a marriage to a spouse without the disorder to one with AUD greatly increased their risk of AUD (seven times the risk in women, and nine times the risk in men).

The report follows a 2016 study published in the American Journal of Psychiatry that men and women married to a spouse with no history of AUD are much less likely to experience AUD themselves. It concluded that while marriage generally was protective against the risk of alcohol use disorder, marriage to a spouse with AUD greatly increased the risk of the disorder for both men and women.

“Although genetic and biological factors contribute strongly to the predisposition to alcohol dependence, these findings complement our prior work on marriage and divorce in showing how close social bonds such as marriage can also powerfully influence, for better or worse, the risk for AUD,” the researchers concluded.

For related information, see the Psychiatric News article “Marriage May Decrease Future Risk of Alcohol Use Disorder.”

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Wednesday, February 7, 2018

Suicides Increased for Months After Death of Robin Williams, Report Suggests

In the five months following the death by suicide of the popular actor and comedian Robin Williams on August 11, 2014, there was a nearly 10% increase in the number of people who died by suicide in the United States, according to epidemiologists at the Columbia University Mailman School of Public Health. Although the uptick in suicides was seen across gender and age groups, men and those aged 30 to 44 had the greatest increases in suicides, according to the report published today in PLOS One.

“Research has shown that the number of suicides increases following a high-profile celebrity suicide, but this is the first study, to our knowledge, that has examined the effect of a high-profile suicide on the general population within the modern era of the 24-hours news cycle,” David S. Fink, M.P.H., M.Phil., of Columbia’s Department of Epidemiology said in a press release.

For the study, Fink and colleagues examined monthly suicide count data and monthly suicide rates from January 1999 to December 2015 by sex, age, and method, collected in a CDC database known as CDC Wonder. The researchers used a statistical method that took into consideration seasonal suicide patterns to estimate the number of suicides that took place between August and December 2014.

The model estimated that 16,849 suicides would occur from August to December 2014; however, 18,690 suicides—an excess of 1,841 suicides (9.85% increase)—were reported. Those aged 30 to 44 showed the greatest increase in suicides at 12.9%.

“[C]ompared to all other methods of suicide, the difference between the observed and predicted number of suicides was greatest and most consistent among suffocation suicides,” the authors wrote. “Specifically, we observed a 32.3% increase in the number of suffocation suicides in the five months that followed Williams’ death, compared to a 3.1% increase in the number of suicides from all other methods combined (for example, cutting/piercing, poisoning, firearm, falls, all other methods), albeit we found a higher than expected number of poisoning suicides and firearm suicides in August and September, respectively.”

The authors continued, “Although we cannot determine with certainty that the excess suicides were attributable to news media reports on Williams’ death, Williams’ death might have provided the necessary stimulus for high-risk segments of the U.S. population (for example, middle-aged men in despair) to move from suicidal ideation to attempt. … Suicide remains a central threat to public health, and high-profile celebrity suicides will continue to occur; preventing such effects will require substantial resources and training, as well as creative responses to emerging media.”

“The potent effects of celebrity suicide reported in this manuscript underscore the need for the media to follow guidelines for reporting suicides,” Maria A. Oquendo, M.D., Ph.D., APA past president and professor and chair of psychiatry at the Perelman School of Medicine at the University of Pennsylvania, told Psychiatric News by email. “Refraining from glamorizing the person in this context and emphasizing the fact that suicide is one of the most devastating sequelae of psychiatric conditions are essential.”

There are multiple resources on points to consider when reporting on suicide, including “Recommendations for Reporting on Suicide,” developed in collaboration with the American Foundation for Suicide Prevention, the National Institute of Mental Health, the Associated Press Managing Editors, and the CDC, among others.

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Tuesday, February 6, 2018

Prevalence of Fetal Alcohol Syndrome May Be Higher Than Previously Assumed, Study Suggests

The prevalence of fetal alcohol syndrome in the United States may be much higher than previous estimates have assumed, with conservative estimates suggesting as many as 1.1% to 5% of first-grade children in four communities are affected, according to a report published today in JAMA.

The results suggest that physicians should be alert to identifying women of child-bearing age who may be at risk for alcohol abuse.

“These prevalence estimates are consistent with mounting evidence that harmful fetal alcohol exposure is common in the United States today,” Philip A. May, Ph.D., of the University of North Carolina at Chapel Hill and colleagues wrote. They “may represent more accurate U.S. prevalence estimates than previous studies but may not be generalizable to all communities.”

Using “active case ascertainment”—an especially rigorous study method for case identification—May and colleagues sampled more than 6,000 first graders in four communities: the Rocky Mountain, Midwestern, Southeastern, and Pacific Southwestern regions. The researchers systematically assessed the children in the four domains relevant to fetal alcohol spectrum disorders: physical growth, dysmorphic features, neurodevelopment, and prenatal exposure. Prenatal exposure was assessed through maternal interviews conducted by trained study staff in person or over the telephone.

Of 6,639 children selected for participation (out of a first-grade population in the four regions of more than 13,000), a total of 222 cases of fetal alcohol spectrum disorders were identified. “Only 2 of the 222 children classified with a fetal alcohol spectrum disorder had been diagnosed previously with the disorder, although many parents and guardians were aware of the learning and behavioral challenges facing their children,” the authors noted.

The researchers derived a conservative estimate (which assumed that those children not included in the final sample did not have fetal alcohol syndrome) of 11.3 per 1,000 children (1.1 percent) in one Midwestern sample to a high of 50 per 1,000 (5 percent) in one Rocky Mountain sample. A second estimate (in which those children not sampled were assumed to have the same rate of fetal alcohol syndrome as the sampled population) ranged from 31 children per 1,000 to 98.5 per 1,000.

“Although the different approaches reflect the uncertainty about the actual prevalence, these new estimates are up to 10 times higher than those previously reported using similar methods from two single-site studies and up to five times higher than a recent meta-analysis of studies from the United States with a pooled prevalence of 2%,” Shannon Lange, M.P.H., Jürgen Rehm, Ph.D., and Svetlana Popova, Ph.D., wrote in an accompanying editorial. The finding that “fetal alcohol spectrum disorders is not a rare condition among the general U.S. population has substantial implications for clinicians and researchers, including that many cases are either missed or misdiagnosed…”

They added, “As the first point-of-contact, physicians and other health care professionals have an important role in prevention and identification. Special attention should be paid to young women who may engage in binge drinking because it can lead to unprotected sex and unplanned pregnancy.”

For related information, see the Psychiatric News article “Strategy Emerges to Combat Effects of Prenatal Alcohol Exposure.”

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Monday, February 5, 2018

Despite Setbacks, Search for Alzheimer’s Therapy Moves Forward

Treatment targeting amyloid beta—a protein that has long been assumed to cause Alzheimer’s disease (AD) through its accumulation in the brain—remains a major focus of research on potential pharmacological treatments, but drug candidates aimed at alternative pathways are catching up in development. Psychiatric News PsychoPharm has compiled a list describing some of the AD drugs in development you may hear more about in the coming year.

The most robust group of non-amyloid drugs are agents that targets tau, another protein that can form toxic aggregations in the brain. Two anti-tau monoclonal antibodies—ABBV-8E12 and RO7105705—are currently in phase 2 clinical trials, while a third BIIB092 will soon begin recruiting patients for a phase 2 trial. This class of medications has experienced its own share of failures, however; the anti-tau drug LMTM—a derivative of the chemical dye methylene blue—recently fizzled in a phase 3 study.

Among other classes of drugs, azeliragon, a small molecule that inhibits the receptor for advanced glycation end products (AGEs), is currently undergoing a phase 3 study. AGE receptors are involved in transporting amyloid beta fragments into brain cells but they are also associated with inflammation. Another agent in the pipeline is lumateperone, a molecule that targets several types of serotonin, dopamine, and glutamate receptors. Lumateperone is not a cognitive agent; rather it is being tested for the treatment of agitation in AD and other dementias.

In parallel with these trials, new tools are being developed to sharpen the picture of a brain with AD. Many recent trials rely on biomarkers from brain scans or cerebral spinal fluid samples to identify people with early stage AD; these approaches are effective but also expensive and invasive. A study published by researchers in Australia and Japan last week identified blood-based biomarkers that might identify people with prodromal AD, which could greatly speed up the recruiting process for clinical studies.

For related information, see the Psychiatric News article “Long-Term SSRI Use May Slow Progression to Alzheimer’s Dementia.”

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Friday, February 2, 2018

ECT Said to Be Underutilized to Treat Major Depression, Bipolar Disorder

Despite its effectiveness in treating severe depression, the use of electroconvulsive therapy (ECT) is “exceptionally uncommon and limited to patients with extensive multimorbidity,” according to a report published Thursday in Psychiatric Services in Advance.

Samuel Wilkinson, M.D., of Yale School of Medicine and colleagues compared the sociodemographic and clinical characteristics of privately insured Americans with major depressive or bipolar disorder who received ECT and those who did not.

The authors found that among the selected individuals in the 2014 MarketScan commercial insurance claims database (N=47,258,528), the ECT utilization rate was 5.56 ECT patients per 100,000 in the population. Of the 969,277 patients with major depression or bipolar disorder, 2,471 (0.25%) received ECT.

Those who received ECT had substantially higher rates of comorbid psychiatric disorders, higher numbers of prescription fills for any psychotropic medication, higher rates of any substance use disorder, and total outpatient psychotherapy visits. States in the west region had significantly lower ECT rates. The disparity was accounted for by strict legal requirements for ECT in one of the states in that region.

“Whereas standard antidepressant therapies achieve response with 16%-17% of patients with treatment-resistant depression, ECT achieves response rates of 50%-70% with such patients. Recent data show that among psychiatric inpatients, ECT is associated with a 46% lower risk of 30-day readmission compared with a matched group of patients with severe depression who did not receive ECT,” Wilkinson and colleagues wrote.

“Given what we know about the prevalence of treatment-resistant depression (TRD), our study suggests that less than 1% of these patients receive ECT,” Wilkinson told Psychiatric News. “Defining an ‘appropriate’ rate of utilization can be challenging. [But to only use for] 1% of TRD patients and 0.25% of patients with major depression or bipolar disorder is significant underutilization.”

Wilkerson and his colleagues noted that underutilization of ECT is thought to reflect a combination of factors, including stigma, risk of cognitive side effects, and restricted access because of limited availability.

For more on this topic, see the Psychiatric News article “Psychiatric Readmissions Lower Among Patients Receiving ECT.”

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Thursday, February 1, 2018

Young People With Psychotic Disorder at Highest Risk of Death in Year Following Diagnosis

Young patients newly diagnosed with a psychotic disorder are at higher risk for mortality, mostly due to injuries and poisoning, particularly for the first year or two after diagnosis, according to a study published Wednesday in JAMA Psychiatry.

In fact, the adolescents and young adults studied were more than eight times more likely to die within the first year of being treated for an initial psychotic disorder diagnosis than were patients who received other outpatient services, according to the report by Gregory E. Simon, M.D., M.P.H., of Kaiser Permanente Washington Health Research Institute and colleagues. After initial diagnosis of unipolar depression, patients were three times more likely to die than general outpatients.

For this cohort study, researchers examined eight years of records from several health systems that serve more than 8 million members. They examined records for 11,713 patients aged 16 through 30 who were first diagnosed with a psychotic disorder along with two comparison groups: 35,576 patients who received outpatient services and 23,415 patients with a first diagnosis of unipolar depression.

The researchers found that for every 10,000 patients, 55 of those with a first diagnosis of psychotic disorder died within the first 12 months, compared with 21 deaths of those with first diagnosis of unipolar depression and 7 of those seen by general outpatient services. Of the 64 patients who died within a year of a psychotic disorder diagnosis, more than half were from injuries or poisoning (34% self-inflicted, 17% unintentional). For patients with an initial diagnosis of unipolar depression, more than half of the 48 deaths (54%) were self-inflicted.

Overall mortality and mortality due to injuries and poisonings decreased gradually during the three years after initial diagnosis with psychosis. However, such mortality remained elevated in comparison with patients who received general outpatient health services and those who were newly diagnosed with unipolar depression.

“Our findings support the importance of systematic early intervention for young people experiencing the first onset of psychosis. Strong evidence supports the effectiveness of coordinated specialty care programs for improving clinical outcomes,” the researchers noted. They added that few such patients receive this type of care. Some studies have suggested that continuous treatment with antipsychotic medication may also reduce mortality in this group.

For related information, see the AJP in Advance article “Care Pathways Before First Diagnosis of a Psychotic Disorder in Adolescents and Young Adults” and the Psychiatric News article “Gralnick Award Lecturer Emphasizes Importance of First-Episode Treatment.”

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