Monday, June 18, 2018

Autistic Traits Associated With Elevated Depression in Youth Aged 10 to 18


At age 10, children with autism spectrum disorder (ASD) and those with high levels of autistic traits have more depressive symptoms than children in the general population, reports a study published in JAMA Psychiatry. These elevated depressive symptoms persist in the children until they are 18 and are significantly influenced by bullying.

“[F]urther research into the role of traumatic experiences, such as bullying, and the utility of interventions to reduce bullying or address its adverse effects could have the potential to reduce the burden of depression in this population,” wrote lead author Dheeraj Rai, Ph.D., of the University of Bristol and colleagues. 

For this study, Rai and colleagues assessed data from the Avon Longitudinal Study of Parents and Children (ALPSAC), which tracked over 15,000 children born in the Bristol area between 1990 and 1992 and their parents until the children turned 18. As part of ALSPAC, investigators conducted periodic clinical assessments and had parents and children complete self-report questionnaires for a range of behavioral issues, including ASD and depression.

The final dataset for the study included 8,087 children. Of this group, 96 children were diagnosed with ASD, 546 had social communication impairments, 526 had problems with speech coherence, 419 displayed repetitive behaviors, and 801 had poor social temperament.

Children with ASD or any of the four autistic traits had higher depressive symptom scores than the general population at age 10, as assessed by the Short Mood and Feelings Questionnaire (SMFQ). The SMFQ scores continued to rise over time, though by age 18 only those with social communication impairments had a significantly higher rate of diagnosed depression than the youth in the general population (1.68 times the risk).

At age 10, the children with ASD and autistic traits who reported being bullied had the highest average SMFQ scores; likewise, youth with social communication impairments who reported being bullied in childhood or adolescence were more likely to have a diagnosis of depression at age 18.

“These findings add to the evidence highlighting a higher burden of depression and also suggest a potentially modifiable pathway, through bullying,” Rai and colleagues wrote. “However, gaps remain in our understanding of the measurement and phenomenology of depression in individuals with autism, which could be a priority for future research. Further work could also focus on improvements in psychological and pharmacological management of depression in ASD.”

To read more about this topic, see the Psychiatric News article, "Social Skills Therapy for ASD Shows Modest Benefits in Routine Settings."

(iStock/Aleksander Rybin)

Friday, June 15, 2018

Highlights From APA’s 2018 Annual Meeting: Issue #1


Everett Sums Up State of Psychiatry in America and Where Profession Is Headed

One of the keys to psychiatry’s future is the development of innovative technologies that will reduce administrative burdens and improve patient care.

Read More >



Talking About Firearms With Patients Necessary, But Examine Your Beliefs First

When talking with patients about gun ownership and storage issues, proceed with respect and neutrality.

Read More >



APA Poll Finds Americans’ Anxiety Is Increasing, Especially About Health, Safety, and Finances

Many Americans are dealing with stress and anxiety in various areas of their lives, especially with regard to money and paying bills, finds an APA poll.

Read More >



Familial History of Psychiatric Disorders Key in Predicting Postpartum Risk

An AJP study reports that the risk of experiencing a postpartum psychiatric episode was highest when mothers had a first-degree relative with bipolar disorder.

Read More >



Online Support Shows Potential of Tech-Based MH Care, Insel Says

Online counseling networks show how simple technological approaches can reduce delays in care and build online help communities.

Read More >

Wednesday, June 13, 2018

Rapid Weight Gain, Decreased Insulin Sensitivity Found in Youth Taking SGAs for First Time


Within 12 weeks of starting treatment with low-dose aripiprazole, olanzapine, or risperidone, youth with disruptive behavioral disorders experienced significant increases in total body fat, according to a study published today in JAMA Psychiatry. The study also found that youth treated with these second-generation antipsychotics (SGAs) experienced decreases in insulin sensitivity over the 12-week period.

The findings point to the importance of continued monitoring for metabolic abnormalities when treating youth with antipsychotics.

For the study, Ginger E. Nicol, M.D., of the Department of Psychiatry at Washington University School of Medicine in St. Louis and colleagues recruited antipsychotic-naïve youth aged 6 to 18 with one or more psychiatric disorders and clinically significant aggression. A total of 144 youth were assigned to aripiprazole, olanzapine, or risperidone for 12 weeks. (According to the study authors, mean final antipsychotic doses were representative of pediatric practice patterns and below the doses typically used to treat psychosis: aripiprazole, 6.0 mg; olanzapine, 6.3 mg; risperidone, 1.0 mg.)

The authors used dual X-ray absorptiometry (DXA) and magnetic resonance imaging (MRI) scans to assess changes in total body fat and abdominal fat over the course of the trial. At baseline and 12 weeks, the youth also received an insulin sensitivity test and answered questions about their symptoms.

Although the youth experienced clinically and statistically significant improvements in irritability, aggression, and overall symptoms over the course of the study, the mean DXA percentage total body fat of the youth increased significantly during 12 weeks for all study treatments—1.66% for aripiprazole, 4.12% for olanzapine, and 1.18% for risperidone. Abdominal fat measured by MRI also “increased significantly in visceral and subcutaneous compartments, … [with] greater subcutaneous mean fat increase with olanzapine compared with risperidone and aripiprazole,” Nicol and colleagues wrote. The researchers also found insulin sensitivity decreased significantly from baseline in the pooled study sample.

“These findings confirm previous reports … which showed rapid-onset obesity and glucose dysregulation in children using SGA medications, as well as the greatest weight gain and adverse changes in glucose metabolism in those treated with olanzapine,” Marc De Hert, M.D., Ph.D., and Johan Detraux, M.Psy., of Katholieke Universiteit Leuven in Belgium wrote in an accompanying editorial. They emphasized the importance of routine weight, glucose, and lipid monitoring when prescribing antipsychotics to youth.

“Although no SGA regimen is absolutely free from metabolic consequences, preference should be given to an SGA drug with a low to moderate metabolic risk (thus avoiding olanzapine), and clinicians should aim for the shortest necessary treatment duration in the case of off-label use,” De Hert and Detraux concluded.

For related news, see the Psychiatric News article “Survey Finds Poor Compliance With Guidelines For Monitoring SGAs in Kids.”

(Image: forestpath/Shutterstock)

Tuesday, June 12, 2018

Psychiatrist Patrice Harris, M.D., M.A., Elected President-Elect of the AMA


APA member Patrice Harris, M.D., M.A., a former APA board member and AMA board member, was elected today as president-elect of the AMA during the AMA’s House of Delegates meeting in Chicago. 

“I believe our American Medical Association has well-crafted policy concerning the changing health care environment in this country,” Harris said in an address to the House following her election. “It will be my honor to represent our AMA in the venues where important issues will be debated. I am committed to preserving the central role of the physician-patient relationship in our healing art.”

Harris is the first African-American woman to hold the office.

Harris served on the AMA Board of Trustees beginning in 2011 and served as secretary for the 2014-2015 term and as chair of the board for the 2016-2017 term. As a practicing psychiatrist trained in child/adolescent and forensic psychiatry, she consults with both public and private organizations on health service delivery. She is also chair of the AMA Task Force to Reduce Opioid Abuse and is an adjunct assistant professor in the Department of Psychiatry and Behavioral Sciences at Emory University. 

“I’m elated that Dr. Harris has been elected president of the AMA,” said APA President Altha Stewart, M.D. “This is a great day for APA and for psychiatry. The APA Board of Trustees looks forward to continuing to work with her as both organizations collaborate to increase patient access to care and improve the practice of medicine.”

Harris previously served as the director of health services in Fulton County, Ga., and the 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. She is a past president of the Georgia Psychiatric Physicians Association.

“We are delighted to have a psychiatrist and a former APA Board of Trustees member leading the house of medicine as president-elect of the AMA,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Her election demonstrates how psychiatrists can be leaders in medicine. We look forward to working with Dr. Harris on continued advocacy for improving the quality of care and integrating psychiatry and mental health within medicine.”

(Image: Mark Moran)

Monday, June 11, 2018

APA Calls on Administration to Defend Patient Protections in ACA


APA has strongly condemned the recent decision by the Department of Justice to not defend the patient protections provided in the Affordable Care Act (ACA) in the case Texas v United States.

Since the ACA took effect in 2013, the uninsured rate among nonelderly adults has dropped 40 percent (from 20.5% in 2013 to 12.2% in 2016), according to the Kaiser Family Foundation. The Justice Department’s decision opens the door for insurers to deny health care coverage to the 130 million individuals with preexisting conditions and allows insurers to raise the premiums for Americans with disabilities, senior citizens, and those who have a history of using more health care.

“We strongly condemn the Administration’s decision not to defend the patient protections provided in the Affordable Care Act, an established law of the land,” APA President Altha Stewart, M.D., said in a statement released Friday. “This is harmful to the health of Americans and is very short-sighted, considering the nation is in the midst of an opioid epidemic and a 30 percent rise in suicide rates. We call upon the administration to reverse this decision and defend the rights of our patients.”

APA also signed on to a similar statement released Saturday with five other medical organizations representing more than 560,000 physician and medical student members. It read, “We strongly urge the Department of Justice to reconsider its decision in Texas v United States and that we all seek policy solutions that increase access to affordable health care that provides all individuals, regardless of their gender, race, and health status, reasonable protections against discrimination in coverage and pricing.”

The Supreme Court had previously upheld the ACA’s individual mandate that required most people to carry minimum essential health insurance, but only in so far as it was a tax provision that yielded at least some revenue for the federal government. But because the Tax Cut Jobs Act eliminates the ACA’s tax/penalty provision of the individual mandate starting in 2019, the Justice Department determined that it will no longer be constitutional as of January 1, according to a memorandum filed June 7. Texas, along with 19 other states, had filed a federal lawsuit in February challenging the individual mandate and other patient protections in the law.

The Justice Department did not uphold the ACA’s “guaranteed issue” and “community rating” provisions. These provisions required insurance companies to provide coverage to those with preexisting conditions and provide the same premiums regardless of medical history.

The Department of Justice’s brief in the case is posted at https://www.justsecurity.org/wp-content/uploads/2018/06/ACA.Azar_.filing.pdf.

(Image: iStock/pabradyphoto)

Friday, June 8, 2018

APA Reacts to CDC Report on Uptick in Suicides Across United States


A report released yesterday by the CDC found suicides rates increased significantly in most states between 1999 and 2016, with 25 states experiencing increases of greater than 30%. The report also suggested that more than half of people who died by suicide did not have a known mental health condition.

“Suicide is a critical issue for all of us who work in health care,” APA President Altha Stewart, M.D., said in statement released today. “We know from other research that most people who die by suicide have mental health conditions, though they may not have been formally diagnosed or treated. People should know that suicide is preventable. Anyone contemplating suicide should know that help is available, and that there is no shame in seeking care for your mental health.”

The National Suicide Prevention Hotline is available 24 hours/7 days a week. For those seeking help, please call 1-800-273-8255.

“Suicide is rarely caused by any single factor, but rather, is determined by multiple factors,” including mental illness and prior suicide attempts, as well as social and economic problems, access to lethal means, and poor coping and problem-solving skills, lead author Deborah Stone, Sc.D., of the CDC and colleagues wrote. “Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning.”

Stone and colleagues used data from National Vital Statistics System to calculate national and state-level suicide rate estimates for people aged 10 and older from 1999 to 2016. Suicide rates increased in all states except Nevada, where the rate was consistently high (above 21 per 100,000 people) throughout the study period; the absolute increases in suicide rates ranged from 0.8 per 100,000 people in Delaware to 8.1 per 100,000 people in Wyoming.

The researchers also compared the characteristics of people who died by suicide, with and without known mental health conditions, in the 27 states with complete data in CDC’s National Violent Death Reporting System in 2015. Their analysis revealed that 54.0% of those who died by suicide did not have known mental health conditions (disorders and syndromes listed in DSM-5). While most of the people who died by suicide were male (76.8%) and non-Hispanic white (83.6%), those without known mental health conditions were more likely to be male (83.6% versus 68.8%) and belong to a racial/ethnic minority than those with known mental health conditions.

“Today's report on suicide reinforces the need to fund and enforce laws ensuring access to mental health services,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Early identification of mental illness is essential, and we are ready to work with Congress and other stakeholders to ensure that Americans can receive treatment when needed.”

For related information, see the Psychiatric News article “How to Reduce Risk of Suicide by Firearms,” by Liza Gold, M.D.

(Image: iStock/carterdayne)

Thursday, June 7, 2018

Alcohol Use Intervention in ED Shows Promise in Reducing Dating Violence, Depression


A single motivational interviewing-based brief intervention used in the emergency department to curb underage drinking may also reduce short-term dating violence and depression, according to a study in the June issue of Pediatrics.

For this study, Quyen M. Ngo, Ph.D., of the University of Michigan Medical School and colleagues analyzed data collected as part of the U-Connect trial. A total of 836 adolescent patients in the emergency department (aged 14 to 20) who screened positive for risky drinking on the Alcohol Use Disorders Identification Test were randomly assigned to a computer-led brief intervention, a therapist-led brief intervention, or a control group that received “enhanced usual care” (staff reviewed a resource brochure with participants). 

In addition to assessing drinking behaviors at three-, six-, and 12-month follow-ups, the researchers asked the participants about exposure to dating violence (using the modified Conflict in Adolescent Dating Relationships Inventory) and symptoms of depression (using the Brief Symptom Inventory).

At three months, patients who received either computer or therapist brief intervention had a 15% lower incidence rate for depression. At six months, computer brief intervention resulted in a reduction of dating violence perpetration (48% lower than control) and depression symptoms (22% lower than control). At the 12-month follow-up, therapist-led brief intervention resulted in a significant reduction of dating violence perpetration (47% lower than that of the control group).

“Currently, no ED-based alcohol interventions have been tested that are also used to address multiple detrimental outcomes, including dating violence perpetration and depression symptoms,” Ngo and colleagues wrote. “Even when controlling for baseline alcohol consumption, we found that these are notable risk reductions, especially given that the intervention was not explicitly focused on dating violence or depression. … With our findings, we suggest that participating in an alcohol BI [brief intervention] may have a broader impact beyond alcohol consumption, including dating violence and depression secondary outcomes.”

For other information on alcohol use in adolescence, see the American Journal of Psychiatry article “Neural Predictors of Initiating Alcohol Use During Adolescence.”

(Image: iStock/Minerva Studio)

Wednesday, June 6, 2018

Internet Addiction May Increase Risk of Suicidality, Meta-Analysis Finds


People with internet addiction appear to be at a higher risk of suicidal behaviors than those with healthy internet use, according to a meta-analysis in the Journal of Clinical Psychiatry.

“We suggest screening individuals with internet addiction for the risk of suicide even if they do not have depression, as other factors may increase the risk of suicide in those with internet addiction,” Yu-Shian Cheng, M.D., of Tsyr-Huey Mental Hospital in Kaohsiung, Taiwan, and colleagues wrote.

While internet addiction disorder is not included as a formal diagnosis in DSM-5, the consequences of pathological internet use continue to attract increasing attention, according to the study authors. (Internet gaming disorder—the persistent and recurrent use of the internet to engage in games, leading to clinically significant impairment or distress—is listed as a condition for further study in DSM-5.) Several studies have suggested that internet addiction is associated with higher rates of suicidal behaviors, but whether this association is driven by other factors, such as depression, remains unclear.

To examine the strength of the association between suicidality and internet addiction, as well as the influence of other suicide risk factors, Cheng and colleagues performed a systematic review and meta-analysis of observational studies that investigated the association between internet addiction and suicidality. A total of 23 cross-sectional studies (n = 270,596) and two prospective studies (n = 1,180) were included in the analysis.

The authors found that prevalence rates of suicidal ideation, planning, and attempts were all significantly higher in study participants with internet addiction than in the controls (odds ratios [OR] of 2.952, 3.172, and 2.811, respectively). When the authors only used data from studies that adjusted for demographics and depression, they found that the prevalence rates of suicide attempts and ideation, though reduced, remained significantly higher in the participants with internet addiction than in the controls (attempts: adjusted OR = 1.559; ideation: adjusted OR = 1.490).

Further analysis “showed higher rates of suicidal behaviors in adolescents compared with adults and also showed a trend of higher prevalence rates of suicidal ideation in those with internet gaming disorder compared with those with internet addiction including any type of internet activity,” Cheng and colleagues wrote.

For related information, see the AJP Residents’ Journal article “Facebook Addiction: An Emerging Problem.”

(Image: iStock/tommaso79)

Tuesday, June 5, 2018

Firearm Seizure Laws Appear to Reduce Firearm-Related Suicides, Study Shows


States that have laws allowing police to temporarily seize firearms from people deemed to be at risk of danger to self or others have experienced a decrease in the number of suicides involving firearms, according to a report in Psychiatric Services in Advance.

In recent years, several states have enacted laws allowing time-limited seizure of firearms, with a level of judicial oversight and due process, from people deemed to be at risk. In 1999, Connecticut became the first state to do so following a mass shooting at the state lottery headquarters. Indiana followed suit in 2005 after the fatal shooting of a police officer in Indianapolis.

Aaron J. Kivisto, Ph.D., and Peter Lee Phalen, M.A., of the University of Indianapolis, analyzed the effects of Connecticut and Indiana’s firearm seizure laws on firearm and non-firearm suicide rates. They used suicide data from 1981 to 2015 in all 50 states to construct a synthetic model of characteristics and suicide trends prior to enactment of the firearm seizure law to compare with trends after enactment.

The authors found that Indiana’s firearm seizure law was associated with a 7.5% reduction in firearm suicides in the first decade following its enactment. Enactment of Connecticut’s law was associated with a 1.6% reduction in firearm suicides shortly after its passage; after the mass shooting at Virginia Tech University in April 2007, after which enforcement of the Connecticut law increased substantially, there was a 13.7% reduction in firearm suicides.

“Whereas Indiana demonstrated an aggregate decrease in suicides, Connecticut’s estimated reduction in firearm suicides was offset by increased nonfirearm suicides,” Kivisto and Phalen wrote. 

“Even though risk-based firearm seizure laws have typically been enacted in response to mass homicides, the laws have functioned primarily as a means of seizing firearms from suicidal individuals,” they concluded. 

For related information, see the Psychiatric News article “How to Reduce Risk of Suicide by Firearms,” by Liza Gold, M.D.

(Image: iStock/DmyTo)

Monday, June 4, 2018

Data Contained in Electronic Health Records May Help Identify Short-Term Suicide Risk


Combining patient responses to the Patient Health Questionnaire (PHQ-9) with clinical information available on electronic health records (EHRs) may someday help clinicians better predict which patients are most likely to attempt suicide, reports a study published in AJP in Advance.

Multiple studies have shown that health data can be helpful in identifying at-risk patients, but most patients do not show any obvious warning signs. Gregory Simon, M.D., M.P.H., of Kaiser Permanente and colleagues tested whether a comprehensive EHR analysis that includes data from the PHQ-9—a simple but effective depression screening tool—might improve prediction accuracy.

Simon and colleagues collected data from nearly 3 million patients aged 13 and older who had a specialty mental health visit or primary care visit and was diagnosed with a mental health disorder between January 1, 2009, and June 30, 2015. The patients were enrolled in one of seven large health systems: HealthPartners in Minnesota and Wisconsin; the Henry Ford Health System in Detroit; and the Colorado, Hawaii, Northwest, Southern California, and Washington regions of Kaiser Permanente. Within this group, the study authors identified 24,133 suicide attempts and 1,240 suicide deaths within 90 days of a primary care or specialty mental health visit.

The authors then stratified the patients by suicide risk using 313 demographic and clinical characteristics—including age, race, income, substance use, psychiatric medications dispensed, use of inpatient or emergency department care, and PHQ-9 results (both total score and answers to item 9, which asks about suicide or thoughts of self-harm).

Of the patients who scored in the top 5% of having the most risk factors out of the 313 that the researchers had identified, 5.4% attempted suicide and 0.26% died by suicide within 90 days. Patients who scored in the top 5% after a mental health specialty visit accounted for 43% of subsequent suicide attempts, while those in the top 5% after a primary care visit accounted for 48% of suicide attempts. This is an improvement over existing suicide prediction models, which identify on average 25% to 33% of subsequent suicide attempts, according to the authors.

The strongest predictors of suicide attempt were similar in mental health specialty and primary care patients: prior suicide attempt, mental health and substance use diagnoses, responses to PHQ-9 item 9, and prior inpatient or emergency mental health care.

“Prediction models cannot replace clinical judgment, but risk scores can certainly inform both individual clinical decisions and quality improvement programs,” the authors concluded. “Accurate risk stratification can also inform providers’ and health systems’ decisions regarding frequency of follow-up, referral for intensive treatment, or outreach following missed or canceled appointments.”

To read more about this topic, see the Psychiatric News article “Study Points to Risk Factors Predictive of Suicide After Emergency Visit.”

(Image: iStock/monkeybusinessimages)

Friday, June 1, 2018

Irregular Hospital Discharge in VA Facilities May Increase Suicide Risk


Patients who leave the hospital against medical advice and/or self-initiate discharge may be at a greater risk of suicide in the year following discharge compared with those who leave the hospital under different circumstances, suggests a report published today in Psychiatric Services in Advance.

Using national Veterans Affairs (VA) administrative data, Natalie Riblet, M.D., M.P.H., and colleagues identified all inpatient discharges and discharge types from 2001 through 2014. The authors used mortality and cause of death data from the Centers for Disease Control and Prevention Death Index to calculate suicide risk within the 12 months following the first discharge in patients. They then compared suicide risk following regular discharge versus irregular discharge from both general medical and psychiatric wards, adjusting for age, gender, and VA facility.

Among the 5,051,051 discharges from general medical or psychiatric wards included in the analysis, 103,995 (2.1%) were documented as being irregular. A total of 666,674 deaths occurred within 12 months of the index discharge date, 5,337 of which were caused by suicide.

Overall, suicide risk was two times higher following irregular discharge compared with regular discharge. However, additional analysis revealed that “suicide risks did not differ significantly between patients who were regularly versus irregularly discharged from a psychiatric ward,” the authors wrote. In contrast, patients leaving general medical wards following an irregular discharge had three times the one-year risk of suicide compared with patients who were discharged in a regular fashion.

“Because acute clinical stabilization and patient engagement in discharge planning play an important role in post-discharge suicide prevention efforts, it is conceivable that an irregular hospital discharge may interfere with suicide prevention efforts, increasing a patient’s risk of suicide after discharge,” Riblet and colleagues wrote. “[P]atients with irregular discharges from inpatient general medical units may represent an important targeted group for suicide prevention efforts.”

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

(Image: iStock/robypangy)

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