Friday, July 19, 2019

ADHD Medications May Lower Risk of Unintentional Injuries in Children, Adolescents With ADHD

Medication for attention-deficit/hyperactivity disorder (ADHD) may help lower the risk of unintentional injuries in children and adolescents with ADHD, a study in the Journal of the American Academy of Child & Adolescent Psychiatry has found.

“[Prior studies] suggest that ADHD is associated with a 40% to 50% increase in the risk of injuries in children and adolescents. Pharmacological treatment for ADHD has been reported to be effective for core symptoms and cognitive deficits associated with ADHD. Hence it may be hypothesized that, by reducing distractibility, impulsivity, and overactivity, ADHD medication may prevent unintentional injuries,” Laura Ghirardi, M.Sc., of the Karolinska Institutet in Stockholm and colleagues wrote.

To test their hypotheses, the researchers analyzed prescription and health data from more than 1.9 million children and adolescents aged 6 to 19 years who had either been diagnosed with ADHD or received a prescription for ADHD medication between 2005 and 2014. They followed the participants for a median of 15 to 17 months and tracked emergency department visits for injuries with an unintentional cause, including traumatic brain injuries. During the follow-up period, 87,154 study participants had at least one emergency department visit for an unintentional injury.

The researchers found that participants who were taking ADHD medications (based on prescription claims data) were 13% to 15% less likely to have unintentional injuries during the follow-up period than participants who were not taking medications. They also found that participants who took ADHD medications were 9% to 15% less likely to have an unintentional traumatic brain injury than participants who did not take the medications.

The researchers also looked at how taking ADHD medications affected risk on an individual level (the difference in risk between taking the medication and not taking the medication in the same person). They found that participants were 29% less likely to have unintentional injuries and 33% to 37% less likely to experience traumatic brain injuries when they took ADHD medications than when they didn’t take the medications.

In their conclusion, the researchers noted that their results were similar for boys and girls at different ages.

“These results highlight how the use of ADHD medication may be associated with beneficial effects that go beyond reducing core symptoms of ADHD and extend to the prevention of health-adverse events, such as physical injuries, including [traumatic brain injury],” they wrote.

For related news, see the Psychiatric News article “Medicated ADHD Patients Have Reduced Risk of Motor Vehicle Crashes” and the Psychiatric Services article “Evidence of Low Adherence to Stimulant Medication Among Children and Youths With ADHD: An Electronic Health Records Study.”

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Thursday, July 18, 2019

Family Involvement in Care of Hospitalized Psychiatric Patients May Boost Discharge Planning, Follow-up Care

Involving families and loved ones in care when psychiatric patients are hospitalized is associated with a greater likelihood of comprehensive discharge planning and follow-up care, a study in Psychiatric Services in Advance has found.

Morgan Haselden, M.P.H., of the New York State Psychiatric Institute and colleagues reviewed the records of 179 individuals hospitalized for a psychiatric condition in New York City in 2012 and 2013. They determined the involvement of family (including anyone close to the patient who provided support) in the patients’ care via documentation in the patients’ medical records of specific activities such as visiting with the patient or attending family therapy sessions. They also determined whether hospital staff had performed three discharge planning activities: communicating with an outpatient health care professional, scheduling a post-discharge mental health appointment for the patient, and forwarding a discharge summary to the provider the patient was scheduled to see. Finally, the researchers determined whether the patient had received follow-up care.

The researchers found that hospital staff were more than twice as likely to complete all three discharge activities for patients whose families visited them in the hospital, communicated with staff about services offered to families, or attended family meetings or therapy sessions than for those whose families did not engage in these activities. Patients were more than twice as likely to attend a mental health appointment within seven days of discharge if their families were contacted by hospital staff, communicated with hospital staff about the patient’s health or mental health, or discussed with staff the patient’s post-discharge treatment plan. Patients were more than three times as likely to attend a mental health appointment within 30 days of discharge if there had been any involvement between family and hospital staff.

“This finding lends support to the benefits of family involvement in mental health care and adds new evidence that these benefits extend to the psychiatric hospitalization setting,” the researchers wrote.

The researchers noted two caveats to their study. First, they stated that medical record documentation “should not be considered as fully representing actual activities and interactions, especially given the pace of inpatient care and the lack of uniform documentation standards.” Second, they noted that the findings may not be generalizable to rural settings because families in urban settings like New York City may live closer to hospitals or have greater access to transportation to visit patients.

The authors concluded, “Involvement of patients’ families is an inexpensive intervention, and although it is standard care for hospital staff to contact and involve families, such interactions do not always occur. Hospitals should formalize efforts to educate staff about the benefits of involving families in treatment and should implement standard procedures requiring contact and communication.”

For related information, see the Psychiatric Services article “Family Involvement in the Clinical Care of Clients With First-Episode Psychosis in the RAISE Connection Program.”

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Wednesday, July 17, 2019

Psychiatrists Describe Dangers in Physician ‘Burnout’ Becoming Catchall Term for Emotional Distress

Despite ongoing efforts by health care systems and professional medical organizations to create tools and practices to decrease physician burnout, physician depression and suicide prevention remain “relatively ignored,” wrote psychiatrists Maria A. Oquendo, M.D., Ph.D., Carol A. Bernstein, M.D., and Laurel E. S. Mayer, M.D., in an article appearing today in JAMA Psychiatry.

The authors described several factors that may contribute to the imbalance between attention paid to physician burnout versus major depressive disorder, including the ongoing stigma of mental illness and its treatment: “[T]he term burnout, which indicates a human reaction to something outside oneself, is less stigmatized [than major depressive disorder],” they wrote. This has allowed it “to become a catchall term for emotional distress experienced by physicians.”

Additionally, many symptoms of burnout overlap with symptoms of major depressive disorder (MDD), they noted. “The shifting definition of burnout, in concert with the overlap with psychiatric symptoms, sets the stage for a situation in which burnout can be invoked and a treatable diagnosis missed,” they wrote. “As a result, a physician dutifully completing a burnout screening inventory for self-evaluation, as now recommended by the Accreditation Council for Graduate Medical Education, could easily conclude that she or he has burnout rather than MDD.” Such missed opportunities may prevent or delay treatments, putting the physician in danger.

What can be done to resolve this problem? Oquendo, Bernstein, and Mayer suggested several solutions including screening physicians for depression, anxiety, and substance use disorders when screening for burnout and creating confidential and easily accessible psychiatric services for physicians and trainees.

“Ultimately, the biggest challenge is rolling back the corrosive effects of stigma so that more affected physicians will feel comfortable acknowledging, at least to themselves and their personal physician, that what ails them is a treatable brain disorder and not simply an impossible work situation,” the authors concluded.

Oquendo is a past APA president and a professor and chair of psychiatry at the Perelman School of Medicine at the University of Pennsylvania. Bernstein is a past APA president and vice chair for faculty development at Albert Einstein College of Medicine/Montefiore Medical Center. Mayer is an associate professor of clinical psychiatry at the Columbia University Vagelos College of Physicians and Surgeons.

For more on burnout, including a Psychiatric News series on this topic, see APA’s Well-being and Burnout Resources.

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Tuesday, July 16, 2019

Frequent Use of Medications for Sleep May Increase Dementia Risk, Especially Among Older White Adults

Frequent use of sleep medications appears to be associated with increased long-term risk of dementia, particularly among older white adults, according to research presented at the Alzheimer's Association International Conference in Los Angeles this week.

“Based on our findings, we recommend that clinicians make more effort to be aware of their patients’ sleep problems including use of sleep aids,” said lead study author Yue Leng, Ph.D., of the University of California, San Francisco, in a press release.

Leng and colleagues studied 3,068 black and white community-dwelling older adults aged 70 to 79 years who did not have dementia and were enrolled in the Health, Aging, and Body Composition study. At the beginning of the study, the participants were asked to rate their use of “sleeping pills or other medication” to help them sleep using the following responses: “never,” “rarely (once a month or less),” “sometimes (2 to 4 times per month),” “often (5 to 15 times per month),” or “almost always (16 to 30 times per month).”

A total of 147 (4.8%) participants reported taking sleep medications “sometimes,” and 172 (5.6%) reported “often” or “almost always.” A total of 34 black participants (2.7%) and 138 white participants (7.7%) reported taking sleep medications “often” or “almost always.”

The researchers tracked whether the participants experienced dementia over a 15-year period using hospital records and records of dementia medication use, as well changes in global cognition scores. After controlling for a variety of factors, including body mass index, depressive symptoms, physical activity, and APOE4 genotype, the researchers calculated the risk associated with sleep medication use. The researchers found that those who reported taking sleeping medication “often” or “almost always” were 43% more likely to develop dementia than those who reported “never” or “rarely” taking sleep medications. Whether the change in risk is due to the medications or sleep problems is not yet known, the researchers noted.

Additional analysis revealed that the increased dementia risk among the frequent users was observed only among the white participants (hazard ratio=1.79). There was no association between use of sleep medication and dementia in black participants (hazard ratio= 0.84). The association did not differ by sex.

“Further studies are needed to examine the cognitive effects of different types of sleep medications and to understand potential mechanisms,” the researchers wrote.

For related information, see the Psychiatric News article “Estimates of Adult Benzodiazepine Use Double.”

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Monday, July 15, 2019

Nabaximols Nasal Spray May Reduce Cannabis Use By Some Patients

A study published today in JAMA Internal Medicine reports that the cannabinoid agonist nabiximols can reduce cannabis use among people with cannabis dependence when combined with behavioral therapy. Nabiximols is a nasal spray composed of purified tetrahydrocannabinol (THC) and cannabidiol (CBD)—two of the primary active components of cannabis.

Study participants who received a combination of nabiximols and behavioral therapy reported using cannabis about 33% fewer days than those allocated to placebo and behavioral therapy, noted Nicholas Lintzeris, M.B.B.S., Ph.D., of Australia’s Drug and Alcohol Services and colleagues. “The reductions in illicit cannabis use and a safer route of administration … suggest the harm-reduction benefits of cannabinoid agonist treatment,” the authors wrote.

Lintzeris and colleagues enrolled 128 adults with cannabis dependence (as defined by the International Classification of Diseases, 10th Revision, or ICD-10) who were seeking treatment to participate in a 12-week trial. As part of the trial, the participants received either nabiximols or placebo nasal spray for daily use and were offered six individual cognitive-behavioral therapy sessions over the course of the trial. Each individual nabiximols spray contains 2.7 mg of THC and 2.5 mg of CBD, and participants could take up to 32 sprays daily.

At baseline, the participants reported using cannabis about 25 of the past 28 days. During the 12-week trial, adults in the placebo group reported significantly more days using cannabis (53 of 84 days) compared with those in the nabiximols group (35 of 84 days). Although there was no statistical difference between the groups in the number of participants who achieved cannabis abstinence (defined as at least 28 consecutive days without use), more adults in the nabiximols group were able to cut their cannabis use by 50% or more (54.1% vs. 28.9%).

The authors noted several limitations of the study, including the finding that only about half of the patients in the placebo and nabiximols groups stayed in treatment throughout the 12-week study. “Although our treatment retention of 46.9% at 12 weeks is comparable with prior randomized clinical trials of cannabinoid agonist treatment (55% at 11 weeks and 67% at 12 weeks), the limited treatment retention across these studies highlights the fact that cannabinoid agonist treatment is not effective for or acceptable to all patients,” Lintzeris and colleagues wrote. “Whereas nicotine-agonist and opioid-agonist treatments are considered frontline therapies, our findings suggest a more cautious approach for cannabinoid agonist treatment at this time.”

For related information, see the Psychiatric News article “Medications May Ease Cannabis Withdrawal But Fail to Achieve Abstinence” and the Psychiatric Services article “Thinking Carefully About Marijuana Legalization: Public Health Considerations for State Policy Makers.”

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Friday, July 12, 2019

Study Pinpoints Activities Associated With Reduced Risk of Cognitive Decline

Mentally stimulating activities like using a computer, playing games, crafting, and participating in social activities were associated with a lower risk of mild cognitive impairment in older people, a study published in Neurology has found. People with mild cognitive impairment, which is not the same as dementia, may have memory loss or have difficulty following conversations or understanding complex information.

Janina Krell-Roesch, Ph.D., of Mayo Clinic’s Translational Neuroscience and Aging Laboratory, and colleagues analyzed five-year data from 2,000 participants in the population-based Mayo Clinic Study of Aging. The participants were at least 70 years old at the beginning of the study, and none of them had mild cognitive impairment when they enrolled. Participants completed a questionnaire about how often they took part in five types of mentally stimulating activities during middle age (ages 50 to 65) and in later life (age 66 and older). The activities were reading books, crafting such as pottery or sewing, doing computer activities, playing games like cards or crossword puzzles, and engaging in social activities such as going out with friends. Participants then took thinking and memory tests every 15 months. Over the course of five years, 532 participants developed mild cognitive impairment.

The researchers found that using a computer in middle age was associated with a 48% lower risk of developing mild cognitive impairment and that using a computer in later life was associated with a 30% lower risk. Engaging in social activities and playing games in both middle age and later life were each associated with a 20% lower risk. Craft activities were also associated with a 42% lower risk, but only in later life.

The more activities in which people engaged during later life, the less likely they were to develop mild cognitive impairment. Engaging in two activities was associated with a 28% lower risk, engaging in three activities was associated with a 45% lower risk, engaging in four activities was associated with a 56% lower risk, and engaging in five activities was associated with a 43% lower risk.

“Persons that engage in mentally stimulating activities may have a higher likelihood of exhibiting other healthy lifestyle behaviors that may be protective against cognitive decline, such as physical activity or a healthy diet,” they wrote. “Engaging in leisure activities may also be associated with better emotional health, which in turn is associated with cognitive health.”

For related news, see the Psychiatric News article “New Insights Into How Staying Active May Delay Onset of Alzheimer’s.”

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Thursday, July 11, 2019

Non-Concussive Head Impacts Not Linked to Cognitive Decline in Young Football Players, Study Finds

Youth aged 9 to 18 years who played tackle football for two seasons did not experience significant, short-term changes in cognition from repeated head impacts that did not cause a concussion, according to a study in Journal of Neurotrauma.

However, younger age and a history of attention-deficit/hyperactivity disorder (ADHD) did predict decline in cognition among the young football players. Longer-term effects are unknown and require further research.

“The study is showing us that sub-concussive impacts don't seem to be associated with changes in neurocognitive function over two seasons of youth football,” said lead author Sean Rose, M.D., a pediatric sports neurologist and co-director of the Complex Concussion Clinic at Nationwide Children's Hospital in Columbus, Ohio. “And we're finding that other factors, such as ADHD and younger age, are more predictive of worsening scores on our pre- and post-season tests.”

Rose and colleagues studied a sample of 166 youth tackle-football players over two seasons: 70 primary-school players aged 9 to 12 years and 96 high-school players aged 15 to 18 years. Sensors were placed in their helmets to record the number as well as the intensity of impacts to the head. All participants completed assessments on a variety of neurological, cognitive (including memory and attention), and behavioral outcomes before and after each football season.

In the subgroup of 55 youth who played in both seasons, neither cumulative impact nor impact intensity predicted change scores from preseason 1 to post-season 2 on any outcome measure. However, younger age did predict worse outcomes in some measures, though these changes were independent of head impacts. Also, a history of ADHD was associated with reduced scores on several cognitive measures and an ADHD symptom self-reporting scale.

“When trying to determine the effects of repeated, sub-concussive head impacts, prospective outcomes studies are an important addition to the existing retrospective studies,” said Rose in a prepared statement. “We designed this study to include a wide variety of neurocognitive outcomes tests to give us new insights into how repeated hits might influence outcomes.”

Despite the study findings, Rose said the longer-term effects of repeated impacts from tackle football on young people’s brains is unknown “We remain concerned about repetitive head impacts in children, and longer follow-up times are necessary to look for delayed effects on neurocognition,” he said.

>For related information, see the Psychiatric News article “Age When Football Hits Began May Determine Future Cognitive Problems.”


Wednesday, July 10, 2019

CBT Program Reduces Addictive Internet Behaviors in Men, Study Finds

A 15-week treatment program that incorporates principles of cognitive-behavioral therapy (CBT) is effective at reducing problem gaming and other addictive internet behaviors in men, according to a study published today in JAMA Psychiatry

“Despite the heterogeneity of the treatment group, we found that our CBT program was effective … regardless of age, comorbidity, or treatment center,” wrote Klaus Wölfling, Ph.D., of the University Medical Center of the Johannes Gutenberg-University in Mainz, Germany, and colleagues. “These findings support a unitary concept of [internet addiction] and point to the flexibility of the STICA [short-term treatment for internet and computer game addiction].”

Internet- and gaming-related addiction is an emerging concept: Internet gaming disorder is listed in the DSM-5 under conditions for further study, and gaming disorder is included in the 11th Revision of the International Classification of Diseases (ICD-11).

Wölfling and colleagues recruited 143 men (average age 26) with addictive behaviors related to the internet and gaming from outpatient psychiatry clinics at university medical centers in Germany and Austria. The problem behaviors reported by the men included online gaming (82 men), offline gaming (9 men), online pornography (23 men), and generalized internet addiction (29 men). Participants were evaluated using the Assessment of Internet and Computer Game Addiction (AICA) scale; AICA is derived from the DSM-5’s proposed criteria for internet gaming disorder but expanded to multiple online activities.

Of the participants, 72 received STICA, which teaches patients to be cognizant of why they engage in dysfunctional internet use and provides skills to help them reduce and control their use. The treatment involved 15 weekly group sessions interspersed with eight individual sessions to aid in patient motivation and monitor participants for any emergent distress. The other 71 men were placed on a wait list and received STICA after 15 weeks.

After 15 weeks, 69% of men who received STICA achieved remission of their addiction (defined as an AICA score of 7 or less) compared with 24% of men on the wait list. The STICA group also reported less time spent online on both weekends and weekdays, fewer depression symptoms, and improved social functioning. 

“The study shows that STICA can be effective in treatment of IA [internet addiction],” Wölfling and colleagues concluded. “Further trials investigating the long-term efficacy of STICA and addressing specific groups and subgroups compared with active control conditions are required.”

For related information, see the American Journal of Psychiatry article “Internet Gaming Disorder: Investigating the Clinical Relevance of a New Phenomenon.”

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Tuesday, July 9, 2019

‘Secret Shopper’ Study Highlights Barriers Faced By Patients Seeking Buprenorphine

Patients seeking treatment for heroin use in areas of the United States hardest hit by the opioid epidemic may experience several barriers to care when reaching out to publicly listed “buprenorphine-waivered” prescribers, according to a study published in the July issue of the Annals of Internal Medicine. Such barriers include prescribers not accepting new patients and waits of a week or more between first appointments and buprenorphine induction.

The findings were based on a “secret shopper” study, in which callers to physicians, nurse practitioners, and physician assistants listed on the Buprenorphine Practitioner Locator website posed as a patient covered by Medicaid or without insurance in the District of Columbia, Maryland, Massachusetts, New Hampshire, Ohio, and West Virginia.

“In six [jurisdictions] with the highest burden of opioid-overdose mortality in the United States, 38% to 46% of callers who reported current heroin use were denied an appointment from a buprenorphine prescriber, and only 50% to 66% of [prescribers] booking a new appointment allowed buprenorphine induction at the first visit,” wrote senior author Michael L. Barnett, M.D., M.S., of the Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital and colleagues. “Nevertheless, among those who were accepting new patients, wait times were not long, suggesting an underused capacity for buprenorphine treatment in areas with great need.”

From July to November 2018, callers attempted to contact 1,076 publicly listed buprenorphine prescribers twice, posing as a 30-year-old woman who was using heroin and seeking to start buprenorphine-naloxone treatment. During one call, scheduling staff was told the patient was covered by Medicaid; in the other, scheduling staff was told the patient was uninsured but willing to pay for care. For each prescriber, the callers made three attempts during business hours to reach a live scheduler.

From the initial sample of 1,076 prescribers in six jurisdictions, 530 were excluded for reasons such as invalid contact information, they were inactive prescribers, or they requested information such as a Medicaid number that the caller could not provide. The callers were also unable to reach a live scheduler for 77 prescribers, while 89 prescribers were reached once but not for both scenarios, resulting in a final sample of 849 contacts for 469 prescribers. The authors found that an appointment was offered in 233 of 432 contacts (54%) by the Medicaid callers and 258 of 417 (62%) by the uninsured–self-pay callers. The median wait time to the first appointment was six days for Medicaid callers and five days for uninsured–self-pay callers.

Additionally, 27% of Medicaid callers and 41% of uninsured–self-pay callers were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time from first contact to possible induction was eight days for Medicaid callers and seven days for uninsured–self-pay callers.

The researchers noted several limitations of the study, including callers’ focus on publicly listed buprenorphine prescribers in five states and the District of Columbia, which limits the generalizability of the findings.

Nonetheless, Barnett and colleagues concluded, “[E]very day without treatment carries an elevated risk for escalating opioid use and overdose. Patients must be in active opioid withdrawal to initiate buprenorphine treatment safely, which makes the timing of induction critical.”

For related information, see the Psychiatric News article “What Psychiatrists Can Do to Address the U.S. Opioid Crisis.”

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Monday, July 8, 2019

Cognitive Decline After Onset of Psychosis Varies Across Cognitive Functions

Patients with schizophrenia and related psychotic disorders continue to experience cognitive decline for years after illness onset, according to a study in AJP in Advance.

“While large deficits in processing speed are already apparent at the first episode [of psychosis], deficits in verbal knowledge and memory continue to increase,” wrote Jolanta Zanelli, Ph.D., of King’s College London and colleagues. Understanding these differences can help guide cognitive remediation therapy in patients, the authors noted.

These findings were based on data collected as part of the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) study—a study that tracked changes in cognitive function in patients following a new diagnosis of psychosis. The study included 187 adults with first-episode psychosis or another psychotic disorder (for example, psychotic depression or persistent delusional disorder) who sought care in southeast London, Nottingham, or Bristol, and 177 healthy controls. All study participants were given a series of neuropsychological tests at enrollment and about 10 years later. Full 10-year data was available for 106 patients and 103 controls.

The baseline data showed that all patients with psychosis performed worse on tests measuring intellectual ability (IQ) as well as specific cognitive functions compared with controls, with patients with schizophrenia showing the greatest impairment. Approximately 10 years later, patients with schizophrenia showed worsening IQ, memory, and verbal skills compared with controls; their processing speed and visual-spatial memory did not decline. In contrast, patients with another psychotic disorder did not exhibit continued IQ decline compared with controls and only worsened in only certain memory functions.

Schizophrenia patients with severe symptoms at baseline showed greater cognitive decline over time than patients with mild or moderate symptoms; there was no evidence for an association between symptom severity and cognitive changes among patients with other psychoses. “While this subgroup was small (21% of the overall group), the magnitude of decline in the memory domain was large. Thus, this finding points to a potential subgroup of schizophrenia patients who may greatly benefit from being specifically targeted for cognitive remediation,” Zanelli and colleagues wrote.

To read more about this topic, see the Psychiatric News article “Could Cognitive Assessments Enhance Ability to Detect Transition to Psychosis?

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Friday, July 5, 2019

Statins May Reduce Symptoms of Depression, Meta-Analysis Suggests

A class of cholesterol-lowering drugs collectively known as “statins” may improve symptoms of depression in people who have been diagnosed with the disorder, according to a meta-analysis in the Journal of Affective Disorders.

Megha S. Yatham, B.Sc., of the University of Manchester and colleagues reviewed data from 10 clinical trials of statins in which participants were randomized to at least one statin or placebo. The trials measured depressive symptoms using scales such as the Hamilton Depression Rating Scale, Beck Depression Inventory, and Geriatric Depression Scale, among others. The primary outcome was the difference in end-of-trial depression scores between participants who took statins and those who took placebo. Participants in three of the trials had been diagnosed with depression, and seven of the trials were conducted in nondepressed participants. In total, 1,348 participants received statins in the trials and 1,169 received placebo.

Yatham and colleagues found that statin use was associated with significantly lower scores on depression rating scales compared with placebo, but only among participants who had been diagnosed with depression. Although statin use was associated with improved scores in nondepressed participants as well, this difference was not enough for the researchers to consider the improvement statistically significant.

“Although the exact mechanisms by which statins might improve depressive symptoms is unknown, the leading theory is that statins decrease the inflammation and oxidative stress reported to be commonly associated with depression,” the researchers wrote. “While the results of the current meta-analysis are very promising and supportive of [the] benefits of statin therapy, further research and trials with larger sample sizes need to be conducted in order to fully explore the benefits of statins in depressed and nondepressed populations.”

For related news, see the American Journal of Psychiatry article “The Effect of Concomitant Treatment With SSRIs and Statins: A Population-Based Study.”

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Wednesday, July 3, 2019

Patients on Isotretinoin Should Get Regular Psychiatric Screenings, Study Suggests

Patients who take isotretinoin for severe acne may be vulnerable to several psychiatric conditions, according to a study published today in JAMA Dermatology. Specifically, depressive disorders, anxiety disorders, and mood swings were among the most common psychiatric adverse events in patients taking isotretinoin reported to the Food and Drug Administration (FDA) over a 20-year period.

Although previous studies and media reports have highlighted an association between suicidality and depression in patients taking isotretinoin, “our results suggest that other, underappreciated psychiatric adverse events may be linked to its use,” wrote senior author Arash Mostaghimi, M.D., M.P.A., M.P.H., of Brigham and Women’s Hospital, and colleagues. The findings suggest the importance of incorporating regular psychiatric screenings as part of follow-up care of patients taking isotretinoin, they noted.

The researchers analyzed reports of 17,829 psychiatric adverse events with isotretinoin as the primary suspect drug in the FDA’s Adverse Event Reporting System from 1997 through 2017. There were 7,547 reports of depressive disorders (42.3% of all adverse event reports); 2,962 reports of emotional lability, such as mood swings and irritability (16.6%); and 2,412 reports of anxiety disorders (13.5%). Additionally, there were 2,278 reports of suicidal ideation, 602 reports of attempted suicide, and 368 reports of completed suicide. Among the 13,553 adverse events that reported patient age, more than half occurred in patients aged 10 to 19.

Additional analysis of suicide data from patients enrolled in an isotretinoin risk-management program known as iPLEDGE in 2009 and 2010 revealed rates of completed suicide per 100,000 persons were 8.4 in 2009 and 5.6 in 2010. (iPLEDGE requires patients meet with physicians monthly to confirm medication is being taken correctly.) The authors noted that these rates were lower than the national suicide rates in the general population and in those aged 15 to 24 during those years.

“Although no causal link has been established between isotretinoin and psychiatric adverse events, it is important to recognize that there are data that suggest patients using this drug may be vulnerable to a number of psychiatric conditions,” the authors wrote. “Mandated monthly visits under the current iPLEDGE infrastructure may provide an opportunity to screen patients for psychiatric conditions and improve patient outcomes.”

For related news, see the Psychiatric News article “Psychiatrists Work to Tease Apart Psychosomatic Aspects of Skin Disease.”

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Tuesday, July 2, 2019

Many Youth With ADHD Fail to Take Stimulants as Prescribed, Study Suggests

More than half of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) may not be taking stimulant medications as prescribed, according to a report in Psychiatric Services in Advance.

“These findings [underscore] the need for active efforts to better understand the problem and develop approaches to help mitigate it, especially in primary care settings,” wrote lead author Joseph Biederman, M.D., chief of the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital, and colleagues.

The researchers analyzed prescription and sociodemographic data from the Partners Health Care Research Patient Data Registry of Massachusetts General Hospital for 2,206 patients aged 4 to 17 years who had been prescribed any of the following stimulants between January 1, 2015, and December 31, 2016: amphetamine/dextroamphetamine, dextroamphetamine, dexmethylphenidate, lisdexamfetamine, or methylphenidate. The researchers included medications prescribed as a single prescription (30-day supply) and medications with prescriptions postdated by up to three months (60- or 90-day supply).

The researchers defined a patient as being “adherent” if a single index prescription was followed by a second prescription within 90 days.

In cases in which index prescriptions were postdated by two months (that is, two prescriptions written the same date), a patient was deemed adherent if a third prescription was filled 31 to 120 days after the first prescription. In cases in which index prescriptions were postdated by three months, a patient was considered adherent if the fourth prescription was filled 61 to 150 days after the first prescription.

Of the 2,206 patients, 95% had single index prescriptions, 4.9% had prescriptions that were postdated by two months, and 0.5% had prescriptions postdated by three months. Only 46% (n=1,023) of patients met the researchers’ criteria for medication adherence, indicating that they refilled their stimulant prescriptions quickly enough to be considered consistently medicated.

Patients who received prescriptions from psychiatric clinics rather than nonpsychiatric clinics had a small but significantly greater likelihood of adherence to treatment. Additional analysis revealed that children tended to adhere to the medication regimen somewhat more than adolescents and adherence was slightly better in boys than in girls.

Biederman and colleagues noted that low adherence may reflect several factors: the complexity of renewing prescriptions for stimulants, which are schedule II medicines; negative side effects of stimulants, such as lack of appetite and difficulty sleeping; or parents’ ambivalence about their child taking medications for ADHD.

“Low adherence may also stem from misinformation or biases about stimulants in the media,” they wrote. “More research is needed to clarify the causes of low medication adherence in ADHD to develop appropriate measures to mitigate them.”

For related information see the American Journal of Psychiatry article “Continued Benefits of Methylphenidate in ADHD After 2 Years in Clinical Practice: A Randomized Placebo-Controlled Discontinuation Study.”

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Monday, July 1, 2019

Study Identifies Different Classes of Childhood Irritability

Irritability is known to be a feature of several psychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD) and disruptive mood dysregulation disorder. A study of irritability in children published today in AJP in Advance suggests there are several forms of irritability, including a “neurodevelopmental/ADHD-like” type with onset in childhood and a “depression/mood” type with onset in adolescence. These findings could have implications for diagnosis and treatment.

Lucy Riglin, Ph.D., of Cardiff University and colleagues assessed data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a long-running, longitudinal study of families in Avon, England, in which children were born between April 1, 1991, and December 31, 1992. This analysis included data from the mothers of 7,924 children, who were asked to assess their children’s irritability (severe temper tantrums, touchy and easily annoyed, and angry and resentful) at ages 7, 10, 13, and 15 using the Development and Well-Being Assessment. Total irritability scores could range from 0 (none) to 6 (high).

The researchers identified five distinct developmental trajectory classes of irritability for these children:
  • Low (81.2%); characterized by irritability scores of less than 1 throughout childhood
  • Decreasing (5.6%); characterized by irritability scores of around 3 at age 7 that gradually went down to less than 1 by age 13
  • Increasing (5.5%); characterized by irritability scores of less than 1 until age 10, then rising to a score of around 4 by age 15
  • Late-childhood limited (5.2%); characterized by irritability scores rising from around 1 to 3 between the ages of 7 to 10, then dropping back below 1 by age 15
  • High-persistent (2.4%); characterized by irritability scores of 4 or more throughout childhood

The decreasing group, high-persistent group, and late-childhood limited group were more likely to be male. In contrast, the increasing trajectory group was about 60% female. The decreasing group, high-persistent group, and late-childhood limited group were also significantly associated with an ADHD diagnosis in childhood. In contrast, the increasing trajectory group was more strongly associated with a diagnosis of depression during adolescence.

“In conclusion, our study identified different developmental trajectories of irritability, including one with characteristics typical of neurodevelopmental/ADHD-like problems—early onset, male preponderance, and clinical and genetic links with ADHD—and one with characteristics typical of depression/mood problems—later onset, female preponderance, and clinical and genetic links with depression,” Riglin and colleagues wrote. “Both groups were associated with risk of adolescent depression, and both were associated with ADHD genetic risk scores. Overall, these findings suggest that the developmental context of irritability may be important in its conceptualization, and this has implications for treatment as well as nosology.”

For related information, see the Psychiatric News article “Irritability in Childhood May Point to Teens At High Risk for Suicide.”

(Image: iStock/Stígur Már Karlsson /Heimsmyndir)

Friday, June 28, 2019

Behavioral Assessments of Kindergarteners May Predict Future Earnings, Study Suggests

Behavioral assessments of children at a young age may offer clues about their employment earnings in adulthood, according to a study in JAMA Psychiatry. Specifically, the study found that higher teacher ratings of inattention and aggression-opposition in kindergarten boys and inattention in kindergarten girls seemed to be associated with lower future earnings after controlling for child IQ and family adversity.

“This study adds to a growing body of literature showing that childhood inattention, antisocial behavior, and low levels of prosociality act as channels for adverse social and economic outcomes in adulthood,” wrote Francis Vergunst, D.Phil., of the University of Montreal and colleagues. “Early monitoring and support for children exhibiting high inattention, aggression-opposition, and low levels of prosocial behaviors could have long-term socioeconomic advantages for those individuals and society.”

The findings were based on data obtained from the Quebec Longitudinal Study of Kindergarten Children—a population-based sample of boys and girls born in 1980 or 1981 in Quebec, Canada, who were followed up through December 2015. As part of the longitudinal study, kindergarten teachers used the Social Behavior Questionnaire to rate students on a three-point scale (0, never true; 1, sometimes or somewhat true; 2, often true) on the following behaviors: anxiety, hyperactivity, inattention, opposition (for example, disobeying and blaming others), physical aggression, and prosociality (for example, helping and showing sympathy toward others). Vergunst and colleagues evaluated the associations between the teacher ratings and reported annual earnings on income tax returns of those same participants at age 33 to 35 years.

The study included 2,850 participants, with a mean age of 35.9 years, of whom 1,470 (51.6%) were male and 2,740 (96.2%) were white. The mean personal earnings at follow-up were U.S. $33,300 for men and $19,400 for women. Higher child IQ was associated with higher earnings, and greater family adversity during childhood was associated with lower earnings for both male and female participants.

A 1-unit increase in inattention score at age 6 years was associated with a decrease in annual earnings of $1,271.49 for male participants and $924.25 for female participants, after the authors adjusted for childhood IQ and family adversity. A combined aggression-opposition score was associated with a reduction in earnings of $699.83 for male participants only, and a 1-unit increase in prosociality score was associated with an increase in earnings of $476.75 for male participants only.

Vergunst and colleagues concluded, “Screening [of children] should begin in kindergarten, in which population-wide assessment is feasible, teachers have a sense of normative social behavior, and teachers’ ratings of children’s behaviors have good predictive validity across a range of outcomes.”

For related information, see the Psychiatric News article “Prospective Study Delves Deeper Into Mental Health Effects of Childhood Trauma.”

(Image: iStock/monkeybusinessimages)

Wednesday, June 26, 2019

Some Antidepressants May Diminish Pain Control With Tramadol

The effectiveness of tramadol, a frequently prescribed opiate painkiller, may be significantly diminished when patients are also taking certain, commonly prescribed antidepressants, such as bupropion (Wellbutrin), fluoxetine (Prozac), or paroxetine (Paxil), according to a study in Pharmacotherapy.

Those, and other, antidepressants inhibit an enzyme known as CYP2D6, which also metabolizes tramadol. The study found that when CYP2D6 is inhibited by an antidepressant, the painkiller becomes less effective, requiring patients to need a short-acting opiate, such as morphine or another painkiller, to control “breakthrough” pain, the acute pain that breaks through the effects of tramadol. (There are five “strong CYP2D6 inhibitors”: bupropion, fluoxetine, paroxetine, terbinafine, and quinidine. Frost and colleagues list 13 other antidepressants as moderate or weak inhibitors.)

“These findings imply that additional considerations may be required for the evaluation of pain management regimens in patients taking one of these [antidepressant] medications, as higher doses or different [pain-control] agents may be required,” wrote Derek A. Frost, Pharm.D., of University Hospitals Portage Medical Center, Ravenna, Ohio, and colleagues.

They assessed 152 hospitalized patients prescribed tramadol for chronic pain. Of these, 76 were also taking one of the strong CYP2D6-inhibiting antidepressants. The primary outcome measure was the amount of breakthrough opiate required by patients.

Patients receiving one of the antidepressants and tramadol required a higher per-day average of breakthrough opiate (18.2 mg) than those in the control group (5.7 mg) and required more total breakthrough opiate overall (42.4 mg vs 10.2 mg).

“This study supports the use of a tramadol alternative for pain management in patients taking a strong CYP2D6 inhibitor,” the authors wrote. “It would also benefit each patient to assess the response to their depression treatment when a pain management regimen is being considered. Patients who are nonresponsive to treatment while taking a strong CYP2D6 inhibitor may be switched to an appropriate alternative regimen for managing their depression.”

For related information see the Psychiatric News article, “NIDA Director Outlines Institute’s Efforts to Understand Pain, Reduce Opioid Misuse.”

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Tuesday, June 25, 2019

Researchers Identify Factors That May Predict CBT Response in Youth With OCD

The extent to which youth with obsessive-compulsive disorder (OCD) avoid situations that trigger distress and compulsions and recognize their symptoms may predict how likely they are to respond to cognitive-behavioral therapy (CBT), reports a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

“[E]xtensive avoidance may mask a youth’s symptom severity at baseline … and prevent, or slow, youth’s engagement in [treatment],” wrote Robert R. Selles, Ph.D., of the University of British Columbia and colleagues. The findings point to the importance of accurately assessing these factors in youth with OCD before starting treatment and monitoring changes throughout therapy.

CBT that emphasizes exposure and response prevention—encouraging a patient to face thoughts, objects, and situations that trigger obsessions while not engaging in compulsive behavior—is a first-line approach to treating pediatric patients with OCD. To examine factors that may predict how youth with OCD respond to CBT, Selles and colleagues analyzed aggregated data from CBT trials involving 573 youth aged 7 to 19 who had been diagnosed with OCD.

As part of these trials, participants answered questions about avoidance behaviors (for example, how often they avoided doing things, going places, or being with people because of obsessions or compulsions) and insight (for example, if they believed their behaviors were reasonable) before and after receiving CBT. Participants also answered questions about the impact of OCD symptoms on daily activities; these responses were then compared with those given by their parents.

Selles and colleagues found that insight among youth before receiving CBT was not significantly related to response to CBT (defined as ≥35% reduction in Children’s Yale Brown Obsessive-Compulsive Scale score). In contrast, greater baseline avoidance and limited child recognition of impairment predicted reduced likelihood of achieving response to CBT. “Response rates steadily declined with worsening avoidance from a 71.9% (n = 69) response rate for youth with no avoidance down to a 48.3% (n = 14) response rate for youth with extreme avoidance,” they wrote. “Only 46.2% (n = 30) of youth with limited recognition of impairment (relative to the parent’s recognition) responded to treatment, in comparison to 62.3% to 66.8% of youth with either concordant or limited parent impairment recognition.” Insight and avoidance substantially improved with CBT.

“[A]voidance, insight, and parent-child concordance on impairment all appear to be variables relevant to CBT. As a result, it is recommended that clinicians assess and monitor these factors prior to and throughout treatment,” Selles and colleagues concluded. “[T]he use of more comprehensive and frequent assessment of these domains throughout the treatment process is recommended to identify reasons for lack of change in or worsening of insight and/or avoidance over treatment.”

For related information, see the Psychiatric News article “Report Highlights Alternative Treatment Options for OCD.”

(Image: iStock/izusek)

Monday, June 24, 2019

FDA Approves Medication to Treat Female Sexual Disorder

The Food and Drug Administration (FDA) on Friday approved Vyleesi (bremelanotide) to treat premenopausal women for acquired, generalized hypoactive sexual desire disorder (HSDD). HSDD (classified as female sexual interest/arousal disorder in DSM-5) is characterized by low sexual desire that causes distress and cannot be explained by a comorbid physical or psychiatric illness, the side effects of substance use or medications, or severe relationship problems. Acquired HSDD means a woman has previously experienced sexual desire (it has not been a lifelong problem).

“There are women who, for no known reason, have reduced sexual desire that causes marked distress and who can benefit from safe and effective pharmacologic treatment,” said Hylton V. Joffe, M.D., M.M.Sc., director of the FDA’s Division of Bone, Reproductive, and Urologic Products in the agency press release. “As part of the FDA’s commitment to protect and advance the health of women, we’ll continue to support the development of safe and effective treatments for female sexual dysfunction.”

The approval of Vyleesi was supported by two 24-week, randomized clinical studies involving 1,247 premenopausal women with HSDD. In both trials, Vyleesi was more effective than placebo at improving patient-reported sexual desire and reducing emotional distress. Vyleesi is not approved to enhance sexual performance, and women should not use more than one dose every 24 hours or more than eight doses per month, according to the FDA statement.

The most common side effects of Vyleesi are headache, nausea, skin flushing, and reactions at the injection site. The medication can temporarily increase blood pressure, so it should not be taken by women with uncontrolled hypertension or those at high risk of cardiovascular disease. Vyleesi should also not be taken by women taking oral naltrexone (used to treat alcohol use disorder and opioid use disorder), as this medication interferes with naltrexone activity.

To achieve the desired effects of Vyleesi, women are advised to inject the medication into their abdomen or thigh at least 45 minutes before anticipated sexual activity. The medication is known to activate receptors for the hormone melanocortin, but the mechanism by which it improves sexual desire and reduces related distress is unknown.

As noted in a statement by AMAG Pharmaceuticals, manufacturer of Vyleesi, the medication is not indicated for treatment of HSDD in men and postmenopausal women. The medication will be commercially available in September at select pharmacies.

For related information, see the Psychiatric News article “Experts Continue to Debate if Addyi Benefits Outweigh Risks.”

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Friday, June 21, 2019

Long Daytime Naps Linked to Increased Cognitive Decline in Older Men

A study in Alzheimer’s & Dementia suggests that older men who sleep more than two hours during the day could have a higher risk of developing cognitive decline.

“While sleep is considered to enhance memory retention and consolidation, especially among healthy younger adults, it remains controversial whether napping could benefit cognition by compensating for poor nighttime sleep, or if napping might be a … risk factor of cognitive impairment in the elderly,” wrote Yue Leng, Ph.D., M.Phil., of the University of California, San Francisco, and colleagues.

Leng and colleagues measured naps in 2,751 men aged 65 years and older who were enrolled in the Osteoporotic Fractures in Men Study between 2000 and 2002. The participants wore devices similar to wristwatches that measured sleep-wake activity for at least five days in a row when they first enrolled in the study, then had at least one follow-up visit over the next 12 years in which researchers measured their cognitive function.

The researchers found that men who napped for at least two hours during the day at baseline were 66% more likely to develop cognitive impairment than those who napped for fewer than 30 minutes. When the researchers included data on how well and how long the participants slept at night, they found that the so-called “long nappers” who also slept soundly or for six to eight hours a night had roughly twice the risk of developing cognitive impairment compared with their counterparts whose naps were shorter than 30 minutes. However, longer naps were not associated with a higher risk of cognitive decline among participants who did not sleep well at night or who only slept a few hours a night.

“This indicates that the effects of napping on cognition are different among those who sleep poorly and those who sleep well at night,” Leng and colleagues wrote. “Napping might help compensate for poor nighttime sleep and thus provide extra benefits on cognition among those who sleep poorly at night. Meanwhile, it is unclear why napping might be associated with increased risk of cognitive impairment among those who sleep well at night.”

Because the study included only men and most participants were white, the researchers cautioned the findings may not be generalizable to women and/or people of other ethnicities. They concluded that excessive napping could be either an early sign or a risk factor of cognitive decline, and they encouraged health professionals to pay attention to 24-hour sleep-wake cycles of older patients.

For related information, see the Psychiatric News article “Sleep Loss Found to Exacerbate Spread of Toxic Protein Associated With Alzheimer’s Disease.”

(Image: iStock/Dean Mitchell)

Wednesday, June 19, 2019

Chronic Physical Conditions in Youth May Raise Risk for Mental Health Conditions

Young people with chronic physical conditions such as asthma or diabetes are more likely to be at risk for later mental health conditions, according to a report released this month in Pediatrics.

Moreover, the limitations that young people may experience because of their chronic physical conditions appear to contribute to their risk for mental health problems, said John Adams, M.D., and colleagues in the Department of Pediatrics at the Cambridge Health Alliance.

“[P]rograms and policies designed to improve care of youth with chronic physical conditions should identify opportunities to … modify the physical or social environment" so young people can “fully participate in activities important to their developmental progress,” they wrote.

Adams and colleagues analyzed data from the Medical Expenditure Panel Survey (MEPS) from 2003 to 2014 on 48,572 youth aged 6 to 25 years. MEPS, a nationally representative survey of the U.S. population conducted by the Agency for Healthcare Research and Quality, asks respondents open-ended questions about health problems and medical encounters that occurred during the reporting period.

MEPS also asks participants if they are limited in their ability to “work at a job, do housework, or go to school” or “participate in social, recreational, or family activities” because of an “impairment or a physical or mental health problem.”

The researchers calculated the two-year cumulative incidence of mental health conditions overall according to whether individuals had a chronic physical condition at baseline. They also looked at whether young people limited their activities due to the physical condition.

Among youth with a physical condition at baseline, 11.5% developed a mental health condition in the next two years compared with 7.1% of youth without a chronic physical condition at baseline. Moreover, youth with baseline physical conditions were three times more likely to report activity limitations, and these youth had a 3.6-times greater risk of a mental health condition.

They calculated that limitations on activity explained 13.5% of the relationship between current physical conditions and subsequent mental health conditions, the researchers stated.

“[S]uch limitations could reduce opportunities for protective exposures or lead to specific harms to mental health such as through decreased educational achievement, increased social stigma, or diminished social well-being,” the researchers said. And these effects may be especially important during adolescence and early adulthood “when gaining autonomy, forming identity, and developing positive relationships are predominant developmental tasks.”

For related information see the Psychiatric News article “Teens With Depression Benefit From Collaborative Care Model.”

(Image: iStock/fstop123)

Tuesday, June 18, 2019

More Pregnant Women Using Cannabis, Possibly Raising Risk of Preterm Birth, Research Shows

It’s becoming more common for pregnant women in the United States to use cannabis: Between 2002 and 2017, the prevalence of past-month cannabis use increased from 3.4% to 7.0% among pregnant women overall and from 5.7% to 12.1% during the first trimester, according to a report published today in JAMA.

These and other findings, which were based on the responses of women to the National Survey on Drug Use and Health (NSDUH), highlight “the importance of screening and interventions for cannabis use among all pregnant women,” wrote Nora Volkow, M.D., director of the National Institute on Drug Abuse, and colleagues.

As part of the NSDUH, interviewers asked women about their pregnancy status; whether they used cannabis in past month; and, if so, how often they used cannabis over the past month (daily/near daily use was defined as 20 or more days of use in the past month). Beginning in 2013, respondents reporting past-year and past-month cannabis use were also asked whether any of their cannabis use was recommended by a health care professional. Those who responded no were categorized as having “nonmedical-only cannabis use.”

Volkow and colleagues analyzed data collected from 467,100 respondents overall between 2002 and 2017. During this time, the adjusted prevalence of past-month daily/near daily cannabis use increased from 0.9% to 3.4% among pregnant women overall, including from 1.8% to 5.3% during the first trimester, from 0.6% to 2.5% during the second trimester, and from 0.5% to 2.5% during the third trimester. Most women reported their cannabis use was not recommended by a health care professional: The prevalence of past-month medical cannabis use among pregnant women aged 12 to 44 years was no more than 0.68%, the authors reported.

In a separate study, also published today in JAMA, researchers reported that women who use cannabis during pregnancy may be more likely to deliver babies preterm.

Daniel J. Corsi, Ph.D., of Ottawa Hospital Research Institute and colleagues examined data collected from 661,617 women aged 15 and older who delivered a baby in an Ontario hospital between April 2012 and December 2017. Corsi and colleagues compared information on birth outcomes of 5,639 mothers who reported use of cannabis during pregnancy with 92,873 mothers who reported no use of cannabis.

After adjustment for confounding variables, Corsi and colleagues found that there was a significant association between reported cannabis use in pregnancy and preterm birth, defined by the authors as less than 37 weeks of gestation. In contrast, there was a statistically significant protective association between reported cannabis exposure and preeclampsia and gestational diabetes, the authors observed.

“These two studies send a straightforward message: cannabis use in pregnancy is likely unsafe; with an increasing prevalence of use (presumably related to growing social acceptability and legalization in many states), its potential for harm may represent a public health problem,” Michael Silverstein, M.D., M.P.H., of Boston Medical Center and colleagues wrote in an accompanying editorial.

For related information, see the Psychiatric Services article “Thinking Carefully About Marijuana Legalization: Public Health Considerations for State Policy Makers.”

(Image: pio3/Shutterstock)


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