Friday, September 20, 2019

Obstructive Sleep Apnea May Increase Depression, Anxiety Risk


Obstructive sleep apnea (OSA) is associated with an increased risk of developing depression and anxiety in adults, a study in JAMA Otolaryngology-Head & Neck Surgery has found. OSA is a condition in which the muscles of the throat relax during sleep and block the airway, which causes breathing to stop and start repeatedly throughout the night. 

Jong-Yeup Kim, M.D., Ph.D., and colleagues at Konyang University in Korea analyzed the health records of 985 adults from the Korea National Health Insurance Service–National Sample Cohort in South Korea database. Between January 2004 and December 2006, 197 patients were diagnosed with OSA. The researchers matched these patients with 788 patients of similar age, sex, income, and more who were not diagnosed with OSA to compare diagnoses of affective disorders between the two groups over the follow-up period.

Over nine years of follow-up, patients who were diagnosed with OSA were nearly three times as likely to develop a depressive disorder and nearly twice as likely to develop an anxiety disorder than those who were not diagnosed with OSA. Women with OSA were more likely to develop these conditions than men.

Kim and colleagues cited prior research of possible reasons why risk of depression and anxiety may be higher in people with OSA, including reduced oxygen saturation (how much oxygen is attached to red blood cells) and increased daytime sleepiness.

“Further studies appear to be needed to validate [our] findings and explore possible underlying mechanisms,” they wrote. “Clinicians may consider taking specific precautions to reduce the risks of development of depressive or anxiety disorders among patients with OSA.”

For related information, see the Psychiatric News article “Overlapping Symptoms Complicate Diagnosis, Treatment of Psychiatric and Sleep Disorders” and the Journal of Neuropsychiatry and Clinical Neurosciences article “Update on Obstructive Sleep Apnea: Implications for Neuropsychiatry.”

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Thursday, September 19, 2019

Transgender Conversion Therapy Linked to More Psychological Distress, Suicide Attempts, Study Finds


Individuals who identify as transgender may be at a greater risk of psychological distress and suicide in adulthood if they were exposed to conversion therapy, according to a study in JAMA Psychiatry. These risks were found to be particularly high if the individual was exposed to the therapy when they were 10 or younger.

“Our results support the policy positions of the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, the American Academy of Pediatrics, and the American Medical Association, which state that gender identity conversion therapy should not be conducted for transgender patients at any age,” Jack Turban, M.D., M.H.S., of Massachusetts General Hospital and colleagues wrote.

The researchers analyzed the responses of 27,715 transgender adults living in the United States to the 2015 U.S. Transgender Survey, whose protocol was reviewed and approved by the University of California, Los Angeles, institutional review board. The respondents’ mean age was 31.2 years, and 42.8% had been assigned male sex at birth; 19,741 reported they had spoken to a professional about their gender identity, and 3,869 reported exposure to gender identity conversion therapy (psychological interventions aimed at aligning an individual’s gender identity with the sex assigned at birth) in their lifetime. The researchers also measured respondents’ severe psychological distress during the previous month (using the Kessler Psychological Distress Scale), as well as their suicidality during the previous year and lifetime.

The researchers found that recalled exposure to gender identity conversion efforts was associated with higher odds of lifetime suicide attempts and severe psychological distress among transgender adults compared with those who discussed gender identity with a professional without conversion efforts.

The authors noted that “recalled lifetime exposure to GICE [gender identity conversion efforts] was highly prevalent among adults: 14.0% of all transgender survey respondents and 19.6% of those who had discussed gender identity with a professional reported exposure to GICE.” Exposure to gender identity conversion efforts before the age of 10 was less common among respondents, with only 1% reporting such an experience. It was, however, “associated with adverse mental health outcomes, including lifetime suicide attempts,” the authors wrote, adding that the odds of lifetime suicide attempts was higher for those exposed to conversion efforts before age 10 compared with those with lifetime exposure. This suggests that “rejection of gender identity may have more profound consequences at earlier stages of development.”

The researchers also found that respondents from more socioeconomically disadvantaged backgrounds more commonly reported exposure to gender identity conversion efforts. “These individuals may have been more likely to receive GICE, or exposure to GICE may have been so damaging that they were impaired in educational, professional, and economic advancement,” the authors wrote.

For related information, see the Psychiatric News article “‘Conversion Therapy’ Misleads, Harms Patients” and the Psychiatric Services article “Affirming Gender Identity of Patients With Serious Mental Illness.”

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Wednesday, September 18, 2019

Patients With Fewer Mental Health Symptoms May Fare Worse When Clinicians Leave


As it can both be costly and negatively impact care quality, clinician turnover is a concern within community behavioral health settings. When it comes to patient outcomes, though, a 12-month study published in Psychiatric Services in Advance observed mixed, and surprising, results, suggesting that turnover could have different impacts on patients depending on their initial symptoms.

Researchers found that turnover was associated with harmful effects for patients who were functioning well at the start of the study, yet, “Curiously, we also found that turnover was associated with no changes or positive changes” in patients with more difficulties at baseline, wrote Annalee Johnson-Kwochka, M.S., of Indiana University-Purdue University Indianapolis and colleagues. Patients “who are doing better may have more to lose when clinicians leave,” they noted.

Johnson-Kwochka and colleagues used observational data collected as part of a larger randomized, controlled trial from two community behavioral health centers (one in an urban setting and the other in a rural setting) for their analysis. As part of the trial, patients at the behavioral health centers identified the clinician they saw the most. The researchers also evaluated the participants for symptoms of depression (using the nine-item Patient Health Questionnaire), anxiety (using the Generalized Anxiety scale), and overall physical and mental health functioning (using the 12-item Short Form Health Survey) at the beginning of the study, after six months, and after 12 months. Of the 328 patients included in the analysis, 24% experienced clinician turnover.

Not only was turnover associated with clinical decline for those who had higher functioning at baseline, older patients also experienced a sharper decline.

“An important secondary finding [of this study] was that for physical health functioning, the relationship with turnover was moderated by age,” the researchers wrote. “Thus, for those who are younger, turnover may affect functioning less, possibly because their physical health may be more resilient in the face of disruptions in care.”

For related information, see the Psychiatric Services article “Clinicians’ Perceptions of How Burnout Affects Their Work.”

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Tuesday, September 17, 2019

Meta-Analysis Highlights Potential Mental Health Benefits of Obesity Treatment for Youth


Despite the known benefits of weight loss for children and adolescents who are obese, some studies suggest that youth who diet may be at an increased risk of depression. A meta-analysis published Monday in JAMA Pediatrics suggests obesity treatment in youth is not associated with an increased risk of depression or anxiety; rather, the analysis points to the mental health benefits of such programs for this population.

“Structured and professionally run obesity treatment with a dietary component is associated with improvements in depression and anxiety for most participants,” wrote Hiba Jebeile, M.Nutr.Diet., of the University of Sydney and colleagues. “Treatment of weight concerns should be considered within the treatment plan for young people with depression and obesity.”

To examine the relationship between obesity treatment interventions and anxiety/depression symptoms in youth who were overweight, the authors searched through electronic databases for studies of interventions for youth who were overweight/obese published between 1987 and 2018. Only studies that evaluated outcomes in youth who participated in interventions with a dietary component (such as nutritional education) and assessed youth for anxiety/depression before and after participating in the intervention were included in the analysis. (Studies evaluating online interventions, pharmacotherapy, and bariatric surgery were not included in the analysis). A total of 44 studies, with a combined sample of 3,702 youth with a mean age range of 5.6 to 16.6 years (BMI range of 24.6 to 44.9), met these inclusion criteria. The duration of the interventions included in the analysis ranged from two weeks to 15 months.

The meta-analysis revealed a small reduction in depressive symptoms in the participants after the intervention, which the authors noted was maintained six months to 16 months from baseline. Similarly, anxiety symptoms were lower in study participants following the interventions and at follow-up.

“Interventions with weekly or fortnightly contact with the study team showed the greatest reduction in depressive symptoms, and longer intervention duration was associated with a larger reduction in anxiety. This may be due to the regular and extended support of a health care team,” Jebeile and colleagues wrote. Additionally, “interventions with a structured exercise program had a greater reduction in anxiety than physical activity education alone. A similar trend, although not statistically significant, was found for depressive symptoms.” They noted that the exercise programs, often delivered in a group format, were offered to participants several times per week, increasing their contact with study personnel and peers.

They concluded, “Overall, obesity treatment interventions are not associated with increased symptoms of depression and anxiety. However, clinicians should be aware that a small proportion of participants may be at risk of developing worsening pathology. Identification of these young people and provision of additional support may improve treatment outcomes.”

For related information, see the Psychiatric News article “Researchers Examine Link Between Mood, Food, and Obesity.”

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Monday, September 16, 2019

Slower Development of Working Memory in Adolescents Associated With Motor Vehicle Crashes


A person’s working memory—which helps one manage complex tasks and maintain attention when faced with distractions—is believed to be a critical element of safe driving. A study in JAMA Network Open has found that adolescents who were involved in a motor vehicle accident had slower development of their working memory than adolescents who were not involved in a crash.

“Monitoring WM [working memory] development across adolescence as part of routine assessment could help to identify at-risk drivers, as well as opportunities for intervention,” wrote Elizabeth A. Walshe, Ph.D., of the Annenberg Public Policy Center at the University of Pennsylvania and colleagues. “Attention and driving-skill deficits due to insufficient [working memory] may be one of the most modifiable risk factors—via experience and skill training.”

Walshe and colleagues analyzed data from a longitudinal study of 118 youth in Philadelphia, who received regular assessments of working memory, sensation seeking, substance dependence, and more between the ages of 11 and 20. A follow-up survey on driving experience identified 84 participants who had a driver’s license and were included in the analysis, and 25 of these drivers reported they had been involved in at least one crash.

All 118 youth performed better on working memory tasks as they grew older, as reflected in their scores rising over time. Additional analysis revealed that working memory gains appeared to slow in the 25 drivers with a crash history; that is, their total score rose less and less each year as they aged. In contrast, the drivers with no crashes showed steady gains in their total scores over time. The youth involved with crashes reported more reckless driving behaviors (like speeding) on average; however, even when factoring in this difference, the authors found that adolescents with slower memory gains had a greater risk of crashing.

Other developmental traits such as the youths’ baseline working memory score, their IQ, or their impulsivity levels were not associated with car crashes, the authors noted.

The rate at which working memory develops “may be an important underlying mechanism of age-graded risk for crashes during adolescent development. However, we do not yet know whether or how [working memory] development may predict crashes and need to further investigate factors that lead to differential trajectories of growth in [working memory] to identify high-risk groups,” Walshe and colleagues wrote. “Future studies should also investigate the role of [working memory] development in the observed increased risk for unsafe driving and crashes among atypically developing populations (e.g., ADHD).”

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Friday, September 13, 2019

Methamphetamine Involved in Rising Number of Heroin Treatment Admissions


Methamphetamine is involved in an increasing number of treatment admissions for heroin, especially among adolescents, a study in Addiction has found.

“The phenomenon of increasing methamphetamine use among people using opioids is of great concern,” Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H., of the Centers for Disease Control and Prevention and colleagues wrote. “Methamphetamine use carries its own risks, including a range of physical and mental health consequences such as psychosis and other mental disorders; cognitive and neurologic deficits; cardiovascular and renal dysfunction; transmission of HIV, viral hepatitis, and sexually transmitted infections; and increased mortality.”

The researchers analyzed data from more than 3.5 million treatment admissions for heroin between 2008 and 2017. The data came from the Treatment Episode Data Set, a national database that provides information on the admissions of people aged 12 years and older to federally funded substance use treatment centers. The percentage of primary heroin treatment admissions reporting methamphetamine use rose each year from 2.1% in 2008 to 12.4% in 2017, an increase of 490%.

In 2017, individuals aged 12 to 24 had the highest rates of admissions for heroin use involving methamphetamine of all the age groups examined: 27.8% of heroin treatment admissions for adolescents aged 12 to 17 years involved methamphetamine, and 17.4% of heroin treatment admissions for young adults aged 18 to 24 involved methamphetamine.

“Not only do these findings highlight a need to focus intervention and treatment efforts aimed at reaching younger age groups, but together with the finding that early age of heroin initiation was associated with methamphetamine use at treatment admission, these findings underscore the importance of expanding policies, programs, and practices that can prevent initiation of these substances in the first place,” the researchers wrote.

Among women, 15.1% of heroin treatment admissions involved methamphetamine in 2017, compared with 10.8% in men. The researchers noted that prior research suggests that females use more methamphetamine and transition from recreational use to dependence more quickly than males.

“Given the increase in risk for negative health outcomes among people using both substances, comprehensive prevention, treatment, and harm-reduction strategies that address the poly-substance nature of opioid use and are appropriately tailored to specific demographic groups and at-risk populations are needed,” Jones and colleagues wrote.

For related information, see the Psychiatric Services article “Use of Drug Treatment Services Among Adults With Opioid Use Disorder: Rates, Patterns, and Correlates.”

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Thursday, September 12, 2019

Mothers’ Stress Early in Life Found to Negatively Impact Their Children


A study in AJP in Advance provides further evidence that the detrimental effects of adverse life experiences can carry across generations. Researchers found that children of mothers who experienced stressful events during childhood had greater biological signs of stress and were more likely to have behavioral problems at 18 months.

“[O]ur data, when combined with findings from other studies, confirm maternal life-course experiences as a potent predictor of offspring mental and physical well-being,” wrote Kyle Esteves, M.P.H., of Tulane University School of Medicine and colleagues. “Our results suggest that screening for maternal ACEs [adverse childhood events] in obstetric, pediatric, and child mental health settings may provide an important indicator of risk for both the mother and the child, especially during infancy.”

Esteves and colleagues recruited 237 pregnant women for the study. During a prenatal assessment, study participants were asked to indicate the presence or absence of 10 types of childhood adversity, including abuse, parental mental illness, and divorce on the Adverse Childhood Experiences questionnaire. The women also completed anxiety, depression, and stress assessments during the prenatal assessment.

The mothers and their children returned for follow-up assessments when the children were 4, 12, and 18 months. At these visits, the researchers screened the mothers for postnatal depression and collected cheek swabs from the children for telomere analysis. Telomeres are the protective caps on the ends of chromosomes, and their length is considered a biomarker of biological stress and aging (shorter telomeres are associated with a broad range of age-related diseases). Child behavior was also assessed at the 18-month visit.

The final analysis included 155 mother-child pairs who completed at least two of the three assessments (103 pairs completed all three assessments). The results showed that higher scores on the Adverse Childhood Experiences questionnaire in mothers correlated with shorter telomeres in the children at all time points. Higher scores also correlated with more externalizing problems (for example, temper tantrums) in the children at 18 months, but not internalizing problems (for example, being quiet and withdrawn). Maternal depression also increased the risk of externalizing problems and internalizing problems; however, higher Adverse Childhood Experiences scores remained associated with shorter telomeres and more externalizing problems, even when accounting for maternal postnatal depression.

“Encouraging the widespread utilization of practical screening tools that have clinical utility and capture stressors across the life course and the broader environment in which children develop may enhance our ability to understand the origins of early mental illness and the effectiveness, rather than the efficacy, of current intervention and prevention efforts,” Esteves and colleagues noted. Additionally, such efforts could help identify ways to buffer the negative effects of maternal early adversity, they added.

For related information, see the Psychiatric News article “Researchers Tackle Complexity of Intergenerational Stress Transmission.”

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Wednesday, September 11, 2019

Getting Patients to Exercise Could Reduce Population Burden of Mental Illness


Could more rigorous efforts on the part of physicians and health systems to encourage people to exercise lower the population-wide burden of mental illness?

In an editorial in JAMA Psychiatry, the author of a study published last year showing that even relatively modest regular exercise has significant beneficial effects on an individual’s mental health said that including exercise in the treatment of mental illness could improve rates of recovery and reduce illness burden.

“[C]linical psychiatry has an ever-increasing need for strategies to reduce the population burden of mental illness,” wrote Adam Chekroud, Ph.D., of Yale University and Alisa Trugerman, Ph.D., of Altru Consulting. “Exercise may be one such strategy, but we are a long way from realizing this potential.”

Chekroud was one of the authors of a study in Lancet Psychiatry last year showing how the specific type, duration, and frequency of physical exercise affects mental health. The study, which received widespread publicity, suggested that an exercise regimen specifically tailored to a person’s needs, capabilities, and lifestyle could have a measurable impact on the individual’s mental health.

In the JAMA Psychiatry editorial, Chekroud and Trugerman wrote that when applied to the entire population, exercise could have a significant effect on reducing the population burden of mental illness. They noted that though the benefits are compelling, the uptake of exercise remains well below federal guidelines: According to the U.S. Centers for Disease Control and Prevention, less than half of the U.S. population reaches the recommended 150 minutes of moderately vigorous physical activity per week, and 30% of the population does no exercise at all.

These are among the areas in which the authors called for action:

  • Educate doctors about how best to prescribe exercise as part of mental health treatment: “We should help train, support, and incentivize clinicians to prescribe exercise actively and in detail,” they wrote. “Professional organizations, health system training programs, and medical school curricula could each be another avenue for increasing professional awareness about how and when to use exercise as an additional therapeutic strategy in mental health treatment.”
  • Reform insurance reimbursement practices: “Although clinicians are paid for providing psychotherapy or medication treatment options, there is little financial imperative or logistical support encouraging them to help their patients to exercise,” Chekroud and Trugerman wrote. “This lack of a reimbursement structure for exercise may contribute to an implicit message that exercise is less worthwhile than medication or therapy. …”
  • Help patients overcome barriers to exercise: “Many symptoms of mental illness serve as barriers to exercising, such as low mood, lack of motivation, and fatigue,” they wrote. “As with many chronic conditions, structured encouragement and adherence monitoring are critical. Aligning the specific type of exercise with the patient’s preference may improve adherence, as could passive wearable or smartphone technologies.”

Chekroud and Trugerman concluded: “The future holds promise. … Along with digital cognitive-behavioral therapy and traditional self-guided educational resources, one could devise a highly scalable and cost-effective active waitlist or lightweight treatment program that requires less time from clinicians. If delivered alongside psychotherapy or medication management protocols, the augmentation of exercise and digital content might also lead to faster patient recovery.”

For related information, see the Psychiatric News article “Minimal Exercise May Help Prevent Future Depression” highlighting the American Journal of Psychiatry article “Exercise and the Prevention of Depression: Results of the HUNT Cohort Study.”

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Tuesday, September 10, 2019

Homophobic Bullying May Increase Suicidal Thoughts in Heterosexual Youth


Adolescents who identify as lesbian, gay, and bisexual report higher rates of bullying than heterosexual youth, and these elevated rates of bullying are associated with higher rates of depression and suicide. A study in the Journal of the American Academy of Child & Adolescent Psychiatry now suggests that heterosexual youth who are victims of homophobic bullying are also more likely to report sadness/hopelessness and consider, plan, and/or attempt suicide compared with heterosexual youth who are not victims of this type of bullying.

Mike C. Parent, Ph.D., of the University of Texas at Austin and colleagues examined data from the 2017 Youth Risk Behavior Survey. Specifically, Parent and colleagues analyzed the responses of youth from the seven states that included the following item on the survey: “During the past 12 months, have you ever been the victim of teasing or name calling because someone thought you were gay, lesbian, or bisexual?” (This question was asked in Arkansas, Colorado, Florida, Illinois, North Carolina, North Dakota, and Rhode Island.) The survey also asked youth about experiences with sadness and hopelessness and suicidal thoughts, plans, and attempts.

Of the 21,871 youth who completed this survey in these states, 15,234 identified as heterosexual; 16.4% of the heterosexual youth in the sample reported general bullying, and 7.1% reported homophobic bullying. In comparison, 24.4% of youth who did not identify as heterosexual reported general bullying, and 22.9% reported homophobic bullying.

After controlling for the effect of general bullying, the researchers found that heterosexual adolescents who reported experiencing homophobic bullying had 3.0 times increased odds of feeling sad, 3.4 times increased odds of considering suicide, 3.0 times increased odds of planning suicide, and 3.1 times increased odds of attempting suicide, compared with youth who did not report homophobic bullying.

“The present study adds to our understanding of homophobic bullying by focusing on the experiences of heterosexual adolescents,” Parent and colleagues wrote. “Future work should examine in more detail the manifestations and effect of such bullying on heterosexual adolescents, and effective messaging to enhance bullying prevention efforts that focus on anti-LGB [lesbian, gay, bisexual] climates and include heterosexual adolescents.”

For related information, see the Psychiatric News article “Bullying Found to Increase Risk for Adolescent Suicide Attempts Worldwide.”

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Monday, September 9, 2019

Patients With Severe Alcohol Withdrawal May Benefit From Phenobarbital, Study Suggests


Phenobarbital, a long-acting barbiturate, may be an effective alternative to benzodiazepines for the treatment of severe alcohol withdrawal symptoms such as hallucinations and seizures, according to a study published in Psychosomatics.

“Considerable data exist on the effectiveness of benzodiazepines for the management of [alcohol withdrawal syndrome],” wrote Mladen Nisavic, M.D., of Massachusetts General Hospital and colleagues. However, since benzodiazepines target the same receptors as alcohol, some people with chronic heavy alcohol use may have developed a tolerance to benzodiazepines in addition to a tolerance to alcohol, the authors noted. In addition, benzodiazepines may pose health risks for some patients, including those with respiratory problems.

Nisavic and colleagues conducted a retrospective assessment on all patients admitted to Massachusetts General Hospital between July 2007 and July 2011 who received either phenobarbital or a benzodiazepine for alcohol withdrawal syndrome. They identified 419 patients who received a benzodiazepine and 143 who received phenobarbital treatment; 16 of the patients who initially received a benzodiazepine were subsequently switched to phenobarbital while one patient was transitioned from phenobarbital to a benzodiazepine.

The patients who started on phenobarbital were significantly more likely to have a history of documented alcohol withdrawal syndrome compared with those started on benzodiazepines (91% vs. 73%); phenobarbital patients were also more likely to have a history of withdrawal-related seizures (73% vs. 45%) and/or present with a seizure on arrival to the hospital (14% vs. 7%).

Despite having more health complications related to alcohol withdrawal, the patients given phenobarbital showed similar treatment outcomes—which included rates of seizures, hallucinations, delirium, or admission to an intensive care unit—as patients given a benzodiazepine. Furthermore, the 16 patients initially treated with a benzodiazepine but then transitioned to phenobarbital showed significantly better outcomes following the switch.

“Given the concordance of our data and the literature, it appears that phenobarbital is a feasible alternative for [alcohol withdrawal syndrome] management, especially in patients with prior known complex [alcohol withdrawal syndrome], and in patients who fail to respond to conventional [benzodiazepine]-based treatment,” Nisavic and colleagues wrote.

For related information, see the Psychiatric News article “APA Releases Practice Guideline for AUD Pharmacotherapy.”

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Friday, September 6, 2019

Risks of Antipsychotics for Treatment of Delirium May Outweigh Benefits, Review Finds


There may be no benefits to treating hospitalized patients experiencing delirium with antipsychotics, suggests a review published this week in the Annals of Internal Medicine.

Delirium—which is characterized by sudden changes in attention, decreased awareness, and cognitive impairment—is known to be associated with worse patient outcomes, wrote Roozbeh Nikooie, M.D., of Johns Hopkins University School of Medicine and colleagues. Such outcomes include increased length of stay in the hospital, long-term cognitive impairment, and mortality.

Although the first-generation antipsychotic haloperidol and second-generation antipsychotics are commonly used to treat hospitalized patients for delirium, the benefits and risks of this treatment strategy remain unclear, the authors wrote. They conducted a systematic review of 26 studies that compared outcomes of hospitalized adults with delirium who were treated with haloperidol, a second-generation antipsychotic (such as risperidone, quetiapine, or olanzapine), or placebo. The studies included 16 randomized, controlled trials involving 1,768 participants and 10 observational studies involving 3,839 participants.

The authors found that patients had similar delirium duration, sedation status, hospital length of stay, and mortality regardless of whether they received an antipsychotic or placebo. (There was insufficient evidence regarding the effect of these medications on cognitive function or delirium severity.) When comparing patients who received haloperidol with those who received second-generation antipsychotics, the authors found that the groups appeared similar in terms of their cognitive function, delirium severity, sedation status, hospital length of stay, and mortality.

While there was “little evidence of harm for haloperidol and second-generation antipsychotics with short-term use for treating delirium in adult inpatients …, potentially harmful cardiac effects tended to occur more frequently with use of antipsychotics, particularly prolongation of the QT interval with second-generation antipsychotics versus placebo or haloperidol,” the authors noted.

Nikooie and colleagues highlighted several limitations of the review: “Some large studies in this review were conducted in critically ill patients, which may affect generalizability of the findings. Moreover, most RCTs [randomized, controlled trials] excluded patients with underlying neurologic or cardiovascular issues, which can potentially underestimate the harms in routine clinical practice.” Nonetheless, they concluded, “Current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.”

For related information, see the American Journal of Psychiatry article “The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.”

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Thursday, September 5, 2019

Hearing Aids May Reduce Risk of Depression, Anxiety, Dementia in Older Adults


Older adults who use hearing aids may be less likely to develop depression, anxiety, and dementia for at least three years after a hearing loss diagnosis compared with those who do not begin using hearing aids, according to a study published Wednesday in the Journal of the American Geriatrics Society. In addition, these individuals appear less likely to get injured in a fall.

“By providing enhanced hearing input, HAs [hearing aids] may facilitate greater social engagement, lower levels of effort to recognize sounds and speech, lower levels of depression or anxiety symptoms, higher levels of physical balance, and greater feelings of independence and self-efficacy,” wrote Elham Mahmoudi, Ph.D., and colleagues at the University of Michigan.

Mahmoudi and colleagues examined insurance claims data from 114,862 adults aged 66 and older who received a hearing loss diagnosis between 2008 and 2013. All the adults included in the analysis remained on the same coverage—a Medicare managed care plan that includes partial coverage for hearing aids—for at least three years after receiving the diagnosis of hearing loss.

The analysis showed that about 11% of women and 13% of men diagnosed with hearing loss began using hearing aids. Over the next three years, the adults who used hearing aids had an 18% reduced risk of being diagnosed with Alzheimer’s/dementia, 11% reduced risk of being diagnosed with anxiety or depression, and a 13% reduced risk of having an injurious fall compared with adults without hearing aids.

“Although [hearing aids] are expensive, the medical costs of many conditions that could be prevented or delayed by using [hearing aids] are substantially more expensive,” the authors concluded. “Any delay in diagnosis of [Alzheimer’s] or dementia could not only lead to large cost savings, but also improve the health and well-being of older adults.”

To read more about this topic, see the American Journal of Psychiatry article “Sensation and Psychiatry: Linking Age-Related Hearing Loss to Late-Life Depression and Cognitive Decline.”

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Wednesday, September 4, 2019

Children With ADHD May Be More Likely to Report Concussion Symptoms


Children with ADHD who play sports may be more likely to report a greater number of concussion-like symptoms and perform worse on balance tests when administered a common concussion assessment than those who do not have ADHD, according to a report in the Journal of Pediatrics. Children in the study were assessed using the Child Sport Concussion Assessment Tool Fifth Edition (Child SCAT5).

“These findings highlight the challenges of interpreting Child SCAT5 performance in children with ADHD following a concussion or suspected concussion and illustrate the value of administering the measure to children to document their pre-injury performance,” wrote Nathan Cook, Ph.D., of Harvard Medical School and colleagues. “[P]roviders using the Child SCAT5 following a concussion or suspected concussion should anticipate that children with ADHD are likely to endorse several symptoms when given concussion symptom rating scales and may also demonstrate balance weaknesses even if they have recovered or were never injured in the first place.”

Cook and colleagues analyzed data obtained from a study of 464 middle school athletes aged 11 to 12, who received preseason testing with the Child SCAT5. Of the total sample, 28 (6%) children reported having been diagnosed with ADHD. For the study, the authors compared how 27 children with ADHD performed on the Child SCAT5 with those without ADHD who were of the same age and sex, played the same sport, and reported the same concussion history.

The children with ADHD reported an average 13.33 concussion symptoms compared with an average of 6.44 reported by children without ADHD. They also reported significantly greater severity of symptoms than children without ADHD. Some of the common symptoms reported by the children with ADHD were those that are commonly associated with ADHD, such as difficulty paying attention and getting distracted easily; however, children with ADHD also more commonly reported headaches, dizziness, feeling nauseous, and neck pain—symptoms not commonly attributed to ADHD.

Children with ADHD also performed worse on the Child SCAT5 balance assessment, committing more errors on average when required to stand on one leg than controls. In contrast, the groups performed similarly on cognitive tests that are part of the Child SCAT5.

“It is important for pediatricians and other providers treating children and adolescents to understand factors and comorbidities that influence results on pediatric concussion assessments,” Cook and colleagues wrote. “This information can help inform concussion diagnosis, evaluation of recovery from the injury, and return-to-activity decisions.”

For related information, see the Psychiatric News article “Saliva Biomarkers May Predict How Long Concussion Symptoms Will Last in Youth.”

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Tuesday, September 3, 2019

Immune System Response May Offer Clues About Psychosis, Study Suggests


Analyzing white blood cell counts and levels of C-reactive protein (CRP)—a protein sent to the blood in response to inflammation—in patients with psychosis may offer clues about psychosis severity and treatment response, suggests a study in Schizophrenia Bulletin.

Johann Steiner, M.D., of Otto von Guericke University Magdeburg in Germany and colleagues analyzed blood collected from 253 patients hospitalized for psychosis; this included 129 patients experiencing a first episode of psychosis (FEP) and 124 patients with schizophrenia. All FEP patients were drug-naïve while patients with schizophrenia were unmedicated for at least six weeks prior to the start of the study. White blood cell counts and CRP levels in patients with psychosis were compared with those of people without psychiatric disorders at the start of the study.

Steiner and colleagues found that neutrophils, monocytes, and CRP levels were significantly higher in patients with psychosis compared with those without psychosis at baseline. In contrast, eosinophils were lower at baseline in patients with psychosis. Patients with higher neutrophil counts at baseline tended to report a greater number of positive symptoms on the Positive and Negative Syndrome Scale (PANSS-P), they noted. CRP levels at baseline correlated with PANSS-P in FEP patients but not in patients with schizophrenia.

A total of 163 patients with psychosis then received antipsychotics for six weeks. Although neutrophil counts and CRP levels decreased in these patients following six weeks of medication, these counts remained elevated compared with people without psychosis. In contrast, eosinophil counts increased in patients with psychosis to the point where they did not differ from controls after six weeks of medication. Additional analysis revealed that the degree of positive symptom improvement after treatment correlated with the amount of change in neutrophil, CRP, and/or eosinophil levels.

“[O]ur analysis of routine laboratory parameters such as neutrophil count and CRP levels identified a subgroup of acutely psychotic FEP and [schizophrenia] patients with signs of innate immune system activation,” Steiner and colleagues concluded. “The decline of neutrophils or CRP and rising eosinophils from baseline to follow-up may be considered as markers of treatment response, as these changes correlated with improvement of PANSS-P.”

For related information, see the Psychiatric News article “PET Reveals Inflammatory Response in Schizophrenia, High-Risk Patients.”

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Friday, August 30, 2019

More Seasons of NFL Play May Be Associated With Increased Risk of Cognitive Problems, Depression


The more seasons that NFL players spend playing in the league, the greater their risk of cognitive problems and depression, according to a study published today in The American Journal of Sports Medicine. Former NFL players who reported more concussion symptoms during playing years were at a particularly elevated risk for cognitive problems and depression and anxiety even 20 years after retirement compared with those who reported fewer symptoms, the authors noted.

“Our findings confirm what some have suspected—a consistently and persistently elevated risk for men who play longer and who play in certain positions,” lead author Andrea Roberts, Ph.D., of the Harvard T.H. Chan School of Public Health said in a press statement. “Our results underscore the importance of preventing concussions, vigilant monitoring of those who suffer them, and finding new ways to mitigate the damage from head injury.”

The findings were based on analysis of the responses of 3,506 former NFL players (average age 53 years) to a survey sent by mail or email. Former players were asked about the positions they most often played professionally, the number of seasons they played, and the number of times they experienced concussion symptoms during their careers. The players were also asked how often they experienced cognitive difficulties over the past week and whether they experienced symptoms of depression or anxiety over the past two weeks and/or were taking medication for depression or anxiety. (Cognition-related quality of life was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition–General Concerns. The Patient Health Questionnaire-4 was used to measure depression and anxiety symptoms.)

One in eight survey respondents was categorized as having poor cognition-related quality of life/severe cognitive impairment. Every five seasons of professional play was associated with a nearly 20% increased risk of cognitive problems—with running backs, defensive lineman, and line backers at a more elevated risk of cognitive impairment than kickers and punters. About 1 in 4 respondents reported symptoms or was taking medications for depression or anxiety, and nearly 1 in 5 respondents reported symptoms or was taking medications for both conditions. Length of career also increased risk of depression, with every five years of professional play increasing risk by 9%; there was no relationship between length of career and risk of anxiety.

Former players reporting the greatest number of concussion symptoms were found to be at a 22.3-fold greater risk of cognitive impairment, 6.0-fold greater risk of depression, and 6.4-fold greater risk of anxiety compared with the former players with the lowest number of concussion symptoms, the authors reported.

Roberts and colleagues highlighted several limitations of the study, including the fact the findings relied on respondents’ ability to recall events that for some occurred decades earlier. Nonetheless, they concluded, “Concussion history and life in football appear to be associated with cognitive and mental health complaints. … Active players, along with medical professionals who care for them, might consider their future health in deciding whether to continue a football career following concussion.”

For related information, see the Psychiatric News article “Study Finds High Prevalence of CTE, Other Disorders in Former Football Players.”

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Thursday, August 29, 2019

1 of 3 Study Participants Found to Drop Out of SUD Treatment Studies


Roughly 30% of people who participate in studies of in-person psychosocial treatment programs for substance use disorders (SUDs) drop out, a meta-analysis in Addiction has found. Dropout rates varied depending on variables such as patient characteristics, the type of substance targeted, and the number and length of treatment sessions.

“The results can be used to establish a base dropout rate against which existing and new treatments can be compared, allow for more careful planning of clinical trials with respect to dropout expectations, and determine which populations or study design characteristics might be at elevated risk for dropout,” Sara N. Lappan, Ph.D., of the University of Alabama at Birmingham School of Public Health and colleagues wrote.

The researchers used data from 151 studies to estimate dropout rates and identify predictors of dropout. The studies were published between 1969 and 2016, included a total of 26,243 participants, and described treatments for SUDs involving alcohol, cannabis, cocaine, heroin, major stimulants in general, methamphetamine, opioids, tobacco, and use of multiple substances.

When comparing studies on treatments for specific drugs, the researchers found that dropout rates were highest for those that targeted cocaine, methamphetamines, and major stimulants in general. The researchers noted that there are no approved medications for treating stimulant dependence, so symptoms of withdrawal may hinder patients’ ability to complete treatment.

The researchers suggested that one reason for increased dropout in psychosocial SUD treatment studies could be participants’ higher level of disinhibition.

“Indeed, behavioral disinhibition is a predictor of addiction onset, and addictive substances elicit disinhibitory states acutely during the period of … intoxication and chronically via changes to cortical regions implicated in cognitive-behavioral control,” they wrote.

Studies that included a greater number of treatment sessions and longer treatment sessions had higher rates of dropout, as well. Lappan and colleagues noted that the more treatment sessions a program has, the more opportunities there are to drop out.

“Nevertheless, we do not advocate here for fewer and briefer sessions in the treatment of SUD,” they wrote. “Rather, there may be a ‘Goldilocks Zone’ with regard to number of treatment sessions and session length wherein dropout is minimized and efficacy is maximized.”

Lappan and colleagues acknowledged limitations to their meta-analysis, notably that many of the studies were conducted in controlled settings and designed to test the efficacy of treatment in ideal conditions. Therefore, “the current results are unlikely to completely generalize to all real-world populations and settings. Clinical judgement is required to determine the relevance of the present findings to real-world practice,” they wrote.

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Wednesday, August 28, 2019

Psychiatrists Offer Recommendations to Help Older Adults With Mental Disorders


As the percentage of U.S. adults older than 65 years continues to grow, so too does the need for preventing mental illness among older adults as well as improving clinical services and outcomes for older patients with psychiatric disorders. So said psychiatrists Warren D. Taylor, M.D., M.H.Sc., of Vanderbilt University Medical Center and Charles F. Reynolds III, M.D., of the University of Pittsburgh in an article published today in JAMA Psychiatry.

“There will never be enough geriatricians, so we need collaborative approaches that allow us to improve treatment and reduce disease burden,” Taylor and Reynolds wrote. “Research in these areas requires transdisciplinary and translational team-based science, where psychiatrists and psychologists work with geroscientists, implementation scientists, and social scientists.”

They outlined several areas of emphasis for research that could help reduce the burden of psychiatric illness in older adults:

  • Expand suicide prevention efforts, including early identification of those at greatest risk. Despite a rise in suicide rates in other populations, older adults have the highest risk of suicide completion, they noted.
  • Develop strategies to prevent the recurrence of psychiatric disorders such as mood and anxiety disorders, which are common in older populations. “While we have substantial information about the acute treatment of these disorders, we know far less about how to keep someone well and avoid future episodes,” they wrote.
  • Determine best ways to treat older patients for substance use disorders. This includes careful consideration of possible untreated general medical conditions and risk of cognitive impairment in these patients.
  • Continue to investigate the impact of mental illness on general medical disorders. “Beyond addiction, other mental disorders negatively affect the outcomes of medical disorders, including cardiovascular disease and diabetes. Further research is needed to elucidate the biological mechanisms underlying these observations and to identify specific targets where intervention may improve both mental and physical prognosis,” they wrote.
  • Elucidate the contribution of mental disorders to cognitive decline and dementia risk. Depression and other mental disorders accelerate cognitive decline and increase risk of dementia. The mechanism underlying this relationship remains unclear, which complicates efforts to reduce this risk and preserve long-term cognitive function in this population, they wrote.

Although “these challenges are daunting … [w]e have a moral obligation to care for the most vulnerable in our society,” Taylor and Reynolds concluded. “We need better research and clinical services focused on mental disorders in the elderly, along with integrated interventions promoting resilience, wellness, and successful aging.”

For related information, see The American Psychiatric Publishing Textbook Of Geriatric Psychiatry, Fifth Edition and the Psychiatric Services article “Gold Award: Providing Accessible, Affordable, and Stigma-Free Behavioral Health Care for Older New Yorkers.”

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Tuesday, August 27, 2019

Sertraline-Olanzapine Combo Found to Reduce the Risk of Relapse in Patients With Psychotic Depression


A study in JAMA supports the combined use of an antidepressant and antipsychotic for maintenance treatment of patients with psychotic depression. In this 36-week study, patients with psychotic depression who achieved remission while taking sertraline plus olanzapine were far less likely to relapse if they continued on this combination therapy compared with those who discontinued olanzapine.

An antidepressant-antipsychotic combination is a frontline strategy for the acute treatment of psychotic depression, but once patients respond, there is no clear-cut long-term strategy, explained study author Alistair Flint, M.B., of the University of Toronto and colleagues. “This is a critical question because premature discontinuation of antipsychotic medication has the risk of relapse of a severe life-threatening disorder. In contrast, the unnecessary continuation of an antipsychotic agent exposes a patient to potentially serious adverse effects.”

For the study, Flint and colleagues relied on data from the second part of a large multistage trial known as The Study of the Pharmacotherapy of Psychotic Depression. The participants included 126 adults aged 18 and older with psychotic depression who had achieved remission or “near remission” of their symptoms following up to 12 weeks of sertraline (150 mg/day to 200 mg/day) and olanzapine (15 mg/day to 20 mg/day) combination therapy. Remission was defined as the absence of delusions and hallucinations as well as a score of 10 or less on the Hamilton Depression Rating Scale (HDRS) for two consecutive weeks; “near remission” was defined as the absence of delusions and hallucinations, an HDRS score of 11 to 15 with a drop in HDRS score of 50% from baseline, and being rated as “very much improved” or “much improved” on the Clinical Global Impression scale.

After remaining on both medications for eight additional weeks, the participants were randomly assigned to either continue their combination therapy of sertraline and olanzapine or have their olanzapine pills switched over to placebo pills over a four-week period. The participants were monitored for up to 36 weeks.

At the end of the trial, 20.3% of patients randomized to olanzapine and 54.8% randomized to placebo experienced at least one relapse. Patients who continued taking olanzapine experienced greater increases in weight gain than those who discontinued olanzapine.

“Relapses resulted in a high frequency of psychiatric hospitalization, highlighting the severity and cost of this disorder and the importance in preventing relapse,” Flint and colleagues wrote.

For related information, see the Psychiatric News article “Benefits of Maintenance Antipsychotics Outweigh Risks, International Panel Concludes.”

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Monday, August 26, 2019

APA Welcomes Administration’s Proposal to Coordinate Care for SUD and General Medical Care


APA and a group of nearly 50 health care organizations are welcoming a proposed rule to change federal regulations that govern the confidentiality of patient records created by federally assisted substance use disorder treatment programs.

The Department of Health and Human Services (HHS) issued the proposed rule today in the Federal Register. It would revise regulations known as “42 CFR Part 2” to support coordinated care among different health care professionals who treat patients with substance use disorders (SUDs) while maintaining privacy safeguards (for instance, patients would still need to give consent in order for their records to be shared). APA is reviewing the rule and will be submitting comments.

First formulated in the 1970s, the 42 CFR Part 2 regulations restrict the sharing of medical records related to substance use treatment. The regulations were originally intended to protect patient confidentiality, but they make it difficult for health care professionals to know whether a patient is being treated for or has a history of substance use disorder.

As part of the Partnership to Amend 42 CFR Part 2, APA and the other health care organizations have been calling for alignment of 42 CFR Part 2 with the Health Insurance Portability and Accountability Act (HIPAA) regulations to allow for information sharing by health care professionals involved in the care of a patient with SUD. The partnership hailed today’s proposed changes as an important step toward integrating mental health and substance use disorder treatment and general medical care for patients with SUD.

“We appreciate the support provided by the administration to align 42 CFR Part 2 with HIPAA and its efforts through regulation to better allow information to flow between health care professionals to provide safer and better care for our patients with substance use disorders,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a press statement. “This is a good step forward in breaking down barriers for people with substance use disorders to receive effective integrated care. We will continue to work with the administration and Congress to address the remaining barriers.”

(In June, the AMA House of Delegates voted to support alignment of 42 CFR Part 2 with HIPAA, a significant victory for the APA delegation to the House.)

According to HHS, the proposed rule is the first of four regulations that have been identified in HHS's “Regulatory Sprint to Coordinated Care,” which seeks to promote value-based outcomes for patients by examining federal regulations that impede coordinated care among health care professionals.

HHS has prepared a fact sheet about the proposed rule. For related information, see the Psychiatric News articles “APA Pushes to Reform Outdated Regulation Jeopardizing Care for SUD Patients” and AMA Backs Alignment of Regs Governing SUD Treatment Records With HIPAA.

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Friday, August 23, 2019

APA Speaks Out Against Administration Effort to Replace Flores Settlement


APA is speaking out against the Trump administration’s attempt to nullify a longstanding legal settlement that limits the time that migrant children can be kept in detention.

The Department of Homeland Security today issued a rule that seeks to replace the Flores Settlement Agreement, the federal consent decree that has set basic standards for the detention of migrant children and teenagers by the United States since 1997. The new rule could expand family detention and increase the time children spend in custody.

According to a report in The Washington Post, Homeland Security officials said the rule would eliminate a 20-day cap for detaining migrant children and create a new license regime that would make it easier for federal officials to expand family detention nationwide. The new rule will require the approval of a federal judge.

APA President Bruce Schwartz, M.D., said in a statement that the move will harm children. “A substantial body of research shows that stressful events during childhood can lead to long-term developmental, learning, and health problems, not to mention a heightened risk of depression, anxiety, and posttraumatic stress disorder,” he said. “The Flores Settlement Agreement was intended to protect the well-being of children who are detained by immigration authorities, but the new rule would endanger their mental health by eliminating the 20-day limit on detainment and weakening licensing requirements of detention centers.”

Flores is a 1997 legal settlement of lawsuits filed on behalf of minors by immigration advocates against what was then known as the Immigration and Naturalization Service (INS) for alleged maltreatment of migrant children. The settlement requires the government to release children from immigration detention without unnecessary delay to their parents, other adult relatives, or licensed programs. It also requires immigration officials to provide detained minors a certain quality of life, including food, drinking water, and medical assistance in emergencies.

“The children and families seeking asylum at the U.S. borders are already coping with the effects of the stress and trauma of leaving their home countries,” Schwartz said. “Compounded by the current conditions of detention centers, we urge the administration to consider the long-lasting, harmful impacts of this policy and withdraw this rule.”

For related information see the Psychiatric News article, "APA Maintains Pressure on Administration Regarding Welfare of Migrant Children."

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