Thursday, November 14, 2019

Genetic Data Can Improve Psychosis Prediction Tool

Incorporating genetic data into a clinical tool that predicts whether a person will develop schizophrenia can improve the accuracy of this tool, according to a study appearing in AJP in Advance.

Diana Perkins, M.D., M.P.H., of the University of North Carolina and colleagues assessed whether polygenic risk scores (PRS) could be used as part of a clinical assessment of schizophrenia risk. A PRS reflects how many individual genetic variants associated with schizophrenia a person has; the higher an individual’s PRS, the greater his or her genetic risk of developing schizophrenia. They looked at health data from 764 young adults (average age 18) considered at high risk for developing psychosis. These young adults were participants in the North American Prodrome Longitudinal Study (NAPLS 2). As part of the NAPLS 2, these individuals were prospectively followed for two years to identify traits that might help predict the onset of schizophrenia.

On the basis of NAPLS 2 data, the researchers developed a risk calculator that was able to predict which high-risk youth might develop schizophrenia with about 70% accuracy. The risk calculator included variables such as age, history of trauma and stressful life events, family history of psychotic disorders, the degree of disordered thoughts, and performance on tasks assessing verbal learning and information processing speed.

The NAPLS 2 participants also provided blood samples, and Perkins and colleagues used these to extract DNA and compute PRS scores for each participant. They found that PRS scores by themselves could predict schizophrenia onset with about 62% accuracy in Europeans and 57% accuracy in non-Europeans. When added to the risk calculator, however, PRS improved the accuracy of these tools.

“Use of a schizophrenia PRS in clinical practice hinges on improved accuracy, especially in persons of non-European ancestry, and [genetic studies] that include individuals from diverse populations are essential,” Perkins and colleagues wrote. “With further improvements and given the relatively low cost and wide availability of genotyping, potential applications of the genetic risk scores to individualized psychosis risk screening warrant further investigation,” they concluded.

For related information on predicting patients most likely to develop psychosis, see the Psychiatric News article “Imaging Advances Could Aid Prediction of Outcome in High-Risk Patients.”

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Wednesday, November 13, 2019

Concussions May Raise Risk of Suicide in High School Students

Having a concussion within the past year may raise the risk of suicidal ideation and behavior in high school students, according to a study in the Journal of Affective Disorders.

Dale S. Mantey, M.P.A., of the University of Texas School of Public Health and colleagues used data from more than 13,000 respondents in grades 9 through 12 who participated in the 2017 Youth Risk Behavior Surveillance Survey (YRBSS). The national YRBSS is conducted every two years by the Centers for Disease Control and Prevention to monitor health behaviors that contribute to the leading causes of death, disability, and social problems among youth and adults in the United States.

For this study, researchers analyzed the respondents’ answers to the question “During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?” They then compared those answers with answers to questions designed to determine whether over the past 12 months the students had depressive symptoms, suicidal ideation, planned suicide attempts, attempted suicide, and/or were treated by a doctor or nurse for an injury, poisoning, or overdose following a suicide attempt.

Overall, 15% of the respondents reported a sports-related concussion in the previous 12 months. Compared with their peers who did not report concussions, these participants were 20% more likely to have experienced depressive symptoms, 25% more likely to have had suicidal ideation, and 60% more likely to have attempted suicide. They were also more than twice as likely to have been treated by a doctor or nurse for a suicide attempt. The risk of a suicide attempt and a suicide attempt treated by a doctor or nurse were more pronounced in boys than girls: Boys with a history of concussion were twice as likely to have a suicide attempt and more than three times as likely to have been treated by a doctor or nurse for a suicide attempt than boys with no history of concussion.

“Though further research is needed to explore the relationship observed in this study, [the] findings suggest a critical need for expanded education, awareness, monitoring, and treatment of sports-related concussions,” the researchers wrote. “[S]uicide awareness, education, and prevention efforts should incorporate history of sports-related concussions (or other traumatic brain injuries) as risk factors for interventional programs. Furthermore, organized physical activities (e.g., sports) should ensure proper monitoring of suicidal risk factors (e.g., changes in mood) following the diagnosis of concussion in youth participants.”

For related information, see the Psychiatric News article “New Analysis Suggests There Is No Such Thing as Harmless Head Contact in Football.”

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Tuesday, November 12, 2019

Anxiety in Older Adults With MDD on Venlafaxine Doesn’t Reduce Chance of Remission, Study Finds

The presence of comorbid anxiety symptoms does not appear to predict the likelihood that older patients with major depressive disorder (MDD) will respond to the antidepressant venlafaxine, according to a study in Depression & Anxiety.

“[R]emission of depression was just as likely in more and less anxious participants,” Yasmina M. Saade, M.D., of Washington University in St. Louis and colleagues wrote.

Previous studies show that older depressed adults with comorbid anxiety often have more severe depression symptoms and cognitive decline and are at greater risk of suicide compared with older depressed adults without anxiety. To examine whether comorbid anxiety influences response to treatment in older adults, Saade and colleagues analyzed data from the Incomplete Response in Late‐Life Depression: Getting to Remission (IRL‐GRey) study, a large prospective antidepressant trial.

For the first phase of the IRL-GRey study, 468 adults aged 60 years or older with MDD received open‐label treatment with venlafaxine extended release, a selective serotonin and norepinephrine reuptake inhibitor. The participants were started at a dose of 37.5 mg/day and titrated up to 300 mg/day if they did not go into remission. Those who were taking a previously prescribed low-dose benzodiazepine were permitted to continue its use. Before starting on venlafaxine, the researchers evaluated the participants using Montgomery-Åsberg Depression Rating Scale (MADRS), the Brief Symptom Inventory anxiety subscale (BSI‐anxiety), the 19‐item Scale for Suicide Ideation (SSI), the Anxiety Sensitivity Index (ASI), and the Penn State Worry Questionnaire (PSWQ). The participants were reassessed using the MADRS, BSI-anxiety, and SSI weekly or biweekly throughout the 12- to 14-week open-label phase.

Baseline anxiety scores did not predict the likelihood of the participants’ remission of depressive symptoms (defined as a MADRS score ≤10 at both of the final two consecutive visits) on venlafaxine, the authors wrote. Similarly, the baseline anxiety scores did not predict time to remission. Participants who expressed some suicidality at baseline, however, tended to have more severe symptoms of depression and anxiety.

“In older adults with MDD, comorbid anxiety symptoms are associated with symptom severity but do not affect antidepressant remission or time to remission,” Saade and colleagues wrote. “The presence of comorbid anxiety should prompt an intensive course of treatment, including frequent follow‐up visits and maximizing the antidepressant dosage before declaring nonresponse. We also speculate that the use of a dual‐reuptake inhibitor may be preferable in depression with comorbid anxiety symptoms.”

For related information, see the American Journal of Psychiatry article “Norepinephrine Transporter Gene Variants and Remission From Depression With Venlafaxine Treatment in Older Adults.”

Pfizer contributed venlafaxine extended-release capsules for this study.

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Friday, November 8, 2019

Adverse Events in Childhood May Raise Health, Socioeconomic Risks in Adulthood

A study published this week in the Morbidity and Mortality Weekly Report adds to the growing body of evidence indicating that experiencing adverse events in childhood such as abuse or witnessing intimate partner violence increases the risk of numerous negative health and socioeconomic outcomes in adulthood.

Researchers from the Centers for Disease Control and Prevention used data from more than 144,000 respondents who participated in the Behavioral Risk Factor Surveillance System (BRFSS) from 2015 to 2017. The BRFSS is an annual state-based telephone survey of adults in which participants report on their health behaviors and whether health care professionals had ever diagnosed them with a health condition. The researchers drew the data from 25 states that had added questions to the BRFSS to assess participants’ exposure to eight types of adverse childhood experiences, including physical, emotional, or sexual abuse; household member substance misuse, incarceration, or mental illness; parental divorce; or witnessing intimate partner violence.

Overall, 60.9% of participants had been exposed to at least one type of adverse childhood experience, and 15.6% had been exposed to four or more. The more types of adverse childhood experiences participants were exposed to, the more likely they were to engage in risky health behaviors or have chronic health conditions or socioeconomic challenges as adults. For example, participants who were exposed to four or more types of adverse childhood events were five times more likely to have depression, roughly three times more likely to have chronic obstructive pulmonary disease or smoke, and nearly twice as likely to have coronary heart disease, drink heavily, or be unemployed compared with participants who reported no exposure to adverse childhood experiences.

The researchers noted that the prevalence of adverse childhood experiences was higher among people aged 34 years and younger, possibly because of differences in risk among people in that age group, their willingness to disclose their history, or their ability to recall adverse childhood experiences.

“Strategies to prevent adverse childhood experiences in the first place and to intervene with those who have been exposed to adverse childhood experiences might help to reduce prevalence of engaging in health risk behaviors [such as smoking or drinking] in young adulthood and subsequent negative health outcomes,” the researchers wrote. “These strategies might also help to break the multigenerational cycle of adverse childhood experiences as these age groups are most likely to start families or raise children.”

For related information, see the Psychiatric News article “Positive Childhood Experiences May Counteract Adverse Experiences” and the Psychiatric Services article “State Legislators’ Opinions About Adverse Childhood Experiences as Risk Factors for Adult Behavioral Health Conditions.”

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Thursday, November 7, 2019

Web-Based Training May Increase Residents’ Treatment of Patients for Tobacco Use

Psychiatry residents were more likely to advise patients on tobacco use disorder and provide treatment after completing an online training course, according to a study published in Psychiatric Services in Advance.

Though tobacco use accounts for half of all deaths of individuals with mental illness or substance use disorder, “educational opportunities for psychiatrists and residents remain limited,” wrote Jill Williams, M.D., of Rutgers-Robert Wood Johnson Medical School in New Jersey and colleagues. The data suggest “that an online training opportunity, especially early in residency, may increase knowledge about tobacco use disorder and, more importantly, increase the frequency of behaviors likely to result in reduced tobacco use in the vulnerable populations these residents will treat,” they noted.

U.S. psychiatry residency program directors provided the researchers with the email addresses of current psychiatry residents; participation was not required. A total of 199 residents completed surveys that evaluated their attitudes toward tobacco treatment practices (such as monitoring patients' progress in attempting to quit and prescribing tobacco treatment medications) and estimated how frequently they applied such practices.

The residents then viewed three one-hour webinars on tobacco treatment, which covered topics such as the prevalence and consequences of tobacco use disorder among individuals with behavioral health conditions, as well as counseling strategies and pharmacological treatments. Of the 152 participants who completed the online course, 89 completed a follow-up assessment three months later.

There was “considerable variability” in residents’ ratings of tobacco treatment practices at baseline, the authors reported. Asking patients about their smoking status was the most highly reported treatment practice, with 47% of residents always asking, and 44% usually asking. Others, such as prescribing tobacco treatment medications or arranging follow-up visits to address smoking, were reported less frequently.

In the three-month follow-up, however, “[r]esidents reported a significant increase in their use of nine of the 12 tobacco treatment practices,” Williams and colleagues wrote. The findings include the following:

  • Residents who said they always assess patients’ willingness to quit smoking increased from 15% at baseline to 23% at follow-up.
  • Residents who said they usually refer patients who smoke to others for appropriate cessation treatment increased from 18% to 36%.
  • Residents who said they usually refer smokers to a telephone cessation service like Quitline increased from 8% to 19%.

The authors found that residents who were earlier in their training (first- and second-year residents) were more likely to change their tobacco treatment practices than third- through fifth-year residents. “This finding may imply that educational efforts are more effective before residents have solidified their practice patterns, even though junior residents have less control over their own practice.”

For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco.”

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Hypothyroidism May Reverse After Lithium Is Discontinued, Study Suggests

People who develop hypothyroidism while using the mood stabilizer lithium may return to normal thyroid function after the drug is discontinued, according to a study in the Journal of Psychopharmacology.

Hypothyroidism—a condition in which the thyroid gland does not produce enough thyroid hormone—has long been known to be associated with the use of lithium. “In most patients lithium-associated hypothyroidism seems reversible once lithium has been discontinued,” wrote Ingrid Lieber, M.D., of Umea University in Sweden and colleagues. “Therefore, in such cases, TRT [thyroid replacement therapy] discontinuation could be attempted much more often than is currently done.”

Lieber and colleagues analyzed follow-up data on 85 patients who discontinued lithium because of hypothyroidism and were being treated with thyroid replacement therapy. They were enrolled in the Lithium–Study Into Effects and Side Effects, a large Swedish study of patients using lithium. The mean delay from starting lithium to starting thyroid replacement therapy was 2.3 years.

Of the 85 patients, 35 stopped thyroid replacement therapy at some point after discontinuation of lithium. Only six patients had to be placed back on thyroid replacement therapy.

Lieber and colleagues said that it is prudent to allow some weeks for the thyroid gland to recover before stopping thyroid replacement therapy. “Based on the limited evidence of our study, we can expect hypothyroidism to recur early after TRT discontinuation, if at all,” they wrote. “Thus, it is advisable to monitor thyroid function for three to six months. TRT reinsertion should then only be reconsidered if there are unambiguous signs of hypothyroidism … .”

For more information, see the chapter “Endocrine and Metabolic Disorders” in The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry, Third Edition.

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Tuesday, November 5, 2019

Newspapers Can Do More to Change Public Perception of Suicide, Report Suggests

Regional and national newspapers in the United States are falling short of meeting guidelines for reporting on suicide deaths, suggests a report in JAMA Network Open. An analysis of coverage following the deaths of Kate Spade and Anthony Bourdain in June 2018 in print newspapers with a minimum circulation of 200,000 shows that the publications adhered to only about half of the national recommendations for reporting on suicide, such as avoiding details of lethal means or use of a sensational headline.

“News media coverage of suicide is associated with an increased risk of subsequent suicides, with the strongest associations following newspaper reporting of celebrity suicides,” wrote Arielle H. Sheftall, Ph.D., of the Ohio State University College of Medicine and colleagues. To educate the media about these risks, leading experts in suicide prevention, public health, and media from the American Foundation for Suicide Prevention, Annenberg Public Policy Center, Columbia University Department of Psychiatry, government agencies, and more in 2001 published the guideline “Recommendations for Reporting on Suicide.”

“Risk of additional suicides increases when the story explicitly describes the suicide method, uses dramatic/graphic headlines or images, and repeated/extensive coverage sensationalizes or glamorizes a death,” according to this document. “Covering suicide carefully, even briefly, can change public misperceptions and correct myths, which can encourage those who are vulnerable or at risk to seek help.”

Sheftall and colleagues analyzed the coverage of the deaths of Spade and Bourdain in the following newspapers: The Chicago Tribune, Denver Post, Houston Chronicle, Los Angeles Times, New York Times, Seattle Times, Tampa Bay Times, USA Today, Wall Street Journal, and Washington Post. Specifically, the authors assessed guideline adherence by the newspapers in the days following the deaths using 14 items derived from “Recommendations for Reporting on Suicide.” These items included avoiding details of notes left behind or location of death, providing information about warning signs of or risk factors for suicide, and listing the National Suicide Prevention Lifeline phone number. The researchers scored the articles by adherence to each guideline (1 for yes; 0 for no; total score: 14).

Overall, the newspapers adhered to a mean of 7.4 of the 14 specific guidelines; none of the newspapers adhered to 80% of the specific guidelines. All of the newspapers adhered to the two following guidelines: “avoided single-cause explanation of suicide death” and “avoided referring to suicide as a growing problem, epidemic, or skyrocketing.” In contrast, none followed recommendations to “share a hopeful message that suicide is preventable” or to “convey that suicidal behaviors can be reduced with mental health support and treatment,” according to the authors.

The findings point to “widespread opportunities for improvement,” Sheftall and colleagues wrote. They noted that steps taken in Canada in April 2014 to establish reporting guidelines for suicide and create checklists for journalists to promote adherence were associated with increased adherence to these guidelines following the death of Robin Williams by suicide in August 2014. “A collaboration between U.S. media staff, governmental agencies, and other stakeholders when updating and disseminating the recommended reporting guidelines for suicide may increase adherence, which in turn might reduce preventable harm,” they concluded.

For related information, see the Psychiatric News article “Preparing for a Sequel: ‘13 Reasons Why’ and Suicide Contagion” by Michael Fadus, M.D., and the Psychiatric Services article “Increases in Demand for Crisis and Other Suicide Prevention Services After a Celebrity Suicide.”

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Monday, November 4, 2019

Symptoms of Grandiosity May Point to Higher Risk of Relapse on Oral Antipsychotic

Schizophrenia patients with severe grandiosity (an inflated sense of self) may be more likely to relapse when taking daily oral antipsychotics compared with patients without such delusions of grandeur, according to a report in Schizophrenia Research. This symptom profile did not affect relapse risk in patients taking long-acting injectable (LAI) risperidone. In addition, many patients who relapsed showed worsening emotional withdrawal as early as eight weeks prior to the relapse event.

“While it is unclear whether this symptom worsening is a predictor of relapse or a part of a relapsing process, this timeline may offer a window for possible interventions in an effort to avert relapses,” wrote Yuta Saito, M.D., of Keio University School of Medicine in Tokyo and colleagues.

These findings come from a secondary analysis of a clinical trial known as PROACTIVE. This trial followed 305 outpatients with schizophrenia taking either biweekly LAI risperidone or daily oral second-generation antipsychotics for up to 30 months. PROACTIVE was conducted in eight clinical centers across the United States and had a primary goal of testing whether LAI risperidone was better than daily antipsychotics at preventing a relapse of schizophrenia symptoms. Researchers assessed schizophrenia symptom severity at the beginning of the study and then every two weeks until the end of the study. For this analysis, Saito and colleagues used that wealth of symptom data to see whether there were any signs that might predict future relapse.

Of the 305 patients in the study, 73 patients (41 receiving LAI risperidone and 32 taking oral antipsychotics) experienced at least one relapse of their schizophrenia symptoms. No individual symptom was associated with relapse in the LAI group; in the oral group, however, a greater initial score in grandiosity was associated with a 43% increased risk of relapse.

Saito and colleagues noted that previous research has shown that grandiosity decreases motivation and medication adherence, which may explain why this symptom increases relapse risk in patients who need to take an antipsychotic every day.

The investigators also found that patients who eventually relapsed were much more likely to experience emotional withdrawal in the weeks prior; significantly elevated emotional withdrawal relative to baseline was observed between two and eight weeks prior to the relapse date.

“[T]hese results point to the value of thorough evaluation of individual symptoms as well as overall symptomatology for relapse prevention among patients with schizophrenia,” Saito and colleagues concluded.

The PROACTIVE trial was funded by NIMH, and the authors reported no external funding for this secondary analysis. Some of the authors have received honoraria, speaker fees, or grants from Janssen, manufacturer of risperidone.

For related information, see the Psychiatric News article “Clozapine, LAI Antipsychotics Found Best at Preventing Relapse.”

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Friday, November 1, 2019

Sexual Minorities Found to Be at Elevated Risk for Eating Disorders

People who are homosexual, bisexual, or unsure of their sexual orientation have both a higher risk and a higher rate of eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder than people who are heterosexual, a study in the International Journal of Eating Disorders has found. Although prior research suggests that members of sexual minorities have a higher risk of eating disorder symptoms than heterosexuals, this study is believed to be the first to use data from a large number of people to determine how common eating disorders are among sexual minority members.

Rebecca C. Kamody, Ph.D., of Yale University School of Medicine and colleagues analyzed data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a survey of roughly 36,000 U.S. adults. The NESARC-III determined if participants had eating disorders based on whether their responses suggested that they met the DSM-5 criteria for eating disorders. They found that eating disorders occurred at the following rates among sexual minorities and heterosexuals:

  • Anorexia nervosa occurred in 1.71% of members of sexual minorities, compared with 0.77% of heterosexuals.
  • Bulimia nervosa occurred in 1.25% of members of sexual minorities, compared with 0.24% of heterosexuals.
  • Binge eating disorder occurred in 2.17% of members of sexual minorities, compared with 0.81% of heterosexuals.
  • Anorexia nervosa occurs in 3.78% of members of sexual minorities who experienced discrimination. There were no significant differences in the prevalence of bulimia or binge eating disorder in those who perceived discrimination

Compared with heterosexuals, members of sexual minorities may be nearly twice as likely to develop anorexia, more than three times as likely to develop bulimia nervosa, and more than twice as likely to develop binge eating disorder at some point in their lives, the study found.

“While there has been an impetus in recent years to increase diversity in [eating disorder] research, … the present study highlights the importance of diversifying further [eating disorder] research in order to inform the development of more responsive evidence-based interventions tailored to individual needs,” Kamody and colleagues wrote. “This may serve as a first step in reducing disparities and promoting health among sexual minority populations.”

For related information, see the Psychiatric News article “Brief Update and Review on Treating Eating Disorders,” by James Lock, M.D., Ph.D.

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Thursday, October 31, 2019

Acetaminophen Use During Pregnancy Associated With Increased Risk of ASD, ADHD in Children


Using acetaminophen during pregnancy may increase the risk of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in children, according to a report published Wednesday in JAMA Psychiatry.

For this study, Yuelong Ji, Ph.D., of the Johns Hopkins Bloomberg School of Public Health and colleagues measured the levels of acetaminophen in umbilical cord blood taken after childbirth from 996 women who were part of a study called the Boston Birth Cohort. The study had a 21-year follow-up period.

Of the 996 children of these women, 257 were subsequently diagnosed with ADHD, 66 were diagnosed with ASD, 42 were diagnosed with both ADHD and ASD, 304 were diagnosed with another developmental disorder, and 327 had no developmental disorders.

The researchers found that the children who were exposed to more acetaminophen in the womb (as reflected by higher acetaminophen concentrations in cord blood) were more likely to have ADHD or ASD. The risk of either disorder was dose-dependent; that is, higher concentrations of acetaminophen in the cord blood equated to greater ADHD or ASD risk.

“Our findings support previous studies regarding the association between prenatal and perinatal acetaminophen exposure and childhood neurodevelopmental risk and warrant additional investigations,” Ji and colleagues wrote.

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Wednesday, October 30, 2019

Substance-Induced Psychosis Associated With Increased Risk of Schizophrenia, Meta-Analysis Finds


People who experience psychosis following the use of cannabis, hallucinogens, or amphetamines (known as substance-induced psychosis) may be at a greater risk of developing schizophrenia, according to a meta-analysis in Schizophrenia Bulletin. This risk was found to be only slightly less than that observed for patients who presented with other brief psychotic disorders.

“These findings have important implications for mental health care and services. Substance-induced psychoses are common reasons for seeking mental health care,” wrote Grant Sara, M.B., of the University of Sydney and colleagues. “Yet despite this, people with substance-induced psychoses are often excluded from early psychosis services or assertive mental health care due to a perception that these are benign or self-limiting conditions.”

Sara and colleagues searched MEDLINE, PsychINFO, and Embase for peer-reviewed, English-language studies published between 1980 and 2018 that looked at how often patients with substance-induced psychoses were later diagnosed with schizophrenia. They compared this group with those who had an initial diagnosis of “brief psychosis,” “atypical psychosis,” “schizophreniform psychosis,” or “psychosis not otherwise specified” who were later diagnosed with schizophrenia.

The researchers identified 50 studies, which included more than 40,500 people. Of these studies, 25 looked at later diagnosis of schizophrenia among people who had substance-induced psychosis (following use of cannabis, hallucinogens, amphetamines, alcohol, sedatives, or opioids).

Overall 25% of people with substance-induced psychosis were later diagnosed with schizophrenia, compared with 36% of people who first presented with brief, atypical, and not otherwise specified psychoses. Among the 25 studies that looked at substance use-induced psychosis, transition to schizophrenia was highest (34%) for cannabis-induced psychoses.

“The importance of assertive intervention in this group is underlined by evidence that integrated care, which addresses substance use disorders and psychosis, can have a significant impact on course,” the researchers wrote. “Such care can double the likelihood of remission in early psychosis; reduce the risk for hospital re-admission; and lead to better symptomatic, drug use, and functional outcomes at 10-year follow-up.”

For more information, see the Psychiatric News article “Substance-Induced Psychosis Associated With Later Schizophrenia, Bipolar Disorder.”

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Tuesday, October 29, 2019

Cannabinoids for Psychiatric Disorders? Evidence of Effectiveness is Lacking, Report Concludes


There is little evidence that the use of cannabinoids can improve symptoms of anxiety, attention-deficit/hyperactivity disorder (ADHD), depression, posttraumatic stress disorder (PTSD), psychosis, or Tourette syndrome, according to a report in Lancet Psychiatry.

“Cannabinoids are often advocated as a treatment for various mental disorders,” wrote Nicola Black, Ph.D., of the University of New South Wales and colleagues. Doctors and patients “need to be aware of the low quality and quantity of evidence for the effectiveness of medicinal cannabinoids in treating mental disorders and the potential risk of adverse events,” they added.

Black and colleagues searched several databases including MEDLINE, the Cochrane Central Register of Controlled Clinical Trials, and the Cochrane Database of Systematic Reviews for studies published between 1980 and 2018 that examined changes in symptoms and/or remission following the use of medicinal cannabinoid for treating adults with anxiety, ADHD, depression, PTSD, psychosis, or Tourette syndrome, either as the primary condition or secondary to other medical conditions. The researchers also searched for unpublished or ongoing studies on ClinicalTrials.gov, the EU Clinical Trials Register, and the Australian and New Zealand Clinical Trials Registry.

They identified 83 studies, including 40 randomized, controlled trials (RCTs), for the analysis. Most of the RCTs were very small (with median sample sizes of 10 to 39 participants) and had short follow-up periods (median trial length of four to five weeks), the authors noted.

“We found little evidence for the effectiveness of pharmaceutical CBD [cannabidiol] or medicinal cannabis for the treatment of any of [the examined] mental disorders,” Black and colleagues wrote. “Some very-low quality evidence was found for the use of pharmaceutical THC [tetrahydrocannabinol] (with or without CBD) in treating anxiety symptoms among individuals with other medical conditions, such as chronic noncancer pain and multiple sclerosis.”

In an accompanying commentary, Deepak Cyril D’Souza, M.B.B.S., M.D., of Yale University cautioned, “The process of drug development in modern medicine is to first demonstrate efficacy and safety in clinical trials before using the drug clinically. With cannabinoids, it seems that the cart (use) is before the horse (evidence). If cannabinoids are to be used in the treatment of psychiatric disorders, they should first be tested in randomized, controlled trials and subjected to the same regulatory approval process as other prescription medications.”

For more information on this topic, see the Psychiatric Services article “The CBD Dialectic in Mental Health: Benign and Powerful?

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Monday, October 28, 2019

Use of Telepsychiatry Nearly Doubles From 2010 to 2017, Study Finds


Nearly twice as many mental health facilities in the United States offered telepsychiatry in 2017 than in 2010, according to a study published in Psychiatric Services. Telepsychiatry was most commonly offered by facilities in underserved and rural areas.

“Facilities with telepsychiatry offer a variety of services to a wide range of populations, and the increased use of these services among populations with greater barriers to access, such as those residing in rural and underserved areas, continues to [show] promise that such services will be made available to patients with the greatest need,” wrote Stanislav Spivak, M.D., of Johns Hopkins University School of Medicine and colleagues.

Spivak and colleagues analyzed national data from the Substance Abuse and Mental Health Services Administration’s National Mental Health Services Survey (NMHSS) collected between 2010 and 2017. The survey asked facilities that provide mental health treatment if they provided telepsychiatry—defined as “the ability for health care providers, working from a distance using telecommunications technology, to communicate with patients, diagnose conditions, provide treatment, and discuss health care issues with other providers to ensure quality health care services are provided.” The researchers compared the ownership, licensing, funding, and treatment setting of those facilities that reported offering telepsychiatry in 2017 with those that did not. They also asked state mental health agency officials whether telemedicine was reimbursed by state funds and/or Medicaid funds, and if the state had initiatives to expand the use of telemedicine.

In 2010, 15.2% (n=1,580) of the facilities surveyed reported using telepsychiatry; in 2017, that number grew to 29.2% (n=3,385) of the facilities surveyed. But the authors noted “considerable variability” among states, with less than 15% of facilities offering telepsychiatry in some states compared with over 60% in others. The increase in the proportion of facilities with telepsychiatry from 2010 to 2017 was highest in states with a rural population of 40% or more, the authors noted.

“Facilities that offered telepsychiatry had higher odds of being funded by federal and local government sources, as well as by private insurance, self-pay, and grant funding compared with facilities without telepsychiatry,” Spivak and colleagues wrote. In contrast, facilities offering telepsychiatry were less likely to be funded by Medicaid than those without telepsychiatry—a finding the authors described as “puzzling, as the federal Medicaid statute allows reimbursement of telemedicine as a regular service.” The lower odds of facilities using telepsychiatry receiving funding from Medicaid “may reflect the effect of state Medicaid regulatory hurdles,” they wrote.

State funding may also explain the variability in telepsychiatry from state to state. States that did not provide direct state funding for telemedicine had lower odds of offering telepsychiatry services (19.3% vs. 29.8%), the authors noted.

For related information, see the Psychiatric News article “Telepsychiatry: Who, What, Where, and How.”

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Friday, October 25, 2019

Limiting Flavored Tobacco Sales May Cut Use in Youth


Restricting the sale of flavored tobacco products may cut tobacco use among adolescents, a study in the American Journal of Preventive Medicine has found.

Melody Kingsley, M.P.H., of the Massachusetts Department of Public Health and colleagues compared tobacco use among youth in two Massachusetts towns, Lowell and Malden. In 2016, Lowell enacted a policy that restricted the sale of flavored tobacco products—those meant to taste like fruit, candy, honey, etc.—to tobacco retail stores such as smoking bars, vape shops, and tobacconists that only sell to adults aged 21 years and older. Malden did not have such a policy at the time of the study.

Researchers used retailer inventory data collected by Massachusetts Tobacco Control Program educators to compare the availability of flavored tobacco products in both towns in September 2016, before Lowell’s flavored tobacco restriction policy took effect, and six months later. More than 500 adolescents in Lowell high schools and more than 600 adolescents in Malden high schools took surveys about their tobacco use in September 2016 and again six months later.

During that timeframe, the percentage of stores where flavored products were available in Lowell dropped from 77.3% to 7.3%, whereas the availability of flavored tobacco products in Malden did not change significantly. Adolescent use of flavored tobacco products dropped 2.4% in Lowell but increased 3.3% in Malden. Adolescent use of non-flavored tobacco products dropped 1.9% in Lowell but increased 4.3% in Malden.

The researchers acknowledged that the surveys did not include all of the same adolescents at both time points, so they were unable to determine whether tobacco use for each adolescent in the study changed over time. Nevertheless, they concluded that overall Lowell’s policy appeared to curb tobacco use in youth.

“With a longer follow-up time, [we] expect these trends will continue, and the policy may begin to impact and reduce flavored tobacco initiation, as exposure to flavored tobacco among younger students continues to decline,” they wrote.

For related information, see the Psychiatric News articles “FDA Seeks Information on Role of Flavors in Initiation, Cessation of Tobacco Use” and “FDA Warns Some E-Cigarette Users Having Seizures, Particularly Youth.”

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Thursday, October 24, 2019

ADHD Medication May Reduce Risk of Injuries in Youth With Co-Occurring Developmental Disorders


ADHD medication may reduce the risk of unintentional injuries in youth with ADHD and co-occurring neurodevelopmental disorders, such as autism, suggests a study in the Journal of Child Psychology and Psychiatry.

While previous studies have found a negative association between ADHD medication use and risk of injuries in children and adolescents, this is the first observational study exploring risk in children with ADHD and a co-occurring neurodevelopmental disorder, wrote Laura Ghirardi, M.Sc., of the Karolinska Institutet in Stockholm and colleagues.

Ghirardi and colleagues used data from Sweden’s Total Population Register and National Patient Register to identify individuals aged 5 to 18 who had received an ADHD diagnosis between 2006 and 2013, including those who had also been diagnosed with the following neurodevelopmental disorders: autism spectrum disorder, communication disorders, intellectual disability, learning disorders, and motor disorders. They then gathered information from the Prescribed Drug Register on the patients’ use of ADHD medications, including methylphenidate, amphetamine, dexamphetamine, lisdexamphetamine, and atomoxetine.

The researchers tracked the youth’s inpatient and outpatient visits reporting injury until the end of 2013, the youth aged out of the study, or death, whichever came first. They then compared the rate of injuries during periods when the youth were taking ADHD medication with the rate of injuries during periods they were not taking medication.

Of the 9,421 children and adolescents with ADHD included in the analysis, 2,986 had a co-occurring neurodevelopmental disorder; 1,390 had autism spectrum disorder. The rate of any unintentional injury and traumatic brain injury was lower during periods when the youth were taking ADHD medication compared with when they were not taking ADHD medication. Youth with co‐occurring neurodevelopmental disorders were 12% less likely to have an unintentional injury and 73% less likely to have a traumatic brain injury when taking ADHD medication.

The findings have “clinical and public health relevance, considering the high rate of comorbidity among [neurodevelopmental disorders] and the fact that unintentional injuries are relatively common among children and adolescents,” the authors wrote.

For related news, see the Psychiatric News article “Many Youth With ADHD Fail to Take Stimulants as Prescribed.”

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Wednesday, October 23, 2019

Aripiprazole Found to Have Fewer Side Effects in Teens With First-Episode Psychosis


Young people with first-episode psychosis (FEP) who are treated with extended-release quetiapine gain more weight and experience worse metabolic effects—including increased lipids, insulin, triglycerides, and total cholesterol—than patients treated with aripiprazole, according to a report in the Journal of the Academy of Child and Adolescent Psychiatry.

“These differences emerged early, are clinically relevant, and should inform treatment choice for youths with early onset psychosis,” especially since studies have shown the two medications are equally effective in treating symptoms, say Karsten Gjessing Jensen, M.D., Ph.D., of the University of Copenhagen and colleagues.

The researchers analyzed data on 113 youth aged 12 to 17 with FEP who were randomized to 12 weeks of extended-release quetiapine (quetiapine-ER) or aripiprazole as part of the Tolerability and Efficacy of Antipsychotics trial. The trial was conducted from June 2010 to April 2014 in seven university child and adolescent psychiatry departments across Denmark.

The primary outcome was change in body weight; secondary outcomes were changes in body mass index (BMI), waist circumference, blood pressure, heart rate, and lipid and glucose metabolism measures. Patients were assessed and blood samples taken at 4 and 12 weeks. The researchers also examined family history for factors that might predict how youth would respond on weight and metabolic measures.

Treatment with quetiapine-ER was associated with greater weight gain at 4 and 12 weeks (2.24 kg and 4.88, respectively) than aripiprazole (0.45 kg at 4 weeks and 1.97 kg at 12 weeks). Patients treated with quetiapine-ER also had increased metabolic measures—including cholesterol, triglycerides, and hyperinsulinemia—than patients treated with aripiprazole. Of the patients in the quetiapine-ER group, 14% had metabolic syndrome at week 12 compared with 8.3% in the aripiprazole group. Family factors that predicted weight gain and BMI in youth were early weight gain, obesity, or type 2 diabetes.

The researchers noted that, aside from the health effects, weight gain is likely to be stigmatizing for young people who may already be marginalized because of their psychosis. “Youths with psychotic disorders are a highly vulnerable patient group who may already feel marginalized by their peers, so that a weight gain of 5 kg may be yet another cause of (self-)stigmatization that may increase the risk of treatment discontinuation and that may impair the alliance between patients and health care providers,” they wrote.

For related information, see the Psychiatric News article “SGAs Increase Teens’ Abdominal Fat, Decrease Insulin Sensitivity.”

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Tuesday, October 22, 2019

Experts Outline Keys to Helping People Manage Prolonged, Disabling Grief


While all bereaved people can benefit from compassionate support, patients who experience intense, persistent, and disabling grief following the death of a loved one may require additional interventions. One intervention that may help is complicated grief therapy, wrote Alana Iglewicz, M.D., of the Veterans Affairs San Diego Healthcare System and colleagues in a paper in Depression & Anxiety.

“While everyone grieves in their own way, bereaved individuals often feel a sense of disconnection from themselves; their past, present, and future; and especially from the person who died,” Iglewicz and colleagues wrote. “[O]ver time, most adapt to their loss by accepting its finality and consequences.” Some people, however, may find themselves struggling with a prolonged grief the authors describe as complicated grief (the authors noted that various other terms have been used to describe this condition, including prolonged grief disorder in ICD-11). These people may be at greater risk of psychiatric and general medical conditions, the authors noted.

“[Complicated grief therapy] is based on the premise that grief emerges naturally after a loss and finds a place in our lives as we adapt to the loss,” the authors wrote. “Adapting entails coping with problems as well as envisioning and finding ways to bring joy and satisfaction into ongoing life. When doing [complicated grief therapy], grief is not an intervention target. Rather we seek to facilitate coping and personal growth and to resolve any impediments to this process.”

The authors outlined how mental health professionals can create a space to engage the patient using the following evidence-based guidance:

  • Understanding and accepting grief: For example, remind the patient that grief is normal and that he or she is not alone.
  • Recognizing painful emotions: For example, encourage the patient to pay attention to how his or her grief changes over the course of the day and what triggers these changes.
  • Thinking about a meaningful and fulfilling future: For example, work with the patient to create goals and formulate steps toward reaching these goals.
  • Reconnecting with others: For example, encourage the patient to identify at least one confidant.
  • Telling the story of loved one’s death: For example, invite the patient to tell the story of his or her loved one’s death repeatedly over several sessions.
  • Learning to live with reminders of the deceased: For example, create a list of activities that the patient has been avoiding and encourage the patient to gradually revisit these activities.
  • Establishing an enduring connection with memories of the person who died: For example, remind the patient of the role that memories play in relationships with loved ones, even when they are no longer alive.

“We suggest each clinician adapts the principles and procedures of complicated grief therapy in the way that fits their work best. Our experience suggests that patients can benefit greatly from a simple intervention that includes the seven core themes described above,” the authors concluded.

For related information, see the Psychiatric News article “Citalopram May Offer Limited Benefit for Patients With Complicated Grief.”

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Monday, October 21, 2019

Prescribing Lithium During Pregnancy Requires Careful Balancing of Benefits, Risks


The risk of giving birth to a child with birth defects may be slightly higher in women with bipolar disorder who take lithium compared with those who do not take lithium, suggests a meta-analysis in AJP in Advance. However, these slight risks may be outweighed by the dangers to mother and child of relapse of illness episodes (either depressive or manic), the authors of the analysis caution.

“Pregnancy should not be considered an absolute contraindication to lithium prescription, given the relatively small increase in risk for any malformation or cardiac malformations, and given that such events, fortunately, remain rare,” wrote Michele Fornaro, M.D., Ph.D., of the University of Naples Federico II School of Medicine and colleagues. In comparison, women with bipolar disorder who are not in treatment may experience frequent relapse of mood episodes during pregnancy and the postpartum period. These episodes themselves can harm the health of the mother and the fetus or newborn.

Fornaro and colleagues compiled data from 29 studies that assessed the efficacy and safety outcomes of lithium treatment during pregnancy and the postpartum period. They found that lithium exposure was not associated with any risk of preterm birth or low birth weight. Compared with women who were not prescribed lithium, however, those who took lithium any time during pregnancy had 1.81 times greater odds of giving birth to a child with a congenital defect and 1.86 times greater odds of giving birth to a child with a cardiac birth defect; these risks were slightly higher for women who started taking lithium in the first trimester (1.81 times for any congenital defect and 1.96 times for a cardiac defect). Women who took lithium in the first trimester also had 3.77 times greater odds of a miscarriage. When the comparisons were limited to women with bipolar disorder, however, women who took lithium did not have any increased risk of miscarriage compared with those who did not, and no increased risk of cardiac birth defects when lithium was taken in the second and/or third trimester.

Women with bipolar disorder who took lithium were 84% less likely to relapse during the postpartum period than women with bipolar disorder who did not take lithium during pregnancy.

To read more on this topic, see the Psychiatric News article “How to Manage Meds Before, During, and After Pregnancy.”

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Friday, October 18, 2019

Risk of Heart Disease Quadruples in Women Hospitalized for Bulimia


The risk of cardiovascular disease skyrockets for women who have been hospitalized for bulimia nervosa, a study in JAMA Psychiatry reports. The risk is greatest in the first two years after hospitalization and remains high for another three years before disappearing at the 10-year mark.

“Our findings suggest that women with a history of bulimia nervosa should be informed of an increased risk of cardiovascular disease and death in the first decade after the index admission for bulimia,” wrote Rasmi M. Tith, R.D., M.P.H., of the University of Waterloo in Ontario and colleagues. “These women may benefit from screening for prevention and treatment of cardiovascular risk factors.”

The study followed more than 416,000 women for up to 12 years from 2006 to 2018. Of the patients, 818 were hospitalized for bulimia, and the rest were hospitalized for pregnancy-related events such as delivery of a live or stillborn infant, abortion, or pregnancy outside the uterus (ectopic pregnancy). The average age of the women at hospitalization was 28 years.

“The comparison group was representative of most women in the province … because 99% of deliveries and a significant proportion of other pregnancy events occur in hospitals,” the researchers wrote.

Compared with women who had been hospitalized for pregnancy-related events, women who had been hospitalized for bulimia had nearly 22 times the risk of heart attack within two years of hospitalization and more than 14 times the risk at five years. Over the entire follow-up, they had more than four times the risk of any cardiovascular disease, including six times the risk of heart attack, seven times the risk of ischemic heart disease (heart problems caused by narrowed heart arteries), and seven times the risk of atherosclerosis. They also had five times the risk of death. Those who had multiple hospitalizations for bulimia had a higher risk of cardiovascular disease and death than those who had been hospitalized only once.

The researchers noted that bulimia has been associated with metabolic changes such as changes in lipids that may affect the risk of cardiovascular disease. They added that bulimia may cause endocrine abnormalities such as low estrogen levels, which may also increase cardiovascular risk.

“Although more studies are needed, the findings from the present study suggest that bulimia nervosa, especially bulimia that requires multiple hospitalizations for treatment, may be associated with a range of cardiovascular disorders,” the researchers concluded. “Bulimia nervosa may be an important contributor to premature cardiovascular disease in women.”

For related information, see the Psychiatric News article “Brief Update and Review on Treating Eating Disorders.”

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Thursday, October 17, 2019

Transcranial Direct Current Stimulation May Effectively Treat Negative Schizophrenia Symptoms


Transcranial direct current stimulation (tDCS) appears to be an effective and safe add-on treatment for ameliorating negative symptoms in schizophrenia, such as loss of interest in everyday activities and emotional withdrawal, according to a study published yesterday in JAMA Psychiatry. This noninvasive therapy delivers weak, direct currents into the brain via electrodes placed on the scalp.

“There is an unmet clinical need for the treatment of negative symptoms in schizophrenia,” wrote Leandro da Costa Lane Valiengo, M.D., Ph.D., of the Instituto Nacional de Biomarcadores em Neuropsiquiatria Faculdade de Medicina in São Paulo, Brazil, and colleagues. “[G]iven its acceptability, tolerability, and short treatment protocol, tDCS could be evaluated as an add-on intervention for patients with schizophrenia with negative symptoms in outpatient settings.”

The double-blind, placebo-controlled, randomized trial took place from September 2014 to March 2018 in two São Paulo outpatient clinics. The 100 participants aged 18 to 55 were all diagnosed with schizophrenia using the Portuguese version of DSM-IV, had Positive and Negative Syndrome Scale (PANSS) negative symptom scores of 20 or more, and had stable positive and negative symptoms for four weeks or more. Participants received tDCS in twice-daily, 20-minute sessions over five consecutive days. A sham group went through the same procedure without receiving tDCS. A total of 95 patients completed the trial.

The participants’ symptoms were assessed at baseline, five days, two weeks, four weeks, six weeks, and 12 weeks after the treatment began. After 12 weeks, there was a 4.5-point improvement in the mean PANSS negative symptoms subscale score for patients who received tDCS, compared with a 1.8-point improvement in the sham group. Forty percent of those in the tDCS group achieved treatment response (a 20% or greater improvement in negative symptoms), compared with only 4% in the sham group. The participants had no serious adverse effects, such as acute psychosis or hospitalization, though those who received tDCS reported a burning sensation over the scalp.

“Our findings encourage the use and optimization of this technique in patients with psychotic disorders,” the authors concluded.

For related information, see the American Journal of Psychiatry article “Low-Intensity Transcranial Current Stimulation in Psychiatry.”

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