Friday, April 19, 2019

Repeated Media Exposure to Mass Violence Linked to Posttraumatic Stress Symptoms


Tomorrow marks the 20th anniversary of the school shooting in Columbine, Colo., that claimed the lives of 15 people, and the media have already begun to bombard viewers with images and footage of the massacre’s aftermath. Although it’s natural to turn to the news to get information about such events, watching coverage of them over and over may be harmful to mental health, according to a study in Science Advances. The researchers, led by Roxane Cohen Silver, Ph.D., at the University of California, Irvine, found that media exposure to traumatic events may make viewers more emotionally sensitive to news reports of other, similar events, and cause anxiety and worry about future occurrences.

In the study, 4,165 U.S. adults responded to four surveys over the span of three years. They completed the first survey two to four weeks after the bombings at the Boston Marathon in 2013, with subsequent surveys six months later, at the second anniversary of the bombings, and five days after the Pulse nightclub shootings in Orlando, Fla., in 2016. The surveys were designed to capture participants’ responses to both tragedies and examine how responses to the Boston bombings affected their reactions to news coverage of the Orlando shootings.

The researchers found that media exposure to the Boston bombings was associated with symptoms of posttraumatic stress and with worry about future events, even two years after the bombings. Furthermore, the more worry and posttraumatic symptoms participants had, the more coverage of the Orlando shootings they watched, which led to even more distress.

“Given the apparent role that worry about the future plays in perpetuating this cycle of sensitivity to distress, this cycle may contribute to a prolonged physiological stress response that heightens risk for stress-related diseases,” Silver and colleagues wrote.

The researchers called upon the media to consider how it covers mass violence and traumatic events.

“Our findings suggest that media organizations should seek to balance the sensationalistic aspects of their coverage (e.g., providing more informational accounts as opposed to lengthy descriptions of carnage) as they work to inform the public about breaking news events,” they wrote. “This may reduce the impact of exposure to one event, reducing the likelihood of increased worry and media-seeking behavior over time.”

(Image: gilaxia/iStock)

Thursday, April 18, 2019

Certain Variations of CBT Found as Effective as Individual CBT


Group, telephone, and guided self-help formats of cognitive-behavioral therapy (CBT) are as effective as individual CBT to treat depression, according to a study published yesterday in JAMA Psychiatry. However, guided self-help CBT is associated with a higher rate of dropouts than the other formats.

“This study suggests that group, telephone, and guided self-help treatments … may be considered as alternatives to individual CBT,” wrote Pim Cuijpers, Ph.D., of Vrije University in the Netherlands and colleagues. “Applying effective and acceptable CBT in a range of different formats will make CBT easier to implement, disseminate, and deliver across different settings and diverse patient populations.”

Cuijpers and colleagues used a technique known as a network meta-analysis to compare 155 clinical trials involving CBT for the treatment of depression. These trials included CBT delivered in individual, group, telephone-based, guided self-help (in which a therapist provides some assistance), and unguided self-help (no therapist contact) formats. The self-help categories grouped together both internet and non-internet (for example, book) delivery methods. These studies also included two types of control groups: usual care and wait list.

The comparisons showed that individual, group, guided self-help, and telephone CBT were all statistically more effective than unguided self-help CBT, as well as wait-list and usual-care controls. No significant differences were found between individual, group, guided self-help, and telephone CBT.

“Unguided self-help differs from the others in that it is the only modality that does not involve at least some contact with a helping person,” wrote Holly Swartz, M.D., and Jay Fournier, Ph.D., of the University of Pittsburgh School of Medicine, in an accompanying editorial. “This finding is consistent with other reports suggesting that individuals with depression benefit more from psychotherapy when there is at least a modicum of human interaction.”

The researchers also assessed differences in acceptability based on the responses of participants who dropped out for any reason. There were no differences in acceptability between individual, group, telephone, and unguided CBT, but guided self-help CBT was less acceptable than both individual and group CBT and both control conditions.

“It is not clear why the acceptability of guided self-help CBT was lower compared with that for the other formats,” Cuijpers and colleagues wrote. “Maybe the absence of direct contact with a professional makes it easier to stop the treatment because there is less personal-relationship pressure to continue with the treatment or the study. However, lower acceptability would then also be expected to happen in unguided CBT, which we did not find. More research is needed to examine this issue.”

To read more about different CBT modalities, see the Psychiatric News article “Guided Online CBT Benefits Patients With Depression, Anxiety.”

(Image: Monkey Business Images/Shutterstock)

Wednesday, April 17, 2019

APA Members: Register by May 1 to Vote in Caucus Elections


APA members have formed seven Minority and Underrepresented (M/UR) Caucuses, which provide networking opportunities, advance treatment of minority patient populations, advocate for minority mental health issues, provide representation in APA governance, and foster communication among members who share interests. To vote in one of the caucuses holding elections later this year—the Caucus of Black Psychiatrists and the Caucus of International Medical Graduates—members must join one of the caucuses and select it as the caucus in which they want to vote by May 1.

(Note: While APA members may join more than one caucus, they can vote for the leadership of only one caucus. APA members who are already a registered caucus member must still select the caucus in which they wish to vote.)

To join a caucus or update your caucus membership, please log in to your member profile. Details on the nominations and election processes will be provided to caucus members who register by May 1.

There are seven M/UR caucuses: American Indian/Alaska Native/Native Hawaiians, Asian Americans, Blacks, Hispanics, LBGTQ members, International Medical Graduates, and Women. Membership is open to all APA members who are interested in topics concerning psychiatrists or patients belonging to these seven groups.

For more information on the caucus leadership positions that will be open for election later this year, check out the Minority and Underrepresented (M/UR) Caucus Elections webpage or email caucuselections@psych.org. 

(Image: iStock/Poike)

Tuesday, April 16, 2019

Women Speakers Underrepresented at Medical Conferences but Numbers on Rise


The proportion of women speakers at medical conferences increased between 2007 and 2017 but continues to be well below 50%, reflecting continued underrepresentation of women in medicine generally, according to an analysis in JAMA Network Open.

“[T]he perceived gender gap in speakers at physician conferences likely represents the overall gender gap in academic medicine rather than a bias specific to conferences,” wrote Shannon M. Ruzycki, M.D., of the University of Calgary and colleagues.

Ruzycki and colleagues analyzed meeting programs and faculty lists of medical and surgical meetings in 2007 and from 2013 through 2017. Each list of names was analyzed using a validated web-based tool that can identify names in a text-based document and predict whether the first name belongs to a woman. The proportion of women speakers was compared with the average proportion of practicing physicians in the United States and in Canada.

There were 701 meeting programs available for analysis. Of those, 82 meetings (12%) had more than 50% women speakers. In addition, the average proportion of conference speakers who were women significantly increased from 2007 to 2017—24.6% to 34.1%.

The mean proportion of women physicians practicing in the United States and Canada saw a similar increase, from 26.1% in 2007 to 32.4% in 2015 (the last year for which data on the sex of practicing physicians were available, according to the study authors).

Ruzycki and colleagues noted that the presence of women role models in careers dominated by men can increase the engagement of young women.

“Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated,” they wrote. “Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine."

For related information, see the Psychiatric News article “Panel Discusses Obstacles Facing Women in Medicine.”

(Image: iStock/piranka)

Monday, April 15, 2019

Smoking Cessation Program Tailored to Patients With SMI Reduces Smoking, Improves Health


A smoking cessation intervention tailored to people with severe mental illness (SMI) such as schizophrenia can lead to reduced smoking and improved physical health in the short term, reports a study published in Lancet Psychiatry.

Compared with patients with SMI who received standard smoking cessation treatment, patients who received the tailored intervention that combined behavioral and pharmacological therapy were more than twice as likely to have successfully quit smoking at six months. These improvements, however, were maintained by only 15% of the patients at the 12-month mark.

“The results of the SCIMITAR+ [Smoking Cessation Intervention for Severe Mental Illness] trial will be helpful in informing clinical practice, since we have shown that quitting can be achieved for people who use mental health services just as it can for the general population of smokers,” wrote Simon Gilbody, D.Phil., of the University of York and colleagues. “Clinicians should therefore ask all of their patients about smoking status and offer referrals to effective smoking cessation services.”

The study included 526 adults with SMI (which included schizophrenia, schizoaffective disorder, and bipolar disorder) who smoked at least five cigarettes a day. All study participants expressed an interest in reducing or quitting smoking. The participants were randomly assigned to receive usual care (access to smoking cessation medications and a telephone helpline) or a tailored cessation intervention for 12 months. The tailored intervention included cessation medications and behavioral therapy adapted to meet the needs of people with SMI; these adaptations included providing assessments and nicotine replacement before setting a quit date, providing home visits, and providing additional face-to-face support following smoking relapse.

The tailored intervention was well received; 234 of the 265 participants (88%) assigned to the intervention attended at least one therapeutic session over 12 months, with an average attendance of 6.4 sessions. After six months, 14% of the participants in the intervention group had successfully quit (which was confirmed with a carbon monoxide breath test) compared with 6% of participants in the usual care group. At 12 months, the participants in the intervention group maintained a higher quit rate compared with usual care (15% versus 10%), though the difference was no longer statistically significant.

“This finding is in line with research in the general population that shows that long-term cessation of smoking is difficult to achieve and remains a challenge in treatment for nicotine dependence in any population,” Gilbody and colleagues wrote.

Among secondary assessments, physical health scores were higher in the intervention group compared with the usual care group after six months, though this improvement also disappeared after 12 months. There were no differences in depression or anxiety scores between the two groups at either six or 12 months, which the authors noted as supportive evidence that smoking cessation interventions are not detrimental to mental health.

For related information, see the Psychiatric News article “Schizophrenia Patients Show Cognitive Improvements After Smoking Cessation.”

(Image: iStock/Sezeryadigar)

Friday, April 12, 2019

Developmentally Adapted Cognitive Processing Therapy Effective for Youth With Abuse-Related PTSD


Adolescents and young adults with a history of childhood sexual and/or physical abuse and symptoms of posttraumatic stress disorder (PTSD) benefitted considerably from developmentally adapted cognitive processing therapy (D-CPT) compared with those in a wait-list group with treatment advice, according to a study published in JAMA Psychiatry. Both study groups showed a significant reduction in PTSD symptom severity, but the outcome of posttreatment assessment was enhanced for those participants receiving D-CPT.

Although cognitive processing therapy is one of the most extensively studied treatments for adult PTSD, “CPT has rarely been tested in traumatized youth and has not been adapted to the specific needs of young people with a history of abuse,” wrote Rita Rosner, D.Phil., of the Catholic University of Eichstätt-Ingolstadt in Germany and colleagues.

For the study, the researchers randomly assigned 88 adolescents and young adults (aged 14 to 21 years) who were seeking treatment in outpatient clinics in Germany to either the D-CPT group or wait-list group with treatment advice. Those in the D-CPT treatment group completed at least 30 50-minute sessions over the course of 16 to 20 weeks. CPT therapy was adapted for adolescents and young adults with childhood abuse by beginning with a commitment phase to enhance treatment motivation and therapeutic alliance as well as a phase on emotion-management techniques. These were followed by an intense CPT phase (15 sessions in four weeks) to address fluctuating motivation in adolescents. Special consideration to developmental tasks, such as career choice and romantic relationships, was also integrated. Participants in the control group were advised to seek treatment outside the trial until after the three-month follow-up, at which time they received D-CPT.

The primary outcome of PTSD severity was assessed using the Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV (CAPS-CA) before treatment, at eight weeks, posttreatment, and at a three-month follow-up. Participants in the D-CPT group had a lower posttreatment mean CAPS-CA score than controls (24.7 versus 47.5, respectively). These treatment effects were maintained through the three-month follow up. Secondary outcomes of self-reported PTSD severity, depression, borderline symptoms, behavior problems, and dissociation also showed greater and stable improvement in D-CPT participants.

These results were comparable to effect sizes reported for CPT in adults. However, treatment effects were not noted until the mid-treatment assessment during the high-intensity CPT phase. The authors wrote, “This finding further challenges the need for a stabilization phase or emotion-regulation training before trauma-focused treatment, at least in adolescents with abuse-related PTSD.”

For related information, see the Psychiatric News article “Beyond PTSD: The Complexity of Diagnosis and Treatment for Teens in Child Welfare Custody.”

(Image: iStock/izusek)

Thursday, April 11, 2019

Pregnant Women May Be Less Likely to Get Depression Treatment Than Other Women


More than half of pregnant women who are depressed may not get depression treatment, according to a study published Wednesday in Psychiatric Services in Advance.

The researchers analyzed results from the 2011-2016 National Survey on Drug Use and Health, zeroing in on the 12,360 women of reproductive age (18 to 44 years) who reported symptoms of a major depressive episode during the past year according to DSM-IV criteria. These women were asked whether there was a time during the past year when they needed mental health treatment or counseling but did not get it and, if so, why not. Researchers then compared the responses of women in the sample who were pregnant (3%) with those who were not (97%).

The researchers found that 51% of pregnant women and 43% of nonpregnant women with depression did not get treatment. Financial concerns, including the cost of the treatment, were cited by both groups of women as the primary reason for not receiving needed mental health treatment or counseling, according to study author Maria X. Sanmartin, Ph.D. (pictured above), an assistant professor at Hofstra University, and colleagues.

“It is surprising that 51% of pregnant women with major depressive episode did not receive any mental health treatment,” Sanmartin told Psychiatric News. “OB-GYNs should be asking about patients’ mental health status, raising patient awareness, and at least be offering patients the opportunity to receive mental health treatment.”

Sanmartin said pregnant women with a major depressive episode reported high prevalence of past-month substance use, including alcohol use (23%), marijuana use (17%), and misuse of prescription pain relievers (6%).

These are among the other findings reported in the study:

  • About 40% of pregnant women reported having an unmet need for mental health care treatment or counseling versus 34% of the nonpregnant women.
  • Financial concerns, including cost of care, were the most commonly cited reason among the women for not getting mental health care (22% of pregnant women versus 18% of nonpregnant women). Pregnant women with a depressive disorder were more likely to be low income, receive public insurance benefits, and were less likely to have a college degree.
  • Prescription medication was the most prevalent form of treatment among pregnant women (40%), despite treatment guidelines recommending evidence-based psychosocial interventions and contact with psychiatrists before initiating pharmacological treatment.

“Although care and intervention before pregnancy would be ideal, greater barriers exist among pregnant women and warrant attention,” the researchers wrote. “Integrated health care delivery models between primary health care and behavioral health, mental health screening during pregnancy, and telepsychiatry services are important tools to pursue in tackling major depressive episodes among women.”

For more information, see the Psychiatric News article “APA Releases New Statement on Perinatal Disorders.”

Wednesday, April 10, 2019

APA Protests New Policy Against Transgender Military Service Members


APA is protesting the implementation of a ban that goes into effect on Friday, April 12, on transgender individuals serving in the military. As of that day, the Department of Defense (DoD) is requiring transgender service members to follow the standards of their biological sex or be removed from service.

DoD policy under former President Barack Obama allowed transgender service members to seek treatment; now DoD intends to discriminate against those who came forward, APA said in a statement released yesterday.

“APA has long fought against discrimination against any patient population,” said APA President Altha Stewart, M.D. “This ban perpetuates discrimination and stigma against transgender people. Furthermore, this ban harms the military by depriving the service branches of willing and capable members.”

President Donald Trump signed the ban last March, which disqualifies individuals who are transgender from serving in the military except under certain limited circumstances. In response, four federal courts issued preliminary injunctions to block it. But in January, a 5-4 Supreme Court decision lifted the injunctions and allowed the ban to take effect while the cases challenging the policy continue to wind their way through the courts.

“As physicians providing treatment for mental illness and substance use disorders, we affirm that being transgender or gender diverse implies no impairment in judgment, stability, reliability, or ability to serve in the military,” APA said in its statement. “We urge the administration to eliminate this policy and instead work with our organization to ensure policy decisions are informed by medical evidence.”

A position statement first approved by the APA Board of Trustees in 2012 and re-approved last year opposes discrimination against transgender and gender-diverse individuals and urges the repeal of laws and policies that discriminate against these individuals.

For related information, see the Psychiatric News article “APA Opposes Ban on Transgender Military.”

(Image: iStock/PeopleImages)

Tuesday, April 9, 2019

Recurrent Phone Call Intervention May Reduce Suicidality in Adolescents Following Hospitalization


Adolescents who have been hospitalized for suicidal behaviors may benefit from recurrent follow-up calls following hospital discharge, according to a report in Psychiatric Services.

Compared with adolescents receiving a single post-discharge call, adolescents receiving recurrent phone calls had a significantly lower rate of suicidal behavior and greater confidence in their suicide safety plan.

For the study, Manviel Rengasamy, M.D., a resident at the University of Pittsburgh Medical Center (UPMC), and Garrett Sparks, M.D., an assistant professor of psychiatry at UPMC, randomly assigned 142 youth aged 12 to 18 who had been hospitalized for suicidal thoughts or suicide attempts to receive either a single telephone call intervention or an intervention involving up to six telephone calls over 90 days

The telephone intervention consisted of a 10- to 20-minute phone call to participants and guardians from a member of the hospital’s child psychiatry house staff. In the call with guardians, staff reviewed parental concerns about suicidality and treatment follow-up. During the call with the adolescents, staff and adolescents assessed suicidality using the Columbia Suicide Severity Rating Scale and reviewed the youth’s confidence in a safety plan (based on the National Suicide Prevention Lifeline’s safety plan). They also reviewed short- and long-term goals and discussed reasons for living.

Adolescents in the recurrent-intervention group received calls at approximately 1, 7, 14, 30, 60, and 90 days post-discharge, whereas those in the single call-intervention group received one call at approximately 90 days post-discharge.

Overall, 16 participants (11%) exhibited suicidal behavior within the 90-day period: four participants were in the recurrent-intervention group and 12 were in the single-call group. The participants receiving recurrent calls reported higher average confidence in their safety plan (95.4%) compared with participants receiving a single call (73.6%).

“Given the urgent need for effective treatments to reduce adolescent suicides, cost-effective and telephone-based, post-discharge interventions should be evaluated in larger trial,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “As Safe as Possible (ASAP): A Brief App-Supported Inpatient Intervention to Prevent Postdischarge Suicidal Behavior in Hospitalized, Suicidal Adolescents.”

(Image: iStock/GCShutter)

Monday, April 8, 2019

Study Suggests Effective Next-Step Treatments for Treatment-Resistant Depression


A new study of predictors and moderators of remission for treatment-resistant major depressive disorder (MDD) found two subgroups of patients who may benefit from specific next-step treatments with aripiprazole or bupropion, according to a report in AJP in Advance.

The study by Sydney Zisook, M.D. (pictured left), a distinguished professor of psychiatry at the University of California, San Diego, and colleagues involved 1,500 mostly older white men with nonpsychotic MDD who were enrolled in the Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) study. To be included in VAST-D, participants had to have previously failed to respond to at least one course of antidepressant treatment.

VAST-D focused on the effectiveness and safety of three next-step treatment strategies over a 12-week trial: switching to sustained-release bupropion, combining the current medication with sustained-release bupropion, or augmenting the current medication with the antipsychotic aripiprazole. VAST-D participants took a battery of tests, including the Quick Inventory of Depressive Symptomatology—Clinician Rated (QIDS-C), the Clinical Global Impressions severity scale (CGI-S), and the Patient Health Questionnaire (PHQ-9) and had treatment visits at baseline and at weeks 1, 2, 4, 6, 8, 10, and 12.

The first report from the trial revealed that patients who took aripiprazole in addition to the antidepressant they were previously taking had the highest 12-week remission and response rates compared with patients who took bupropion in addition to antidepressants or switched to bupropion.

This latest study focused on helping clinicians predict the most effective treatment strategies for individual patients based on sociodemographic or clinical features, a subject on which Zisook told Psychiatric News there has been very little research to date. These features included age, ethnicity, and employment status; depressive symptom severity, chronicity, and subtype; level of anxiety; mixed hypomanic symptoms; childhood adversity; grief; co-occurring general medical and psychiatric conditions; positive mental health; and quality of life.

The analysis revealed that augmentation with aripiprazole was more effective for patients aged 65 years and older, compared with the bupropion regimens, whereas for patients with severe mixed hypomanic symptoms, augmentation with aripiprazole or combination of current treatment and bupropion was more effective than switching to bupropion.

The researchers also found that most patient demographic features did not predict overall remission at 12 weeks. However, remission was more likely for individuals who were employed, less severely and chronically depressed, less anxious, and not experiencing complicated grief symptoms and who had not experienced childhood adversity. Participants with longer durations of the initial antidepressant medication trial, better quality of life, and positive mental health were also more likely to achieve remission.

“Overall, it’s really a balancing act, and there’s no clear rule that’s going to apply to each patient,” Zisook said. “When considering what’s most likely to be effective versus potential side effects, you should always engage the patient when coming up with next-step treatments—because they’re the ones that need to be compliant in taking the medication. So they should be partners in making the decision.”

For more information, see the Psychiatric News article “Study to Answer What Comes Next When MDD Patients Don’t Respond.”

Friday, April 5, 2019

Teachers’ Mental Health Linked to Students’ Well-Being, Study Shows


Teachers’ mental health and well-being can affect the mental health and well-being of their students, according to research published in the Journal of Affective Disorders.

Sarah Harding, M.Sc., of Bristol Medical School in the United Kingdom and colleagues collected data from 3,215 12- and 13-year-old students and 1,182 teachers in 25 secondary schools in England and Wales in June and July 2016. They measured all participants’ well-being with the Warwick Edinburgh Mental Wellbeing Scale, for which a higher score means greater well-being. They used standard questionnaires and scales to assess the teachers’ depressive symptoms and presenteeism (working while physically or psychologically ill or stressed) and student psychological distress. The researchers also created a questionnaire to measure the quality of teacher-student relationships in which students were asked to rate the following statement, “teachers and students generally have good relationships at this school” from “strongly disagree” to “strongly agree.”

The researchers found that greater teacher well-being and better teacher-student relationships were associated with greater student well-being and lower student psychological distress. They also found that higher teacher presenteeism and absence—but not teacher depressive symptoms—were associated with poorer student well-being and higher student psychological distress. Stronger teacher-student relationships appeared to offset the impact of teacher depressive symptoms on student psychological distress.

The researchers also noted that student mental health and well-being could affect teacher mental health and well-being as well.

“The relationships between teacher well-being, the quality of teacher-student relationships, teacher presenteeism, and student mental health outcomes are clearly complex and likely to be interrelated,” the authors wrote. “The results of this study suggest that improving teacher well-being may lead to better student well-being via more supportive relationships or reduced teacher presenteeism.”

(Image: iStock/SolStock)

Thursday, April 4, 2019

FDA Warns Some E-Cigarette Users Having Seizures, Particularly Youth


Psychiatrists may wish to ask patients about vaping, particularly adolescents and young adults, in response to a special announcement released yesterday by the Food and Drug Administration (FDA) regarding the incidence of seizures following use of e-cigarettes.

An FDA review of voluntary adverse event reports for e-cigarettes identified 35 cases of seizures following use of these products between 2010 and early 2019. Seizures or convulsions are known potential side effects of nicotine toxicity and have been reported following intentional or accidental swallowing of e-liquid. Some e-cigarettes deliver high concentrations of nicotine, with some containing as much nicotine as an entire pack of regular cigarettes.

“While 35 cases may not seem like much compared to the total number of people using e-cigarettes, we are nonetheless concerned by these reported cases,” wrote outgoing FDA Commissioner Scott Gottlieb, M.D., and Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D., in a joint statement.

Gottlieb and Abernethy asserted that e-cigarettes could “serve as an off-ramp for currently addicted adult smokers to completely switch to a potentially less harmful form of nicotine delivery.” At the same time, however, the pair acknowledged “tremendous concern for epidemic-level rises of youth e-cigarette use.” The results of the 2018 National Youth Tobacco Survey showed that e-cigarette use rose by nearly 80 percent among high schoolers and 50 percent among middle schoolers from 2017 to 2018.

“We also recognize that not all of the cases may be reported,” wrote Gottlieb and Abernethy. “We believe these 35 cases warrant scientific investigation into whether there is in fact a connection.” Such seizures have been reported among first-time e-cigarette users and experienced users, and after a few puffs or up to one day after use.

The FDA is asking health care professionals and the public to report any unexpected health or safety issues involving e-cigarettes through the agency’s Safety Reporting Portal at https://www.safetyreporting.hhs.gov.

For more information, see the Psychiatric News article “Experts Call For More Action to Thwart Youth Vaping ‘Epidemic.’

Wednesday, April 3, 2019

Repeat Ketamine Infusions Found to Have Cumulative, Sustained Antidepressant Effects


Repeat infusions of ketamine, starting thrice weekly then transitioning to once weekly, elicit a cumulative and sustained antidepressant response in patients with treatment-resistant depression, reports a study in AJP in Advance. This three-phase study also provides some of the first data to directly compare the response rates of single versus repeated infusions of ketamine, which will help inform clinical practice.

“Although the antidepressant effects of ketamine become evident within a few hours or one day of a single infusion, the benefits generally disappear within one week,” wrote Jennifer Phillips, Ph.D., of the Royal’s Institute of Mental Health Research and colleagues. As the clinical use of ketamine increases, studies like this can help identify the ideal course of long-term treatment to maximize benefits with the least number of ketamine infusions, the authors wrote.

The study included 41 participants who met DSM-IV-TR criteria for major depressive disorder and had failed at least two six-week trials of other antidepressant medications and two six-week augmentation trials prior to the present episode.

For phase one, all participants received separate infusions of both ketamine or midazolam (order determined at random) at least seven days apart. Patients whose symptoms returned to baseline—assessed using Montgomery-Åsberg Depression Rating Scale (MADRS) scores—proceeded to phase two and received six open-label ketamine infusions thrice weekly over a two-week period. Participants who showed an antidepressant response (defined as a ≥50% decrease in MADRS total score from baseline) after three weeks proceeded to phase three and received once weekly ketamine infusions for an additional four weeks.

The results of the first phase demonstrated that ketamine provided a superior antidepressant response to midazolam at all measured time points (2 hours, 24 hours, and 7 days post-infusion). All 41 participants returned to baseline and proceeded to phase two. In phase two, 23 participants (59%) achieved an antidepressant response, including 9 of 11 patients who responded in phase one. “This suggests that ketamine may differ from other medications used to treat mood disorders, with which patients may fail to achieve a response after relapse if a medication is discontinued prematurely,” Phillips and colleagues wrote.

An average of three infusions was required to obtain a response, and the MADRS total score decreased by an average of two points with each infusion. These improvements in mood remained stable throughout the four-week maintenance phase. No serious adverse events were reported during the trial.

For more information, see the Psychiatric News article “ ‘Cautious Optimism’ Marks Outlook for Ketamine, Mood Disorders.”

(image: iStock/slobo)

Tuesday, April 2, 2019

Family Risk of Suicide Mediated by Presence of Psychiatric Disorders, Study Shows


Suicide runs in families, especially those in which family members have two or more psychiatric disorders, according to a report in JAMA Psychiatry. Individual family members with bipolar disorder are especially likely to have a history of suicide attempt.

Additionally, a family history of social anxiety, regardless of individual mental health status, appears to confer an increased risk for suicide.

“More than half of [first-degree relatives] with a history of suicide attempts had more than two lifetime conditions including mood, anxiety, and substance use disorders as compared to about 15% of those without a history of suicide attempts,” Kathleen Merikangas, Ph.D., of the Genetic Epidemiology Research Branch in the Intramural Research Program at NIMH (pictured left) told Psychiatric News.

A total of 1,119 study subjects and 5,355 of their first-degree relatives were recruited at two sites in Washington, D.C., and Lausanne, Switzerland. The study subjects included 154 with bipolar disorder, 475 with major depressive disorder, 182 with other non-mood disorders, and 308 controls. Data were collected and analyzed from October 2004 to December 2016.

The study found that a total of 90 study subjects (8.0%) and 199 relatives (3.7%) had a lifetime history of a suicide attempt. Among the relatives who had a suicide attempt, 56.8% (113 of 199) had a history of more than two disorders.

Relatives with bipolar I or II disorder, with or without a second psychiatric disorder, had a 36 percent higher risk of having a history of suicide attempt.

Merikangas and colleagues also found that a family history of social anxiety, regardless of individual mental health status, was associated with suicide attempts. This may reflect increased reactivity of people with social anxiety to stressors, especially those of a social nature such as loss or isolation, she said.

Screening for suicide attempts should be broadened to include individuals with mood and anxiety disorders and comorbid conditions rather than only those with major depressive disorder, Merikangas told Psychiatric News.

For related information, see the Psychiatric News article "Upping Our Game to Prevent Suicide."

(Image courtesy Kathleen Merikangas, Ph.D.)

Monday, April 1, 2019

Reduction in Irritability Found to Predict Response to Depression Treatment


Early reductions in irritability are a reliable indicator of whether a patient with depression will respond to treatment after eight weeks, reports a study published Friday in AJP in Advance.

Despite the wide prevalence of irritability in patients with depression, “measurement-based care protocols and treatment guidelines for major depressive disorder do not systematically assess or incorporate irritability in clinical decision making," wrote Manish Jha, M.B.B.S., of the University of Texas Southwestern Medical Center and colleagues. “These findings support [the] inclusion of assessments of irritability in measurement-based-care approaches for the treatment of patients with major depression.”

Jha and colleagues used patient data from the Combining Medications to Enhance Depression Outcomes (CO-MED) trial to calculate how changes in irritability in the first four weeks of antidepressant treatment affect outcomes after eight weeks. According to the authors, four weeks was chosen as the timeframe to measure change from baseline in irritability and depressive symptom severity because this is considered the first critical decision point for assessing treatment response. Irritability was measured with the five-item irritability section of the Concise Associated Symptom Tracking (CAST-IRR) scale.

The authors found that the patients who had experienced about a 25% reduction in irritability scores in the first four weeks had a 73% increased likelihood of remission (defined as a score 5 or less on the clinician-rated Quick Inventory of Depressive Symptomatology, or QIDS-C scale) and a 72% decreased likelihood of showing no meaningful benefit (defined as a 30% or lower drop in QIDS-C score in response to treatment) at week 8. These effects were independent of changes in other depressive symptoms or overall severity of the depression. The results were validated in patients from a second depression study.

Jha and colleagues have created an easy-to-use interactive calculator to determine the probabilities of treatment response in their patients at eight weeks based on QIDS-C and CAST-IRR scores at baseline and after four weeks of antidepressant therapy.

To read more about early predictors of depression outcomes, see the Psychiatric News article “Productivity, Exercise May Predict Antidepressant Response.”

(image: iStock/sturti)

Disclaimer

The content of Psychiatric News does not necessarily reflect the views of APA or the editors. Unless so stated, neither Psychiatric News nor APA guarantees, warrants, or endorses information or advertising in this newspaper. Clinical opinions are not peer reviewed and thus should be independently verified.