Friday, September 13, 2019

Methamphetamine Involved in Rising Number of Heroin Treatment Admissions

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

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

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

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

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

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

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

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

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Thursday, September 12, 2019

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

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

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

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

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

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

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

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

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Wednesday, September 11, 2019

Getting Patients to Exercise Could Reduce Population Burden of Mental Illness

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

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

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

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

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

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

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

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

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

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Tuesday, September 10, 2019

Homophobic Bullying May Increase Suicidal Thoughts in Heterosexual Youth

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

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

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

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

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

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

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Monday, September 9, 2019

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

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

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

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

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

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

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

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

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Friday, September 6, 2019

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

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

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

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

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

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

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

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

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Thursday, September 5, 2019

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

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

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

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

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

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

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

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Wednesday, September 4, 2019

Children With ADHD May Be More Likely to Report Concussion Symptoms

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

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

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

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

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

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

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

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Tuesday, September 3, 2019

Immune System Response May Offer Clues About Psychosis, Study Suggests

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

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

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

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

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

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

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