Friday, February 14, 2020

Secondhand Smoke May Raise Risk of Depressive Symptoms in Adolescents

Adolescents who are exposed to secondhand smoke may be more likely to develop symptoms of depression, a study in the American Journal of Preventive Medicine has found. The risk is also dose-dependent, meaning that the more secondhand smoke to which an adolescent is exposed, the higher the risk.

“Smoking has been linked with depressive symptoms in adolescents, but data on secondhand smoking and depressive symptoms in low- and middle-income countries are scarce,” wrote Louis Jacob, Ph.D., of the University of Versailles Saint-Quentin-en-Yvelines in France and colleagues. “This is an important omission as enforcement of tobacco control policy legislation is weaker in [low- and middle-income countries] compared with high-income countries.”

The researchers analyzed data from the 2003-2008 Global School-Based Student Health Survey of more than 37,000 adolescents aged 12 to 15 years who had never smoked and who lived in 22 low- or middle-income countries. To determine participants’ exposure to secondhand smoke, they were asked, “During the past seven days, on how many days have people smoked in your presence?” To determine whether participants had experienced symptoms of depression, they were asked, “During the past 12 months, did you ever feel so sad or hopeless every day for two weeks or more in a row that you stopped doing your usual activities?”

Overall, 53.6% of the participants had been exposed to secondhand smoke on at least one day in the past week, and 24.5% had experienced depressive symptoms in the past year. Nearly 29% of participants who were exposed to secondhand smoke every day over the past week had experienced depressive symptoms compared with 23% of those who were not exposed to secondhand smoke. Compared with those who were not exposed to secondhand smoke over the previous week, those who were exposed on at least three days were 48% more likely to have experienced depressive symptoms, while those who were exposed on all seven days were 63% more likely to have experienced depressive symptoms.

The researchers wrote that the increased risk of depressive symptoms in adolescents exposed to secondhand smoke may stem from increased levels of perceived stress because of physical discomfort, the association between secondhand smoke and chronic physical conditions in childhood and adolescence such as asthma, and/or the effects of nicotine on neurotransmitters and inflammation.

“If corroborated by further longitudinal studies, these findings suggest that reducing [secondhand smoke] exposure may be important not only for the prevention of physical diseases such as ischemic heart disease, lung cancer, and asthma, but also for adolescent depressive symptoms in [low- and middle-income countries],” the researchers wrote.

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Thursday, February 13, 2020

Psychiatric Medications Not Associated With Poorer Weight Loss Following Bariatric Surgery

Psychiatric medications do not appear to interfere with weight loss in obese patients who have had bariatric surgery, according to a report in Psychosomatics, the journal of the Academy of Consultation-Liaison Psychiatry.

Moreover, serotonin-norepinephrine reuptake inhibitors (SNRIs) may be associated with greater weight loss than other types of antidepressants one year after bariatric surgery, according to Michael Hawkins, M.D., of the Scarborough Health Network-Centenary Site in Ontario and colleagues.

Comorbid psychiatric illness is common among obese patients who have bariatric surgery, and some antidepressants are known to cause weight gain. Hawkins and colleagues sought to determine whether psychiatric medications affected the amount of weight lost following surgery.

They analyzed data on 190 patients who had bariatric surgery. Of these, 61 were taking psychiatric medications before surgery, and 50 continued taking psychiatric medications one year after surgery. Antidepressants and benzodiazepines/hypnotics were the most common medications taken by patients before and after surgery.

They found no significant difference in total weight loss between patients taking a psychiatric medication before surgery compared with those who were not; nor was there a difference in weight loss among those taking a psychiatric medication one year after surgery compared with those who were not. Among patients taking antidepressants, those taking SNRIs lost significantly more weight than patients taking serotonin selective reuptake inhibitors (36.4% vs. 27.8%).

“This longitudinal study suggests that psychiatric medication use was not associated with poorer [percent total weight loss] at one year after bariatric surgery, wrote the researchers. “Within class, antidepressant use may have differential effects on weight loss after bariatric surgery and warrants further investigation.”

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

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Wednesday, February 12, 2020

APA Announces Results of 2020 Election

APA’s Committee of Tellers has approved the following results of APA’s 2020 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting on March 14 and 15 in Washington, D.C.

Vivian B. Pender, M.D.

Richard F. Summers, M.D.

Michele Reid, M.D.

Area 2 Trustee
Glenn A. Martin, M.D.

Area 5 Trustee
Jenny Boyer, M.D., Ph.D., J.D.

Resident-Fellow Member Trustee-elect
Sanya Virani, M.D., M.P.H.

“I congratulate Dr. Pender and all of today’s successful candidates on their election,” said APA President Bruce Schwartz, M.D. “I look forward to collaborating with them as APA works to improve access to and quality of mental health care for all.”

Pender’s term as APA president-elect will begin this April at the conclusion of the APA Annual Meeting in Philadelphia, when current President-elect Jeffrey Geller, M.D., M.P.H., begins his one-year term as president.

“APA members and the profession of psychiatry will be well served by the leadership of Dr. Pender,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “I have known her for years, and her dedication and passion for psychiatry will greatly benefit APA during her tenure.”

Complete results of the election will be reported in the March 6 issue of Psychiatric News.

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Tuesday, February 11, 2020

Exposure to Mother’s Heightened Immune Response in Womb May Increase Schizophrenia Risk

Exposure to a mother’s heightened immune response early in pregnancy may increase an individual’s risk of developing schizophrenia, suggests a study in Lancet Psychiatry.

“We found that higher concentrations of proinflammatory cytokines [TNFα, IL-1β, and IL-6] in specifically the first half of pregnancy were associated with a risk for psychosis among offspring, implicating an earlier timepoint in gestation than previously understood,” wrote Dana Allswede, M.S., and Tyrone Cannon, Ph.D., of Yale University and colleagues. “These three cytokines are potent proinflammatory proteins that have a critical role in the initial response to infection and in initiating and sustaining inflammatory responses.”

The findings were based on data collected for the National Collaborative Perinatal Project (NCPP)—a large-scale prospective longitudinal study. As part of this study, pregnant women from across the United States provided blood samples at prenatal visits and birth from 1958 to 1965.

Allswede, Cannon, and colleagues focused on the women and offspring in the Philadelphia cohort of NCPP, which included 9,236 surviving offspring of 6,753 pregnant women. The researchers examined medical records to determine whether the offspring developed psychotic disorders by adulthood. They also analyzed the concentrations of the following cytokines in the maternal blood samples: TNFα, IL-1β, IL-5, IL-6, IL-8, IL-10, and IL-17a.

The final sample included 90 offspring who later developed psychosis, 79 siblings who did not have psychotic disorder, and 273 matched controls who did not have psychosis. The researchers found that concentrations of proinflammatory cytokines TNFα, IL-1β, and IL-6 were significantly higher in the maternal blood samples of the offspring who later developed psychosis compared with maternal blood samples of the matched controls. “These differences were greatest in the first half of pregnancy …, with no difference observed during the second half of pregnancy,” the authors noted. Siblings and the matched controls did not significantly differ for any of the cytokines.

“Understanding which environmental factors interact with maternal inflammation to increase the risk for psychotic conditions in the offspring, and the pathways through which they act, might provide a framework for early intervention (whether at the maternal, paternal, or childhood level) and build momentum for a much-needed preventive approach to neuropsychiatric disorders,” wrote Bruno Agustini, M.D., Ph.D., and Michael Berk, Ph.D., M.B.B.Ch., of Deakin University in an accompanying editorial.

For related information, see the American Journal of Psychiatry article “Maternal Bacterial Infection During Pregnancy and Offspring Risk of Psychotic Disorders: Variation by Severity of Infection and Offspring Sex.”

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Monday, February 10, 2020

Computer Model Might Help Identify Patients at Risk of Not Taking Their Antidepressants

Using electronic health records, researchers have developed a computer program that can predict which patients are at risk of not taking their prescribed antidepressants with about 70% accuracy. The study was published in Translational Psychiatry.

“Treatment discontinuation may reflect a range of features, from depression-associated amotivation and hopelessness to failure to perceive a benefit to concerns about cost,” wrote Melanie Pradier, Ph.D., of Harvard University and colleagues. “However heterogeneous, the consequences of treatment discontinuation are substantial, contributing to poor treatment outcomes and depression chronicity.”

To build the computer program, Pradier and colleagues analyzed electronic health record data of adult patients aged 18 to 80 who received at least one antidepressant prescription between 2008 and 2014. The study included 51,683 patients who had a diagnosis of a depressive disorder and began treatment with one of nine common antidepressants (bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine) and at least one follow-up visit 90 days or more after their first prescription.

The final sample included 70,121 prescription initiations (as many patients switched antidepressants during treatment). Of these prescriptions, 23.77% were associated with a discontinuation of treatment (for example, no prescription refill and no evidence in the medical record of any nonpharmacological depression treatment). Paroxetine was associated with the highest discontinuation rate (27.71%) while venlafaxine was associated with the lowest (20.78%).

The computer program then analyzed patients’ sociodemographic features and medical history to predict the risk of discontinuation for each of the nine antidepressants. Overall, the program was able to predict the patients who would discontinue an antidepressant with 69% accuracy. For individual medications, the model’s accuracy ranged from 62% for paroxetine to 80% for escitalopram.

Pradier and colleagues highlighted two possible applications for their program: “[T]he risk for discontinuation predicted by the machine-learned model might help in prioritizing interventions aimed at retention in treatment and adherence, including making follow-up phone calls, deploying mobile applications, … or simply scheduling an earlier return visit,” they wrote. Alternatively, these models might be applied in settings where multiple medications would be equally reasonable choices for a patient. “Here, all other things being equal, the clinician might prefer the medication with the lowest risk of treatment discontinuation for that patient.”

For related information, see the Psychiatric News article “Tips for Recognizing, Treating Symptoms of SSRI Discontinuation.”

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Friday, February 7, 2020

Family Conflict, Low Parental Supervision Risk Factors for Suicidality in Children, Study Finds

Family conflict and low parental supervision are associated with suicidality in children, according to a study published today in JAMA Network Open.

“Although many factors that influence a child’s risk for suicide may not necessarily be directly modifiable, family conflict and parental monitoring present targets for intervention,” wrote Danielle C. DeVille, M.A., of the Laureate Institute for Brain Research and colleagues.

DeVille and colleagues analyzed baseline data from the Adolescent Brain Cognitive Development (ABCD) study, a longitudinal study supported by the National Institute of Mental Health that is tracking children from across the United States over a period of 10 years. As part of the ABCD study, 11,814 children (aged 9 and 10) and their caregivers were asked whether the children had current or past suicidal thoughts and/or had ever tried to hurt themselves. Suicidality categories included passive suicide ideation (a wish to be dead), nonspecific active suicidal ideation (wanting to end one’s own life without considering a method or plan to do so), active suicidal ideation, or past suicide attempts. Nonsuicidal self-injury (NSSI) was defined as intentional self-inflected damage to the body without suicidal intent. Children were placed in a given suicidality category if either they or their caregiver reported the behavior.

The researchers gathered information on family and home environments, including parental surveys that detailed the extent to which the parents supervised and/or tracked their children. They also collected the children’s reports of family conflict, including fighting, anger, criticism, competitiveness, yelling, and/or temper within the family.

Overall, 6.4% of the children had a lifetime history of passive suicidal ideation; 4.4% had nonspecific active suicidal ideation; 2.4% had active ideation with a method, intent, or plan; 1.3% had a past suicide attempts; and 9.1% had a NSSI. Additional findings include the following:

  • High family conflict was significantly associated with suicidal ideation and NSSI.
  • Low parental monitoring was significantly associated with ideation, attempts, and NSSI.
  • Most children’s reports of suicidality and NSSI were either unknown or not reported by their caregivers; for 77% of the children who reported suicidal ideation, their caregivers denied all forms of suicidal ideation or attempts. (Families with a history of depression were less likely to have suicidality reports in which the child and parent didn’t agree.)
  • Rates of suicidal ideation and NSSI were higher in boys, though there was no significant difference between boys and girls in the prevalence of suicide attempts.
  • Greater financial problems were found among children who reported suicidal ideation, suicide attempts, and NSSI.
  • No significant differences were found on the basis of race or ethnicity.

“The high levels of parent-child discordance in the reporting of ideation, suicide attempts, and NSSI observed in the current study may have important clinical implications,” the authors wrote. “Our findings highlight the need to ensure that suicide assessments are conducted with children directly rather than solely with the child’s caregivers.”

For related information, see the Psychiatric News article “Preteen Suicides: Rare, Mysterious, and Devastating.”

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Thursday, February 6, 2020

Pain Linked to Increased Risk of Hazardous Drinking in Smokers

Experiencing frequent or intense pain is linked to hazardous drinking in people who smoke tobacco, a study in the American Journal on Addictions has found. The study also suggests that the impact of pain on a person’s mood may be partly to blame.

“Relative to the general population, smokers are four times more likely to be dependent on alcohol and are more likely to experience severe pain,” wrote Lisa R. LaRowe, M.S., of Syracuse University in New York and colleagues. To examine the relationship between pain and alcohol use among smokers, the researchers analyzed measurements of pain and alcohol use in 225 people who smoked at least 15 tobacco cigarettes a day, with an average of 22 tobacco cigarettes a day.

Participants rated the amount of bodily pain they experienced in the four weeks prior to the study on a 6-point scale, with 0 representing “none” and 5 representing “very severe.” They also rated the intensity of their pain over the previous 24 hours on a scale of 0 to 10, with 10 representing the most severe. The researchers used the Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol Urge Questionnaire to determine how much alcohol the participants drank, whether the participants’ alcohol use was hazardous, and whether the participants experienced a strong urge to drink. The researchers also measured the intensity of the participants’ negative emotions via the negative affect subscale of the Positive and Negative Affect Schedule.

Approximately 35% of participants who reported experiencing pain in the prior four weeks scored above the AUDIT cut-off for hazardous drinking, compared with 19% of those who reported experiencing no pain in the prior four weeks. Each one-point increase in pain severity was associated with a 47% greater likelihood of screening positively for hazardous drinking. Moreover, the higher participants scored on pain intensity, the more likely they were to experience negative moods. In turn, the more negative moods they had, the greater the urge they had to drink alcohol.

“These findings provide initial evidence that smokers with greater pain severity may also report hazardous patterns of alcohol use,” the researchers wrote. “The observed indirect association between pain intensity and urge to drink via a negative affect adds to a growing literature indicating that pain can be a potent motivator of substance use in general, and alcohol use in particular.”

For related information, see the American Journal of Psychiatry article “U.S. Adults With Pain, a Group Increasingly Vulnerable to Nonmedical Cannabis Use and Cannabis Use Disorder: 2001–2002 and 2012–2013.”

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Wednesday, February 5, 2020

Experts Say Coronavirus Outbreak Demands Swift Mental Health Response

Mental health care is urgently needed for patients and health care workers affected by coronavirus, wrote Yu-Tao Xiang, M.D., of the University of Macau in China and colleagues in an editorial published Tuesday in Lancet Psychiatry. The authors suggest that the lessons learned from the 2003 severe acute respiratory syndrome (SARS) outbreak can guide the mental health response to coronavirus.

The outbreak of the 2019 novel coronavirus pneumonia (2019-nCoV) has garnered international attention and produced a wave of anxiety. Officials in China, where the outbreak originated, and elsewhere have enacted a range of measures to combat the spread of the virus. Yet, according to Xiang and colleagues, mental health care for patients affected by the virus and those caring for them have largely gone unaddressed.

“The observations of mental health consequences and measures taken during the 2003 SARS outbreak could help inform health authorities and the public to provide mental health interventions to those who are in need,” Xiang and colleagues wrote.

To meet the mental health needs of those affected by the 2019-nCoV outbreak, Xiang and colleagues recommend the following:

  • Authorities should clearly and regularly communicate accurate updates about the 2019-nCoV outbreak to health workers and patients in order to address their sense of uncertainty and fear.
  • Mental health workers should regularly screen suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals caring for infected patients for depression, anxiety, and suicidality.
  • Multidisciplinary mental health teams established by health authorities at regional and national levels (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) should deliver mental health support to patients and health workers.
  • Secure services should be set up to provide psychological counseling using electronic devices and applications for affected patients, as well as their families and members of the public. Using such communication channels between patients and families should be encouraged to decrease isolation.

“In any biological disaster, themes of fear, uncertainty, and stigmatization are common and may act as barriers to appropriate medical and mental health interventions,” Xiang and colleagues wrote. “Based on experience from past serious novel pneumonia outbreaks globally and the psychosocial impact of viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are crucial and pressing goals for the health response to the 2019-nCoV outbreak.”

For related information, see the book Disaster Psychiatry: Readiness, Evaluation, and Treatment, from APA Publishing.

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Tuesday, February 4, 2020

Many Older U.S. Adults Who Died By Suicide Did Not Have Known Mental Illness, Study Suggests

Many U.S. adults 65 and older who died of suicide between 2003 and 2016 did not have a known mental illness, according to a report in the American Journal of Preventive Medicine. The majority those who died of suicide were reported as having physical health problems—a precipitating circumstance that was more commonly documented for older adults without known mental illness.

“Suicide risk increases with age, and evidence exists for the underdiagnosis and undertreatment of suicide risk in older adults,” wrote Timothy J. Schmutte, Psy.D., and Samuel T. Wilkinson, M.D., both of Yale School of Medicine.

To better understand the similarities and differences between older adults with and without known mental illness who died of suicide, Schmutte and Wilkinson analyzed data from the National Violent Death Reporting System (NVDRS). This U.S. database contains extensive information on the characteristics of suicide decedents and the circumstances that precipitated their deaths. Known mental illness was defined as whether a decedent was identified as having a current mental health problem based on law enforcement or coroner/medical examiner reports.

Of the 26,884 suicide deaths recorded during the study period, 83.2% occurred in men. Most older men (69.1%) and women (50.2%) who died of suicide did not have a known mental illness.

Most suicide deaths involved firearms, which were disproportionately used by decedents without known mental illness (81.6% of men and 44.6% of women) compared with those with known mental illness (70.5% of men and 30.0% of women).

“[T]his study highlights a need for prevention efforts that address a broad range of risk factors for late-life suicide. ... Targeted community efforts to reduce stigma and improve help-seeking in older adults, particularly men, and other population-based strategies (for example, legislation that reduces access to handguns) may be effective at reaching vulnerable adults and reducing suicide rates,” Schmutte and Wilkinson wrote.

For related information, see the Psychiatric News article “Loss of Partner to Suicide Increases Risk of Mental Health Problems, Death.”

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Monday, February 3, 2020

Optimizing Stimulant Treatment May Help Reduce Aggression in Children With ADHD

Children with attention-deficit/hyperactivity disorder (ADHD) who also have aggression problems might benefit from adjustments to their stimulant regimen and behavioral therapy, reports a study in the Journal of the American Academy of Child and Adolescent Psychiatry. If these interventions do not adequately reduce aggressive behaviors, additional treatment with the antipsychotic risperidone or the mood stabilizer divalproex may be advised, the study found.

Joseph Blader, Ph.D., of the University of Texas Health Science Center at San Antonio and colleagues enrolled 175 children aged 6 to 12 with ADHD and either oppositional defiant disorder or conduct disorder for the study. Although the children had been taking stimulant medication for at least 30 days, all the children had clinically significant aggressive behavior—defined as a score of >24 on the parent-reported Retrospective-Modified Overt Aggression Scale (R-MOAS).

At the beginning of the trial, all children received extended-release methylphenidate tablets whose effects last up to 12 hours. The researchers adjusted the stimulant dose for each child weekly until they found the most effective dose. Children who were experiencing problems in the evening (poor appetite or sleep) while taking the extended-release methylphenidate were switched to a shorter eight-hour methylphenidate formulation; children who experienced negative side effects on methylphenidate were switched to extended-release amphetamine tablets. All children and their parents also received family-based behavioral therapy during this optimization phase, which lasted until aggression symptoms went away or the child reached the maximum dose on their best tolerated medication (the average time of optimization was 69 days).

Of the sample, 151 completed the stimulant-optimization phase, 96 of whom achieved a remission of their aggression symptoms (R-MOAS <15). Forty-five children who continued to show high aggression following this first phase were randomly given risperidone, divalproex, or placebo in addition to their stimulant medication and family therapy for eight more weeks.

After eight weeks, children taking either risperidone or divalproex had statistically greater reductions in their aggression symptoms than those taking placebo. Due to the small sample size, though, the researchers could not determine whether risperidone or valproate was superior at reducing aggression. Children taking risperidone experienced more weight gain than those taking divalproex or placebo.

These results reinforce the clinical value of optimizing first-line stimulant therapy for youth with ADHD and aggression by methodically adjusting their medication dose and providing family-based behavioral therapies, Blader and colleagues wrote. “Given the adverse-effect liabilities of adjunctive medications, it is important to improve ADHD care so that clinicians initiate antipsychotic and other co-therapies as sparingly as possible. For those who do not experience sufficient benefit from thoroughly implemented initial treatments, this study adds to the emerging evidence base that such adjunctive medications may be helpful,” they continued.

To read more on this topic, see the Psychiatric News article “Many Youth With ADHD Fail to Take Stimulants as Prescribed.”

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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.