Friday, May 14, 2021

Overweight, Obesity in Early Adulthood Linked to Late-Life Dementia

People who are overweight or obese in early adulthood may have a higher risk of dementia later in life, a study in Alzheimer’s and Dementia suggests.

Adina Zeki Al Hazzouri, Ph.D., of Columbia University and colleagues analyzed data from 5,104 older adults from the Cardiovascular Health Study and the Health, Aging, and Body Composition study. The participants were between 69 and 78 years old at enrollment and were followed for roughly eight years on average. Hazzouri and colleagues estimated the participants’ BMIs in early adulthood (aged 20 to 49 years) based on trends among their peers in the Coronary Artery Risk Development in Young Adults study and the Multi Ethnic Study of Atherosclerosis. They defined overweight as a body mass index (BMI) between 25 and 30 and obesity as a BMI higher than 30.

Compared with women who had an early adulthood BMI of less than 25, women who were overweight or obese had 1.82 times the odds and 2.45 times the odds of developing dementia in late life (age 70 to 89), respectively. Compared with men who had an early adulthood BMI of less than 25, men who were overweight or obese had 1.35 times the odds and 2.47 times the odds of developing dementia in late life, respectively.

“In light of the growing obesity epidemic among U.S. adults, with recent figures suggesting about 40% of U.S. adults ages 20 years or older are obese, our findings suggest that interventions aimed at modifying trends in obesity early in the life course may reduce the risk of dementia by potentially modifying the course of its preclinical phase.”

For related information, see the Psychiatric News article “Drops in Blood Pressure, BMI Common Prior to Dementia Diagnosis.”

(Image: iStock/PIKSEL)

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Thursday, May 13, 2021

Patients Report Greater Satisfaction With Extended-Release Over Daily Buprenorphine

Patients with opioid dependence who received weekly or monthly buprenorphine injections reported greater satisfaction compared with patients who took oral buprenorphine daily, according to a study in JAMA Network Open. The results highlight the importance of using patient-reported outcomes when developing medication treatment for substance use disorders.

“Long-acting injectable depot buprenorphine formulations have been developed to mitigate some of the concerns of daily dosing,” but few studies have compared the patients’ experiences with the injectable versus oral form of the medication, wrote Nicholas Lintzeris, M.B.B.S., Ph.D., of the University of Sydney Discipline of Addiction Medicine in Australia and colleagues.

Lintzeris and colleagues conducted an open-label trial involving 119 participants aged 18 and older, recruited from six outpatient clinical sites in Australia. All participants met the criteria for opioid dependence according to ICD-10 and were receiving daily buprenorphine before the study began. They were randomized to receive either weekly or monthly injections of extended-release buprenorphine or daily oral buprenorphine as a film formulation. Those who received the extended-release buprenorphine were administered injections of the medication with a maximum weekly dose of 32 mg or a maximum monthly dose of 160 mg. Those who received daily buprenorphine were administered a maximum daily dose of 32 mg.

Participants completed the Treatment Satisfaction Questionnaire for Medication (TSQM) at baseline and at weeks four, eight, 12, 16, 20, and 24. Higher scores indicated greater satisfaction with treatment. By week 24, the depot buprenorphine group expressed significantly higher satisfaction compared with the group receiving daily buprenorphine. The mean TSQM scores at baseline were 71.2 in the depot buprenorphine group and 73.8 in the daily group, but at 24 weeks the mean scores were 82.5 and 74.3, respectively.

In an accompanying commentary, Nora Volkow, M.D., director of the National Institute on Drug Abuse (NIDA), and Wilson Compton, M.D., M.P.E., deputy director of NIDA, noted the importance of including the voice of the patient in medication development. “Patient preferences and apparently improved function may prove to be useful secondary outcomes in medication trials, and the measures used in this new study deserve consideration,” they wrote.

They continued: “[T]he greater treatment satisfaction by patients receiving [extended-release] buprenorphine suggests that [extended-release] formulations might help to improve long-term retention and, as such, be a valuable tool to help combat the current opioid epidemic and reduce its associated mortality,” Volkow and Compton wrote.

For related information, see the Psychiatric News article “Factors to Consider Before Prescribing Buprenorphine.”

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Wednesday, May 12, 2021

Studies Point to Promise of Digital Interventions for Patients With Depression, OCD

A pair of articles published this week in JAMA point to the potential promise of using digital interventions to help youth and adults who are experiencing symptoms of mental illness.

One article describes two separate trials involving adults aged 21 years and older who had clinically significant depressive symptoms (Patient Health Questionnaire-9 score of 10 or greater) and were being treated for hypertension and/or diabetes in São Paulo, Brazil, and Lima, Peru.

One group of participants received a smartphone with an app that regularly sent users automated behavioral activation sessions that could be completed in 10 minutes or less. The behavioral activation sessions focused on encouraging participation in activities pleasant or meaningful to the patient. Nurse assistants met with participants in the intervention group for an initial face-to-face meeting to go over the app and followed up by phone with participants who did not appear to be using the app. The second group received enhanced usual care, which included regular evaluations for depressive symptoms over the course of the trial and referral to specialists as needed. Participants in both groups received regular health services for depression, diabetes, or hypertension.

“[A] significantly greater proportion of participants who received the digital intervention compared with enhanced usual care experienced at least a 50% reduction in depressive symptoms at three months (40.7% vs. 28.6% in Brazil; 52.7% vs. 34.1% in Peru), although the differences were no longer statistically significant at six months,” reported Ricardo Araya, M.D., Ph.D., of King’s College London and colleagues. “In the intervention group, worsening of depressive symptoms occurred in 10% of patients and worsening of suicide ideation occurred in 6% of patients vs. worsening by 12% and 7% in the control group,” they added.

The second article describes a trial in Sweden comparing outcomes in children and adolescents aged 8 to 17 years with obsessive-compulsive disorder (OCD) who received either online cognitive-behavioral therapy (CBT) for 16 weeks followed by traditional in-person CBT if necessary (stepped-care group) versus in-person CBT alone (control group).

The online CBT program consisted of 14 modules, which included text, movies, and exercises centered on education, exposure with response prevention, and relapse prevention. The families of patients in the stepped-care group were assigned a therapist whom they could contact via an online platform. Participants in the control group received manualized in-person CBT with up to 14 sessions over 16 weeks. Youth in either group who were classified as nonresponders at three months were offered up to 12 sessions of in-person CBT between the three-month follow-up and six-month follow-up. Responder status was defined as those who experienced at least a 35% reduction on the Yale-Brown Obsessive-Compulsive Scale from baseline to follow-up.

“After six months, the mean Children’s Yale-Brown Obsessive-Compulsive Scale score was 11.57 in those treated with internet-delivered CBT vs. 10.57 in those treated with in-person CBT”—a difference that suggests the treatments are similarly effective, reported Kristina Aspvall, Ph.D., of the Karolinska Institutet and colleagues. “Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups.”

“Although these two studies featured different countries (high-income vs. low-/middle-income), different digital technology approaches (self-help app vs. computerized stepped care), different diseases (depression vs. OCD), and different ages (children and adolescents vs. adults), they shared underlying commonalities around the universal application of digital mental health, including the importance of human support, the need to monitor and assess digital interventions, and the need for assessment in the clinical population,” wrote psychiatrist John Torous, M.D., in an accompanying editorial. Torous is the director of the Digital Psychiatry Division in the Department of Psychiatry at Beth Israel Deaconess Medical Center and leads APA’s work group on the evaluation of smartphone apps. “Both studies also offer behavioral treatments that are low risk and thus may not be considered a high priority for clinician monitoring. … However, both studies show that low risk does not mean that there is no risk or need to follow and monitor patient progress.”

Torous concluded, “The two studies reported in this issue of JAMA are timely contributions that underscore how digital interventions can help patients today. They also highlight how high-quality research can advance digital health science and raise the next generation of questions to make digital approaches even more effective and clinically important.”

For related information, see the Psychiatric Services article “User Engagement in Mental Health Apps: A Review of Measurement, Reporting, and Validity.”

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Tuesday, May 11, 2021

People at High Risk for Psychosis Found to Have Thinner Cortex

Individuals who are at high risk for psychosis appear to have a thinner cortex as measured by structural magnetic resonance imaging (sMRI) than healthy individuals, according to a report in JAMA Psychiatry.

Moreover, lower brain volume measurements among at-risk individuals, especially between the ages of 12 and 16, appear to predict whether they will later become acutely psychotic. “Findings from this international effort suggest that conversion to psychosis among those at clinical high risk is associated with lower cortical thickness (CT) at baseline,” write Maria Jalbrzikowski, Ph.D., an assistant professor of psychiatry at the University of Pittsburgh, and colleagues.

The researchers analyzed sMRI images of the brains of 1,792 individuals at clinical high risk (CHR) for psychosis, including 253 individuals who later developed acute psychosis, and 1,377 healthy controls at 31 centers around the world participating in the ENIGMA Clinical High Risk for Psychosis Working Group. From the sMRI images, they formulated 155 measures of cortical thickness, surface area, and subcortical volume, as well as three global neuroimaging measures—total intracranial volume, average cortical thickness, and total surface area.

High-risk participants had smaller overall brain volume measurements compared with healthy controls, with the greatest difference in cortical thickness. (There was no difference in cortical surface area or subcortical volume.) Additionally, the 253 individuals who later developed psychosis had thinner cortexes than the high-risk individuals who did not develop psychosis and the healthy controls in three brain regions—the paracentral, superior temporal, and fusiform regions.

Finally, compared with the healthy control group, those aged 12 to 16 in the high-risk group—including those who did and did not later develop psychosis—had significantly thinner cortexes in the paracentral and fusiform region.

“In the largest study of brain abnormalities in individuals at CHR to date, we found robust evidence of a subtle, widespread pattern of CT differences, consistent with observations in psychosis,” the investigators write. “These findings also point to age ranges … when morphometric abnormalities in individuals at CHR might be greatest.”

For related information, see the Psychiatric News article “Imaging Advances Could Aid Outcome in High-Risk Patients.”

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Make Plans Now to Attend Royal College of Psychiatrists Meeting, June 21-24

Join thousands of psychiatrists worldwide at the Royal College of Psychiatrists’ first-ever Virtual International Congress. The Congress will take place June 21 to 24 on an interactive and immersive event platform.


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Monday, May 10, 2021

Researchers Identify Childhood Behaviors That May Signal Future Self-Harm

Researchers have identified two distinct pathways by which adolescents develop self-harming behaviors: the first is associated with years of emotional difficulties and bullying: the second is associated with more willingness to take risks and experiencing less security with peers and family during adolescence. These findings were published in the Journal of the American Academy of Child and Adolescent Psychiatry.

“There is global consensus that self-harm is a prevalent concern in adolescence and a priority for public health efforts,” wrote Stepheni Uh, M.Phil., of the University of Cambridge and colleagues. “Establishing early risk factors and profiles that can be traced and tracked across development provides a crucial step towards the early identification of these young people … and ultimately prevention and treatment.”

Uh and colleagues analyzed data from the Millennium Cohort Study, a longitudinal assessment of about 19,000 young people throughout the United Kingdom. They focused on 1,580 participants (73% female) who had reported engaging in self-harm at age 14 and used computer modeling to identify any social or behavioral similarities in this group compared with peers who did not self-harm. Data were taken from the participants’ responses on the Strength and Difficulties Questionnaire and Mood and Feelings Questionnaire (MFQ) at ages 5, 7, 11, and 14; a positive answer on the MFQ question “In the past year have you hurt yourself on purpose?” was used as an indicator of self-harm.

The model found that most of the adolescents who harmed themselves fit into one of two behavioral clusters. The first group, which included 379 teens, was characterized by emotional and behavioral difficulties such as hyperactivity or conduct problems as early as age 5; these children also reported frequent bullying. The second and larger cluster (905 teens) did not exhibit any childhood psychopathology; rather, self-harm was associated with increased risk-taking behaviors and changes in their relationship with family and friends during adolescence. Uh and colleagues also found that adolescents in both clusters reported low self-esteem and difficulty sleeping at age 14.

“A key implication of our findings is that we have a decade-long window to intervene for some children who are at increased risk of self-harm as adolescents,” Uh and colleagues wrote. “Early targeted interventions, particularly those focused on emotion regulation, may be helpful for this [first] group.”

The larger group of self-harming adolescents without childhood psychopathology “represents the challenge we face to assist those in the general population,” the authors continued. “However, their indication of poorer mental health on the MFQ than the Comparison sample at age 14 as well as both risk-taking and peer-related factors suggest that access to universal programs and materials for self-help and problem-solving/conflict regulation … may be effective.”

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

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Friday, May 7, 2021

Contingency Management Programs May Help Patients With Cocaine Use Disorder

Contingency management interventions that reward patients for abstaining from cocaine use may be an effective treatment option for patients with cocaine use disorder, a meta-analysis published today in JAMA Network Open suggests.

Brandon S. Bentzley, M.D., Ph.D., of Stanford University and colleagues analyzed data from 157 clinical trials that included 402 treatment groups and 15,842 participants aged 18 years or older with cocaine use disorder. Participants enrolled in the trials on average used cocaine about three days week and had been using cocaine for several years.

The most common treatments were psychotherapy and contingency management programs. Other interventions included treatment with anticonvulsants, antidepressants, antipsychotics, dopamine agonists, opioids, psychostimulants, or placebo. The primary outcome was a negative urine test for cocaine metabolites at the end of treatment.

Overall, 26.9% of patients completed treatment and were cocaine-free at the end of treatment.

The researchers found that only contingency management programs were associated with an increased likelihood of having a negative urine test at the end of treatment. Patients who participated in contingency management programs were roughly twice as likely to have a negative urine test compared with those in placebo groups.

The researchers noted that contingency management programs have been helpful in treating substance use disorders at the U.S. Department of Veterans Affairs.

“Given the results of our study and the fact that the Department of Veterans Affairs is the largest integrated provider of addiction services in the U.S., consideration of the implementation of contingency management programs on a national level or within other major health care systems in the U.S. is warranted,” they wrote.

Psychotherapy did not appear to have a significant impact on cocaine use. However, the researchers noted that their analysis did not take into account the type or dose (session length and frequency) of psychotherapy. They added that their approach to analyzing the data cannot rule out the benefits associated with specific approaches or doses of psychotherapy.

For related information, see the American Journal of Psychiatry article “Searching for Treatments for Cocaine Use Disorder: The Quest Continues.”

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Interested in Loan Repayment Program? NHSC Welcomes Applicants

The deadline to submit applications for the National Health Service Corps (NHSC) Loan Repayment Program has been extended until Thursday, May 27 at 7:30 p.m. ET. Learn more about your eligibility and the application process here.


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Thursday, May 6, 2021

Sustained Model May Be Effective for Smoking Cessation in Psychiatric Patients

A hospital-based smoking cessation intervention that involves motivational counseling and post-discharge follow-up helps patients maintain abstinence longer than usual care, according to a study published Wednesday in JAMA Psychiatry.

“Individuals with serious mental illness (SMI) smoke cigarettes at disproportionately higher rates, are more likely to smoke heavily, and have lower cessation rates than the general population,” wrote Richard A. Brown, Ph.D., of the University of Texas at Austin; Nancy Rigotti, M.D., of Harvard Medical School; and colleagues. “These findings, if replicated, provide a scalable approach to achieving sustained smoking cessation in patients with SMI following a psychiatric hospital stay.”

Brown, Rigotti, and colleagues conducted a clinical trial involving 342 participants aged 18 and older receiving inpatient treatment for SMI who smoked at least five cigarettes per day when not hospitalized. Participants’ diagnoses included depressive, anxiety, bipolar, psychotic, and personality disorders, among others. The participants were randomly assigned to one of two interventions: usual care or sustained care.

Patients assigned to the usual care group received five to 10 minutes of smoking cessation information and advice from the admitting nurse, self-help materials, and an offer of nicotine replacement therapy to use after discharge. Those in the sustained care group received a single 40-minute motivational interview tailored for patients with SMI provided by a smoking cessation counselor; four weeks of free transdermal nicotine patches upon discharge; access to free telephone-, text-, or web-based cessation counseling after discharge provided by a counselor trained to work with callers with psychiatric diagnoses; and enrollment in an automated, interactive voice response telephone system that asked participants about their smoking and intentions to quit following discharge.

The participants in both groups were asked about their use of smoking cessation treatment (smoking counseling and/or pharmacological interventions) at one, three, and six months after hospital discharge. At the six-month follow-up, participants were also asked about smoking in the past seven days; smoking status was also biochemically verified. Participants reported smoking an average of 17 cigarettes per day prior to hospitalization. At the six-month follow-up, those in the sustained care group had significantly higher rates of seven-day abstinence compared with the participants who received usual care (8.9% vs. 3.5%). Participants in the sustained care group were also significantly more likely to report using smoking cessation treatment over the six months following their hospitalization compared with those in the usual care group (74.6% vs. 40.5%).

“These findings are notable, given that two-thirds of this sample could be considered economically disadvantaged (with household annual incomes less than $25,000), in addition to having SMI,” the authors wrote. “Both of these factors are associated with higher smoking rates and less success at quitting.

“Our findings suggest that combining this evidenced-based, client-centered counseling approach with automated, proactive resources, such as [interactive voice response], text messaging, and other technology-assisted interventions … increases the likelihood of successful attempts at quitting,” the authors continued.

For related information, see the Psychiatric News article “Psychiatrists Can Do More to Help Patients Quit Smoking.”

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