Wednesday, November 25, 2020

Older Adults May Be More Resilient During Pandemic Than Younger People

Older adults may be more resilient to the anxiety, depression, and stress-related mental disorders that are being reported by younger adults during the COVID-19 pandemic, according to an article in JAMA.

“[S]tudies from different countries have shown that at least some older adults are not experiencing disproportionately increased negative mental health consequences commensurate with the elevated risks they faced during the first few months of the COVID-19 pandemic,” wrote Ipsit Vahia, M.D., medical director of Geriatric Psychiatry Outpatient Services at McLean Hospital; past APA President Dilip Jeste, M.D., director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego; and Charles Reynolds III, M.D., a professor of psychiatry at the University of Pittsburgh Medical Center.

Vahia and colleagues cited a survey of 5,412 community-dwelling adults conducted by the Centers for Disease Control and Prevention from June 24 to 30. The survey found that compared with younger age groups, the percentage of participants aged 65 years or older with anxiety disorder (6.2%), depressive disorder (5.8%), or trauma- or stress-related disorder (9.2%) was lower. According to the report, of the 731 participants aged 18 through 24 years, 49.1% reported anxiety disorder; 52.3%, depressive disorder; and 46%, trauma- or stress-related disorder. The findings mirror those of other high-income countries, including Spain, Canada, and the Netherlands, they noted.

Vahia and colleagues cautioned that the results are from surveys conducted early in the pandemic, and the longer-term effects of COVID-19, “especially in countries like the U.S. with very high rates of disease, remain unclear.” Moreover, there are no similar data on subgroups of older adults such as those with dementia, those caring for persons with dementia, or those residing in assisted-living facilities or nursing homes. The effect of comorbid chronic medical or psychiatric conditions also remains unclear.

But they noted that older adults may have traits of resilience that have enabled them to withstand the stresses of COVID-19, especially wisdom and a tendency to value the quality of a few close relationships over having many more superficial relationships. The authors noted that several recent studies involving various groups of people across the adult lifespan have shown a significant inverse correlation between loneliness and wisdom; other data also suggest that compassion may reduce loneliness and promote greater well-being.

“Understanding the factors and mechanisms that drive [older people’s] resilience can guide intervention approaches for other older people and for other groups whose mental health may be more severely affected,” the authors concluded.

For related information, see the Psychiatric News article “Interventions That Promote Wisdom May Help Patients With Psychiatric Conditions.”

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Tuesday, November 24, 2020

Effects of Sertraline-Olanzapine on Weight, Cholesterol May Differ According to Patient Age

Older adults with psychotic depression may experience less weight gain and increases in total cholesterol than younger adults when taking a combination of sertraline and olanzapine over an extended period, suggests a study in the American Journal of Geriatric Psychiatry.

The findings are from the Study Pharmacotherapy of Psychotic Depression II (STOP-PD II). The original STOP-PD trial established that a combination therapy of the antidepressant sertraline plus the antipsychotic olanzapine was more likely to lead to remission of psychotic depression than olanzapine alone over 12 weeks of therapy. STOP-PD II examined the risks and benefits of patients continuing to take sertraline and olanzapine to prevent a relapse of the symptoms. (Eli Lilly provided olanzapine and matching placebo pills and Pfizer provided sertraline; neither company provided funding for this study.)

“Older adults are more likely to experience psychotic features during a major depressive episode than younger adults,” wrote Alastair J. Flint, M.B., of the Department of Psychiatry at the University of Toronto and colleagues. Metabolic disorders, such as diabetes and hyperlipidemia, also increase later in life. “It is therefore important to determine whether there are age-related differences in anthropometric and metabolic outcomes associated with the treatment of psychotic depression with antipsychotic medication,” Flint and colleagues wrote.

They analyzed data from 269 adults aged 18 to 85 years with psychotic depression who were treated with open-label sertraline plus olanzapine for up to 12 weeks (acute phase). A total of 126 participants who remained in remission for eight weeks (stabilization phase) on the sertraline-olanzapine combination were then randomly divided into two groups: one group continued taking the sertraline-olanzapine combination, and the other group was transitioned to a sertraline-placebo combination; the randomized phase was for 36 weeks. The researchers evaluated changes in participants’ weight, waist circumference, plasma lipids, glucose, hemoglobin A1c, and insulin over the course of the study, comparing participants aged 18 to 59 (younger) with those 60 to 85 (older).

While both younger and older participants experienced weight gain and an increase in total cholesterol levels when treated with sertraline-olanzapine versus sertraline-placebo, “the increase in these measures was less in the older group,” Flint and colleagues reported.

“At the acute-stabilization termination visit, mean weight in older participants remained below their mean premorbid weight, whereas it was approximately 18 lb. higher than premorbid weight in younger participants,” they continued. “These findings suggest that the weight gained during the acute and stabilization treatment of psychotic depression was partial restoration of lost weight in older patients [during depressive episodes] but clinically significant excess weight in younger patients.” There were no clinically significant differences between younger and older participants in glycemic measures.

For related information, see the Psychiatric News article “Maintenance Antipsychotic Lowers Risk of Psychotic Depression Relapse.”

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Monday, November 23, 2020

Prazosin Can Reduce Drinking in AUD Patients With Severe Withdrawal Symptoms

Prazosin is effective at reducing alcohol consumption in adults with alcohol use disorder (AUD) and severe withdrawal symptoms such as sweating, headache, and nausea, reports a study in AJP in Advance.

In a 12-week, randomized clinical trial of 112 treatment-seeking adults with AUD, those with severe withdrawal symptoms who took prazosin had half as many drinking days and only one-fifth the number of heavy drinking days as adults with severe withdrawal symptoms taking placebo. In contrast, there was no difference in drinking days between participants taking prazosin who were experiencing few or no symptoms of alcohol withdrawal and those taking placebo. 

“In parallel, we found that the higher the alcohol withdrawal symptom severity, the greater the benefit of prazosin in reducing anxiety, depressed mood, and alcohol craving over the course of the trial,” wrote Rajita Sinha, Ph.D., of Yale University School of Medicine and colleagues. “These findings support the speculation that prazosin’s benefits may be mediated by its effects on the high craving, negative mood, and anxiety that are clinically observed in those with greater alcohol withdrawal symptom severity.”

Sinha and colleagues randomized adults with AUD to receive either 16 mg/day prazosin or placebo along with weekly behavioral counseling sessions for 12 weeks. At baseline, the participants’ withdrawal symptoms were assessed using the Clinical Institute Withdrawal Assessment for Alcohol–Revised. The participants were then divided into low/no-withdrawal and high-withdrawal groups.

The participants reported their drinking each day using their smartphones or automated voice messaging. Additionally, the researchers evaluated the patients’ vital signs, medication adherence, and breath alcohol levels during biweekly outpatient visits.

At 12 weeks, adults in the high-withdrawal group taking prazosin reported drinking on 27.46% of total days and heavy drinking (four to five drinks per day) on 7.07% of days, while those on placebo reported drinking 58.47% of total days and heavy drinking on 35.58% of days. The researchers found no benefit of prazosin among adults with low or no withdrawal symptoms.

Prazosin was found to be safe and well tolerated, and there were no significant differences in medication adherence between the prazosin and placebo groups, the authors added.

To read more on this topic, see the Psychiatric News article “Gabapentin Found to Work Best for Those With Severe Alcohol Withdrawal Syndrome.” 

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Friday, November 20, 2020

Suicidality Among Childbearing Women Found to Increase Over 12-Year Period

From 2006 to 2017, the prevalence of suicidal ideation and intentional self-harm among women in the year before or after birth increased substantially, according to a study published this week in JAMA Psychiatry.

“Maternal health experts note that the lack of consistent, inclusive data on suicidality before and after birth is alarming,” wrote Lindsay Admon, M.D., M.Sc., of the University of Michigan and colleagues. “Further, … suicidal ideation and intentional self-harm remain excluded from standard measures of severe maternal morbidity.”

Admon and colleagues conducted the Maternal Behavioral Health Policy Evaluation study to evaluate suicidality trends from 2006 to 2017 among women aged 15 to 44. They used Optum Clinformatics Data Mart, which included medical claims data from a national, commercially insured population from all 50 states. The researchers compared women with or without a suicidality diagnosis (defined as a diagnosis of suicidal ideation and/or intentional self-harm in inpatient or outpatient settings) in the year before and after giving birth. The authors also identified whether the patients had clinical comorbidities, including depression, anxiety, bipolar disorder, psychosis, and substance use disorders.

The authors identified 698,239 deliveries among 595,237 commercially insured women during the study period. Of these women, 2,683 individuals were diagnosed with suicidal ideation or intentional self-harm one year before or after giving birth. Other findings, as described by the authors, include the following:

  • Suicidality increased from 0.2% per 100 individuals in 2006 to 0.6% per 100 individuals in 2017.
  • Suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017.
  • Intentional self-harm increased from 0.1% per 100 individuals in 2006 to 0.2% per 100 individuals in 2017.
  • Suicidality with comorbid depression or anxiety increased from 1.2% per 100 individuals in 2006 to 2.6% per 100 individuals in 2017.
  • Suicidality with comorbid psychotic disorders increased from 7.1% per 100 individuals in 2006 to 47.6% per 100 individuals in 2017.

The authors noted that Black women, those with lower incomes, and younger women experienced the larger increases in suicidality. “Given the severe maternal mortality crisis among racial/ethnic minority individuals, especially Black women, it is imperative to include psychiatric risks in predictive models and practice guidelines,” they wrote.

“[P]olicymakers, health plans, and clinicians should ensure access to universal suicidality screening and appropriate treatment for pregnant and postpartum individuals and seek health system and policy avenues to mitigate this public health crisis, particularly for high-risk groups,” they concluded.

For related information, see the Psychiatric News article “Drugs, Suicide Among Leading Causes of Postpartum Death in California.”

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Thursday, November 19, 2020

COVID-19 Patients With Delirium in Emergency Department May Experience Worse Outcomes

Nearly 30% of adults aged 65 and older who are diagnosed and treated for COVID-19 in U.S. emergency departments (EDs) may present with delirium, suggests a report published today in JAMA Network Open. These patients appear to have worse outcomes, including longer stays in the intensive care unit (ICU) and in-hospital death than those with COVID-19 who do not show signs of delirium.

“These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation,” wrote Maura Kennedy, M.D., M.P.H., of Massachusetts General Hospital and colleagues.

Kennedy and colleagues analyzed data from older adults who were seen in one of seven ED study sites across the United States and diagnosed with COVID-19 on or after March 13 (the date COVID-19 was declared a national emergency in the United States). They specifically focused on outcomes in patients whose medical records noted delirium symptoms at the time of arrival to the ED.

A total of 817 patients (mean age 77.7 years) were included in the analysis; 226 patients had delirium at presentation. Common symptoms of delirium noted in the medical record included impaired consciousness (122 patients), disorientation (96 patients), hypoactive delirium symptoms (45 patients), and agitation or hyperactive delirium symptoms (35 patients).

Of patients with delirium, 37 had delirium as a primary presenting complaint. Importantly, 84 of these patients had no fever or shortness of breath. The researchers found that delirium at presentation to the ED was significantly associated with increased risk for spending more than eight days in the ICU, discharge to a rehabilitation facility, and death.

“Our study demonstrates that clinicians must include COVID-19 in the differential diagnosis of delirium among older adults, regardless of whether they have other symptoms of COVID-19 infection. This is important to avoid missing diagnoses altogether and to better identify severe cases of COVID-19 at high risk for poor outcomes and death,” Kennedy and colleagues wrote.

“Furthermore, the data from this multicenter study strongly support an immediate revision in CDC guidance on symptom profiles for COVID-19 to include delirium as an important COVID-19–related symptom. Current CDC guidance lists new confusion as an emergency warning sign only, not as a presenting symptom in COVID-19. Many centers use the CDC guidance to prioritize screening, testing, and evaluation of presenting patients. By continuing to exclude delirium as a known presenting symptom of COVID-19, many cases will be missed or diagnoses delayed, as is already happening on a wide scale, particularly in older adults.”

For related information, see the Psychiatric News article “Do Not Forget Delirium During the COVID-19 Scramble.”

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Wednesday, November 18, 2020

Specific Symptoms of Borderline Personality Disorder Linked to Suicide Risk

Certain symptoms of borderline personality disorder—especially chronic feelings of emptiness, fear of abandonment, and disturbances in one’s sense of identity—appear to be significantly associated with suicide attempts, according to a report published today in JAMA Psychiatry.

“[T]he results of this study show the importance of assessing and targeting identity disturbance, abandonment, and emptiness in patients with BPD [borderline personality disorder] when considering suicide prevention, symptoms that may often be overshadowed by affective or behavioral features of BPD [borderline personality disorder],” wrote Shirley Yen, Ph.D., of Beth Israel Deaconess Medical Center in Boston and colleagues.

Yen and colleagues analyzed data from the Collaborative Longitudinal Study of Personality Disorders, a multisite, prospective study of adults with at least one of four personality disorders (schizotypal, borderline, avoidant, and obsessive compulsive) and a comparison group of adults with major depressive disorder. They looked at the occurrence of suicide attempts in both groups over a 10-year period and examined the associations between specific symptoms and suicide attempts.

Of all disorders, borderline personality disorder emerged as the most robust factor associated with suicide attempts, even after controlling for demographic and clinical factors (such as childhood sexual abuse, alcohol use disorder, substance use disorder, and posttraumatic stress disorder).

Among the specific borderline personality disorder criteria, identity disturbance, chronic feelings of emptiness, and “frantic efforts to avoid abandonment” were significantly associated with suicide attempts.

“These criteria may interfere with self-direction, development of meaningful and lasting interpersonal relationships, and engagement in goals and value-directed living, becoming increasingly problematic throughout the life span because these facets of life might otherwise buffer suicidal tendencies,” Yen and colleagues wrote.

For related information, see the Psychiatric News article “Data Mining May Help Identify Suicide Risk.”

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Tuesday, November 17, 2020

Impact of Racism Across Generations Discussed at APA Town Hall

The adverse effects of structural and interpersonal racism persist across generations, said panelists last night in the third online town hall meeting hosted by APA’s Presidential Task Force to Address Structural Racism Throughout Psychiatry.

“This is a period of turbulence in our country, and we are all being forced to confront the disparities in the treatment of Black, indigenous, and people of color,” said moderator, task force member, and APA Trustee-at-Large Michele Reid, M.D. She is a clinical assistant professor in the Department of Psychiatry and Behavioral Neurosciences at Wayne State University in Detroit and the chief medical officer of CNS Healthcare. “The COVID-19 pandemic has highlighted long-standing inequities caused by race, ethnicity, and income.”

Chuan-Mei Lee, M.D., an assistant clinical professor in psychiatry at the University of California, San Francisco (UCSF), and a child and adolescent psychiatrist at UCSF Benioff Children’s Hospital, spoke about the long-term, epigenetic effects of adverse childhood events (ACEs) that may occur as the result of structural and interpersonal racism.

“Experiences of discrimination produce the type of chronic stress that increases allostatic load, sets off cortisol production, shortens telomeres, and methlylates DNA,” Lee explained.

Ebony Dix, M.D., an assistant professor in the Department of Psychiatry at Yale University School of Medicine and an inpatient geriatric psychiatrist, discussed how structural racism affects Black adults on a daily basis. She cited differential treatment of patients in the emergency department due to their race, as an example.

“Take an African-American male who is 50 years old and a white female who is 50 years old presenting to the same ED with the same psychotic symptoms,” Dix said. “I’ve seen time and time again that the full … work-up will be given to the white woman, but for the Black man the first things at the top of the differential is substance abuse or schizophrenia.”

Peter Ureste, M.D., an assistant clinical professor in the UCSF Department of Psychiatry and Behavioral Sciences, discussed how structural racism affects Latinx and LGBTQ populations, including transgender people of color.

“Transgender and gender nonconforming individuals face extraordinarily high rates of social and health inequalities, including poverty and discrimination by employers. They are [more likely to be] victims of violence, and they face higher rates of family rejection and homelessness than their cisgender peers. I would say this is even more so for transgender people of color,” Ureste said.

At the end of the discussions, Reid gave an update on the task force’s work. Highlights include the following:

  • A website resource, psychiatry.org/TaskForce, that offers a recommended reading list, educational content, and a glossary of terms approved by the APA Board of Trustees.
  • Three mini-surveys issued to guide the task force’s work and engage APA’s membership.
  • A report by the task force’s Assembly work group that outlined eight actions to improve diversity and inclusion and reduce structural racism in the Assembly, actions that have since been approved by the Board of Trustees.
  • Feedback sessions with APA councils and committees.
  • Presentations made at the Kentucky, Missouri, North Dakota, Ohio, Utah, and Virginia district branches.

The next town hall will take place on February 8, 2021, from 8 to 9:30 p.m. ET.




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