Monday, October 19, 2020

Large Genetic Alzheimer’s Study of African American Individuals Uncovers Differences in Risk Factors From Whites

In a large analysis of nearly 8,000 African American genome samples, researchers have uncovered more than two dozen genetic variants associated with the risk of Alzheimer’s. The findings were published today in JAMA Neurology.

Most of these variants were linked with biological processes already implicated in the development of Alzheimer’s—such as the immune response and fat metabolism—noted Brian W. Kunkle, Ph.D., M.P.H., of the University of Miami Miller School of Medicine and colleagues. However, the variants themselves were different from those previously identified in White individuals. Additionally, the analysis pointed to a possible relationship between the kidney system and Alzheimer’s in African American individuals.  

The findings suggest that while the molecular pathways implicated in the development of Alzheimer’s disease in African Americans are similar to those in Whites, the variants influencing these pathways may differ, the authors noted. 

Kunkle and colleagues analyzed genome data from 2,748 African American individuals with Alzheimer’s disease and 5,222 African American individuals without Alzheimer’s disease to look for variants associated with disease risk. Their analysis confirmed the relationship between several genetic variants and Alzheimer’s found in smaller studies, but also found nearly 20 new genetic Alzheimer’s links—most of which have not been implicated in White individuals. 

Of the eight biological pathways implicated by these new variants in African American individuals, seven have been previously implicated in genetic studies of White individuals. The novel pathway implicated in African American individuals was kidney system development. Interestingly, variants associated with the production of amyloid and tau proteins—which have been found in genome studies of White individuals—were not identified in this study. 

While Kunkle and colleagues noted that while additional research is needed, the findings “significantly help to disentangle [Alzheimer’s disease] etiology in African American individuals, aid to clarify the molecular mechanisms underlying observed health disparities, and help to pinpoint molecular targets for therapeutic intervention in this ethnic group.”

(Image: iStock\FatCamera) 

Friday, October 16, 2020

Preterm Birth Linked to Childhood Depression

Preterm birth before 28 weeks of gestation may be linked to childhood depression, suggests a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

Subina Upadhyaya, M.P.H., and colleagues at the University of Turku in Finland analyzed data from several large Finnish health care databases to identify 37,682 cases of childhood depression in people born between January 1987 and December 2007. These patients were diagnosed before December 2012, when they were at least 5 years old. The researchers then matched these patients with 148,795 control patients without childhood depression.

Compared with patients born at full term, the odds of developing childhood depression were 89% higher in those who were born at 25 weeks of gestation or less, 162% higher in those born at 26 weeks of gestation, and 93% higher in those born at 27 weeks of gestation.

“The potential mechanisms underlying depression in extremely preterm children and adolescents may be related to the causes of preterm birth, including genetic predispositions, pathologies during pregnancy, immature brain development in infants born extremely preterm, and psychosocial risks related to the postnatal hospital environment and later growth environment of preterm infants,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “Prenatal Primary Prevention of Mental Illness by Micronutrient Supplements in Pregnancy.”

(Image: iStock/brazzo)

How Does Racism Impact Your Practice? APA Task Force Wants to Know

The APA Presidential Task Force on Structural Racism Throughout Psychiatry is fielding a new short survey on the impacts of racism on psychiatric practice. Help inform the task force’s important work and share your thoughts by Friday, October 23. Learn more about the task force and view the results of its previous two surveys on the task force webpage.


Thursday, October 15, 2020

Psychotherapy Combined With Medication May Prevent Recurrence in Patients With Bipolar Disorder

When combined with pharmacotherapy, manualized psychosocial interventions were associated with a lower risk of illness recurrence in patients with bipolar disorder compared with pharmacotherapy alone, a meta-analysis in JAMA Psychiatry found.

“There is increasing recognition that pharmacotherapy alone cannot prevent recurrences of bipolar disorder or fully alleviate post-episode symptoms or functional impairment,” wrote David J. Miklowitz, Ph.D., of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues.

Miklowitz and colleagues identified 39 randomized clinical trials involving 3,863 participants aged 12 years or older with bipolar disorder in which psychotherapy combined with pharmacotherapy was compared with treatment as usual (defined as pharmacotherapy with routine monitoring visits). The primary outcome was episode recurrence of any type—depressed, manic, or mixed—among participants in the first 12 months after the trial began.

“In our analysis, family therapy [cognitive-behavioral therapy], and group psychoeducation—all modalities that include patients as active participants—were associated with significantly improved outcomes compared with [treatment as usual] with regard to recurrence prevention and depression stabilization,” the authors wrote.

Additionally, the authors found that psychoeducation interventions with guided practices of illness management skills in a family or group format were associated with reduced illness recurrences compared with the same strategies in an individual format. Cognitive-behavioral therapy, family or group therapy, and interpersonal therapy were associated with stabilizing depressive symptoms compared with treatment as usual. 

“What do our findings suggest about treating outpatients with bipolar disorder? When the goals center on prevention of recurrences, patients should be engaged in family or group psychoeducation with guided skills training and active tasks to enhance coping skills (e.g., monitoring and managing prodromal symptoms) rather than being passive recipients of didactic education,” they wrote.

“Miklowitz and colleagues’ contribution may further serve as a call to action to enhance availability and uptake of these treatments in the community,” wrote Tina R. Goldstein, Ph.D., and Danella M. Hafeman, M.D., Ph.D., of the University of Pittsburgh School of Medicine in an accompanying editorial. “Unfortunately, data suggest substantially lower rates of psychotherapy receipt (26%-50%) compared with medication management (46%-90%) among adults with [bipolar disorder].”

For related information, see the Psychiatric News article “Antipsychotics Increasingly Prescribed for Bipolar Disorder.”

(Image: iStock/Chinnapong)

Wednesday, October 14, 2020

Overwhelming Second Wave of Psychiatric Disorders Expected Due to Pandemic

Even as public health experts warn of a new tide of COVID-19 cases and deaths, another “second wave” is building in the form of mental and substance use disorders associated with social isolation, economic insecurity, and loss of family and community supports, cautioned Naomi M. Simon, M.D., M.Sc., director of the Anxiety and Complicated Grief Program at the NYU Grossman School of Medicine, and colleagues in an article published Monday in JAMA.

They especially emphasized the risk of psychiatric disorders related to grief from the loss of loved ones. “This interpersonal loss at a massive scale is compounded by societal disruption,” they wrote. “The necessary social distancing and quarantine measures implemented as mitigation strategies have significantly amplified emotional turmoil by substantially changing the social fabric by which individuals, families, communities, and nations cope with tragedy.”

The piece accompanied another report in the journal on the number of excess deaths in the United States between February and August attributed to COVID-19.

Simon and colleagues wrote that in the wake of so much death related to the pandemic—and in the absence of normal social, cultural, and religious connections and rituals for coping with grief—survivors are at risk of prolonged grief disorder, major depressive disorder, and posttraumatic stress disorder. 

“This imminent mental health surge will bring further challenges for individuals, families, and communities including increased deaths from suicide and drug overdoses,” they wrote.

To cope with the coming tsunami of psychiatric disorders, Simon and colleagues called for a three-pronged public health strategy of screening, mental health risk assessment, and treatment for those at highest risk for prolonged grief and posttraumatic stress.

Crucial to prevention is rebuilding forms of social and community support. “Clinicians can help bereaved families find creative ways to safely honor traditions, memorialize the deceased, and improve social support,” they wrote. “Public health campaigns and public policy initiatives could be created to support the implementation of these preventive strategies.”

They concluded: “A second wave of devastation is imminent, attributable to mental health consequences of COVID-19. The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations.”

For related information, see the Psychiatric News article “Expect a ‘Long Tail’ of Mental Health Effects From COVID-19.”

Tuesday, October 13, 2020

Suicidal Thoughts Elevated Among Depressed Patients Reporting Anger Attacks

People with major depressive disorder (MDD) who often experience sudden bouts of anger—also known as anger attacks—may have elevated levels of suicidal ideation compared with those who do not experience anger attacks, suggests a study in Depression & Anxiety.

“While patients with anger attacks typically experience improvement with antidepressants, previous reports have found new‐onset anger attacks in a small minority of patients,” wrote Manish Kumar Jha, M.D., of the Icahn School of Medicine at Mount Sinai and colleagues. “Thus, there is an urgent need to develop treatment strategies that specifically target anger attacks.”

Jha and colleagues analyzed data from the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study. EMBARC was a 16-week randomized, controlled trial that compared the responses of patients aged 18 to 65 with MDD who took sertraline and/or bupropion with those who took placebo.

The researchers specifically focused their analysis on 293 participants who completed the Massachusetts General Hospital Anger Attack Questionnaire (AAQ) at the start of the EMBARC trial. Through the AAQ, patients reported experiences with anger attacks, including how often the attacks occurred in the past month, physical symptoms that accompanied such attacks (for example, dizziness, shortness of breath, and trembling), and whether the attacks led to aggressive behavior (for example, physically or verbally attacking others). As part of the trial, the participants were also asked weekly whether or not they agreed with the following statements: “I have been having thoughts of killing myself,” “I have thoughts about how I might kill myself,” and “I have a plan to kill myself.”

At baseline, 37.2% of the participants reported anger attacks within the past six months. Aggressive behaviors were reported by 32.8%. Levels of suicidal ideation were found to be significantly higher in MDD participants with anger attacks than those with MDD with no anger attacks. Specifically, participants who reported experiencing nine or more anger attacks in the previous month reported significantly higher suicidal ideation at baseline than those who reported fewer anger attacks. Participants who reported anger attacks at baseline continued to report higher suicidal ideation while taking antidepressants, the authors reported.

“These associations between anger attacks and [suicidal ideation] were significant even after controlling for related constructs such as irritability and hostility or other features associated with [suicidal ideation] such as depression, anxiety, previous history of suicidal tendencies, pain, and hopelessness. Similar findings were noted for the presence of aggressive behaviors,” Jha and colleagues wrote. “Taken together, these findings suggest that the presence of anger attacks may identify a subgroup of depressed patients with persistently elevated [suicidal ideation].”

For related information, see the Psychiatric News article “The Role of C-L Psychiatrists in Assessing Suicide.”

(Image: iStock/Chinnapong)

Friday, October 9, 2020

Most Parents Support Depression Screening in Middle School

Most parents support school-based depression screening starting in middle school, a study in the Journal of Adolescent Health suggests.

Deepa L. Sekhar, M.D., M.Sc., of Penn State College of Medicine and colleagues analyzed the responses of 770 parents who participated in the University of Michigan’s C.S. Mott Children’s Hospital National Poll on Children’s Health, a cross-sectional Internet-based survey about child health topics. The parents all had children in either middle or high school.

When asked whether their children’s school should screen all students for depression, 70.5% said either “definitely yes” or “probably yes,” and the remaining 29.5% said “probably no” or “definitely no.” Nearly 47% said screenings should begin in sixth grade, and just over 15% said screenings should begin in seventh grade. The researchers wrote that these responses suggest a “desire for further support in recognizing adolescent depression and the need for additional services that begin in the middle school years.” They also noted that the majority preference for beginning screening in middle school is consistent with the U.S. Preventive Services Task Force recommendations for screening for depression in children and adolescents.

More than 93% of parents said that a child’s parents should be informed if the child has signs of depression, and about 3% felt the child should decide whether the parents are informed. However, more than 47% of parents did not know whether their children’s school currently provides mental health services for students.

“This suggests a lack in parent understanding of how schools will handle screening results and the availability of mental health resources, or perhaps highlights parent expectation to directly manage results,” the researchers wrote.

For related information, see the Psychiatric News article “New Primary Care Guidelines Recommend Routine Screening for Depression in Adolescents.”

How Does Racism Impact Your Practice? APA Task Force Wants to Know

The APA Presidential Task Force on Structural Racism Throughout Psychiatry is fielding a new short survey on the impacts of racism on psychiatric practice. Help the Task Force inform its important work and share your thoughts by October 23. Learn more about the Task Force and view the results of its previous two surveys on the Task Force webpage.


Thursday, October 8, 2020

New App Helps People With Serious Mental Illness Develop a Crisis Plan

APA on Wednesday announced the release of My Mental Health Crisis Plan, a mobile app that allows people with serious mental illness (SMI) to create a plan to inform their treatment should they experience a mental health crisis.

Through the app, users can easily create and share a psychiatric advance directive (PAD), a legal document that outlines one’s preferences around treatment during a crisis. Informational videos in the app explain to users what PADs are and how they work. The app also includes state-specific requirements, such as signatures or witnesses, for completing the PAD.

The app was developed by SMI Adviser, an APA initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). It is available in the Apple App Store and Google Play.

“A psychiatric advance directive is an important tool for individuals with serious mental illness to be able to plan ahead and have some control over their treatment at a time when they may not be able to make decisions,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a news release. “We are pleased to partner with SAMHSA in creating this important technological tool for people with serious mental illness.”

The app allows users to clearly state their preferences for care, as well as designate a person to make decisions on their behalf in the event of a crisis. They can also choose what hospitals, physicians, and medications they prefer. Additionally, they can note who should be notified about their admission into a psychiatric hospital, and who should care for their children if they are unable to do so.

“During a mental health crisis, you may not be able to think clearly, or you may be confused,” the app’s informational video explains. “A PAD is a way to plan ahead in case of a crisis. … In short, a PAD allows you to be an active part of your treatment even when you are not well...”

For related information, see the Psychiatric News article “SMI Adviser Smartphone App Delivers Expert Guidance With Just a Few Taps.”


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