Researchers Find Brain Changes in Teens Who Were Maltreated

Child maltreatment can change the brain as it develops in the teenage years, according to researchers who studied the brains of 117 adolescents using magnetic resonance imaging, first at about age 12 and then around age 16. They asked the teens about childhood maltreatment and assessed them for the presence of psychiatric disorders. They found differences in the growth of two areas of the brain known to respond to stress: the hippocampus and the amygdala.

 “Childhood maltreatment was associated with larger baseline left hippocampal volumes and retarded growth of the left amygdala over time and was indirectly associated, through the experience of psychopathology, with retarded growth of the left hippocampus and accelerated growth of the left amygdala over time,” compared with participants who were not maltreated, wrote Nicholas Allen, Ph.D., of the Melbourne School of Psychological Sciences at Australia's University of Melbourne, in the September Journal of the American Academy of Child and Adolescent Psychiatry.

For more about how social adversity affects physical and mental health, see the Psychiatric News article, “Research Could Boost Prospects of Kids Harmed by Stress."

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Milestone Project Signals Major Shift in Psychiatry Training

The Milestone Project is poised to exert a significant impact on current and future psychiatry residents as well as the educators and senior clinicians who are responsible for their training. It is a key element in a move in medical education toward assessing competency via measurement-based outcomes and will be implemented by all U.S. accredited residency programs next July. The project is an outgrowth of the Accreditation Council for Graduate Medical Education's six core competencies, which it described in 1999.

"By using the milestones, we can provide better, more specific, and targeted markers for program directors in terms of being able to document that a resident has achieved certain skills," Christopher Thomas, M.D., of the University of Texas Medical Branch at Galveston and chair of the Psychiatry Milestone Group, told Psychiatric News. "It really is a major paradigm shift in how we approach resident education." Added Richard Summers, M.D., chair of the APA Council on Medical Education and Lifelong Learning, "This is an exciting national experiment to see if by defining outcome measures and assessing our residents against those outcomes, we can demonstrably improve resident education." For psychiatry, he said, it helps residency programs think about areas in which they might need to expand such as the ability of psychiatrists to work within systems of care and the application of clinical neuroscience to patient care.

To learn more about the Milestone Project, including a description of what the psychiatry milestones will measure, see the Psychiatric News article, "Milestone Project Called Paradigm Shift in Residency Education." To listen to an audio interview with Thomas and Summers on the Milestone Project, click here.

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Change, Challenge, and Opportunity: Psychiatry in an Age of Reform and Enlightenment

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. Please send your comments to pnupdate@psych.org.

To paraphrase the old Chinese saying, we are either blessed or cursed to live in interesting times. I believe that it is the former. Of course, that may be a matter of opinion, and it may require a bit of cognitive reframing to convince ourselves that this is the case, but while there may be some question about whether the current times are good or bad, there can be no question that we are entering a time of change.

To address this profoundly important matter—important to psychiatrists as well as to our patients—this article will be the first of a three-part series on the topic of our changing profession. (It is not by coincidence that the theme of APA’s 2014 annual meeting is “Changing Practice and Perception of Psychiatry.”) The articles will focus on the forces that are impacting psychiatric medicine and mental health care, particularly health care financing and scientific discovery. This first article will place these events in historical context.

The discipline of psychiatry has evolved to its current form over the past 200 years. Its history is punctuated by certain inflection points, which mark transformative changes in our profession. I believe that we are approaching another such moment in our profession’s development. For this reason, it is useful to revisit and reflect on the past to understand better not just where we are now, but also where we are going.

To read more, click here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman. To do so, go to https://twitter.com/DrJlieberman, log in or register, and click on “Follow.”

Study Finds Intermittent Antipsychotic Therapy Not as Effective as Chronic Therapy

Researchers with the Cochrane Schizophrenia Group at England's University of Nottingham reported in the Cochrane Database of Systematic Review that intermittent antipsychotic therapy is less effective than long-term therapy in preventing episodic recurrences in individuals with schizophrenia.

The study analyzed data from multiple randomized trials—covering  50 years—that  evaluated relapse and hospitalization rates of 2,252 patients undergoing intermittent or chronic therapy for schizophrenia or schizophrenia-like psychosis. The data showed that episodic recurrence and hospital readmission rates were higher among individuals receiving intermittent therapy than those receiving continuous maintenance treatment. However, intermittent therapy was more effective than placebo. 

William Carpenter Jr., M.D., a professor of psychiatry and pharmacology at the University of Maryland School of Medicine, told Psychiatric News, "We should avoid the assumption that it is a horse race and that the winning horse is best for everyone. Continuous medication is best for relapse prevention for patients who will be medication adherent, but low medication adherence rates suggest alternatives...doctors have to individualize treatment decisions."

For more information about schizophrenia treatments, see "Optimism Grows About Potential to Aid Schizophrenia Cognition" in Psychiatric News. Also see Clinical Manual for Treatment of Schizophrenia from American Psychiatric Publishing.

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Ketamine May Be Beneficial in Treatment-Resistant Depression, Study Finds

Pursuing effective therapies to alleviate treatment-resistant depression can be challenging for both patient and clinician, but a study published today in AJP in Advance may offer some hope to those who have not responded to a standard depression treatments.

Researchers at the Michael E. Debakey VA Medical Center, Baylor College of Medicine, and Icahn School of Medicine at Mount Sinai investigated the rapid antidepressant efficacy of the FDA-approved anesthetic drug—ketamine. It was the largest ketamine study to date and first to compare ketamine with a psychoactive control, according to Sanjay Mathew,M.D., corresponding author and psychopharmacology chair of Baylor’s Mood Disorder Program.

Seventy-three patients with treatment-resistant depression were divided into two groups: those receiving a single intravenous dose of ketamine and those receiving the active placebo, midazolam. Results showed that within 24 hours, drug response rate for the ketamine group was 64%, compared with 28% in midazolam group. Though drug response rates did not differ between the groups after seven days of drug infusion, 45% of individuals in the ketamine group reported fewer depressive symptoms. Ketamine did raise concerns, including the drug’s likelihood to increase blood pressure by 20 points within an hour following administration.

Mathew told Psychiatric News, “The results from this study are still preliminary.... The goal of future research is to find out ways to prolong benefits beyond the acute phase. We are investigating repeated infusions as one option, [and]larger studies, which seek to optimize dose, are in the planning stages.” The study was funded by the National Institute of Mental Health, the Brain & Behavior Research Foundation, the Brown Foundation, and the National Center for Advancing Translational Sciences.

For more research on the use of ketamine in psychiatric illness, see the Psychiatric News article "Bipolar-Depression Improvement Follows Ketamine Infusion." 

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Antipsychotic Use Drops in Nursing Homes, but 2013 Goal Not Yet Reached

Use of antipsychotics in nursing homes for dementia and other conditions has fallen since the start of a new government program, according to data from the Centers for Medicare and Medicaid Services (CMS) reported today in The Lund Report, a health care newsletter.

In 2012, CMS  launched the National Partnership to Improve Dementia Care in response to data showing that more than 17% of nursing home patients had daily dosages of antipsychotics exceeding recommended levels. The partnership’s goal is to reduce antipsychotic drug usage by 15% by the end of 2013. The new data show the national prevalence of antipsychotic use in long-stay nursing home residents had been reduced by 9.1% by the first quarter of 2013, compared with the last quarter of 2011.

At least 11 states have hit or exceeded a 15% target, and others are approaching that goal. States that have met or exceeded the target are Alabama, Delaware, Georgia, Kentucky, Maine, North Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee and Vermont.

Geriatric psychiatrist and immediate past APA President Dilip Jeste, M.D., said the use of antipsychotics in nursing home patients is a complicated issue. "On one hand, a number of patients with dementia have severe psychotic symptoms that impact their well-being and overall management, and these need treatment," he told Psychiatric News. "On the other hand, there are no FDA-approved medications for psychosis in people with dementia, and the available medications, including antipsychotics, have significant side effects. The real solution to this dilemma would be improving the standard of care in nursing homes and making data-based psychosocial interventions a part of regular treatment.”

For more on the partnership see the Psychiatric News article "Dementia Patients Likely to Receive Fewer Antipsychotics."

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Study Points to Factors That May Raise Dementia Risk in Diabetes Patients

Diabetes is a known risk factor for dementia. Now some of the major factors that determine whether a diabetes patient is at risk of developing dementia have been identified by Lieza Exalto, M.D., of the University Medical Center Utrecht in the Netherlands, and colleagues based on follow-up data for some 30,000 patients with type 2 diabetes. The factors they identified are older age, a lower level of education, a history of depression, diabetic foot deformities, acute severely irregular blood sugar levels, and cerebrovascular, cardiovascular, and microvascular conditions.

Using these factors, the researchers developed a clinically practical summary risk score that can be used to provide an estimate of the 10-year dementia risk for individuals with type 2 diabetes. They then validated the score in some 2,400 diabetes patients.

"The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials," the researchers wrote in their study report in The Lancet Diabetes & Endocrinology.

More information about the link between dementia and diabetes can be found in the Psychiatric News article "Dementia Risk Rises When Depression, Diabetes Comorbid." Also see the Journal of Neuropsychiatry and Clinical Neurosciences for more research on this topic.

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American Psychiatric Foundation Program Featured in National TV Report

The NBC-TV news show “The Daily Nightly” featured a report last night about the American Psychiatric Foundation’s (APF) innovative program for identifying mental illness in teens. Earlier this year, The Miami-Dade County school system in Florida adopted the APF program “Typical or Troubled” to train school personnel to identify signs of mental illness among middle-school and high-school students in the district. And last night NBC reporter Mark Potter delivered a  report about the program and its adoption by Miami-Dade schools; the report aired five days after a man in Decatur, Ga., reported to have a history of mental illness, began firing shots at an elementary school; that man was apprehended by police before anyone was hurt.

The “Typical or Troubled” program has been used in more than 900 schools to train teachers, coaches, administrators, and other school personnel to identify signs of mental illness, to distinguish them from more “typical” behavior of teenagers, and to refer youth who appear to be at risk to mental health professionals. In the Miami-Dade County schools, the program is being offered in Spanish, English, and a Haitian-Creole translation. During the report, Miami-Dade County School Superintendent Alberto Carvalho described the reason for adopting the APF program: “Less metal detection and more mental detection, done in a respectful, reasonable, and well-researched way.”

APF Executive Director Paul Burke told Psychiatric News that the foundation is delighted with NBC's report and that it will further publicize what has already been a successful outreach program. “The NBC News story captures our successful partnership with Miami-Dade County Public Schools,” he said. “Through this partnership, 'Typical or Troubled' serves a very large and diverse school community, one that is 65 percent Hispanic. When teens with mental health problems get support and treatment, they have a better chance of doing well at home, in school, and in the future.”

Judge Steven Leifman, a judge with the Miami-Dade County Court Criminal Division and a member of the APF Board, was also featured in the report. “The earlier we identify children with mental health issues, the sooner we can get them to treatment, recovery, and leading full lives, while the chances of them getting into trouble later on greatly diminishes,” he told Psychiatric News.

To learn more about "Typical or Troubled," see the Psychiatric News article Miami-Dade Schools Adopt Foundation’s ‘Typical or Troubled?’ Program.

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Poor Diet Can Take Toll on Children's Mental Health, Study Finds

An unhealthy diet during pregnancy and the early years of a child's life can adversely affect that child's mental health, a large long-term prospective study of about 23,000 mothers and their offspring suggests. The study, published in the Journal of the American Academy of Child and Adolescent Psychiatry, was headed by Felice Jacka, Ph.D., director of the Division of Nutritional Psychiatry Research at Deakin University in Australia and funded by the Brain & Behavior Research Foundation.

Data about the mothers' diets were collected from them when they were pregnant. Once their children were born, the children were evaluated at ages 6 months and 1.5, 3, and 5 years at which times researchers assessed internalizing and externalizing problems. Even when possible confounding factors were considered, the mothers who had higher intakes of unhealthy foods during pregnancy were more likely to have children with behavior problems, such as tantrums and aggression, than mothers who had higher intakes of healthy foods during pregnancy. In addition, the children's diets at 18 months and 3 years were also evaluated, and those with unhealthy diets were more likely to experience not just behavior problems, but also internalizing problems such as anxiety and depression, than were children eating healthy diets.

To read more about the role of diet in children's mental health, see the Psychiatric News articles "Choline May Protect Infants From Developing Schizophrenia" and "When Parents Focus on Weight, Kids' Eating Disorder Risk Rises."

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Geography May Determine Accessibility of Mental Health Care Under Medicaid Expansion

States that opt to expand their Medicaid coverage under the new health care reform law—the Affordable Care Act—will see an increase in the number of enrollees needing mental health care. This is significant because Medicaid already funds more mental health services than any other payer in the United States. But concerns have been raised over whether there are enough mental health clinicians and facilities that accept Medicaid available to serve those new enrollees and whether this newly eligible population will face access obstacles. There is a particular severe shortage of such clinicians and facilities in many rural areas and in communities with large percentages of black or Hispanic residents, said Emory University’s Janet Cummings, Ph.D., Benjamin Druss, M.D., M.P.H., and colleagues, in JAMA Psychiatry online August 21. The effect size was largest for rural communities.

The researchers compared data from the 2008 National Survey of Mental Health Treatment Facilities with sociodemographic information from more than 3,100 U.S. counties.

“More than one-third of counties do not have any outpatient mental health facilities that accept Medicaid,” they pointed out. “If communities with a high concentration of black and/or Hispanic residents experience higher than average Medicaid enrollment but are more likely to lack these facilities, policies will need to be implemented to ensure that the Medicaid expansion does not exacerbate disparities in the accessibility of services for these communities.”

For more in Psychiatric News about the ACA’s effect on Medicaid patients, see “States’ Decisionon Expanding Medicaid Will Impact Inpatient Psychiatric Care.” Additional information on Medicaid funding for mental health care can be found in Psychiatric Services.

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Blood-Flow Measure May Help Clinicians Diagnose Bipolar Disorder

Brain scans that measure the flow of blood may be a diagnostic tool that can aid in the sometimes difficult task of differentiating bipolar disorder from unipolar depression, according to a report published online today in the British Journal of Psychiatry. Led by Jorge Almeida, M.D., Ph.D., an assistant professor of psychiatry at the University of Pittsburgh, and colleagues, the study assessed a new imaging procedure called Arterial Spin Labeling, which measures blood flow in regions that are associated with depression. The study assessed 54 women—18 with bipolar disorder, 18 with depression, and 18 healthy controls. The subjects in the first two groups were all experiencing a depressive episode during their assessment.

Using this imaging method, the researchers were able to identify which women were depressed and which had bipolar disorder with 81% accuracy. Commenting on the findings, Almeida called the results "very promising," and said, "Earlier and more accurate diagnoses can make an enormous difference for patients and their families and may even save lives." He added, "These results also suggest that we may one day be able to predict future bipolar disorder in younger adults who haven't shown any symptoms, allowing for earlier and more accurate treatment."

For comprehensive information about bipolar disorder, see Handbook of Diagnosis and Treatment of Bipolar Disorders and Clinical Guide to Depression and Bipolar Disorder: Findings From the Collaborative Depression Study, both available from American Psychiatric Publishing.

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Study Links Heroin Use to Abuse of Prescription Pain Medication

A report published today by the Substance Abuse and Mental Health Services Administration (SAMHSA) may help clinicians and health officials seeking explanations for a dramatic rise in heroin use over the last few years. SAMHSA researchers report that it appears to be linked to the rapid spread of yet another drug-abuse epidemic, that of prescription pain medications.

The study showed that people aged 12 to 49 who abused pain medications by using them for nonmedical purposes were 19 times more likely to have initiated heroin use within the 12 months prior to being surveyed than were their age-matched peers. About 80% of recent heroin initiates had a history of nonmedical use of prescription pain medication. Commenting on the new findings, Peter Delany, Ph.D., director of SAMHSA's Center for Behavioral Health Statistics and Quality, said, “Prescription pain relievers when used properly for their intended purpose can be of enormous benefit to patients, but their nonmedical use can lead to addiction, serious physical harm and even death. This report shows that it can also greatly increase an individual’s risk of turning to heroin use, thus adding a new dimension of potential harm.”

Showing the extent of the heroin-addiction problem and its rapid spread, SAMHSA reported that approximately 373,000 people used heroin in 2007, while about 620,000 did so in 2011. Of these people, 179,000 were dependent on heroin in 2007 compared with 369,000 in 2011.

For more information about the problem of prescription pain medication abuse, see the articles "Rule on Dispensing Buprenorphine Eased" and "Medication Shows Promise in Treating Opioid Painkiller Addiction" in Psychiatric News.

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Risk of Type 2 Diabetes Increased in Youth Taking Antipsychotics, Study Finds

Antipsychotic drug use has been associated with increased risk for onset of type 2 diabetes in adults, and according to a study in today’s JAMA Psychiatry, the risk may hold true in children as well. Researchers in the departments of Psychiatry and Preventive Medicine at Vanderbilt University conducted a one-year study that compared the probability of antipsychotic-mediated type 2 diabetes onset in 43,000 youth ranging from age 6 to 24. The subjects were divided into two groups: those receiving treatment with an antipsychotic and those who not receiving such a medication. After one year, subjects were evaluated for diabetes, and changes in medication dosages were observed.  

Results showed that those receiving antipsychotic therapy were three times more likely to develop type 2 diabetes than those not taking the medication. The risk increased with accumulative drug doses and remained elevated for one year after discontinuation of drug use.

Corresponding author Wayne Ray, Ph.D., noted in an interview with Psychiatric News that “these drugs are used very commonly in youth for indications other than psychosis. When considering antipsychotics outside of psychosis, such as ADHD and conduct disorders, it's important to consider alternative options…and if you must prescribe antipsychotics, aim for the lowest dosage.” Ray also suggested that it may be beneficial to monitor metabolic changes that may induce the risk of diabetes in youth receiving prolonged antipsychotic therapy.

For more information on issues related to antipsychotic drug use in young patients, see the Psychiatric News article “Increase in Off-Label Antipsychotic Use Seen in Canadian Youth.”

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Child Bully Victims Fare Worse as Adults on Several Measures, Study Finds

 “Being bullied is not a harmless rite of passage or an inevitable part of growing up but throws a long shadow over affected children’s lives,” said Dieter Wolke, Ph.D., of the University of Warwick in the U.K., and William Copeland, Ph.D., an assistant clinical professor of psychiatry and behavioral sciences of Duke University Medical Center, and colleagues, online in Psychological Science. They drew on data from the Great Smoky Mountain Study, which followed children aged 9 to 13 in western North Carolina until ages of 24 to 26. Children who bullied others, children who were bullying victims, and children who were both perpetrators and victims of bullying had worse health, lower incomes, and poorer social relationships as adults when compared with children not involved with bullying, the researchers found.

After adjustment for family hardship and childhood psychiatric disorders, however, the “pure” bullies were at no great risk than their unaffected peers. Bully-victims were much more likely to fail to complete their education, have difficulty holding a job, and have problems forming and maintaining friendships, said Wolke and Copeland. “Involvement with bullying can be easily assessed and monitored by health professionals and school personnel, and effective interventions for reducing victimization are available,” they concluded.

To read more about mental health consequences of bullying, see the Psychiatric News article “Effects of Bullying Don’t End When School Does.” Also see the book Preventing Bullying and School Violence from American Psychiatric Publishing. 

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Study Finds 1 in 3 Children of Parents With SMI Also at Risk for Mental Illness

Offspring of parents with severe mental illness (SMI) are at increased risk for a range of psychiatric disorders ,and one-third of them may develop a SMI by early adulthood, according to a report published online this week in Schizophrenia Bulletin. Researchers at Dalhousie University in Canada conducted meta-analyses of rates of mental disorders in children of parents with schizophrenia, bipolar disorder, or depression in family high-risk studies published by December 2012.

They found that children of parents with SMI had a 32 percent probability of developing SMI themselves by age 20, and this risk was more than twice that of control offspring. High-risk children had a significantly increased rate of developing the disorder present in the parent as well as of developing other types of SMI. For example, the risk of mood disorders was significantly increased among offspring of parents with schizophrenia, and the risk of schizophrenia was significantly increased in offspring of parents with bipolar disorder, but not among offspring of parents with depression.

The researchers said that their analysis "suggests that by early adulthood, the offspring has a 1-in-3 risk of developing a psychotic or major mood disorder a and 1-in-2 risk of developing any mental disorder."

For more information on the link between parental mental illness and such disorders in their offspring, see the Psychiatric News article, "Family Bipolar History Predicts Risk of Certain Childhood Disorders."

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Short Hospitalizations Found to Be Risk Factor for Readmission of Schizophrenia Patients

Short hospital stays for patients with schizophrenia are associated with risk of early readmission, possibly because the person is insufficiently stabilized, according to a report in Psychiatric Services in Advance. Researchers at the University of South Florida and other institutions used Medicaid and service-use data to identify adults with schizophrenia discharged from hospitals and crisis units who were taking antipsychotics. Data were extracted on demographic characteristics, service use before admission, psychopharmacologic treatment after discharge, and readmission to acute behavioral health care.

Study subjects had 6,633 inpatient episodes. Readmission occurred for 84 percent of the episodes, 23 percent of them within 30 days after initial discharge. Variables associated with an increased readmission risk in the first 30 days were shorter hospital stay, shorter time on medication before discharge, greater prehospitalization use of acute care, serious general medical comorbidity, and prior substance abuse treatment.

“This finding suggests that some patients may have been discharged before they were sufficiently stabilized,” the researchers said. “Patients with shorter stays and those not sufficiently stabilized on their medication should receive more vigorous discharge planning and follow-up care to ensure smoother transition to treatment in the community.”

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Early-Onset Dementia Linked to Alcohol Abuse in Young Men, Study Finds

Heavy chronic alcohol has been shown to adversely affect health in a number of ways, and it appears that one of those is to help set the stage for early-onset dementia, a large Swedish study published in JAMA Internal Medicine has found. "It seems that alcohol intoxication is a much stronger risk factor for early-onset dementia than anyone could have expected," the lead researcher, Peter Nordstrom, Ph.D., of Umea University in Sweden, told Psychiatric News.

The study included some 500,000 Swedish men who were followed for 37 years beginning at an average age of 18. Nine risk factors emerged for early-onset dementia—that is, dementia occurring before age 65. And the leading risk factor was alcohol abuse. Those subjects who had been hospital-treated for alcohol intoxication were five times more likely to develop early-onset dementia than those who had not been hospitalized for this reason.

Considerable research has been underway in recent years on more effective ways to treat alcohol abuse. To read more, see "Varenicline Shows Promise as Alcohol Abuse Treatment" in Psychiatric News. For additional information on alcohol abuse and treatment, see The American Psychiatric Publishing Textbook of Substance Abuse Treatment, Fourth Edition.

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Bipolar Patients at Risk of Dying Prematurely, New Data Suggest

Individuals with bipolar disorder tend to die, on average, nine years prematurely. This troubling finding emerged from a study conducted by American and Swedish researchers and reported in JAMA Psychiatry. The lead researcher was Casey Crump, M.D., Ph.D., a clinical assistant professor of medicine at Stanford University. However, the researchers also learned that while bipolar subjects' highest odds of dying prematurely were from suicide, their leading causes of premature death were cardiovascular disease and cancer. And when they received timely medical care for such illnesses, they tended to not die any earlier from these illnesses than did the general population.

If Crump could offer psychiatrists one piece of advice regarding these findings, it would be this, he told Psychiatric News: "Regular follow-up with primary, preventive health care is a critical part of managing bipolar disorder and its health consequences."

Other new findings about bipolar disorder can be found in the Psychiatric News articles "Side Effects Limit Drug Options in Bipolar Patients," "Gene Research on Bipolar Disorder Raises New Areas for Study," and "ADHD With Bipolar Disorder May Be Distinct Illness."

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Genetic Link to Maternal Depression Associated With Psychiatric Illness in Children, Study Finds

Variations in the allele of the oxytocin receptor gene (OXTR) may be a cause of long-term psychiatric disorders in children of women who suffer from postpartum and chronic depression, according to a study published July 12 in AJP in Advance. Researchers at the University Bar-Ilan in Israel and the National University of Singapore evaluated 46 chronically depressed mothers who reported depressive symptoms two days after giving birth and compared them with 103 mothers reporting no depression. Six years later, children from each group were assessed for psychiatric disorders, social engagement, and empathy.

Results showed that 61% of children of depressed mothers were diagnosed with Axis I disorders using DSM-IV criteria. Children of nondepressed mothers were four times less likely to develop psychopathologies and were more likely to be socially interactive and empathetic than those who mothers had depression.

The researchers then looked at the association between oxytocin levels and oxytocin-related genetic variations and depression. Previous research has shown that individuals with a single variant of the OXTR rs2254298 polymorphism (the G variant) are at greater risk for autism and major depressive disorder, and those possessing two copies (the GG variant) are more likely to have emotional detachment. However, the presence of the A variant is associated with heightened emotional security. AA homozygous trait carriers have been shown to exhibit social synchrony and physical affection because they have higher levels of oxytocin.

Data showed that depressed mothers and their children had significantly lower oxytocin levels and a greater incidence for the GG trait than families of nondepressed mothers. Among depressed mothers, the presence of the GG allele correlated with a 62% occurrence of child Axis I disorders, while the possession of a single A or AA allele, regardless of depression state, decreased the offsprings’ psychopathologies by at least half.

“What’s amazing is that this study is exquisitely sensitive to epigenetic effects,” Eric Hollander, M.D., director of the Compulsive, Impulsive and Autism Spectrum Disorder Program at Albert Einstein College of Medicine, who reviewed the report for Psychiatric News, said in an interview. “It’s seems that having the resilience [AA] allele, rather than the pathological [GG] allele, is more important, because the presence of A allele rescued children of depressed mothers from psychiatric disorders.”

For more about this study, see the Psychiatric News article "Genetic Link to Maternal Depression Associated With Psychiatric Illness in Children."

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FDA Considers Whether Paper Labelling Is Relic of Earlier Time

It's been a decade since the Food and Drug Administration (FDA) mandated that manufacturers submit information via electronic labeling so it would be easily accessible on the Internet and in electronic medical record systems. But a debate has been going on in the agency in recent years over whether to keep paper labeling as well, which now exists as a parallel system. The General Accounting Office (GAO) issued a report on the issue at the FDA's request, but found that the stakeholders were far from a reaching a consensus on the issue. (This issue is not the label on a medication bottle, but the package insert directed at medication prescribers; the patient package insert; and the "Medication Guide," which is also targeted at patients and alerts them to potential risks.)

Manufacturers and some other stakeholders favor eliminating the paper labeling to ensure that the most current labeling is the one people are reading. The paper versions cannot be updated and distributed anywhere near as quickly. This is important as the FDA learns of side effects or approves new indications. Electronic labeling is also easier to read since it can be enlarged on a computer screen. The GAO noted, however, that eliminating paper labeling would require regulatory changes, since federal regulations say that labeling must be included with the medication package. Patient advocates worry that some people don't have Internet access and thus can't read electronic labeling.

To read more about this debate, see the article "Is It Time to Retire Paper Labeling?" in Psychiatric News.

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Early Detection of Schizophrenia: The Time Is Now

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. Please send your comments to pnupdate@psych.org.


Medical research often takes a slow and unpredictable pace. The hours spent defining the question, setting up the experiment, and acquiring and then analyzing the data before getting to see the results makes for a long and arduous process. When you then add the time that it takes for new research findings to be translated into clinical practice, the rate of change in health care can be glacial. Psychiatry is certainly no exception to the seemingly snail’s pace of progress in health care.

But despite this pervasive pattern, research does periodically gain sufficient momentum to make inroads into clinical practice and move the field forward, as was the case with the introduction of antipsychotic and antidepressant drugs, lithium, community mental health, the development of time-limited forms of psychotherapy (for example, cognitive-behavioral therapy, interpersonal therapy, and dialectical behavior treatment) and cognitive remediation.

I believe that we are at another game-changing moment in psychiatry with the rise of the early detection and intervention strategy (EDIS). This new therapeutic strategy and model of care could have a significant effect on our ability to treat and limit the morbidity of mental illness beginning with schizophrenia and related psychotic disorders.

To read more, click here.

Common Genetic Variation May Underlie Different Mental Illnesses

An international group of psychiatric researchers has identified a 15% overlap between schizophrenia and bipolar disorder in heritability attributable to common genetic variation, according to a study by the Cross Disorders Group of the Psychiatric Genomics Consortium, published online in Nature Genetics August 11.

The group of more than 300 researchers in 20 countries used genomewide genotype data from thousands of people and compared them with control subjects. Besides the relationship between schizophrenia and bipolar disorder, there was a 10% overlap in heritability between bipolar disorder and depression, a 9% overlap between schizophrenia and depression, and a 3% overlap between schizophrenia and autism. The common genetic variants with small effects revealed in this and related studies will eventually be supplemented by other research on other variations.

“Shared variants with smaller effects, rare variants, mutations, duplications, deletions, and gene-environment interactions also contribute to these illnesses,” said study co-leader Naomi Wray, Ph.D., of the University of Queensland in Australia, in a statement accompanying the study. “Since our study only looked at common gene variants, the total genetic overlap between the disorders is likely higher.”

The study was funded in part by the National Institute of Mental Health.

Read more about the work of the Psychiatric Genomics Consortium in Psychiatric News here.

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Decreased Red Blood Cells May Be Associated With Dementia, Study Finds

A study reported in Neurology finds that anemia appears to be linked to dementia. Kristine Yaffe, M.D., the Roy and Marie Scola Endowed Chair of Psychiatry at the University of California, San Francisco, and colleagues analyzed medical records of 2,552 adults aged 70 to 79 to assess the likelihood of dementia onset in anemia patients. The patients—who were all free of dementia at the study's onset—were  divided in to two groups: those with and without anemia.

The seniors with anemia had a 40% higher risk of developing dementia than their counterparts without anemia. The association remained significant even after adjusting for common factors such as race, sex, and education level that are linked with dementia risk.

"There are several explanations for why anemia may be linked to dementia. For example, anemia may be a marker for poor health in general, or low oxygen levels resulting from anemia may play a role in the connection. Reductions in oxygen to the brain have been shown to reduce memory and thinking abilities and may contribute to damage to neurons," said Yaffe.

For more information on causes of dementia, see Psychiatric News here and here.

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Different Personality Types Increase Dementia Risk, Study Suggests

There may be a link between personality and the development of dementia, according to a study published August 1 in the American Journal of Geriatric Psychiatry. Researchers at the Dementia Collaborative Research Centre at the University of New South Wales in Australia conducted a meta-analysis of multiple case-control and longitudinal studies that assessed the association between personality and onset of dementia and mild cognitive impairment (MCI).

 With data from more than 5,000 subjects, the analysis found that neuroticism—which included feelings of guilt, anger, anxiety, and depression—was associated with a greater risk for dementia and MCI. In contrast, conscientiousness was shown to be protective against dementia and MCI. In addition, the analysis suggested that extroverted and submissive behaviors had no correlation with the cognitive disorders.

Chair of psychiatry at Johns Hopkins Bayview Medical Center, Constantine Lyketsos, M.D., commented to Psychiatric News that "Age and genetics are the major risk factors for dementia...but it's not clear what the mechanism of the link actually is. It could be that people of different personalities practice different behaviors that are differentially associated with dementia. An important consideration is age...as personality does change somewhat with aging, it will be important to understand how age and personality interact in the onset of dementia."

To read more on dementia and related cognitive disorders in Psychiatric News, click here and here.

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Psychotic Symptoms Linked to Suicide Risk in Adolescents

Psychotic symptoms are a striking marker of suicide danger in adolescents, especially in those adolescents who demonstrate other types of psychiatric pathology as well. So reports a team of European researchers in JAMA Psychiatry.

This finding came as a surprise to the lead researcher, Ian Kelleher, M.D., Ph.D., a research fellow with the Royal College of Surgeons in Ireland. He told Psychiatric News, "While we knew that people with psychotic disorders are at high risk of suicidal behavior, we did not know that there was such a strong relationship between psychotic experiences (which are much more common than psychotic disorders) and suicidal behavior in the population."

"This is a very interesting study," said child and adolescent psychiatrist Kayla Pope, M.D., of Boys Town National Research Hospital in Nebraska, in an interview. "We need better markers for assessing suicide risk, and the finding in this study is an important step in that direction."

More information about suicide risks can be found in Psychiatric News here, here, and here. Information about suicide is also available in The American Psychiatric Publishing Textbook of Suicide Assessment and Management, Second Edition.

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Youngsters' Chronic Abdominal Pain May Presage a Future of Worry

Chronic abdominal pain in childhood may forecast not only a long-term predilection to anxiety, but possibly to depression as well. This is the finding from a study published today in Pediatrics, the journal of the American Academy of Pediatrics. The senior researcher was Lynn Walker, Ph.D., of Vanderbilt University.

Cross-sectional studies had already linked youngsters' chronic abdominal pain with anxiety and depression, but this appears to be the first long-term prospective study to do so. Three hundred-and-thirty-two children with recurrent abdominal pain, as well as 147 control subjects, were evaluated for anxiety and depression not only during adolescence, but into young adulthood—on average for 20 years.

By the time of follow-up in adolescence and young adulthood, half (51 percent) of the abdominal-pain group met criteria for an anxiety disorder at some point, and about one-third (30 percent) currently met criteria for an anxiety disorder. In contrast, only one-fifth (20 percent) of controls met criteria for an anxiety disorder at some point, and even less(12 percent) met criteria for a current anxiety disorder.

Regarding depressive disorder, the lifetime risk was significantly higher in the abdominal-pain group than in controls—40 percent versus 16 percent—but compared with anxiety disorders, current depressive disorders were rare at follow-up.

"This is an important study conducted by an outstanding group of researchers," John Campo, M.D., chair of psychiatry at Ohio State University, told Psychiatric News. Campo has conducted research on this subject in the past.  "A cross-sectional relationship between functional abdominal pain and anxiety has been noted in multiple studies in children, adolescents, and adults, but the nature of this observed 'comorbidity' is unclear....This study's findings that functional abdominal pain and anxiety are associated longitudinally into adulthood offers some support for the notion that functional abdominal pain and anxiety may share common risk factors or perhaps even be manifestations of a common disorder."

More information about the link between anxiety, depression, and stomach pain can be found in Psychiatric News.

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Buprenorphine Implants May Be Treatment for Opioid Dependence, Study Finds

A study published in yesterday’s Addiction journal compared the effectiveness of buprenorphine implants (BI) with placebo implants (PI) and sublingual buprenorphine/naloxone tablets (BNX) in reducing drug use among opioid addicts. In the study, Richard Rosenthal, M.D., of the Department of Psychiatry at Columbia University College of Physicians and Surgeons and colleagues randomized 287 individuals with opiate addiction into three groups—BI, PI, and BNX. Urine was screened for opioid and cocaine concentrations for six months to determine drug relapse. In addition, magnitude of withdrawal was assessed using the Opiate Withdrawal Scale. 

Results showed that 31.2% of urine samples from the BI group tested negative for opiates, compared with 13.4% in the placebo group. There was no significance difference among the BI and BNX subjects, the latter of whom tested 33.5% negative for opioids. Drug withdrawals, however, showed that BI recipients experienced less withdrawal symptoms than did the PI group, but more symptoms than BNX subjects.

Rosenthal told Psychiatric News that “many [opioid-dependent] patients have difficulty adhering to medication regimens, [thus] it is important that we have as many options to avoid relapse among patients with addiction.”

The study was funded by NIH and Titan Pharmaceuticals.

For more information on opioid and drug addiction, see Psychiatric News here. Also see American Psychiatric Publishing's Clinical Manual of Adolescent Substance Abuse Treatment here. 

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Study Points to More Effective Smoking-Cessation Treatment

Researchers appear to have identified a strategy to "rescue" a significant proportion of smokers whose attempts to quit using a nicotine patch alone failed, according to a report in the August American Journal of Psychiatry (AJP). Jed Rose, Ph.D., and Frederique Behm, C.R.A., of Duke University's Department of Psychiatry and Behavioral Sciences, initiated nicotine-patch treatment in 606 subjects two weeks before an agreed-upon quit date. Subjects who did not decrease their smoking by at least 50% on the patch were randomly assigned to one of three conditions—continuing on the patch, the patch plus bupropion, or the patch plus the smoking-cessation drug varenicline.

Results showed a significant benefit at the end of treatment for the patch plus bupropion group, and a less robust effect for the patch plus varenicline—from the quit date to week 11, 16% were abstinent on the patch alone, 28% on bupropion, and 23% on varenicline. Rose and Behm concluded that their findings show "It is possible to rescue a significant portion of smokers who would have failed to achieve abstinence if left on the nicotine patch alone by identifying these smokers before their quit date and implementing adaptive changes in treatment."

In an accompanying editorial, AJP Editor-in-Chief Robert Freedman, M.D., called the study "a remarkable first attempt to improve smoking cessation by selecting treatment...based on an initial test period." He did note, however, that, "Although many patients in this study were helped, most had returned to smoking at 6 months, which points out the recalcitrance of this addiction to remediation."

To read more on smoking-cessation research, see Psychiatric News here and here.

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Military Suicides Linked to Mental Illness, Not Combat or Deployments

Neither combat experience, number of deployments, nor cumulative days deployed were significantly associated with suicide among current and former U.S. service members, found a study of 151,560 military personnel published today in JAMA. Instead, having depression or bipolar disorder, having alcohol-related problems, and being male are the strongest risk factors for suicide, reported Cynthia LeardMann, M.P.H., of the Naval Health Research Center in San Diego and colleagues.

The analysis used data from the Millennium Cohort Study, an ongoing effort that began in 2001 and is scheduled to continue for six decades. “[T]he increased rates of suicide in the military may largely be a product of an increased prevalence of mental disorders in this population,…” the researchers concluded.

This is "an impressive epidemiologic study—carefully done, with key variables clearly defined, and with a thoughtful analytic approach,” commented Eve Moscicki, Sc.D., M.P.H., director of the Practice Research Network at APA’s American Psychiatric Institute for Research and Education and an expert on the epidemiology of suicide. “The study makes an important contribution to our understanding of suicide in the military,” Moscicki told Psychiatric News. “And it sends a clear message that prevention, identification, and appropriate treatment of mental disorders is the most promising approach to suicide prevention.”

To read more about suicide risks in military populations, click here and here. Also see Psychiatric Services here.

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Cannabinoids Explored as Potential Anxiety Therapy

Cannabinoids, natural modulators of regular memory processes, deserve a closer look as potential adjuncts to exposure-based therapies for PTSD and other anxiety disorders, say University of Michigan researchers. Exposure-based therapies are currently the best-supported treatments for many anxiety disorders. Several neurotransmitter systems have been studied as routes to enhance the extinction learning process that lies at the heart of exposure therapy. Both D-cycloserine, which acts on the glutaminergic system, and yohimbine, an alpha2-receptor antagonist, have been investigated for such purposes, for example.

Now, Israel Liberzon, M.D, a professor of psychiatry, psychology, and neuroscience at Michigan, and research fellow Christine Rabinak, Ph.D., have found that tetrahydrocannabinol (THC) given during extinction learning in healthy subjects lead to better recall the next day of extinction memory compared with those who received placebo. The effect occurred even though no drug remained in the body.

“We speculate that the THC is doing something in the brain, to change areas that are activating or interacting after learning—but exactly what is still unknown,” Rabinak said in an interview with Psychiatric News.

“Learning is governed and modulated by several systems,” added Liberzon. Each system might modulate specific components of cognition and might lead ultimately to targeted interventions that could be tailored to the individual patient, he said.

For more in Psychiatric News about Liberzon’s and Rabinak’s work, click here.

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Fitness Mentor Can Improve Health for Overweight Patients With Serious Mental Illness

An exercise intervention in which overweight patients with serious mental illness were paired with a fitness trainer and given one-year membership in a fitness club achieved clinically significant reduction in cardiovascular risk for almost one-half of participants at 12 months. That was the finding from a study appearing online August 1 in Psychiatric Services.

Researchers at Dartmouth University conducted a randomized controlled trial with 133 individuals with serious mental illness and a body mass index (BMI) greater than 25. The participants were assigned either to the In SHAPE program (one year of weekly sessions with a fitness trainer plus a fitness club membership) or to one year of fitness club membership and education. Assessments were conducted at baseline and three, six, nine, and 12 months later. Although In SHAPE did not contribute to greater mean weight loss or reduction in BMI when compared with fitness club membership and education, at 12-month follow-up the intervention was associated with three times greater fitness club attendance, twice as much participation in physical exercise, greater engagement in vigorous physical activity, and improvement in diet. Twice the proportion of participants (40% versus 20%) achieved clinically significant improvement in cardiorespiratory fitness.

“The results of this study suggest that integrated provision of a fitness program that includes a health mentor as a component of community mental health services is feasible and associated with clinically significant reduction in cardiovascular risk,” the researchers said. “…It is likely that individually tailored health promotion interventions will be needed to optimize outcomes.”

For more information about fitness and serious mental illness, see Psychiatric News here.