Behaviors That Characterize ODD May Be Developmentally Distinct, Study Suggests

When children exhibit specific emotions or behaviors characteristic of oppositional defiant disorder (ODD) at one age, they are likely to do so at other stages of childhood as well, new research has found. The study was headed by Edward Barker, Ph.D., director of the Developmental Psychopathology Lab at the Institute of Psychiatry, King's College, London. The results are published in the Journal of the American Academy of Child and Adolescent Psychiatry.

More than 6,000 children and their mothers participated in this longitudinal study. The children were evaluated for three emotions or behaviors that often characterize ODD—irritability, being headstrong, and being intentionally hurtful—at ages 8, 10, and 13. Youngsters who displayed one of the emotions or behaviors at one age were also likely to display the same emotion or behavior at another age.

Moreover, the three emotions or behaviors tended to be developmentally distinct from one another over the years studied. However, being headstrong at age 10 was associated with being irritable at age 13, suggesting that being headstrong might be driving some of the later irritability. The researchers also looked to see whether being irritable, headstrong, or intentionally hurtful at age 8, 10, or 13 predicted depression or conduct disorder at age 16. They found that irritability predicted depression and that being headstrong predicted conduct disorder. Being intentionally hurtful predicted neither.

The findings have clinical implications, the researchers believe. For instance, ODD  appears to be a complex psychiatric condition, and "clinicians treating ODD and service planners may do well to assess the three dimensions described here to predict and tailor the most appropriate treatment for each individual."

Information about the refinements that have been made to ODD in DSM-5 can be found in the Psychiatric News article "New DSM Chapter to Focus on Disorders of Self-Control." Also see "Psychiatric Disorders in Preschoolers: Continuity From Ages 3 to 6" in the American Journal of Psychiatry. 

 

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"60 Minutes" Focuses on Schizophrenia and Violence

Yesterday evening, the CBS television program "60 Minutes" gave extensive exposure to the issue of how recent mass shootings in the U.S. appear to be preventable tragedies—symptoms of a seriously flawed mental health system. Correspondent Steve Kroft interviewed two experts on the subject—Jeffrey Lieberman, M.D., president of APA and chair of psychiatry at Columbia University, and E. Fuller Torrey, M.D., executive director of the Stanley Medical Research Institute. Several individuals with schizophrenia as well as their relatives were also interviewed.

Several major points emerged from the segment, including that schizophrenia is a brain illness. Lieberman documented this knowledge with brain images showing changes in the brains of people with schizophrenia. He also explained that the illness, which "usually emerges in late adolescence and early adulthood, affecting perception and judgment," may cause a person to hear voices, among other symptoms. In the worst cases, people with auditory hallucinations "can't distinguish the voices from their illness, and they think the voices are part of them, and if they tell them what to do, they'll follow it."

Another point made was that there are effective treatments for the hallucinations that individuals with schizophrenia experience, but not all of those individuals have access to such treatments. In other cases, they won't acknowledge their illness and thus refuse treatment. Some untreated individuals with schizophrenia occasionally listen to their "voices" telling them to commit violence.

However, both Lieberman and Torrey emphasized that the vast majority of individuals with schizophrenia do not commit violence. They are the ones who suffer the most from their illness. And the tragic fact is that many people with serious mental illness are not receiving treatment in the community and end up in jails and prisons. For example, the Cook County Jail in Chicago contains thousands of mentally ill inmates, and its director said that it is the largest mental health facility in the country.

Click here to view the "60 Minutes" segment.

Study Finds No Link Between Celiac Disease and Onset of Autism Spectrum Disorder

For years scientists have debated whether there is an association between celiac disease (CD)—characterized by gluten intolerance—and the onset of autism spectrum disorder (ASD). A study published this week in JAMA Psychiatry said that there is no evidence that such a link exists.

Researchers from Sweden collected data from approximately 43,000 patients with CD, intestinal inflammation, or a normal intestinal lining with a positive CD serology and compared them with 213,000 age-matched controls. Patients' medical records were evaluated for a prior diagnosis of ASD. The results showed that having a prior ASD diagnosis was not associated with CD or intestinal inflammation, but was highly correlated with a normal intestinal lining, with positive serology for CD.

“The link between autism and normal mucosa and positive celiac serology could be due to three things,” said Jonas Ludvigsson, M.D., Ph.D., lead author and a professor of epidemiology at Karolinska Institutet. "It could be a chance finding....It could be that patients with autism are more often tested for celiac...or it could be a true biological cause, perhaps an increase in mucosal permeability.” Though he said that this study is definitive, Ludvigsson noted that ASD association with other intestinal conditions should not be ruled out.

To read more about research into the causes of ASD, see the Psychiatric News article "CSF Excess in Brain May Help Predict Autism" and "Much of Autism's Groundwork May Be Laid Before Birth."


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Prenatal Stress May Lead to Conduct Disorder Under Certain Genetic Conditions, Study Finds

Prenatal stress can be a cause of conduct disorder in children only if they possess a particular variant of the dopamine receptor gene, a study published in the Journal of Child Psychology and Psychiatry suggests. The senior researcher was Manfred Laucht of the Central Institute of Mental Health in Mannheim, Germany. The researchers evaluated prenatal stress in 308 women, then followed their children until age 15 to see whether the children developed DSM-IV conduct disorder or oppositional defiant disorder. The children were also genotyped to see which variant of the dopamine receptor gene they possessed. The researchers found that prenatal stress alone did not increase the children's risk of having conduct disorder or oppositional defiant disorder. But it did do so in children who had one or two copies of a particular variant of the dopamine receptor gene—the 7r variant.

Thus, reducing prenatal stress might be a way to reduce the risk of conduct disorder and oppositional defiant disorder in  children who have the dopamine receptor gene variant in question, the researchers believe. Commenting on the study for Psychiatric News, Adelaide Robb, M.D., a professor of psychiatry and pediatrics at George Washington University School of Medicine, said the significance of the study is the researchers' conclusion that "reduction in prenatal stress might be a primary-prevention measure for the development of externalizing disorders.”

Information about brain abnormalities that appear to contribute to conduct disorder, along with possible therapeutic or preventive implications, can be found in the Psychiatric News article "Brain Abnormalities Found in Girls With Conduct Disorder."

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Study Finds Depression With Irritability, Anger Points to Poorer Prognosis

People whose major depression is accompanied by irritability and anger have a more unfavorable prognostic outlook than do people who have a major depression without those two additional factors, a large prospective study published in JAMA Psychiatry has found. The lead researcher was Lewis Judd, M.D., of the University of California, San Diego.

The researchers followed 536 subjects with major depression, half of whom also experienced irritability and anger, for an average of 16 years and compared the outcomes for the two groups. The irritability group took significantly longer than the depression-alone group to recover from the major depression they had at the study's onset. Furthermore, during the years of follow-up, they were significantly more likely than the depression-alone group to experience affective symptoms or a major affective episode; to have substance use disorders or anxiety disorders; to have difficulties with their partners or trouble performing at work or school; and to experience a lower quality of life. The study was funded by the National Institute of Mental Health.

"It is important for clinicians to identify overt irritability/anger in patients who experience a major depressive episode, because such symptoms are a clinical marker for a significantly more complex, chronic, and severe form of major depression," Judd and his colleagues emphasized.

Although DSM-5 does not include a subtype of major depression accompanied by anger and irritability, it does reflect an effort to move the depressive disorders away from a strict categorical designation to a more dimensional approach where depressive disorders can present with different degrees of severity and in the presence of comorbid symptoms, said Jan Fawcett, M.D., chair of the DSM-5 Mood Disorders Work Group, in interview with Psychiatric News.

For more information on this topic, see the Psychiatric News article "DSM-5 Updates Depressive, Anxiety, and OCD Criteria." Also see the Psychiatric Services article "The Diagnosis of Anger as a Presenting Complaint in Outpatient Medical Settings."

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Mothers' Prenatal Cocaine Use Lowers Teens' Brain Volume, Study Finds

Adolescents exposed in the womb to cocaine have a lower volume of gray matter in the brain and show an increased likelihood of initiating substance use themselves, according to a study led by Rajita Sinha, Ph.D., a professor of psychiatry at Yale School of Medicine. Sinha and colleagues reported on data from 42 teenagers aged 14 to 17, part of a larger group they have followed since birth. Another 21 adolescents who had not been exposed to cocaine prenatally served as controls.

“The adolescents with prenatal cocaine exposure had lower gray matter volume in key brain regions involved in emotion, reward, memory, and executive function, compared with non-exposed adolescents,” said the researchers in the October 1 Biological Psychiatry. Decreased gray matter volume was also associated with an increased probability of starting substance use.

“Thus, for the first time in children we see how mothers’ in-utero cocaine use may translate to brain changes in the offspring that impact cognition, mood, and health of the affected offspring later in life,” said Sinha in a statement. “One can speculate that in the future, with additional validation, such specific brain alterations may serve as biomarkers of risk that can be targeted to prevent drug use and abuse.”

For more in Psychiatric News about the effects of prenatal substance use, see the article “How Do Abused Drugs Affect Fetus, Newborn?”

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Screening Test May Help Identify PTSD Risk in Preschoolers

Swiss researchers report that clinicians using a “short, valid, and reliable screening instrument” can evaluate acute stress symptoms in preschool children as a way to help predict later onset of posttraumatic stress disorder (PTSD). The 87 children in the study, aged 2 to 6, had suffered road accidents or burns and were treated at University Children’s Hospital Zurich. The children were assessed with the 21-item Pediatric Emotional Distress Scale Early Screener (PEDS-ES) between six and 13 days of the accident. They were also evaluated six months later for symptoms of PTSD.

The PEDS-ES produced 85 percent sensitivity and 63 percent specificity for identifying full or partial PTSD, wrote Didier Kramer, M.Sc., a doctoral candidate, and Markus Landholt, Ph.D., a professor at the University of Zurich, in the October Pediatrics. Asking families about preexisting child or family trauma or history of psychiatric problems did not improve the predictive value of the screening, they said.

“The PEDS-ES can be used within a stepped-care model for early identification of preschool-aged children for whom early psychological support should be provided,” concluded the authors.

To read more in Psychiatric News about children and PTSD, see "Study of Trauma Treatment in Children Proves Controversial." Also see the book Care of Children Exposed to the Traumatic Effects of Disaster from American Psychiatric Publishing.

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Study Finds Form of CBT Superior to Antipsychotic Medication for Refractory OCD

A form of cognitive-behavioral therapy known as exposure-response therapy, when combined with serotonin reuptake inhibitor (SRI) medication, appears to work better for obsessive-compulsive disorder (OCD) than does antipsychotic medication. That was the finding from a study published in JAMA Psychiatry by researchers who compared exposure-response therapy with risperidone as an adjunct to SRI medication for OCD.

They conducted a randomized clinical trial at two academic outpatient research clinics that specialize in OCD and anxiety disorders. One hundred patients aged 18 to 70 with OCD of at least moderate severity despite a therapeutic SRI dose for at least 12 weeks were randomized to either risperidone, exposure-response therapy, or placebo.

Patients randomized to exposure-response therapy had significantly greater reduction on the Yale-Brown Obsessive Compulsive Scale, which was used to measure OCD severity. Moreover, patients receiving risperidone did not significantly differ from those receiving placebo. Adding exposure-response therapy was also superior to risperidone and placebo in improving insight, functioning, and quality of life.

“Patients with OCD receiving SRIs who continue to have clinically significant symptoms should be offered exposure-response therapy before antipsychotics, given its superior efficacy and less-negative adverse effect profile,” the researchers said.

To read more about research on OCD, see the Psychiatric News article, "Familial OCD: Environment, Genes Both Play Role."

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Antidepressants Help Patients Focus on the Positive, Study Shows

Antidepressant medication appears to modify emotional information by helping people focus more on positive stimuli and less on negative stimuli. That is the key finding of the study "Effect of Antidepressant Medication Use on Emotional Information Processing in Major Depression" by researchers at Oklahoma State University and three other institutions using an eye-tracking test to examine how medicated and unmedicated patients with depression processed visual information. The findings are published in AJP in Advance. The researchers used the test to examine the effects of antidepressant medication on selective attention for emotional stimuli in a sample of 47 patients with major depressive disorder (21 medicated and 26 unmedicated) and 47 matched comparison subjects without depression.

Participants completed a passive-viewing eye-tracking task assessing selective attention for positive, dysphoric, threatening, and neutral stimuli in addition to providing medication information and self-report measures of depression and anxiety severity.

Both depressed subjects currently taking antidepressants and nondepressed comparison subjects showed greater total gaze duration and more fixations for positive stimuli compared with unmedicated depressed subjects. Depressed subjects taking an antidepressant also had fewer fixations for dysphoric stimuli than did depressed subjects not on medication.

“These results are consistent with previous work and indicate a robust effect for antidepressants on positive information processing,” the researchers concluded. “They also provide further evidence for modification of information processing as a potential mechanism of action for antidepressant medication.”

To read more about the use of antidepressants, see The Evidence-Based Guide to Antidepressant Medications from American Psychiatric Publishing.

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APA Joins 'Choosing Wisely' Project With Cautions on Antipsychotic Prescribing

Friday marked the inauguration of APA’s public involvement in the Choosing Wisely campaign—an initiative sponsored by the American Board of Internal Medicine Foundation that encourages physicians, patients, and other health care stakeholders to engage in a dialogue concerning unnecessary medical procedures that, in some instances, could result in harm. As part of the Choosing Wisely campaign, APA has released a list of cautionary principles that should be considered when prescribing antipsychotic medications, noting that they are sometimes prescribed inappropriately.

“Antipsychotic medications have tremendous benefits and improve the quality of life for many people with serious mental illness; however, they carry risks including potentially harmful side effects. Unnecessary use or overuse of antipsychotics can contribute to chronic health problems, such as metabolic, neuromuscular, or cardiovascular problems, in people with serious mental illness,” said Joel Yager, M.D., chair of the APA Council on Quality Care (COQC). “Because of these risks, APA has recommended that antipsychotics should not be used routinely, and should never be used without considerable thought...”

The cautionary principles, developed by the COQC and unanimously approved by the APA Board of Trustees Executive Committee are as follows:

• Do not prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.
• Do not routinely prescribe two or more antipsychotic medications concurrently.
• Do not use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.
• Do not routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.
• Do not routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

To view the complete APA list and additional information, see http://www.psychiatry.org/choosingwisely. And for information on prescription practices for antipsychotic  medications, see the Psychiatric News articles, “Caution Urged for Clinicians Who Prescribe Opioids” and "Prescribing for Mentally Ill Children Generally in Line With Best Practices."

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APA Files Amended Complaint Against Insurer Over Parity-Law Violations

APA announced today that it has filed an amendment to its complaint against Anthem Health Plans Inc. in Connecticut and its parent company, Wellpoint Inc. Also joining in the amended action are the Connecticut Psychiatric Society and the Connecticut Council for Child and Adolescent Psychiatry. The original lawsuit was filed in April and maintains that Anthem is in violation of the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and Connecticut's insurance parity law as a result of changes the company made to its rate schedules for services provided to psychiatrists after changes to CPT codes went into effect in January.

The complaint asked the insurer and the Connecticut Insurance Division to fix problems inherent in its rate schedule that make it more difficult or expensive for patients to receive psychotherapy from a psychiatrist. The complaint alleges that through its rate schedule, Anthem is forcing psychotherapy patients to make two appointments, thus missing more time from work and imposing an unfair financial burden on them. It also calls for fixes to Anthem's practice of reimbursing psychiatrists less than other physicians for evaluation and management services.

The amended complaint was filed to address changes Anthem made in its rate schedule after the original complaint was filed because, "Sadly, neither Anthem nor the Connecticut Insurance Division have made any effort to solve the problem," said APA President Jeffrey Lieberman, M.D. The insurer's action, he emphasized, "is an example of the kinds of barriers to care insurance providers impose on people with mental illness.... The MHPAEA is a good law that needs to be enforced so that people in need of mental health care do not slip through the cracks. We can no longer tolerate discriminatory practices that impede access to care."

To read about an APA letter to Anthem calling for changes to the insurer's payment policies, see the article "APA, Connecticut Psychiatrists Protest Insurer's Practices" in Psychiatric News.

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NIH, FDA Create Centers to Study Tobacco Use, Health Consequences

To address the complex health and regulatory issues raised by the use of tobacco products, the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) announced today that they are partnering to spend $53 million to fund 14 centers—called Tobacco Centers of Regulatory Science—to conduct research that the agencies hope will lead to changes in tobacco regulations with the goal of protecting public health. They noted, "Despite decades of work to reduce tobacco use in the United States, it continues to be the leading cause of preventable death and disease."

Each of the centers to be funded will study a specific area that will increase understanding of the risks that come with tobacco use and tobacco addiction. In a statement announcing the new initiative, NIH Director Francis Collins, M.D., Ph.D., said, “While we’ve made tremendous strides in reducing the use of tobacco products in the U.S., smoking still accounts for one in five deaths each year, which is far too many.” The partnership, he added, will "keep us focused on reducing the burden and devastation of preventable disease caused by tobacco use."

The research will concentrate on the following seven areas relevant to tobacco manufacturing and use: reducing addiction, adverse health consequences, reducing toxicity and carcinogenicity, marketing of tobacco products, communication, economics and policies, and the diversity of tobacco products.

To read about issues concerning tobacco use and mental health, see the Psychiatric News articles "Nicotine Vaccine's Effects on Brain Evaluated" and "Many Smoking Cessation Failures Linked to Lack of Professional Help."

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Depression Questionnaire Item Helps Identify Patients at Risk of Suicide, Study Finds

One question on the nine-item Patient Health Questionnaire (PHQ-9), a depression-assessment tool commonly used in clinical practice, can help identify outpatients who have an increased risk of suicide attempt or suicide death, according to a report in the APA journal Psychiatric Services in Advance. 

Researchers at the 650,000-member Group Health Cooperative in Washington state and Idaho, led by Gregory Simon, M.D., M.P.H., used electronic medical records of patients who were seen for a depression-related visit for a five-year period beginning in 2007. They evaluated the ability of item 9 to assess suicidal ideation. It asks: "Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?" Response options are "not at all," "several days," "more than half the days," or "nearly every day."

At one year, the probability of a suicide attempt or completed suicide ranged from about .4% for those answering "not at all" to 4% (1 in 25) for those answering "nearly every day." Even after accounting for treatment history and demographic factors, "item 9 remained a strong predictor of any suicide attempt," the researchers said. Immediate risk was low, they noted, but increased over several days and persisted over several months. Treating clinicians were aware of PHQ-9 results, so the risks found "reflect the consequences of any clinical response" to questionnaire answers. They concluded that while denying suicidal thoughts "does not rule out subsequent suicide attempt,...Systematic use of the PHQ-9 (or some other standard outcome assessment) is an essential element of effective depression treatment."

To read more about this study, see the report "Does Response on the PHQ-9 Depression Questionnaire Predict Subsequent Suicide Attempt or Suicide Death?" in Psychiatric Services in Advance.

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Private-Practice Medicine Still Going Strong, AMA Finds

The AMA today released new data on physician practice arrangements showing that private-practice medicine remains strong despite an increase in hospital employment. This is the first nationally representative study of physician practice arrangements in five years.

“To paraphrase Mark Twain, the reports of the death of private-practice medicine have been greatly exaggerated,” said AMA President Ardis Dee Hoven, M.D. “This new data shows that while there has been an increase in hospital employment, more than half of physicians (53.2 percent) were self-employed in 2012, and 60 percent worked in practices wholly owned by physicians. Needed innovation in payment and delivery reform must recognize the wide range of practice types and sizes that exist today so all physicians can participate in the move to a more patient-centered system that rewards high-quality care and reduces costs.”

While this study shows 60 percent of physicians in physician-owned practices, there has been a trend toward more hospital employment during the last five years. In 2012, 29 percent of physicians worked either directly for a hospital (5.6 percent) or for a practice that was at least partially owned by a hospital (23.4 percent). A 2007/2008 AMA survey did not distinguish between direct hospital employment and employment in a hospital-owned practice, but found that 16.3 percent of physicians worked in one of the two settings.

For more news from the AMA, see the Psychiatric News articles, "AMA's Psychiatrist President Hails Involvement of APA" and "AMA Releases Insurer Report Card, Award Innovative Schools."

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Bath Salts Abuse Linked to Nearly 23,000 ED Visits

A new federal report reveals that “bath salts,” a group of drugs containing amphetamine-type stimulants, were linked to nearly 23,000 visits to hospital emergency departments in 2011. The report by the Substance Abuse and Mental Health Services Administration (SAMHSA) is the first national study to track bath salts drugs to emergency department visits since these drugs emerged a few years ago.

"Although bath salts drugs are sometimes claimed to be ‘legal highs’ or are promoted with labels to mask their real purpose, they can be extremely dangerous when used,” said Elinore McCance-Katz, M.D., SAMHSA’s chief medical officer. “Bath salts drugs can cause heart problems, high blood pressure, seizures, addiction, suicidal thoughts, psychosis and, in some cases, death—especially when combined with the use of other drugs.”

The SAMHSA report shows that about 67 percent of emergency department visits involving bath salts also involved use of another drug. Only 33 percent of the bath salts-related emergency department visits involved just the use of bath salts; 15 percent involved combined use with marijuana or synthetic forms of marijuana, and 52 percent involved use of other drugs.

For more information about the spreading epidemic of bath salts use, see the Psychiatric News articles "Psychiatrist Goes to Battle Against Bath-Salts Abuse" and "Spread of Synthetic Drugs Challenges Clinicians, Law Enforcement."

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Mental Health Response Quickly Follows Navy Yard Shooting

The shooting of 12 workers at the Washington Navy Yard Monday morning, September 16, set in motion a rapid response from APA to assist area mental health professionals as they helped those affected by the tragedy. After offering its sympathies, APA sent a toolkit with information on coping with traumatic events to the Washington Psychiatric Society (WPS). The toolkit contained specific advice on communicating with the public and the media about trauma and about how to talk to children about the event.

“We know our colleagues may be called upon to deal with the mental health consequences that may arise from this traumatic event, and we are confident they will meet this challenge,” said APA President Jeffery Lieberman, M.D., in an accompanying letter.

“We are interested in being helpful, not only to those directly involved, but to the wider community as well,” said Avram Mack, M.D., WPS immediate past president, in response.

The Navy quickly set up an emergency family assistance center at Joint Base Anacostia-Bolling in Washington, D.C. In addition, children’s emergency response teams and school-based mental health clinicians from the District of Columbia Department of Mental Health (DCDMH) responded today to requests for help from schools in the area. “We are working with the D.C. Office of Victims Services and other District government agencies, the FBI, and the American Red Cross on longer-term services for families,” said DCDMH Director Steve Baron, L.C.S.W.

APA’s Disaster Psychiatry web page contains links to important information on coping with the mental health aftermath of disasters and tragedies. The Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences in Bethesda, Md., also sent out relevant information sheets, including one on workplace violence.

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BRAIN Initiative Urged to Focus on Circuitry and Behavior

President Obama’s BRAIN Initiative, announced in April, should develop new research tools and increased collaborations with non-neuroscientists as it focuses on complex circuits and activity in the brain, said an advisory group's interim report presented yesterday at the National Institutes of Health.

The program should begin by generating a census of cell types and create structural maps of the brain, said committee co-chairs Cornelia Bargmann, Ph.D., a professor at Rockefeller University in New York, and William Newsome, Ph.D., a professor at Stanford University, in a teleconference. “We’re seeking an understanding of the dynamics of the brain: where signals come from and how they are related to internal states,” said Newsome.

Work should begin with animal models, but human research data could come from patients undergoing diagnostic brain imaging or monitoring or those receiving deep brain stimulation or other technological interventions, the group suggested. Key to the suggested approach will be development of new or improved technologies to record brain activity and to manipulate brain circuits. That research and the tools to process the immense quantities of data require close collaboration among neuroscientists and computer specialists, statisticians, physicists, engineers, and other scientists. Rapid dissemination of these tools as they are developed, through training modules and summer courses, would accelerate progress, said Bargmann and Newsome. The focus on technology development fits with the initiative's overarching mission, which is, as the BRAIN acronym suggests, “Brain Research through Advancing Innovative Neurotechnologies.”

The advisory committee will present its final report in June 2014.

For more in Psychiatric News about the BRAIN Initiative, see "Obama Calls for Major Initiative to Advance Brain Research."

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Cognitive Restructuring Helps Prevent Depression in At-Risk Teens, Study Suggests

A cognitive-behavioral prevention program, when compared with usual care, showed significant sustained effects in preventing depression in teens at high risk for depressive illness, said William Beardslee, M.D., a professor of child psychiatry at Harvard Medical School, and colleagues in JAMA Psychiatry.

The study included 316 youth aged 13 to 17 who were the offspring of parents with current or prior depressive disorders and who themselves had a history of or current depression or had depressive symptoms that did not yet meet criteria for a full-blown depressive disorder. The teens were randomly assigned to usual care or to a cognitive-behavioral prevention (CBP) program in which, during eight weekly group sessions and six monthly group booster sessions, they learned how to deal with negative or unrealistic thoughts. The subjects were evaluated for depression at baseline, after the acute intervention (month 2), after the booster sessions (month 9), and again at one year (month 21) and two years (month 33) after that. Over the 33-month period, and for the sample as a whole, the intervention was shown to be significantly effective. Thirty-seven percent of the teens in the CBP group experienced a depression, compared with 48 percent in the usual-care group. (Usual care was defined as the ability to initiate or continue any non-study mental illness care.)

"We were quite pleased that the effects noted in our earlier analysis nine months after enrollment were sustained at 33 months, as it is difficult to demonstrate longer-term prevention effects," Beardslee told Psychiatric News. At the nine-month follow-up, 21 percent of the teens randomized to the CBP condition had experienced depression, in contrast to 33 percent in the usual-care group.

During the past decade or so, there has been an explosion in mental illness prevention research such as that conducted by Beardslee and his colleagues. See the Psychiatric News article "Future Looks Promising for Mental Illness Prevention" to read more about the research. Also see "Maintenance Cognitive-Behavioral Therapy and Manualized Psychoeducation in the Treatment of Recurrent Depression..." in the American Journal of Psychiatry.

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C-reactive Protein May Predict Development of Late-Onset Schizophrenia, Study Finds

In a large prospective study, researchers found that elevated blood levels of a major factor in the body's immune system—C-reactive protein—were associated with a six- to 11-fold increased risk of developing late-onset schizophrenia. The senior researcher was Boerge Nordestgaard of Denmark's Copenhagen University Hospital. The results are published in Schizophrenia Bulletin.

"The association of C-reactive protein with late-onset schizophrenia is very robust, even after health-related confounds are addressed," William Carpenter, M.D., a professor of psychiatry at the University of Maryland and a schizophrenia expert, told Psychiatric News. However, "The immediate challenge with this report is the causal direction," he pointed out. "Is elevated C-reactive protein causing a porous blood brain barrier, permitting entry for pro-inflammatory cytokines, for example, or are variables associated with schizophrenia, such as therapeutic or abuse drugs, causing the C-reactive protein elevation?"

But assuming that C-reactive protein is actually contributing to schizophrenia risk, he indicated, then it helps support the "inflammatory pathophysiology hypothesis in schizophrenia"—a hypothesis that "is opening new opportunities for etiology and therapeutic discovery."

For example, during the past five years, scientists at the Maryland Psychiatric Research Center, as well as those in England, Israel, and Japan, have reported that the antibiotic minocycline countered not just schizophrenia's positive symptoms, but negative ones as well in some patients. To read more about this subject, see the Psychiatric News article "Will Antibiotic Fulfill Its Psychosis-Fighting Promise?"

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New Report Identifies Factors That Increase Likelihood of Child Abuse and Neglect

It has been 20 years since the National Research Council (NRC) issued a report on child neglect and abuse. Yesterday, the Institute of Medicine and National Research Council released a report, New Directions in Child Abuse and Neglect Research, to provide updated statistical information and recommendations concerning this public-health challenge that affects approximately 6 million children a year.

The NRC found that while rates of child neglect have remained steady and physical and sexual abuse have declined since its 1993 report—emotional and psychological abuse, which can lead to depression and attention difficulties, have risen. The leading factors linked to increased risk for child abuse and neglect were parental depression, substance abuse, and a history of abuse and neglect as a child. Home mortgage foreclosure also increased likelihood for child abuse and neglect, but not parental unemployment.

Though research has made major advances in illuminating developmental and biological processes associated with abuse and neglect—such as alternations in prefrontal cortex physiology—the Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade, Phase II, which was organized by the NRC and the Institute of Medicine to study the issue, emphasized that "federal support [of programs to reduce the incidence of child abuse] needs to be established and implemented immediately." The committee recommended the implementation for more collaborations between federal agencies, private foundations, and academic institutions to pinpoint at risk populations, and further expand research that assesses the long term mental and physical affects child abuse and neglect.

 To read more about research studies on the long-term effects of child abuse and neglect, see the Psychiatric News article "Childhood Abuse Can Weaken Adults’ Immune Response to Skin Cancer."

 

Key Ingredient in Chantix Does Not Appear to Cause Psychiatric Events, Study Finds

As Pfizer Pharmaceuticals pays out millions of dollars in claims related to depression and suicide associated with the antismoking drug Chantix, the study "Varenicline, Smoking Cessation, and Neuropsychiatric Adverse Events" reported today in AJP in Advance, finds that the drug may be less harmful than other smoking-cessation therapies. Researchers from the Department of Psychiatry at the University of Chicago and at Columbia University analyzed data from previous placebo-controlled and drug-comparison trials to assess the efficacy and safety of varenicline—the key in ingredient in Chantix—in more than 40,000 users with and without psychiatric disorders. 

The data showed that varenicline was highly associated with inducing nausea among patients, but not suicide events, depression, or aggression. Current or past psychiatric illness increased the risk of neuropsychiatric events equally among the varenicline and placebo groups. In the drug-comparison studies, the rate of neuropsychiatric events in the varenicline cohort was significantly less than in those receiving nicotine-replacement therapy. Overall, varenicline was more successful in achieving smoking abstinence than placebo or nicotine-replacement therapy.

J. John Mann, M.D., study author and vice chair for research in the Department of Psychiatry at Columbia, told Psychiatric News that, “Patients report side effects. Often they are real and important.... Sometimes the side effects or adverse effects reported are due a change in the illness or in this case due to nicotine withdrawal or the loss of the cognitive enhancing effects of nicotine…. Some reports are due to the patient being alert to the possibility [of a side effect] and [thus] more likely to report its occurrence, and sometimes the person feels they have the complication but objective examination fails to confirm this.”

The study was funded by the National Institute of Mental Health. Pfizer provided no financial support.

For information on research into varenicline, see the Psychiatric News article "Varenicline Shows Promise as Alcohol Abuse Treatment." For a report on nicotine-vaccine research, see the article "Nicotine Vaccine's Effect on Brain Evaluated."

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Institute to Feature Patrick Kennedy, Celebrate Community Psychiatry

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.

I am pleased to share highlights of APA’s 2013 Institute on Psychiatric Services with you as we get ready to meet in Philadelphia from October 10 to 13. The conference theme is “Transforming Psychiatric Practice, Reforming Health Care Delivery,” and I am very excited about this year’s meeting for many reasons. As APA president, I had the privilege of selecting the theme and have worked closely with the Scientific Program Committee in planning a learning experience that is innovative, diverse, comprehensive, and professionally fulfilling. In this column I want to share my thoughts on how this year’s theme is particularly relevant given the changes we are experiencing in the profession and some of the exciting program events that I hope will support APA’s goal of being in the forefront of changes in the profession under health care reform.
 

I am also very excited to announce two special events planned for this year’s attendees. Thanks to the support of the American Psychiatric Foundation, former Rep. Patrick Kennedy, a strong advocate for improved access to mental health services as part of health care reform, will join me for a session in the “Conversations” format, where we will discuss changes in psychiatric practice, stigma, and the need for increased advocacy to improve access to psychiatric treatment. I am also chairing a special symposium on the role of psychiatrists in the transformed health care system with esteemed colleagues Ellen Katz, Ann Sullivan, and Grant Mitchell.

To read more, click here.

Evidence Grows That Infection May Play Role in Schizophrenia Risk

Research has indicated that the presence of antibodies to influenza, toxoplasmosis, and other infectious agents in the blood of pregnant women is associated with increased risk of mental illness among their offspring. Now a new study in nonhuman primates finds that activating the maternal immune system leads to abnormal behavioral development in offspring.

Researchers treated pregnant rhesus monkeys with synthetic double-stranded RNA in the first or second trimesters and then studied their offspring for two years. Beginning at age 6 months, the young monkeys “exhibited abnormal responses to separation from their mothers,” compared with controls, said Melissa Bauman, Ph.D., of the M.I.N.D. Institute and the Department of Psychiatry and Behavioral Sciences at the University of California, Davis, online September 5 in Biological Psychiatry. They displayed abnormal repetitive behaviors, decreased affiliative vocalizations, and species-inappropriate proximity to unfamiliar monkeys.

“These results extended the findings in rodent MIA models to more human-like behaviors resembling those in both autism and schizophrenia,” concluded Bauman and colleagues.

To read more about research on links between infection and mental illness, see the article, "Psychiatrist Hunts for Evidence of Infection Theory of Schizophrenia" in Psychiatric News.

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Q & As from APA’s Practice Management HelpLine

APA’s Practice Management HelpLine provides practical assistance to APA members on a wide variety of day-to-day issues that arise in managing a practice. These include CPT coding changes, reimbursement problems, relationships with managed care companies, documentation of services provided, Medicare, Medicaid, establishing a private practice, and closing a practice, among others. To see recent questions received by HelpLine staff and how they answered them, see Psychiatric News.


APA members can submit their questions to the HelpLine by phone at (800) 343-4671 and e-mail at hsf@psych.org. Questions will be answered in future issues of Psychiatric News.

Psychoeducation Helps in Maternal Depression, Trauma Associated With Preterm Birth

A short, highly manualized intervention for mothers of preterm infants significantly reduced symptoms of trauma and depression associated with preterm birth, according to a report published online September 2 in Pediatrics. Researchers at Stanford University and New York University medical schools randomized 105 mothers of preterm infants (25–34 weeks’ gestational age with a birth weight of less than 600 g) to receive a six-session intervention developed to target parental trauma or to a comparison group.

Mothers in the intervention group received a combination of trauma-focused treatments, including psychoeducation, cognitive restructuring, progressive muscle relaxation, and development of a “trauma narrative.” The intervention also incorporated material targeting “infant redefinition”—the process of changing a mother’s negative perceptions of her infant and the parenting experience. Mothers in the intervention group reported greater reduction in both trauma symptoms and depression than mothers in the comparison group. And mothers with higher ratings of baseline stress in the neonatal intensive care unit benefited more from the intervention than did mothers who had lower ratings.

“The intervention is feasible, can be delivered with fidelity, and has high ratings of maternal satisfaction,” the researchers said. “Given that improvements in mothers’ distress may lead to improved infant outcomes, this intervention has the potential for a high public-health impact.”

To read more about this topic, see the Psychiatric News articles "Screening of Postpartum Women Shows High Rates of Depression" and "Data Clarify Link Between Antidepressant Use, Preterm Birth." Also see the report "Effects on Children of Treating Their Mothers' Depression: Results of a 12-Month Follow-Up" in Psychiatric Services.

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FDA Announces Labeling Changes, Postmarket-Study Requirements for Opioids Analgesics

Today, the Food and Drug Administration (FDA) mandated safety labeling changes and new postmarket study requirements for all extended-release and long-acting (ER/LA) opioid painkillers. The ruling was prompted by the high incidence of overdose-related deaths and misuse of opioid drugs, which was reportedly used by 2.4 million Americans in 2010, according to government data.

The new class wide-labeling changes for ER/LA opioids will include detailed information to assist clinicians with tailoring medication to patients' individual needs, as well as a boxed warning to caution about drug use during pregnancy, which can result in neonatal opioid withdrawal syndrome. The FDA noted that the medications are intended for patients who exhibit “around-the-clock” pain and have exhausted all other options—such as non-opioid medication and immediate-release opioids—to alleviate pain. In addition, the FDA is requiring all ER/LA opioid manufacturers to conduct clinical trials that will assess the serious risks for misuse, abuse, increased sensitivity to pain, addiction, overdose, and death of these medications.

“The FDA’s primary tool for informing prescribers about the approved uses of medications is the product labeling,” said Douglas Throckmorton, M.D., deputy director for regulatory programs in the FDA’s Center for Drug Evaluation and Research. “Today’s safety labeling changes reflect the FDA’s current understanding of the risks and benefits of these products. The FDA will evaluate the results of the postmarket studies, continue to monitor relevant safety data, and take further safety action, as warranted.”

For more information about FDA regulation regarding opioid analgesics, see the articles  "Caution Urged for Clinicians Who Prescribe Opioids" and "FDA Opioid Abuse Proposal Said to Be Too Weak" in Psychiatric News.

(Image: Courtesy of FDA.gov)

Individuals With Autism May Excel at Math

A study in Biological Psychiatry provides new evidence that some individuals with high-functioning autism have enhanced cognitive ability in mathematics.

"The findings should remind clinicians, parents, and educators that the brains of individuals with autism could potentially be 'gifted' with superior abilities, math being one of them," the lead researcher told Psychiatric News. She is Teresa Luculano, Ph.D., a postdoctoral fellow in psychiatry and behavioral sciences at Stanford University.

Luculano and her colleagues also found that while autism subjects were solving math problems, their brains showed different patterns of activation than did the brains of controls while doing so. They were especially intrigued by their finding that the ventral-temporal-occipital cortex predicted math abilities in autism subjects, she said, since this area is "normally devoted to face processing, which other labs have shown to be hypo-activated in children with autism when processing faces and generally social stimuli."

Individuals with autism may also be gifted with an exceptionally sharp visual perception of moving objects. See the Psychiatric News article "Visual Perception Appears Heightened in autism."

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Nobel Laureate Comments on Biology of Psychiatric Disorders

In an op-ed essay that appeared in the May 28 New York Times, David Brooks claimed that psychiatry is not really a science, but a semi-science. This claim prompted Eric Kandel, M.D., to respond in his own op-ed essay, which appeared in the September 6 New York Times. In addition to being a professor at Columbia University, Kandel was a recipient of the 2000 Nobel Prize in Physiology or Medicine.

"The reason that Mr. Brooks is understandably conflicted about seeing psychiatry as a medical discipline is that we do not understand the biological substratum of most psychiatric disorders, and certainly we are nowhere near understanding them as well as we understand disorders of the liver or the heart," Kandel told Psychiatric News. "But the fact is that we are beginning to make some progress, and although it is slow, it is accelerating. I wrote the New York Times response to give the reader a few examples of that."

For example, "We are beginning to discern the outlines of a complex neural circuit that becomes disordered in depressive illnesses," he wrote. "Helen Mayberg, at Emory University, and other scientists used brain-scanning techniques to identify several components of this circuit, two of which are particularly important." They are the subcallosal cingulate region, "which mediates our unconscious and motor responses to emotional stress," and the right anterior insula, "a region where self-awareness and interpersonal experience come together."

Moreover, he wrote, "ANY discussion of the biological basis of psychiatric disorders must include genetics. Most mutations produce small differences in our genes, but scientists have recently discovered that some mutations give rise to structural differences in our chromosomes. Such differences are known as copy number variations....Matthew State, at the University of California, San Francisco, has discovered a remarkable copy number variation involving chromosome 7. An extra copy of a particular segment of this chromosome greatly increases the risk of autism, which is characterized by social isolation. Yet the loss of that same segment results in Williams syndrome, a disorder characterized by intense sociability."

Click here for Kandel's New York Times essay, "The New Science of Mind."

APA Spokesperson Patrick Kennedy Holds Media Tour on Mental Health Issues

As next month marks open enrollment for the Affordable Care Act and the 50th anniversary of President Kennedy’s signing of the Community Mental Health Act, former Congressman and APA spokesperson Patrick Kennedy is taking steps to ensure that the plea for adequate health care for those with mental illness is being heard by the masses.


On September 4 and 5, Kennedy led a national media tour from Boston to Los Angeles in honor of National Suicide Prevention Month. The tour consisted of 24 interviews across television, radio, and digital media outlets and showcased APA’s leadership role in fighting the stigma that prevents many Americans from receiving effective care for suicide prevention, psychiatric conditions, and substance abuse disorders.

“Health care reform is a big win for us, because it eliminates the preexisting condition clause...but we are looking for a rule that will define mental health…If you provide coverage of asthma, diabetes, cardiovascular disease…you must treat a mental illness in the same respect,” he said during an interview on MSNBC’s "Andrea Mitchell Reports." Kennedy emphasized that preventative care is highly important in treating mental illness. “The job of reducing suicide is to treat the underlying mental health issue, and hopefully that is what parity will begin to do,” he concluded.

For more information on Kennedy's commitment to mental health issues, see the Psychiatric News article "APA Holds Press Conference on Key Mental Health Issues." Also, see Kennedy's interview on MSNBC's "Andrea Mitchell Reports."

Soft Drink Consumption Leads to Behavioral Problems in Young Children

A study in last month's Journal of Pediatrics evaluated approximately 3,000 5-year old children to examine the relationship between soda consumption and aggressive and withdrawal behaviors and attention problems. Soft drink consumptions and behaviors of children were monitored over two months and reported to researchers by the participants’ mothers.

The results showed that aggression, withdrawal, and attention problems were associated with at least one serving of soft drink per day. The association remained significant after adjusting for sociodemographic factors, maternal depression, and parental incarceration. In addition, children who drank four or more soft drinks per day were more than twice as likely to destroy things belonging to others, participate in fights, and physically attack people.

“We found that the child's aggressive behavior score increased with every increase in soft drinks servings per day," said Shakira Suglia, Sc.D., lead author and professor at the Columbia University Mailman School of Public Health. Although the study cannot identify the exact mechanism of the association between soft drink consumption and problem behaviors, limiting or eliminating a a child's consumption of soft drinks may reduce behavioral problems.

For more information on the association of soda consumption and behavioral problems, see the Psychiatric News article "Are Soda-Swilling Teens More Apt to Be Violent?"

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