Pesticide Ingredient Increases Risk for Alzheimer's Disease, Study Finds

According to a study published Monday in JAMA Neurology, elevated blood levels of dichlorodiphenyltrichloroethylene (DDE), a metabolite of the banned pesticide dichlorodiphenyltrichloroethane (DDT), may increase risk for the development of Alzheimer’s disease (AD)—especially in those who are genetically at higher risk of AD. Researchers from the Rutgers-Robert Wood Johnson Medical School and Emory University Alzheimer’s Disease Research Center analyzed blood samples of 175 elderly patients with and without AD to investigate the association between serum levels of DDE and the onset of AD and whether the presence of the apolipoprotein E4 (APOE4)—a genetic risk factor for AD—modifies the association.

The results showed that DDE serum levels were nearly four times higher in individuals with AD than in controls. The highest blood levels of DDE was associated with low scores on cognitive function tests, as well as the presence of the APOE4 genotype. In addition, the researchers found that DDE increased levels of amyloid precursor protein, after exposing human neuronal cells to DDE in vitro.

“This is one of the first studies identifying a strong environmental risk factor for Alzheimer's disease," commented coauthor Allan Levey, M.D., Ph.D., director of Emory's Alzheimer's Disease Research Center and chair of neurology at Emory University School of Medicine. "The magnitude of the effect is strikingly large—it is comparable in size to the most common genetic risk factor for late-onset Alzheimer's." The study’s authors noted that identifying people who have elevated levels of the long lasting toxin and carry an APOE4 allele may lead to early identification of some cases of AD.

To read more about how environmental factors can contribute to psychiatric disorders see the Psychiatric News articles, “Autism Linked to Air Pollution In Preschool Children” and “Destructive Mining Practice Worsens Depression in Appalachia.”

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Electronic Medical Records Can Compromise Physician-Patient Engagement, Study Suggests

As the age of electric health records begin to burgeon, the engagement between patient and physician may be growing distant. Researchers at Northwestern University Feinberg School of Medicine conducted a study examining the impact of electronic health records on eye-gaze patterns between patients and physicians. The study was published in the International Journal of Medical Informatics.

To assess engagement patterns between patients and clinicians, the scientists observed 100 doctor-patient visits in which physicians used paper or electronic health records to support patient care. The results showed that clinicians who used electronic health records spent 31% of the visit gazing at the screen, while physicians who used paper charts gazed at those records for 9% of the visit. In addition, patients gazed significantly more at health charts that were on the screen—whether or not they could see the screen or understand the contents—than those whose care was supported by paper charts.

John Luo, M.D., a psychiatrist and senior physician informaticist at the University of California Los Angeles Health, who was not involved with the study, commented to Psychiatric News that “electronic medical records are not perfect. They have many advantages such as legibility, access from many sites, and others; however, in mental health care, providers need to pay close attention to body language and other nonverbal cues of patients—[particularly] in medication management, where this situation would most likely occur.” Luo concluded that future training should include instruction that will foster more effective doctor-patient interactions as the use of electronic health records become more prevalent in clinical care.

To read more about electronic medical records, see Psychiatric News articles, "Psychiatry Joins the Digital Revolution," and "Safety Is Key to Use of Electronic Health Records." For more about electronic health records in psychiatric care, see the studies, "Best Practices: The Electronic Medical Record Is an Invaluable Clinical Tool: Let’s Start Using It" in Psychiatric Services and "Randomized Trial of an Electronic Personal Health Record for Patients With Serious Mental Illnesses" in the American Journal of Psychiatry.

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Treatment for Child Anxiety Disorders Beneficial, but Needs to Be Longer, More Intensive, Study Finds

While there have been studies showing the effectiveness of treatment of childhood anxiety disorders in the short term, a new study provides evidence of treatment effectiveness over the longer term. Although researchers in this new study found that young people diagnosed with anxiety disorders were more likely to be in remission six years later if they had responded during the acute phase of a treatment study, they also found that “Relapse occurred in almost half (48%) of acute responders, suggesting the need for more intensive or continued treatment for a sizable proportion of youths with anxiety disorders.”

The report of the study was published online yesterday in JAMA Psychiatry. It was conducted by Golda Ginsburg, Ph.D., of the Division of Child and Adolescent Psychiatry in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, and colleagues. Their findings about relapse rates are particularly important, the researchers pointed out, because pediatric anxiety disorders "are considered gateway disorders in that they predict adult psychiatric problems."

They evaluated 288 patients from the Child and Adolescent Anxiety Multimodal Study (CAMS), which was sponsored by the National Institute of Mental Health. Subjects' average age at baseline was 11 years. Overall, 46.5% of the participants were in remission at an average of six years later. However, 52% of children who responded to treatment and 37.6% of those who did not respond were in remission.

Those early treatment responders were also more likely to have less-severe anxiety symptoms and higher functioning, regardless of treatment type (cognitive-behavioral therapy, medication, or a combination), said Ginsburg and colleagues. Once patients randomized to placebo were removed from the analysis, responder status predicted only lower anxiety severity scores. Male participants and those with better family functioning and higher socioeconomic status fared better than other patients, noted the authors.

For a review of state-of-the-art psychiatric care for children and adolescents and research developments in the field, see the recently revised second edition of the Clinical Manual of Child and Adolescent Psychopharmacology from American Psychiatric Publishing. Also see the report "Childhood Separation Anxiety and the Pathogenesis and Treatment of Adult Anxiety" in the January American Journal of Psychiatry.

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Follow-up Needed to Better Evaluate Studies of Early Autism Screening, Say Researchers

A review of the scientific literature on approaches to early detection of autism spectrum disorders in community settings has found that “the effectiveness of such efforts on reducing time to diagnosis and services enrollment remains largely untested,” wrote lead author Amy Daniels, Ph.D., assistant director of public-health research at Autism Speaks in New York, and colleagues in the February Journal of the American Academy of Child and Adolescent Psychiatry.

The researchers found 40 studies describing 35 approaches, published from January 1990 through January 2013. They grouped the approaches into three categories: awareness, routine screening, and practice improvement to enhance screening. Use of practice-improvement approaches was related to increased screening and referral, while clinicians using awareness approaches indicated greater knowledge about autism. Use of routine screening produced greater rates of screening and referrals, although few studies evaluated the effect of routine screening on the age at which the disorder was diagnosed or on the services that were provided.

However, "that few studies reported outcomes beyond rates of referral indicates the need for enhanced methodological rigor, particularly with respect to length of follow-up and quality of measures used,” concluded Daniels and colleagues.

To read more about research on autism spectrum disorders, see the Psychiatric News article, “Pieces of Autism Puzzle Slowly Coming Together.” For a comprehensive review of the field, see Textbook of Autism Spectrum Disorders from American Psychiatric Publishing.

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Offspring of Younger, Older Parents at Risk for Different Mental Illnesses, Study Shows

The offspring of younger mothers and older fathers—as opposed to offspring of parents aged 25 to 29—are at risk for different mental health disorders, according to a report published online in JAMA Psychiatry.

John McGrath, M.D., of the University of Queensland in Australia and colleagues used records from the Danish Psychiatric Central Research Register to follow 2,894,688 individuals born in Denmark from January 1, 1955, through December 31, 2006. They examined incidence of a broad range of mental disorders and maternal and paternal age at birth. A total of 218,441 members of the cohort had a first psychiatric contact for any psychiatric disorder during the study period. Based on the overall risk of developing psychiatric disorders, the offspring of both younger and older parents were at increased risk compared with those of parents aged 25 to 29.

Compared with the offspring of mothers aged 25 to 29, the offspring of mothers aged 12 to 19 had a 51% increased risk of having a mental disorder; no significantly increased risk for the offspring of older mothers was found. In contrast, paternal age showed a U-shaped relationship, with the offspring of teenaged fathers having a 28% increased risk for a psychiatric disorder, whereas the offspring of the fathers aged 45 or older had a 34% increased risk.

Interestingly, different disorders were associated with different parental age extremes. For example, the offspring of older fathers were at increased risk for schizophrenia and related disorders, mental retardation, and autism spectrum disorders. In contrast, the offspring of young mothers (and to a lesser extent young fathers) were at an increased risk for substance use disorders, hyperkinetic disorders, and mental retardation, according to the report. “These differences can provide clues to the complex risk architecture underpinning the association between parental age and the mental health of offspring,” the researchers said.

For more information on this subject, see the Psychiatric News article, “Gene Mutation Explains Link of Paternal Age, Mental Illness." Also see the American Journal of Psychiatry study, “Selfish Spermatogonial Selection”: A Novel Mechanism for the Association Between Advanced Paternal Age and Neurodevelopmental Disorders."

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Study Finds That Persistent Internalizing Disorders May Lead to Accelerated Aging

Having persistent internalizing disorders during the first several decades of life may lead to accelerated telomere shortening—that is, accelerated cellular aging, a study reported in Molecular Psychiatry has found.

The study cohort included more than 1,000 individuals who were evaluated for depression, generalized anxiety disorder, and posttraumatic stress disorder from ages 11 to 38. The length of their telomeres was evaluated at age 38. The researchers found in males, but not in females, that persistence of internalizing disorders across repeated assessments predicted shorter telomeres at age 38 in a dose-response manner, and this finding held true even when potential confounders such as childhood maltreatment, smoking, psychiatric medication use, poor physical health, or low socioeconomic status were considered.

"Because internalizing disorders are treatable, the findings suggest [that] treating psychiatric disorders in the first half of the life course may reduce the population burden of age-related disease and extend health expectancy," the researchers concluded. However, they do acknowledge that "long-term follow-up studies are needed to test whether accelerated telomere erosion indeed mediates the link between internalizing disorders and later age-related disease outcomes."

The study was conducted by Idan Shalev, Ph.D., of the Duke University Department of Psychology and Neuroscience, and an international group of colleagues.

More information about telomeres and psychiatric illness can be found in the Psychiatric News articles, "Telomeres Hold Considerable Sway Over Our Health" and "The Tale of the Telomeres Gets Ever-More Complex."

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Depression Appears Linked to Higher Risk for Death, Analysis Finds

People with depression appear to have a higher risk of dying prematurely than do nondepressed individuals, according to a meta-analysis of studies from 35 countries published online in AJP in Advance. The study is titled "Comprehensive Meta-Analysis of Excess Mortality in Depression in the General Community Versus Patients With Specific Illnesses."

Dutch and Chinese researchers conducted systematic searches of PubMed, PsycINFO, and Embase. Studies were included if depression was measured with a standardized instrument and mortality was reported for both depressed and nondepressed participants at follow-up. A total of 293 studies including 1,813,733 participants (135,007 depressed and 1,678,726 nondepressed) from 35 countries were included. The overall unadjusted relative risk of mortality in depressed relative to nondepressed participants was 1.64. This statistic declined somewhat when the researchers adjusted for possible methodological problems in the studies.

With the exception of chronic obstructive pulmonary disease, they found no strong indications that the risk of death was different across relatively healthy community samples and specific patient samples with heart disease, cancer, kidney disease, or other disease. That suggests that generic factors associated with the biology of depression—not disease-specific factors—are responsible for the higher death risk.

“Our observation that the association between depression and mortality is not strikingly different between community-based samples and patient samples suggests that the association between depression and mortality may be explained better by generic mechanisms, such as biological dysregulations and lifestyle factors that have a general impact on health, than by disorder-specific mechanisms…” they concluded.

For more information on the association between mental illness and mortality risk, see the Psychiatric News article, “Mental Illness Linked to Premature Death in Epilepsy Patients."

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Somatic Symptoms of Depression May Predict Heart Attack, Study Finds

New data suggest that the increased heart attack risk that numerous studies have associated with depression "may be primarily driven by the somatic cluster" of depression symptoms. The study that produced these new finding was led by Jesse Stewart, Ph.D., of Indiana University-Purdue University Indianapolis. The findings are published in the January Psychosomatic Medicine.

Study participants were more than 2,500 primary care patients aged 60 or older who were free of cardiovascular disease at study onset. They were screened for four clusters of depressive symptoms—depressed affect, somatic symptoms, interpersonal problems, or lack of positive effect—with the Center for Epidemiologic Studies Depression Scale. The subjects were followed for 15 years to determine whether any experienced a heart attack; a total of 678 did. The researchers then assessed whether any of the four clusters of depressive symptoms could have predicted a heart attack, after adjusting for various cardiovascular risk factors and for presence of the remaining clusters. They found that somatic symptoms of depression were a risk factor for heart attack in their study population.

"Our results...could inform the development of interventions designed to simultaneously treat depression and reduce coronary artery disease risk among older men and women," the researchers concluded. "Such interventions should have demonstrated efficacy for the somatic symptoms of depression, particularly reduced appetite and fatigue, if cardiovascular benefits are to be expected. Existing depression interventions that may be good candidates and worthy of further evaluation include appetite-stimulating antidepressants, such as mirtazapine, and exercise training."

More information about the complex relationship between depression and cardiovascular disease can be found in the Psychiatric News articles "Red Blood Cell Size Linked to Depression in Heart-Disease Patients," and "Depression-Cardiovascular Link Found in Young Adults." Also see the study, "Comprehensive Meta-Analysis of Excess Mortality in Depression in the General Community..."published January 17 in AJP in Advance.

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NIDA Introduces Online Resources for Treating Youth With Substance Use Disorder

Yesterday, the National Institute on Drug Abuse (NIDA) introduced resources to help health care professionals treat teenagers with substance use disorder and identify those who may be at risk for such illness. The resources were inspired by the 2012 National Survey on Drug Use and Health findings which showed that only 10 percent of adolescents aged 12 to 17 needing medical intervention for substance use disorder received any services for their addiction.

“Because critical brain circuits are still developing during the teen years, this age group is particularly susceptible to drug abuse and addiction,” said NIDA Director Nora Volkow, M.D. “These new resources are based on recent research that has greatly advanced our understanding of the unique treatment needs of the adolescent.”

The resources include a new online publication, Principles of Adolescent Substance Use Disorder Treatment: A Research Based Guide, which includes 13 principles to consider in treating youth with substance use disorder, as well as evidence-based approaches in treating adolescent drug abuse. NIDA also released an online video curriculum for medical students and resident physicians, "The Substance Use Disorder in Adolescents Screening and Engagement in Primary Care Setting," which demonstrates skills to use in screening adolescents who are at risk for substance use disorder. NIDA stated that although the tools are created for training purposes, the resources are open to anyone in the public seeking information on how to interact with teenagers at risk for addiction.

To view NIDA’s new resources on treating teenage substance abuse see Principles of Adolescent Substance Use Disorder Treatment: A Research Based Guide and "Substance Use Disorders in Adolescents: Screening and Engagement in Primary Care Settings." Also see the book, Clinical Manual of Adolescent Substance Abuse Treatment, published by American Psychiatric Press.

The Truth About Psychiatry and Health Care Insurance

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.

A recent study by Bishop et al. in JAMA Psychiatry prompted a New York Times article (“Fewer Psychiatrists Seen Taking Health Insurance," December 11, 2013) and dialogue (“Invitation to a Dialogue: Hurdles to Mental Care,” January 4, 2014). This relatively limited study in a psychiatry specialty journal obviously touched a nerve and sparked a public debate in the media in which psychiatrists were not portrayed very favorably. From the article, one could conclude that psychiatrists do not accept insurance because it does not pay enough; they accepted patients only with “deep pockets,” and they were not willing to participate in provider networks.

Although there were elements of truth in the media coverage, the truth is more complicated, as is frequently the case. The truth of the matter begins with the fact that our country’s health care system is challenged by a shortage of mental health care providers, especially psychiatrists. Half the counties in the United States lack practicing psychiatrists. The inability to access care is further exacerbated by discriminatory, and often illegal, barriers to mental health and addiction services for patients imposed by insurance companies. Psychiatrists are routinely paid less for their services, even when they are using the same Evaluation/Management (E/M) codes, than other physicians and even though they typically spend significantly more time with patients. Patients with depression can see their primary care doctor or they can see a psychiatrist. However, primary care physicians, who are not as well trained in mental health care as psychiatrists, are paid more. In response to improvements to the CPT coding structure for psychiatry, some insurance companies reduced the rates they would agree to pay psychiatrists for E/M and psychotherapy. The Mental Health Parity and Addiction Equity Act prohibits this disparity, and APA has sued Anthem and WellPoint in Connecticut to end discriminatory reimbursement practices that lead to inadequate networks of psychiatrists.

Click here to read more.

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

New Findings on Genetic Mutations Shed Light on Schizophrenia—and More

Much of the genetic risk for schizophrenia is inherited, but not all. Now, a study finds that a small number of de novo mutations—those occurring in the individual but not the parents—disrupt certain genes encoding postsynaptic proteins, which may have a part in triggering the disorder.

Furthermore, the study of 623 patients and their families found significant overlaps between these mutations and pathogenic mechanisms underlying autism and intellectual disability, wrote Michael Owen, M.D., Ph.D., director of the Institute of Psychological Medicine and Clinical Neurosciences at Britain’s Cardiff University, and colleagues. The study was published today in the journal Nature.

“How disruption of these synaptic mechanisms affects brain function to produce psychopathology cannot be answered by genetic studies alone, but our identification of de novo mutations in these gene sets provides the basis to address this,” said Owen and colleagues. Findings of overlaps among the mechanisms associated with schizophrenia, autism, and intellectual disability may add support to approaching research into mental illnesses that “places more emphasis on domains of psychopathology (for example, cognition) and their neurobiological substrates rather than current diagnostic categories,” they suggested.

To read more about research directions in mental illness, see the Psychiatric News article, "Despite Brain Research Advances, Significant Challenges Remain." Also see the American Journal of Psychiatry study,
"Genome-Wide Linkage Analyses of 12 Endophenotypes for Schizophrenia From the Consortium on the Genetics of Schizophrenia."

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Type of Antidepressant Doesn't Affect Teens' Risk for Suicide, Study Finds

Adolescents taking an antidepressant that is not FDA-approved to treat depression did not show any increase in suicide attempts compared with adolescents taking fluoxetine—the only FDA-approved antidepressant for patients in this age group. Researchers from the Department of Pediatrics at Vanderbilt University and Department of Psychiatry at the University of Alabama, Birmingham, collected data from approximately 37,000 youth with major depressive disorder to compare the risk for suicidality among new users of fluoxetine with that for new users of other antidepressants that don't have FDA approval to treat depression in children or teens.

The results, reported in Pediatrics showed no significant difference in suicide attempts among participants prescribed fluoxetine and those prescribed non-FDA-recommended antidepressants for adolescent depression—such as sertraline and citalopram. However, youth taking multiple antidepressants concomitantly were two times more likely to attempt suicide than those with prescriptions for a single antidepressant.

David Fassler, M.D., a clinical professor of psychiatry at the University of Vermont, told Psychiatric News that “in considering these findings, it's important to note that the majority of child and adolescent suicide attempts never actually come to medical attention...[however,] these results may provide some degree of assurance for physicians and parents with respect to the choice of specific antidepressant medication.” Fassler, in agreement with the study’s authors, concluded that further research is needed to identify the mechanisms associated with antidepressant use and suicidal behaviors.

To read more about issues concerning suicidal behaviors and suicide rates in youth, see the Psychiatric News article “Teens’ Psychotic Symptoms Strongly Associated With Suicidal Behavior.” To read about the challenges clinicians face in preventing and managing suicidal behavior, see the American Psychiatric Publishing Textbook of Suicide Assessment and Management, Second Edition.

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Involuntary Commitment Laws for Substance Abuse Vary Across States

Civil commitment statutes vary greatly by state in terms of clarity and specificity regarding which mental illnesses are included for the purpose of involuntary hospitalization. The status of substance abuse is especially problematic: many states do not clearly reference substance abuse in civil commitment laws while others specifically exclude it.  Those are the findings of a report appearing online in Psychiatric Services in Advance, “Statutory Definitions of Mental Illness for Involuntary Hospitalization as Related to Substance Use Disorders.”

Robin Williams, M.D., M.B.E. and colleagues in the Department of Psychiatry at New York University School of Medicine, examined state mental health statutes to better understand the national landscape of civil commitment law with a specific focus on substance use disorders.

“In New York City, individuals gravely disabled by substance use disorders repeatedly present to emergency rooms,” the authors stated. “Although these individuals are at high risk of death and often lack the capacity to make treatment decisions, the laws in New York State are unclear about whether substance use disorders qualify as mental illnesses for the purpose of involuntary hospitalization."

Their review revealed that New York is not alone. They found that 21 states and Washington, D.C., do not reference substance use disorders in their statutory definitions of mental illness. Of the 29 that do, eight states include substance use disorders, and 21 explicitly exclude them. In addition, nine states have separate inpatient commitment laws specifically addressing substance use disorders.

“Mental health professionals and policymakers should discuss whether individuals gravely disabled by substance use disorders, a complex and vulnerable population, should be more widely included under standard civil commitment law,” they wrote.

For more on involuntary treatment see the Psychiatric News article, "Rulings Guide Psychiatrists on Forced-Treatment Limits."

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Electronic Personal Health Record Improves Care for Those With Serious Mental Illness, Study Finds

Having a personal health record results in significantly improved quality of medical care and increased use of medical services among patients with serious mental illness, according to the study, “Randomized Trial of an Electronic Personal Health Record for Patients With Serious Mental Illnesses,” published online today in AJP in Advance.

Psychiatrist Benjamin Druss, M.D., and colleagues at Emory University randomly assigned 170 individuals with a serious mental disorder and a comorbid medical condition treated in a community mental health center to either a personal health record or usual care. One-year outcomes assessed quality of medical care, service use, and health-related quality of life. Patients in the intervention group used an electronic personal health record called “My Health Record” to facilitate self-management of their illnesses and interactions with the health system. Core features of the record are personal details; diagnoses; goals and action steps; health indicators, including fields for blood pressure, cholesterol, and glucose levels; medications and allergies; hospital visits; immunizations; and health and family health history. Prompts remind patients about routine preventive services.

Patients used the personal health record a mean of 42.1 times during the intervention period. In the personal health record group, the total proportion of eligible preventive services received increased from 24% at baseline to 40% at the 12-month follow-up, whereas it declined in the usual-care group from 25% to 18%. In the subset of patients with cardiometabolic conditions (N=118), the total proportion of eligible services received improved by 2% in the personal health record group and declined by 11% in the usual-care group.

“This study demonstrated that personal health records hold potential to improve the quality of care among individuals with serious mental illnesses treated in public mental health settings,” Druss and colleagues said.

For more information about innovative work Druss is doing to improve quality of care for the serious mentally ill see the Psychiatric News article, "Psychiatrist Focuses on Populations in Health Delivery Services."

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Major Survey Finds Suicide Rates Higher in Illicit Drug Users Than General Population

Today, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that adults using illicit drugs are significantly more likely to contemplate suicide than the general adult population. The report is based on the findings from SAMHSA's 2012 National Survey on Drug Use and Health, which included interviews of approximately 70,000 noninstitutionalized individuals in the U.S. aged 12 or older.

Based on survey responses, SAMHSA estimated that in a given year, 3.9 percent of U.S. adults—9.0 million—have serious thoughts of suicide, but this increased to 9.4 percent among adults who used illicit drugs. In addition, risk for suicidal ideation among people using illicit substances varied by type of drug used. Adults using sedatives for nonmedical purposes were at greatest risk for suicidal thoughts at approximately 21 percent, followed by those using opioid pain relievers at 13 percent, and marijuana at 10 percent.

“Suicide takes a devastating toll on individuals, families, and communities across our nation," said Peter Delany, Ph.D., director of SAMHSA’s Center for Behavioral Health Statistics and Quality, in a press statement. He stated that in order to prevent unnecessary deaths, it is of utmost importance to reach out to all segments of the community to provide support and treatment to those who are at greatest risk for suicidal ideation.

For complete findings from SAMHSA's 2012 National Survey on Drug Use and Health, click here. To read about strategies to reduce substance abuse, see the Psychiatric News article “Early Intervention May Ward Off Need for Substance Abuse Treatment.” For comprehensive information about treating addictions, see Clinical Manual of Addiction Psychopharmacology, Second Edition, new from American Psychiatric Publishing.

Brief Self-Exam Helps Detect Cognitive Impairment in Community Settings

A 10- to 15-minute self-administered cognitive examination may be an important tool in detecting cases of mild cognitive impairment in community settings such as health fairs or senior centers, providing a tool for proactively identifying individuals who show early signs of cognitive decline. In a study published in APA's Journal of Neuropsychiatry and Clinical Neurosciences led by Douglas Scharre, M.D., director of the Division of Cognitive Neurology at Ohio State University Wexner Medical Center, researchers evaluated the functionality of the Self-Administered Gerocognitive Examination (SAGE) given at 45 community events of different sizes to more than 1,000 individuals over age 50. Cognitive impairment was detected in 28% of the participants.

The researchers note that with "cognitive loss becoming increasingly prevalent in the United States," having tools that allow early detection of mild cognitive impairment and dementia is "critical," since early pharmacological intervention may be able to delay the progress of Alzheimer's and other dementias. The problem, they point out, is that "[U]nfortunately, most cognitively impaired patients do not seek early medical attention, and physicians may not recognize subtle cognitive deficits during routine office visits. Patients typically present to their doctor 3-4 years after symptoms have begun." The success with which the SAGE screening tool detected mild cognitive impairment in a quick, self-administered test that doesn't require computer use suggests that it can overcome "the many obstacles encountered by physicians for early identification" of mild cognitive impairment. Previous studies of community screening have been used to find signs of dementia, but not mild cognitive impairment, the researchers note. They did caution that limitations with the SAGE include that individuals must be literate and have adequate vision and writing skills to answer the questions, and their study had too few minority test takers to generalize about the test in those groups.

Read more about this study in the report "Community Cognitive Screening Using the Self-Administered Gerocognitive Examination (SAGE)" Also see the Psychiatric News article "Mild Cognitive Disorder Added to DSM."

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Study Finds Link Between Traumatic Brain Injury and Premature Death

People who experienced a traumatic brain injury (TBI) were three times more likely to die prematurely than were matched control subjects, according to a study based on medical and population records of more than 2 million people in Sweden. The study, headed by Seena Fazel, M.D., a senior research fellow in the Department of Psychiatry at the University of Oxford in England, was published online today in JAMA Psychiatry.

The individuals were born in 1954 or later, and medical records covered the 40 years from 1969 to 2009. Within that group, 218,300 incurred TBIs, and 2,378 (1.1%) died at least six months or more after their injury. TBI was an independent risk factor for premature mortality, half of which was due to “external causes”—injuries, suicide, or assault. About 61 percent of those with TBI who died prematurely had lifetime substances abuse or other psychiatric diagnoses.

Yet those diagnoses may not explain these early deaths, said Robert Robinson, M.D., a professor of psychiatry at the University of Iowa, in an accompanying editorial. "[O]ne of the most likely explanations for the findings in the current study is the existence of personality characteristics of impulsiveness, risk-taking behaviors, and proneness to substance abuse,” Robinson said. “These patients incur a TBI and continue to demonstrate these behaviors after the TBI, which ultimately leads to a fatality.”

To read more about traumatic brain injury and psychiatric issues, see the Psychiatric News article, “When Traumatic Brain Injury Is Complicated by Personality Disorders.” Also see the book Management of Adults With Traumatic Brain Injury from American Psychiatric Publishing.

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Connection Between Concussion and Depression Said to Need Close Attention

Adolescents who have suffered a previous concussion have a three-fold greater risk of having a current diagnosis of depression than those without a concussion, according to a study published online in the Journal of Adolescent Health. However, the direction of that association is not clear, wrote pediatrician Sara Chrisman, M.D., M.P.H., a fellow in adolescent medicine at the University of Washington in Seattle, and Laura Richardson, M.D., M.P.H., of Seattle Children’s Hospital.

They based their study on data from 36,060 adolescents aged 12 to 17, as part of the National Survey of Children’s Health 2007-2008. The increased risk may be due to reasons other than direct causation, said the authors. A concussion may lead to an unscheduled visit to the doctor, which in turn provides an opportunity to diagnose depression. Or the association may result from diagnostic confusion, given that some symptoms of concussion and depression overlap. Perhaps even the treatment for concussion—reduced physical and cognitive activity—may lead to depression, speculated Chrisman and Richardson. More research is needed to clarify the association between concussion and depression, they said. Nevertheless, they concluded, “[c]linicians caring for youth with concussion should be aware of this association and should screen youth for depressive symptoms.”

To read more about the connection between concussion and psychiatric disorders, see the Psychiatric News article “Traumatic Brain Injury: Why Psychiatrists Matter.” Additional information on this topic can be found in the American Psychiatric Press book, Management of Adults With Traumatic Brain Injury.

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Maternal Warmth May Be Protective for Boys Whose Mothers Are Depressed, Study Shows

The experience of warmth and affection from mothers may be a protective factor for boys exposed to maternal depression by affecting brain regions associated with how children plan for, anticipate, and enjoy rewards, a feature associated with depression. That’s the finding from a report by researchers at the University of Pittsburgh published online in the Journal of the American Academy of Child and Adolescent Psychiatry.

At 18 months and 24 months, 120 boys and their mothers participated in two semi-structured tasks that required maternal interaction. Mothers’ warmth was coded using the Early Parenting Coding System. They were assessed for lifetime depression using a structured clinical interview when the boys were 42 months old; they reported on current depressive symptoms using the Beck Depression Inventory when the boys were aged 10 and 11. At age 20 the boys underwent functional magnetic resonance imaging while playing monetary reward games.

Maternal warmth during early childhood was associated with levels of activation in two areas crucial to anticipating and experiencing loss or gain of rewards—the striatum and the medial prefrontal cortex (mPFC). And the association between maternal warmth during early childhood and early adolescence and reward function in the striatum and mPFC was stronger for boys exposed to maternal depression relative to boys who were not.

“Greater maternal warmth may prevent boys from overanalyzing their performance during disappointment,” the researchers say. “...[A]s indicated by heightened caudate activation when experiencing loss, boys who have experienced greater maternal warmth may find the pursuit of rewards pleasurable even when experiencing disappointment. These neural responses to reward and loss may promote healthy reward seeking.”

For related information, see the Psychiatric News article, "Maternal Depression May Affect Brains of Unborn Children."

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Lack of Thyroid Hormone Doesn't Contribute to Cognitive Impairment, Study Finds

A new population study has failed to find a significant association between hypothyroidism and mild cognitive impairment, after accounting for possible confounding factors. The lead researcher was Ajay Parasaik, M.D., of the University of Texas and the Mayo Clinic. The results appear in JAMA Neurology.

Their findings, the researchers conclude, "suggest that neither clinical nor subclinical hypothyroidism is a risk factor for mild cognitive impairment...[and raise] questions about the need for routine testing of thyroid function as a part of the diagnostic workup in patients with mild cognitive impairment."

"This is a well-designed study of over 1,900 adults," Dilip Jeste, M.D., chair in aging at the University of California, San Diego, and a past APA president, told Psychiatric News. "After controlling for relevant variables, the investigators found no significant association between mild cognitive impairment (now labeled 'mild neurocognitive disorder' in DSM-5) and either clinical or subclinical hypothyroidism. The finding was notable as it comes from an outstanding and experienced group of researchers in the field, with the senior author—Ronald Petersen, M.D., Ph.D.—having served as co-chair of the DSM-5 Neurocognitive Disorders Work Group."

"The authors caution, however, that this was a cross-sectional study and that longitudinal replication of their finding is needed before  concluding that thyroid dysfunction is unrelated to mild neurocognitive disorder in older adults," Jeste said. "Also, the study did not evaluate people with dementia (major neurocognitive disorder). Therefore, although the study results are of considerable clinical value, they do not necessarily suggest abandoning thyroid function assessment in older adults at high risk for mild or major neurocognitive disorder."

More information on how patients should be evaluated for mild neurocognitive disorder or major neurocognitive disorder can be found in the Psychiatric News article, "New Guidance on Alzheimer's Spells Out Three Stages." Information on the subject can also be found in American Psychiatric Publishing's Clinical Manual of Alzheimer Disease and Other Dementias.

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New Data Suggest Oxytocin Treatment Can Improve Social Communication in Autism

A study reported in JAMA Psychiatry found that a single dose of intranasal oxytocin enhanced the ability of people with autism spectrum disorder (ASD) to process complex verbal and nonverbal communications. Moreover, the researchers found that this improvement was associated with increased activity in the medial prefrontal cortex, which has been shown to be diminished in ASD. The study was led by Hidenori Yamasue, M.D., Ph.D., a psychiatrist at the University of Tokyo School of Medicine in Japan.

"This is an extremely impressive study," Andrew Gerber, M.D., an assistant professor of psychiatry at Colulmbia University and a child and adolescent psychiatrist, said in an interview with Psychiatric News. "Though previous studies have hinted at the efficacy of intranasal oxytocin in improving the core symptoms of autism, this is the first well-designed randomized controlled trial to show its effect on conflicting verbal and nonverbal social information."

There is also reason to believe that oxytocin treatment might benefit social cognition in individuals with schizophrenia, Stephen Marder, M.D., of UCLA's Semel Institute for Neuroscience, reported at the 2013 International Congress on Schizophrenia Research.

For more information about these findings, see the Psychiatric News article "Social Cognition in Schizophrenia May Improve With Oxytocin.

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Physicians’ Personal Information Tracked by Medical Communication Companies, Study Finds

Authors of a study published in the Journal of the American Medical Association have found that medical communication companies (MCCs)are doing more than offering online continuing medical education (CME) courses to physicians—the companies may be monitoring clinicians' website behavior.

Researchers from the Mailman School of Public Health at Columbia University investigated the financial relationship between MCCs and drug companies and whether MMCs accurately represent themselves to clinicians. More than 19,000 grants were evaluated to assess the financial giving practices of 15 major pharmaceutical and device companies from Fiscal 2010.

Data showed that of the $657 million in grant money awarded, 26 percent was allocated to MMCs, followed by academic medical institutions at 21 percent and disease-targeting advocacy organizations at 15 percent. The MCCs receiving the most funding offered online CME courses and acknowledged using cookies and Web beacons to track physicians’ online activity, in addition to sharing personal information with third parties, including “educational partners” and companies with which they have a working relations. Although MCCs did not elicit users' explicit consent, the companies did interpret “participating in a CME course and navigating the website as an implicit agreement to share information with third parties.”

Paul Appelbaum, M.D., a former APA president and the Dollard Professor of Psychiatry, Medicine, and Law at Columbia University College of Physicians and Surgeons, said that "even 'free' CME courses come with a price." As chair of APA's Committee on Judicial Action, Appelbaum told Psychiatric News that information collected by MCCs may be shared with pharmaceutical companies for market research or targeted promotions, leading to physicians being visited by certain drug representatives. He urged all clinicians to evaluate the privacy policies of the companies before signing up for CME courses. "If physicians aren’t comfortable with the amount of information they will be revealing, they should decline to participate," Appelbaum concluded.

To read more about pharmaceutical marketing, see the Psychiatric News article "Industry Influence Can Be Mediated by Understanding Theory Behind It."

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Older Patients Underreport Psychiatric Diagnoses, Study Finds

A study published in this week’s JAMA Psychiatry reported that mental disorders are still being underreported by patients, including those who are in midlife to late life.

Researchers in the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health investigated the discrepancies in reporting past mental health disorders and general medical conditions among midlife to late-life adults. The study included 1,071 adults who were asked to report any previous diagnosis for psychiatric disorders—such as major depressive disorder and substance use disorder—and other general medical disorders, such as diabetes and cancer. Self-reports from patients were compared with criteria-based diagnoses from records dating back 24 years. The results showed that 81 percent of the participants with a diagnosis for mental illness underreported their condition, compared with 13 percent who underreported general medical conditions.

"Stigma associated with mental disorders, as well as the fluctuating course of mental illnesses, might partly explain the discrepancies as well as differences in ages of onset of mental and physical disorders,” said Ramin Mojtabai, M.D., Ph.D., M.P.H., an associate professor and senior author of the study. Mojtabai concluded that because symptoms associated with general medical illnesses may be more prevalent in late life, patients may feel the need to report current ones over past mental illnesses.

To read more about stigma associated with mental illness and psychiatric disorders and late-late adults, see the Psychiatric News articles “Jeste, Saks Discuss Stigma, Resilience, and Recovery From Mental Illness.”

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