Naltrexone, Acamprosate More Effective in Treating Alcohol Addiction, Study Finds

Several medications are available to help people with alcohol use disorder (AUD) maintain abstinence or reduce drinking, but the amount of information available on the efficacy of such medications for AUD may be too cumbersome for providers to digest, according to researchers from the University of North Carolina at Chapel Hill (UNC).

Clinician-scientists from the Evidence-based Practice Center and Bowles Center of Alcohol Studies at UNC conducted a systematic review of 122 randomized, controlled trials to assess the benefits and potential harms of medications—approved and unapproved by the Food and Drug Administration—for adults with AUD. The results, published in JAMA, showed acamprosate and naltrexone to have the best evidence for maintaining abstinence from drinking and reducing days of heavy drinking. As for medications sometimes used off-label for AUD, there were moderate improvements in some drinking outcomes for topiramate and nalmefene.

James Garbutt, M.D. (pictured above), senior author of the study and a professor of psychiatry at UNC, commented, “This work expands upon the growing evidence that medications can play a valuable role in the treatment of alcohol use disorders. We are hopeful that this information will encourage clinicians to strongly consider these medications and those individuals will gain awareness that there are medications that can help them to stop or significantly reduce their alcohol use.”

To read more about pharmacotherapies intended to treat alcohol use disorder, see the Psychiatric News articles, "Anticonvulsant Drug Shows Efficacy in Treating Alcoholism," and "Genes May Determine Drug’s Alcohol-Treatment Success."

FDA Recommends Lower Starting Dose for Popular Sleep Medication

The Food and Drug Administration
(FDA) has announced that it is recommending that health care professionals who prescribe the sleep medication eszopliclone (marketed as Lunesta) lower the current recommended starting dose due to risk of impairment the morning after use of the sleeping aid. The recommended starting dose has been decreased from 2 milligrams to 1 milligram.

The dose change is based in part on findings from a study of nearly 100 healthy volunteers, aged 25 to 40, who were given 3 milligrams of eszopliclone or placebo. The data showed that administration of 3 milligrams of eszoplicone was associated with severe next-morning memory and psychomotor impairment—which included driving skills—in both men and women up to 11 hours after taking the drug. According to the study, despite the long-lasting effects, patients were often unaware that they were impaired.

The FDA recommends that patients currently taking 2 milligram or 3 milligram doses of eszoplicone contact their physician to ask for instructions on how to continue to take their medicine safely at a dose that is best for them.

“Recently, data from clinical trials and other types of studies have become available, which allowed the FDA to better characterize the risk of next-morning impairment with sleep drugs,” commented Ellis Unger, M.D., director of the Office of Drug Evaluation I at the FDA. “To help ensure patient safety, health care professionals should prescribe, and patients should take, the lowest dose of a sleep medicine that effectively treats their insomnia.”

To read the FDA Safety Communication click here. To read more about sleep disorders, see the Psychiatric News articles, "Eating, Sleep Disorder Criteria Revised in DSM-5" and "Combining Insomnia, Depression Treatment May Improve Outcome."

APA Calls for Comprehensive, Biopsychosocial Care for Youth in Foster Care

APA told Congress today in a hearing on the treatment of mental illness in foster care that children at risk for psychiatric illness in the foster care system deserve a comprehensive psychiatric evaluation and a biopsychosocial treatment plan. The hearing was convened by a House of Representatives committee to address the treatment of mental illness in the foster care system and especially the use of psychotropic drugs.

In a letter to Subcommittee Chair Rep. Dave Reichert (R-Wash.), APA CEO and Medical Director Saul Levin, M.D., M.P.A., said APA has endorsed the policy recommendations laid out in the American Academy of Child and Adolescent Psychiatry’s "Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline," which call for all youth with apparent emotional disturbances to receive “a comprehensive psychiatric evaluation, a biopsychosocial treatment plan if indicated, proper case management, and effective medication management that includes monitoring response to treatment and screening for adverse effects.”

Levin added, “Children in foster care systems experience high rates of mental illness and require a broad spectrum of mental health services. According to the National Survey of Child and Adolescent Well-Being, upwards of three-fourths of children entering foster care exhibit behavior or social competency problems that warrant mental health care…. It is clear that this vulnerable population demands responsible policymaking and appropriate oversight to ensure that best practices in mental health delivery are employed.”

Levin also told the subcommittee that the shortage of child and adolescent psychiatrists is a major obstacle to the promotion of sound mental health among youth in foster care. “APA urges Congress to support federal programs that seek to address this shortage and provide children and adolescents with care from the highest quality and most specifically trained clinicians,” he said. "[W]e would like to highlight valuable programs like the Massachusetts Child Psychiatry Access Project (MCPAP), which provides critical mental health expertise to primary care providers in order to improve access to treatment for children with psychiatric disorders. Congress should incentivize states to incorporate innovative programs like MCPAP in order to mitigate this workforce shortage.”

Child and adolescent psychiatrist Michael Naylor, M.D., an associate professor of psychiatry at the University of Illinois at Chicago, also testified at the hearing today. Look for further coverage of the hearing in an upcoming issue of Psychiatric News.

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Supreme Court Rules on Use of IQ in Death Penalty Cases

The U.S. Supreme Court yesterday decided that a fixed IQ score alone cannot be used by the states to evaluate intellectual disability and thus determine eligibility for the death penalty. In a 5-to-4 decision, the Court ruled in favor of Freddie Lee Hall, convicted more than three decades ago in Florida for the rape and murder of a 21-year-old woman.

“The majority demonstrated a recognition of the complexities in diagnosing intellectual disability and that such a diagnosis involves much more than reliance on an IQ score,” Richard Frierson, M.D., a professor of clinical psychiatry at the University of South Carolina School of Medicine, told Psychiatric News.

APA contributed to an amicus curiae brief on Hall’s behalf, arguing that an IQ score of 70 could not be used without also considering adaptive functioning and the age of onset of the condition. Those criteria reflect standards adopted in DSM-5, which the Court cited in its opinion. “As the majority opinion indicates, there are areas where professional expertise can inform the legislature and the courts so that the decision makers will have the consensus of the field before them in these very important determinations, commented APA President Paul Summergrad, M.D. “APA is pleased that the Court considered the advances in diagnosis contained in DSM-5 and our arguments in the amicus brief we filed along with the American Psychological Association in outlining the legal approach to be used for the determination of intellectual disability in death penalty cases.”

“The Court’s decision in Hall recognizes that criteria for diagnosis of mental disorders—here specifically intellectual disability—should be determined by professional standards, not by the arbitrary decisions of state legislatures,” said Paul Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine, and Law and director of the Division of Law, Ethics, and Psychiatry at Columbia University, in an interview. “From a court that is often skeptical of psychiatry, this is a major acknowledgment that courts should turn to psychiatry when issues related to the diagnosis of mental disorders arise.” Appelbaum is chair of the APA Committee on Judicial Action.

For more in Psychiatric News about the case Hall v. Florida, see the article, "High Court Weighs Standards for Intellectual Disability."

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fMRI Reveals Brain Changes in Meth Users That May Influence Risk-Taking, Poor Decision-Making

Risk-taking and poor decision-making by methamphetamine users may reflect dysfunction within the mesocorticolimbic system, coupled with reduced prefrontal cortical connectivity, according to a report published online in JAMA Psychiatry.

Researchers at UCLA used a performance test known as the Balloon Analogue Risk Task to assess risk-taking and maladaptive decision-making in 25 methamphetamine-dependent and 27 healthy comparison subjects. The task involved the choice to pump a balloon or to cash out of the task in the context of uncertain risk. Functional magnetic resonance imaging was used to study subjects' brain activity at rest and when performing the performance task. The researchers measured resting-state functional connectivity, as well as the degree to which activation in the striatum and right dorsolateral prefrontal cortex changed as a linear function of risk and potential reward while performing the task.

They reported that methamphetamine-dependent subjects showed important differences in resting-state connectivity—especially heightened connectivity within the mesocorticolimbic system—and reduced prefrontal cortical connectivity during the performance task.

“Heightened resting-state connectivity within the mesocorticolimbic system, coupled with reduced prefrontal cortical connectivity, may create a bias toward reward-driven behavior over cognitive control in methamphetamine users,” the researchers suggested. “Interventions to improve this balance may enhance treatments for stimulant dependence and other disorders that involve maladaptive decision making.”

To read more about brain changes and methamphetamine use, see the Psychiatric News article, "Psychotic Symptoms Increase With More Frequent Meth Use."

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Unexpected Loss of Loved One Raises Mental Illness Risk Across the Lifespan, Study Finds

Unexpected death of a loved one appears to increase the incidence across the life span for major depressive episode, panic disorder, and posttraumatic stress disorder (PTSD), and in older age groups for manic episode, phobias, alcohol use disorders, and generalized anxiety disorder.

These findings are reported in the new study, “The Burden of Loss: Unexpected Death of a Loved One and Psychiatric Disorders Across the Life Course in a National Study,” published in AJP in Advance. Researchers from Columbia University and the Department of Psychiatry at Boston Children’s Hospital, estimated the relationship between unexpected death of a loved one and onset of lifetime DSM-IV disorders using data from the National Epidemiologic Survey on Alcohol and Related Conditions, a national face-to-face survey of noninstitutionalized adults that included assessment of lifetime experience of unexpected death, other potentially traumatic experiences, and PTSD. There were 27,534 respondents in the final analysis.

The researchers found that unexpected loss of a loved one was the most common traumatic experience and most likely to be rated as the respondent’s worst, regardless of other traumatic experiences. Increased incidence after unexpected death was observed at nearly every point across the life course for major depressive episode, panic disorder, and PTSD. Increased incidence was clustered in later adult age groups for manic episode, phobias, alcohol use disorders, and generalized anxiety disorder.

“The bereavement period is associated with elevated risk for the onset of multiple psychiatric disorders, consistently across the life course and coincident with the experience of the loved one’s death,” the researchers said. “Novel associations between unexpected death and onset of several disorders, including mania, confirm multiple case reports and results of small studies and suggest an important emerging area for clinical research and practice.”

For more on this subject, see the Psychiatric News article, "Trauma Disorder Criteria Reflect Variability of Response to Events."

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Study Finds Lower Hippocampus Volume in Patients With Psychosis

The Bipolar-Schizophrenia Network on Intermediate Phenotypes—consisting of institutions that include Harvard University, Wayne State University, and the University of Texas Southwestern—conducted a neuroimaging study in 549 patients with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder to evaluate hippocampal volume in individuals with psychosis and the consequences of hippocampal volume as it relates to severity of the psychosis. The participants were compared with 337 healthy volunteers.

The results, published in JAMA Psychiatry, showed that volume in the hippocampus was significantly reduced in all three groups of patients with psychotic disorders when compared with that of controls. Reduced hippocampal volumes were correlated with worse psychosis severity, declarative memory, and overall cognitive performance.

“The causal mechanisms underlying psychotic symptoms are not well known,” Matcheri Keshavan, M.D. (pictured above), a professor of psychiatry at Harvard Medical School, told Psychiatric News in an interview. “The findings in this study point to the hippocampus…as a critical node on the network of brain regions that underlie the generation of psychotic symptoms such as delusions and hallucinations. Such understanding can help clinicians explain the nature of psychotic illnesses to patients and [their] families.” Keshavan concluded that more studies investigating the consequences of physiological and biochemical alterations in the hippocampus “are critically needed.”

Short Stay Behind Bars Before Diversion Does Not Affect Mental Health Outcomes, Study Finds

Criminal offenders who went to jail before being diverted into mental health treatment fared no better in the long run than those who go straight into diversion programs, according to a study of Connecticut defendants.

“Short stays in jail before diversion did not appear to be associated with improved mental health and reoffending outcomes, even though they appeared to improve receipt of psychotropic medication,” said Allison Robertson, Ph.D., M.P.H., an assistant professor of psychiatry and behavioral sciences at Duke University, and colleagues online this week in Psychiatric Services in Advance. The researchers compared 102 diversion participants who first went to jail with 102 who went directly into diversion.

The “jail first” strategy did lead to a greater chance that the prisoner would receive psychotropic medications, but all other indicators—use of outpatient services, psychiatric hospitalizations, jail days, emergency visits, or rearrest—demonstrated similar outcomes whether the person was sent to jail or diversion first.

These findings may indicate that the participant’s risk may be influenced not only by mental health treatment but also by criminogenic factors like unstable housing, unemployment, or lack of social services, said Robertson. “These analyses offer an early but important indication that a brief incarceration before diversion to the community does not ultimately achieve the goals of the courts—reduced recidivism and improved public safety,” the researchers said.

To read more about diversion programs for offenders with mental illness, see the Psychiatric News articles, "Program Prepares Defendants for Return to the Community" and "Combined Effort Needed to Prevent Incarceration of Mentally Ill People."

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ABPN Enacts Maintenance of Certification (MOC) Changes Urged by APA

The American Board of Psychiatry and Neurology (ABPN) has revised several of the requirements in its Maintenance of Certification (MOC) program to make them more flexible for psychiatrists. APA had argued for the changes extensively over the last year after hearing protests from many of its members.

Beginning immediately, the ABPN said, feedback modules now will require that diplomates collect feedback from only one of the following options, making patient surveys just one of the options: five patient surveys, five peer evaluations of general competencies, five resident evaluations of general competencies, 360-degree evaluation of general competencies with five respondents, institutional peer review of general competencies with five respondents, or one supervisor evaluation of general competencies. In addition, requirements for the 10-year MOC program have been modified to include 300 Category 1 CME credits, 24 Category 1 credits from self-assessment activities, and 1 performance-in-practice (PIP) unit.

Another change is that Lifetime Certificate holders will no longer be referred to as "not participating in MOC." ABPN will instead categorize them as "not required to participate in MOC." Also, Qualifying Quality Improvement projects will now satisfy PIP requirements for chart review.

Commenting on the changes, APA President Paul Summergrad, M.D., said, “APA is gratified to see that the American Board of Psychiatry and Neurology has added greater flexibility to its Maintenance of Certification program for psychiatrists. These changes allow more options in several key categories for psychiatrists while ensuring high-quality care and support for the privacy of sensitive communications. In addition, the ABPN will be working with APA and district branch leadership to help members understand the changes and meet all the requirements for MOC. We owe thanks to many groups in APA and especially the APA Assembly Work Group on MOC, which worked hard to bring about these needed changes.”

Deborah Hales, M.D., director of the APA Division of Education, emphasized that "APA will continue to develop MOC products and activities to assist our members with these requirements."

Information about the MOC requirements is posted at http://abpn.com/.

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Preventive Services Task Force Finds Insufficient Evidence for Suicide Screening in Primary Care

Evidence for the effectiveness of screening for suicide in primary care practices appears to be insufficient and is not recommended, according to a report in Annals of Internal Medicine by the United States Preventive Services Task Force (USPSTF).

The USPSTF reviewed evidence on the accuracy and reliability of instruments used to screen for increased suicide risk, benefits and harms of screening for increased suicide risk, and benefits and harms of treatments to prevent suicide. The reviewed studies used various screening tools targeting primary care patients aged 18 to 70.

The sensitivity and specificity of screening tools generally ranged from 52% to 100% and from 60% to 98%, respectively. The instruments showed a wide range in accuracy, but data were limited and no instruments were examined in more than one study.

The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in a primary care setting.

“Screening for suicide (not suicidal behaviors) has a low specificity and sensitivity rate,” said Jan Fawcett, M.D., who was chair of the DSM-5 Mood Disorder Work Group and Suicide Sub-Work Group. “What should the primary care physician do to prevent the predicted suicide? Send the patient to an ER? Try to admit the patient involuntarily for psychiatric care? There is no evidence that the PCP [primary care provider] can prevent a suicide, much less determine which patients scoring high on the scale are `really’ suicidal. Why should the PCP want to accumulate high suicide screens if they cannot do anything about them and can be held liable for not being successful?.... Perhaps teaching PCPs to evaluate, treat, and refer suicidal depression patients would be more useful than using untested check lists from patients.”

For more information about suicide-related issues, see the Psychiatric News article, “Suicide Experts Identify Six Questions to Guide Research in Next Decade.” Also see American Psychiatric Publishing's “Textbook of Suicide Assessment and Management, Second Edition.”

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Peer Support for Substance Abusers Appears Effective, but Studies Have Limitations

Studies on the effectiveness of “peer recovery support” programs—in which individuals in recovery from substance use disorders provide help to peers with substance use or co-occurring mental disorders—generally meet the minimum criteria for moderate level of evidence, according to the review, “Peer Recovery Support for Individuals With Substance Use Disorders: Assessing the Evidence” published yesterday in Psychiatric Services in Advance. But a number of methodological concerns with studies of peer recovery support hamper the ability to definitively distinguish the effects from other recovery services and activities in which a patient may be engaged.

Those were the findings from the latest installment of the “Assessing the Evidence Base” series that the journal has been publishing.

Researchers from the Substance Abuse and Mental Health Services Administration (SAMHSA) and DMA Health Strategies assessed outcome studies of peer recovery support services from 1995 through 2012. The authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of methodology. They also described the evidence for the effectiveness of the peer recovery services.

The studies demonstrated reduced relapse rates, increased treatment retention, improved relationships with treatment providers and social supports, and increased satisfaction with the overall treatment experience. But methodological concerns included inability to distinguish the effects of peer recovery support from other recovery support activities, small samples, heterogeneous populations, lack of consistent or definitive outcomes, and lack of appropriate comparison groups.

The authors state that to better show the effectiveness of peer recovery support, researchers should isolate its effects from other peer-based services. “It is clear that individuals with lived experience of mental or substance use disorders who work as peer recovery support providers have become an increasingly important part of the treatment continuum. Their unique perspective and ability to empathize with participants enhance the treatment experience and support recovery from substance use disorders. However, until we have a better understanding of this service and are able to move beyond idiosyncratic programs, it will be difficult to determine whether to incorporate peer providers on a broad scale and, if they are incorporated, how best to do so.”

The article is part of a series of literature reviews commissioned by SAMHSA and published in Psychiatric Services. To read more about the "Assessing the Evidence" series, see the Psychiatric News articles, "Study Finds Evidence Showing Supported Employment Works" and "Housing Programs Effective, but Studies Plagued by Limitations."

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Adverse Life Experiences May Be Risk Factors for Bipolar Disorder, Study Suggests

Both childhood traumas and ones that occur later in life appear to contribute to the initial onset of bipolar disorder as well as to recurrent episodes of the illness, a new study published in Molecular Psychiatry has found.

For example, subjects who had incurred physical abuse, sexual abuse, or economic deprivation during childhood were two to three times more likely to develop bipolar disorder than subjects who had not experienced such adversities. And among the some 1,200 subjects who had entered the study with bipolar disorder, such negative childhood experiences were also strong predictors of bipolar episodes recurring. Moreover, past-year traumatic events were associated with a significantly higher risk for both the onset of bipolar disorder and recurrent bipolar episodes.

The researchers concluded that their findings "demonstrate a role of social experiences in the initial onset of bipolar disorder, as well as in its prospective course, and are consistent with etiologic models of bipolar disorder that implicate deficits in developmentally established stress-response pathways."

The study was headed by Stephen Gilman, Sc.D., of the Harvard School of Public Health and Roy Perlis, M.D., an associate professor of psychiatry at Harvard Medical School and medical director of the Bipolar Clinic and Research Program at Massachusetts General Hospital.

These findings also have clinical implications, Perlis told Psychiatric News. "We should redouble our efforts to do psychotherapy with people with bipolar disorder" in order to help them deal with negative life experiences that may be contributing to their illness.

More information about bipolar disorder and psychotherapy can be found in the Psychiatric News article, "Bipolar Treatment Study Assesses Psychotherapy Efficacy." Additional information is included in American Psychiatric Publishing's "Clinical Guide to Depression and Bipolar Disorder."

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Study Finds Substantial Recent Declines in Several Types of Violence Directed at Youth

It looks as if violence perpetrated against America's youth is on a downward trajectory, according to a study published in JAMA Pediatrics. The study was headed by David Finkelhor, Ph.D., director of the Crimes Against Children Research Center at the University of New Hampshire, and was based on three national phone surveys of 10,183 children from 2003 to 2011. The researchers used the survey results to track trends in 50 aspects of youth victimization by violence. Even when demographic variables were controlled, there were 27 significant declines and no significant increases in the trends during the eight years included in the analysis. For example, the survey found that attempted or completed rape declined 43 percent, dating violence declined 39 percent, physical assaults in general declined 33 percent, and child maltreatment declined 26 percent.

The researchers offer several possible explanations for their positive findings, including that school-based violence-prevention programs—such as those targeting bullying, interpersonal conflicts, or sexual and dating violence—are working.

"There is no single more preventable and important cause of psychiatric harm to children than exposure to violence," Andrew Gerber, M.D., Ph.D., an assistant professor of psychiatry at Columbia University and a child and adolescent psychiatrist, told Psychiatric News. "It is enormously encouraging to learn that the concerted effort over the past two decades to minimize this exposure appears to be paying off in the form of reduced exposure to violence in our nation's children."

More information about a school program to identify and treat mental health problems before they emerge as more serious issues such as suicide and violence can be found in the Psychiatric News article, "Miami-Dade Schools Adopt Foundation's 'Typical or Troubled?' Program." Information about mental health consequences of bullying can be found in the Psychiatric News article, "Effects of Bullying Don't End When School Does."

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Brief Screening Tool Uses Five Questions to Identify Violence Risk Among Veterans

The stresses of military deployment and combat have raised concerns about the risk of violence among a subset of returning troops. Now a new evidence-based screening tool can help identify candidates for a more comprehensive assessment of risk and protective factors, writes Eric Elbogen, Ph.D., an associate professor of psychiatry at the University of North Carolina School of Medicine, and colleagues in AJP in Advance.

They based their study, "Screening for Violence Risk in Military Veterans: Predictive Validity of a Brief Clinical Tool," on a national survey sample of veterans, combined with a smaller in-depth assessment sample. The researchers found that a combination of five factors was associated with long-term violence risk in these veterans. The Violence Screening and Assessment of Needs (VIO-SCAN) asked veterans about financial stability, combat experience, alcohol misuse, history of violence or arrests, and probable posttraumatic stress disorder (PTSD) plus anger. Among other things, the researchers concluded that "PTSD alone does not automatically lead to high risk of violence in veterans."

“[I]t is hoped that the screen will provide clinicians with a rapid, systematic method for identifying veterans at higher risk of violence, prioritizing those in need a full clinical workup, structuring review of empirically supported risk factors, and developing plans collaboratively with veterans to reduce risk and increase successful reintegration in the community,” concluded Elbogen and colleagues.

To read more about psychiatric issues in military populations, see the Psychiatric News article, “More Evidence Needed in Military Mental Illness Prevention Programs.” For more information on this topic, see the new book, Care of Military Service Members, Veterans, and Their Families, from American Psychiatric Publishing.

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Marines Receiving Mindfulness Training Recover Better From Stress of Combat Exercises, Study Finds

Mindfulness training can help Marines recover better from the stress of an intensive combat training exercise, according to the study, "Modifying Resilience Mechanisms in At-Risk Individuals: A Controlled Study of Mindfulness Training in Marines Preparing for Deployment," published online today in AJP in Advance.

Four Marine platoons were randomly assigned to a 20-hour mindfulness training course and then compared with four control platoons. The Mindfulness-based Mind Fitness Training program emphasized “interoceptive awareness, attentional control, and tolerance of present-moment experiences,” wrote Douglas Johnson, Ph.D., an assistant professor of psychiatry at the University of California, San Diego (UCSD), and colleagues.

All the Marines then took part in a one-day combat program at Camp Pendleton, Calif. The mindfulness group reacted more strongly to stress but also recovered more quickly, as measured by their heart and breathing rates. Functional MRI examination of a subset of Marines showed greater attenuation of brain activity, particularly in the right insula and anterior cingulate cortex, compared with controls. “The results show that mechanisms related to stress recovery can be modified in healthy individuals prior to stress exposure, with important implications for evidence-based mental health research and treatment,” said the researchers.

“Mindfulness training won’t make combat easier,” added co-author Martin Paulus, M.D., a professor of psychiatry at UCSD, in a statement. “But we think it can help Marines recover from stress and return to baseline functioning more quickly.” To read more about prevention of posttraumatic stress disorder, see the Psychiatric News article, “Early Intervention Offers Hope For Preventing PTSD.”

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Study Identifies Genetic Biomarker That May Contribute to Development of OCD

In a study published in this week’s Molecular Psychiatry, researchers from Johns Hopkins University School of Medicine provide some insight into factors that may underlie obsessive-compulsive disorder (OCD), which affects about 2% of the U.S. population, according to the National Institute of Mental Health.

Gerald Nestadt, M.D., Ph.D. (pictured above), director of the OCD program at Johns Hopkins, and colleagues conducted a genomewide association study to identify genetic biomarkers associated with OCD. The researchers scanned the genomes of more than 1,400 individuals with OCD and approximately 1,000 close relatives (as a control group) of other people with OCD. The study results showed that patients with OCD expressed a particular biomarker located near the protein tyrosine phosphokinase gene—a genetic region that has been previously suggested to be important in the pathology of OCD.

"OCD research has lagged behind other psychiatric disorders in terms of genetics," stated Nestadt. "We hope this interesting finding brings us closer to making better sense of it." Nestadt concluded that, "If this finding is confirmed...we might ultimately be able to identify new drugs that could help people with this often disabling disorder, [for whom] current medications work only 60 percent to 70 percent of the time."

To read more about genetic factors associated with OCD, see the Psychiatric News article, "Familial OCD: Environment, Genes Both Play Role" and the study, "COMT Val158Met Polymorphism and Executive Functions in Obsessive-Compulsive Disorder," in the Journal of Neuropsychiatry and Clinical Neurosciences. More information on OCD is available in the book, Obsessive-Compulsive Spectrum Disorders: Refining the Research Agenda for DSM-V, from American Psychiatric Publishing.

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High Initial Antidepressant Dosages in Youth May Raise Risk for Deliberate Self-harm, Study Finds

High initial dosages of antidepressants appear to increase risk of deliberate self-harm in children and young adults, according to data from a study published in JAMA Internal Medicine. Researchers from the Harvard School of Public Health conducted a study to examine the relationship between suicidal behavior and antidepressant dosage, and whether such a relationship, if it exists, is dependent on a patient's age. The study assessed data from 162,625 people—aged 10 to 64—with depression who initiated antidepressant therapy with a selective serotonin reuptake inhibitor at “modal” (most prescribed dose on average) or higher than modal dosages.

The analysis showed that participants aged 24 and younger who initiated antidepressant therapy at high doses were twice as likely to exhibit suicidal behaviors than were their age-matched counterparts who received modal doses—corresponding to one additional event of deliberate self-harm for every 150 patients treated with high-dose antidepressant therapy. The authors found no dose-dependent risk for suicidal behavior among adults aged 25 to 64.

In a commentary, David Brent, M.D., a professor of psychiatry, pediatrics, and epidemiology at the University of Pittsburgh, who was not involved in the study noted that "while initiation at higher than modal doses of antidepressants may be deleterious, this study does not address the effect of dose escalation… Studies on the impact of dose escalation in the face of nonresponse remain to be done, there are promising studies that suggest in certain subgroups, dose escalation can be of benefit.” However, Brent concluded, these findings "add further support to current clinical recommendations to begin treatment with lower antidepressant doses."

To read about prescribing practices of antidepressants for child and adolescent patients, see the Psychiatric News article, "Prescribing for Mentally Ill Children Generally in Line With Best Practices." To read about challenges clinicians face in preventing and managing suicidal behavior, see the American Psychiatric Publishing Textbook of Suicide Assessment and Management, Second Edition.

(Editor's note: In a Psychiatric News Alert yesterday, we used an incorrect term to describe pediatric IBD in children. It should have been "inflammatory" bowel disease, not "irritable" bowel disease. We apologize for the error.)

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Collaborative Care for Obstetric Patients With Depression Improves Symptoms, Satisfaction With Care, Study Shows

Collaborative depression care adapted to women's health settings appears to improve depressive and functional outcomes and quality of depression care, according to a report online in the journal Obstetrics and Gynecology. Researchers at the University of Washington randomized 102 women to 12 months of collaborative depression management and 103 women to usual obstetric care at two obstetric care sites. All of the women met criteria for major depression, dysthymia, or both. Participants were age 39 on average, and 56 percent had a diagnosis of posttraumatic stress disorder.

The collaborative care model is team-based care that involves psychiatrists, other clinicians, and depression care managers who meet weekly to review patient progress and provide treatment recommendations. The care manager follows up with patients.

Outcomes at six- month, 12-month, and 18-month follow-ups were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50 percent decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care.

Patients receiving collaborative care had greater improvement in depressive symptoms at 12 months and 18 months and improved functioning over the course of 18 months. They were also more likely to have at least 50 percent decrease in depressive symptoms at 12 months, greater likelihood of at least four specialty mental health visits, to be taking an adequate dose of an antidepressant, and to express greater satisfaction with care.

To read more about collaborative care for patients with psychiatric illness, see the Psychiatric News article, "Collaborative Care for Depression Can Reduce Risk for Hearts Attacks, Stroke."

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Psychotherapies Can Aid Depressive Symptoms in Pediatric IBD, Study Shows

Two forms of psychotherapy—cognitive-behavior therapy (CBT) and supportive non-directive therapy (SNDT)—resulted in significant reductions in depressive symptoms in children with inflammatory bowel disease (IBD), according to a report published online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Eve Szigethy, M.D., Ph.D., an associate professor of psychiatry and pediatrics at the University of Pittsburgh, and colleagues randomly assigned 161 depressed youth with Crohn's disease and 56 depressed youth with ulcerative colitis to a three-month course of CBT or SNDT. The children ranged in age from 9 to 17. The primary outcome was reduction in depressive symptom severity; secondary outcomes were depression remission, increase in depression response, and improved health-related adjustment and IBD activity.

Both psychotherapies resulted in significant decreases in total Children's Depression Rating Scale Revised score (37.3% for CBT and 31.9% for SNDT), but the difference between the two treatments was not significant. CBT showed a greater reduction in “IBD activity”—which is based on a questionnaire filled out by gastroenterologists that captures degree of inflammation as well as symptoms related to having active IBD—but no greater improvement on the Clinical Global Assessment Scale and health-related quality of life. Over 65% of youth had a complete remission of depression at three months, with no difference between the two therapies.

Szigethy told Psychiatric News that depression is common in chronic pediatric diseases and, if untreated, is associated with poorer outcomes and increased medical costs. “The significance of this study is that it provides evidence that psychotherapy may be a useful adjunct to medical treatment in chronic physical diseases like IBD and underscores the importance of integration of behavioral health into pediatric medical care delivery,” she said.

For related information, see the Psychiatric News article, "Childhood Stomach Pains May Foretell Adult Anxiety Disorders."

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Long-Term Prognosis for Youth With DMDD Is Poor, Study Finds

The long-term outlook for children who have persistent irritability punctuated by frequent temper outbursts—criteria that qualify them for a diagnosis of disruptive mood dysregulation disorder (DMDD)—is characterized by a "bleak prognosis," according to a study published in AJP in Advance. The senior researcher was E. Jane Costello, Ph.D., a professor of psychiatry and behavioral sciences at Duke University.

The study included 1,420 children who were followed into young adulthood. Researchers found that 4 percent of them had had DMDD as youngsters (the diagnosis has been incorporated into DSM-5, published last year). The DMDD group was significantly more likely as young adults to be anxious and depressed and to have multiple health problems, as well as low educational attainment, impoverishment, social isolation, and police contact, than were subjects who as children had had no psychiatric disorders or had psychiatric disorders other than DMDD.

"I think this is a very interesting study," Ellen Leibenluft, M.D., chief of the Section on Bipolar Spectrum Disorders of the National Institute of Mental Health and an expert on DMDD, told Psychiatric News. "The fact that children with DMDD are at risk for anxiety and depression is consistent with research looking at outcomes for irritability generally. But it is helpful to have the finding confirmed in a sample in which the researchers explicitly applied criteria for DMDD."

"The other thing that is particularly interesting about the study is how it demonstrates the severe impairment that children with DMDD experience as adults, even when compared with children with other psychiatric disorders," Liebenluft added. We already knew how impairing the condition was in childhood. Now we know that it continues to have long-term adverse consequences as well."

The challenge now, Leibenluft continued, is to determine whether first-line treatmetns for anxiety or depressive disorders, such as antidepressants or cognitive-behavioral therapy, can help children with DMDD. "We are conducting a clinical trial at NIMH currently to answer this question."

More information about DMDD can be found in the Psychiatric News articles, "Severe Childhood Mood Disorder May Be Unique Syndrome" and "DSM-5 Self-Exam: Depressive Disorders."

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Levels of Immune Molecules Related to Onset of Schizophrenia, Study Finds

The levels of certain immune-related molecules in the cerebrospinal fluid appear to differ in individuals with schizophrenia and at risk for schizophrenia compared with healthy control subjects, scientists report in Schizophrenia Bulletin. The study was headed by Lindsay Hayes, Ph.D., a postdoctoral fellow at the Johns Hopkins Schizophrenia Center, and Akira Sawa, M.D., Ph.D., director of the center.

Another potentially important finding the researchers reported was that the levels of these molecules in schizophrenia-risk subjects were "exacerbated" compared with the levels in subjects who already had been diagnosed with schizophrenia. Thus the levels of these molecules might serve as predictive biomarkers for the onset of schizophrenia, the researchers believe. "However, this data is very preliminary and needs to be validated with additional large cohorts and in longitudinal studies to confirm their predictive impact," Hayes told Psychiatric News.

Alan Brown, M.D., a professor of psychiatry and epidemiology at Columbia University and an expert on infectious agents that have been linked to schizophrenia, said in an interview that since "the abnormalities appeared to be greater in those with at-risk mental states than in those with schizophrenia suggests that a longitudinal study with cerebrospinal fluid immunologic biomarkers in the same individuals tested at different time points could be very promising."

More information about the immune system's possible links to schizophrenia can be found in the Psychiatric News article, "Immune System Protein Could Give Clue to Late-Onset Schizophrenia." To read about the value of early schizophrenia detection and treatment, see "Early Detection of Schizophrenia: The Time Is Now," a column by then-APA President Jeffrey Lieberman, M.D.

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Experts Recommend New Approach for Treating Neuropsychiatric Symptoms of Dementia

A panel of neurocognitive experts from the University of Michigan and Johns Hopkins University proposed in an article in the Journal of the American Geriatrics Society, an alternative method to help reduce unfavorable neuropsychiatric symptoms such as agitation—that are often associated with dementia.

“Often, more than memory loss, behavioral symptoms of dementia are among the most difficult aspects of caring for people with dementia,” said Helen Kales, M.D., lead author and a professor of psychiatry at Michigan. “These symptoms are experienced almost universally… [They] are often associated with poor outcomes including early nursing home placement, hospital stays, caregiver stress and depression, and reduced caregiver employment.”

The approach, dubbed DICE—presented this week at APA’s annual meeting—focuses on the implementation of environmental modifications and other interventions, such as exercise, as a first-line method to alleviate neuropsychiatric symptoms.

Briefly described, the components are:

•D: Describe - Asking the caregiver, and the patient if possible, to describe the "who, what, when, and where" of situations in which problem behaviors occur and the physical and social context for them. These observations will be shared with caregivers.

•I: Investigate – Having the health provider look into all aspects of the patient's health, including dementia symptoms and current medications and sleep habits, that might be combining with physical, social, and caregiver-related factors to produce the behavior.

•C: Create – Working together, the patient's caregiver and health providers develop a plan to prevent and respond to behavioral issues, including everything from changing the patient's activities and environment to educating and supporting the caregiver.

•E: Evaluate – Giving the provider responsibility for assessing how well the plan is being followed and how it's working, or what might need to be changed.

In an interview with Psychiatric News, Kales said, “Innovative approaches are needed to support and train the front-line providers for older populations with behavioral symptoms of dementia. We believe that the DICE approach offers clinicians an evidence-informed structured clinical reasoning process that can be integrated into diverse practice settings.”

To see read more about nonpharmacological therapies for treating symptoms of neurocognitive disorders, see the Psychiatric News article, "Mindful Exercises and Meditation: Neurobiological Effects." Also, watch a Psychiatric News interview with Kales here.

Thank You for the Opportunity

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.

The reward of a thing well done is having done it.
—Ralph Waldo Emerson

As I entered the final month of my APA presidency, someone asked me how I would like this past year to be remembered. I responded that I wanted this time to be seen as “the year that APA got its mojo going.” This was the year that we confronted the need for change and didn’t shrink from the challenge. Instead, we addressed and embraced it with energy, creativity, and action, in ways that advanced psychiatry scientifically, socially, and politically and enabled it to better help patients and fulfill its mission.

When I was elected APA president, I believed my role was to set a clear vision, articulate expectations, engage talented colleagues in the work at hand—and then communicate with our members about what we were seeking to achieve and why. I wanted to use all of the power and influence of APA to speak out and stick up for our profession and our patients.

As I prepare to give up this important leadership role in American psychiatry, I want to thank APA members for giving me the opportunity to serve. I can reasonably hope that we have been at least partially successful in tackling the pressing issues that psychiatry faces and in making APA a better and more effective organization. I couldn’t have asked for a better or more dedicated team of individuals who helped me to move APA forward this past year.

The year began with the official launch of DSM-5. After experiencing a tumultuous gestation and overcoming numerous challenges, the fifth edition of APA’s diagnostic manual has proved a great success as reflected by favorable reviews, impressive sales, and gratifying clinical feedback.

To read more, click here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman.

Vice President Biden Hails 'Astounding Possibilities' in BRAIN Initiative, Parity Law

Understanding of the brain and treatment of mental illness and brain diseases are at a transformative crossroads. That’s what Vice President Joseph Biden said today as he presented the William C. Menninger Convocation Lecture at APA’s 2014 annual meeting in New York City. Biden said passage of the mental health parity law and the release last year of regulatory guidance for the law, along with the new Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative, announced by the Obama administration last year, are creating a transformative moment for psychiatry and patients with mental illness.

“We are on the cusp of astounding possibilities,” the vice president said. “I know that we are poised to create the tools to find new ways to treat, cure, and even prevent conditions affecting the brain. And we are on the cusp of identifying the biomarkers for mental illness, designing early prevention treatments for psychosis and revolutionizing the understanding of the brain circuitry and function. Imagine the possibilities for millions of young people right at the age when they want to explore the world if we have these tools of early detection to prevent mental illness from taking over their lives.”

Biden continued, “Just as we couldn’t imagine how the moon landing would yield technologies for semiconductors and the iPhone, I don’t think we can begin to imagine the breakthroughs that will occur tomorrow as a consequence of this BRAIN Initiative.”

Similarly, Biden said that the Mental Health Parity and Addiction Equity Act and the Affordable Care Act open new opportunities for patients to access treatment. “A major step forward is breaking down the structural barriers [to care] and expanding access,” he said. “I am fully aware that enforcement is the key, but patients are now empowered to find out more information and to hold their insurer accountable if they are denied coverage. None of us believe that will automatically happen—this is new territory. But rest assured that we know the next step is enforcement and getting it right.”

Biden hailed the work of psychiatrists, recalling a visit he received from a college roommate whose son had serious mental illness. “I remember the metaphor he used…. He said, 'I don’t know what to do. I feel like my boy is at the end of a string, and if I pull too hard it will break. And I will lose him forever.’

“I found the metaphor incredibly compelling,” Biden said. “There are too many people who know that feeling—they don’t know what to do, but they know if they pull too hard that string may break and they will lose their blood. "But you give them hope they are not alone," Biden said to the thousands of psychiatrists sitting before him and watching from monitors placed at a number of annual meeting locations. "We need you more than ever, and frankly we need more of you. You are the only ones who can help pull the string and significantly decrease the prospect that it will break.”

APA leaders hailed the vice president’s remarks. “I am delighted that Vice President Biden accepted our invitation to address the thousands of attendees at APA’s 2014 annual meeting,” said APA President Jeffrey Lieberman, M.D. “The vice president has been an ardent advocate for improved mental health services, the elimination of stigma, and increased research on mental illness. The administration's pledge last year to devote $100 million to increasing access to mental health services, convening the White House National Conference on Mental Health in 2013, and the Brain Research Through Advancing Innovative Neurotechnologies Initiative have demonstrated the president and vice president's commitment to addressing this critical public-health need. Vice President Biden has shown great insight and compassion for the plight of individuals with mental illness and appreciation for the ability of health care services to reduce the suffering of the people so afflicted and the burden of illness to our country.”

Incoming APA President Paul Summergrad, M.D., called Biden a “staunch ally in the battle to end the stigma surrounding mental illness and to guarantee that everyone who needs appropriate psychiatric care receives it. It was a rare honor to hear Mr. Biden say this with the true passion that he so clearly feels. We are grateful for the support of the vice president and the administration for making sure that mental health care occurs for all who need it."

APA CEO and Medical Director Saul Levin, M.D., M.P.A., said, “It is to the nation’s benefit that we in the mental health and psychiatric treatment field can look forward to participating in the work with Vice President Biden that will transform the way mental illness is treated in this country with respect to equality of services, access, and network adequacy for persons with mental health needs.”

Lithium Exposure During Pregnancy May Contribute to Birth Defects, Miscarriages, Study Finds

Researchers from the Israel Ministry of Health in Jerusalem and the Motherisk Program at the Hospital for Sick Children in Toronto evaluated the impact of lithium exposure on pregnancy and the likelihood of offspring birth defects. The study, “Pregnancy Outcome Following In Utero Exposure to Lithium: A Prospective, Comparative, Observational Study” published this week in AJP in Advance, evaluated 183 women with bipolar disorder who were exposed to lithium during pregnancy and 748 expecting mothers with bipolar disorder who were not exposed to lithium. Participants were assessed on rates of miscarriage, preterm birth deliveries, and cardiovascular anomalies in their offspring.

Results showed that the lithium-exposed subjects were nearly five times more likely to have a miscarriage or elective termination of pregnancy than their non-lithium-exposed counterparts. In addition, cardiovascular anomalies—assessed by fetal echocardiography—were seven times more likely to occur during the first-trimester of pregnancy in women exposed to lithium than those who were not exposed. The rate for preterm delivery was approximately 14% in the lithium group, compared with 6% in the group without lithium exposure.

Nada Stotland, M.D., a professor of psychiatry at Rush University and expert in OB-GYN psychiatry, told Psychiatric News that there are several factors to consider when treating bipolar disorder in women who are pregnant. “If the patient has had a history of full-blown manic or depressive episodes, physicians should really think of the mental health consequences that may arise if that patient is taken off medication. In the case of patients with milder episodes and a strong support system, lessening dosages could be considered in the first trimester.” Stotland, a former president of APA, emphasized that choosing the best treatment for expectant mothers with bipolar disorder is not a “one-size-fits-all” situation and that clinicians should “balance the risks of lithium exposure during pregnancy against the risk and consequences of not treating bipolar disorder.”

To read more about lithium use during pregnancy, see the Psychiatric News article, "New Data Provide Guidance on Lithium Use in Pregnancy." Also see Clinical Manual of Women's Mental Health from American Psychiatric Publishing.

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Obama Proclaims May as National Mental Health Awareness Month

In a proclamation issued yesterday, President Obama has designated May as National Mental Health Awareness Month. In explaining the importance of focusing on mental health and mental illness, Obama emphasized that, "Despite great strides in our understanding of mental illness and vast improvements in the dialogue surrounding it, too many still suffer in silence." He said this special month is an opportunity to "reaffirm our commitment to building our understanding of mental illness, increasing access to treatment, and ensuring those who are struggling know that they are not alone." He stressed the increased access to mental health care that will follow passage of the Affordable Care Act, as well as special initiatives his administration has fostered to address the mental health needs of children and veterans.

In responding to the President's proclamation, APA CEO and Medical Director Saul Levin, M.D., M.P.A., said, “APA applauds President Obama’s proclamation of May as National Mental Health Awareness Month, especially his focus on the need to increase awareness of mental illnesses and make mental health treatment, including for substance use disorders, more accessible to the millions who suffer in silence. In emphasizing that mental illness should not be viewed differently from other illnesses, he is taking a step toward reducing the stigma that too often deters people from seeking help.”

Read the full text of the proclamation here.