Quetiapine Appears Effective in Treatment of Borderline Personality Disorder, Study Finds

A new study, "Comparison of Low and Moderate Dosages of Extended-Release Quetiapine in Borderline Personality Disorder: A Randomized, Double-Blind, Placebo-Controlled Trial," in AJP in Advance provides evidence for the antipsychotic quetiapine's use as a potential therapy for borderline personality disorder (BPD). A research team led by Donald Black, M.D. (photo at left), vice chair of education and a professor of psychiatry at the University of Iowa Carver College of Medicine, conducted a study comparing the efficacy and tolerability of low and moderate dosages of extended-release quetiapine in adults with BPD.

“A variety of psychotherapies have been developed [for BPD], and while research on the use of medication is ongoing, no drug has been approved in the United States or elsewhere for its treatment,” the researchers pointed out. “This study was designed to provide a rigorous test of extended-release (ER) quetiapine in the treatment of borderline personality disorder.”

They randomly assigned 95 participants who met DSM-IV criteria for BPD to receive low (150 mg/day) or high dosages (300 mg/day) of ER-quetiapine or to placebo for eight weeks. The Zanarini Rating Scale for Borderline Personality Disorder was used to analyze changes in BPD symptoms. The results showed that participants receiving both low and high dosages of ER-quetiapine had significant improvements in BPD symptoms compared with those receiving placebo. Adverse events associated with ER-quetiapine included sedation, change in appetite, and dry mouth. Participants taking high dosages were more likely to experience adverse events.

The researchers noted that "while quetiapine was effective in treating many symptoms of borderline personality disorder, its adverse effects must be taken into consideration." They concluded that their findings emphasize a need for more studies to be conducted to confirm the efficacy of quetiapine—both extended- and immediate-release forms—intended for BPD. Funding for the study was provided by AstraZeneca, which makes the Seroquel brand of quetiapine.

To read more about potential pharmacotherapies for BPD, see the Psychiatric News article, "Several Therapies Show Success in Treatment of Personality Disorders."

(Image: University of Iowa Carver College of Medicine)

Prenatal Exposure to Antidepressants Shows No Cardiac-associated Risk in Offspring, Study Finds

New research shows that antidepressant pharmacotherapy does not appear to pose a risk for cardiac defects in infants born to women taking the medicines during the first trimester of pregnancy—including those that are contraindicated for pregnant women.

A research team led by Krista Huybrechts, Ph.D., of Harvard Medical School conducted a large-scale study with nearly 950,000 pregnant women from 2000 to 2007 to compare the potential risk of congenital cardiac birth defects in offspring of mothers exposed to antidepressants during the first trimester of pregnancy with those who were not taking the drugs.

Study findings, published in the New England Journal of Medicine, showed no significant difference between infants in terms of congenital cardiac defect born to women who took antidepressants during the first trimester and those who did not. In addition, the study found no association between cardiac abnormalities in offspring and maternal exposure to paroxetine or sertraline, drugs classified by the Food and Drug Administration as pregnancy category C and D for potential risks for ventricular defects in the fetus. The study was funded by the Agency for Healthcare Research and Quality and the National Institutes of Health.

“This is very reassuring news,” stated Nada Stotland, M.D., a professor of psychiatry at Rush University and expert in OB-GYN psychiatry, during an interview with Psychiatric News. "Nevertheless, psychotherapy is the optimal first choice for treatment for mild to moderate depression during pregnancy; there are no negative side effects, and the patient can also benefit from the support and insight intrinsic to psychotherapy." Stotland, a former APA president, emphasized that more-serious episodes of depression warrant a trial of antidepressant medication, because "untreated depression poses risk for mother, fetus, and newborn."

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Use of Antipsychotics Concurrent With Other Psychotropic Meds Has Increased in Medicaid-Insured Youth, Study Finds

Use of second-generation antipsychotics (SGAs) concurrently with other psychotropic medications in children in the Medicaid program has increased over the last few years, according to a report published online in the Journal of American Academy of Child and Adolescent Psychiatry.

Researchers at Children’s Hospital of Philadelphia used data from the Medicaid program to estimate the probability and duration of concurrent SGA use with different psychotropic medication classes over time and to examine concurrent SGAs in relation to clinical and demographic characteristics. Their analysis showed that while SGA use overall increased by 22%, about 85% of such use occurred concurrently with use of other psychotropic medications. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. The concurrent SGA use occurred for long durations (69%-89% of annual medication days).

"We knew that antipsychotic use was increasing among youth, but were surprised to learn just how often a child with ADHD or depression receives an antipsychotic as part of their treatment, and when they do, it is for sustained periods of time," said senior author David Rubin, M.D., co-director of the Policy Lab at Children's Hospital of Philadelphia. “In all likelihood, the use of the antipsychotics illustrates the great challenge clinicians are having when responding to disruptive and challenging behaviors in youth that don't neatly fit common diagnostic categories. In a society that often doesn't offer other services to respond to these behaviors, we should not be surprised how quickly the use of antipsychotics has grown.”

For more information on antipsychotic use in children and adolescents, see the Psychiatric News article, "Increase in Off-Label Antipsychotic Use Seen in Canadian Youth." A comprehensive review of psychotropic medication use in this age group can be found in American Psychiatric Publishing's Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition.

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Study Finds Minimal Benefit for Oxytocin in Patients With Early Psychosis

What appears to be the first randomized controlled trial of oxytocin nasal spray for patients with early psychosis found no benefit over placebo with regard to social functioning—although a follow-up analysis looking at dosing suggests that increased use of oxytocin nasal spray was associated with reductions in negative symptoms. The findings appear in a study published online in Schizophrenia Bulletin.

Oxytocin is a hormone that has been associated with empathy and other factors critical to social functioning. Some preliminary studies have suggested that oxytocin might benefit patients with psychosis, especially with regard to the cognitive and social deficits experienced by schizophrenia patients.

Researchers at the Brain and Mind Institute at Australia's University of Sydney conducted a double-blind, randomized, placebo-controlled trial in which 52 individuals aged 16 to 35 diagnosed with an early psychosis schizophrenia-spectrum illness received oxytocin or placebo nasal spray twice-daily for six weeks, combined with group social cognition training. Assessments were conducted at baseline, post-treatment, and three-month follow-up. Primary outcomes were scores on standardized tests measuring social cognition, social functioning, and negative symptoms. Secondary outcomes included self-report and behavioral assessments of social cognition, symptom severity, and social functioning. The data analysis showed that on all primary and secondary outcomes, there was no benefit of oxytocin nasal spray treatment compared with placebo. However, additional exploratory analysis looking at dosing suggested that increased use of nasal spray was associated with reductions in negative symptoms.

“Although the results suggest no benefit of oxytocin treatment, results also highlight an urgent need to consider nasal spray delivery and dose-related variables for future clinical trials," the researchers said.

Psychiatrist Stephen Marder, M.D., of the Semel Institute for Neuroscience at UCLA, has conducted research using oxytocin to study its effects on empathy. Commenting on the Schizophrenia Bulletin study, Marder said that though the findings are disappointing, the results are important for clarifying when and how oxytocin might be useful. “All of the subjects in the trial received social cognition training,” he said. “It's possible that this was very effective, and oxytocin could add little to it.” He added that it could be that oxytocin loses some of its effectiveness when it is administered chronically, as in this study. “As the authors indicate, more work should be done to clarify the best dose of oxytocin and when it should be administered."

To read more about research on this topic, see the Psychiatric News article, "Social Cognition in Schizophrenia May Improve With Oxytocin."

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CBT Following Fluoxetine May Reduce Depression Relapse Risk in Youth, Study Shows

Following a course of fluoxetine with cognitive-behavioral therapy (CBT) appears to be effective in reducing the risk of relapse in young people with major depression, according to a report online in AJP in Advance titled “Sequential Treatment With Fluoxetine and Relapse-Prevention CBT to Improve Outcomes in Pediatric Depression.”

Researchers at the University of Texas Southwestern Medical Center and Children’s Medical Center of Dallas randomly assigned youth aged 8 to 17 with major depression who responded well to an initial six weeks of fluoxetine treatment to either continued monotherapy with fluoxetine or continued medication management combined with CBT for six months. Primary outcome measures were time to remission (with remission defined as a score of 28 or less on the Children’s Depression Rating Scale–Revised [CDRS-R]) and rate of relapse (with relapse defined as either a CDRS-R score of 40 or more with a history of two weeks of symptom worsening, or clinical deterioration).

During the 30-week continuation treatment period, time to remission did not differ significantly between treatment groups, but the medication management plus CBT group had a significantly lower risk of relapse than the medication management only group. The estimated probability of relapse by week 30 was 9% with medication management plus CBT and 26.5% with medication management only.

“To our knowledge, this is the first randomized controlled trial of a sequential treatment strategy to prevent relapse in youths with major depressive disorder,” the researchers said. “The results demonstrate that, as in adults, sequencing treatments can reduce risk of relapse and lengthen time to relapse in depressed youths.”

For more information on the use of CBT in youth with depression, see the Psychiatric News article, “CBT Program Helps Some Teens Lower Their Depression Risk.”

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IOM Faults Pentagon, VA for Lack of Data to Assess Effectiveness of PTSD Care

In a just-published two-year study, the Institute of Medicine (IOM) has concluded that despite enormous investments of time, money, and effort in programs to treat posttraumatic stress disorder (PTSD), neither the Department of Defense (DoD) nor the Department of Veterans Affairs (VA) "knows with certainty whether those programs and services are actually successful in reducing the prevalence of PTSD in service members or veterans and in improving their lives."

The 300-page report points out that between 7% and 20% of U.S. service members and veterans of the Iraq and Afghanistan wars may have PTSD and that it can "pervade all aspects of a service member's or veteran's life...," yet neither department collects much treatment outcome data, and what few data exist "suggest that there are only modest improvements in PTSD symptoms after treatment in these programs." To remedy this situation, the IOM committee urges the agencies to develop "an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for service members, veterans, and their families, including female veterans and minority group members."

Committee members emphasized as well that the number of mental health care providers "has not kept pace with the growing demand for PTSD services," and the two agencies have "no formal procedures for evaluating those providers" who have been hired in the last few years or for tracking the care they deliver.

APA President Paul Summergrad, M.D., said, "The IOM's report and recommendations are helpful as our nation contemplates comprehensive reforms to the VA. The IOM Committee found that DoD and VA "should have available an adequate workforce of mental health care providers," especially to meet the demand for PTSD treatment, which is why APA is strongly advocating for the passage of the Ensuring Veterans' Resiliency Act. We also agree that it's crucial to have accurate data and mechanisms in place to evaluate which programs are most effective in relieving PTSD symptoms."

To read about the IOM committee's initial report on PTSD programs in the DoD and VA, see the Psychiatric News article, "Military, VA Can Do Better in PTSD Response, Experts Say."

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Depression Linked to Higher Risk for Cardiovascular Events In Younger Women, Study Finds

A new study published in the Journal of the American Heart Association investigates whether depression can be a "hidden" risk factor to explain why younger women with depression suffer at a disproportionately higher rate from adverse cardiac events compared with age-matched men.

Researchers from the departments of cardiology and epidemiology at Emory University School of Medicine conducted a study to assess whether depression in women aged 55 and younger is associated with higher risk for coronary artery disease and adverse outcomes compared with age-matched males and older women with depression. The study included more than 3,200 patients with depression, assessed by the Patient Health Questionnaire (PHQ)-9, and with known or suspected coronary artery disease. Participants were required to undergo coronary angiography and three years of follow-up.

The results showed that each 1-point increment in symptoms of depression was associated with a 7% increased risk for coronary artery disease in women aged 55 and younger, but not aged-matched male and older female counterparts with depression. Young women with moderate to severe depression were twice as likely to suffer a heart attack, die of heart disease, or require an artery-opening procedure during the follow-up compared with males and older women.

Viola Vaccarino, M.D., Ph.D., senior author of the study and chair of epidemiology and a professor cardiology at Emory, said, "Although the risks and benefits of routine screening for depression are still unclear, our study suggests that young women may benefit for special consideration...unfortunately this age group has largely been understudied..." In March, the American Heart Association issued a scientific statement—endorsed by APA—recommending that depression be formally considered as a risk factor, like diabetes and hypertension, for coronary artery disease. “Our data are in accordance with this recommendation, but suggest that young and middle-aged women may be especially vulnerable to depression as a risk factor," Vaccarino concluded.

To read more about depression as a heart-disease risk factor, see the Psychiatric News articles, "Depression Should Be Listed as Heart Disease Risk, Says AHA Panel," and "Building a Bridge Between Cardiology, Psychiatry."

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Study Finds Differences Between Brain Activity in Youth and Adults With Bipolar Disorder

While studies using functional magnetic resonance imaging (fMRI) have begun to investigate the neural mechanisms underlying bipolar disorder, very few have investigated whether differences exist between brain activity of youth with the disorder and adults with the disorder.

Researchers from the PediMind Program at Bradley Hospital at Brown University conducted the first meta-analysis comparing the brain activity of youth and adults with bipolar disorder. The analysis included data from 100 studies that used fMRI to measure changes in the brain in response to various forms of stimuli. The researchers focused on regions of the brain that are significant for emotional reactions.

The results, published in JAMA Psychiatry, showed that when participants viewed images of emotional faces, youth with bipolar disorder displayed greater amygdala activity than adults with the disorder. When using emotional stimuli, the researchers found that brain activity was greater in the inferior front gyrus and precuneus areas of youth than of adults. Nonemotional stimuli showed a lack of brain activity in youth when compared with adults.

"Despite our best current treatments, bipolar disorder exacts a considerable toll on youth, including problems with friends, parents, and at school, and high rates of psychiatric hospitalization and suicide attempts," said Daniel Dickstein, M.D., senior author and an associate professor of psychiatry and of pediatrics at Brown. "More research into targeted treatments is needed now that we know children's brains are impacted in specific, identifiable ways by bipolar disorder. Locating the underlying brain change in bipolar youth could lead us to new, brain-based ways to improve how we diagnose and treat this disorder."

To read more about research on pediatric bipolar disorder and underlying mechanisms that may be associated with it, see the Psychiatric News articles "Family-Focused Therapy Reduces Bipolar Symptoms in Youth" and "Same Brain Circuits Linked With Psychosis in Two Disorders."

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Varenicline, Bupropion Combo Found Useful in Smokers Who Don't Respond to Patch

Combination treatment with varenicline and bupropion proved more efficacious for smoking cessation than did varenicline and placebo for male smokers and smokers with a high degree of nicotine dependence who did not show an initial response to prequit nicotine-patch treatment, according to a report in AJP in Advance.

In a randomized, double-blind, parallel-group adaptive treatment trial, researchers in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center identified 222 cigarette smokers who failed to show a reduction of more than 50 percent in smoking after one week of nicotine-patch treatment. Smokers were randomly assigned to receive 12 weeks of varenicline plus bupropion or varenicline plus placebo. The primary outcome measure was continuous smoking abstinence at weeks 8 to 11 after the target quit date.

Participants who received the combination treatment had a significantly higher abstinence rate than those who received varenicline plus placebo. Combination treatment had a significantly greater effect on abstinence rates of male smokers than female smokers. It also had a significantly greater effect in highly nicotine-dependent smokers than in smokers with lower levels of dependence.

“In addition to showing superior efficacy of combination treatment in specific subpopulations of smokers, our results further validate an adaptive treatment model, in which smokers receive a week of prequit nicotine-patch treatment, and, based on their reduction in ad lib smoking, either remain on the patch or receive adaptive modifications of treatment,” the authors wrote.

For more information, see the Psychiatric News article, “Smoking Cessation for Patients Called an Urgent Priority.”

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FDA Warning Against Antidepressants Linked to Increased Suicidality in Youth, Study Finds

A study published yesterday in BMJ suggested that the U.S. Food and Drug Administration's implementation of a black-box warning that children and adolescents taking antidepressants were at increased risk of suicidality (suicidal ideation and behavior) may have had unintended consequences.

Researchers from Harvard Medical School’s Department of Population Medicine and the Harvard Pilgrim Healthcare Institute collected data from 7.5 million patients—aged 10 to 64—to examine changes in antidepressant use, suicide attempts, and deaths by suicide before and after the highly publicized FDA warning was first issued in 2003.

The analysis showed that one year after the implementation of the warning, use of antidepressants dropped 31 percent among adolescents, 24.3 percent among young adults, and 14.5 percent among adults. Simultaneously, there was a 21.7 percent increase in suicide attempts by psychotropic drug poisoning among adolescents, and a 33.7 percent increase for such among young adults. The number of deaths by suicide did not change for any age group.

Mark Olfson, M.D., M.P.H., a professor of psychiatry at Columbia University Medical Center and an expert in mood disorders, told Psychiatric News that "the new findings shed little light on the complex associations between anxiety and depressive disorders, antidepressant treatment, and the risk of self-harm and suicide. The measure of suicide attempts used in this study, psychotropic poisonings (ICD-9 code 969), is only loosely related to suicide attempts. Most suicide attempts in young people do not involve poisoning by psychotropic drugs and most intoxications do not represent suicide attempts."

Because of the recent substantial increase in unintentional poisonings from stimulants, Olfson stated that the increase in psychotropic overdose could be a result of an underlying substance use disorder rather than suicide. “This trend [of psychotropic overuse by youth], which may be driven by complex societal factors, deserves study and clinical attention,” Olfson concluded.

To read other studies investigating the consequences of the FDA warning, see the Psychiatric News article “Analysis Continues of Fallout From FDA's SSRI Warning.” Also see the American Journal of Psychiatry's study, “Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents.”

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APA Urges Members to Show Their Support for Bills on Psychiatric Workforce at VA

Your voice is needed! APA is asking psychiatrists to urge their members of Congress and senators to cosponsor bills H.R. 4234/S. 2425, the bipartisan Ensuring Veterans Resiliency Act, which seeks to secure a stronger and more stable psychiatric workforce in the Department of Veterans Affairs (VA).

Veterans face significant mental health challenges, yet only half of first-time patients in the VA receive a full mental health evaluation within the prescribed 14 days, at least partly because of a shortage of clinicians, including psychiatrists. APA believes that the shortage and turnover of psychiatrists are factors contributing to the inability of the VA to deliver mental health services when needed.

To remedy that shortfall, APA supports the legislation, which would create a three-year pilot program to encourage at least 10 psychiatrists per year to enter full-time, long-term employment with the VA by offering medical school loan repayments of up to $60,000 per year. The bill also calls for a study of pay discrepancies among psychiatrists within the VA. "Access to appropriate and timely psychiatric care for our wounded veterans is essential," said APA President Paul Summergrad, M.D. "This legislation will increase access to psychiatrists, and I encourage State Associations, District Branches, and members to reach out to their elected leadership in Congress."

APA members may write their elected officials through an Action Alert posted by APA’s Department of Government Relations.

For more details in Psychiatric News on the legislation, see the article, “Bill Seeks to Boost Number of Psychiatrists in VA.”

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Antidepressant Therapy Alone in Bipolar Disorder Associated With Mania Risk, Study Shows

Antidepressant monotherapy in patients with bipolar disorder appears to be associated with an increased risk of mania, according to a report online in AJP in Advance today titled, “The Risk of Switch to Mania in Patients With Bipolar Disorder During Treatment With an Antidepressant Alone and in Combination With a Mood Stabilizer.” In contrast, no increased risk of mania was seen in patients receiving an antidepressant while treated with a mood stabilizer, highlighting the importance of avoiding antidepressant monotherapy in the treatment of bipolar disorder, the researchers said.

Researchers used Swedish national registries to identify 3,240 patients with bipolar disorder who started treatment with an antidepressant and had no antidepressant treatment during the previous year. Patients were categorized into those receiving antidepressant monotherapy and those receiving an antidepressant plus a mood stabilizer. The researchers compared the rate of mania 0–3 months and 3–9 months after the start of antidepressant treatment with a preceding nontreatment period.

Nearly 35 percent of the patients were treated with antidepressant monotherapy. The increased risk of treatment-emergent mania—with a hazard ratio of 2.83—was confined to patients on antidepressant monotherapy. Among patients treated with a concurrent mood stabilizer, no acute change in risk of mania was observed during the 3 months after the start of antidepressant treatment, and a decreased risk was foiund during the period 3–9 months after treatment initiation.

Michael Thase, M.D., a psychiatrist at the University of Pennsylvania and one of the study co-authors said that even though current practice guidelines recommend using antidepressants in combination with mood stabilizers in bipolar disorder patients, in Europe the practice of monotherapy is not uncommon. "Our findings suggest that antidepressants alone are associated with increased manic switching, and when it happens it happens pretty quickly," he told Psychiatric News. "The converse finding is that patients who got mood stabilizers while treated with antidepressants not only did better in the short term but had an improved course in the long run. This means if you can prevent cycling or switching to any degree, your patients have a better chance of staying well over the long-term."

For more information, see the Psychiatric News article, "Bipolar Treatment Study Assesses Psychotherapy Efficacy." In addition, treatment guidelines for bipolar disorder are available on the APA website.

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Study Shows Association Between Mental Illness Severity and Employment and Income

More severe mental illness appears to be associated with lower employment rates in recent years, and people with serious mental illness are less likely than people with no, mild, or moderate mental illness to be employed after age 49, according to the report, “Employment Status of People With Mental Illness: National Survey Data From 2009 and 2010,” published in Psychiatric Services in Advance.

Researchers from Dartmouth Psychiatric Research Center and the Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine examined data on a sample of more than 77,000 participants aged 18–64 from the 2009 and 2010 National Survey on Drug Use and Health. Two well-established scales to assess mental health distinguished participants with none, mild, moderate, or serious mental illness. Analyses compared employment rate and income by mental illness severity. Employment status was estimated with statistical analysis controlling for demographic characteristics and substance use disorders.

Researchers found that employment rates decreased with increasing mental illness severity (no mental illness, 75.9% employment; mild, 68.8%; moderate, 62.7%; and serious, 54.5%). In addition, 38.5% of people with serious mental illness had annual incomes of less than $10,000, compared with 23.1% of people with no mental illness.

“Education status, known to facilitate employment opportunities, was the strongest predictor of employment even among people with serious mental illness,” the researchers said. “This finding is consistent with previous research in clinical and community samples and suggests that facilitating educational achievement may facilitate job placement. Longitudinal research is needed to test alternative explanations: educational achievement may be a proxy for later illness onset, less serious illness, or more intensive service use.”

To read more about employment and mental illness, see the Psychiatric News article, “Study Finds Evidence Showing Supported Employment Works.”

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Brief Telephone Intervention Using CBT Can Prompt Vets to Reconsider PTSD Treatment

A one-time brief telephone intervention appears to be effective in engaging service members in PTSD treatment earlier than conventional methods and may lead to immediate symptom reduction, according to a report, "RCT of a Brief Phone-Based CBT Intervention to Improve PTSD Treatment Utilization by Returning Service Members," published in Psychiatric Services in Advance.

Researchers at White River Junction Veterans Affairs Medical Center and Dartmouth Medical School randomly assigned 300 service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom and screened positive for PTSD but had not engaged in PTSD treatment to either a brief cognitive-behavioral therapy (CBT) intervention or to usual care. The intervention session was administered by telephone by a psychologist and lasted about 45 to 60 minutes. The sessions were based on CBT principles and focused on modifying thoughts about receiving treatment for PTSD symptoms. For example, the thought “I don’t need treatment” might become “I might need treatment, considering how hard it is to sleep and the impact it is having on my relationships and job.” Participants identified individual beliefs about treatment during the intervention session, and the intervention session addressed a maximum of three beliefs with each participant.

All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization. Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.

“There were no differences at the longer-term follow-up, suggesting the need for additional intervention to build on initial gains. Additional intervention could include a booster session that occurs at two weeks or one month subsequent to the initial intervention session. This additional session could bolster the individual’s intention to seek or to stay in PTSD treatment and would allow for continued use of coping skills or even allow service members to continue to explore the meaning of the trauma experienced.”

To read more about this subject, see the Psychiatric News article, "Expectations Deter Vets From Seeking Mental Health Care."

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Study Finds Differences in Adverse Effects Among Generations of Antipsychotics

A study in the Journal of the American Medical Association (JAMA) reports on the first research to compare the effectiveness and safety of a second-generation long-acting injectable antipsychotic with an older long-acting injectable antipsychotic.

The study was conducted by researchers at the departments of Psychiatry at Georgia Regents University and Columbia University who randomized 311 adults with schizophrenia or schizoaffective disorder to receive monthly injections of either haloperidol decanoate (the older long-acting antipsychotic) or paliperidone palmitate (the second-generation long-acting antipsychotic; trade name Invega Sustenna) for 24 months. Rates for efficacy failure were determined by a need for psychiatric hospitalization or crisis stabilization and a substantial increase in frequency of outpatient visits. Patients were also monitored for adverse health events.

The analysis revealed no significant difference in the rate of efficacy failure among the two treatment groups. However, participants taking paliperidone gained weight progressively over time, while those taking haloperidol lost weight. Treatment with paliperidone was associated with elevated serum levels of the prolactin hormone, whereas haloperidol was associated with more akathisia.

In an accompanying editorial, JAMA Associate Editor Donald Goff, M.D., said, “The results from [this] trial suggest that drug selection should be based on anticipated adverse effects rather than efficacy.” Goff, who is the vice chair for psychiatry research at New York University Langone Medical Center, emphasized that additional data are needed to investigate how long-term exposure to extended-release drugs and a wider range of antipsychotics contribute to adverse effects. “Not only is the compilation of reliable data about these drugs essential, so also is the clear communication of this information to patients as part of the shared decision-making process,” Goff concluded.

To read more about extended-release antipsychotics, see Psychiatric News article, "Company Describes Encouraging Outcomes of Schizophrenia Drug Trials." For more about medications to treat psychotic disorders, see The Evidence-Based Guide to Antipsychotic Medications from American Psychiatric Publishing.

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Antidepressants May Have Role in Preventing Alzheimer's Disease, Study Suggests

Research conducted by Yvette Sheline, M.D., a professor of psychiatry at the University of Pennsylvania, and colleagues and reported in Science Translational Medicine suggests that antidepressants might someday be a long-sought weapon in the fight against Alzheimer's disease.

After older mice genetically modeled to have Alzheimer's disease were chronically given the SSRI antidepressant citalopram, it stopped the growth of preexisting beta-amyloid plaques and reduced the appearance of new plaques in the mice's brains by 78%. And when 23 healthy human volunteers were given either a 50 mg dose of citalopram or a placebo, amyloid production in the cerebrospinal fluid was slowed by 37% in the citalopram group compared with the placebo group.

"The ability to safely decrease beta-amyloid concentrations is potentially important as a preventive strategy for Alzheimer's disease," the researchers said.

Cautions are in order, however, until the results are replicated. "It has to be emphasized that these were not clinical studies and that no treatment recommendations can be based on these preliminary reports," Joel Yager, M.D., a professor of psychiatry at the University of Colorado and chair of the APA Council on Quality Care, told Psychiatric News. "Additional studies will be required to see whether reductions in beta-amyloid production in fact persist with long-term SSRI treatment in humans, and whether reduced production might actually result in clinically meaningful reductions in plaque formation and cognitive impairment. In addition, studies will have to consider potential adverse effects of long-term chronic SSRI treatments in the elderly. All that said, these results might suggest preventive strategies for future practice, of special interest for those who are at high risk for Alzheimer's disease."

More information about research on preventing Alzheimer's can be found in the Psychiatric News articles, "For Now, Preventive Efforts Are Best Alzheimer's Weapon" and "Cognitive Training May Bestow Long-Term Benefits for Seniors."

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Study Finds Substantial Costs Associated With Caring for People With ASD

It takes millions of dollars to support people with an autism spectrum disorder (ASD) throughout their lives, according to a new study published online in JAMA Pediatrics this week. A literature review of studies of ASD patients and their families in the United States and the United Kingdom found that the lifetime cost for someone with the disorder but without intellectual disability was $1.4 million per person in both countries. For those with intellectual disability, the costs were significantly higher: $2.4 million per person in the U.S. and $2.2 million in the U.K., said Ariane Buescher, M.Sc., of the London School of Economics and Political Science, David Mandell, Sc.D., of the Center for Mental Health Policy and Services Research at the University of Pennsylvania, and colleagues.

“These costs are much higher than previously suggested,” the researchers noted. Costs were also surprisingly similar in the two countries, despite the differences between their health care systems. Direct nonmedical costs, such as for special education, and indirect costs, such as for lost parental productivity, are the largest contributors to total costs in both countries across all age groups. For adults with ASD, the highest costs came from residential care or supportive-living accommodations and from loss of individual productivity. Other direct medical costs are higher, too, especially among adults.

In a related editorial, Paul Shattuck, Ph.D., and Ann Roux, M.P.H., praise the study for breaking new ground and called for viewing costs as investments and then measuring long-term outcomes across the lifespan.

To read more in Psychiatric News about autism across the lifespan, see the articles, "Teens, Adults With Autism Need More Support" and "Adult ASD Knowledge Expands Rapidly." For more information about ASD, see American Psychiatric Publishing's Autism and Other Neurodevelopmental Disorders.

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AMA House Calls for Protocols for Post-'Taser' Medical Assessments

The AMA House of Delegates approved a resolution this week calling on the AMA and other organizations and medical specialty societies to develop a standardized, postexposure medical protocol for the use of conducted electrical devices (CEDs or “Tasers”) and to support the incorporation of such a protocol into law enforcement procedures and training.

During reference committee hearings, Jennifer Piel, M.D., J.D., a delegate from the American Academy of Psychiatry and the Law, spoke in support of the resolution and told delegates that Tasers are frequently used at the time of arrest  or in prison settings with individuals who have mental illness. She said post-Taser medical assessments should include an assessment of mental status with appropriate follow-up treatment.

The annual policymaking meeting of the AMA concludes today. During the four-day meeting, delegates considered and approved a range of reports and resolutions vital to psychiatrists and other physicians. Subjects addressed by the House included the crisis at the VA, problems associated with conversion to ICD-10; the risk of concussions associated with youth sports, adequacy of health plan physician networks to provide true access to care, and the integration of behavioral and general medical care. For coverage of these and other issues, see upcoming editions of Psychiatric News.

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AMA Delegates Seek Models for Implementing Integrated Care

The AMA will work with APA and other organizations to provide recommendations on implementing models for integrating physical and behavioral health care. At the meeting of the AMA House of Delegates, a resolution was approved that directs the AMA, along with interested specialty and state societies, to study and report back at next year’s meeting on the current state of knowledge regarding integration of physical and behavioral health care, including pediatric and adolescent health care, and to provide recommendations for implementing models of physical and behavioral health care integration. The resolution was brought to the House by the delegation from Colorado, with support from the Section Council on Psychiatry.

“It is well documented that persons with medical conditions who have co-occurring mental health disorders and those persons with primary mental health disorders who also have chronic medical conditions are often medically complex and typically incur significantly higher than average total health care costs,” said psychiatrist Jerry Halverson, M.D., speaking in support of the resolution. “In primary care settings, more than 80% of patients who have co-occurring mental health disorders are either undertreated or receive no treatment for their mental illness at all. There are now over 80 randomized, controlled trials that provide a robust evidence base for the collaborative care model. Evidence shows that it is vital to have a psychiatrist as part of the collaborative team.”

“This support by the AMA House of Delegates represents an important next step to improve the quality and access for psychiatric and general medical care provided to patients and families throughout the United States,” commented APA President Paul Summergrad, M.D. “We look forward to working closely with our colleagues at the AMA on this project, which is an APA priority.”

For more information see the Psychiatric News articles "Board Report on Reform Focuses on Integrated Care" and "A Primer on Integrated Care: FAQ Answered by Experts."

AMA Delegates Seek Data, Recommendations on Sports-Related Concussions

Delegates in the AMA House of Delegates want the AMA’s Council on Science and Public Health (CSPH) to prepare a report summarizing the data on risk of concussion in youth sports and to develop specific recommendations to aid physicians in efforts to reduce the risk of concussion.

Concussion risk associated with sports was the subject of several resolutions at the AMA’s annual policymaking meeting this week, including one sponsored by the AMA Section Council on Psychiatry calling for a report by the CSPH. In reference committee hearings on Sunday, the resolution received supportive testimony from many physicians, and during the meeting of the House of Delegates yesterday, the resolution was referred without debate to the AMA Board of Trustees, which will then request a report from the CSPH.

“I evaluate many young people who have histories of significant head trauma, including sports-related concussions. I’ve seen the effects of these injuries firsthand,” said David Fassler, M.D., alternate delegate for the American Academy of Child and Adolescent Psychiatry, at reference committee hearings. “While many children and adolescents recover fully from a concussion, a significant number experience serious and lasting consequences including headaches, problems paying attention, impaired memory, irritability, sleep disturbance, and depression.... Our resolution asks the [CSPH] to prepare a report summarizing the existing data on the risk of concussion in youth sports. Such a report would also provide a scientific basis for educating physicians and the general public and for influencing public policy at the state, local, and national levels.”

In-depth coverage of this issue will appear in a future issue of Psychiatric News.

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Psychiatry Urges AMA to Address Health Plan Network 'Inadequacy'

Physicians at this year's annual policymaking meeting at the AMA were widely supportive of a resolution brought by the AMA Section Council on Psychiatry to address the problem of health plan network “inadequacy” and efforts by health plans to restrict access to specialists.

Section council representatives told delegates that insurance plans are appearing within the new health exchange networks that offer “thin and ultra-thin” networks—provider lists with few or very few specialists. Moreover, patients also face “phantom networks,” a phenomenon whereby plans list providers in their networks who are not really available to treat patients, or in some cases who are deceased.

The section council resolution, which received supportive testimony from physicians in several disciplines, seeks to have AMA advocate for adherence to existing statutory and regulatory measures for ensuring network adequacy and to work with state medical societies to advocate for such regulations in states where they do not exist.

Psychiatrist Paul O’Leary, M.D. (pictured above), told delegates that the problem of network inadequacy and health plan efforts to restrict access to specialists can be especially problematic for young physicians starting out in practice and seeking to be included on panels or receive referrals of patients.

O’Leary made his remarks yesterday during reference committee hearings where reports and resolutions are debated before being sent to the full House of Delegates; the House will be meeting today through Wednesday to discuss the section council resolution and many other issues.

Look for additional Alerts and upcoming editions of Psychiatric News for in-depth coverage of this and other issues of importance to psychiatry.

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AMA Delegates Debate Extension of 'Medicaid Payment Bump' to Psychiatry

Psychiatry should be included in increased Medicaid payments to physicians providing primary care mandated by the Affordable Care Act, said psychiatrist Jerry Halverson, M.D., during hearings at the annual policymaking meeting of the AMA House of Delegates in Chicago.

Halverson (pictured at left) and others argued that psychiatrists—some of whom act as primary care providers to Medicaid patients who have severe and persistent mental illness—and neurologists should also be included among physicians receiving increased Medicaid payments under the ACA. (The law calls for increasing Medicaid payment to Medicare levels for physicians who predominantly bill for evaluation and management services.)

Debate at the AMA yesterday centered around a Council on Medical Services report that recommends that the AMA advocate for inclusion of OB-GYNs among clinicians receiving the "Medicaid bump" in payment based on prior AMA policy that classifies OB-GYNs as primary care physicians. But Halverson and others argued that psychiatrists and neurologists should also be included. "Overall, psychiatry has a disproportionate number of patients in the Medicaid population," he said. "Medicaid is a safety-net program that is intended to protect the most disabled and vulnerable children and adults struggling with severe chronic illness and severe disabilities, such as mental illness. Medicaid is now the dominant source of funding for treatment and support services for both children and adults living with severe mental illnesses.

"The pay for specialty psychiatric services is lower than the rate paid for general medical services in Medicaid, and this results in lower participation rates for psychiatrists, ultimately contributing to worsening access to psychiatrists," Halverson said. "Should psychiatrists receive this Medicaid bonus payment, more are likely to participate in Medicaid.... OB-GYNs, neurologists, and psychiatrists all provide a significant amount of services to Medicaid patients that are considered to be primary care. These physicians should not be denied pay parity on technical or arbitrary grounds."

Said APA President Paul Summergrad, M.D., "Psychiatry is by definition a disproportionate-share specialty. Having Medicaid pay psychiatrists at Medicare rates will be especially beneficial for the ability of community mental health centers and hospital-based clinics to provide care by psychiatrists who are often the only physicians for these complex patients. Our AMA delegation should be commended for bringing this issue forward.”

Halverson testified yesterday at reference committee hearings at which reports and resolutions are debated before being sent to the full House of Delegates for consideration; the House will debate the report and other issues of concern to psychiatry at meetings through Wednesday.

Look for additional Alerts and upcoming editions of Psychiatric News for more coverage of issues discussed at the meeting.

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AMA Membership Up, Harris Tells Delegates as Policymaking Meeting Begins

Membership in the AMA is up for the third year in a row, said psychiatrist and AMA Trustee Patrice Harris, M.D.

At the annual policymaking meeting of the AMA, which began this weekend in Chicago, Harris—a former member of the APA Board of Trustees—painted a bright picture of the AMA’s financial position with an increase in total revenue last year. Especially good news was the fact that in 2013 the AMA recorded an increase in membership for the third year in a row; revenue from membership dues increased across all member categories, without an increase in dues rates for members, Harris said. 

At the meeting this week, AMA delegates will be considering a number of reports and resolutions of vital interest to psychiatry, including several brought by the Section Council on Psychiatry. Among the issues to be discussed are head injuries and concussions associated with youth sports, gun violence, adequacy of health plan physician networks to provide true access to care for patients, and Medicaid payment to psychiatrists.

Harris delivered her report on AMA finances this morning at the opening of reference committee hearings where reports and resolutions are debated before being sent to the House of Delegates; the House will be meeting Monday through Wednesday. "The AMA is well positioned strategically and financially to pursue its ambitious agenda to improve the health of the nation,” Harris told delegates.


Look for additional Alerts and upcoming editions of Psychiatric News for more coverage of the AMA meeting.

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NIH Proposes Multibillion Dollar Increase in Funding for BRAIN Initiative

Yesterday, the National Institutes of Health (NIH) called for $4.5 billion in new federal funding over 10 years—beginning in Fiscal 2016—for research as part of the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, a White House-sponsored research effort announced by President Obama last year. This would quadruple the initial budget for the multiyear project from $100 million a year for the next five years to $400 million a year.

“How the brain works and gives rise to our mental and intellectual lives will be the most exciting and challenging area of science in the 21st century," said NIH Director Francis Collins, M.D., Ph.D. (pictured above with Obama) "As a result of this concerted effort, new technologies will be invented, new industries spawned, and new treatments and even cures discovered for devastating disorders and diseases of the brain and nervous system.”

The NIH efforts on the BRAIN Initiative will seek to map the circuits of the brain, measure the fluctuating patterns of electrical and chemical activity flowing within those circuits, and understand how such factors interplay to create specific cognitive and behavioral capabilities. The NIH plans to achieve goals through the following core principles:

• Identify and provide experimental access to the different brain cell types to determine their roles in health and disease.
• Generate circuit diagrams that vary in resolution from synapses to the whole brain.
• Produce a dynamic picture of the functioning brain by developing and applying improved methods for large-scale monitoring of neural activity.
• Link brain activity to behavior with precise interventional tools that change neural circuit dynamics.
• Produce conceptual foundations for understanding the biological basis of mental processes through development of new theoretical and data analysis tools.
• Develop innovative technologies to understand the human brain and treat its disorders; create and support integrated brain research networks.
• Integrate new technological and conceptual approaches produced in the other goals to discover how dynamic patterns of neural activity are transformed into cognition, emotion, perception, and action in health and disease.

The NIH emphasized that its cost estimates for the budget for the BRAIN Initiative will be needed to supplement—not supplant—the agency’s existing investment in the broader spectrum of basic, translational, and clinical neuroscience research.

Click here to read the NIH press release for the new budget proposal for the BRIAN Initiative. For more information on the BRIAN Initiative, see the Psychiatric News articles, “BRAIN Initiative Seeks Innovations For Studying Circuits and Cells,” and "Advisory Group Draws Roadmap for President’s BRAIN Initiative.”

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NIDA Summarizes Research on Negative Health Consequences of Marijuana Use

A new comprehensive research review published this week in the New England Journal of Medicine reports that marijuana use is linked to several adverse effects—particularly in youth. The review was conducted by scientists at the National Institute on Drug Abuse (NIDA) who compiled data from previous studies highlighting the adverse consequences of marijuana use among teenagers. The NIDA review showed that teenage marijuana use was associated with impaired critical thinking and memory functions that last up to days after drug use, impaired driving, and lowered IQ scores into adulthood. The review also suggested that risks for adverse effects are increase when the drug is used along with alcohol.

The authors noted that because older studies are based on the effects of marijuana containing lower levels of THC—the primary psychoactive chemical in cannabis—stronger adverse health effects may occur with the use of today’s more potent marijuana. They emphasized that more research must be done on the potential health consequences of second-hand marijuana smoke, the long-term impact of prenatal cannabis exposure, and effects of marijuana legalization policies on public health.

"It is important to alert the public that using marijuana in the teen years brings health, social, and academic risk,” said lead author and NIDA Director Nora Volkow, M.D. “Physicians in particular can play a role in conveying to families that early marijuana use can interfere with crucial social and developmental milestones and can impair cognitive development.”

To read more about the use of marijuana among teens and legislation concerning marijuana use in this population, see the Psychiatric News articles, “News Is Mixed on Teenagers and Substance Use” and “Marijuana Legalization and Young Brains: Time for Serious Study.”

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38-Year Study Assesses Violence and Premature Mortality in People With Schizophrenia

People with schizophrenia and related disorders have increased rates of suicide, premature mortality, and convictions for violent offenses, according to a report from British and Swedish researchers published Tuesday in Lancet.

The study compared 24,297 Swedish patients with their unaffected siblings and matched controls from the general population, assessing outcomes from 1972 through 2009. Within five years of diagnosis, 13.9% of male patients and 4.7% of female patients recorded one of those three adverse outcomes. Overall, those adverse outcomes were 7.5 times more likely compared with men in the general population and 11.1 times more likely for women, wrote Seena Fazel, M.D., an honorary consultant forensic psychiatrist in the University of Oxford’s Department of Psychiatry, and colleagues.

The authors assessed adverse outcomes in all three study groups and found that three risk factors present in all three cohorts predicted the adverse outcomes: drug use disorders, criminality, and self-harm. "Schizophrenia and related disorders are associated with substantially increased rates of violent crime, suicide, and premature mortality," they concluded. "Risk factors for these three outcomes included both those specific to individuals with schizophrenia and related disorders, and those shared with the general population. Therefore, a combination of population-based and targeted strategies might be necessary to reduce the substantial rates of adverse outcomes in patients with schizophrenia and related disorders."

"[T]he authors suggest that to best manage violence and suicide risk, we should perhaps now turn our attention to those factors evident across populations," added Eric Elbogen, Ph.D., an associate professor, and Sally Johnson, M.D., a professor of psychiatry at the University of North Carolina, in a related commentary. "In this way, we might not only reduce actual risk in people with schizophrenia, but appropriately place this in the context of violence reduction for society as a whole. The potential to achieve practical, evidence-based, and potentially less stigmatising interventions is one of the most exciting implications of this study."

To read more research on violence risk in those with schizophrenia, see the Psychiatric News articles, "Antisocial Behavior Raises Violence Risk in Some Psychosis Patients" and "Untreated Schizophrenia Increases Risk for Violence By Inmates." Also see "Systematic Suicide Risk Assessment for Patients With Schizophrenia: A National Population-Based Study" in Psychiatric Services.

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Less Recidivism Found in Offenders Processed Through Mental Health Court

Offenders who participated in a mental health court program recorded significantly better recidivism outcomes compared to matched control defendants in the traditional criminal court system, according to Joye Anestis, Ph.D., an assistant professor of psychology at the University of Southern Mississippi in Hattiesburg, and co-author Joyce Carbonell, Ph.D., director of women’s studies at Florida State University in Tallahasee.

The study published online in Psychiatric Services in Advance compared two groups of 198 criminal offenders with mental illnesses. Overall, the mental health group had a lower occurrence of rearrest, a longer time to reoffending, and had fewer rearrests. Severity of the rearrest offense did not differ between the two groups, however.

A within-subject analysis of mental health court offenders found that those charged with misdemeanors had a higher occurrence of rearrest than those charged with felonies, but the two groups did not differ on odds of arrest or time to rearrest. Also, violent and nonviolent offenders showed no difference in recidivism outcomes, said Anestis and Carbonell.

The results may suggest that keeping mentally ill offenders out of jail and in community treatment may have positive effects on recidivism, as may the increased attention and supervision they receive, said the authors.

“Future research would benefit from a focus on the mechanisms of change in [mental health courts] and on identifying characteristics of individuals who respond best to participation in [them],” they concluded.

For more in Psychiatric News about mental health diversion options, see: “Judges, Psychiatrists Confer on Handling Mental Illness inJustice System.”

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Study Identifies Decreased Dopamine Transmission in Cortex of Patients With Alcoholism

Individuals with alcoholism appear to have decreased transmission of dopamine in the brain's cortex region, according to a report published in AJP in Advance titled, “Decreased Prefrontal Cortical Dopamine Transmission in Alcoholism.”

Researchers from the departments of Psychiatry and Radiology at the University of Pittsburgh used positron emission tomography to measure cortical dopamine transmission in 21 recently abstinent individuals with alcohol dependence and 21 matched healthy comparison subjects before and after administration of amphetamine. They found significantly decreased dopamine transmission in the cortex of patients with alcoholism. Cortical regions that demonstrated lower dopamine transmission in the alcohol-dependent group included the dorsolateral prefrontal cortex, medial prefrontal cortex, orbital frontal cortex, temporal cortex, and medial temporal lobe.

The researchers said further research is necessary to understand the clinical relevance of decreased cortical dopamine to evaluate whether it is related to impaired executive function, relapse, and outcome in alcoholism. “Decreased dopamine transmission…likely contributes to anhedonia, amotivation, and decreased reward sensitivity in alcohol dependence,” they said. "The fact that there is also less dopamine in the prefrontal cortex, which governs executive functions, is important because it could impair the addicted person’s ability to learn and utilize informational/behavioral strategies critical to relapse prevention.”

To read more about alcoholism research, see the Psychiatric News article, "Anticonvulsant Drug Shows Efficacy in Treating Alcoholism." For information about treatments for alcohol abuse, see American Psychiatric Publishing's Clinical Manual of Addiction Psychopharmacology, Second Edition.

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Study Finds IOPs as Effective as Inpatient Treatment for Most People With Substance Use Disorders

Intensive outpatient programs (IOP) for substance use disorders are an "important part of the continuum of care" for those disorders and appear to be "as effective as inpatient treatment for most individuals," according to the study, “Substance Abuse Intensive Outpatient Programs: Assessing the Evidence,” published online in Psychiatric Services in Advance.

Standardization of the elements included in IOPs may improve their quality and effectiveness, but public and commercial health plans should consider IOP services as a covered health benefit, say researchers at the Department of Public Health and Preventive Medicine at Oregon Health and Science University and DMA Health Strategies, Lexington, Mass. They searched major databases and identified 12 studies and one review published from 1995 to 2012, categorizing the research findings based on benchmarks for the number of studies and quality of the methodology. They also assessed evidence of service effectiveness.

Based on the quality of trials, diversity of settings, and consistency of outcomes, the level of evidence for IOPs was rated high. Multiple randomized trials and naturalistic analyses that compared IOPs with inpatient or residential care found comparable outcomes. All studies reported reductions in alcohol and drug use. However, the studies did reveal substantial variability in the operationalization of IOPs and outcome measures.

“There is a high level of evidence...that IOPs are as effective as inpatient and residential treatments when studies compare these approaches directly,” the researchers said. “IOPs allow participants to avoid or step down successfully from inpatient services. This is an important consideration for policymakers, providers, and individuals engaged in substance abuse treatment services when deciding which level of care is most appropriate for specific clinical situations."

The Assessing the Evidence Base (AEB) series, of which this was a part, reviewed 13 commonly used, recovery-focused mental health and substance abuse services. The research was sponsored by the Substance Abuse and Mental Health Services Administration to help inform decisions about which services should be covered in public and private insurance plans.

To read about the findings of another report in the AEB series, see the Psychiatric News article, “Study Finds Evidence Showing Supported Employment Works.”

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Antidepressant About as Effective as Estrogen for Menopausal Symptoms, Study Finds

In the first randomized trial comparing estrogen (estradiol 0.5 mg/day) and an antidepressant (venlafaxine 75 mg/day) for treating the hot flashes and night sweats common in menopause, both agents were found to be effective and well tolerated. "Low-dose oral estradiol and venlafaxine are effective treatments for [vasomotor symptoms] in women during midlife. While the efficacy of low-dose estradiol may be slightly superior to that of venlafaxine, the difference is small and of uncertain clinical relevance," the researchers said. The study was headed by Hadine Joffe, M.D., an associate professor of psychiatry at Harvard Medical School, with results published in JAMA Internal Medicine.

"It is nice to see this head-to-head study comparing estradiol and venlafaxine in the treatment of menopausal hot flashes," Claudia Reardon, M.D., an assistant professor of psychiatry at the University of Wisconsin and an expert on women's issues, told Psychiatric News. "While venlafaxine may not be quite as effective as estradiol in the treatment of these symptoms, it does appear to work notably better than placebo. Our women patients often talk to us as their mental health providers about their bothersome menopausal symptoms, and this study helps us to be able to discuss the likely relative efficacy of their options with them."

"The results of this carefully conducted study provide women and their physicians with critical data to guide treatment for vasomotor symptoms (hot flashes and night sweats), which affect the lives of the majority of midlife women," Katherine Wisner, M.D., a professor of psychiatry and obstetrics and gynecology at Northwestern University, told Psychiatric News.

"Caveats are that this study is not a direct comparison between estradiol and venlafaxine (both were compared with placebo) and that medroxyprogesterone was not given during the study as it would be with clinical use of estrogen (it was given only after unblinding). [But] overall, the study adds valuable information about an alternative to estrogen for the treatment of bothersome menopausal vasomotor symptoms," commented Laura Miller, M.D., medical director of women's mental health at the Edward Hines Jr. VA Hospital in Illinois.

Information about menopause and depression can be found in the Psychiatric News article, "Close Depression Monitoring Urged During Menopause, Postmenopause." Additional information about menopause and mental health can be found in American Psychiatric Publishing's "Menopause: A Mental Health Practitioner's Guide."

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