High Dose and Extended Use of Anticholinergic Drugs May Increase Risk for Dementia, Study Suggests

Previous studies have suggested that medicines—both prescription and over-the-counter—aiming to block the actions of acetylcholine may be associated with increased risk for cognitive impairment, but a new study published this week in JAMA Internal Medicine shows that use of such medicines in older adults may increase risk for dementia.

Researchers from the Geriatric Pharmacy Program at the University of Washington led a study with over 3,400 participants, aged 65 years and older and no history of dementia at the study's initiation, to examine whether a correlation existed between cumulative anticholinergic drug use and the onset of dementia. Pharmacy-dispensing data were analyzed over a 10-year period to ascertain patients’ cumulative anticholinergic exposure.

The results showed that individuals taking daily dosages of at least 10 mgs of tricyclic antidepressants such as doxepin, 4 mgs of first-generation antihistamines such as chlorpheniramine, or 5 mgs of antimuscarinics for bladder control such as oxybutynin for more than three years were at greater risk for developing dementia than their counterparts who did not use such medicines long term.

The researchers noted that the study highlights the need to increase awareness among health care professionals and older adults about the potential risk associated with extended use of anticholinergic drugs, as well as a need for efforts to minimize such drug use. "Older adults should be aware that many medications—including some available without a prescription, such as over-the-counter sleep aids—have strong anticholinergic effects," said the study’s lead author, Shelly Gray, Pharm.D., M.S., director of the geriatric pharmacy program. "If providers need to prescribe a medication with anticholinergic effects because it is the best therapy for their patient," Gray stated, "they should use the lowest effective dose, monitor the therapy regularly to ensure [that] it's working, and stop the therapy if it's ineffective."

In future studies with postmortem brain tissue, the researchers plan to investigate differences, if any, of dementia-related pathology between brains that were expose long term to anticholenergic drugs and those that were not.

To read about other medicine use that has been associated with an increased risk for the dementia, see Psychiatric News article "Long-Term Use of Benzodiazepines May Be Linked to Alzheimer’s."

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Amyloid and Anxiety May Speed Cognitive Decline in Preclinical Alzheimer's, Study Suggests

High levels of anxiety concurrent with elevated amyloid beta (Aβ) levels in the brain were significantly associated with cognitive decline in healthy older adults, according to a report in JAMA Psychiatry. The results suggest that the combination could be crucial during the long preclinical phase of Alzheimer’s disease (AD). AD is known to have a preclinical phase in which pathophysiologic processes develop many years, even decades, before the onset of clinical symptoms.

To evaluate the association between Aβ status and cognitive changes, and the role of anxiety and depressive symptoms in moderating Aβ-related cognitive changes in the preclinical phase of AD, researchers at multiple institutions studied 333 healthy older adults at hospital-based research clinics. They measured levels of Aβ in the brain at baseline, and 18-, 36-, and 54-month follow-up assessments. They also used Hospital Anxiety and Depression Scale scores and comprehensive neuropsychological evaluations to measure global cognition, verbal memory, visual memory, attention, language, executive function, and visual-spatial ability.

They found that a positive Aβ (Aβ+) status at baseline was associated with a significant decline in global cognition, verbal memory, language, and executive function. Further, the researchers found that compared with the Aβ+, low-anxiety group, slopes of cognitive decline were significantly more pronounced in the Aβ+, high-anxiety group.

“These results provide additional support for the deleterious effect of elevated Aβ levels on cognitive function in preclinical AD,” the authors stated. “They further suggest that elevated anxiety symptoms moderate the effect of Aβ on cognitive decline in preclinical AD, resulting in more rapid decline in several cognitive domains. Given that there is currently no standard anti-amyloid therapy and that anxiety symptoms are amenable to treatment, these findings may help inform risk stratification and management of the preclinical phase of AD.”

For more information on Alzheimer's research, see the Psychiatric News article, "Imaging Uncovers Brain Changes Long Before Alzheimer's Diagnosis."

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Rep. Murphy Pushes for Comprehensive MH Reform Law

Rep. Tim Murphy (R-Pa.-18) will reintroduce in Congress the Helping Families in Mental Health Crisis Act, a comprehensive reform of the American mental health system.

Murphy outlined the proposed bill as he was awarded the 2014 Torrey Advocacy Commendation by E. Fuller Torrey, M.D., founder of the Treatment Advocacy Center, at a meeting on Capitol Hill in Washington, D.C., yesterday.

“We must turn a system of pessimism, closed doors, and bureaucratic hurdles into one that embraces innovation, evidence-based care, and a spectrum of treatment options that fits the patient’s needs,” said Murphy.

In response, APA President Paul Summergrad, M.D., announced that APA’s Board of Trustees had voted unanimously last month to support Murphy’s bill.

“We hope for broad bipartisan support for something that should be above partisan politics,” said Summergrad. “APA’s psychiatric physicians will be there every step of the way to get this task accomplished.”

The bill has provisions for improving community services and integrating them with primary care, protecting access to psychiatric medications under Medicare and Medicaid, reauthorizing suicide prevention programs, and expanding research at the National Institute of Mental Health, said Murphy.

Other provisions include implementing mental health parity and monitoring its enforcement, ending the shortage of inpatient psychiatric beds, and expanding the mental health workforce.

Murphy asked for help from professional and patient groups to advocate for the legislation.

“I will not rest, nor yield, nor turn my back until we solve this problem,” he said.

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Study Finds Extended-Release Venlafaxine Effective in Spinal Cord Injury Patients With Depression

Extended-release venlafaxine was well tolerated and appears to be an effective antidepressant for decreasing core symptoms of depression and improving disability related to spinal cord injury, according to a report in JAMA Psychiatry.

Researchers at the Department of Psychiatry at the University of Washington and from several other institutions randomized 133 participants who were being treated at spinal cord injury centers to either a 12-week trial of extended-release venlafaxine or placebo using a flexible-dose algorithm. Participants were aged 18 to 64, at least one month after spinal cord injury, and diagnosed with major depressive disorder or dysthymic disorder.

Main outcome measure was score on the Hamilton Depression Rating Scale (HAM-D 17-item version and Maier subscale, which focuses on core depression symptoms and excludes somatic symptoms) over 12 weeks, and on the Sheehan Disability Scale.

Statistical analyses showed a significant difference between the venlafaxine and placebo groups in improvement on the Maier subscale but not on the HAM-D. Participants receiving venlafaxine reported significantly less disability related to spinal cord injury on the Sheehan Disability Scale at 12 weeks compared with placebo. Blurred vision was the only significantly more common new or worsening adverse effect in the venlafaxine group compared with the placebo group.

“Depression is prevalent and associated with negative outcomes in individuals with spinal cord injury,” the researchers stated. “Antidepressants are used routinely to treat depression, yet no placebo-controlled trials have been published in this population to our knowledge…. Further research is needed to determine the optimal treatment and measurement approaches for depression in chronic spinal cord injury.”

For more information, see "The Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill," published by American Psychiatric Publishing.

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ADHD Drug Can Reduce Binge Eating, Preliminary Study Suggests

The attention-deficit/hyperactivity disorder (ADHD) medication lisdexamfetamine dimesylate (trade name Vyvanse) may help in the treatment of binge-eating disorder, according to new clinical research appearing in JAMA Psychiatry.

The study, which carried out both safety and efficacy analyses, found that 50 and 70 mg doses of Vyvanse helped more participants curtail their binges than placebo (a 30 mg dosage had no effect). Forty-two percent of those taking 50 mg of the drug and 50 percent taking 70 mg were able to avoid excess consumption for four weeks, compared with 21 percent of the placebo group.

Nearly 85 percent of participants taking the medication experienced some form of adverse event, though, compared with around 59 percent in the placebo group. Among these cases, none of the participants in the placebo group and three in the Vyvanse group were classified as having a serious adverse event; six discontinued because of side effects. The study authors stated that the safety profile was in line with the known effects of the drug in treating ADHD, including the potential changes in heart rate. Other researchers, however, have cautioned that more work, particularly studies of long-term usage, need to be carried out.

Binge-eating is a recently recognized psychiatric disorder, having been included as a distinct category for the first time in the fifth edition of APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The disorder is characterized by recurrent episodes of excessive food consumption accompanied by feelings of a lack of control.

This clinical trial was funded by Shire Development, LLC, the manufacturer of Vyvanse.

To learn more about the latest challenges and hope regarding eating disorders, see the Psychiatric News article “Expert Hopeful About Future of Treatment for Eating Disorders.”

One can also read about the current state of psychological and pharmacological treatments for eating disorders in the 5th edition of Gabbard’s Treatments of Psychiatric Disorders (chapters 30-32).

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Escitalopram Linked to Significant Improvement of Mother’s Depression and Child’s Symptoms

Previous studies have shown that when symptoms of a depressed mother remit after treatment, her offspring’s psychiatric symptoms are decreased. A study published today in AJP in Advance may shed light on some antidepressant treatment options that could lead to this domino effect.

Myrna Weissman, Ph.D., a professor of psychiatry and chief of the division of clinical and genetic epidemiology at New York State Psychiatric Institute, analyzed 76 depressed mothers and 135 offspring—aged 7 to 17—to compare which antidepressants taken by mothers would eventually lead to less psychiatric symptoms in offspring. Maternal participants were given either escitalopram, bupropion, or the combination of the two for 12 weeks. Offspring psychiatric symptoms were assessed prior to maternal initiation of therapy and at study endpoint.

Though maternal subjects in all three groups were able to achieve remission, escitalopram alone was found to be associated with statistically significant improvement in mothers' depression and subsequent improvements in offspring's psychiatric symptoms, whereas treatment with bupropion and combined bupropion and escitalopram therapy did not. In addition, mothers in the escitalopram cohort were more likely to report improvement in their ability to listen and talk to their children over the 12-weeks than mothers administered bupropion or combined therapy. Children of the escitolapram group reported their mother to be more caring after treatment.

These findings "highlight the importance of active treatment of depressed mothers, which may help them and their children," the researchers noted. "Personalizing the treatment of depressed mothers may be enhanced by assessing parental behavior and monitoring the impact on children.” The researchers concluded that antidepressants that also reduce symptoms of anxiety and irritability—like escitalopram—may be necessary to properly assess the impact of the parent’s remission on the well-being of their offspring.

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More Psychiatric Care for Minorities Could Mean Substantial Savings to Health System, Study Finds

Reducing disparities in mental health care access for racial and ethnic minorities would lead to subsequent reductions in some general medical expenditures for the same populations, said Benjamin Lê Cook, Ph.D., M.P.H., a senior scientist at the Center for Multicultural Mental Health Research and an instructor at the Harvard Medical School, and colleagues in the study "The Costs and Benefits of Reducing Racial-Ethnic Disparities in Mental Health Care" published in Psychiatric Services in Advance.

The researchers looked at data on 6,206 people with mental illness from the 2004-2010 Medical Expenditure Panel Survey. Relative to whites, African Americans and Latinos who received outpatient mental health care in one year spent less on inpatient and emergency general medical care the following year. Latinos receiving mental health care in year 1 spent less than others on inpatient general medical care in year 2. In addition, Latinos taking psychotropic drugs in year 1 showed reductions in inpatient general medical care.

The U.S. health care system would need to provide additional care to approximately 1.3 million blacks and 1.1 million Latinos with probable mental illness to eliminate disparities, wrote the researchers. “For blacks and Latinos, the potential savings in inpatient general medical expenditure are substantial (as much as $1 billion), providing preliminary evidence of a ‘business case’ for reducing disparities in mental health care access.

For more in Psychiatric News about the effect of racial and ethnic disparities in mental health, see the article "Satcher Outlines Roadmap to Reducing Health Disparities."

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Duration of First Psychosis Found Longer in U.S. Community Settings

Patients experiencing a first-episode psychosis and treated at community based clinics had longer duration of psychosis (DUP) than has been reported for those treated at academic medical centers, according to the study “Duration of Untreated Psychosis at Community Treatment Centers in the United States,” published online in Psychiatric Services.

Researchers with the National Institute of Mental Health (NIMH) Early Treatment Program (ETP)—which is part of an NIMH initiative called Recovery After an Initial Schizophrenia Episode (RAISE)—examined DUP among persons receiving care in community mental health centers in the United States. Longer DUP has been found to be associated with poorer long-term trajectory of illness and poorer overall functioning.

Participating in the study were 404 individuals (ages 15–40) who presented for treatment for first-episode psychosis at 34 nonacademic clinics in 21 states.

The median duration of psychosis was 74 weeks, and 68 percent of patients had a DUP of greater than six months. DUP was significantly shorter for participants living in northern states compared with those from midwestern and southern states. No differences in DUP were observed for rural, suburban, or urban location or for insurance status.

The correlates of longer DUP included earlier age at first psychotic symptoms, substance use disorder, positive and general symptom severity, poorer functioning, and referral from outpatient treatment settings.

“This study reported longer DUP than studies conducted in academic settings but found similar correlates of DUP,” the researchers stated. “Reducing DUP in the United States will require examination of factors in treatment delay in local service settings and targeted strategies for closing gaps in pathways to specialty first-episode psychosis care.”

For more information, see the Psychiatric News article “Benefits Persist Decade After Early Psychosis Intervention.”

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Some Symptoms of Mild Dementia May Predict Progression to Severe Dementia, Early Death

Specific neuropsychiatric symptoms are associated with shorter survival time from mild Alzheimer’s dementia to severe dementia and/or death, according to a report appearing online in AJP in Advance titled “Neuropsychiatric Symptoms as Predictors of Progression to Severe Alzheimer’s Dementia and Death: The Cache County Dementia Progression Study.”

Constantine Lyketsos, M.D., of Johns Hopkins University School of Medicine, and colleagues used data from the Cache County Dementia Progression Study, a longitudinal study of dementia progression in incident cases of dementia, to examine the link between clinically significant neuropsychiatric symptoms in mild Alzheimer’s dementia and progression to severe dementia or death.

Three hundred thirty-five patients with incident Alzheimer’s dementia were studied. Sixty-eight (20 percent) developed severe dementia over the follow-up period.

To identify potentially predictive neuropsychiatric symptoms, the researchers used the 10-item Neuropsychiatric Inventory, a structured interview that provides a systematic assessment of the 10 neuropsychiatric symptom domains: delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/euphoria, apathy/indifference, disinhibition, irritability/lability, and aberrant motor behavior.

They found that psychosis, agitation/aggression, and any one clinically significant neuropsychiatric symptom were associated with more rapid progression to severe dementia. Psychosis, affective symptoms, agitation/aggression, mildly symptomatic neuropsychiatric symptoms, and clinically significant neuropsychiatric symptoms were associated with earlier death.

“The treatment of specific neuropsychiatric symptoms in early dementia should be examined for its potential to delay time to severe dementia or death,” researchers wrote.

For more information, see the Psychiatric News article “DICE Rolls to New Approach for Treating Dementia Symptoms.”

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FDA Approves Mobile App for Evaluating Traumatic Brain Injury

A new app will soon be available to help clinicians diagnose traumatic brain injury in as little as five minutes in almost any setting, including environments of combat.

The app, called the Defense Automated Neurobehavioral Assessment (DANA), runs on multiple mobile platforms and was recently granted U.S. Food and Drug Administration (FDA) approval. “It's like a brain thermometer,” stated Lt. Col. Chessley Atchison, a program manager for the Combat Casualty Care Research Program of the U.S. Army Medical Research and Materiel Command (USAMRMC). “And once we get it right, we’re going to put it fairly far forward in the field.”

According to the USAMRMC, DANA operates much like a video game. Service members will undergo a baseline series of on-screen exercises during which both their speed and accuracy are recorded. Those who may have had a serious head injury will then participate in a series of both cognitive efficiency tests and self-administered questionnaires. Afterward, a clinician will review the results, comparing them with the results of the baseline exercises. The combination of the app's cognitive and psychological components allows for insight into the prevalence of symptoms related to both traumatic brain injury and posttraumatic stress disorder, USAMRMC said in a press statement.

USAMRMC stated that once DANA is fully validated for battlefield use, it may be used to help assess fitness for duty. The app is currently being tested on tablet devices.

For more information on diagnosing traumatic brain injury, see the Psychiatric News article "I Can’t Think Clearly: Diagnosing Traumatic Brain Injury with DSM-5."

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Telephone Consultation Improves Care of Children's Mental Health in Primary Care, Study Finds

Pediatric primary care providers in Massachusetts reported a dramatic improvement in their ability to meet their patients' psychiatric needs because of a project to provide telephone child psychiatry consultations and specialized care coordination to primary care providers.

The Massachusetts Child Psychiatry Access Project is described in a report in Health Affairs, by John Strauss, M.D., director for special projects at Massachusetts Behavioral Health Partnership, a ValueOptions company in Boston, and Barry Sarvet, M.D., chief of child psychiatry and vice chair of the Department of Psychiatry at Baystate Health in Springfield.

Beginning as a pilot project at the University of Massachusetts, the project received legislative approval in June 2004 to be administered by the Massachusetts Behavioral Health Partnership. The project consists of six regional hubs, each with one full-time-equivalent child psychiatrist, licensed therapist, and care coordinator. Collectively, the hubs are available to over 95 percent of the children in Massachusetts. In fiscal year 2013 the Massachusetts Child Psychiatry Access Project served 10,553 children.

“Access to behavioral health care for children is essential to achieving good health care outcomes,” Strauss and Sarvet said. "Pediatric primary care providers have an essential role to play in identifying and treating behavioral health problems in children. However, they lack adequate training and resources and thus have generally been unable to meet children’s need for behavioral health care.....Telephone child psychiatry consultation programs for pediatric primary care providers, many modeled after the Massachusetts project, have spread across the United States."

The website for the Massachusetts Child Psychiatry Access Project is here. For information about a similar project in New York, see the Psychiatric News article, "New York Child Psychiatry Divisions Fill Gap in Collaborative Care Model."

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Physicians, Patients Not Getting Full Information on Antipsychotic Drugs

Elements of package inserts for second-generation antipsychotic medications aimed at both physicians and patients for use in affective illness “may belie scientific data regarding the neuropsychiatric risks of these drugs,” according to Frederick Jacobsen, M.D., M.P.H., a clinical professor of psychiatry and behavioral sciences at the George Washington University School of Medicine and Health Sciences.

This oversight has significant public health implications, given the increasingly broad prescription of these drugs for mood-related disorders and for off-label uses, wrote Jacobsen in the February issue of the American Journal of Public Health. He reviewed online package inserts for 10 second-generation antipsychotics. Advertisements for the drugs also inaccurately suggest reversibility of chronic neurotoxicty, he wrote.

“Inspection of SGA package inserts ‘Patient Counseling Information’ sections … omit tardive syndromes and other long-term neuropsychiatric side effects," Jacobsen wrote. "These surprising omissions are accompanied by a shift of responsibility for identifying or monitoring long-term neurotoxicity from physician to patient: 7 of 10 SGA package inserts included ‘Medication Guides’ (for patients) that mentioned abnormal movements as potential side effects. Three of these ‘Medication Guides’ instruct patients to ‘notify the prescribing physician if such movements are noticed.’ ”

The lack of appropriate patient counseling may be tied to the brevity of clinical trials (6 to 12 weeks) used for FDA approval compared to the chronic duration of clinical use.

“Patients deserve better information and education regarding the long-term side effects,” said Jacobsen. “Long-term efficacy and safety outcomes, including side effects, of SGAs in affective illness—and in off-label uses (anxiety, sleep, children, elderly, and so on)—need to be documented in meaningful long-term trials corresponding to the realities of clinical practice.”

For more in Psychiatric News on the benefits and risks of the use antipsychotic medications, see “First- and Second-Generation Antipsychotics Compared in Federal Agency Monograph.”

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House Passes Bill Aimed at Improving Psychiatric Care in the VA

APA hailed passage yesterday by the House of Representatives of legislation that would help the Veterans Health Administration (VHA) attract and retain psychiatrists and improve the agency's suicide-prevention efforts. The Clay Hunt Suicide Prevention for American Veterans (SAV) Act is named in honor of an Iraq and Afghanistan war veteran and suicide-prevention advocate who took his own life in 2011. The bill sailed through the House in December, but it stalled in the Senate after a retiring senator, Tom Coburn (R-Okla.), objected to the cost.

“Too often the men and women who serve our country do not have timely access to the mental health care they need and deserve,” said APA President Paul Summergrad, M.D. “Losing 22 veterans a day to suicide should move us all to immediate action. APA strongly supports the Clay Hunt SAV Act, which will make a real difference in the lives of many veterans by improving access to much needed mental health care.... We now ask that the Senate adopt this important legislation for our veterans.”

The bill would establish a pilot project encouraging more psychiatrists to choose a career with the VHA by offering medical school loan repayments on par with other government agencies and private organizations. Current policy makes it difficult for the VHA to compete with employers that offer employment incentives, such as medical school loan repayment. The bill would authorize the agency to recruit at least 10 psychiatrists into the loan-repayment program each year. It would also authorize a Government Accountability Office study of pay disparities affecting psychiatrists at the VA.

A summary of the bill is posted here. For more information, see the Psychiatric News article, “Push for Suicide Prevention Law Hits Senate Roadblock.”

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Rate of Nicotine Metabolism May Predict Best Way to Quit Smoking

How quickly a smoker metabolizes nicotine could determine which type of cessation strategy has the best chance of success, according to a new study that represents one of the largest pharmacogenetic analyses of tobacco dependence to date.

The study found that smokers with normal metabolism levels had better quit rates with varenicline therapy, which does not involve nicotine replacement, compared to a nicotine patch. For people with slow nicotine metabolism, the patch may be the better option.

It has been known for a while that smokers clear nicotine from their bodies at different rates, but until now it wasn’t known if this measurable trait--the nicotine metabolite ratio (NMR)--could be used to optimize treatment and improve outcomes.

The study researchers randomly assigned 1,246 smokers (662 slow metabolizers and 584 normal metabolizers) to 11 weeks of the nicotine patch and placebo pill, varenicline and placebo patch, or double placebo; all participants also received behavioral counselling.

After 11 weeks of treatment, normal metabolizers taking varenicline were about twice as likely not to smoke as those using the nicotine patch. And while slow metabolizers displayed similar effectiveness rates on varencline or the patch, they reported far fewer side effects for patch therapy.

To read more about how smoking cessation leads to improved mental health, see the Psychiatric News article "Smoking Cessation Bestows Multiple Mental Health Benefits." Also, to learn about a potential new adaptive cessation strategy, see the American Journal of Psychiatry study "Combination Treatment With Varenicline and Bupropion in an Adaptive Smoking Cessation Paradigm."

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Family-Based Interpersonal Therapy Found Effective for Child Depression

Family-based interpersonal psychotherapy appears to be an effective treatment for preadolescent depression and proved superior to child-centered therapy, according to a report published online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Researchers from the University of Pittsburgh School of Medicine and Columbia University College of Physicians and Surgeons/New York State Psychiatric Institute (NYSPI) randomly assigned 42 preadolescents with depression family-based interpersonal psychotherapy (FB-IPT) or to child-centered therapy (CCT). Depressive symptoms in children were measured by the Children’s Depression Rating Scale, Revised, and the Mood Feeling Questionnaire, Child and Parent Versions.

Preadolescents receiving FB-IPT had higher rates of remission (66.0 percent vs. 31 percent), a greater decrease in depressive symptoms from pre- to post-treatment, and lower depressive symptoms at post-treatment than did preadolescents with depression receiving CCT. Children receiving FB-IPT also reported significant reductions in anxiety and interpersonal impairment than did preadolescents in the CCT condition. There was a significant indirect effect for decreased social impairment accounting for the association between the FB-IPT and preadolescents’ post-treatment depressive symptoms.

“These findings provide strong support for FB-IPT as an effective treatment for preadolescent depression with medium to larger effect sizes,” the researchers stated. “There was a significant indirect effect for decreased social impairment mediating the association between the FB-IPT and preadolescents’ post-treatment depressive symptoms. This may suggest that reducing social impairment is one mechanism by which FB-IPT may decrease preadolescents’ depressive symptoms.”

For related news, see the Psychiatric News article "Family Intervention Benefits Children of Depressed Parents."

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Better Screening, Treatment Access Needed for Teens With Major Depression

About 60% of teenagers with DSM-IV major depressive disorder (MDD) receive treatment, but only 35% were treated by a mental health professional, according to a nationally representative survey of 10,123 adolescents.

Lifetime prevalence of MDD was 11% among that sample, and 12-month prevalence was 7.5%, said Shelli Avenevoli, Ph.D., of the Division of Translational Research at the National Institute of Mental Health and colleagues in the January Journal of the American Academy of Child and Adolescent Psychiatry.

Age and gender influenced prevalence, they said. Severe MDD was more common among older adolescents, and girls had two to three times the risk of MDD and four times the risk of severe depression than boys. Almost 30% of those with MDD reported suicidality, and 10.8% said they had made a suicide attempt. Significant levels of impairment and comorbid psychiatric disorders were present as well.

"[However,] the majority of depressed adolescents did not receive treatment specifically for their depression or from the mental health sector for any emotional or behavioral problem," Avenevoli and colleagues found. "These findings underscore the ubiquitous nature of this disorder in youth, suggest that a significant portion of depressive disorders have their first onset in adolescence, and support the notion of routine and universal screening during adolescence.”


To read more about treatment of adolescent depression, see the Psychiatric News article “Teens With Depression Benefit From Collaborative Care Model.” Also see the report "Increase in Untreated Cases of Psychiatric Disorders During the Transition to Adulthood" published January 2 in Psychiatric Services in Advance.

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PTSD Increases Risk for Type 2 Diabetes in Women

Women with the highest number of posttraumatic stress disorder (PTSD) symptoms may have a two-fold increased risk of developing type 2 diabetes than women without PTSD, according to a study published today in JAMA Psychiatry.

Researchers from Harvard School of Public Health and Mailman School of Public Health at Columbia University analyzed data from a 22-year longitudinal study with nearly 50,000 women subjects—between ages 24 and 42 at study enrollment—to examine whether an association exists between PTSD and the incidence of type 2 diabetes in civilian women.

The analysis showed that PTSD symptoms were associated with the development of type 2 diabetes in a “dose-response” fashion—the greater the number and severity of PTSD symptoms, the greater a woman’s risk of developing type 2 diabetes. Of the approximately 2,000 women who reported the highest number of PTSD symptoms (six to seven symptoms) in any given year of the study, 12 percent of them developed type 2 diabetes, whereas less than 7 percent of the women who reported no trauma exposure had type 2 diabetes. Results also showed that antidepressant use and elevated body mass index associated with PTSD accounted for nearly half—34 percent and 14 percent, respectively—of the increased risk of type 2 diabetes in participants with PTSD. Smoking, diet quality, alcohol intake, and physical activity did not increase risk for type 2 diabetes in women with PTSD, according to the study.

Lead author Andrea Roberts, Ph.D., a research associate in behavioral science at Harvard School of Public Health, stated that “women with PTSD and the health professionals who care for them should be aware that these women are at greater risk for diabetes. As fewer than half of Americans with PTSD receive treatment, our study adds urgency to the effort to improve access to mental health care to address factors that [could potentially] contribute to diabetes and other chronic diseases." 

To read more about psychosomatic risks related to PTSD, see the Psychiatric News article “APA Calls for Better Training to Treat Chronic Pain, Addiction Among Vets.” 

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Treatment-Resistant Bipolar Disorder Responds Better to ECT Than Medication, Study Finds

Electroconvulsive therapy (ECT) for treatment-resistant bipolar disorder appears to be more effective than an algorithm-based pharmacologic treatment in terms of symptom improvement, says the report “Treatment-Resistant Bipolar Depression: A Randomized Controlled Trial of Electroconvulsive Therapy Versus Algorithm-Based Pharmacological Treatment” in the January American Journal of Psychiatry.

But remission rates did not differ between the two groups and remained modest regardless of treatment choice for this challenging clinical condition.

Norwegian researchers randomly assigned 73 bipolar disorder patients with treatment-resistant depression to receive either ECT or pharmacological treatment. ECT included three sessions per week for up to six weeks, right unilateral placement of stimulus electrodes, and brief pulse stimulation. The pharmacologic treatment was based on an algorithm published in 2007 by Jamison and Goodwin. Patients who had experienced no effect or intolerable side effects while taking one of the medications listed in the algorithm could be switched to the next treatment option according to the algorithm.

ECT treatment was significantly more effective than the pharmacological treatment. The mean scores at the end of the treatment period were lower for the ECT group by 6.6 points on the Montgomery-Åsberg Depression Rating Scale, 9.4 points on the Inventory of Depressive Symptomatology–Clinician-Rated, and 0.7 points on the Clinical Global Impression for Bipolar Disorder. The remission rate, however, did not differ between the groups (34.8 percent versus 30.0 percent).

In an editorial accompanying, Mauricio Tohen, M.D., Dr.P.H., and Christopher Abbott, M.D., M.S., noted that a possible limitation of the study is whether the patients truly represent treatment-resistance; additionally, they said, the duration of each pharmacologic treatment is not provided. “In spite of the above limitations, this report adds major value to the evidence-based data on the use of ECT as a treatment option for bipolar depression,” they said.

For more research on the use of ECT in depressive disorders, see the Psychiatric News article, “Ketamine Outperforms ECT in Depression Study.”

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Danish Researchers Offer Explanation for Increase in ASD Diagnoses

While changes in how autism spectrum disorder (ASD) are classified are widely believed to contribute to the recent surge in ASD diagnoses, no study has yet attempted to quantify that contribution. A new study coming out of Denmark, published today in JAMA Pediatrics, suggests that reporting practices play a sizeable role, accounting for 60 percent of the observed rise in ASD over the past couple of decades.

Making use of the robust data in their national health registries, the Danish researchers analyzed the prevalence of autism among all children born in the country from 1980 to 1991. This encompasses a period right before two significant changes in physician reporting: the switch to the 10th revision of the International Statistical Classification of Diseases (ICD-10) in 1994 and the inclusion of psychiatric diagnoses for outpatient admissions in 1995.

They modeled different scenarios based on reported diagnoses before, during, and after these changes and concluded that these two changes explained 60 percent of the observed rise in ASD; ICD-10 revisions alone explained about 33 percent of the rise, while the outpatient effect explained 42 percent.

The authors also found that the ICD-10 changes had a much larger effect on ASD diagnoses in males compared with females, whereas outpatient effect did not show large gender differences.

To learn more about some recent autism prevalence data, see the Psychiatric News article “Prevalence Rate of Autism Continues Steady Rise.”

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Patients With First-Episode Schizophrenia Disorders Show Greater Body Fat, Cardiovascular Risk, Study Finds

The duration of psychiatric illness and treatment for patients after first-episode schizophrenia spectrum disorders (FES) appears to be associated with weight gain and having other cardiometabolic abnormalities, according to a study published in JAMA Psychiatry.

Christoph Correll, M.D., a professor of psychiatry and molecular medicine at the Zucker Hillside Hospital in New York, and colleagues studied approximately 400 patients with FES to assess potential cardiometabolic risk and its relationship to illness duration and treatment with antipsychotics. The mean age of the patients was 23.6.

Data showed that when evaluated after experiencing FES, nearly 50% were obese or overweight, 40% had prehypertension, 10% had hypertension, and 13.2% had some form of metabolic syndrome. Longer psychiatric illness duration correlated significantly with higher body mass index, fat percentage, and waist circumference. Treatment with antipsychotic medications, such as olanzapine and quetiapine, was associated with higher triglyceride levels in the blood.

The researchers concluded that “in patients with FES, cardiometabolic risk factors and abnormalities are present early in the illness and likely related to the underlying illness, unhealthy lifestyle, and [use of] antipsychotic medications, which interact with each other. Prevention of and early interventions for psychiatric illness and treatment with lower-risk agents, routine antipsychotic adverse effect monitoring, and smoking-cessation interventions are needed from the earliest illness phases.”

To read more about research into cardiovascular risk associated with psychiatric illness and use of psychotropic medications, see the Psychiatric News articles, "Depression Should Be Listed as Heart Disease Risk, Says AHA Panel" and FDA Responds to AJP Manuscript on Citalopram Safety." For more on this topic, see the study "State Partnerships for First-Episode Psychosis Services" published today in Psychiatric Services in Advance.

(Photo Courtesy of Zucker Hillside Hospital)