Attention-Bias Modification May Benefit Adolescents With MDD

Adolescents with major depressive disorder who performed a computer-based task designed to shift their attention from negative to positive stimuli over the course of several weeks showed greater reductions in self-reported depressive and anxious symptoms 12 months later than those attending equally to neutral and sad stimuli, according to a study appearing in the March issue of the Journal of the American Academy of Child & Adolescent Psychiatry. The findings suggest that this technique, known as attention-bias modification (ABM), may offer a potential treatment tool for treating youth with mild to moderate depression.

Adults and adolescents with depression, as well as adolescents at risk for MDD, often show a biased attention to sad-related negative stimuli and an absence of biases toward positive stimuli. During ABM treatment, participants are exposed to pairs of words that differ in emotional valence for a short period, followed by a probe that is more frequently presented in the location of the neutral stimuli than the negative ones. Several studies have found that ABM decreases depressive symptoms in adults, but little is known of whether such findings extend to youth with depression.

Researchers in China randomly assigned 45 youth with MDD in grades 7 to 12 who were not receiving psychotherapy and/or pharmacotherapy to an active ABM intervention or placebo ABM training. Participants in the active ABM group first completed eight 20-minute ABM sessions over two weeks designed to shift participants’ attention away from sad words to neutral words. At a nine-week follow-up, participants completed four 30-minute ABM sessions over two weeks that were designed to shift attention to positive words. The participants in the placebo group performed the same number of ABM sessions, but attention was directed toward neutral and sad words equally often. Attentional biases and depressive symptoms were assessed before and after each training period, and depressive symptoms were reassessed at eight- and 12-month follow-ups.

The authors found that adolescents in the active ABM group showed larger reductions in both negative attention bias and clinician-rated depressive symptoms and higher remission rates after the initial two-week intervention compared with adolescents performing the same task but attending equally to neutral and sad words. Greater reductions in self-reported depressive and anxious symptoms at a 12-month follow-up were also found in adolescents who completed the active ABM task.

“Our findings are consistent with a growing body of literature demonstrating that modifying cognitive biases directly through computerized tasks can be beneficial for psychopathology in youth with depressive symptoms and anxiety,” the authors wrote. “More generally, results support cognitive conceptualizations of depression proposing that negative biases in attention may be causally related to the maintenance of depressive symptoms.”

For related information, see the Psychiatric News article “Attention-Control Training Reduces PTSD Symptoms.”

(Image: iStock/Rasica)

Young Transgender Children With Family Support Show No Rise in Depression

Young children who identify as transgender and are supported by their families are no more likely to have symptoms of depression and only marginally elevated levels of anxiety than nontransgender children in the same age range, said researchers from the University of Washington.

“These data suggest at least the possibility that being transgender is not synonymous with, nor the direct result of, psychopathology in childhood,” wrote Kristina Olson, Ph.D., an associate professor of psychology at the University of Washington in Seattle, and colleagues, in an article published online today in the March Pediatrics.

The researchers used a community-based sample of 73 prepubescent children aged 3 to 12 “who persistently, insistently, and consistently identify as the gender identity that is the ‘opposite’ of their natal sex.” These children were socially transitioned—using the names, personal pronouns, hair length, and clothing associated with their affirmed gender. Social transition is a reversible, nonmedical intervention. About 70 percent were non-Hispanic white children, and 85 percent came from families with incomes above $75,000.

Depression and anxiety symptoms were reported by the parents. Transgender children’s symptoms of depression were not greater than those of the population average. Anxiety symptoms were slightly above national averages but still lower than preclinical or clinical thresholds.

“[T]his finding is crucially important to professionals who work with these children, as well as their families, in showing us that they are not likely to suffer any additional harm and may benefit from early social transition,” wrote pediatrician Ilana Sherer, M.D., of the Palo Alto Medical Foundation in Dublin, Calif., in an accompanying commentary.

For more in Psychiatric News about transgender youth, see “SAMHSA Report Calls for End to‘Conversion’ Therapy for Youth.”

(Image: istock/PeopleImages)

Study Suggests People With Psychiatric Illness Tend to Partner With Each Other

Understanding how psychiatric illness is transmitted across families and generations holds tremendous importance for both identifying and treating people who may develop a mental disorder, while also helping to understand the evolutionary trajectory of mental illness. A study published yesterday in JAMA Psychiatry has offered a clue in this regard, suggesting that people with psychiatric conditions are more likely to pair up with others who have psychiatric conditions.

Researchers from Karolinska Institutet in Sweden and the University of Carolina at Chapel Hill relied on population registers from Sweden to determine the nature and extent of nonrandom mating within and across psychiatric conditions, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, schizophrenia, bipolar disorder, major depression, generalized anxiety disorder, substance abuse, and more.

For the purposes of comparison, cases of select nonpsychiatric conditions of similar incidence and age at onset were also identified, including Crohn’s disease, type 1 and type 2 diabetes mellitus, multiple sclerosis, and rheumatoid arthritis. Mating relationships were identified through marriage records or records of individuals being the biological parent of a child in other registers.

On average, an individual’s psychiatric disorder was associated with a twofold to threefold increase in the likelihood that his or her mate would also have a psychiatric disorder, with slightly higher odds that it would be the same disorder. These risks were elevated in autism, ADHD, and schizophrenia. This trend was not seen in the nonpsychiatric disorders, with the exception of multiple sclerosis (but even this was a moderate effect compared to many psychiatric similarities).

“This phenomenon may hold important implications for how we understand the familial transmission of these conditions and the ubiquity of comorbidity and complex symptoms in clinical populations,” the study authors wrote. “Furthermore, the results challenge a fundamental assumption of current genetic research methods, suggesting that more attention to this issue is warranted.”

In a related editorial, Robert Plomin, Ph.D., of King’s College London and colleagues wrote, “Beyond genetics and genomics, assortative mating matters because it means that the person closest to an individual with a psychiatric disorder is also likely to have psychiatric problems, which could exacerbate problems for both spouses and their offspring.”

For more about the importance and implications of the heritability of psychiatric disorders, see the Psychiatric News article “Familial Mental Illness Risk Cuts Across Disorders.

Benefits of Taking Antidepressants During Pregnancy Outweigh Risks, Expert Says

As conflicting studies about the risk of birth defects in offspring of women who use antidepressants during pregnancy continue to be published, some experts say it is important to compare the risk of exposure to the medication with the risk of exposure to untreated maternal psychiatric illness.

“Many of these studies [exploring the association between antidepressants and birth defects in offspring] have resulted in sensational headlines when there have been positive findings,” Jennifer L. Payne, M.D. (pictured above), director of the Women’s Mood Disorders Center at Johns Hopkins School of Medicine, wrote in a recent column for Psychiatric News. “However, there are a number of limitations in these studies that, when taken into account with other studies, resulted in negative findings that do not seem to make it into the headlines.”

A major limitation of studies attempting to examine the risks of in utero exposure of antidepressants, Payne noted, is that they fail to control for factors associated with the psychiatric illness. For example, diabetes, obesity, smoking, and substance use are more common in patients with a history of depression than in the general population of pregnant women.

“Studies that have not controlled for the underlying psychiatric illness and its attendant risks may find associations between antidepressants and outcomes that are not caused by exposure to the medication itself, but by the presence of other risk factors that are highly prevalent in the population of patients who take antidepressants during pregnancy,” Payne wrote, before describing several studies that suggest that the association between antidepressant and cardiac defects is likely secondary to other underlying risk factors in women with depression.

“Depression is not a benign illness for either mother or child that can be ignored and untreated during pregnancy,” Payne concluded. “When considered as a whole, the literature supports the use of antidepressants in pregnancy in appropriate cases. In most cases, the benefits of treating maternal depression outweigh the minimal and rare risks of in utero exposure to antidepressants.”

Payne’s full column is posted at “Yes or No: Prescribing Antidepressants to Pregnant Patients.”

(Photo Courtesy of Johns Hopkins School of Medicine)

DBT Better Than Usual Care in Reducing Self-Harm, Suicidal Thinking in Teens, Study Shows

A form of dialectical behavior therapy (DBT) adapted for use with adolescents appears to be superior to usual care in reducing self-harm and suicidal thinking in teenagers with repetitive self-harming behavior, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Norwegian researchers randomly assigned 77 adolescents with a history of self-harming behavior to either DBT adapted for adolescents (DBT-A) or “enhanced” usual care (EUC) for 19 weeks. (Patients in the EUC group received at least 1 session of psychodynamically oriented therapy or cognitive-behavioral therapy per week throughout the trial.)

There were no suicides during the follow-up period. EUC patients reported a mean of 22.5 episodes of self-harm in the 19 weeks of treatment and 14.8 during the subsequent follow-up year, while DBT-A patients reported an average of just 9.0 and 5.5 episodes of self-harm in the corresponding time intervals—a between-group difference that was statistically significant at both time intervals.

Additionally, DBT-A participants at 19 weeks had a significantly lower level of suicidal ideation than participants who received EUC, though the difference was no longer statistically significant at one year.

“Based on these findings, it seems reasonable to conclude that DBT-A both in the short term and in a 1-year post-treatment follow-up perspective leads to a significantly more favorable outcome with respect to reduction in the frequency of self-harm behavior,” the authors wrote. “This is clinically important since repetitive self-harm is a strong predictor of suicide and linked to a range of psychosocial problems.”

For related information, see the Psychiatric News article “Various DBT Interventions Reduce Suicide Risk.”

(iStock/Steve Debenport)

Testosterone Replacement Shows Modest Benefits for Depression and Mood

In addition to improving sexual and physical function, testosterone-replacement therapy may decrease depressive symptoms and improve mood in older men with low testosterone levels, according to a study in the New England Journal of Medicine.

A total of 790 men 65 years and older with a serum testosterone concentration of less than 275 ng per deciliter were randomly assigned to receive testosterone gel or placebo gel for 1 year. Each man participated in one or more of three trials—the Sexual Function Trial, the Physical Function Trial, and the Vitality Trial; the latter trial included assessments of fatigue, positive and negative mood symptoms (as measured by the Positive and Negative Affect Scale, or PANAS), and depression level (measured by Patient Health Questionnaire 9, or PHQ-9) after 3, 6, 9, and 12 months of treatment.

Testosterone treatment increased serum testosterone levels to the mid-normal range for men 19 to 40 years of age during the treatment period. Among participants in the Vitality Trial, there were significant differences between the testosterone and placebo group in the PANAS positive affect score (mean difference, 0.47 points), the PANAS negative affect score (mean difference, −0.49 points), and the PHQ-9 depression score (mean difference, −0.72 points). The men who received testosterone were more likely than men who received placebo to report that their energy was better at the end of the trial.

These results, combined with the findings from the other trials, “should inform decisions about testosterone treatment for men 65 years of age or older whose levels are low for no apparent reason other than age. Such decisions will also require knowing the risks of testosterone treatment, which will necessitate larger and longer trials,” the authors concluded.

For related information, see the Psychiatric News article “Discontinuing Hormone Therapy May Increase Risk of Depression in Some Women.”

(Image: Diego Cervo/Shutterstock)

Unilateral, High Dose ECT Found to Have Fewer Cognitive Side Effects Than Bilateral ECT

Twice-weekly high-dose unilateral electroconvulsive therapy (ECT) appears to be no less effective than bi-temporal ECT for depression and may be preferable because of its better cognitive side-effect profile, according to a report published today in AJP in Advance.

Researchers in Ireland and England assessed the short- and long-term effectiveness and cognitive side effects of high-dose unilateral ECT compared with bi-temporal ECT for severe depression in routine practice over six months. A total of 138 participants were randomly assigned to bi-temporal or high-dose unilateral ECT. “Seizure threshold”—the minimum charge required to induce the generalized seizure needed for therapeutic effect—was established by dose titration at the first session, and subsequent treatments were 1.5 times this threshold for bi-temporal ECT and six times this threshold for unilateral ECT.

The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HAM-D) score after the ECT course. A pre-specified range of a four-point difference was established as “non-inferior.” Secondary outcomes included response and remission rates, relapse status after six months, and cognition.

The researchers found that high-dose unilateral ECT was not inferior to bi-temporal ECT on HAM-D scores, with a mean difference of 1.08 points in favor of unilateral ECT (within the range of “non-inferiority”). There were no significant differences for response and remission or six-month relapse status. Recovery of orientation was quicker following unilateral ECT, and bi-temporal ECT was associated with a lower percent recall of autobiographical information.

“Our findings justify considering high-dose unilateral ECT as the preferred ECT option for treating depression and may help improve acceptability and availability of this effective treatment,” wrote Maria Semkovska, Ph.D., of the Department of Psychiatry at Trinity College Dublin and colleagues.

In Related News on ECT--APA Urges Your Involvement

The Food and Drug Administration (FDA) is proposing to reclassify ECT from a Class III (high risk) medical device to Class II (low risk), a change APA supports. APA urges psychiatrists to contribute their comments to the FDA in favor of the reclassification. A template letter has been prepared that provides talking points. The FDA must receive comments by March 28.

“[I]t is so important for psychiatrists to take the lead in expressing their views in regard to the role that ECT plays in clinical practice and in the treatment of major depressive disorder,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., and APA President Renée Binder, M.D., in a blog post. “For appropriate patients, ECT has been a lifesaver. It has given them an opportunity for a normal, functional life.”

For information about previous efforts to reclassify ECT, see the Psychiatric News article “FDA Advisory Panel Favors ECT in High-Risk Category.”

(Image: KonstantinChristian/Shutterstock)

Framingham Study Suggests Dementia Rates May Be Falling

Many experts predict that as people live longer, the prevalence of dementia will climb. However, a study published in the New England Journal of Medicine now suggests the incidence of dementia may be falling.

Researchers from Boston University School Medicine analyzed data from 5,205 people aged 60 and older who were participants in the Framingham Heart Study, a community-based, longitudinal cohort study that was initiated in 1948. Since 1975, the cognitive status of the original cohort has been regularly monitored via the Mini-Mental State Examination, neurological and neuropsychological examinations, and subjective memory questioning.

By using statistical models adjusted for age and sex, the researchers determined the incidence of dementia during each of four distinct time periods: from the late 1970s to early 1980s (first epoch), from the late 1980s to early 1990s (second epoch), from the late 1990s to the early 2000s (third epoch), and from the late 2000s to the early 2010s (fourth epoch). The researchers also examined the interactions between epoch and age, sex, apolipoprotein E ε4 status, and educational level.

The researchers found a progressive decline in dementia over the 30-year period, with incidence rates, relative to the first epoch, declining by 22%, 38%, and 44% during the second, third, and fourth epochs, respectively. This risk reduction was observed only among persons who had at least a high school diploma. In parallel with the trend toward a lower incidence of dementia, participants in the Framingham Heart Study also had improvements in most indicators of cardiovascular health, with the exception of a trend toward increasing prevalence of diabetes and obesity.

“Although projections suggest an exploding burden of dementia over the next four decades owing to an increasing number of older persons at risk, primary and secondary prevention might be key to diminishing the magnitude of this expected increase,” the authors wrote. “Our study offers cautious hope that some cases of dementia might be preventable or at least delayed. However, it also emphasizes our incomplete understanding of the observed temporal trend and the need for further exploration of factors that contribute to this decline in order to better understand and possibly accelerate this beneficial trend.”

For related information, see the Psychiatric News article “Cardiovascular Risk Factors May Serve as Early Indicator of Cognitive Decline.”

(Image:iStock/wildpixel)

People Who Use Marijuana May Be More Likely to Develop Other SUDs

A prospective analysis of the results of a survey of U.S. adults suggests marijuana use may be associated with an increased risk for developing alcohol and drug disorders, but not mood or anxiety disorders, according to a study published today in JAMA Psychiatry.

“Our findings suggest caution in the implementation of policies related to legalization of cannabis for recreational use, as it may lead to greater availability and acceptance of cannabis, reduced perception of risk of use, and increased risk of adverse mental health outcomes, such as substance abuse disorders,” Mark Olfson, M.D., M.P.H., of Columbia University Medical Center and colleagues wrote.

Olfson and colleagues prospectively examined the associations of cannabis use with the prevalence and incidence of mood, anxiety, and substance abuse disorders in a nationally representative sample of 34,653 U.S. adults interviewed three years apart (wave 1: 2001 to 2002; wave 2: 2004 to 2005) as part of the National Epidemiologic Survey on Alcohol and Related Conditions.

Cannabis use was assessed by asking respondents whether they had used cannabis in the 12 months preceding the interview, and psychiatric disorders were measured according to DSM-IV using the Alcohol Use Disorder and Associated Disabilities Interview Schedule. Incidence refers to disorders that were reported at wave 2 among respondents without a lifetime history of the disorder at wave 1.

Analysis of the data revealed that cannabis use in wave 1, which was reported by 1,279 respondents, was significantly associated with substance use disorders in wave 2 (odds ratio of any alcohol use disorder, cannabis use disorder, and nicotine dependence were 2.7, 9.5, and 1.7, respectively), but not any mood disorder. However, the authors noted that the study was unable to determine a causal association between cannabis use and new onset of substance use disorders.

“While the health benefits of cannabis use require further testing among patients who are unresponsive to more traditional treatments, the association of cannabis use with negative mental health outcomes, such as substance use disorders, appears strong,“ the authors concluded.

For related information, see the Psychiatric News article “NIDA Research Series to Shed Light on Opioid, Marijuana, and Tobacco Use. Also, orders for the new book Marijuana and Mental Health are now being accepted by APA Publishing.

(Image: iStock/francisblack)

New Evidence for Air Pollution as Autism Risk

An interaction between genes conferring risk for autism and the prenatal environment may be occurring near the freeways and heavily traveled streets of Los Angeles, according to Beate Ritz, M.D., Ph.D., a professor of epidemiology at the University of California, Los Angeles.

Studies of the effects of air pollution have typically tracked growth, lung function, or mortality in developing children but less often on fetuses, said Ritz on Sunday at the annual meeting of the American Association for the Advancement of Science in Washington, D.C.

So Ritz and her colleagues used data from 200 air monitors emplaced across Los Angeles according to a land use regression model they developed. This model was based on approximately 300 measurements of outdoor air pollution taken during 2006-2007 in locations across Los Angeles County. The researchers linked that information with 7,603 cases of autism among children born in Los Angeles from 1995 to 2006 and diagnosed with autism between 1998 and 2009 as recorded by the California Department of Developmental Services. The researchers compared each child in this cohort with 10 children who were born during the same period but did not have autism.

The researchers found an increased risk of autism of 9 percent for higher interquartile rates of ozone, 8 percent for particles 2.5 [mu]m or smaller, and 9 percent for nitric oxide and nitrogen dioxide exposure. Research by others has suggested that prenatal exposure to these pollutants may have adverse neuromotor or neurobehavioral effects. Ritz also observed higher rates among children of mothers with less than a high school education, a pattern opposite to that seen in clinics, where children of better educated parents present more frequently.

Although pollution levels have declined in Los Angeles in recent decades, the study suggests that heavily polluted cities like Beijing should be concerned about the connection with autism, Ritz concluded.

For more in Psychiatric News about air pollution and autism risk, see “Autism Linked to Air Pollution In Preschool Children.”

(Image: Tyler Olson/Shutterstock)

Buprenorphine-Samidorphan Combination May Reduce Symptoms in Patients With MDD

A small study investigating an adjunctive combination of drugs affecting different opioid receptors demonstrated efficacy in reducing symptoms of depression, according to a paper published today in AJP in Advance.

The study used buprenorphine (a partial µ-opioid receptor agonist that also blocks κ-opioid agonists) and samidorphan (a µ-opioid receptor antagonist), developed by Alkermes, which sponsored the clinical trial. Study participants included 142 people with major depressive disorder (MDD) who had been treated with a selective serotonin reuptake inhibitor or a serotonin-norepinephrine reuptake inhibitor but had an “inadequate response” to one or two courses of treatment.

The researchers used a two-stage sequential parallel design in which first-round placebo nonresponders were randomized to placebo or high- or low-dosage levels of the drug combination, wrote Maurizio Fava, M.D. (pictured above), a professor of psychiatry at Harvard Medical School and executive vice chair of psychiatry at Massachusetts General Hospital, and colleagues.

Significant improvements in scores on the Hamilton-Depression Rating Scale, the Montgomery-Åsberg Depression Scale, and the Clinical Global Impressions severity scale were recorded among patients taking a 2mg/2mg combination of buprenorphine/samidorphan compared with placebo after four weeks. There was also evidence of improvement in the 8mg/8mg dosage group, although this evidence did not reach statistical significance. Nausea, vomiting, and dizziness were commonly occurring side effects, and there was no evidence of opioid withdrawal or consistent signal of abuse liability, the authors reported.

“These results support the premise of the sequential parallel comparison design as a strategy to enhance signal detection in relatively smaller samples, and they are consistent with the finding that signal detection is enhanced in placebo nonresponders, as the effect size of buprenorphine/samidorphan was greater in stage 2 than in stage 1,” Fava and colleagues wrote. “These results support the hypothesis of a significant role of opioid dysregulation in major depression and the therapeutic potential of opioid modulation,” they concluded.

For more in Psychiatric News about the use of buprenorphine in treating depression, see “Low-Dose Buprenorphine Found to Decrease Suicidal Ideation, but Experts Remain Cautious.”

Adjunctive Pramipexole May Benefit Patients With Refractory Depression

An article published in the February issue of the American Journal of Psychiatry shows that pramipexole—a selective D3 receptor agonist approved for the treatment of Parkinson’s disease and restless legs syndrome—may be an effective adjunctive therapy for treatment-resistant depression.

Studies have long suggested that agents that enhance dopamine neurotransmission may be particularly useful in reducing treatment-resistant depression. A previous study comparing pramipexole with placebo in an 8-week randomized, double-blind trial with 60 outpatients with major depression for whom at least one adequate antidepressant medication trial (mean, two trials) had failed reported a modest statistically significant benefit of pramipexole (mean= 1.35 mg/day) over placebo, but neither the response rates (40% compared with 33%) nor the remission rates (27% compared with 23%) differed significantly between groups.

For the current treatment series, Jan Fawcett, M.D. (pictured above), a professor of psychiatry at the at the University of New Mexico School of Medicine, and colleagues administered pramipexole (0.25 mg to 5.0 mg/day) to 42 patients aged 25 to 84 with treatment-resistant depression for 2 weeks to 60 months. All patients took pramipexole while maintaining their treatment regimen for depression, which included selective serotonin reuptake receptor inhibitors, tricyclics, and monoamine oxidase inhibitors, as well as electroconvulsive therapy (ECT).

Overall, 76% of the patients showed a meaningful clinical response (achieving remission or a reduction of symptoms), which persisted over a 16-month follow-up period, while 24% were intolerant or nonresponsive to pramipexole. Effective pramipexole dosages ranged from 0.75 mg/day to 5.0 mg/day, with a mean effective dosage of pramipexole in responders and remitters of 2.46 mg/day. Intolerance was encountered early, often at a low dosage and usually due to nausea.

“To our knowledge, this is the first case series of adjunctive pramipexole in patients with treatment-resistant depression,” the authors wrote. They added that although the case series was not a planned study, with patients being managed and evaluated clinically without rating scales or structured interviews, the results “support the notion that pramipexole—and potentially other dopamine agonists—are of value for patients in a treatment-resistant depressive episode. Appropriate precautions, careful patient monitoring, and gradual dosage escalation are advised.”

Pramipexole has not been approved by the Food and Drug Administration for the treatment of depression.

To read more about potential therapies for depression, see the Psychiatric News article “The Ketamine Challenge: When Practice Leaps Ahead of Science.”

(Photo Courtesy of UNMSM)

APA Announces Results of 2016 National Election

APA’s Committee of Tellers has approved the following results of APA’s 2016 national election. Please note that these results are considered public, but not official until approved by the Board of Trustees at its meeting on March 19 and 20.

President-Elect
Anita S. Everett, M.D.

Treasurer
Bruce J. Schwartz, M.D.

Trustee at Large
Richard F. Summers, M.D.

Area 3 Trustee
Roger Peele, M.D.

Area 6 Trustee
Melinda L. Young, M.D.

Resident-Fellow Member Trustee-Elect
Uchenna B. Okoye, M.D., M.P.H.

Complete results of the election will be reported in the March 4 issue of Psychiatric News.

New Process Announced to Avoid EHR Penalties in 2017; Apply Now

The government has issued an update to previous rules governing the Electronic Health Records Incentive Program and is now allowing blanket “hardship” exemptions to the program so that clinicians, hospitals, and critical access hospitals can avoid penalties that would have been incurred in 2017 had they not complied with “meaningful use” requirements in 2015.

The deadline to apply for the exemption is July 1 for eligible professionals, hospitals, and critical access hospitals.

The update, which also reduces the amount of information that eligible professionals, hospitals, and critical access hospitals must submit for an exemption, is the result of the Patient Access and Medicare Protection Act (PAMPA). This law established that the secretary of Health and Human Services may consider hardship exemptions for “categories” of eligible professionals, hospitals, and critical access hospitals. Prior to this law, the Centers for Medicare and Medicaid Services (CMS) was required to review applications on a case-by-case basis. Under the group application, multiple providers and provider types may apply together using a single submission.

This is the first time that an individual may apply for the hardship exemption on behalf of a group of physicians. This individual may be the physician applicant or the individual filling out the information on behalf of a physician group (for example, a member of the group’s administrative staff). CMS will provide notice of its hardship-exception decisions—which are final and cannot be appealed—via the email address provided on the application.

Applying for the hardship will not prevent a physician from earning an incentive; it simply protects a physician from receiving a meaningful-use penalty. Therefore, physicians who believe that they met the requirements for the 2015 reporting period should still apply for the hardship protection.

The update rectifies problems related to CMS’s delayed notification of the meaningful-use rule regarding exemptions; that delay would have adversely impacted many physician practices. The final rule was released last October, which left less than 90 days for physicians to submit data for what should have been a 90-day reporting period before the end of 2015. Because of this delay, the hardship category applies to all physicians.

The new applications and instructions for a hardship exception from the Medicare Electronic Health Records Incentive Program 2017 payment adjustment are posted at the CMS website. For more information, contact APA’s Department of Practice Management and Delivery Systems at practicemanagement@psych.org.

(Image: istockphoto/DragonImages)

Adults Diagnosed With Concussion May Be at Heightened Long-Term Risk of Suicide

Adults who have been diagnosed with a concussion may be at a heightened long-term risk of suicide, reports a study published today in the Canadian Medical Association Journal. According to the authors, the findings suggest that a history of concussion may be relevant when assessing a patient's suicide risk.

Donald Redelmeier, M.D., of Sunnybrook Health Sciences Centre in Toronto and colleagues examined 235,110 records of patients in Ontario who had a concussion between 1992 and 2012. During the follow-up period, 667 suicides occurred, equivalent to 31 deaths per 100,000 patients annually—three times the population norm.

Weekend concussions (considered more likely to be caused by recreational injuries) were associated with a one-third further increased risk of suicide compared with weekday concussions (considered more likely to be caused by occupational injuries). For people with a prior suicide attempt, a psychiatric or substance use disorder, or multiple concussions, this risk was even higher; however, even individuals who met none of these criteria still had double the long-term suicide risk following a concussion.

“[C]oncussions are rarely deemed relevant for consideration by psychiatrists or other physicians when eliciting a patient’s history,” the authors wrote. “Greater attention to the long-term implications of a concussion in community settings might save lives because deaths from suicide can be prevented.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Suicide and Chronic Traumatic Encephalopathy.”

(Image: Triff/Shutterstock)

Study Finds Chronic Viral Infections May Contribute to Cognitive Decline

Some chronic viral infections such as herpes could contribute to subtle cognitive deterioration in otherwise healthy older adults, according to a study published in Alzheimer Disease and Associated Disorders.

While previous work had found an association between cognitive problems and viruses, this study offers temporal evidence to suggest infections may contribute to cognitive decline down the road.

Over a period of five years, researchers from the University of Pittsburgh School of Medicine (UPMC) and Johns Hopkins University annually assessed cognitive function (attention, memory, language, and more) in 1,000 adults 65 years and older. At study entry, nonfasting blood samples were obtained and assayed for exposure to cytomegalovirus (CMV), Herpes Simplex virus 1 and 2 (HSV-1, HSV-2), and Toxoplasma gondii (TOX).

The team found that baseline antibody levels for HSV-2 were significantly associated with baseline cognitive scores, while CMV, HSV-2, and TOX (though not HSV-1) were significantly associated with greater cognitive decline over the five-year period—independent of other age-related variables.

“This is important from a public health perspective, as these infections are very common and several options for prevention and treatment are available,” Mary Ganguli, M.D., M.P.H., a professor of psychiatry at UPMC, said in a press statement. “As we learn more about the role that infectious agents play in the brain, we might develop new prevention strategies for cognitive impairment.”

To read more about the potential role of infection in mental health, see the Psychiatric News article “Researchers Consider Infection as One Cause of Depression.”

(Image: Spectral-Design/Shutterstock)

APA Urges Members to Support Reclassification of ECT Devices

Five years after it last broached the matter, the Food and Drug Administration (FDA) is again proposing to reclassify electroconvulsive therapy (ECT) from a Class III (high risk) medical device to Class II (low risk). APA supports this change.

Opposition from anti-psychiatry groups was blamed for the FDA's maintaining the Class III status in 2011. Opponents to reclassification argued then that ECT causes memory problems, cognitive impairment, and other adverse effects. Supporters noted that current ECT practices, using anesthesia and muscle relaxants, significantly reduce those effects.

The FDA in a recent Federal Register notice acknowledged some side effects but concluded: “FDA believes that in the specified patient population, and with the application of general and special controls as described in this document, the probable benefit to health from use of the device outweighs the probable injury or illness from such use.”

APA urges psychiatrists to contribute their comments to the FDA in favor of the reclassification. A template form letter has been prepared that provides talking points. The FDA’s draft guidance on the proposed reclassification and a link to post comments can be accessed here. The FDA must receive comments by March 28.

“[I]t is so important for psychiatrists to take the lead in expressing their views in regard to the role that ECT plays in clinical practice and in the treatment of major depressive disorder,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., and APA President Renée Binder, M.D., in a blog post. “For appropriate patients, ECT has been a lifesaver. It has given them an opportunity for a normal, functional life.”

For more in Psychiatric News about the previous attempt to reclassify ECT, see “FDA Advisory Panel Favors ECT in High-Risk Category.”

Veterans With Prior Suicidal Thoughts Rate Emergency Department Intervention Highly

Veterans who received training in coping skills before leaving the emergency department (ED) following a suicide-related concern and follow-up calls weekly until they entered outpatient treatment reported that the program was helpful in preventing further suicidal behavior and fostering treatment engagement, according to a study published Monday in Psychiatric Services in Advance.

Patients discharged from EDs following suicide attempts often fail to connect with follow-up care or experience significant delays between ED discharge and outpatient treatment. The literature suggests that up to 50% of these individuals fail to seek recommended follow-up care, and among those who do seek treatment, approximately 40% discontinue treatment within three months.

In an effort to improve treatment engagement and reduce the risk of suicide attempts in veterans after their first contact with the ED, a team of researchers developed the SAFE VET intervention, a two-part intervention that teaches individuals who present in EDs coping strategies prior to leaving the ED and engages patients weekly by phone until their first outpatient treatment appointment. A previous study found SAFE VET enhanced treatment engagement. In the current study, Barbara Stanley, Ph.D., of Columbia University and colleagues asked a sample of 100 veterans who participated in SAFE VET to rate the acceptability, usefulness, and helpfulness of the intervention.

Most participants found the SAFE VET intervention to be useful in mitigating suicide risk (93%) and in increasing the likelihood of attending follow-up mental health appointments (77%). The overwhelming majority (99%) said they found the SAFE VET intervention very acceptable, reporting that they would recommend it to a friend in crisis. Participants also rated the program’s ability to assist them in identifying professional support (46%) and having “someone check in regularly” (75%) as being the most helpful components of the program.

“This intervention was designed to fill a crucial gap in the current system of care,” the study authors noted. The authors cautioned that “although the combined intervention was found to be both acceptable and helpful,” further studies are needed to assess whether the results would be the same in EDs outside the VA system.

For related information, see the Psychiatric News article “Study Points to Risk Factors Predictive of Suicide After Emergency Visit.”

(Image: Straight 8 Photography/Shutterstock)

Renaming Psychiatric Medications May Lead to Improved Patient Care, Recovery

Classifying psychiatric medications by their pharmacology and mode of neurobiological action as opposed to the clinical indication for which they were first discovered may help to improve patient care and recovery, according to an international group of psychopharmacologists.

“The current nomenclature reflects a system of classification that has not received any attention for decades,” said psychiatrist David Kupfer, M.D. (pictured left), who was the chair of the DSM-5 Task Force. “Neuroscience and the science of pharmacology have advanced enormously, but our nomenclature is a thing of the past.”

A recent Psychiatric News article describes a new international initiative under way called Neuroscience-based Nomenclature (NbN)—which aims to develop a nomenclature that reflects contemporary neuroscientific knowledge—and a proposal for an updated neuropsychopharmacological nomenclature. Kupfer is one of a 10-member task force spearheading the initiative, and APA President-elect Maria Oquendo, M.D., is a member of a North American working group of the NbN.

“Referring to drugs based on the condition that they were first discovered to address presents several problems,” Oquendo told Psychiatric News. “Most importantly, it is at odds with what happens in a clinical encounter. Many psychiatrists have likely had conversations with patients who want to know why they are being prescribed an antidepressant for anxiety or an antiepileptic for a mood disorder. It is possible that this confusion can result in problems with adherence.”

Oquendo noted that in other fields of medicine, drugs are increasingly classified according to their target receptors, enzymes, ion channels, and other biologically precise targets.

“One of the best weapons we have against stigma is to reinforce the idea that psychiatric conditions are biological in nature,” Oquendo said. “A reconsideration of nomenclature would be a powerful tool in this effort.”

Oquendo and Kupfer will present a presidential symposium on the subject at APA’s 2016 Annual Meeting in Atlanta.

For more on the proposal to replace indication-based titles for psychiatric medications with a nomenclature based on pharmacology and neurobiological action, see the full Psychiatric News article “Psychopharmacologists Seek New Nomenclature for Psychiatric Drugs.”

Study Highlights Value of Investing in Intensive, Early Care for Psychosis

Analysis of the Recovery After Initial Schizophrenia Episode (RAISE) trial has found that coordinated specialty care for young people with first-episode psychosis may be more cost-effective than typical community care, according to a study appearing today in Schizophrenia Bulletin.

An earlier report on the NIMH-funded RAISE Early Treatment Program found that patients who receive NAVIGATE, a type of coordinated specialty care, “experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school” compared with controls.

In the current study, Robert Rosenheck, M.D., a professor of psychiatry and public health at Yale University, and colleagues analyzed data from the RAISE program to compare the cost-effectiveness of the NAVIGATE (NAV) intervention package (n=223) with that of standard community care (n=181) over 2 years.

The researchers found that there were no significant differences during the 2-year follow-up period in inpatient service use, with 14% greater mental health or medical surgical days among NAV patients. However, NAV patients received 6.5 (35%) more mental health outpatient visits per 6-month period than community care patients; they also received more clinical, rehabilitation, and family treatment visits, but fewer peer support visits than those in community care. Those additional care visits, plus use of newer medications and increased training for clinicians, contributed to a 27% increase in cost over usual community care, the researchers noted.

The incremental cost-effectiveness ratio was $12,081/Quality of Life Scale (QLS-SD), with a .94 probability that NAV was more cost-effective than community care at $40,000/QLS-SD. When converted to monetized Quality Adjusted Life Years, NAV benefits exceeded costs, especially at future generic drug prices.

“[T]hese additional expenses have now been shown to be worth the investment in improving individuals’ health and functioning,” Robert Heinssen, Ph.D., director of the Division of Services and Intervention Research at NIMH, said in a press release.

For more information, see the Psychiatric News article “Psychosocial Treatments Found Effective for Early Psychosis” and the Psychiatric Services article “The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components.”

(Image: hxdbzxy/Shutterstock)