Online CBT for Insomnia May Lead to Long-Lasting Sleep Improvements

Although cognitive-behavioral therapy for insomnia (CBT-I) is recommended as a first-line treatment for patients with chronic insomnia, there are a limited number of clinicians currently trained to deliver this therapy. A study published today in JAMA Psychiatry suggests that participation in an online CBT-I program may lead to long-lasting sleep improvements for adults with chronic insomnia.

“This study provides compelling evidence that the self-guided, web-based CBT-I intervention SHUTi can effectively treat insomnia,” Lee Ritterband, Ph.D., of the University of Virginia School of Medicine and colleagues wrote. “It extends findings that internet-delivered CBT-I can meaningfully improve insomnia symptoms and sleep variables, including when insomnia is comorbid with other conditions.”

Ritterband and colleagues randomly assigned 303 adults aged 21 to 65 with chronic insomnia to either SHUTi or an online patient education (PE) program. Participants in the SHUTi group were given access to six intervention “core” assignments, with a new assignment made available seven days after the completion of the previous one, to parallel traditional weekly CBT-I sessions; the program featured personalized goal-setting, feedback, and more. Participants in the PE group were given access to non-tailored material on insomnia, including information about symptoms and behavioral strategies to improve sleep. Participants in both groups had access to the online materials for nine weeks.

Self-reported ratings of insomnia severity (as measured by the Insomnia Severity Index) and online sleep diary-derived values for sleep-onset latency and wake after sleep onset symptoms were collected at the beginning of the study, and again at nine weeks, six months, and one year.

While participants in both intervention groups experienced significant improvements in insomnia symptom severity, sleep-onset latency, wake after sleep onset, and overall sleep quality, 52.6% of the SHUTi group experienced a reduction of greater than 7 points on the ISI (responders) from baseline to nine weeks compared with only 16.9% of the PE group. At the six-month follow-up, 59.7% of the SHUTi group and 35.7% of the PE group were considered to be responders, while 69.7% of the SHUTi group and 43.0% of the PE group were deemed responders at the one-year follow-up. Adherence to the SHUTi program was also good, with 60.3% of SHUTi participants completing all six cores of the program.

“Although their study excluded individuals with medium to high suicide risk, severe depression, bipolar disorder, alcohol or drug abuse in the past year, and those with medical comorbidities that were likely to worsen insomnia, their results provide an indication that the benefits conferred by SHUTi are not diminished by the presence of either psychiatric or medical comorbidities,” Andrew Krystal, M.D., of the University of California, San Francisco, and Aric Prather, Ph.D., of Duke University School of Medicine wrote in a related editorial. “Still, a true characterization of how SHUTi performs in patients seen in clinical practice will require evaluation in a setting where less-stringent eligibility criteria are applied.”

For related information, see the Psychiatric News article “Treat Chronic Insomnia With CBT-I, Says American College of Physicians.”

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Findings Related to Auditory Hallucinations Could Lead to New Antipsychotics

A small RNA (microRNA) has been identified that may be associated with experiencing auditory hallucinations in schizophrenia, according to a report appearing today in the journal Nature Medicine.

The finding suggests that the microRNA could be a specific target for a new class of antipsychotic medications with fewer side effects.

In laboratory research using mice models, Stanislav Zakharenko, M.D., Ph.D., and colleagues at St. Jude Children’s Research Hospitals identified a microRNA (known as miR-338-3p) that regulates production of the protein D2 dopamine receptor (Drd2). In previous work, Zakharenko and colleagues linked elevated levels of Drd2 in the auditory thalamus to brain-circuit disruptions in the mutant mice. Additionally, the protein was elevated in the same brain region of individuals with schizophrenia, but not healthy adults.

In the Nature Medicine paper, the researchers reported that a decline in miR-338-3p and associated increase in Drd2 resulted in reduced signaling in the circuit that links the thalamus and auditory cortex, a brain region implicated in auditory hallucinations. Levels of miR-338-3p are also lower in the thalamus of individuals with schizophrenia compared with individuals of the same age and sex without the diagnosis.

Replenishing levels of the microRNA in the auditory thalamus of mutant mice reduced Drd2 protein and restored the circuit to normal functioning. That suggests that the microRNA could be the basis for a new class of antipsychotic medications that act in a more targeted manner with fewer side effects.

The researchers noted that levels of miR-338-3p appear to decline as normal mice age, but are liable to remain above the threshold necessary to prevent overexpression of the Drd2 protein (and the resulting disruption of the auditory circuit). In contrast, mice with the mutation appear to be at risk for dropping below that threshold.

“[W]e identified the microRNA that is a key player in disruption of that circuit [linking the thalamus and auditory cortex] and showed that depletion of the microRNA was necessary and sufficient to inhibit normal functioning of the circuit in the mouse models,” Zakharenko said in a statement on the St. Jude’s website. “A minimum level of the microRNA may be necessary to prevent excessive production of the Drd2 that disrupts the circuit.”

For related information see the Psychiatric News article “Genomic Analysis Yields Link Between Gene Networks, Schizophrenia Types.”

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Methylphenidate-CBT Combination May Improve Cognitive Functioning in Patients Following TBI

Treating patients experiencing cognitive impairments following a traumatic brain injury (TBI) with a combination of methylphenidate and a type of cognitive-behavioral therapy (CBT) known as Memory and Attention Adaptation Training (MAAT) may lead to greater improvements in attention, working memory, and episodic memory than either treatment alone, reports a study published last week in Neuropsychopharmacology.

The findings of the small clinical trial point to the potential value of combining cognitive rehabilitation and pharmacotherapy to tackle one of the most persisting and debilitating TBI-related issues.

Brenna McDonald, Psy.D., M.B.A., of Indiana University School of Medicine and colleagues randomly assigned 76 adults aged 18 to 65 who reported cognitive deficits resulting from a traumatic brain injury to one of two cognitive rehabilitation interventions: MAAT, which aims to enhance skills for self-managing and coping with cognitive failures in daily life, and Attention Builders Training (ABT), a repetitive practice intervention with no active cognitive-behavioral component. Patients in each rehabilitation group were randomly assigned to receive either placebo or methylphenidate (MPH) twice daily. All the patients in the study had experienced a TBI at least four months prior to the study enrollment.

After six weeks, patients in the MAAT/MPH group showed significantly higher performance than the ABT/MPH group on the Paced Auditory Serial Addition Test Trial 3, which measures divided attention and working memory; the MAAT/MPH group also scored higher on the episodic memory-testing Brown Location Test than both the ABT/MPH and MAAT/placebo groups.

“We demonstrated that combined treatment with a manualized cognitive rehabilitation approach and MPH resulted in modest but statistically significant improvements in cognitive functioning on measures of verbal and nonverbal learning, working memory, and divided attention in adults with persistent cognitive symptoms after TBI,” the authors wrote. “While additional research is needed to replicate these promising initial findings, the current results provide support for multimodality treatment approaches to improve cognitive functioning even months to years after TBI.”

For related information, see the Psychiatric News article “Targeted CBT May Be Best for Treating Cognitive Problems in Cancer Survivors.”

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Study Suggests Omega-3s May Not Improve Outcomes in People at High Risk of Psychosis

For years, researchers have been encouraged by evidence from a small, single-center trial that suggested omega-3 polyunsaturated fatty acids (PUFAs) might reduce the risk of onset and improve outcomes in patients at ultrahigh risk (UHR) for psychosis. The results of a multicenter study published today in JAMA Psychiatry now suggest omega-3s may be no better than placebo at preventing psychosis, reducing symptoms, or improving function in UHR patients.

“Although ω-3 PUFAs were well tolerated, they did not demonstrate an advantage over placebo in the prevention of psychosis at 6- or 12-month follow-up evaluations,” Patrick McGorry, M.D., Ph.D., of the University of Melbourne and colleagues wrote. “Secondary outcome measures of psychiatric symptoms and functioning tended to favor the placebo group.”

For the study, McGorry and colleagues recruited individuals from 10 specialized early psychosis programs in Australia, Asia, and Europe who met UHR criteria. They randomly assigned 304 people (aged 13 to 40) to take capsules containing 1.4 grams of omega-3 PUFA or placebo daily in combination with up to 20 sessions of cognitive-behavioral case management (CBCM) for six months. After the six-month intervention phase, the patients stopped taking the capsules but could continue to access CBCM as needed. Patients were allowed to take antidepressants for depression throughout the trial.

When the authors compared the rates of transition to psychosis status at six and 12 months, they found no significant difference between the groups; transition rates were 5.1% and 11.2% in the control group compared with 6.7% and 11.5% in the PUFA group. 

In a related editorial, John Kane, M.D., and Christoph Correll, M.D., of Hofstra Northwell School of Medicine in New York offer several factors to consider when interpreting the findings, including the “possibility … that this study did not show inefficacy of ω-3 PUFAs, but rather efficacy of the control condition (CBCM), which was given to both groups.”

“McGorry et al are to be congratulated on the conduct of this important replication study. … One hopes that two additional multisite studies of ω-3 PUFAs will further clarify its role in the prevention of psychosis,” they concluded.

For related information, see the Psychiatric News article “Multimodal Approach May Improve Ability to Predict Transition to Psychosis.”

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Internet-Based Cognitive-Behavioral Therapy May Help Youth With OCD

Internet-based, therapist guided cognitive-behavior therapy (ICBT) appears to be a promising low-intensity intervention for adolescents with obsessive-compulsive disorder (OCD), according to a report in the Journal of the American Academy of Adolescent and Child Psychiatry. The study found that adolescents with OCD who participated in a ICBT program experienced significant symptom improvements after 12 weeks. 

While randomized, controlled trials have demonstrated the efficacy of ICBT in adults with OCD, this study was one of the first to evaluate the effectiveness of therapist-guided ICBT for adolescents with the disorder. 

Researchers at several Swedish institutions randomly assigned 67 adolescents (aged 12 to 17) with OCD to a 12-week clinician- and parent-supported ICBT program or a waitlist condition. (Some of the participants lived more than 200 miles from the clinic, the authors noted.) Using a personal password-secured account, youth and parents in the ICBT group were invited to learn about OCD and the rationale for cognitive-behavioral interventions and perform exposure with response prevention (ERP) exercises and cognitive strategies; the intervention also offered tips on problem solving and relapse prevention.

Youth were assessed at the start of the study, after 12 weeks, and three months after ICBT. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS).

The researchers found that at posttreatment, the group receiving the intervention had significantly lower CY-BOCS total scores compared with the waitlist group. The intervention group also showed further improvement from posttreatment to three-month follow up. Average clinician support time was 17.5 minutes per patient per week. Additionally, 28 of the waitlist patients crossed over to ICBT at 12 weeks and experienced a significant improvement on the CY-BOCS.

“The per-patient clinician time spent supporting the patients was approximately a third to a fourth the time that would have been necessary in standard face-to-face CBT, suggesting that ICBT has great potential to increase the capacity of mental health services to treat more patients with the available resources,” including those who may have limited access to a clinic for in-person treatment, the authors wrote. “ICBT could be a promising first step in a stepped-care model, freeing resources for face-to-face CBT and medication as a second step for non-responders and/or more complex cases.”

For related information, see the Psychiatric News article “Online CBT-I Program May Reduce Depression, Anxiety Symptoms.”

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Dementia Prevalence in United States Falls From 2000 to 2012, Report Finds

Between 2000 and 2012, the proportion of U.S. adults 65 and older with dementia decreased significantly, from 11.6% to 8.8%, reported a study published today in JAMA Internal Medicine. Dementia rates fell even as obesity, diabetes, and hypertension—cardiovascular risk factors believed to increase dementia risk—went up.

In addition to helping experts to better estimate the future societal impact of dementia, continuing to monitor dementia trends could one day lead to a better understanding of potential protective and risk factors for cognitive decline.

While recent studies have suggested that the age-specific risk of dementia may be declining in several high-income countries, this is the first study to provide this evidence in a nationally representative population. 

Kenneth M. Langa, M.D., Ph.D., and colleagues at the University of Michigan Medical School, analyzed data from the Health and Retirement Study—a nationally representative longitudinal survey of U.S. adults (65 years or older) that collects data on health, cognition, family, employment, and wealth. The sample included about 10,500 people from the 2000 and 2012 waves of the survey, and about 4,000 participants were featured in both the 2000 and 2012 datasets.

The study revealed that as dementia rates fell from 11.6% in 2000 to 8.8% in 2012, educational attainment increased significantly, with those 65 years or older in 2012 having nearly one additional year of education compared with the 2000 cohort. More years of formal education were associated with a lower risk for dementia. 

“Our study, along with prior studies, supports the notion that ‘cognitive reserve’ resulting from early-life and lifelong education and cognitive stimulation may be a potent strategy for the primary prevention of dementia in both high- and low-income countries around the world,” wrote the study authors. “However, it should be noted that the relationships among education, brain biology, and cognitive function are complex and likely multidirectional.”

The authors also noted that while rates of cardiovascular risk factors have gone up since 2000, treatments for cardiovascular disease have improved, which may contribute to the reduced dementia incidence.

For more information, see the Psychiatric News article “Framingham Study Suggests Dementia Rates May Be Falling” and the AJP article “Computerized Cognitive Training in Older Adults With Mild Cognitive Impairment or Dementia: A Systematic Review and Meta-Analysis.”

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Hallucinations May Predict Relapse in Alzheimer's Patients When Antipsychotic Discontinued

Antipsychotic medications are used off-label to treat agitation and psychosis among patients in nursing homes with Alzheimer’s disease or dementia. However, federal regulations call for "gradual dose reductions ... in an effort to discontinue these drugs."

To help determine which patients, if any, might benefit from being kept on antipsychotic medication, researchers led by Anjali Patel, D.O., of the Division of Geriatric Psychiatry at Columbia University, and colleagues set out to identify what neuropsychiatric symptoms might predict relapse following discontinuation of an antipsychotic. The results of the study were reported today in AJP in Advance.

The researchers undertook a 16-week, open-label study of 180 patients—average age about 80, with 50 percent living in nursing homes—and 110 responded to risperidone. Of those, 43 had hallucinations at baseline, compared with 15 of 110 after 16 weeks of treatment. The 110 responders were then randomized to receive risperidone for 32 weeks, or risperidone for 16 weeks plus placebo for 16 weeks, or placebo for 32 weeks.

Using the Neuropsychiatric Inventory, the researchers found that auditory hallucinations at baseline were the only symptom associated with relapse at week 32 of the continuation trial, raising questions about whether medication should be stopped for such patients. Visual hallucinations did not predict relapse.

“[I]f patients with severe auditory hallucinations respond to treatment with antipsychotics, discontinuation should be approached with caution, and close monitoring after discontinuation is advisable,” wrote the authors. “Antipsychotic discontinuation should be considered in many patients in order to decrease morbidity and mortality due to side effects, but it is important to recognize that many patients respond well to antipsychotics without problematic side effects, and maintaining these patients on antipsychotics may be advantageous.”

For more in Psychiatric News about antipsychotic use for Alzheimer’s disease patients, see “Mortality Risk High for Dementia Patients Taking Antipsychotics.”

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U.S. Surgeon General’s Report Offers Next Steps for Tackling Drug, Alcohol Addiction

U.S. Surgeon General Vivek Murthy, M.D., M.B.A, today released a report that highlights the toll that substance misuse and related disorders are having on Americans and calls for the integration of substance use-related services in health care systems. 

“Substance use disorders affect nearly everyone in America, either directly or indirectly,” Murthy said during a conference call. “We have 20.8 million people in America with a substance use disorder—that’s around the same number of people with diabetes and 1.5 times greater than the number of people [in the U.S.] with all cancers combined. Yet only one in 10 people are getting treatment.”

One reason for this treatment gap, the report suggests, is a lack of screening for substance misuse and substance use disorders in health care settings: “While services for the prevention and treatment of substance misuse and substance use disorders have traditionally been delivered separately from other mental health and general health care services, effective integration of prevention, treatment, and recovery services across health care systems is key to addressing substance misuse and its consequences; it represents the most promising way to improve access to and quality of treatment.” 

The report continues, “Increasing the number of insured Americans and integrating substance use disorder services with mainstream health care has the power to improve outcomes for individuals, reduce overall health care costs for them and their families, reduce health disparities among high-risk groups, and reduce costs for health care systems and communities.”

In addition to highlighting successful prevention, treatment, and recovery programs, the report offers several key recommendations for reducing substance use in the future.  

“We are encouraged by the focus on the nationwide substance use epidemic and the many ways we can collectively work to address it,” said APA President Maria A. Oquendo, M.D., Ph.D. “The disease of addiction affects people from all backgrounds across our society and we have the knowledge and tools to provide effective treatment.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., added, “APA has worked extensively in collaborative efforts to improve addiction treatment and train psychiatrists and other physicians to use the best evidence-based treatments available.”

For related information, see the Psychiatric News article “Obama Proposes Raising Caps on Buprenorphine Prescribing.” 

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Take Action on Comprehensive Mental Health Reform

APA has joined with mental health and allied stakeholders in launching a coordinated grassroots effort urging Congress to pass major mental health reform legislation before it adjourns at the end of this year. Please get involved and help push mental health reform over the finish line.

• If you wish to contact your members of Congress to express support for mental health reform via Twitter, please click here.
• If you wish to contact your members of Congress to express support for mental health reform via email or phone, please click here.

Adjunctive Taurine May Reduce Psychotic Symptoms in Patients With FEP

Despite treatment with antipsychotics, people with first-episode psychosis often experience ongoing symptoms and cognitive impairments while on antipsychotics. A study published in the Journal of Clinical Psychiatry now suggests that adding the amino acid taurine daily to an antipsychotic regimen reduces psychotic but not cognitive symptoms.

Previous studies have shown that taurine—an inhibitory neuromodulatory amino acid in the central nervous system that has been shown to activate GABA and glycine receptors and inhibit N-methyl-D-aspartate receptors—reduces psychosis and leads to cognitive improvements in patients with a history of psychosis. 

To investigate the effectiveness of adjunctive taurine in improving symptomatology and cognition in patients with first-episode psychosis, an international team of researchers randomly assigned 86 patients aged 18 to 25 with first-episode psychosis to 4 g of taurine or placebo daily for 12 weeks. All participants had been taking antipsychotics for at least three months and continued to take them throughout the trial. Patients were evaluated using the Brief Psychiatric Rating Scale (BPRS) and cognitive tests at the beginning of the study and at week 12.

The researchers found that relative to placebo, taurine resulted in significant improvements in total symptomology as well as measures of positive symptoms, depression, and general functioning over 12 weeks. There was no difference in cognitive scores between the taurine and placebo groups. While the overall rates of side effects were low among both groups at week 12, the taurine group was significantly more likely to report symptoms of fatigue.

“Taurine had a statistically significant and clinically important effect on symptomatology and functioning in patients with first-episode psychosis and was found to be safe and well tolerated,” wrote the researchers. “The findings of the current study … suggest that the properties of taurine and its potential therapeutic benefits in early psychosis warrant further investigation.”

For related information, see the Psychiatric News article “Gralnick Award Lecturer Emphasizes Importance of First-Episode Treatment.”

(Olimpik/Shutterstock)

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Take Action on Comprehensive Mental Health Reform

APA has joined with mental health and allied stakeholders in launching a coordinated grassroots effort urging Congress to pass major mental health reform legislation before it adjourns at the end of this year. Please get involved and help push mental health reform over the finish line.

• If you wish to contact your members of Congress to express support for mental health reform via Twitter, please click here.
• If you wish to contact your members of Congress to express support for mental health reform via email or phone, please click here.

Smartphone App Found to Help Users Cope With Emotional Difficulties

A smartphone app that reminds users about reasons for living as well as puts distraction, relaxation, and coping tools at their fingertips may help patients at risk of self-harm to better cope with unpleasant thoughts and emotions, according to a study published today in Psychiatric Services in Advance.

To augment cognitive-behavioral therapy, clinicians advise some patients experiencing significant distress to use a “hope box”—a physical container that stores items that serve as reminders of positive life experiences, people who care, and coping and distracting strategies.

On the basis of this concept, Nigel Bush, Ph.D., of the National Center for Telehealth and Technology and colleagues created the Virtual Hope Box (VHB), which uses smartphone capabilities to enhance and personalize the physical hope box on a highly accessible medium.

To assess the impact of the VHB on coping self-efficacy and clinical outcomes, the researchers randomly assigned 118 U.S. service veterans who were in treatment and had a recent history of suicidal ideation to receive treatment as usual supplemented with the VHB app or to a control group who received treatment as usual supplemented with printed materials about coping with suicidality over a 12-week period.

The Coping Self-Efficacy Scale, Beck Scale for Suicidal Ideation, and Brief Reasons for Living Inventory were collected at baseline (before randomization), and again at three, six, and 12 weeks. Secondary measures—the Interpersonal Needs Questionnaire, Perceived Stress Scale, and Columbia-Suicide Severity Rating Scale—were collected at baseline and 12 weeks.

Patients who used the VHB showed the greatest improvements in their ability to cope with unpleasant emotions and thoughts over time compared with those in the control group, with the largest difference between the treatment groups seen at 12 weeks. In contrast, the VHB was not associated with increases in coping efficacy to enlist support from friends and family. There were no statistically significant differences between the treatment groups on the secondary outcome measures.

“Usage data from this study confirmed that the VHB was used regularly and frequently, was reported as easy to use, was found helpful and beneficial in dealing with stress and emotional difficulties, was likely to be used in the future, and would be recommended to others,” the authors wrote. “Moreover, user self-reports indicated that the VHB was used as intended—for relaxation and distraction or inspiration when feeling distressed, when emotions were overwhelming, or when they felt like hurting themselves. Clinician feedback was similarly positive.”

The authors concluded, “Military behavioral health patients experiencing distress, emotional dysregulation, or suicidal ideation are often separated from direct clinical support when they need it. Although impacts on some outcomes in this study were limited, users of the VHB nonetheless noted multiple benefits. The VHB smartphone app offers a highly portable, accessible, and discreet suite of tools for effectively increasing coping self-efficacy.”

For related information, see the Psychiatric News article “Expert Calls on Psychiatry, APA to Lead in Testing Tech Advances.”

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Take Action on Comprehensive Mental Health Reform

APA has joined with mental health and allied stakeholders in launching a coordinated grassroots effort urging Congress to pass major mental health reform legislation before it adjourns at the end of this year. Please get involved and help push mental health reform over the finish line.

• If you wish to contact your Members of Congress to express support for mental health reform via Twitter, please click here.
• If you wish to contact your Members of Congress to express support for mental health reform via e-mail or phone, please click here.

Study Suggests Social Networks Affect Post-Disaster Risk of Depression, PTSD

Disasters increase rates of mental health problems, including depression and posttraumatic stress disorder (PTSD), but few studies have examined how social structures affect mental health after a disaster. A study of survivors of a major bushfire disaster in Australia suggests that people who are depressed may be more socially connected with others who are also depressed, while PTSD is linked with fractured social networks. The findings appeared today in AJP in Advance.

“[T]hese findings highlight the need to look beyond individual effects if posttraumatic mental health is to be adequately understood. Delineating social structures after disaster and how these moderate mental health trajectories can shed light on social interventions that may facilitate adjustment after disaster,” Richard Bryant, Ph.D., of the University of New South Wales, Sydney, and colleagues wrote.

In February 2009, Australia experienced one of its most devastating disasters when severe bushfires tore through the state of Victoria, resulting in 173 fatalities and damage to over 3,500 buildings. From December 2011 to January 2013, Bryant and colleagues interviewed adults from communities affected by the fires, where they asked participants about social connections, as well as the events that took place during and since the fires. They also administered the Posttraumatic Stress Disorder Checklist–Civilian Version and the PHQ-9.

Of the 558 participants included in the analysis, the rate of probable PTSD was 15.6% (N=87), and the rate of probable depression was 38.5% (N=215).

Analysis of the social network data revealed that depression risk was higher for participants who reported fewer social connections, were connected to other depressed people, or were connected to people who had left their community. PTSD risk, on the other hand, was more closely tied to fewer people reporting a connection with the participant, or if the participant was linked to others who were themselves not interconnected. PTSD risk also increased in people who were close to a participant who had higher levels of property loss, suggesting that contact with others who have experienced trauma and social disruption may compound PTSD symptoms.

For related information, see the Psychiatric News article “Study of 9/11 Responders Continues to Unveil New Information on PTSD.”

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Take Action on Comprehensive Mental Health Reform

APA is joining forces with several other allied groups in a coordinated grassroots effort throughout this week, urging Congress to pass mental health reform before it adjourns at the end of this year.

APA members are strongly encouraged to contact their members of Congress by Twitter, email, or phone beginning on Tuesday, November 15.

Learn about the legislation and how to take action in a few quick steps at our Action Center.

Ziprasidone Augmentation for MDD Appears Safe, But Precautions Advised

Although the atypical antipsychotic ziprasidone has shown promise as an add-on therapy for patients with major depressive disorder (MDD), little is known of possible side effects from this intervention. A study in the Journal of Clinical Psychiatry now suggests that patients with MDD who take ziprasidone in combination with escitalopram may be at greater risk of weight gain, akathisia, and an increase in the QT interval compared with those taking escitalopram alone. 

The findings were based on a randomized, double-blind, placebo-controlled trial of 139 adults with MDD who were assigned to take ziprasidone (mean dose of 98 mg/d) or placebo in combination with escitalopram for eight weeks after failing to respond to escitalopram alone. As was previously reported in the American Journal of Psychiatry, ziprasidone used adjunctively with escitalopram demonstrated greater antidepressant efficacy in patients with MDD compared with adjunctive placebo. As part of this trial, the researchers regularly measured metabolic and cardiac effects, and the Barnes Akathisia Scale and Abnormal Involuntary Movement Scale were used to assess akathisia and extrapyramidal symptoms, respectively.

In a follow-up analysis, David Mischoulon, M.D., Ph.D., of Massachusetts General Hospital and colleagues reported that patients on ziprasidone treatment had a significant increase in weight compared with placebo—with the ziprasidone-treated patients averaging a weight gain of 7.7 pounds compared with 2.2 pounds in the placebo-escitalopram group. Patients taking ziprasidone experienced a greater corrected QT interval (QTc) increase (8.8 milliseconds), which the authors noted is “generally in line with the known risks of ziprasidone on the QTc.” Ziprasidone-treated patients also encountered a greater increase in global akathisia scores compared with placebo, and about one-third of the patients on the combination therapy experienced sedation.

“Our findings, in the context of the risk of QTc prolongation with ziprasidone and SSRIs, suggest that the combination of ziprasidone and SSRIs is very likely safe but should be undertaken with caution, and clinicians who administer such combinations should monitor ECGs regularly,” the authors wrote. They also advised regular monitoring of weight, extrapyramidal symptoms, and involuntary movements.

For related information, see the Psychiatric News article “Ziprasidone May Be Effective as Adjunctive Therapy for Depression.”

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APA Pledges to Work With Trump Administration to Advance Mental Health Reform

The election yesterday of Donald Trump as the next president of the United States represented not just a change in administrations but perhaps broader changes in the nation’s health care system, as well.

APA today reiterated its commitment to engage with the Trump administration in a bipartisan manner to advance psychiatry’s objectives.

“We welcome the opportunity to work with President-Elect Trump and the Republican Party on improving mental health in this country,” said APA President Maria A. Oquendo, M.D., Ph.D., in a press statement. “Mental health is a bipartisan issue that affects millions of Americans from all walks of life, and we pledge to work with President-Elect Trump’s administration to ensure these Americans get the care they need.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., agreed. He pointed to APA’s work with the current Congress as an example of its commitment to building relationships across party lines to improve access to mental health care and bring other needed reforms to the country’s mental health system.

“Our issue is one that must reach across party lines for it to be successful,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We have worked in a bipartisan manner with Rep. Tim Murphy, a Republican from Pennsylvania, who has spearheaded mental health reform in Congress for the last three years, as well as Rep. Eddie Bernice Johnson, a Democrat from Texas. We also worked with Sen. Chris Murphy, a Democrat from Connecticut, and Sen. Bill Cassidy, a Republican from Louisiana, to promote mental health reform in the Senate.”

Study Finds Link Between Cortical Amyloid, Loneliness in Older Adults With Normal Cognition

Cognitively normal older adults who have a high burden of cortical amyloid—suggestive of a risk for Alzheimer’s disease (AD)—may be more likely to report feelings of loneliness, according to a report in JAMA Psychiatry.

The findings suggest that “relatively subtle, self-reported feelings of social detachment may be among the first symptoms of brain changes due to Alzheimer’s disease prior to the stage of mild cognitive impairment,” wrote Nancy Donovan, M.D., and colleagues from Brigham and Women’s Hospital, Harvard Medical School, and Massachusetts General Hospital.

The researchers analyzed data on 79 older, cognitively normal, community-dwelling participants (average age of 76.4) from the Harvard Aging Brain Study. Specifically, they looked at the association between loneliness, as determined by the three-item UCLA Loneliness Scale, and cortical amyloid burden, measured by positron emission tomography.

Study participants were asked the following three questions: How often do you feel you lack companionship? How often do you feel left out? How often do you feel isolated from others? Each question was scored on a four-point scale: 1, never; 2, rarely; 3, sometimes; or 4, often, with higher total scores indicating greater loneliness. 

Amyloid-positive individuals were 7.5 times more likely than those in the amyloid-negative group to be classified as lonely (defined as endorsement of any of the three loneliness items as present sometimes or often); this association remained after controlling for age, sex, symptoms of depression and anxiety, social network, and more. In addition, the association of amyloid burden and loneliness was stronger in carriers of the AD genetic risk factor APOEε4 than in noncarriers, further strengthening the link between AD pathophysiology and loneliness.

“It has been increasingly clear that AD affects more than just cognition and that neuropsychiatric symptoms in cognitively healthy older adults may be prodromal symptoms of AD. … The study by Donovan et al. suggests that there is room for discovery in this area,” Paul Rosenberg, M.D., of Johns Hopkins University School of Medicine wrote in a related editorial. “They found that a feeling of loneliness—not associated with social networks—reflected a potential AD biomarker. Perhaps other emotions (fear? existential angst? dread? or more positive emotions) might reflect amyloid burden or other biomarkers of preclinical AD.”

He continued, “In the future, we may be able to develop interventions targeting these novel symptoms; based on this first report of loneliness, such interventions might well be new approaches to cognitive-behavioral therapy rather than medications.”

For related information, see the Psychiatric News article “Automated Speech Analysis May Identify People With Alzheimer’s Disease.”

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Study Suggests Few Gamers Meet Proposed Criteria for Internet Gaming Disorder

DSM-5 lists Internet gaming disorder as a potential psychiatric disorder, but notes the prevalence of the disorder is unclear and little is known of its impact on physical, social, and mental health. 

A study published Friday in AJP in Advance suggests that while Internet-based games among adults are popular, only a small proportion of gamers appear to meet the proposed criteria for Internet gaming disorder listed in DSM-5. While those who met the proposed criteria for Internet gaming disorder played video games more regularly than those who did not meet the criteria for the disorder, there were no differences between the groups in physical, social, and mental health outcomes, Andrew K. Przybylski, Ph.D., of the University of Oxford and colleagues reported.

These conclusions were drawn from an analysis of survey data responses from four cohorts totaling nearly 19,000 adults in the United States, United Kingdom, Canada, and Germany; two of the cohorts were exclusively young adults (aged 18 to 24) while the other two included adults of all ages. The surveys were designed to answer several questions, including what is the acute prevalence rate of the Internet gaming disorder and how does this prevalence compare with that for gambling disorder? 

The researchers found that between 0.3% to 1.0% of the population might qualify for an acute diagnosis of Internet gaming disorder, though about two-thirds of active gamers do not report any diagnostic symptoms. The estimated prevalence of acute gambling disorder in the same cohort was between 1.0% to 2.6%. “This provides tentative evidence that despite being a new and popular activity, Internet-based games might be less dysregulating than gambling,” the authors wrote.

The authors continued, “If one extrapolates from our data, upwards of 160 million American adults play Internet-based games, and as many as one million of these individuals might meet the proposed DSM-5 criteria for addiction to online games. This represents a large cohort of people struggling with what could be clinically dysregulated behavior. However, because we did not find evidence supporting a clear link to clinical outcomes, more evidence for clinical and behavioral effects is needed before concluding that this is a legitimate candidate for inclusion in future revisions of the DSM.”

For related information, see “Can Medications Help People With Gambling Disorder?” by Grace Hennessy, M.D., the director of the Substance Abuse Recovery Program at the Department of Veterans Affairs at New York Harbor Heath Care System.

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Neurocognitive Tests May Enhance Ability to Predict Those Most Likely to Convert to Psychosis

Neurocognitive dysfunction is a well-known feature of schizophrenia, but questions remain as to the extent changes in cognitive function might predict transition to psychosis. A study published this week in JAMA Psychiatry found that people in the clinical high-risk (CHR) period of psychosis show significant impairments across neurocognitive dimensions compared with healthy controls. Those who converted to psychosis were significantly impaired in attention/working memory and declarative memory abilities compared with those who did not, Larry Seidman, Ph.D., of Harvard Medical School and colleagues reported.

“To our knowledge, this is the largest study of neuropsychological functioning in prodromal, clinical high-risk individuals to date,” Abraham Reichenberg, Ph.D., and Josephine Mollon, M.Sc., of Icahn School of Medicine at Mount Sinai wrote in a related editorial. “The results provide a new reference point for clinicians and researchers by elucidating the profile of neurocognitive deficits associated with the prodrome as well as their potential as risk markers for conversion to clinical psychosis.” 

Seidman and colleagues compared the baseline cognitive performance of 689 CHR individuals (including 89 who later converted to psychosis) with 264 healthy controls, collected as part of the second phase of the North American Prodrome Longitudinal Study (NAPLS 2). 

They found that the CHR group performed significantly worse than healthy controls on 19 psychological tests combined and on 14 of the 19 individual neuropsychological tests. Additional analysis revealed that people in the CHR group who transitioned to psychosis performed significantly worse on attention/working memory and declarative memory tests than those who did not transition to psychosis. Time to conversion in those who transitioned to psychosis was significantly predicted by high premorbid verbal abilities and impaired declarative memory abilities, the authors reported.

“This pattern of high verbal premorbid ability and impaired memory, coupled with the unusual thought content or delusional ideas and suspiciousness or persecutory ideas, appears to be a pernicious combination predicting conversion and needs replication,” they wrote. “Neurocognitive tests used in concert with other clinical and psychobiological measures may enhance prediction of psychosis or functional outcome.”

For related information, see the Psychiatric News article “CBT for Ultra-High-Risk Patients Lowers Incidence of Psychosis” and AJP articles “An Individualized Risk Calculator for Research in Prodromal Psychosis” and “Personalized Prediction of Psychosis: External Validation of the NAPLS-2 Psychosis Risk Calculator With the EDIPPP Project.”

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Medicare Final Rule Increases Payment for Psychiatric Consultation in Collaborative Care

The Centers for Medicare and Medicaid Services (CMS) last night released a final rule on the 2017 Medicare Fee Schedule including the 2017 fee for Psychiatric Collaborative Care Management Services, with improved payment amounts over those included in the proposed rule issued in August.

The coding for these services will support payments to psychiatrists for consultative services they provide to primary care physicians in the collaborative care model. The model was developed by the late Wayne Katon, M.D., and Jürgen Unützer, M.D., M.P.H., at the AIMS Center of the University of Washington. It is the only evidence-based model of its kind and has been proven effective in more than 80 randomized, controlled trials. The AIMS Center has been an invaluable ally to APA in advocating for reimbursement coding for collaborative care.

In a weblog post, CMS Acting Administrator Andy Slavitt wrote that “these changes will result in an estimated $140 million in additional funding in 2017 to physicians and practitioners providing these services.”

Initial analysis of the rule by APA staff indicates that the Obama Administration heeded several points that APA made earlier this year in its response to the proposed rule, which led to the higher payment in the final rule. “We are grateful to the administration for acting on recommendations we provided to address what we believe was a significant undervaluing in the proposed rule of the work a psychiatrist performs in the collaborative care model,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.

In comments submitted to CMS in August, Levin noted that the CMS proposal to crosswalk the work of the psychiatric consultant to CPT code 90836 (Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service) was not appropriate and resulted in a work value that Levin said was not sustainable.

The new work value is based on a crosswalk to a level three evaluation and management service. APA staff say that while this work value is an improvement, it is difficult to know whether it will be sufficient over the long term. 

“Establishing a sustainable payment for psychiatric participation in collaborative care is vital to making this important new model of care successful,” Levin told Psychiatric News. “We look forward to continuing to work with  Congress and the administration around this important issue.”

The new code and work value should help underscore the importance of the CMS Transforming Clinical Practice Initiative (TCPI). APA is a Support and Alignment Network within this initiative and to date has trained over 800 psychiatrists in the collaborative care model. APA will begin to train primary care practitioners later this year. 

Look for more information about the fee schedule in an upcoming edition of Psychiatric News. More information about the TCPI and APA's collaborative care training for psychiatrists is posted at www.psych.org/SAN.

Cultural Formulation Interview Can Help You Identify Unique Needs of Patients

Culturally sensitive care has the potential to improve trust and communication between clinicians and patients and, in turn, promote service use. In an article published Tuesday in Psychiatric Services in Advance, Esperanza Diaz, M.D., and colleagues from the Department of Psychiatry from Yale University School of Medicine describe how the Cultural Formulation Interview (CFI) can be used to tailor more culturally responsive mental health services.

Diaz and colleagues describe several themes that emerged when 30 Spanish-speaking adults aged 18 to 70 from several Latin American countries who were receiving outpatient services at the Hispanic Clinic of the Connecticut Mental Health Center were interviewed using the 16-question CFI, which aims to elicit information about perceived cultural influences of care.

Those interviewed reported disruptions of key relationships, loss of trust, and psychosocial needs as key drivers for seeking care

“Traditionally, mental health services for minority groups have not been organized to increase trust, address stigma, mend relationships with church and family, and address psychosocial needs. The data elicited through the CFI support framing the core treatment functions to include these issues and enhance the cultural responsiveness of care,” the authors wrote. “These findings suggest that trust should be considered as a key facilitator of treatment engagement. Moreover, clinicians should explore patients’ social ties, perceived as broken, to address their restoration during the treatment. Restored trust and restored social ties then become treatment outcomes.”

They concluded, “When used routinely, the CFI can help clinicians identify unique needs and preferences by providing a better understanding of an individual within the context of his or her culture. The CFI can help identify what works for a specific group and uncover new evidence of cultural responsiveness,” the researchers wrote.

For related information, see the Psychiatric News article “Implementing Cultural Competence Means Inclusion Plus Measurement.”

Study Challenges Conventional Theories About Link Between Child Abuse, Cognitive Deficits

While adolescents and adults with a history of childhood victimization tend to be more likely to experience cognitive deficits than those without such history, a study published Monday in AJP in Advance suggests these cognitive deficits may predate the abuse.

The findings suggest that the relationship between early victimization and cognitive deficits is more complex than previously thought, and in fact cognitive deficits may be risk factors for victimization.

“The results suggest that cognitive deficits should be conceptualized as children’s individual risk factors for victimization as well as potential complicating features during treatment,” Andrea Danese, M.D., Ph.D., of King’s College London and colleagues wrote. “Interventions attempting to support and improve cognition in individuals with a history of childhood victimization can be useful to complement more commonly used interventions for emotional and behavioral disturbances in this population.”

The researchers analyzed data on more than 3,000 individuals from two large longitudinal population studies—the U.K. Environmental Risk (E-Risk) study and the New Zealand Dunedin Study—looking at the associations between collected measures of childhood violence victimization and cognitive functions in childhood, adolescence, and adulthood.

The authors found that childhood victimization between the ages of 5 and 12 was associated with cognitive deficits at age 12 and 18; however, these differences were significantly attenuated after preexisting differences in child IQ at age five or earlier and family socioeconomic status were taken into account.

Similar results were seen when the researchers examined whether childhood victimization had late-onset (“sleeper”) effects on IQ in young adulthood and midlife. The authors found that children who experienced poly-victimization (being subject to several forms of victimization) between ages 5 and 12 had lower IQ at age 18 than nonvictimized children, but these differences were significantly attenuated after preexisting differences in IQ at age 5 and family socioeconomic status were taken into account. Children exposed to maltreatment between ages 3 and 11 also had lower IQ scores than nonmaltreated children at age 38, but again these differences were significantly attenuated after controlling for indicators of preexisting cognitive functioning and family socioeconomic status.

“The results of this study confirm that children exposed to violent victimization are more likely to experience pervasive impairments in clinically relevant cognitive functions later in life,” child psychiatrist David Fassler, M.D., told Psychiatric News. “However, the authors conclude that the observed deficits can be largely explained by cognitive limitations that predated childhood victimization and by confounding genetic and environmental variables. For this reason, they appropriately caution against ‘simplistic case formulations for individuals with complex traumatic histories.’”

For related information, see the Psychiatric News article “New Study Challenges Assumptions of Child Abuse.”

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