Study Highlights Ways Clinicians Can Help Families Overcome Burden of Pediatric OCD

The challenges faced by children with obsessive-compulsive disorder (OCD) can ripple outward to negatively impact family function in myriad ways, concluded a study published online this week in the Journal of the American Academy of Child and Adolescent Psychiatry. The findings of the study point to several ways that clinicians can work with families to overcome the burden that pediatric OCD may place on them.

For the study, S. Evelyn Stewart, M.D., an associate professor of psychiatry at the University of British Columbia, and colleagues recruited children with OCD, their mothers, and their fathers from pediatric OCD programs in Boston and Vancouver, Canada. A total of 354 mothers, fathers, and affected young people were evaluated using several measures, including the OCD Family Functioning Scale—which gauges OCD-related family functioning impairment at current and worst-ever symptom time points.

The study revealed that disruptions in morning and bedtime routines presented the greatest challenges for families, which can lead to “accommodation” by family members (including ritual facilitation and enabling avoidance of triggers). Such behaviors can worsen OCD symptoms and disease severity, as well as treatment response, the authors noted. “In addition to treatment of OCD symptoms, direct coaching by the treatment team is advisable regarding sleep hygiene, management of bedtime routines, and reduction/prevention of related parental accommodation,” Stewart and colleagues wrote. 

The study also highlighted the emotional challenges that families of youth with OCD face, as youth and parents alike reported feelings of stress and anxiety, followed by frustration/anger in youth and sadness in parents. Additionally, nearly half of the mothers and one-third of the fathers interviewed reported daily occupational impairment.

“It is striking that the majority of youth, mothers, and fathers reported living with stress and anxiety either often or always, both at the time of assessment and at worst OCD severity. This has strong clinical implications, given that distress tolerance is required by family members in order to resist family accommodation,” they wrote. “Participation in family-based CBT may assist in amelioration of both family accommodation and coercive and disruptive behaviors.”

The authors concluded, “[T]hese results highlight the need for routine screening and a multi-informant approach with respect to family impacts in pediatric OCD.”

For related information, see the AJP study “A Diffusion Tensor Imaging Study in Children With ADHD, Autism Spectrum Disorder, OCD, and Matched Controls: Distinct and Non-Distinct White Matter Disruption and Dimensional Brain-Behavior Relationships.”

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Sleep Disturbance Found to Be Significantly Greater in Patients at High Risk for Psychosis

Patients at clinical high risk (CHR) for psychosis appear to experience more sleep problems than those who do not show a heightened risk for psychosis, according to a study in Psychiatry Research. The report also found that sleep disturbance was related to greater positive and negative symptoms and worse overall functioning.

The results suggest that targeting sleep disturbance in CHR individuals may provide alternative means of treating the CHR syndrome, the study authors say.

Researchers from Columbia University Medical Center and the New York State Psychiatric Institute compared sleep disturbance in 194 help-seeking patients aged 13 to 30 who met criteria for CHR with 66 matched healthy comparison participants. The group used the Structured Interview for Psychosis-Risk Syndromes (SIPS) G1 (“Sleep Disturbance”) measure to assess sleep disturbance in all participants. The seven items of G1 are 0 (absence of sleep disturbance), 1 (restless sleep), 2 (hyposomnia), 3 (daytime fatigue), 4 (sleep pattern disruption), 5 (day/night reversal), and 6 (insomnia for two days). The Global Assessment of Functioning and Global Functioning Social and Role scales were used to evaluate social, occupational, and overall functioning.

The researchers found significant differences in positive symptoms, negative symptoms, sleep disturbance (SIPS G1), and general functioning between the two groups—the former three were greater in CHR subjects and the latter lesser in CHR. While no specific sleep items predicted conversion to psychosis or social and role functioning, sleep disturbance item 4 (sleep pattern disruption) and item 5 (day/night reversal) were related to greater positive symptoms. These two specific sleep disturbances and item 3 (daytime fatigue) were also significantly related to negative symptom severity. Sleep disturbance item 4 (sleep pattern disruption) was related to worse overall functioning.

“This study confirms previous findings of sleep disturbances [in CHR patients], offers new support and specificity to these findings, and is supportive of intervention studies targeting both negative symptoms and sleep disturbances,” the researchers stated. “Intervention studies will be an important future focus.”

For related information, see the Psychiatric News article “Clinicians Need More Training on Value of Sleep, Statement Says.”

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Study Suggests ADHD Medications May Reduce Risk for Subsequent, Concurrent Depression

Previous studies suggest that depression occurs in youth with attention-deficit/hyperactivity disorder (ADHD) at a higher rate than youth without ADHD, but the effects of ADHD medication on the development of depression are unclear. A study in Biological Psychiatry now suggests that individuals taking ADHD medications may be at reduced risk for subsequent and concurrent depression.

Zheng Chang, Ph.D., of the Karolinska Institutet in Sweden, and colleagues used several population-based registers in Sweden to identify 38,752 patients with ADHD who were born between 1960 and 1998 and were living in Sweden in 2009. 

The researchers tracked the individuals from January 2006 through December 2009 to assess the association between ADHD medication (methylphenidate, amphetamine, dexamphetamine, and atomoxetine) and depression. The primary outcome was occurrence of depression between January 1, 2009, and December 31, 2009, including diagnoses from both hospital admissions and outpatient visits for depression. A total of 2,987 patients experienced depression events in 2009.

After adjusting for sociodemographic and clinical confounders, the researchers found that ADHD medication was associated with a reduced risk of depression (hazard ratio = 0.58). For each year an individual was taking ADHD medication during the study period, there was a 21% decrease in the rate of depression in 2009. In addition, the analysis showed that concomitant occurrence of depression was 36% less common during periods when patients received ADHD medications compared with periods when they did not receive medication.

“[O]ur study provided new evidence that ADHD medication does not increase the risk of later depression, but rather is associated with a reduced risk for subsequent and concurrent depression,” the researchers wrote. “Ascertaining the effect of ADHD medication on the development of depression can provide critical information to clinicians treating youths with ADHD.”

For related information, see the Psychiatric News article “Better Ways to Treat Child ADHD, New Thinking for Adults Needed.

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Adolescent Marijuana Use May Rise Following Legalization of Drug for Recreational Use

A study published today in JAMA Pediatrics has found that marijuana use increased and the perceived risks of using the drug decreased among eighth and 10th graders in Washington following the state’s legalization of the drug for recreational use in 2012. No such differences were observed in students in Colorado—which also legalized recreational marijuana use in 2012—and students in other U.S. states that had not legalized the drug. 

The findings raise questions about how the legalization of marijuana for adult recreational use might change behavior in adolescents.

For the study, Magdalena Cerdá, Dr.P.H., M.P.H., of the University of California Davis School of Medicine and colleagues analyzed survey data from 253,902 students in eighth, 10th, and 12th grades from 2010 to 2015 in U.S. schools. The authors compared changes in past-month marijuana use and perceived harmfulness of marijuana use in Washington and Colorado prior to recreational marijuana legalization (2010-2012) with post-legalization (2013-2015) and compared these findings with trends in states that did not legalize recreational marijuana use.

In Washington, marijuana use increased 2.0% and 4.1% among eighth and 10th graders, respectively, from 2010-2012 to 2013-2015 while perceived harmfulness declined by 14.2% and 16.1%. In contrast, among states that did not legalize recreational marijuana use, marijuana use decreased by 1.3% and 0.9% among eighth and 10th graders, respectively, while harmfulness decreased by 4.9% and 7.2% over the same period. These trends were significantly different from those seen in states that did not legalize marijuana. No changes were seen in marijuana use or perceived harmfulness among Washington 12th-graders or students in the three grades in Colorado.

“Although further data will be needed to definitively address the question of whether legalizing marijuana use for recreational purposes among adults influences adolescent use, and although these influences may differ across different legalization models, a cautious interpretation of the findings suggests investment in evidence-based adolescent substance use prevention programs in any additional states that may legalize recreational marijuana use,” the authors concluded. 

“Differences in overall use rates before and after changes in legal status, while important and perhaps the easiest change to monitor, are but one aspect of the marijuana use puzzle that merits study,” wrote JAMA Pediatrics Associate Editor Alain Joffe, M.D., M.P.H., of Johns Hopkins University in a related editorial. “Changes in who uses and how frequently use occurs also merit careful assessment. Data from the study by Cerdá et al suggest increases in use were limited to younger (eighth and 10th grade) compared with older (12th grade) adolescents in Washington; this is particularly worrisome, as the adverse effects of marijuana use are generally believed to be greater for younger teenagers, especially those younger than 16 years.”

For related information, see the Psychiatric News article “What You Should Know About Marijuana Use in the United States,” by Michael T. Compton, M.D., M.P.H., chair of the Department of Psychiatry at Lenox Hill Hospital in New York and a professor of psychiatry at Hofstra Northwell School of Medicine.

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MH Parity Law Successful at Reducing Quantitative Treatment Limits

The mental health parity law appears to have been effective at eliminating quantitative treatment limits (QTLs) for large insurance plans, according to a study in Psychiatric Services in Advance.

Before the  Mental Health Parity and Addiction Equity Act (MHPAEA) went into effect in 2010, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such QTLs were allowed only if they were “at parity” with medical-surgical limits. A study of claims processed by Optum, a large managed behavioral health organization, found significant differences after the law went into effect, reported Amber Thalmayer, Ph.D., and colleagues. At the time of the study, Thalmayer was affiliated with Optum; she is now at the Institute of Psychology, University of Lausanne, Lausanne, Switzerland.

Between 66 percent and 90 percent of plans in 2008-2009 had annual limits on inpatient or outpatient services, with medians of 30 days and 45 visits, said Thalmayer and colleagues. By 2011, fewer than 1 percent of carveout plans and 3 percent of carve-in plans still had limits on those services.

The researchers speculated that the potential administrative burden of matching mental health coverage with other types of medical/surgical coverage made it simpler to eliminate the treatment limits. 

Perhaps most important was the benefit to patients, wrote the researchers. “One of the most meaningful impacts of MHPAEA is improved insurance protection for needed specialty behavioral health care for children and adults with depression, bipolar disorder, or psychosis, who were most likely to reach their inpatient and outpatient limit thresholds preparity.”

The researchers also pointed out, however, that increasing access to behavioral health care means going beyond QTL changes and looking at other areas of benefit management.

For more in Psychiatric News about mental health parity, see “White House Task Force Issues Report to Improve Parity Compliance.”

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DEA Announces Update to Renewal Application Policies

Earlier this year, the Drug Enforcement Administration (DEA) announced that effective January 1, 2017, it would implement stricter renewal policies for registrants of the Controlled Substance Act of 1970. The changes included eliminating the grace period for registrants who failed to file a timely renewal application, as well as reducing the number of renewal notifications sent to registrants.

This week, the DEA reversed its decision and posted a notice that it is retaining its current policy and procedures, with one minor change, regarding registration renewals. The revised DEA post states that “starting January 1, 2017, DEA will no longer send its second renewal notification by mail. Instead, an electronic reminder to renew will be sent to the email address associated with the DEA registration.” 

The policy and procedures that remain in place are the following:

• If a renewal application is submitted in a timely manner prior to expiration, the registrant may continue operations, authorized by the registration, beyond the expiration date until final action is taken on the application.
• The DEA allows the reinstatement of an expired registration for one calendar month after the expiration date. If the registration is not renewed within that calendar month, an application for a new DEA registration will be required.
• Regardless of whether a registration is reinstated within the calendar month after expiration, federal law prohibits the handling of controlled substances or List 1 chemicals for any period of time under an expired registration.

DEA registration can be renewed on the DEA's website. To log in, registrants need to refer to information on their current renewal notice and/or registration certificate.

(Photo Courtesy of the Drug Enforcement Administration)

Most Anorexia, Bulimia Patients Achieve Long-Term Recovery, Study Suggests

While much is known of the chronic nature of anorexia nervosa and bulimia nervosa, few studies have examined the likelihood of recovery decades after presentation. A study that tracked the progress of women with anorexia and bulimia for more than 20 years now suggests that the majority of patients achieve long-term recovery. The findings were published Tuesday in the Journal of Clinical Psychiatry.

“In contrast to the extant literature characterizing eating disorders as chronic illnesses, our longitudinal data demonstrate that continued symptom improvement and meaningful recovery are possible in anorexia nervosa beyond the first decade of follow-up,” wrote Kamryn Eddy, Ph.D., of the Massachusetts General Hospital Eating Disorders Clinical and Research Program and colleagues. “For bulimia nervosa, if recovery is not observed by nine-year follow-up, it is less likely to occur in the subsequent decade.”

Eddy and colleagues recruited women with a DSM-III-R diagnosis of anorexia nervosa or bulimia nervosa from Boston-area outpatient services from 1987 to 1991. During the first wave of the study, participants were interviewed every 6 to 12 months for nine years. In the second wave, participants were re-contacted by telephone between 20 and 25 years after the start of the trial and asked to assess symptoms in the past year. Eating disorder recovery was defined as an anorexia and bulimia psychiatric status rating (PSR) score of two or less for 52 consecutive weeks.

Of the initial 246 women in the study, 176 participated in the 20- to 25-year follow-up. During the first wave, 31.4% of participants with anorexia and 68.2% with bulimia had recovered. By the second wave, 62.8% of participants with anorexia and 68.2% of those with bulimia had recovered. Approximately half of those with anorexia who had not recovered by nine years progressed to recovery at 22 years. 

“While for most patients with anorexia nervosa and bulimia nervosa, recovery is durable, we found that 10.5% of those with anorexia nervosa and 20.5% of those with bulimia nervosa who achieved recovery in the first decade had relapsed at long-term follow-up,” the authors wrote.

“The message of recovery for the majority of individuals with eating disorders is promising, but the subtext remains that one-third of patients will remain ill with an eating disorder even at long-term follow-up. Further, time to recovery even for those who do achieve it is long, and a subset of those who recover will relapse,” they wrote. “Ongoing efforts to increase effectiveness of prevention and treatment, improve early response rates, and identify individuals who are most vulnerable to a chronic course are critical.”

More information on this topic can be found in the Handbook of Assessment and Treatment of Eating Disorders from APA Publishing. APA members may purchase the book at a discount here.

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Early Decline in Social Functioning Said to Predict Long-term Outcome in Psychosis

Social functioning appears to be a useful indicator of long-term outcome in people with psychotic disorders and may be an important treatment target that could lead to improvements in other areas of functioning, according to a study in AJP in Advance.

Eva Velthorst, Ph.D., of the Icahn School of Medicine at Mount Sinai and colleagues analyzed data from the Suffolk County Mental Health Project, a 20-year prospective study of first-admission patients with psychotic disorders. They looked at social functioning and long-term outcome in 485 individuals with schizophrenia spectrum disorder (schizophrenia, schizoaffective disorder, or schizophreniform disorder), major depressive disorder with psychosis, and bipolar disorder with psychosis, as well as a control group of individuals who had never experienced psychosis.

Using statistical analysis, the researchers identified four distinct trajectories over the 20-year period among the individuals with psychosis: preserved functioning (n=82), moderately impaired functioning (n=148), severely impaired functioning (n=181), and profoundly impaired functioning (n=74).

The trajectories of profoundly and severely impaired social functioning were associated with worse 20-year real-life functional outcomes in a variety of domains, such as not having obtained a high school diploma, being unemployed, not living independently, and using public assistance.

The researchers also found that differences in the level of social functioning were already evident in childhood. The years between early adolescence and first hospitalization appear to be a period in which a substantial number of individuals who later developed a psychotic disorder displayed a steep decline in social functioning.

The researchers stated, “[O]ur findings are consistent with recent programs of research focused on adolescence as the critical intervention window and support current early intervention strategies for high-risk individuals and those that offer intensive treatment to first-admission patients aimed to prevent social withdrawal in severe psychotic illnesses.”

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FDA to Remove, Update Boxed Warnings on Mental Health Side Effects of Chantix, Zyban

The Food and Drug Administration (FDA) announced Friday that it will remove the boxed warning related to serious mental health side effects from the smoking cessation medication Chantix (varenicline). The language describing the serious mental health side effects seen in patients quitting smoking will also be removed from the boxed warning in the Zyban (bupropion) label. (Because the active ingredient in Zyban is in the antidepressant class, the label carries the class boxed warning for suicidality and antidepressants. This language will remain in a boxed warning for Zyban and other bupropion products.) The announcement was made after a large clinical trial found such risks were lower than previously suspected.

The FDA previously requested that the manufacturers of Chantix and Zyban conduct a clinical trial to evaluate the neuropsychiatric safety of the medications in patients without and with a history of psychiatric disorders. The trial enrolled over 8,000 patients in 16 countries who took Chantix (1 mg twice daily), Zyban (150 mg twice daily), nicotine replacement therapy (NRT), or placebo for 12 weeks, followed by a non-treatment phase of 12 weeks. 

Clinically significant neuropsychiatric adverse events occurred at a similar frequency across treatment arms in patients without psychiatric diagnoses (3.1% to 3.5% in the treatment groups versus 4.1% in placebo group). There was a higher incidence of neuropsychiatric adverse events in patients with psychiatric diagnoses who took Chantix and Zyban (11.8% to 12.2% versus 9.5%). The results of the trial also confirmed that Chantix and Zyban were superior to placebo in promoting smoking abstinence regardless of a person’s mental health history.

“The risk of these mental health side effects is still present, especially in those currently being treated for mental illnesses such as depression, anxiety disorders, or schizophrenia, or who have been treated for mental illnesses in the past,” the FDA announced. “However, most people who had these side effects did not have serious consequences such as hospitalization.” Therefore, the FDA believes that this trial confirms that the benefits of taking these drugs for smoking cessation outweigh the risk of neuropsychiatric adverse events.

Still, the agency cautioned that patients taking Chantix or Zyban should stop taking the medication if they notice significant side effects while on the medication. Patients and health care professionals are encouraged to report side effects involving Chantix, Zyban, or other medications to the FDA MedWatch program. 

For related information, see the Psychiatric News article “Large Population Study Does Not Link Varenicline With Suicide, Psychosis, or Traffic Incidents.”

Abortion Does Not Lead to Long-Term Mental Health Problems, Study Suggests

A study that tracked the long-term mental health outcomes of women who obtained or were denied abortions has concluded that abortion does not increase a woman’s risk of mental health problems five years later. In fact, as was reported this week in JAMA Psychiatry, women who had obtained an abortion demonstrated more positive outcomes initially compared with women who were denied an abortion.

“There is a considerable amount of misinformation about negative mental health consequences as a result of abortion,” said former APA President Nada Stotland, M.D., who was not involved with the study. Stotland is an expert in reproductive psychiatry. “It’s important that we, as mental health professionals, have and provide evidence-based information to patients so that they may make their own decisions … without being influenced by inaccurate information,” she told Psychiatric News. 

For the study, M. Antonia Biggs, Ph.D., of the University of California, San Francisco, and colleagues recruited women aged 15 and older from 30 abortion clinics in 21 states throughout the United States. A total of 956 women were interviewed one week after seeking an abortion, and then every six months for five years. The researchers compared the mental health trajectories of women who received and were denied an abortion (due to the pregnancy being beyond the gestational limits of the facility). The group of women turned away from abortion was further divided into those who gave birth and those who miscarried or later had an abortion elsewhere.

The researchers found that women who were denied an abortion, particularly those who later miscarried or had an abortion elsewhere, had the most elevated levels of anxiety and lowest self-esteem and life satisfaction one week after being denied an abortion. These differences quickly improved and approached levels similar to those in the other groups by 6 to 12 months. 

“Our findings add to the body of evidence rejecting the notion that abortion increases women’s risk of experiencing adverse psychological outcomes,” Biggs and colleagues wrote. “Thus, there is no evidence to justify laws that require women seeking abortion to be forewarned about negative psychological responses.”  

“It’s time for mental health professionals and for our professional organizations to be more active advocates for this important issue,” Stotland said.

For related information, read APA's Position Statement on Abortion and Women’s Reproductive Health Care Rights. 

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APA Sponsors Hill Briefing on Steps to Stop 'Nationwide Tragedy of Suicide'

“Suicide is like a bomb that goes off, killing one person but injuring everyone in range,” Kirk Brower, M.D., a professor of psychiatry at the University of Michigan, told Congressional staffers at an APA-sponsored briefing yesterday on Capitol Hill.

Brower knows the subject intimately. His brother died by suicide when both were in their teens. He recounted living in the years since then with a varying mixture of guilt, anger, relief, and fear—the collateral damage of a single suicide.

The ongoing nationwide tragedy of suicide takes the lives of 44,000 Americans a year and knows no geographic, demographic, or cultural bounds, APA President Maria A. Oquendo, M.D., Ph.D., told the 100 or so people in attendance.

In fact, suicide claimed more American lives in 2015 than war, homicide, and natural disasters, added Christine Moutier, M.D., chief medical officer of the American Foundation for Suicide Prevention.

Not all suicidal behavior is the same, and different types may have different symptomatic or neurobiological signatures, said Oquendo. Further research could help could tease out subtypes, explore heritable factors, and develop better screening tools. However, she noted, “One of the most surprising things about research budgets is that the research funding is not in line with morbidity and mortality.”

J. John Mann, M.D., a professor of translational neuroscience in psychiatry and radiology at Columbia University, has devoted much of his career researching suicide. He noted that 95 percent of suicides occur among people with some psychiatric illness, often depression and often untreated. Mann has conducted imaging studies showing how the structure and function of the brains of people who commit or attempt suicide differs from those of controls. The difference was expressed in their decision-making capacity—a trait that could be tested for and monitored as a preventive measure.

In addition to higher research budgets, improved access to mental health care—like that embodied in the 21st Century Cures Act, signed into law the day before by President Barak Obama—could help chip away at the ongoing tragedy of suicide, concluded Oquendo.

For more in Psychiatric News about suicide prevention, see Group Unveils Strategy for Reducing Suicide Rate 20 Percent by 2025.

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Adolescent Depression May Be Predicted by Irritability, Anxiety, and Adversity

Irritability and fear/anxiety appear to be prominent clinical antecedents of new-onset major depressive disorder (MDD) among adolescents in at-risk families, according to a report by researchers in the United Kingdom. Moreover, economic disadvantage and recent psychosocial adversity were also found to play a significant role in the development of new-onset MDD in adolescents.

The results, published online in JAMA Psychiatry, suggest that prevention and early intervention strategies may need to not only target clinical features in high-risk children but also incorporate public health and community strategies to help overcome social risks, especially poverty and psychosocial adversity.

The researchers conducted a four-year longitudinal study (April 2007 to March 2011) of offspring of depressed parents in the general community. The participants included 337 families in whom the index parent (315 mothers and 22 fathers) had experienced at least two episodes of MDD and among whom there was a biologically related child in the age range of 9 to 17 years living with the index parent at baseline.

The severity of parental MDD and familial loading for MDD in other family members were used to index the degree of offspring familial risk. Standardized questionnaires and scales were used to assess mood, anxiety, fear, irritability, and disruptive behavior among the youth at baseline. A measure of psychosocial adversity was derived by asking participants about stressful life events occurring within the past 12 months. Sample items included the death of a close friend, serious illness, being bullied, and increased quarreling between parents. Furthermore, low parent-reported household income was considered a measure of economic disadvantage and was defined as a gross income of £20,000 ($24,368) or less.

Twenty adolescents (6 males and 14 females) had new-onset MDD, with a mean age at onset of 14.4 years. Irritability and fear and/or anxiety were significant independent clinical antecedents of new adolescent-onset MDD. All the measured familial/genetic and social risk indicators directly influenced risk for new-onset MDD.

“Family-based programs may be indicated in children at high familial risk of depression because parental depression is associated with social adversity (poverty and stress exposure) and moderates the effectiveness of preventive programs focusing on the child,” the authors wrote. 

For related information, see the Psychiatric News column “‘Typical or Troubled’: Early Intervention Program With Proven Effectiveness,” by then APA President Renée Binder, M.D.

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APA Applauds Signing of Mental Health Reform Law

President Barack Obama today signed the wide-ranging $6 billion 21st Century Cures Act into law, a week after it passed by overwhelming margins in both the House of Representatives and Senate. The law includes significant mental health components.

The president thanked Democrats and Republicans who had worked together on the legislation.

“I’m confident it will lead to better years and better lives for millions of Americans,” said Obama at the White House signing ceremony. “I hope in the years ahead, Congress keeps working together in a bipartisan fashion to move us forward and not backward in the health of our people.”

Among other provisions, the law will increase coordination among federal agencies responsible for treating mental illness by establishing medical leadership in the Substance Abuse and Mental Health Services Administration, improving how the federal government finances and manages evidence-based mental health services, promoting workforce development and integrated care, and strengthening enforcement of parity.

“It was an honor to see the president sign this significant piece of legislation,” said APA President Maria A. Oquendo, M.D., Ph.D., who attended the ceremony. “This marks the passage of the first mental health reform bill in more than 50 years and is long overdue. We should enjoy this moment, but that does not mean our work is over.”

For more in Psychiatric News about mental health legislation, see “House Approves Comprehensive Mental Health Reform Bill.”

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Study Highlights Long-Term Use of Psychiatric Medications

About one in six adults in the United States reported taking at least one psychiatric medication in 2013, and most reported taking the medications long term, according to a research letter published today in JAMA Internal Medicine.

The findings highlight the need for more research into the effects of long-term use of the most commonly prescribed psychiatric medications.

Thomas Moore, A.B., of the Institute for Safe Medication Practices in Alexandria, Va., and Donald Mattison, M.D., of Risk Sciences International in Ottawa, Canada, used the 2013 Medical Expenditure Panel Survey to calculate the percentages of adults using antidepressants; anxiolytics, sedatives, and hypnotics; and antipsychotics. Long-term use was defined as a patient having filled three or more prescriptions in 2013 or reporting that they had started taking the drug in 2011 or earlier.

Overall, 16.7% of 242 million U.S. adults reported filling one or more prescriptions for psychiatric drugs, including 12.0% taking antidepressants; 8.3% taking anxiolytics, sedatives, and hypnotics; and 1.6% taking antipsychotics. A total of 84.3% of the psychiatric drug use reported was long term.

The authors noted that antidepressant prescribing information includes limited information about appropriate duration of treatment, while many hypnotics such as benzodiazepines have warnings related to long-term risks.

“Safe use of psychiatric drugs could be improved by increasing emphasis on prescribing these agents at the lowest effective dose and systematically reassessing the need for continued use,” the authors wrote.

The study also revealed that overall psychiatric drug use was higher in women compared with men (21.2% versus 11.9%); whites (20.8%) compared with Hispanics, blacks, and Asians (8.7%, 9.7%, and 4.8%, respectively); and older adults (25.1% among adults 60 to 85, 18.8% among adults 40 to 59, and 9.0% of adults 18 to 39).

For related information, see the Psychiatric News article “Long-Term Use of Benzodiazepines: Issues and Challenges,” by George Dawson, M.D., and the Psychiatric Services article “A Prescription for ‘Deprescribing’ in Psychiatry.

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Gastrointestinal, Pulmonary Illnesses Top List in Hospitalized Patients on Clozapine, Study Finds

When prescribing clozapine—the only antipsychotic that has been FDA-approved for treatment-resistant schizophrenia—clinicians have been required by an FDA boxed warning to closely monitor patients’ blood to reduce the risk agranulocytosis and other adverse events. However, a study published in Psychosomatics now suggests pulmonary and gastrointestinal illnesses may be the most likely reason for patients prescribed clozapine to be hospitalized.

These findings are not unexpected, wrote Robert Morgan, M.D., Ph.D. (pictured above), and colleagues from the Mayo Clinic in Minnesota, “given that clozapine-related neutropenia and myocarditis have the highest incidence within several months after first exposure and are likely to be discovered through vigilant monitoring. Discovery then allows for early clozapine discontinuation and resolution of the adverse event, potentially avoiding medical hospitalization.”

The researchers conducted a retrospective chart review of patients with schizophrenia or schizoaffective disorder who were taking clozapine and admitted to an inpatient medical unit at the Mayo Clinic for nonpsychiatric illness between January 1, 2003, and August 1, 2005. A total of 104 adults aged 18 and older were included in the analysis. They were admitted into the hospital a total of 248 times, and the mean clozapine dose prescribed at the index admission was 407.2 mg.

Pulmonary illness and gastrointestinal illness were the most common reasons for hospitalizations at 32.2% and 19.8%, respectively. The most common pulmonary diagnosis was pneumonia, accounting for 58% of pulmonary admissions. The most common reason for gastrointestinal diagnosis was hypomotility, at 61.2%. The authors noted that clozapine was discontinued due to neutropenia in two patients; there were no patients admitted for myocarditis.

Psychiatric consultation was obtained in 25% of the hospitalizations, “most frequently for ‘clozapine management,’ retitration recommendations, or possible clozapine toxicity. Clozapine dosage adjustment infrequently occurred, and complete discontinuation was rare,” they wrote.

“While these findings are not indicative of causal relationships, an increased awareness of medical problems that lead to hospitalization in patients prescribed clozapine is required among all disciplines,” the authors concluded. 

For related information, see the Psychiatric News article “Why Won’t Clinicians Use Clozapine Despite Proven Superiority?” 

(Photo Courtesy of Mayo Clinic, Rochester)

Depression Found to Be More Prevalent in Medical Students

A systematic review and meta-analysis published Tuesday in JAMA suggests that depressive symptoms may be more prevalent among medical students than others of similar age in the general population. The findings, which also revealed that a low percentage of these students seek care, point to the importance of identifying physicians at every stage of their career who are experiencing distress and helping them get the care that they may need.

For the report, Douglas Mata, M.D., M.P.H., of Harvard Medical School and colleagues analyzed 195 studies that reported on the prevalence of depression, depressive symptoms, or suicidal ideation in 129,123 medical students in 47 countries. 

According the analysis, 27.7% of students screened positive for depression—a percentage the authors noted is “higher than that reported in the general population.” A total of 11.1% reported suicidal ideation during medical school (prevalence estimates ranged from 7.4% to 24.2% depending on the screening instrument and cutoff score). Among the medical students who screened positive for depression, 15.7% reportedly sought psychiatric treatment, additional analysis revealed.

The authors outlined several limitations of the study, including the fact the analyzed data “were almost exclusively derived from self-report inventories of depressive symptoms that varied substantially in their sensitivity and specificity for diagnosing major depressive disorder.” Nonetheless, they wrote, “Combined with the finding that only 15.7% of medical students who screened positive for depression sought treatment, the high prevalence of suicidal ideation underscores the need for effective preventive efforts and increased access to care that accommodates the needs of medical students and the demands of their training.”

In September, APA President Maria A. Oquendo, M.D., Ph.D., wrote of the mental health challenges that some physicians face and the factors that may contribute to their hesitancy to seek mental health care in a Psychiatric News column. “[M]ost physicians have enormous personal strength, both emotional and intellectual ‘reserves.’ Accordingly, they often are able to compensate for the presence of psychiatric symptoms, which both makes it difficult to identify them so they can receive assistance and leads them to feel more isolated, since no one knows how they really feel,” she wrote.

In a related editorial also published Tuesday in JAMA, Stuart J. Slavin, M.D., M.Ed., of St. Louis University School of Medicine posed the following question in response to these and other findings: “What is it about the culture of medicine and of medical education that has allowed this problem to remain so long unaddressed and for studies of interventions to lag so far behind the number of studies of the nature of the problem?” 

The stigma surrounding mental illness and an environment that holds “the firm belief that more pressure, more hours, and more demands must lead to better educational outcomes” are two of several factors Slavin suggests may have led to “the delayed and until recently muted response to the long-standing problem of poor mental health of medical students.” 

Slavin concluded, “Medical schools need to step up to address the mental health crisis among medical students, and solutions cannot just come from the mental health side; the problem needs to be viewed as an environmental health issue.”

(Image: iStock/Wavebreakmedia)

Major Health Legislation Passes Final Hurdle

By a vote of 94-5, the U.S. Senate today passed the 21^st Century Cures Act, one of whose goals is to improve and reform the American mental health system. The House passed the same legislation a week ago, and it now goes to the White House for President Barack Obama’s signature

“The bipartisan passage of the 21st Century Cures Act is an example of the progress we can make when people from both parties work together to improve the health of our families, friends, and neighbors,” said the president in a statement.

The bill includes elements of legislation previously put forth by Reps. Tim Murphy (R-Pa.) and Eddie Bernice Johnson (D-Texas) in the Helping Families in Mental Health Crisis Act, as well as provisions in the Mental Health Reform Act of 2016, sponsored by Sens. Chris Murphy (D-Conn.) and Bill Cassidy (R-La.)

APA noted its approval of the Senate action.

“This long-awaited and much-needed mental health reform will help to increase access to care and improve the quality of care for people with mental health and substance use disorders, especially for the 13 million Americans living with serious mental illness,” said APA President Maria A. Oquendo, M.D., Ph.D., in a statement. “The bill will toughen enforcement of existing parity laws, helping to ensure that mental health care services are covered just like other health care services.”

These are among the legislation's provisions:

• Reauthorizing grants to support integrated care models so that mental health professionals can work more closely with primary care doctors.
• Reauthorizing grants for training programs, such as the APA Foundation’s Typical or Troubled? program, which trains school officials to identify students in need of mental health services.
• Requiring the Department of Health and Human Services to develop a plan to ensure enforcement of federal parity laws that mandate that insurers cover mental illness the same as any other disorder.
• Providing $1 billion in state grants to address the opioid epidemic.

“We look forward to working with the administration and Congress to help ensure resources are available for full implementation,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.

(Image: kropic1/shutterstock.com)

Expert Group Proposes Consensus Criteria for Determining Treatment-Resistant Schizophrenia

An international group of experts has proposed consensus criteria for determining when schizophrenia is “treatment resistant.” The criteria are described in a report appearing in AJP in Advance today.

More standardized criteria in clinical trials could aid in the development of better treatments for patients with refractory schizophrenia, according to the authors of the paper. 

The criteria were formed by the Treatment Response and Resistance in Psychosis (TRRIP) working group, an international group of more than 50 experts on schizophrenia and treatment resistance. The group performed a systematic review of definitions of treatment-resistant schizophrenia used in randomized antipsychotic clinical trials. They found wide variation in criteria that were used to define treatment resistance, particularly in the domains of symptom severity, prior treatment duration, and antipsychotic dosage thresholds; only two studies used the same criteria.

To address this variation, the working group developed “consensus criteria” specifying minimum and optimal criteria for each domain. A few of the domains and their optimal criteria for determining treatment resistance include the following: 

• Symptom severity and change: Treatment-resistant patients’ symptoms should be at least moderately severe, as defined on a standardized rating scale such as the Positive and Negative Syndrome Scale. They should experience less than 20% symptom reduction, also using a standardized rating scale, during a prospective trial or observation of six or more weeks.
• Functioning: Treatment-resistant patients should be determined to have at least moderate functional impairment, measured using a validated scale such as the Social and Occupational Functioning Scale.
• Past treatment: Treatment-resistant patients should have experienced at least two past unsuccessful treatment episodes with different antipsychotic drugs, of at least six weeks duration at a therapeutic dosage for both trials.
• Dosage: Treatment-resistant patients should have received a therapeutic dose in previous medication trials equivalent to at least 600 mg of chlorpromazine per day. 

“The management of treatment resistance remains a real clinical challenge,” John Kane, M.D. (pictured above), a co-chair of the working group, told Psychiatric News. “I think we need to focus a lot more of our research energy on how we can better serve those patients who don’t respond adequately to the medications we have. A key goal [of the proposed criteria] is to help advance efforts to provide help to these patients by conducting more and better designed research in those people who are treatment resistant.”

For related information, see the Psychiatric News article “Clozapine Use Varies From State to State.”

(Image: Courtesy of John Kane, M.D.)

Response to Initial rTMS for Depression Found to Predict Subsequent Response

Repetitive transcranial magnetic stimulation (rTMS) has emerged as a safe and effective treatment option for patients with treatment-resistant depression, but many patients fail to respond to the treatment or experience a relapse of symptoms. While some studies suggest the best strategy for sustaining the antidepressant effect of rTMS is regular maintenance sessions, others suggest offering the treatment only if relapse occurs (known as reintroduction of rTMS).

A study published in the Journal of Neuropsychiatry and Clinical Neurosciences in Advance has found that a patient’s response to rTMS the first time may predict how well he or she will respond to a subsequent session of rTMS. The study authors noted these findings support the use of rTMS reintroduction therapy for responders, which could potentially reduce the number of sessions that they might have otherwise received as part of maintenance therapy.

The findings arose from a retrospective chart review of 225 patients who received rTMS for treatment-resistant depression as a part of the clinical program at the Berenson-Allen Center or Noninvasive Brain Stimulation at Harvard Medical School from 2000 to 2015. Of this group, 18 patients met the criterion of having a reintroduction of TMS therapeutic strategy, though two were excluded for inadequate symptom data.

Ten of the 16 remaining patients were responders to the initial rTMS treatment (classified as at least a 50% reduction in Beck Depression Inventory [BDI] score), and eight of these 10 responders were also responders to reintroduction. Three patients who partially responded to the initial rTMS treatment (25-50% reduction in BDI) also responded to reintroduction rTMS.

There was also some correlation in the overall strength of response between sessions; that is, patients who had a strong improvement in depression symptoms after the initial session tended to have greater BDI reductions after the reintroduction session as well. The authors estimated that the magnitude of the initial response explains approximately one-third of the magnitude of subsequent response.

“Thus, other factors, either not evaluated in this study or requiring a larger sample size to achieve significance, such as gender, age, refractoriness, baseline severity, and comorbid disorders, could also have a significant predictive role,” they wrote. Nonetheless, the authors noted that the findings support “an approach involving watchful waiting and reintroduction of TMS when [responders] experience a relapse, thus placing rTMS as a viable long-term treatment regimen for treatment-resistant depression.”

For related information, see the Psychiatric News column “Neuromodulation May Benefit Patients With Varying Psychiatric Illnesses,” by Andrew Leuchter, M.D., director of the Neuromodulation Division at the Semel Institute for Neuroscience and Human Behavior at the Semel Institute for Neuroscience and Human Behavior at the David Geffen School of Medicine at the University of California, Los Angeles.

(Image: iStock/Henrik5000)

Court Ruling May Increase Role of Mental Health Professionals in Evaluating Gun Rights

This past September, the U.S. Circuit Court of Appeals for the Sixth Circuit ruled that a federal law permanently barring the sale of firearms to people who have been involuntarily hospitalized for a mental illness was unconstitutional. The case centered around a 74-year-old Michigan man named Clifford Tyler, who, in 2011 was denied from purchasing a gun after a background check revealed that 25 years earlier, distraught over an impending divorce, he had been committed to a psychiatric hospital.  

In a column published yesterday in Psychiatric Services in Advance, Paul Applebaum, M.D. (pictured above), the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law at Columbia University, pointed out that this decision could impact mental health professionals and organizations that predominantly favor gun restrictions and a desire to reduce discrimination among people with mental illness. “There is likely … to be a certain amount of ambivalence about endorsing an approach that will restore gun access to at least some people with histories of involuntary hospitalization, even if doing so enhances the extent to which they are treated as ordinary members of society—otherwise an important goal,” he wrote.

“A parallel dilemma likely to arise in the wake of Tyler will be the demand for psychiatrists and psychologists to become involved in determining when it is safe to restore firearm access,” he continued. Understandably, there are concerns by clinicians of the liability, adverse publicity, and sanctions they could face should their decisions turn out to be wrong. 

“The decision in Tyler suggests that we may be moving toward more individualized determinations of risk for larger groups of people, for whom the predictors of violence are even less well specified. If that’s true, the odds are that mental health professionals will once again be asked to undertake that role,” he concluded.

For related information, see the Psychiatric News column “Psychiatrists Have a Role to Play in Latest Gun Law Debates” by APA President Maria A. Oquendo, M.D., Ph.D., and “APA Weighs In on Cases Where Law Intersects With Psychiatry.”

House Passes Major Mental Health Legislation

The House of Representatives last night passed the 21st Century Cures Act by a vote of 392-26. This wide-ranging, $6 billion bipartisan health legislation includes significant mental health components and had the support of the Obama administration.

The new act embeds medical leadership in the Substance Abuse and Mental Health Services Administration (SAMHSA), improves how the federal government finances and manages evidence-based mental health services, promotes workforce development and integrated care, and toughens the enforcement of mental health parity.

“This legislation will greatly benefit our patients with mental illness and substance use disorders,” said APA President Maria A. Oquendo, M.D., Ph.D., in a statement. “The bill strengthens existing parity laws so that mental illness is treated just like any other illness, and it better coordinates the efforts of federal agencies responsible for treating mental illness.”

The bill incorporates elements of legislation previously put forth by Reps. Tim Murphy (R-Pa.; pictured above) and Eddie Bernice Johnson (D-Texas) in the Helping Families in Mental Health Crisis Act as well as provisions in the Mental Health Reform Act of 2016, sponsored by Sens. Chris Murphy (D-Conn.) and Bill Cassidy (R-La.)

These are some of the provisions that the legislation includes:

• Appointment of a chief medical officer at SAMHSA who must hold a medical degree and have experience treating patients with mental illness or substance use disorders.
• $1 billion in state grants to address the opioid epidemic.
• Grants for promoting integrated care models for primary care and behavioral health care services.
• Grants for training programs like as the APA Foundation’s Typical or Troubled? program, which trains school officials to identify students who may need mental health care.
• Request for “clarification” of the permitted uses and disclosures of health information covered by the Health Information Portability and Accountability Act.

“With the House passage, we urge the Senate to pass this important legislation before adjourning for the year,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Our mental health system needs to be retooled to meet the growing demands of our patients.”

For more in Psychiatric News about mental health legislation, see “House Approves Comprehensive Mental Health Reform Bill.”

(Image: Aaron Levin/PN)

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Annual Meeting Registration Now Open for Members!

Join your colleagues from across the U.S. and around the world for the premier psychiatry event of the year! APA’s 2017 Annual Meeting will be held May 20 to 24 in San Diego. Expand your knowledge, network, and meet certification and licensure requirements with more than 450 educational sessions and courses.

Starting today, members can register for the meeting and reserve a hotel room. Nonmember registration and housing reservations open Dec. 15.

Browse the Annual Meeting site and the preliminary program for more information.