Young Women With Bulimia Show Improvements After CBT, Psychodynamic Therapy

Rates of remission from bulimia nervosa were similar among female adolescents receiving cognitive-behavioral therapy (CBT) or psychodynamic psychotherapy (PDT), according to a report in the Journal of the American Academy of Child and Adolescent Psychiatry.

Though additional studies are needed to determine potential differences between the two treatments, the authors said the findings suggest that clinicians should consider both treatments as potentially effective approaches for treating bulimia nervosa in this age group.

The study was conducted between 2007 and 2012 in cooperation with local psychotherapists at two German research centers. A total of 81 females aged 14 to 20 who met DSM-IV criteria for bulimia nervosa or partial bulimia nervosa were randomly assigned to receive regular outpatient CBT or PDT sessions for one year. Both treatments were manualized for standardization and focused specifically on treating bulimia nervosa.

Participants were assessed at baseline; at the 15th, 30th, and 45th sessions; and at the final therapy session. A follow-up assessment was also administered to participants 12 months after the end of therapy.

At the end of treatment, 33.3% CBT participants and 30.2% PDT participants were no longer diagnosed with an eating disorder. There were small differences favoring CBT for reduction in binge episodes and purging episodes, and a small difference favoring PDT in reducing subjective eating concerns among patients. The improvements remained stable at the 12-month follow-up in both groups. The researchers noted that though both treatments in the study led to similar outcomes, the small sample size did not allow detection of other potential differences between the two treatments.

“The results show that CBT and PDT are both helpful for participants with BN [bulimia nervosa],” they wrote. “PDT is especially effective when implemented in a disorder-focused manner. Clinicians treating this age group should consider CBT [or] PDT… as potentially effective approaches for older adolescents and young adults with BN.”

For related information, see the Focus article “Practice Parameter for the Assessment and Treatment of Children and Adolescents With Eating Disorders.”

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Low-Cost Reminder Devices May Not Improve Medication Adherence

Low-cost approaches that remind patients to take their medications may not be enough to improve medication adherence in people with chronic conditions, according to a study published today in JAMA Internal Medicine.

Niteesh Choudhry, M.D., Ph.D., of Brigham and Women’s Hospital in Boston and colleagues enrolled nearly 54,000 participants (including 16,000 patients taking antidepressants) in the Randomized Evaluation to Measure Improvements in Nonadherence (REMIND) trial to evaluate one of three low-cost adherence devices: a pill bottle with seven affixed toggles that can be slid after each daily dose is taken, a pill bottle cap with a digital timer displaying elapsed time since medication was last taken, or a standard pillbox with seven separate compartments.

The patients were all chosen based on a prescription history of suboptimal adherence (defined as a medication possession ratio between 30% and 80%) and randomized to receive one of the three devices in the mail (along with instructions and a number to call for assistance); patients in the control group did not receive any devices. Over 12 months, the researchers measured medication adherence using pharmacy refill data (with a medication possession ratio of 80% or more being considered adherent).

They found no discernible difference between any of the interventions and controls, both for the larger patient cohort and subgroups taking either cardiovascular drugs or antidepressants. In each study arm, about 15% of participants became adherent within one year of receiving their intervention.

The authors stated that is possible that these three devices simply may not work, but cautioned that other factors could affect the results. For example, they noted that as part of a pragmatic approach (echoing real-world practice), the device mailings were not coordinated with medication refills; patients may therefore have had difficulty transitioning to the device in the middle of a prescription fill.

“[F]or patients without established routines around medication taking, the additional cues from these devices may not be sufficient to overcome forgetfulness,” the authors wrote. “Moreover, the devices may not have promoted periodic medication refilling, which is necessary for long-term adherence. For these devices to work, they may need to be administered with additional support mechanisms.”

In an accompanying editorial, Ian Kronish, M.D., M.P.H., and Nathalie Moise, M.D., of Columbia University described the challenges of medication nonadherence and several strategies to improve adherence. 

“Innovations in e-prescribing have made it possible to leverage pharmacy fill data such that clinicians can identify nonadherent patients at the point of care. Targeting intensive behavioral adherence interventions at high-risk nonadherent patients may be an approach to achieving value,” they wrote. “When nonadherence is suspected, clinicians are encouraged to explore the reasons for nonadherence and to incorporate behavior-change techniques from effective, multicomponent interventions into their practice. These techniques may include providing feedback on self-monitoring, enlisting social supports, and recommending use of reminder systems.” 

To read about other strategies to promote medication adherence, see the Psychiatric News article “Independent Living May Improve Adherence When Combined With ACT.”

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Older Adults With Mild Depression May Benefit From Collaborative Care

Collaborative care may lead to improvements in older adults with subthreshold depression, according to a study published this week in JAMA. Although more research is needed to understand the long-term effects of the therapy, the findings point to a brief and relatively inexpensive method that might be able to reduce the likelihood that patients with mild depression develop more severe symptoms.

Simon Gilbody, Ph.D., of the University of York in the United Kingdom and colleagues randomly assigned 705 adults aged 65 years or older with subthreshold depression (according to DSM-IV) to receive either usual care from their primary care physician or a collaborative care intervention in addition to their usual primary care. 

Patients receiving collaborative care were paired with a case manager, who led on average six, 30-minute sessions over seven to eight weeks addressing the behavioral deficits of depression such as avoidance of social interaction and the absence of rewarding activities; two sessions were delivered in person and four were delivered by telephone. Patients in the usual care group received primary care management of subthreshold depressive symptoms only. Patients were asked to complete the nine-item Patient Health Questionnaire (PHQ-9; score range, 0-27) at the start of the trial and again at four- and 12-month follow-ups.

Of the 705 patients who started the trial, 519 remained at the 12-month follow-up (representing a loss to follow-up of 31.7% in the collaborative care group and 21.3% in the usual care group). The PHQ-9 score was 7.8 in both groups at baseline and declined to 5.4 in the collaborative care group and 6.7 in the usual care group at four months (mean difference, −1.31)—a difference that remained at 12-month follow-up. 

Additional analysis revealed that while the progression to threshold-level depression (defined in this trial as a PHQ-9 score ≥10) was not different between the two groups at four months (17.2% versus 23.5%), it was significantly less frequent in the collaborative care group compared with usual care at 12 months (15.7% versus 27.8%). Patients in the collaborative care intervention also demonstrated improvements in anxiety, functional status, and more compared with those in the usual care group.

“The need to carefully weigh the benefits of treating individuals who have symptoms but fall short of meeting criteria for major depression is not unique to subthreshold depression but is applicable to prediabetes, mild obesity, statins for primary prevention, and numerous other health care decisions in individuals with mild disease,” Kurt Kroenke, M.D., of the Indiana University School of Medicine wrote in a related editorial. Before expanding treatment beyond major depression to the larger number of patients with subthreshold depression, further research to identify those most likely to benefit is warranted. ... Patients with persistent symptoms, functional impairment, and a desire for treatment may particularly benefit.”

For related information, see the Psychiatric News article “Self-Reported Health Status May Predict Response to Depression Treatment.”

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Cat Ownership Not Linked to Increased Risk of Psychosis

Does having a cat increase the risk of psychosis in humans?

House cats are often carriers of the parasite Toxoplasmosis gondii. Epidemiological and animal studies at least suggest an increased risk for schizophrenia following in utero or early childhood exposure to the parasite.

There may be such a connection, but mere ownership of a cat during pregnancy or in early childhood does not increase the risk of psychotic events when children reach age 13 or 18, wrote Francesca Solmi, Ph.D., a postdoctoral research associate in psychiatric epidemiology at University College London, in a study published yesterday in Psychological Medicine.

Solmi and her colleagues used data from the Avon Longitudinal Study of Parents and Children, based on an initial cohort of 16,734 pregnant women in southwestern England who gave birth in the 13 months after April 1991. The study assessed 6,705 children at age 13 and 4,676 at age 18. After adjustment for several potential confounders, they found no evidence that cat ownership when the mothers were pregnant or when children reached age 4 or 10 was associated with psychotic symptoms at ages 13 and 18.

Previous studies that have concluded otherwise may have been compromised by small convenience samples, retrospective design, and lack of control for some confounders, said Solmi.

“While pregnant women should continue to avoid handling soiled cat litter, given possible T. gondii exposure, our study strongly indicates that cat ownership in pregnancy or early childhood does not confer an increased risk of later adolescent psychotic experiences,” she concluded.

For more in Psychiatric News about toxoplasmosis and psychosis, see “Psychiatrist Hunts for Evidence of Infection Theory of Schizophrenia.”

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Inadequate Gestational Weight Gain Linked to Nonaffective Psychosis In Offspring Later in Life

Extremely inadequate weight gain during pregnancy is associated with an increased risk in children later in life for nonaffective psychosis, even among an affluent and well-nourished population, according to a study published today in JAMA Psychiatry.

Previous research has shown prenatal exposure to starvation is associated with a twofold increased risk of nonaffective psychosis in children, so the study authors set out to investigate whether gestational weight gain throughout pregnancy and maternal body mass index (BMI) in early pregnancy were also associated with risk of nonaffective psychosis in offspring.

Renee Gardner, Ph.D., of the Karolinska Institutet, Stockholm, and colleagues used data from national health and population registries to follow up 526,042 individuals who were born in Sweden from 1982 through 1989. The individuals were tracked from age 13 to the end of 2011. Gestational weight gain of the mother was calculated as the difference in maternal weight between the first prenatal visit and delivery.

At the end of the study period, 2,910 offspring had an ICD-9 or ICD-10 diagnosis of nonaffective psychosis, which included 704 with narrowly defined schizophrenia.

Among the individuals with psychosis, 184 (6.32%) had mothers with extremely inadequate gestational weight gain (less than 17.6 pounds for mothers with normal BMI), compared with 23,627 (4.52%) individuals without psychosis. Outcomes were similar in analyses that adjusted for confounding factors such as maternal weight at baseline.

In the analysis measuring the impact of the maternal baseline BMI, a modest association was found between the risk of noneffective psychosis and maternal thinness (BMI >17.0 and <18.5) and class 2 obesity (BMI >35 and <40.0). 

While the authors suggested that malnutrition is a potential mediating factor, they pointed out that other factors may be involved. "Severely inadequate gestational weight gain may ... be indicative of an existing maternal medical condition, such as endrocrinologic disorders, malabsorption, anorexia nervosa, bulimia nervosa, or hyperemesis gravidarum," they wrote. "Insufficient weight gain can also occur in otherwise healthy individuals owing to insufficient medical guidance or by a drive to conform to societal (but not medical) standards of appropriate weight gain."

The researchers emphasized that more research is needed to understand the association between conditions that lead to insufficient maternal weight gain and the risk for nonaffective psychosis in children.

For related information on the role that fetal development plays in the risk for mental illness, see “Fetal Origins of Mental Health” in the American Journal of Psychiatry.

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Teen Suicide Attempts Fell After Legalization of Same-Sex Marriage, Study Finds

Same-sex marriage laws appear to be associated with a reduction in the proportion of high school students reporting suicide attempts, according to a report published Monday in JAMA Pediatrics.

Researchers and psychiatrists who commented on the study for Psychiatric News say the report points to how social policy that reflects greater tolerance and reduced stigma may improve mental health.

Julia Raifman, Sc.D., of the Johns Hopkins Bloomberg School of Public Health and colleagues analyzed data on more than 700,000 public high school students who participated in the Youth Risk Behavior Surveillance System (YRBSS) from 1999 through 2015. The authors looked at changes in suicide attempts among the students before and after the implementation of state policies in 32 states permitting same-sex marriage and year-to-year changes in suicide attempts in 15 states without such policies. A secondary analysis examined how same sex-marriage laws affected suicide attempts among high school students who self-identified as belonging to a “sexual minority.”

Same-sex marriage policies were associated with a 0.6 percentage point reduction in suicide attempts—equivalent to a 7% decline in the proportion of all high school students reporting a suicide attempt within the past year. Among students who identified as belonging to a sexual minority, the absolute decrease in suicide was 4.0 percentage points—equivalent to a 14% relative decline in the proportion of adolescents who were sexual minorities reporting suicide attempts in the past year.

Marshall Forstein, M.D. (pictured above), president of the APA Assembly Caucus of Lesbian, Gay, Bisexual, Transgender and Questioning/Queer Psychiatrists, said he believes marriage-equality laws are a marker for a host of social factors that create a more tolerant atmosphere for sexual minority youth, which, in turn, can help to diminish stigma and reduce the risk of suicide. “Marriage equality is a proxy for many changes in attitudes that create a matrix of social support for LGBT young people,” he said. “Increasing social tolerance creates the environment for increasing self-esteem.”

Brian Hurley, M.D., representative to the AMA Section Council on Psychiatry from GLMA: Health Professionals Advancing LGBT Equality, agreed. He noted that while most LGBT people are not suicidal, the study demonstrates the important role of sexual identity in mental health outcomes. “[O]ne implication of the study for individual psychiatrists is that speaking to patients about their sexual identity is a relevant part of a safety assessment and is clinically important,” he said.  

For related information, see the Psychiatric News article “Clinician Insight Can Help Meet MH Care Needs of LGBT People.”

U.S. Appeals Court Upholds Doctors Right to Ask Patients About Gun Ownership

The 11th U.S. Circuit Court of Appeals yesterday upheld a lower federal court ruling against Florida’s Firearms Owners Privacy Act, which sought to restrict discussions by physicians and other medical professionals about firearm safety.

The 2011 law included penalties for physicians who routinely asked patients and their families if they owned firearms. The Florida chapter of the American Academy of Pediatrics (AAP), other medical groups, and six individual physicians challenged the law as a violation of the First Amendment right to free speech.

“We are pleased with the 11th Circuit’s common-sense decision, which allows physicians the right to counsel families on firearms ownership and storage,” said Madeline Joseph, M.D., president of the Florida chapter of the AAP, in a statement.

APA, along with the AMA and numerous other medical groups, filed an amicus brief supporting the pediatricians, stating that discussion of gun safety is a legitimate public health concern and the law violates physician and patient First Amendment rights.

“Careful history-taking about firearm access is the cornerstone of risk assessment in vulnerable patients,” said Marvin Swartz, M.D., a professor of psychiatry and behavioral sciences at Duke University and chair of APA’s Committee on Judicial Action. “This long-awaited ruling from the Florida appeals court defends the free speech physicians must exercise to appropriately care for their patients and preserves the privacy of the physician-patient relationship without the unwarranted intrusion of a political agenda.”

The decision is likely to be appealed.

For more on APA’s role in Wollschlaeger et al., versus Governor, State of Florida, see the Psychiatric News article “APA Weighs In on Cases Where Law Intersects With Psychiatry.”

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Addressing Substance Use Early in Psychosis May Be Key to Better Outcomes

Substance use—known to be common in people with psychosis—is associated with poorer outcomes, including more severe psychopathology, higher relapse rates, and lower life expectancy. While previous studies have suggested discontinuing substance use early in the course of illness can improve symptoms and function, most of these were short-term trials. 

A study in Schizophrenia Bulletin that tracked the relationship between substance use, early abstinence, and psychosis longitudinally over 10 years now suggests the detrimental effects of substance use on mental health may be reversed if the person quits early on.

A global team of researchers, led by a group in Norway, analyzed data from a long-term study of people enrolled at one of four Scandinavian health care sectors. From this population, the researchers identified 301 patients with first-episode psychosis. These patients were followed up at three months and then again one, two, five, and 10 years later. 

Of these 301 patients, 266 could be classified into one of four groups based on their patterns of substance use in the first two years after diagnosis: persistent users (n=43), episodic users (n=48), stop-users (stopped substance use within two years after diagnosis, n=34), and nonusers (n=141).

After 10 years, stop-users had similar symptom profiles as nonusers, and both groups had fewer symptoms than episodic or persistent users. In fact, while persistent users had Positive and Negative Syndrome Scale negative scores that increased over the 10-year period, the negative scores of stop-users decreased over time.

“Our results, showing improvement in negative symptoms with cessation of substance use, are of interest as these are symptoms difficult to treat with antipsychotics. In addition, these symptoms are closely linked to daily and social functioning and quality of life.” the authors concluded. “The fact that harm can be substantially minimized with early discontinuation gives a hopeful message for patients who struggle with addiction and psychosis.”

For related information, see the Psychiatric Services article “Substance Use Disorder Among People With First-Episode Psychosis: A Systematic Review of Course and Treatment” and the Focus article “Substance Use Disorders and Schizophrenia.”

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Meta-Analysis Reveals Several Predictors of MDD, PTSD Following TBI

A history of pre-injury depression and shorter period of amnesia following injury are just two of several factors that may predict whether a person with traumatic brain injury (TBI) is likely to later develop major depressive disorder (MDD) or posttraumatic stress disorder (PTSD), according to a meta-analysis published Tuesday in The Journal of Neuropsychiatry and Clinical Neurosciences.

“This knowledge could be used to flag patients who might benefit from additional monitoring or (preventive) therapeutic interventions, which have shown to be effective in people at risk for MDD and PTSD,” Suzanne Polinder, Ph.D., of Erasmus Medical Center in The Netherlands and colleagues wrote.

Polinder and colleagues systematically reviewed the literature on predictors and multivariable models for MDD and PTSD after TBI. A total of 26 observational studies were found. Participants in the studies were civilian adults at least 16 years of age who sustained TBI.

The researchers found that MDD following TBI was associated with female gender, preinjury depression, post-injury unemployment, and lower brain volume. Individuals who experienced PTSD following TBI were more likely to have shorter periods of posttraumatic amnesia and memory of the traumatic event. They were also more likely to have early posttraumatic symptoms.

The researchers noted that some of the studies included in the analysis had methodological problems and more research is needed to confirm the predictors of MDD and PTSD after TBI. “The results of this systematic review imply that there is still limited knowledge regarding which patients develop MDD and PTSD after TBI,” they wrote.

“Physicians could be extra aware regarding female patients with a preinjury history of depression and postinjury unemployment or psychiatric symptoms. Also, a reduction in brain volume might indicate a risk of developing MDD postinjury. Furthermore, patients with a shorter [amnesia after the trauma], with a clear memory of the traumatic event, and with early posttraumatic symptoms might be at higher risk of developing PTSD post-TBI,” they concluded.

For related information, see the Psychiatric News article “Sertraline May Help Prevent Depression Following Traumatic Brain Injury.”

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APA Announces Winners of 2017 Election

APA’s Committee of Tellers has approved the following results of APA’s 2017 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting March 4-5.

President-Elect
Altha J. Stewart, M.D.

Secretary
Philip R. Muskin, M.D., M.A.

Minority/Underrepresented Representative (M/UR) Trustee
Ramaswamy Viswanathan, M.D., D.M.Sc.

Area 2 Trustee
Vivian B. Pender, M.D.

Area 5 Trustee
Jenny Boyer, M.D., Ph.D., J.D.

Resident-Fellow Member Trustee-Elect
Tanuja Gandhi, M.D.

Complete results of the election will be reported in the March 3 issue of Psychiatric News.

CNS Polypharmacy in Seniors Doubled From 2004 to 2013, Study Finds

Between 2004 and 2013, the number of Americans 65 and older who took three or more central nervous system (CNS) medications doubled, according to a study published today in JAMA Internal Medicine. In nearly half of these cases, the seniors—who were taking antidepressants, antipsychotics, painkillers, and/or sleep aids—did not appear to have a mental health or pain diagnosis.

The findings suggest that despite concerns over the risks of CNS polypharmacy, some older patients continue to be prescribed multiple CNS medications at once.

Donovan Maust, M.D., a geriatric psychiatrist at the University of Michigan Medical School in Ann Arbor, and colleagues analyzed data on patients 65 or older from the 2004 through 2013 National Ambulatory Medical Care Survey (NAMCS), which included 97,910 patients.

They found that annual polypharmacy visits by seniors rose from 0.6% in 2004 to 1.4% in 2013. Applied to the entire U.S. senior population, this translates to an increase from 1.5 million annual doctor visits to 3.68 million annual doctor visits involving CNS polypharmacy. The sharpest rise in CNS polypharmacy occurred among seniors living in rural areas, where mental health specialists are rare. The rate of rural polypharmacy visits tripled during the study period, and rural patients accounted for 16.6% of all CNS polypharmacy visits in 2013.

“Because of limited access to specialty care and a preference to receive treatment in primary care settings, it is unsurprising that mental health treatment has expanded in nonpsychiatric settings,” the researchers wrote. “The growth in polypharmacy in rural settings, where access to specialty mental health or pain care is particularly limited, is part of this broader trend.”

For related information, see the Psychiatric Services study “Antidepressant Prescribing in Primary Care to Older Adults Without Major Depression,” also by Donovan Maust, M.D., and colleagues.

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Imaging Study Points to Pathway Linking Child Abuse With Mental Illness

Childhood maltreatment is known to be associated with changes in brain structure and with psychopathology, but more needs to be learned about the biological connection between the two.

A longitudinal study of 51 adolescents with a history of abuse now suggests that changes in cortical thickness are associated with increased risk of internalizing and externalizing symptoms. The findings by Daniel Busso, Ed.D., of the Harvard Graduate School of Education and colleagues were published in the Journal of Child and Adolescent Psychiatry.

Busso and colleagues first assessed the adolescents for abuse exposure, then conducted structural magnetic resonance imaging scans and diagnostic interviews with the youth 14 months later. About two years later, the participants completed additional mental health assessments.

The researchers found that child abuse was associated with reduced cortical thickness in several regions of the lateral and medial prefrontal cortex and temporal cortex. The thickness of the left and right parahippocampal gyrus predicted antisocial behavior symptoms, and the thickness of the middle temporal gyrus predicted general anxiety symptoms. The authors found no association between abuse and volume of the amygdala or hippocampus.

“Our findings reflect the impact of abuse on cortico-limbic areas implicated previously in behavioral and emotional control functions,” Busso and colleagues concluded. “The medial temporal lobe and interconnected limbic structures are involved in the pathophysiology of both internalizing and externalizing psychopathology, including ODD/CD [oppositional defiant disorder/conduct disorder], ASB [antisocial behavior], and depression, potentially because they reflect underlying deficits in emotion processing or regulation that are relevant to these disorders.”

For more information about adolescent brain development, see the Psychiatric News article “NIH Kicks Off National Adolescent Brain Development Study.”

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Study Highlights Importance of Screening Patients With Schizophrenia for OCD

More than one in four patients with schizophrenia experience comorbid symptoms of obsessive-compulsive disorder (OCD), according to a study published in the Psychiatry Research. The findings highlight the importance of regularly evaluating OCD symptoms in this patient population, which could inform treatment strategies. 

For the current study, Sandeep Grover, M.D., a professor of psychiatry at the Postgraduate Institute of Medical Education and Research in India and colleagues recruited 181 adults with schizophrenia. The patients were evaluated using several screening tools, including the Yale-Brown Obsessive-Compulsive Scale, the Yale-Brown Obsessive-Compulsive Symptom Checklist, and the Positive and Negative Syndrome Scale. 

The analysis showed that 51 (28.2%) patients met the criteria for current OCD and 71 (39.2%) reported having experienced at least one obsession or compulsion for one month or more. The most common obsessions reported by patients were those of contamination (25.4%) and a need for symmetry and exactness (11.6%); the most common compulsions were cleaning/washing (27.1%) and checking (24.3%). 

When the authors compared patients with current OCD with those without, they found patients with current OCD were more likely to have experienced the onset of schizophrenia at a younger age. Patients with schizophrenia and OCD were also more likely to have comorbid depression and report suicidal ideation. 

Additional analysis revealed that patients with schizophrenia who were in remission but met the criteria for OCD had higher levels of disability in the domains of communication and understanding than those without OCD; those in clinical remission with OCD also had higher a prevalence of depression. 

Based on these findings, the authors recommended that all patients with schizophrenia undergo regular evaluations for symptoms of OCD. 

For related information, see the Psychiatric News article “Early Social Functioning May Predict Long-Term Outcome in Psychosis.”

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Children With Autism Acquired More Health Services Following Implementation of Parity Law

Children with autism spectrum disorder (ASD) appear to have obtained more health care services without driving up out-of-pocket spending by families following the implementation of the federal mental health parity law in 2010, according to a study in Health Affairs. 

“The fact that we did not observe such an increase [in family out-of-pocket spending] suggests that the federal parity law might have conferred financial protection to families seeking to avail themselves of treatments now covered more generously under the law—a central intent of its architects,” Elizabeth A. Stuart, Ph.D., of Johns Hopkins Bloomberg School of Public Health and colleagues wrote. 

For the study, Stuart and colleagues analyzed health insurance commercial group claims data on children 18 and under with autism from 2007 to 2012. The researchers compared the use of mental health care, speech and language therapy, and occupational or physical therapy; the quantity of services used among service users; total spending (insurer plus out of pocket) among service users; and out-of-pocket spending among service users before and after the implementation of the Mental Health Parity and Addiction Equity Act, which went into effect in 2010.

Stuart and colleagues found that the law’s implementation was associated with a modest increase in the use of health care services among children with autism spectrum disorder. “[O]ver the first year following parity, this translated into 1.6 additional mental health visits per user of mental health services, 0.4 additional speech and language therapy visits per user of speech and language therapy, and 0.7 additional occupational and physical therapy visits per user of occupational and physical therapies,” they wrote. Although there were small but significant increases in trends for total health care spending during the first year following the implementation of the parity law, “the increase in total spending was not accompanied by an increase in out-of-pocket spending by families,” they added.

The authors concluded, “This study provides evidence that the federal parity law was associated with greater use of services paid for through insurance for children with ASD without driving up the out-of-pocket spending paid by families through their insurance policies. However, the higher rates of use after the implementation of the law are still well below what one might expect in the context of increasing levels of impairment and service needs over the past few years … Our findings suggest that more stringent parity enforcement, additional policy approaches, or both, might be needed to ensure that children with ASD are connected to evidence-based services and supports.”

For related information, see the Psychiatric News article “Insurers Found to Be Complying With Certain Parts of Parity Law” and the Psychiatric Services article “The Impact of Insurance Coverage Types on Access to and Utilization of Health Services for U.S. Children With Autism.”

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EtG-Based Contingency Management May Help Patients With Alcohol Use Disorder, Mental Illness

An intervention that rewards patients for alcohol abstinence—determined by negative ethyl glucuronide (EtG) urine tests—and regular attendance at treatment appears effective for alcohol use disorders in people with serious mental illness, according to a study in AJP in Advance.

“Funding for reinforcers and urine tests can be a barrier to implementation. However, this barrier is likely surmountable as cost-effectiveness studies of contingency management in those with and without serious mental illness support the intervention’s cost-savings,” Michael G. McDonell, Ph.D., of Washington State University and colleagues wrote.

McDonell and colleagues randomized 79 outpatients with serious mental illness and alcohol dependence to one of two treatment arms: one group was assigned to 12 weeks of “contingency management,” where participants were eligible to win prizes for EtG-negative urine samples (defined as < 150 ng/mL) and attendance at treatment sessions; participants in the other group were eligible to receive prizes regardless of EtG results or treatment attendance. Participants in both groups provided urine samples three times per week for 12 weeks. 

Each time that participants in the contingency management group tested negative for EtG, they drew tokens from a container representing different magnitudes of reinforcement—50% of the tokens read “good job” (no prize), while the other 50% represented prizes ranging in value from $1 to $80. One additional prize draw was earned for each week of continuous alcohol abstinence, and patients received gift cards for attending all ($10.00) or at least one ($5.00) treatment meeting each week.

Noncontingent participants were eligible for prize draws for each urine sample submitted, regardless of EtG results. They did not need to attend addiction treatment to earn gift cards; instead they received gift cards equal to those earned by the contingency management group during the previous week.

On average the longest duration of alcohol abstinence among individuals randomly assigned to contingency management was more than twice as long as the average longest duration for noncontingent participants, with approximately 1.5 additional weeks of abstinence compared with controls. Contingency management participants were 3.13 times more likely to submit an EtG-negative urine sample during the intervention period compared with controls. They also had significantly fewer days of any drinking and drinking to intoxication throughout the intervention period.

“Results of this study strongly support the efficacy of an EtG-based contingency management intervention for alcohol use disorders,” the researchers wrote. “Group differences in alcohol use observed in this study … suggest that contingency management may be a particularly effective intervention for those with co-occurring serious mental illness and substance use disorders, a high-cost and difficult-to-engage population.”

For related information, see the Psychiatric News article “Researchers Identify Gene Variant Linked With Alcohol Preference.”

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Social, Communication Difficulties in Children May Increase Risk of Social Anxiety Disorder

Children who show signs of social and communication problems early on may be at risk of later development of social anxiety, according to a study in the Journal of the American Academy of Child and Adolescent Psychiatry. 

“These findings suggest the potential usefulness of incorporating social skills training alongside effective interventions to prevent or alleviate symptoms of [social anxiety] in childhood,” William Mandy, Ph.D., of the University College London and colleagues wrote.

The researchers analyzed parent reports of social and communication difficulties (measured by the Social and Communication Disorders Checklist) and anxiety symptoms (measured by Social Fears and General Anxiety subscales of the Development and Wellbeing Assessment) in 9,491 children at three separate age points: 7, 10, and 13 years. The children were all part of the Avon Longitudinal Study of Parents and Children.  

The researchers found that more parent-reported social and communication difficulties were associated with heightened social anxiety symptoms across all ages. In addition, if a child without social anxiety presented with social and communication difficulties at age 7 or 10, they had a greater risk of developing social anxiety three years later. There was no correlation between social and communication difficulties and general anxiety disorder. 

“Previous research using social skill interventions based on cognitive-behavioral therapy approaches have been effective at both increasing social skills and decreasing symptoms of anxiety in adolescents with ASD [autism spectrum disorder],” Mandy and colleagues wrote. “Building on this work, our results support the use of social skill programs alongside gold standard interventions in children, which offers the opportunity to develop [social and communication] skills, while simultaneously improving symptoms of [social anxiety].”

For related information, see the Psychiatric News article “Adding Paroxetine May Not Improve CBT for Social Anxiety.”

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Majority of Patients With Mental Illness Will Experience Some Form of Violence

People with a serious mental illness are likely to be affected by violence in some way—an understanding that should inform clinical practice, wrote John Monahan, Ph.D. (pictured left), a professor of law, psychiatry, and psychology at the University of Virginia in Charlottesville, and colleagues in an article published yesterday in Psychiatric Services in Advance.

The researchers analyzed data from the MacArthur Violence Risk Assessment Study on 951 patients discharged from acute inpatient psychiatric facilities and followed for a year. They found that one year after discharge 58% (n=555) of the patients experienced at least one form of violence. A total of 43% of the patients reported violent victimization by others, 28% reported acting violent toward others, and 23% reported violent self-victimization (defined as attempting hurting oneself). Over one-quarter (28%) of patients experienced at least two forms of violence, and 7% of patients experienced all three forms of violence.

Compared with patients who were not involved with violence, patients with a history of violence were more likely to have a diagnosis of alcohol or drug use disorder, to report being physically abused as children, and to have fathers who were arrested at least twice during their childhood. They were also more likely to have been homeless or unemployed for at least part of the one-year follow-up.

“[G]iven the substantial overlap among the three forms of violence studied here, clinicians should routinely screen patients who report one form for the occurrence of the other two forms of violence,” the authors wrote. “The co-occurrence of several forms of violence involvement may require a package of interventions with components geared to each.”

For more information, see the Psychiatric News article “How to Best Assess Violence Risk of Youth in Emergency Department,” by Ruth Gerson, M.D., director of the Bellevue Hospital Children’s Comprehensive Psychiatric Emergency Program, and Fadi Haddad, M.D., a child and adolescent psychiatrist at the New York University School of Medicine.

(Image: University of Virginia)

Patients With Bipolar II Depression May Benefit From Antidepressant Monotherapy

A study published Tuesday in AJP in Advance suggests patients with bipolar II depression who take sertraline monotherapy may be at no greater risk of hypomanic switch than those taking lithium monotherapy or a lithium/sertraline combination treatment.

“To date, clinicians have little evidence-based data to guide their approach to the treatment of acute bipolar II depression,” Trisha Suppes, M.D., Ph.D., of Stanford University and colleagues wrote. “[O]ur results support the possibility that, unlike in bipolar I patients, an antidepressant monotherapy may be appropriate and carries few risks in some patients with bipolar II disorder.”

The researchers randomly assigned 142 patients with bipolar II disorder who were experiencing a major depressive episode to sertraline, lithium, or lithium/sertraline combination therapy for 16 weeks. To evaluate dosing, side effects, and mood, patients were seen weekly for six weeks and then every two weeks for 10 weeks.

Of the 142 participants, 20 (14%) experienced a switch at some point during the study period. Seventeen (12%) developed hypomania, and three (2%)–one in each treatment arm–developed severe hypomania. No participant switched to a manic episode or was hospitalized for switching to hypomania. Of the 20 participants who experienced a switch, 11 (55%) switched within the first four weeks of treatment and 15 (75%) within the first five weeks.

Although there were no significant differences in response rates between treatment groups, the pattern of treatment response differed between rapid and nonrapid cyclers: the rapid cyclers showed no difference across the three regimens, whereas the nonrapid cyclers had a significantly lower response to the lithium/sertraline therapy. Additionally, patients in the combination group had a greater overall dropout rate.

While Suppes and colleagues acknowledged several limitations of the study, including that they cannot be certain of whether switch rates are attributable to treatment or natural course of illness, they noted that the results underscore the importance of closely monitoring patients during the first five weeks of treatment.

Additionally, “As there was a higher dropout rate in the lithium/sertraline group with no significant response advantage, combination therapy may be the least desirable option for short-term treatment,” they added.

For more information, see the Psychiatric News article “Combining Quetiapine, Lamotrigine May Reduce Bipolar Depression.”

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LAI Aripiprazole May Reduce Recurrence of Mood Episodes in Patients With Bipolar I Disorder

Treating patients with bipolar I disorder with a once-monthly long-acting injectable (LAI) form of aripiprazole may reduce the recurrence of mood episodes, according to a study published Tuesday in the Journal of Clinical Psychiatry.

“These findings support the role of AOM 400 [aripiprazole once-monthly 400 mg] as the first monthly LAI for the maintenance treatment of BP-I [bipolar I disorder],” Joseph Calabrese, M.D., director of the Bipolar Disorders Research Center at Case Western Reserve School of Medicine, and colleagues wrote.

Poor adherence to treatment is a significant problem in patients with bipolar disorder, putting patients at increased risk of recurrence of mood episodes, hospitalization, and suicide. Previous studies of LAI risperidone—the only LAI atypical antipsychotic approved by the FDA for the treatment of bipolar I disorder—suggest LAI antipsychotics can potentially improve outcomes in patients.

For the current study, the researchers examined the effectiveness and safety of aripiprazole once-monthly 400 mg (AOM 400) in patients with bipolar I disorder who were experiencing a manic episode.

The study was divided into multiple phases which required patients to be first stabilized on oral aripiprazole, before receiving AOM 400 injections every four weeks. A total of 266 patients who met stability criteria for eight weeks or more (outpatient with Young Mania Rating Scale [YMRS] total score ≤ 12, Montgomery-Asberg Depression Rating Scale [MADRS] total score ≤ 12, and no active suicidality) were then randomized to receive injections every four weeks for 52 weeks of AOM 400 or placebo. 

A total of 64 (48.1%) of 133 in the AOM 400 group and 38 (28.6%) of 133 in the placebo group completed the study. The primary measure outcome was time from randomization to recurrence of any mood episode.

The authors found that significantly fewer patients in the AOM 400 group (26.5%) experienced any mood episode compared with the placebo group (51.1%), with the effects observed predominantly on manic episodes. The LAI aripiprazole group was significantly more likely report weight gain, akathisia, insomnia, and anxiety than the placebo group.

“These efficacy results are consistent with the known efficacy of oral aripiprazole monotherapy in the maintenance treatment of BP-I [bipolar I disorder],” wrote Calabrese and colleagues. “[A]dditional studies on the potential benefits of LAIs in bipolar disorder are needed, including comparisons with oral formulations.”

This study was funded by Otsuka Pharmaceutical Development & Commercialization and H. Lundbeck A/S, makers of AOM 400.

For related information, see the Psychiatric News article “Some Experts Urge More Use of Long-Acting, Injectable Antipsychotics” and the Psychiatric Services article “Off-Label Prescribing of Psychotropic Medication, 2005–2013: An Examination of Potential Influences.”

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