Midlife Obesity Linked to Greater Risk of Dementia

Midlife obesity is a risk factor for dementia that could contribute to higher future dementia rates, according to a study published in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.

The study found that a body mass index (BMI) of 30 or greater at age 50 years but not at 60 or 70 years was associated with an increased risk of dementia. 

“Taken together, the present data demonstrate that the association between obesity and dementia is modified by age at obesity measurement, such that midlife obesity is a risk factor for dementia, but BMI begins to decline in those with dementia in the years before diagnosis,” Archana Singh-Manoux, Ph.D., of University College London and colleagues wrote. 

For the study, 10,308 adults (33% women) aged 35 to 55 years in 1985, who were participants in the Whitehall II study, were followed up until 2015. (The Whitehall II study is an ongoing cohort study of men and women originally employed by the British civil service in London-based offices.) BMI was assessed six times, and 329 cases of dementia were recorded. Changes in BMI for more than 28 years before dementia diagnosis were compared with changes in BMI in those who did not develop dementia. 

Researchers modeled the risk associated with obesity at ages 50, 60, and 70 years. To study the changes in BMI, they used repeat data and model trajectories of BMI for more than 28 years and a backward timescale anchored to the year of dementia diagnosis. The World Health Organization classification was used to categorize BMI as ≥30 (obese), 25 to 29 (overweight), and <18.5 (underweight). 

A total of 10.9% of the participants in the trial were obese at age 50, 17.1% at age 60, and 18.7% at 70 years. BMI in those with dementia was higher at age 50 years but not different from those without dementia at age 60 and 70 years. “BMI is suitable for the assessment of risk of dementia and death,” Singh-Manoux and colleagues concluded.

“In the past 40 years there has been a startling increase in the number of obese persons, rising from 105 million in 1975 to 641 million in 2014,” they wrote. “Our results suggest midlife obesity is a risk factor for dementia, and the extent to which the continuing obesity epidemic will create a surge in future dementia rates is an important public health issue.”

For related information, see the Psychiatric News article “New Dementia Measures Address Disclosure of Diagnosis to Patients.”

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Asenapine More Effective Than Placebo in Preventing Recurrence of Mood Episodes in Patients With Bipolar I

Long-term treatment with asenapine, an atypical antipsychotic approved for treatment of bipolar mania and schizophrenia, was more effective than placebo in preventing recurrence of any mood events in adults with bipolar I disorder, according to a report in AJP in Advance.

Patients with bipolar I disorder are at high risk for recurrences and relapses, noted Armin Szegedi, M.D., Ph.D., of Allergan Pharmaceuticals and colleagues. “Ideally, a compound would control symptoms of both polarities, both acutely and in the long term; however, few treatments have demonstrated this profile,” the authors wrote. 

For the study, which was supported by Allergan affiliate Forest Laboratories, adults with bipolar I disorder who were experiencing an acute manic or mixed episode were enrolled in a randomized, placebo-controlled trial consisting of an initial 12- to 16-week open-label period and a 26-week double-blind randomized withdrawal period. The target asenapine dosage was 10 mg twice-a-day in the open-label period but could be titrated down to 5 mg. After completing the open-label period, subjects meeting stabilization/stable-responder criteria (based on Young Mania Rating Scale [YMRS] and Montgomery-Åsberg Depression Rating Scale [MADRS] scores ≤12) were randomized to asenapine or placebo treatment in the double-blind period.

A total of 549 subjects entered the open-label period, of whom 253 enrolled in the double-blind randomized withdrawal period (127 in the placebo group; 126 in the asenapine group). The researchers found that time to recurrence of any mood episode was significantly longer in patients treated with asenapine compared with those treated with placebo. 

Asenapine was generally well tolerated. The most common treatment-emergent adverse events were somnolence (10.0%), akathisia (7.7%), and sedation (7.7%) in the open-label period, and mania (11.9% of the placebo group compared with 4.0% of the asenapine group) in the double-blind period. 

“Long-term asenapine therapy was more effective than placebo in preventing recurrence of mood events in stabilized adult subjects with bipolar I disorder,” the authors concluded. “The known safety and tolerability profile for asenapine was confirmed in this trial, with no detection of new safety or tolerability signals.”

For related information, see the Psychiatric News article “Diagnosing Possible Bipolar Disorder in Depressed Patients,” by Terence Ketter, M.D.

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Marijuana Use May Increase Risk of Developing Opioid Use Disorder

People who use marijuana may be at a greater risk of misusing prescription opioids and developing opioid use disorder than those who do not use marijuana, according to a report published in AJP in Advance. The findings offer a key piece of information for those debating whether marijuana could drive down prescription opioid misuse and overdose.

The suggestion that broader access to marijuana might reduce prescription opioid misuse and overdose comes largely from two recent reports, Mark Olfson, M.D., M.P.H., of the New York State Psychiatric Institute and Columbia University Medical Center and colleagues wrote in the AJP paper. These studies found aggregate annual death rates from opioid overdoses were lower in states with medical cannabis laws compared with states without such laws. “Such ecologic analyses, however, provide no information on whether individual patients who use cannabis have a lower or higher risk of developing opioid use disorders,” they noted.

To determine the association between cannabis use and nonmedical prescription opioid use and disorders in individual patients, Olfson and colleagues analyzed data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). They compared the interview responses of more than 34,000 U.S. adults conducted as part of the 2001-2002 NESARC (wave 1) and its 2004-2005 follow-up (wave 2).  

All diagnoses were made according to DSM-IV criteria, and nonmedical use of a prescription opioid was defined as using prescription analgesics “without a prescription, in greater amounts, more often, or longer than prescribed, or for a reason other than a doctor said you should use them” during the 12 months preceding the interview. Pain was assessed using the pain item of the Medical Outcomes Study 12-Item Short Form Health Survey, Version 2. 

After controlling for demographic and clinical covariates associated with cannabis use, the authors found that cannabis use at wave 1 was associated with increased nonmedical prescription opioid use and opioid use disorder at wave 2. Among adults with pain at wave 1, cannabis use was also associated with increased nonmedical opioid use at wave 2.

“Although the great majority of adults who used cannabis did not go on to initiate or increase their nonmedical opioid use, a strong prospective association between cannabis and opioid use disorder should nevertheless sound a note of caution in ongoing policy discussions concerning cannabis and in clinical debate over authorization of medical marijuana to reduce nonmedical use of prescription opioids and fatal opioid overdoses,” the authors wrote.

For related information, see the Psychiatric News article “Trump Declares Opioid Epidemic a National Emergency.”

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Avoid Medicare Penalties With Aid of New APA Resource

APA has released a new guide to help psychiatrists avoid potential financial penalties from Medicare’s new quality performance program, known as the Merit-based Incentive Payment System (MIPS).

The MIPS was created in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). It is part of Medicare’s new Quality Payment Program, along with incentives for “Advanced” Alternative Payment Models.

MIPS rewards or penalizes physicians for performance quality. For the current performance year of 2017, rewards or penalties will be applied in 2019. Over 16,000 psychiatrists could be subject to MIPS penalties in 2019 if they fail to do MIPS reporting for 2017.

The APA guide, “Take Action Now to Avoid Medicare Penalties,” offers step-by-step instructions to help psychiatrists navigate the new MIPS policies. The guide includes a checklist to determine whether MIPS reporting is required, information on when and where to file reports, and recommendations on improvement activities in which psychiatrists can participate to receive performance credit.

For example, psychiatrists participating for at least 90 days in PsychPRO, APA’s new ational mental health registry, can receive credit for several improvement activities for being part of a “qualified clinical data registry.” 

As an important note, most improvement activities must be done for at least 90 days, and the last 90-day period in 2017 begins October 3.

“Take Action Now to Avoid Medicare Penalties” was prepared with substantial input from APA members.  In addition to the detailed instructions, the guide includes additional resources and contact information for experts at APA and the Centers for Medicare and Medicaid Services. All APA members who see Medicare patients are urged to check out the guide. 

For more help and information related to the Quality Payment Program, please visit the APA Payment Reform Toolkit.

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Smartphone Apps May Help Reduce Depressive Symptoms

Smartphone applications (apps) can be effective tools for improving symptoms of mild to moderate depression, reports a meta-analysis published in World Psychiatry. Apps that are entirely smartphone based and apps that provide direct feedback are associated with better results than those that require additional components or feedback from humans.

"Patients and doctors are faced with a vast array of mental health apps these days, and knowing which ones are helpful is imperative," said study co-author John Torous, M.D., co-director of the digital psychiatry program at Beth Israel Deaconess Medical Center and a chair of APA’s Smartphone App Evaluation Work Group.

Torous and his colleagues evaluated 18 clinical studies with 3,400 participants who tested mobile health apps for depressive symptoms. The 18 studies included people with clinical or self-reported depression as well as other disorders with depressive elements such as bipolar disorder, anxiety, or posttraumatic stress disorder.

Overall, the authors found that the use of a mental health app provides modest improvements in symptoms, with larger effects seen when the app was compared with an inactive control (like a waitlist) versus an active control (such as a non-mental health app). That suggests that some of the improvements are due to having a device--a sort of digital placebo. 

Benefits were also more pronounced for patients with mild to moderate depression; smartphone apps did not appear helpful for individuals with major depressive disorder, bipolar disorder, or anxiety disorders. The the data for these conditions, however, were limited.

Next, the authors separated the studies on the basis of common features to gain insight into which aspects of smartphone interventions make them effective. They found that apps delivered entirely via smartphones had significantly greater effects than those that also required external components/devices, such as downloadable training modules. Similarly, apps that provided users with specific feedback, like summary statistics and progress scores, were more effective than those without such measurements. In contrast, apps that included therapist chats or other “in-person feedback” elements had generally lower effects than those thatdid not.

“It seems counterintuitive that additional features/human feedback would decrease smartphone effectiveness,” Torous and colleagues wrote. “However, this relationship is likely due to the fact that apps not relying on external components have been designed as more comprehensive and self-contained tools.”

To read more about this topic, see the Psychiatric News article, “How Might Technology Change Mental Health Care?” Also, information about mental health apps, including APA's mobile app evaluation tool, is available here. 

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Direct-to-Consumer Advertising Linked to Lower Medication Adherence

Research on direct-to-consumer advertising (DTCA) for pharmaceuticals has focused mostly on whether patients requested and physicians prescribed the featured medications. A study published in Psychiatric Services explores a new angle—whether exposure to DTCA influences adherence to medications already prescribed to people with serious mental disorders. The findings point to the importance of talking to patients about adhering to their medication regimen and encouraging them to discuss any concerns they might have as a result of reading or viewing medication ads directed to consumers.

The study found a significant association between self-reports of DTCA exposure and self-reported medication nonadherence. “Notably, the odds of being nonadherent were nearly five times greater among individuals exposed to DTCA than among those not exposed,” wrote lead author Charee E. Green, L.C.P.C., of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine.

“Our findings highlight the importance of prescriber awareness of the many sources of information, such as listed side effects in DTCA, that affect patient decisions about their care,” according to Green and colleagues.

Participants were drawn from a pool of outpatients aged 18 years or older at a mental health clinic at Johns Hopkins Hospital in Baltimore. Front-desk staff invited patients with scheduled appointments between June 13, 2016, and July 11, 2016, to complete a brief, anonymous survey. The survey was developed by the research team to assess exposure to advertising and patients’ adherence behaviors. Nonadherence was assessed with this question: “Have you ever missed taking a prescription medication for two or more days in one week?”

Of the 630 patients seen in that period, 246 patients (39%) completed the survey. Sixty-one percent of those exposed to DTCA reported nonadherence (72 of 118 patients), compared with 26% of those not exposed (32 of 122 patients). About 48% of the respondents (118) reported exposure to DTCA, and 42% (104) reported nonadherence.

Among those exposed to DCTA and reporting medication nonadherence, 59% reported that they either changed how they took their medications or stopped taking the medication, “specifically as a result of their exposure to side-effect information.” Only 39% of these respondents waited to speak to their physician before making the changes, according to the study.

“This raises concerns about the limitations of the role of physician input in decision-making process about their treatment,” the authors wrote. “A substantial proportion (36%) did not take physician input into account at all.”

For related information, see the Psychiatric News article “AMA Calls for Ban On Advertising Directed at Consumers.”

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Early Exposure to Football May Have Long-Term Behavioral Consequences

A neuropsychiatric assessment of former football players has found that those who began playing the sport before the age of 12 were more likely to report symptoms of depression and apathy decades later than those who started playing after they turned 12.

This association was independent of the players' current age, duration of football play, or history of learning disabilities, suggesting that age of first exposure to football is an independent risk factor for behavioral problems. The findings were published Tuesday in Translational Psychiatry.

This analysis included 214 former amateur (high school and college players) and professional football players who were part of an ongoing study called the Longitudinal Examination to Gather Evidence of Neurodegenerative Disease (LEGEND). As part of the LEGEND study, these players were asked to take a series of annual cognitive and mood tests, including the Brief Test of Adult Cognition by Telephone (BTACT), Behavior Rating Inventory of Executive Function-Adult Version, Center for Epidemiologic Studies Depression Scale, and the Apathy Evaluation Scale.

When the investigators, led by Robert Stern, Ph.D., of the Boston University Alzheimer’s Disease and Chronic Traumatic Encephalopathy Center, divided the group based on age of first exposure (AFE) to football, they found that players with an AFE <12 had about twice the odds of having worse scores on their executive function and apathy tests, and three times the odds of elevated depression scores. There were no significant effects on overall cognition as measured with BTACT. 

Stern and colleagues did caution that while there was a robust group-level difference, there was a wide range of scores at an individual level and many players with an AFE <12 were normal. 

The findings suggest that “[y]outh exposure to football may have long-term neurobehavioral consequences,” the authors wrote. “Future longitudinal studies that objectively monitor the clinical function of youth football players throughout life, including those who do not go on to play football at the high school, college, or professional level, are ultimately needed to understand the long-term neurological safety implications of youth tackle football.”

For related information, see the Psychiatric News article “Study Finds High Prevalence of CTE, Other Disorders in Former Football Players.”

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APA Calls for Rejection of Latest Republican Effort to Repeal ACA

APA is urging members to contact their U.S. senators and voice their opposition to the Graham-Cassidy bill—the latest effort by Republicans to repeal and replace the Affordable Care Act. The bill, which was drafted by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) and unveiled last week, appears to be gaining traction in the Senate. 

“This legislation … will lead to millions of Americans losing their health care coverage,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said Tuesday in a press release. “We are particularly concerned that this bill would make drastic cuts to the Medicaid program and roll back expansion, which has allowed 1.3 million Americans with serious mental illness and 2.8 million Americans with substance use disorder, to gain coverage for the first time. This bill harms our most vulnerable patients.”

Among its many proposals, the bill would allow states to change what qualifies as an essential health benefit, eliminating guaranteed coverage of substance use disorders and mental health treatment services. It would also stop the Affordable Care Act’s Medicaid expansion and cost-sharing subsidies and instead put that money into block grants that states could use to design their own health care systems.

“The APA is ready to work with members of both parties to craft a bipartisan solution that stabilizes the health insurance market and ensures Americans have access to quality, affordable health care,” Levin said.

Last week APA joined with five other medical specialty organizations representing more than 560,000 physicians in a letter to Senate Majority Leader Mitch McConnell and Minority Leader Charles Schumer to oppose the bill. The organizations noted that “a similar proposal was put forth by these two senators in July. Based on our analysis, the revised proposal may actually be worse than the original.”

The Republicans are up against a tight deadline of September 30 to secure the 50 votes needed to pass the measure using the budget reconciliation process. After this date, they would need 60 votes to pass the legislation. The Congressional Budget Office (CBO) on Monday announced that while it will aim to have a preliminary assessment of the Graham-Cassidy bill by early next week, it will not be able to provide point estimates of the bill’s effects on the deficit, health insurance coverage, or premiums for at least several weeks.

APA members are urged to call and email their senators today and register their opposition to the bill through a special portal on the APA website.

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Methylphenidate Found to Reduce Apathy in Patients With Mild Alzheimer’s Disease

Methylphenidate appears to improve apathy in patients with mild Alzheimer’s disease (AD), according to a study of community-dwelling veterans with mild AD published in AJP in Advance.

Prasad Padala, M.D., an associate director for clinical programs at the Geriatric Research Education and Clinical Center at the Central Arkansas Veterans Healthcare System, and colleagues also found that methylphenidate improved cognition, functional status, caregiver burden, Clinical Global Impression (CGI) scores, and depression.

Padala and colleagues randomized 60 community-dwelling male veterans with mild Alzheimer’s disease to methylphenidate or placebo. All participants were started on 5 mg of methylphenidate or a look-alike placebo twice daily and titrated to 10 mg twice daily at two weeks. The protocol allowed the study physician to decrease the dose if adverse events were reported. Otherwise, participants continued to take 10 mg twice daily until 12 weeks, at which time the dose was tapered to 5 mg twice daily for three days and stopped.

The primary outcome measure was the score on the clinician-reported Apathy Evaluation Scale (AES-C). The secondary outcome measures were scores on the Modified Mini-Mental State Examination and instruments evaluating cognition and function, including ability to carry out daily activities, and depression.

Padala and colleagues found significant differences over time for apathy in the methylphenidate group but not in the placebo group. After adjusting for baseline scores on the AES-C, they found that the methylphenidate group had significantly greater improvement than the placebo group at four weeks, and apathy continued to improve at eight weeks and 12 weeks. The behavioral and cognitive domains improved by eight weeks, and the emotional domain finally improved at 12 weeks. 

“These results suggest that improvement in the emotional domain may be mediated by improvements in the cognitive and behavioral domains,” Padala and colleagues wrote.

They added, “Although the ideal duration of treatment with methylphenidate is unknown, a case for longer duration can be made because the results of these studies were proportional to the duration of treatment, with the highest improvement in apathy and cognition noted with 12-week treatment. Longer duration studies need to be conducted to investigate if the improvement in apathy continues with the duration of treatment or if it plateaus at a certain point.”

For related information, see the Psychiatric News article “Kunadlini Yoga Found to Enhance Cognitive Functioning in Older Adults.”

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FDA Clears First App to Treat Substance Use Disorder

The Food and Drug Administration last week announced that it has cleared the first mobile app to help treat individuals with substance use disorders (SUD). 

The app, known as Reset, uses cognitive-behavioral therapy and is intended to be used in combination with outpatient therapy to treat alcohol, cocaine, marijuana, and stimulant SUDs. The goal is to increase retention in outpatient therapy programs and promote abstinence from substance abuse. The app is not intended to be used for the treatment of opioid dependence, the FDA noted.

“This is an example of how innovative digital technologies can help provide patients access to additional tools during their treatment,” Carlos Peña, Ph.D., M.S., director of the Division of Neurological and Physical Medicine Devices in FDA’s Center for Devices and Radiological Health, said in a press release. 

The Reset app is indicated as a 12-week prescription-only adjunct treatment for patients with SUD who are not currently on opioid replacement therapy, who do not abuse alcohol solely, or who do not have an opioid use disorder. The product combines patient-facing interventions and assessments via a mobile app with clinician-facing dashboards and data analytics.

The FDA reviewed data from a multisite, unblinded 12-week clinical trial of 399 patients who received either standard treatment or standard treatment with the addition of a desktop-based version of Reset, which could be accessed at the clinic or at home. The data showed a statistically significant increase in adherence to abstinence for the patients with alcohol, cocaine, marijuana, and stimulant SUD in those who used Reset (40.3%) compared with the patients who did not (17.6%). The clinical trial did not demonstrate effectiveness of using Reset in patients reporting opioid use.

There were no reports of side effects associated with the device, according to data from the clinical studies.

With the FDA’s clearance of Reset, Pear Therapeutics (based in Boston and San Francisco), the developer of the technology, can now begin to market the app.

For related information, see the Psychiatric News article “APA to Provide Framework to Evaluate Mobile Health Apps.”

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Changes to ICD-10-CM Codes for DSM-5 Diagnoses Effective October 1

Revised 2018 ICD-10-CM codes, released by the National Center for Health Statistics (NCHS), are scheduled to take effect on October 1, 2017. The codes include new, updated, or deleted codes for diagnoses listed in ICD-10-CM, including some 65 codes related to mental health conditions listed in DSM-5. All practitioners and payers must use the codes.  

Coding updates are typically made to provide greater diagnostic specificity, which in turn impacts reimbursement levels.  

NCHS is a federal agency within the Centers for Disease Control and Prevention, which oversees the ICD-10-CM. The ICD-10 Coordination and Maintenance Committee, a federal committee co-chaired by a representative from NCHS and from the Centers for Medicare and Medicaid Services, approves proposed changes to ICD on a yearly basis. 

The coding changes that impact DSM-5 are posted on the APA website. The diagnoses are listed alongside two columns—one column listing the codes that were used through September 30, 2017, and the other column listing the new codes that will become effective October 1. Two versions of the table are provided—one listing the codes in numerical order and the other listing them in the order that they appear in DSM-5.

CBT Provides Long-Term Benefits for Pediatric Patients With OCD

Children and adolescents with obsessive-compulsive disorder (OCD) who respond to cognitive-behavioral therapy (CBT) appear to continue to experience benefits from the therapy even after their initial course of treatment ends, according to a study published Wednesday in the Journal of the American Academy of Child and Adolescent Psychiatry.

Other research has suggested that CBT for pediatric OCD is a durable therapy, but these studies had been limited by either small samples sizes or having CBT combined with other treatments. 

For the current trial, Per Hove Thomsen, D.M.Sc., of Aarhus University in Denmark and colleagues tracked one-year outcomes in 155 youth with OCD aged 7 to 17, whose symptoms improved (Children’s Yale-Brown Obsessive-Compulsive Scale [CY-BOCS] scores ≤15) after receiving 75-minute, manualized, exposure-based CBT once a week for 14 weeks. 

During the one-year follow-up, CBT booster sessions could be given at any time, if required, with a maximum of three sessions per six-month period. About 40% of the participants had at least one booster session during the first six months, and 15% received at least one booster CBT session during the second six months.

At the one-year mark, 142 of the 155 participants still had CY-BOCS scores ≤15, and 121 had CY-BOCS scores of ≤10 (OCD remission). Only 13 of the patients, or 8%, experienced a relapse.

On average, CY-BOCS total scores dropped by 1.72 points during the first year after terminating the initial treatment, with children’s scores lowering by 1.34 points and adolescent scores dropping by 2.08 points. The authors noted that the adolescent group had a higher average CY-BOCS at the start of the study, so that may have enabled a greater reduction one year later.

“Clinically, these results imply that it is important to regularly monitor patients during the first year after successful first-line CBT,” Thomsen and colleagues wrote. “[O]ffering booster sessions to selected patients during follow-up might further strengthen the long-term effect of CBT.” 

For related information, see the Psychiatric News article “Report Highlights Alternative Treatment Options for OCD.” 

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Increase in Suicide Attempts Appears Driven By Young Adults With Less Formal Education, Psychiatric Disorders

An overall increase in suicide attempts from 2004-2005 to 2012-2013 appears to have disproportionately affected younger adults with less formal education and those with antisocial personality disorder, anxiety disorders, depressive disorders, and a history of violence, according to a report published today in JAMA Psychiatry.

Borderline personality disorder (BPD) continues to be the disorder most associated with suicide attempt risk, but the percentage of individuals with BPD attempting suicide dropped during the period of analysis, possibly suggesting increased access to evidence-based treatments.

Lead author Mark Olfson, M.D., M.P.H. (pictured above), of Columbia University and colleagues noted that because attempted suicide is the greatest known risk factor for completed suicide, reducing suicide attempts is an important public health and clinical goal. “The trends revealed in the study support a clinical and public health focus on young, socioeconomically disadvantaged adults, especially those who have made previous suicide attempts and those who have common mood, anxiety, and personality disorders,” he told Psychiatric News.

Olfson and colleagues used data from the 2004-2005 wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and the 2012-2013 NESARC-III. These nationally representative surveys asked identical questions to 69,341 adults, aged 21 years and older, concerning the occurrence and timing of suicide attempts.

During the study period, the percentage of U.S. adults who reported making a recent suicide attempt increased from 0.62% in 2004-2005 to 0.79% in 2012-2013. In both surveys, most adults with recent suicide attempts were female (60.17% and 60.94% for the two periods, 2004-2005 and 2012-2013, respectively) and younger than 50 years (84.75% and 80.38%, respectively).

Statistical analysis showed significantly higher risk of suicide attempt among adults aged 21 to 34 years than among adults aged 65 and older; adults with no more than a high school education than among college graduates; and adults with antisocial personality disorder, a history of violent behavior, or a history of anxiety or depressive disorders than among adults without these conditions.

“Although we don’t understand all of the factors that are driving these trends, it may be that younger adults and adults with less education have been especially hard hit by the recent recession in terms of economic and psychological stress,” Olfson said. “Unemployed adults, those with less education, and adults with lower family incomes were all especially likely to report a recent suicide attempt.”

He called the decrease in the percentage of individuals with BPD reporting recent suicide attempt a bright spot in the study. In 2004-2005, 6.9% of adults with BPD made a suicide attempt compared with 4.57% in 2012-2013.

“This may be in part because more psychiatrists and other mental health professionals are being trained to deliver dialectical behavioral therapy,” Olfson said. 

For related information, see the Psychiatric News article “Netflix Drama About Teen Suicide Prompts Related Google Searches.”

(Image: courtesy Mark Olfson, M.D., M.P.H.) 

Personal Recovery Predicts Well-Being in Patients With Schizophrenia

Personal recovery—the process of developing a positive sense of self and achieving goals in spite of illness—appears to predict well-being in patients with schizophrenia spectrum disorders six months later, according to a report in Schizophrenia Bulletin. The findings point to the importance of integrating elements of personal recovery into therapy for people with schizophrenia spectrum disorders.

To examine how clinical, functional, and personal recovery contribute to well-being, Winnie W.S. Mak, Ph.D., of the Chinese University of Hong Kong and colleagues recruited patients with schizophrenia spectrum disorders from psychiatric outpatient clinics and mental health service organizations in Hong Kong.

A total of 181 participants (mean age: 31; mean duration of mental illness: 2.45 years) were included in the study; 96.6% were taking psychiatric medication. Mak and colleagues used several scales to measure patients’ positive and negative symptoms, social and occupational functioning, personal recovery (feelings of hope, optimism, self-worth, and empowerment), and well-being (positive feelings and contentment, meaningful engagement with others) at the beginning of the study and six months later.

The authors found that “[a]cross [the] three types of recovery process[es] examined, personal recovery was consistently found to be predictive of well-being above and beyond clinical symptomatology and functioning.” Additionally, the effect of personal recovery on well-being did not depend on clinical and functional recovery, which the authors noted “implies that people with schizophrenia can participate in the process of personal recovery and enjoy positive well-being regardless of their clinical stability and functional competence.”

They concluded, “Given its prominent role in promoting well-being, elements of personal recovery … should be integrated into existing therapeutic interventions and psychiatric rehabilitation services for people with schizophrenia spectrum disorders.”

For related information, see the Psychiatric News article “Psychosocial Treatments Found Effective for Early Psychosis.”

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Postpartum Depression Screening During Well-Child Visits May Improve Maternal Mental Health

Screening for postpartum depression in a well-child care setting may be an effective way to reduce maternal depressive symptoms and improve overall maternal mental health and parenting, according to a study in Pediatrics.

“Significantly fewer mothers in the intervention group were depressed at nine months postpartum compared with the care-as-usual group (0.6% vs. 2.5% for major depression),” wrote lead author Angarath I. van der Zee-van den Berg, M.D., of the University of Twente in Enschede, Netherlands and colleagues. Furthermore, these mothers scored significantly better on most maternal secondary outcomes, such as parenting and anxiety symptoms, according to the study.  

“This is a nice study that shows screening at well-child visits is feasible, and when paired with referral and treatment, may be able to reduce the incidence and consequences of maternal depression,” Jennifer Payne, M.D., director of the Women’s Mood Disorders Clinic at Johns Hopkins School of Medicine in Baltimore, told Psychiatric News.

Based on the findings, the researchers suggest that routine screening for postpartum depression in well-child care settings should be “seriously considered.” The practice would fit in well with the recommendation statement on screening for depression in adults by the U.S. Preventive Services Task Force and the 2017 recommendations for preventive pediatric health care released by the American Academy of Pediatrics in March, the study noted.

For the study, mothers visiting Dutch well-child care centers were assigned to either the intervention group (n=1,843) or care-as-usual group (n=1,246). Mothers in the intervention group were asked to complete an Edinburgh Postnatal Depression Scale (EPDS) form assessing depression symptoms before well-child care visits at one, three, and six months postpartum. During the well-child care visits, physicians scored the EPDS and discussed the outcome and any recommendations for follow-up care with the mother. Mothers in the care-as-usual group and their newborns visited the well-child care centers with the same frequency as those in the intervention group, but received no EPDS screening that guided further advice and referral.

Symptoms of depression were assessed at the beginning of the study as well as at nine months postpartum using the Mini International Neuropsychiatric Interview. Maternal anxiety, quality of parenting, health-related quality of life, and more were assessed at 12 months postpartum using the Spielberger State-Trait Anxiety Inventory, the Short Form 12-Item Health Survey, and the Maternal Self-Efficacy in the Nurturing Role questionnaire. 

“One potential flaw of the study, which limits interpretation of the results, is that the lifetime history of major depression in the intervention group was significantly lower compared to the care-as-usual group. It also would have been good to know how many women in each group received diagnoses and psychiatric interventions,” Payne noted. 

For related information, see the Psychiatric News article “Early Postpartum Depression Screenings Not Enough to Identify High-Risk Women.”

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Survey Finds Young Adults Have Highest Prevalence of Severe Mental Illness

For the first time since the Substance Abuse and Mental Health Services Administration (SAMHSA) began collecting data on the mental health and substance use of Americans, the percentage of younger adults (aged 18 to 25) in the country with severe mental illness (SMI) is greater than the percentage of SMI in adults aged 26 and older, according to the latest National Survey on Drug Use and Health (NSDUH).

At a press conference announcing the results of the 2016 NSDUH yesterday, Elinore McCance-Katz, M.D., Ph.D., assistant secretary for mental health and substance use in the Department of Health and Human Services (HHS), noted that in addition to having a higher prevalence of SMI, nearly half of young adults with SMI were not receiving proper mental health treatment. Such limited access may be contributing to the growing numbers of young adults who report thinking about, planning, and/or attempting suicide, she said. Since 2008, the rate of young adults reporting suicidal thoughts or actions has risen significantly.

The NSDUH is an annual survey of 67,500 individuals ages 12 and older across the United States. The 2016 NSDUH data indicated that 44.7 million adults in the United States had a mental illness, and 23% of these people reported a SMI that significantly impacted daily living. In 2016, 5.9% adults aged 18 to 25 had an SMI compared with 5.3% of adults aged 26 to 49 and 2.7% of adults aged 50 and up.

During the press conference, HHS Secretary Tom Price, M.D., stressed the public health impact of untreated SMI. “Ten million people each year have an SMI, they live 10 years shorter on average, and there are 10 times more people with SMI in prisons than inpatient psychiatric facilities,” he said. “It is within our power to help.”

The NSDUH survey also found that the use of illicit substances, including opioids and other psychoactive medications (such as stimulants and hypnotics), appears to have stabilized or even decreased slightly since last year’s survey. A total of 11.8 million people reported misusing opioids in 2016, for example, a decrease from 12.6 million in 2015. However, as McCance-Katz pointed out, this has not slowed the rise of drug-related deaths. For instance, heroin use has risen by 230% since 2002, but heroin-related deaths have gone up 630%. She noted that part of this rise might be due to an increased trend of drug mixing, such as adding fentanyl to heroin.

For related information, see the Psychiatric News article “U.S. Experiences Uptick In Rates of Suicide.”

Mental Health Provider Participation in Physician Networks Lower Than Primary Care, Study Finds

Significantly fewer mental health professionals participate in provider networks than do primary care providers, according to an analysis of Affordable Care Act (ACA) provider networks appearing in the September issue of Health Affairs. However, network participation was significantly higher among psychiatrists compared with non-physician mental health care providers, according to the study.

So-called “narrow networks” have been a prominent tool by insurers to restrict access to care. Extremely low payment rates and/or administrative burdens are often cited as reasons by providers for not participating in networks. Additionally, some insurers have advertised “phantom” networks including names of clinicians who are no longer taking new patients, have moved out of the geographical area, or, in some cases, have died. 

Jane M. Zhu, M.D., and colleagues at the University of Pennsylvania identified 531 unique provider networks offered by 281 different insurance issuers in the ACA marketplaces in all fifty states plus the District of Columbia, using a database of 5,022 on-market qualified health plans. The final analysis sample consisted of 535,114 primary care providers and 562,379 mental health care providers, of whom 51,499 were psychiatrists and 103,328 were psychologists. (The other mental health providers included nurse practitioners, physician assistants, behavioral specialists, counselors, and therapists.) 

Overall, 120,453 (21.4%) of the mental health care providers and 243,718 (45.6%) of the primary care providers in the sample participated in at least one ACA Marketplace network. Specifically, 42.7% of psychiatrists participated in at least one network compared with 58.4% of primary care physicians, a difference of 15.7 percentage points. A similar difference was observed between the two fields among non-physician providers.

“In the context of efforts to provide mental health benefits on a par with those for general medical conditions, these findings highlight important structural barriers to parity that not only necessitate provider-side interventions to encourage greater network participation, but also require consensus about and regulation of network adequacy standards,” the authors wrote.

Irvin “Sam” Muszynski, J.D., APA senior policy advisor and director of parity implementation and enforcement, said network inadequacy is a significant parity issue and an advocacy priority for the APA. “The contributing factors—provider payment rates and managed care protocols—are themselves parity issues,” he said. “Many states are grappling with this currently and the APA is working with several of them to develop a solid analytical approach to evaluating the problem respecting parity compliance.”

For more information, see the Psychiatric News article “APA Study Reveals Network Inadequacy in D.C. Exchange Plans.”

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Study Offers Clues on Increasing Resiliency in Children Exposed to Abuse

Experiencing multiple forms of abuse early in life can increase the likelihood a child will develop psychotic symptoms. A report in Schizophrenia Bulletin now suggests there are several factors that may offer some protection from this risk. According to the authors of the study, such findings could be used to inform the content or focus of interventions for at-risk youth.

The findings are based on data collected as part of the Environmental Risk Longitudinal Twin Study, which began tracking the development of a nationally representative birth cohort of 2,232 U.K.-born twins at age 5. At the start of the trial, children were given tests to assess IQ, cognitive function, and prosocial behavior. Information on household income, education, and occupation was also collected at the study start to determine family socioeconomic status (SES). The researchers assessed the children for exposure to physical maltreatment by an adult, sexual abuse, emotional abuse and neglect, bullying, and domestic violence at ages 5, 7, 10, and 12 through interviews with children, mothers, and/or direct observation. At age 12, the children were asked to report any hallucinations or delusions and complete several assessments to gauge anxiety and depression. Several measures were also used to assess the children for conduct disorder at age 12.

A total of 140 children were found to have been exposed to two or more types of victimization prior to age 12; 1,986 were exposed to one or no types of victimization. Psychotic symptoms at age 12 were more commonly reported by children who were exposed to multiple types of victimization than in those who were not (19.3% vs 4.9%, respectively)—an association that remained after controlling for SES and family history of mental health problems. A more positive atmosphere at home and relatively high IQ were associated with a reduced likelihood of psychotic symptoms emerging among children exposed to poly-victimization.

“[I]t is possible that a relatively high IQ could facilitate the development of effective coping styles that have previously been found to bolster resiliency against mental health problems, and therefore, might also be protective against the onset of psychotic symptoms,” wrote Helen Fisher, Ph.D., of King’s College London and colleagues. Additionally, “[e]ven for children where victimization does take place within the home, if there are other positive aspects to the environment, then children may be able to benefit from these, perhaps by buffering their overall stress response.” 

About 81% of the poly-victimized children did not report psychotic symptoms at age 12, but, compared with children who were not victimized, they were more likely to have conduct disorder (24.8% vs. 4.1%, respectively), depression (10.6% vs 2.3%), and extreme levels of anxiety (11.5% vs 5.0%) at age 12. 

For related information, see the Psychiatric News article “Hallucinations Can Be Marker For Variety of Psychiatric Disorders in Youth.”

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CBT, Some Meds Found Effective for Anxiety in Kids, but Many Remain Symptomatic

While treatment with cognitive-behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), or serotonin-norepinephrine reuptake inhibitors (SNRIs) alone appears to reduce anxiety symptoms in youth with childhood anxiety disorders, a combination of CBT and medication may be best, according to a report published in JAMA Pediatrics.

The meta-analysis involving more than 7,000 patients highlighted how different treatments fared on different measures and compared with other treatments.

Zhen Wang, Ph.D., and colleagues at the Mayo Clinic searched six large medical databases for studies comparing CBT, pharmacotherapy, or a combination to treat children and adolescents for a range of anxiety disorders.

A total of 115 studies with 7,719 patients with diagnoses of separation anxiety disorder, generalized anxiety disorder, social anxiety disorder, specific phobia, or panic disorder were included in the analyses. The medication trials included SSRIs (sertraline, fluoxetine, fluvoxamine, or paroxetine), SNRIs (atomoxetine, duloxetine, or venlafaxine), tricyclic antidepressants (clomipramine or imipramine), and benzodiazepine (clonazepam).

These were among the major findings:

• SSRIs significantly reduced primary anxiety symptoms and increased remission and response. 
• SNRIs significantly reduced clinician-reported primary anxiety symptoms. 
• Benzodiazepines and tricyclics were not found to significantly reduce anxiety symptoms.
• When CBT was compared with wait-listing/no treatment, CBT significantly improved primary anxiety symptoms, remission, and response. 
• CBT reduced primary anxiety symptoms more than fluoxetine and improved remission more than sertraline.
• The combination of sertraline and CBT significantly reduced clinician-reported primary anxiety symptoms and response more than either treatment alone. 

Adverse events, which were mostly not serious, were more common with pharmacotherapy than CBT. 

In an accompanying editorial, Joan Rosenbaum Asarnow, Ph.D., of the Semel Institute of Neuroscience and Behavior at UCLA, said the meta-analysis by Wang and colleagues demonstrates that there are acute treatments that work.

“Still, roughly 40% to 50% of anxious children who receive gold-standard CBT or an SSRI remain symptomatic following acute treatment,” they wrote. “While this is comparable with effects for treatments of pediatric medical conditions, such as asthma, this means that full remission is not expected for many children, even with our best treatments. Additional research and practice advances are needed to clarify how best to address this prevalent and impairing illness. The hope is that at the next review, treatments with stronger, more pervasive, and lasting benefits will be identified, with strategies for integrating these treatments within service delivery systems tested and ready to be implemented to improve behavioral health in our children.”

For related information, see the Psychiatric News article “CBT for Child Anxiety May Confer Long-term Protection from Suicidality.”

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Need for MH Services for Youth Found to Be Higher Than Previous Estimates

An estimated 1 in 10 youth in the United States is in need of psychiatric treatment or referral to mental health services, according to a study published today in Psychiatric Services.

The systematic review and meta-analysis of 12 population-based U.S. studies found that within the previous 12 months, 10.06% of youth experienced serious emotional disturbance (SED) with substantial impairment in one of more functional domains and that 6.36% of youth experienced SED with substantial impairment in two or more domains.

“The large numbers of youth and families affected by SED, the significant long-term consequences of these conditions, and the considerable costs and complexity of treating these disorders underscore the need for comprehensive and effective prevention and treatment services,” wrote Nathaniel J. Williams, Ph.D., L.C.S.W., an assistant professor in the School of Social Work at Boise State University, and colleagues.

Previous research found that 4% to 17% of youth in the United States met criteria for SED; however, each of those reviews used a unique sample and method and as a result produced unique prevalence estimates, according to the authors. The goal of this study was to determine pooled prevalence estimates of SED.

Researchers identified studies through electronic searches of the MEDLINE and PsycINFO databases and nine prior reviews. Two raters evaluated 423 full-text, peer-reviewed articles from January 1, 1980, through January 1, 2017. Studies were included if they evaluated psychopathology and functional impairment among community samples of youth aged 18 and younger in the United States using structured interviews or standardized, nationally normed rating scales. Prevalence estimates of SED with domain-specific and global impairment were extracted, along with study characteristics and case definitions. Twelve studies met the inclusion criteria.

These estimates of SED are sufficiently precise to guide clinical decision making, mental health policy, and consideration of child psychiatry workforce needs in this country, according to the investigators. They cited previous research showing that only about 50% of youth with SED receive any mental health treatment within a one-year period.

Given these estimates, an important area of concern is the shortage of child psychiatrists to provide care. “Only about 8,700 child psychiatrists deliver services in the United States, implying an untenable 620:1 ratio of youths with SED per child psychiatrist,” wrote the researchers. 

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