Blaming Mass Shootings on Serious Mental Illness Has Harmful Effects, Says APA Past President

In the two weeks since a 19-year-old opened fire at Marjory Stoneman Douglas High School in Parkland, Fla., killing 17 students and faculty members, there has been much talk by politicians about the need to address untreated serious mental illness in the United States.

In an article published today in JAMA Psychiatry, APA Past President Renée Binder, M.D., and Matthew Hirschtritt, M.D., M.P.H., both of the University of California, San Francisco, wrote that while political rhetoric focusing the blame for mass shootings on individuals with serious mental illness may be “politically expedient,” such an approach “stigmatizes an already vulnerable and marginalized population, fails to identify individuals at the highest risk for committing violence with firearms, and distracts public attention from policy changes that are most likely to reduce the risk of gun violence.”

Binder and Hirschtritt summarized several studies that suggest serious mental illness is not a specific indicator for risk of violence. The article notes that such studies have found that people with mental illness are three times more likely to be victims than perpetrators of violence and only 4% of criminal violence in the United States can be attributed to people with mental illness.

Multiple factors other than serious mental illness contribute to violence risk, Binder and Hirschtritt wrote, including being male, young, having a history of perpetrating violence or being a victim of violence, and unlawful use of firearms. Certain triggers, including intoxication and severe stress, have also been shown to increase the risk of gun violence in people with and without mental illness.

“Addressing the risk of future mass shootings requires addressing a wide range of individual, community-level, and national and state policy factors, including decreasing access to guns, especially during periods of heightened violence risk,” they wrote. “Likewise, identifying and assisting those with serious mental illness requires the investment of resources and coordination of services, including supportive case managers, law enforcement and emergency personnel, and mental health clinicians.”

Psychiatrists should work to counter the perception that mental illness is the primary cause of gun violence, Binder told Psychiatric News. “I believe that psychiatrists have a role in advocacy and education. We have a responsibility in terms of educating people that guns are very dangerous, should be safely stored, and should be taken away from dangerous people,” she said. “Most people with mental illness will never commit a mass shooting, and this rhetoric leads to increased shame, societal reduction, stigmatization, and problems in gaining stable employment and housing.”

For related information, see the Psychiatric News Alert “APA Joins Other Physician Groups to Demand Action on Gun Violence.”

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SSRIs Appear Superior to SSNRIs for Pediatric Anxiety, Study Shows

Selective serotonin reuptake inhibitors (SSRIs) appear to be superior to selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) in the treatment of pediatric anxiety disorders, though both are associated with statistically significant improvement after two weeks, according to a meta-analysis in the Journal of the American Academy of Child and Adolescent Psychiatry. 

“These results are meaningful to clinicians as they choose which antidepressant class to use when treating anxious youth,” wrote Jeffrey Strawn, M.D., of the University of Cincinnati College of Medicine and colleagues. “Additionally, given the magnitude and trajectory of SSRI response, relative to SSNRI response observed herein, clinicians might preferentially use SSRIs as first-line psychopharmacologic interventions in pediatric patients with anxiety disorders.” 

Strawn and colleagues searched the literature for prospective, randomized, placebo-controlled trials (RCTs) that evaluated the efficacy of SSRIs or SSNRIs in the treatment of social, generalized, and/or separation anxiety disorder in children or adolescents. Overall, nine double-blind RCTs (1,805 patients) conducted between 1997 and 2014 were included in the analysis. 

Four SSRIs were evaluated: fluoxetine, fluvoxamine, paroxetine, and sertraline. Three SSNRIs were evaluated: atomoxetine, venlafaxine, and duloxetine. Five studies were federally funded, and four were funded by industry. All studies were conducted in outpatient settings. The primary outcome for these analyses was the change in Pediatric Anxiety Rating Scale (PARS) total score from baseline to endpoint.

Patients taking both SSRIs and SSNRIs improved significantly by week two over those taking placebo and continued to have statistically significant improvement throughout the study period. However, treatment response among those taking SSRIs was statistically greater at week two than among those taking SSNRIs, and that difference remained statistically significant over the subsequent 10 weeks of treatment. 

“Our results suggest that antidepressant response in pediatric patients occurs early in the course of treatment and occurs with a greater magnitude and more rapid trajectory with SSRIs compared to SSNRIs,” Strawn and colleagues wrote. “These data raise the possibility that SSRIs should be first-line antidepressants in youth with anxiety disorders and extend prior observations in pediatric patients with anxiety that more serotonergically selective agents may be more effective.”

For related information, see the Psychiatric News article “SSRIs/SNRIs Effective in Children, but Risks, Benefits Vary.” 

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Patients Taking SSRIs/SNRIs in Combination With Triptans at Low Risk of Serotonin Syndrome, Study Finds

In 2006, the Food and Drug Administration (FDA) issued a health advisory warning that patients who take selective serotonin reuptake inhibitors or selective norepinephrine reuptake inhibitors (SSRIs/SNRIs) together with triptan antimigraine drugs may be at a heightened risk of serotonin syndrome—a potentially fatal condition believed to arise from elevated serotonin levels. This advisory was based in part on several case reports of serotonin syndrome in patients treated with triptans and SSRIs/SNRIs.

A study published today in JAMA Neurology suggests that the risk of serotonin syndrome associated with concomitant use of triptans and SSRIs/SNRIs is low.

“In [a] large population-based study with more than 30,000 person-years of exposure to coprescription of these drugs, we found no cases of life threatening serotonin syndrome and no cases in which triptan use was unequivocally implicated as a cause,” Yulia Orlova, M.D., Ph.D., of the University of Florida College of Medicine and colleagues wrote. “Our results cast doubt on the validity of the FDA advisory and suggest that it should be reconsidered.”

The authors assessed data from the Partners Research Patient Data Registry, which contains health record information for more than 6 million members of the Partners HealthCare Network in the greater Boston area. They identified 19,017 patients who had received a prescription for both a triptan and SSRI/SNRI at some point between January 1, 2001, and December 31, 2014.

In this group, serotonin syndrome had been clinically suspected in 17 patients, though only in seven cases did the syndrome occur in the same year that a patient had a documented prescription of both medications (resulting in an incidence rate of 2.3 cases per 10,000 person-years of medication exposure). Of these seven patients, only two were classified with definite serotonin syndrome (resulting in an incidence rate of 0.6 cases per 10,000 person-years of medication exposure).

“Overall, our results are reassuring and suggest that patients with coexisting affective disorders and migraine need not forgo management of one condition to treat the other,” the authors concluded.

For related information, see the Psychiatric News PsychoPharm article “Common Pain Relievers Do Not Appear to Interfere With Mood Stabilizers.”

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Varenicline May Lower Heavy Drinking, Smoking in Men With AUD

Varenicline, an FDA-approved smoking-cessation medication (Chantix), may be effective in treating both alcohol use disorder (AUD) and smoking in men, according to a study in the February issue of JAMA Psychiatry.

“Men appeared to derive benefit from varenicline, compared with placebo, on measures of heavy drinking, whereas women did better taking placebo,” wrote lead author Stephanie S. O’Malley, Ph.D., director of the Division of Substance Abuse Research in Psychiatry at Yale School of Medicine.

Researchers conducted the phase 2, randomized, double-blind, placebo-controlled trial at two outpatient clinics (New York City and New Haven, Conn.) from September 19, 2012, to August 31, 2015. The researchers recruited men and women aged 18 to 70 who were seeking treatment for AUD. Individuals who met the criteria for alcohol dependence (according to the DSM-IV-TR), reported heavy drinking (≥5 standard alcoholic drinks for men and ≥4 drinks for women) two or more times a week and cigarette smoking two or more times per week were included in the trial.

O’Malley and colleagues randomly assigned 131 participants to receive either 2 mg of varenicline or placebo daily for 16 weeks. Medication was titrated in the following standard doses: 0.5 mg once daily for three days, 0.5 mg twice daily for four days, and 1 mg twice daily for the remainder of the 16-week treatment. Daily medication adherence was monitored through a combination of pill counts returned from blister packs and self-reported compliance.

Over the course of the trial, participants attended 12 medical management sessions during which they met with a medical professional to discuss the tolerability of the assigned medication, medication adherence, and the importance of drinking goals as well as the development and implementation of strategies for changing drinking behaviors. The participants were also asked about their drinking and smoking behavior, adverse effects of the medication, changes in mood, and more.

The mean change from baseline in the percentage of heavy drinking days in the overall sample by the end of the study was not different between the placebo and medication groups, but varenicline appeared to have different effects on drinking in men and women. Compared with placebo, varenicline resulted in a greater decrease in percentage of heavy drinking days in men and a smaller decrease in percentage of heavy drinking days in women. Even though the subjects were not seeking or provided smoking-cessation counseling, varenicline resulted in significantly higher rates of smoking abstinence compared with placebo (13% vs 0%) at the end of treatment.

“This study adds to the growing body of evidence suggesting varenicline to be well tolerated in those with active substance use disorders,” wrote A. Eden Evans, M.D., Ph.D., and John F. Kelly, Ph.D., both of the Center for Addiction Medicine at Massachusetts General Hospital and Harvard Medical School., in an accompanying editorial in JAMA Psychiatry. “These findings highlight the importance of the National Institutes of Health’s emphasis on systematically evaluating sex or gender in treatment effects and add to the converging evidence of the need for more specific and targeted treatments for women and men.”

For related information, see the Psychiatric News article “APA Releases Practice Guideline for AUD Pharmacotherapy.”

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Only 35% of Parents With Child At Risk of Self-Harm Properly Store Firearms, Survey Finds

A child’s history of risk factors for self-harm does not appear to influence caretaker decisions about whether to keep firearms in the home, or whether those firearms are kept unloaded and in locked storage.

That’s the finding from an analysis of data from an online survey published in Pediatrics.

“Given the prevalence of household firearms in the United States, our findings suggest that millions of U.S. children are placed at substantially higher risk of fatal firearm injury, especially suicide, than would be the case were parents to follow guidelines first put forward by the AAP [American Academy of Pediatrics] more than a quarter century ago,” wrote John Scott, B.S., Deborah Azrael, Ph.D., and Matthew Miller, M.D., M.Sc., of Northeastern University and Harvard University.

The researchers used data from a Web-based survey conducted by the survey firm Growth for Knowledge (GfK) to assess firearm ownership, storage practices, and use among a nationally representative sample of U.S. adults. Respondents were asked about gun ownership and about various storage practices for their household guns, including the number of guns stored and whether they were locked and unloaded. Participants were also asked if there were children living in the household and if so, what their relationship was to these children.

Respondents who reported to be the caregiver or health care decision-maker (“parent”) of a child under 18, were also asked if this child had attention-deficit/hyperactivity disorder (ADHD), depression, or mental health conditions other than depression. Respondents who answered “yes” to any of these were said to have a child with a self-harm risk factor. (Respondents were not asked whether children ever received a formal diagnosis.)

Of 3,949 respondents, approximately 1 in 3 U.S. households contained firearms (34.8%), irrespective of whether the household included children. Among the subset of adults who self-identified as parents, approximately 2 in 5 households contained firearms (42.4%).

Among parents who own guns, 34.9% stored all guns locked and unloaded when they had a child with a history of self-harm risk factors, compared with 31.8% when none of their children had such a history.

In an accompanying editorial, David C. Grossman, M.D., M.P.H., of the Kaiser Permanente Washington Health Research Institute, said clinicians caring for teenagers play a critical role in preventing youth suicide, including routine screening of adolescents for depression and ascertaining information about firearms in the household and their storage.

“When screening yields concerns of depression, a natural opportunity arises to ask about access to household firearms and provide intensive behavioral counseling on safe storage,” Grossman wrote. “Ongoing treatment of teenage depression involves systematic monitoring of treatment effectiveness, possibly including message reinforcement about firearm storage. Clinicians may need to engage other family members to ensure that treatment and storage recommendations are followed.”

For related information, see the Psychiatric News article “Firearms and Suicide: Risk Assessment and Management,” by Liza Gold, M.D.

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Depression Screening, Treatment Can Improve Outcomes of Individuals With HIV

The more days that an adult living with HIV spends depressed, the greater the risk he or she will miss appointments for HIV primary care, experience HIV treatment failure, and/or die prematurely, according to a study published today in JAMA Psychiatry.

“Even modest increases in time spent depressed led to clinically meaningful upticks in negative outcomes,” lead author Brian Pence, Ph.D., of the University of North Carolina at Chapel Hill, told Psychiatric News by email. “The implication [of these findings] is that regular depression screening and rapid, evidence-based depression treatment—by shortening the duration of depression—hold the potential to have a meaningful impact on HIV outcomes,” he said.

To examine the association between the persistence of depression and multiple HIV care continuum indicators, Pence and colleagues analyzed data on adult patients who received HIV care at six U.S. academic medical centers participating in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) between September 22, 2005, and August 6, 2015. As part of routine clinical visits, patients were regularly given the PHQ-9 every six or so months.

Pence and colleagues focused their analysis on information collected on CNICS participants with two or more consecutive PHQ-9 measures (defined as two PHQ-9 measures separated by less than 365 days). Patients entered and remained in the analysis until one of the following occurred: death, a lapse in PHQ-9 measures (12 months after the last consecutive PHQ-9 measure), loss to care (≥12 months without an HIV primary care appointment), six years’ follow-up, or until the end of the available data from the patient’s site. The main outcomes assessed during the follow-up period included missed HIV primary care appointments, detectable HIV viral load (HIV RNA viral load measure of 75 copies/mL or more), and all-cause mortality.

A total of 5,927 participants were included in the analysis. During the follow-up period, Pence and colleagues found that the participants’ median percentage of days with depression was 14%, 10,361 of 55,040 scheduled visits (18.8) were missed, 6,191 of 28,455 viral loads (21.8%) were detectable, and the mortality rate was 1.5 deaths per 100 person-years.

“Increasing PDD [percentage of days with depression] was associated in a dose-response fashion with an increased risk of missed appointments, increased risk of detectable viral load, and accelerated mortality. Each 25% increase in PDD led to an 8% increase in the risk that a particular scheduled appointment would be missed, a 5% increase in the risk that a particular viral load would be detectable, and a 19% increase in the mortality hazard,” the authors wrote.

For related information, see the Psychiatric News article “Advisory Council Member Offers Voice for Psychiatry in New HIV/AIDS Strategy.”

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Adolescents With Depression Found to Benefit From Collaborative Care Program

Depression is common among adolescents, yet an estimated 40% never receive treatment. A study in Psychiatric Services in Advance suggests that embedding psychiatric services within a primary care setting can reduce depressive symptoms in this group.

For the study, Nathan Shippee, Ph.D., of the University of Minnesota, Minneapolis, and colleagues from the Mayo Clinic assessed the effectiveness of EMERALD (Early Management and Evidence-based Recognition of Adolescents Living with Depression), a collaborative care program in a busy primary care practice in the Midwest.

Patients aged 12 to 18 with a depression diagnosis score of ≥10 on the nine-item Patient Health Questionnaire for Adolescents (PHQ-9A) who did not have a bipolar disorder diagnosis were eligible to participate. The sample included 162 EMERALD participants and 499 non-EMERALD participants with the same diagnostic profile.

After receiving an initial diagnosis of depression from a primary care provider (PCP), patients and parents who verbally agreed to participate in the EMERALD program were referred to a registered nurse care coordinator trained in depression management and motivational interviewing. For each adolescent, the nurse checked in by phone or face-to-face weekly or biweekly, and with one or both parents biweekly. The nurse used motivational interviewing and other strategies to encourage patients to identify specific concerns and goals for each visit. In weekly case review meetings with the nurse, a child and adolescent psychiatrist made treatment recommendations. The nurse passed the recommendations to the PCP, who made the final decision. The nurse then worked with the patient and his or her parents on the recommendations.

Patients who did not enter EMERALD received usual care from a PCP.

Patient outcomes were tracked via a clinical registry. The primary clinical outcomes were six-month remission of depression (score <5) and six-month treatment response (>50% reduction from baseline), as measured by the PHQ-9A. Overall, patients receiving collaborative mental health care experienced higher rates of remission (11 percentage points higher) and treatment response (14 percentage points higher) than patients who received treatment as usual.

“Practices may want to consider implementation of an analogous model of care to improve depression outcomes among adolescents,” the authors wrote. “Future studies could examine which groups might benefit most and flexible payment models to support these services.”

For related information, see the Psychiatric News article “Collaborative Care for Youth: Statewide Success Stories,” by Robert J. Hilt, M.D., M.S.

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APA Joins Other Physician Groups to Demand Action on Gun Violence

In the aftermath of Wednesday’s shooting that killed 17 students and staff members at Marjory Stoneman Douglas High School in Parkland, Fla., APA and four organizations representing 450,000 physicians and medical students called on President Donald Trump and Congress to take meaningful action against gun violence.

Joining with APA were the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American College of Physicians.

“Gun violence is a public health epidemic that is growing in frequency and lethality, and it is taking a toll on our patients,” the groups said in a statement released today. “We urge our national leaders to recognize in this moment what the medical community has long understood: we must treat this epidemic no differently than we would any other pervasive threat to public health. We must identify the causes and take evidence-based approaches to prevent future suffering.”

The groups have asked the president and Congress to take the following actions:

• Label violence caused by the use of guns a national public health epidemic.
• Fund appropriate research at the Centers for Disease Control and Prevention as part of the FY 2018 omnibus spending package.
• Establish constitutionally appropriate restrictions on the manufacture and sale, for civilian use, of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.

While mass shootings attract much attention from the public and the media, the groups noted that current policies regarding access to guns in this country expose Americans daily to the risks of violent acts including suicide, homicide, and unintentional injury.

“The families of the victims in Parkland and all those whose lives have been impacted by daily acts of gun violence deserve more than our thoughts and prayers. They need action from the highest levels of our government to stop this epidemic of gun violence now,” the statement concluded.

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FDA Approves First Blood Test to Detect Concussions

The Food and Drug Administration (FDA) on Wednesday approved the first blood test to evaluate mild TBI (mTBI) or concussion.

The test, called the Brain Trauma Indicator, works by measuring levels of two proteinsUCH-L1 (ubiquitin C-terminal hydrolase L1) and GFAP (glial fibrillary acidic protein). These proteins are released from the brain following a head injury and appear in the blood within hours of the injury.

“A blood-testing option for the evaluation of mTBI/concussion not only provides health care professionals with a new tool, but also sets the stage for a more modernized standard of care for testing of suspected cases,” FDA Commissioner Scott Gottlieb, M.D., said in a press release.

Health care professionals currently evaluate patients suspected of head injuries with the 15-point Glascow Coma Scale followed by a computed tomography (CT) scan of the head to detect intracranial lesions that may need follow-up care. More than 90% of patients presenting to the emergency department with mild TBI or concussion have a negative CT scan, according to Banyan Biomarkers, Inc., the developer of the Brain Trauma Indicator.

The FDA evaluated data from a multicenter, prospective clinical study of 1,947 individual blood samples from adults with suspected mTBI/concussion and reviewed the product’s performance by comparing mTBI/concussion blood tests results with CT scan results. According to the FDA, the Brain Trauma Indicator was able to predict the presence of intracranial lesions on a CT scan 97.5% of the time and those who did not have intracranial lesions on a CT scan 99.6% of the time.

“These findings indicate that the test can reliably predict the absence of intracranial lesions and that health care professionals can incorporate this tool into the standard of care for patients to rule out the need for a CT scan in at least one-third of patients who are suspected of having mTBI,” the agency noted in the press release. The results of the test are available within three to four hours.

For related information, see the Psychiatric News article “Blood Test May Detect Concussions Days Later.”

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Antidepressants May Reduce Opioid Use in Patients With Comorbid Depression, Chronic Pain

Patients experiencing chronic pain and depression may be more likely to stop taking opioids if they adhere to their antidepressants, reports a study published in the British Journal of Psychiatry. Further analysis also suggests that halting opioid use contributes to improvements in depression.


“Depression can worsen pain and is common in patients who remain long-term prescription opioid users,” Jeffrey Scherrer, Ph.D., of the Saint Louis University School of Medicine said in a press release. “Effective depression treatment may break the mutually reinforcing opioid-depression relationship and increase the likelihood of successful opioid cessation.”

Scherrer and colleagues analyzed electronic medical records from the Veterans Health Administration for this study. They identified 2,821 patients who received antidepressants for a new diagnosis of depression following at least 90 days of opioid use for chronic pain (excluding cancer pain or HIV pain). Of this group, 1,077 of the patients were adherent to antidepressants (took at least 80% of their prescribed amount) and 1,744 were not.

The authors calculated that antidepressant adherence was associated with a 24% greater likelihood of opioid cessation; this association was not related to duration of opioid use, degree of pain, or number of other medical comorbidities.

An exploratory analysis of all four patient subgroups (adherent/nonadherent and opioid cessation/noncessation) revealed that patients who stopped using opioids—regardless of their adherence—showed greater improvements in their depressive symptoms. However, antidepressant adherent patients who stopped using opioids showed the greatest improvements.

While the authors cautioned more studies are needed to confirm these preliminary findings, they wrote “together, these results provide preliminary evidence that a reduction in depression may lead to OAU [opioid analgesic use] cessation … opioid taper paired with antidepressant medications could result in a faster reduction of depression symptoms and increase the likelihood of successful OAU cessation.”

To read more on this topic, see the Psychiatric News article “Many Prescription Opioids Go to Adults With Depression, Anxiety.”

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APA Commends Bipartisan Budget Deal for Health, MH Provisions

The bipartisan budget agreement passed last week by Congress won praise from APA for its inclusion of funding for many mental health, substance use, and criminal justice programs that will benefit millions of Americans living with serious mental and substance use disorders. APA had lobbied hard on many of these issues for months leading up to the vote.

Among the major provisions of the legislation is an extension of the Children’s Health Insurance Program through 2028, marking the longest reauthorization in the program’s history. CHIP is a federal-state partnership that provides comprehensive health insurance coverage for children whose families earn too much to qualify for Medicaid but not enough to afford private insurance. CHIP insures 9 million children, including 850,000 with serious behavioral or emotional disorders.

The budget agreement also provides the following:

• $6 billion to help fight the nation’s opioid epidemic, primarily through state grants that expand substance abuse and mental health treatment. In addition, $2 billion has been earmarked over the next two years to support research at the National Institutes of Health, including its study of nonopioid pain therapies.
• Two-year reauthorizations of funding for the community health centers; the National Health Service Corps, which provides student loan forgiveness to health professionals who work in rural or underserved areas; and the Teaching Health Center Graduate Medical Education Program. These all provide critical health-related resources to vulnerable communities.
• Technical corrections related to the Medicare Access and CHIP Reauthorization Act (MACRA), which will help ease regulatory burdens faced by physicians.
• Additional funding for Department of Veterans Affairs hospitals and clinics.
• Funding that will improve access to telehealth services by Medicare Advantage enrollees.

“Through enhanced federal commitment to programs—stimulating the mental health workforce, furthering evidence-based practices, and advancing medical research—we can ensure the next generation of mental health professionals are well prepared to combat current and future health-related challenges,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., wrote in a letter to congressional leaders following the bill’s passage. “APA looks forward to continued collaboration to build and support robust systems of care, innovative programs, and a high-performing workforce to ensure the stability of our healthcare system now and for the future.”

Detailed information on the budget agreement will appear in the March 2 issue of Psychiatric News.

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ABMS Online Survey Seeks Feedback From Physicians on MOC

Physicians are invited to provide feedback about Maintenance of Certification (MOC) requirements through an online survey being conducted by the American Board of Medical Specialties (ABMS).

The survey is part of an ABMS initiative titled “Continuing Board Certification: Vision for the Future.” The feedback from the survey, which members of the public and other stakeholders are also invited to take, will help identify key concerns regarding MOC and inform the work of ABMS’s new Vision for the Future Commission. The commission will use the survey results as part of a comprehensive assessment of continuous board certification to make it "meaningful to physicians and the patients they serve well into the next decade." The commission will submit a draft report for public comment in November; a final report will be submitted to the ABMS Board of Directors in February 2019.

According to an ABMS spokesperson, the survey will be live for another three to four weeks.

The 27-member commission is co-chaired by psychiatrist Christopher Colenda, M.D., M.P.H., president emeritus of the West Virginia University Health System (WVUHS). According to the ABMS website, the commission will “engage and gather the perspectives of those involved and affected by physician certification, including practicing physicians; advocates for patients and the public; state medical societies; specialty associations and societies; accreditors; credentialing organizations; health care delivery systems; experts in assessment, learning, and quality improvement; certifying boards; and other professional organizations.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., said the survey is an opportunity for APA members to register their concerns about MOC and its relevance to physicians and patient care. “APA leadership continues to be aware of the serious concerns many members have about the current structure of MOC and continuing board certification,” Levin said. “We wholeheartedly support the value of lifelong learning but believe that the process for professional self-regulation needs to be clinically relevant and not add to the administrative burdens with which many physicians are already wrestling.

“I encourage APA members to use the ABMS survey to share their experience and expertise and help mold the future direction of MOC and continuing board certification,” he said.

For more information, see the Psychiatric News article “Board Opposes Use of MOC Status to Penalize Physicians.”

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APA Announces Winners of 2018 Election

APA’s Committee of Tellers has approved the following results of APA’s 2018 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting March 17-18.




President-Elect
Bruce J. Schwartz, M.D.

Treasurer
Gregory W. Dalack, M.D.

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

Early Career Psychiatrists Trustee-at-Large
Ayana Jordan, M.D., Ph.D.

Area 1 Trustee
Eric M. Plakun, M.D.

Area 4 Trustee
Cheryl D. Wills, M.D.

Area 7 Trustee
Annette M. Matthews, M.D.

Resident-Fellow Member Trustee-Elect
Rana Elmaghraby, M.D.

Complete results of the election will be reported in the March 2 issue of Psychiatric News.

For Better or Worse: Risk of Alcohol Use Disorder Rises When Spouse Is Diagnosed

A study of married couples in Sweden found that spouses strongly resemble one another in their risk for alcohol use disorder (AUD), with the way spouses interact with each other playing a strong causal role, according to a report published yesterday in JAMA Psychiatry.

Women in a first marriage with no history of AUD were nearly 14 times more likely to be diagnosed with AUD immediately after their husbands were diagnosed with AUD and about four times as likely after two years, compared with women who had no spousal exposure to AUD, according to Kenneth S. Kendler, M.D., at the Virginia Institute for Psychiatric and Behavioral Genetics and colleagues. Similarly, husbands with no history of AUD were more than nine times as likely to be diagnosed with AUD immediately after their wives were diagnosed, and about three times as likely after three years.

Researchers examined population, medical, pharmacy, and crime registries in Sweden to determine marital and AUD status, excluding married partners who did not reside together. First, they identified 8,562 married couples where neither had a history of AUD prior to marriage and one spouse developed AUD during the marriage. These couples were compared with individuals who did not reside with a spouse with an AUD. The researchers then studied 4,891 individuals with multiple marriages whose first spouse had no AUD diagnosis and second spouse did, or vice versa.

Researchers noted that individuals who remarried were more likely to move from having a spouse without AUD to a spouse with AUD than vice versa. When individuals moved from a marriage to a spouse with AUD to a spouse without the disorder, they cut their risk for AUD by half. By contrast, individuals who moved from a marriage to a spouse without the disorder to one with AUD greatly increased their risk of AUD (seven times the risk in women, and nine times the risk in men).

The report follows a 2016 study published in the American Journal of Psychiatry that men and women married to a spouse with no history of AUD are much less likely to experience AUD themselves. It concluded that while marriage generally was protective against the risk of alcohol use disorder, marriage to a spouse with AUD greatly increased the risk of the disorder for both men and women.

“Although genetic and biological factors contribute strongly to the predisposition to alcohol dependence, these findings complement our prior work on marriage and divorce in showing how close social bonds such as marriage can also powerfully influence, for better or worse, the risk for AUD,” the researchers concluded.

For related information, see the Psychiatric News article “Marriage May Decrease Future Risk of Alcohol Use Disorder.”

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Suicides Increased for Months After Death of Robin Williams, Report Suggests

In the five months following the death by suicide of the popular actor and comedian Robin Williams on August 11, 2014, there was a nearly 10% increase in the number of people who died by suicide in the United States, according to epidemiologists at the Columbia University Mailman School of Public Health. Although the uptick in suicides was seen across gender and age groups, men and those aged 30 to 44 had the greatest increases in suicides, according to the report published today in PLOS One.

“Research has shown that the number of suicides increases following a high-profile celebrity suicide, but this is the first study, to our knowledge, that has examined the effect of a high-profile suicide on the general population within the modern era of the 24-hours news cycle,” David S. Fink, M.P.H., M.Phil., of Columbia’s Department of Epidemiology said in a press release.

For the study, Fink and colleagues examined monthly suicide count data and monthly suicide rates from January 1999 to December 2015 by sex, age, and method, collected in a CDC database known as CDC Wonder. The researchers used a statistical method that took into consideration seasonal suicide patterns to estimate the number of suicides that took place between August and December 2014.

The model estimated that 16,849 suicides would occur from August to December 2014; however, 18,690 suicides—an excess of 1,841 suicides (9.85% increase)—were reported. Those aged 30 to 44 showed the greatest increase in suicides at 12.9%.

“[C]ompared to all other methods of suicide, the difference between the observed and predicted number of suicides was greatest and most consistent among suffocation suicides,” the authors wrote. “Specifically, we observed a 32.3% increase in the number of suffocation suicides in the five months that followed Williams’ death, compared to a 3.1% increase in the number of suicides from all other methods combined (for example, cutting/piercing, poisoning, firearm, falls, all other methods), albeit we found a higher than expected number of poisoning suicides and firearm suicides in August and September, respectively.”

The authors continued, “Although we cannot determine with certainty that the excess suicides were attributable to news media reports on Williams’ death, Williams’ death might have provided the necessary stimulus for high-risk segments of the U.S. population (for example, middle-aged men in despair) to move from suicidal ideation to attempt. … Suicide remains a central threat to public health, and high-profile celebrity suicides will continue to occur; preventing such effects will require substantial resources and training, as well as creative responses to emerging media.”

“The potent effects of celebrity suicide reported in this manuscript underscore the need for the media to follow guidelines for reporting suicides,” Maria A. Oquendo, M.D., Ph.D., APA past president and professor and chair of psychiatry at the Perelman School of Medicine at the University of Pennsylvania, told Psychiatric News by email. “Refraining from glamorizing the person in this context and emphasizing the fact that suicide is one of the most devastating sequelae of psychiatric conditions are essential.”

There are multiple resources on points to consider when reporting on suicide, including “Recommendations for Reporting on Suicide,” developed in collaboration with the American Foundation for Suicide Prevention, the National Institute of Mental Health, the Associated Press Managing Editors, and the CDC, among others.

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Prevalence of Fetal Alcohol Syndrome May Be Higher Than Previously Assumed, Study Suggests

The prevalence of fetal alcohol syndrome in the United States may be much higher than previous estimates have assumed, with conservative estimates suggesting as many as 1.1% to 5% of first-grade children in four communities are affected, according to a report published today in JAMA.

The results suggest that physicians should be alert to identifying women of child-bearing age who may be at risk for alcohol abuse.

“These prevalence estimates are consistent with mounting evidence that harmful fetal alcohol exposure is common in the United States today,” Philip A. May, Ph.D., of the University of North Carolina at Chapel Hill and colleagues wrote. They “may represent more accurate U.S. prevalence estimates than previous studies but may not be generalizable to all communities.”

Using “active case ascertainment”—an especially rigorous study method for case identification—May and colleagues sampled more than 6,000 first graders in four communities: the Rocky Mountain, Midwestern, Southeastern, and Pacific Southwestern regions. The researchers systematically assessed the children in the four domains relevant to fetal alcohol spectrum disorders: physical growth, dysmorphic features, neurodevelopment, and prenatal exposure. Prenatal exposure was assessed through maternal interviews conducted by trained study staff in person or over the telephone.

Of 6,639 children selected for participation (out of a first-grade population in the four regions of more than 13,000), a total of 222 cases of fetal alcohol spectrum disorders were identified. “Only 2 of the 222 children classified with a fetal alcohol spectrum disorder had been diagnosed previously with the disorder, although many parents and guardians were aware of the learning and behavioral challenges facing their children,” the authors noted.

The researchers derived a conservative estimate (which assumed that those children not included in the final sample did not have fetal alcohol syndrome) of 11.3 per 1,000 children (1.1 percent) in one Midwestern sample to a high of 50 per 1,000 (5 percent) in one Rocky Mountain sample. A second estimate (in which those children not sampled were assumed to have the same rate of fetal alcohol syndrome as the sampled population) ranged from 31 children per 1,000 to 98.5 per 1,000.

“Although the different approaches reflect the uncertainty about the actual prevalence, these new estimates are up to 10 times higher than those previously reported using similar methods from two single-site studies and up to five times higher than a recent meta-analysis of studies from the United States with a pooled prevalence of 2%,” Shannon Lange, M.P.H., Jürgen Rehm, Ph.D., and Svetlana Popova, Ph.D., wrote in an accompanying editorial. The finding that “fetal alcohol spectrum disorders is not a rare condition among the general U.S. population has substantial implications for clinicians and researchers, including that many cases are either missed or misdiagnosed…”

They added, “As the first point-of-contact, physicians and other health care professionals have an important role in prevention and identification. Special attention should be paid to young women who may engage in binge drinking because it can lead to unprotected sex and unplanned pregnancy.”

For related information, see the Psychiatric News article “Strategy Emerges to Combat Effects of Prenatal Alcohol Exposure.”

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Despite Setbacks, Search for Alzheimer’s Therapy Moves Forward

Treatment targeting amyloid beta—a protein that has long been assumed to cause Alzheimer’s disease (AD) through its accumulation in the brain—remains a major focus of research on potential pharmacological treatments, but drug candidates aimed at alternative pathways are catching up in development. Psychiatric News PsychoPharm has compiled a list describing some of the AD drugs in development you may hear more about in the coming year.

The most robust group of non-amyloid drugs are agents that targets tau, another protein that can form toxic aggregations in the brain. Two anti-tau monoclonal antibodies—ABBV-8E12 and RO7105705—are currently in phase 2 clinical trials, while a third BIIB092 will soon begin recruiting patients for a phase 2 trial. This class of medications has experienced its own share of failures, however; the anti-tau drug LMTM—a derivative of the chemical dye methylene blue—recently fizzled in a phase 3 study.

Among other classes of drugs, azeliragon, a small molecule that inhibits the receptor for advanced glycation end products (AGEs), is currently undergoing a phase 3 study. AGE receptors are involved in transporting amyloid beta fragments into brain cells but they are also associated with inflammation. Another agent in the pipeline is lumateperone, a molecule that targets several types of serotonin, dopamine, and glutamate receptors. Lumateperone is not a cognitive agent; rather it is being tested for the treatment of agitation in AD and other dementias.

In parallel with these trials, new tools are being developed to sharpen the picture of a brain with AD. Many recent trials rely on biomarkers from brain scans or cerebral spinal fluid samples to identify people with early stage AD; these approaches are effective but also expensive and invasive. A study published by researchers in Australia and Japan last week identified blood-based biomarkers that might identify people with prodromal AD, which could greatly speed up the recruiting process for clinical studies.

For related information, see the Psychiatric News article “Long-Term SSRI Use May Slow Progression to Alzheimer’s Dementia.”

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ECT Said to Be Underutilized to Treat Major Depression, Bipolar Disorder

Despite its effectiveness in treating severe depression, the use of electroconvulsive therapy (ECT) is “exceptionally uncommon and limited to patients with extensive multimorbidity,” according to a report published Thursday in Psychiatric Services in Advance.

Samuel Wilkinson, M.D., of Yale School of Medicine and colleagues compared the sociodemographic and clinical characteristics of privately insured Americans with major depressive or bipolar disorder who received ECT and those who did not.

The authors found that among the selected individuals in the 2014 MarketScan commercial insurance claims database (N=47,258,528), the ECT utilization rate was 5.56 ECT patients per 100,000 in the population. Of the 969,277 patients with major depression or bipolar disorder, 2,471 (0.25%) received ECT.

Those who received ECT had substantially higher rates of comorbid psychiatric disorders, higher numbers of prescription fills for any psychotropic medication, higher rates of any substance use disorder, and total outpatient psychotherapy visits. States in the west region had significantly lower ECT rates. The disparity was accounted for by strict legal requirements for ECT in one of the states in that region.

“Whereas standard antidepressant therapies achieve response with 16%-17% of patients with treatment-resistant depression, ECT achieves response rates of 50%-70% with such patients. Recent data show that among psychiatric inpatients, ECT is associated with a 46% lower risk of 30-day readmission compared with a matched group of patients with severe depression who did not receive ECT,” Wilkinson and colleagues wrote.

“Given what we know about the prevalence of treatment-resistant depression (TRD), our study suggests that less than 1% of these patients receive ECT,” Wilkinson told Psychiatric News. “Defining an ‘appropriate’ rate of utilization can be challenging. [But to only use for] 1% of TRD patients and 0.25% of patients with major depression or bipolar disorder is significant underutilization.”

Wilkerson and his colleagues noted that underutilization of ECT is thought to reflect a combination of factors, including stigma, risk of cognitive side effects, and restricted access because of limited availability.

For more on this topic, see the Psychiatric News article “Psychiatric Readmissions Lower Among Patients Receiving ECT.”

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Young People With Psychotic Disorder at Highest Risk of Death in Year Following Diagnosis

Young patients newly diagnosed with a psychotic disorder are at higher risk for mortality, mostly due to injuries and poisoning, particularly for the first year or two after diagnosis, according to a study published Wednesday in JAMA Psychiatry.

In fact, the adolescents and young adults studied were more than eight times more likely to die within the first year of being treated for an initial psychotic disorder diagnosis than were patients who received other outpatient services, according to the report by Gregory E. Simon, M.D., M.P.H., of Kaiser Permanente Washington Health Research Institute and colleagues. After initial diagnosis of unipolar depression, patients were three times more likely to die than general outpatients.

For this cohort study, researchers examined eight years of records from several health systems that serve more than 8 million members. They examined records for 11,713 patients aged 16 through 30 who were first diagnosed with a psychotic disorder along with two comparison groups: 35,576 patients who received outpatient services and 23,415 patients with a first diagnosis of unipolar depression.

The researchers found that for every 10,000 patients, 55 of those with a first diagnosis of psychotic disorder died within the first 12 months, compared with 21 deaths of those with first diagnosis of unipolar depression and 7 of those seen by general outpatient services. Of the 64 patients who died within a year of a psychotic disorder diagnosis, more than half were from injuries or poisoning (34% self-inflicted, 17% unintentional). For patients with an initial diagnosis of unipolar depression, more than half of the 48 deaths (54%) were self-inflicted.

Overall mortality and mortality due to injuries and poisonings decreased gradually during the three years after initial diagnosis with psychosis. However, such mortality remained elevated in comparison with patients who received general outpatient health services and those who were newly diagnosed with unipolar depression.

“Our findings support the importance of systematic early intervention for young people experiencing the first onset of psychosis. Strong evidence supports the effectiveness of coordinated specialty care programs for improving clinical outcomes,” the researchers noted. They added that few such patients receive this type of care. Some studies have suggested that continuous treatment with antipsychotic medication may also reduce mortality in this group.

For related information, see the AJP in Advance article “Care Pathways Before First Diagnosis of a Psychotic Disorder in Adolescents and Young Adults” and the Psychiatric News article “Gralnick Award Lecturer Emphasizes Importance of First-Episode Treatment.”

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