Doctors Release Charter Calling for Policies to Support Physician Well-Being

Taking steps to support physician well-being benefits patients, physicians, and the health care system, but how can organizations, medical leaders, and policymakers take steps toward achieving this goal?

This was the question that medical educators, leaders at academic medical centers, and experts in burnout from the Collaborative for Healing and Renewal in Medicine set out to answer in the “Charter on Physician Well-Being.” The charter, published yesterday in JAMA, offers a framework for promoting physician wellness, beginning in early training. Publication of the charter comes at an opportune time since today is National Doctors' Day.

Several of the key commitments identified by the group include the following:

Advocate for Policies That Enhance Well-Being: This section describes the importance of policies that “better align regulatory and documentation requirements with clinical activity” and reduce excessive administrative work. It also notes the importance of establishing processes to encourage physicians to seek routine mental health care without fear of licensing penalty.

Develop Engaged Leadership: This section describes the role that leaders within medical schools, residency programs, hospitals, health care systems, and more can play in advocating for the well-being of students, residents, and physicians as an organizational priority.

Anticipate and Respond to Inherent Emotional Challenges of Physician Work: Adverse events, patient deaths, and exposure to the pain and distress of patients and their families are inherent to physician work. “Incorporating coping strategies for such experiences into training and continuing education may help mitigate their effect, promote emotional awareness, and normalize seeking support,” the authors wrote.

Prioritize Mental Health Care: Individuals and organizations can do more to encourage students, trainees, and physicians to seek mental health care. This section describes how making confidential mental health services available during off hours and supporting coverage to attend appointments might decrease barriers to seeking care. “More broadly, psychological support should be considered as a means to optimize physician performance proactively rather than solely as a response to crises,” the authors wrote.

“The Charter on Physician Well-Being is intended to inspire collaborative efforts among individuals, organizations, health systems, and the profession of medicine to honor the collective commitment of physicians to patients and to each other,” the authors concluded.

In an accompanying article, Thomas Schwenk, M.D., of the University of Nevada Reno School of Medicine cautioned, “Physicians in 2018 are the proverbial ‘canary in the coal mine.’ While the canary may be sick, it is the mine that is toxic. Caring for the sick canary is compassionate, but likely futile until there is more fresh air in the mine.”

“This is a first step on a national level to lay out guiding principles and commitments that we consider essential for physician well-being throughout a career, beginning with the earliest training,” Colin West, M.D., Ph.D., a clinician and researcher at Mayo Clinic and senior author of the charter, said in a press release.

APA’s toolkit to help psychiatrists achieve well-being and address individual and system-level challenges that contribute to professional burnout is posted at “Well-being and Burnout.”

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Maintenance Ketamine May Offer Alternative for Patients With Treatment-Refractory Anxiety Disorders

A small, open-label study of patients with treatment-refractory anxiety found that most patients who responded to ketamine remained in remission with maintenance treatment over a three-month period, according to an article in the March issue of the Journal of Psychopharmacology.

“Ketamine treatment was safe and well tolerated, and most patients reported marked improvement in work and social functioning,” wrote Paul Glue, M.D., a professor at the School of Medical Sciences at the University of Otago in New Zealand, and colleagues.

The researchers recruited patients with treatment-refractory generalized anxiety disorder (GAD) and/or social anxiety disorder (SAD) who had responded to ketamine in a previous study. Over a three-month period, the study participants were administered 1 mg/kg of ketamine by subcutaneous injection. Patients remained on current medication regimens and/or continued with ongoing psychotherapy over the course of the trial, but no new treatments were started or doses/visit schedules altered over the course of the trial.

In total, 20 patients received ketamine injections at least weekly (16 patients received one ketamine injection weekly, and four patients whose symptoms recurred at about four days received the injection twice weekly). The researchers assessed patient levels of anxiety using the Fear Questionnaire and the Hamilton Anxiety Scale before each ketamine injection, as well as one and two hours after they had received the injection. Dissociation was assessed using the Clinician Administered Dissociative States Scale.

One hour after receiving the ketamine injection, Fear Questionnaire ratings decreased by about 50%, as did Hamilton Anxiety ratings. The patients’ mean scores on the Clinician Administered Dissociative States Scale also declined over time, from 20 points at Week 1 to 8.8 points at Week 14. The most common nondissociative adverse events reported by the patients were nausea, dizziness, and blurred vision.

Of the 18 patients who completed the trial, all reported improved social and/or work functioning during the three months of maintenance treatment. Once maintenance treatment ended, five patients (25%) remained well over at least three months of follow-up. Eight patients reported partial re-emergence of anxiety symptoms, and five patients reported full re-emergence of anxiety symptoms within two weeks of their last ketamine dose.

The researchers concluded that maintenance ketamine may be a therapeutic alternative for patients with treatment-refractory GAD/SAD. “Their experience of ketamine treatment enabled them to make substantial changes to their lives (for example, employment, study, making friends, engaging socially, and travelling),” the authors wrote. “Reduced anxiety meant everyday tasks were less onerous. Most patients reported an increase in their ability to concentrate, leading to improvement in their functionality.”

Glue and another researcher for this study have contracts with Douglas Pharmaceuticals to develop novel ketamine formulations.

For related information on ketamine, see the Psychiatric News article “‘Cautious Optimism’ Marks Outlook for Ketamine, Mood Disorders.”

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Irritability in Childhood May Point to Adolescents at Greater Risk of Suicide

Children who display high levels of depressive/anxious mood symptoms and irritability appear to be at a greater risk of suicide during adolescence, according to a study published today in JAMA Psychiatry.

The findings suggest that “childhood irritability should be considered when assessing adolescent suicidal risk, especially among those presenting with symptoms of high depressive/anxious mood,” wrote Massimiliano Orri, Ph.D., of McGill University and colleagues.

To investigate the association of childhood irritability and depressive/anxious mood with adolescent suicidality, Orri and colleagues pulled data from the Québec Longitudinal Study of Child Development (QLSCD). The study included infants born in Québec in 1997 and 1998 who were assessed annually during childhood and biannually during adolescence through age 17.

The QLSCD dataset included evaluations by school teachers of depressive/anxious mood and irritability in the children at 6, 7, 8, 10, and 12 years. Teachers were asked to rate the children on multiple symptoms of depressive/anxious mood (including crying and worrying) and irritability (including temper tantrums and aggressive reactions when teased or something was taken away). At ages 13, 15, and 17, the youth were asked about whether they had ever seriously thought about attempting suicide and, if so, how many attempts they had made.

Of the 1,430 children who were followed up to age 17, 172 (12.0%) adolescents reported suicidal ideation or suicide attempt, 90 (6.3%) reported serious suicidal ideation, and 82 (5.7%) reported suicide attempt.

Children who were categorized as having high irritability and high depressive/anxious mood reported higher rates of suicidality (25 of 152, or 16.4%) as adolescents compared with children with the lowest symptom levels (91 of 831, or 11.0%). Children with high irritability and high depressive/anxious mood were twice as likely to report serious suicidal ideation and/or to attempt suicide during adolescence compared with those with low irritability and low depressive/anxious mood. Girls categorized as having high irritability and high depressive/anxious mood had a higher risk of suicidality (odds ratio, 3.07) than boys (odds ratio, 2.13).

“Manifestations of irritability during childhood are associated with a significant risk for suicidal behaviors during adolescence,” Orri and colleagues wrote. “This risk was especially high when high levels of irritability were accompanied by high levels of depressive/anxious mood and particularly for girls.”

For related information on suicide, see the Psychiatric News article “Impulsivity May Be Strong Contributor to Childhood Suicides.”

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Patients With Early Psychosis May Benefit From App on How to Cope With Symptoms

Actissist—a smartphone app that prompts patients with early psychosis to share information about psychotic symptoms and responds with tips on how best to manage these symptoms—may offer an advantage over apps that capture data about symptoms alone, according to a report published in Schizophrenia Bulletin.

Sandra Bucci, D.Clin.Psy., of the University of Manchester and colleagues randomly assigned 36 patients with early psychosis to use either Actissist or ClinTouch (a symptom monitoring app) and receive treatment as usual (regular clinician meetings, medication, risk monitoring, and psychosocial interventions) for 12 weeks.

Patients assigned to the Actissist and ClinTouch groups received regular daily notifications from the smartphone apps, prompting them to answer questions about symptoms, but the steps that followed once a patient submitted a response to the notification differed.

“If [an Actissist] user accepts a notification or initiates use, they are invited to select an intervention domain(s) [for instance, “suspicious thoughts”] and then complete a series of self-assessment questions structured as question-answer exchanges that focus on cognitive appraisals, belief conviction, emotions, and associated behaviors,” Bucci and colleagues wrote. “Depending on the appraisal selected, the exchange is followed by … cognitive or behavioral strategies aimed at suggesting ways of coping with distressing experiences.”

In contrast, ClinTouch invited participants to use a touchscreen slider to rate the severity of 12 symptoms on a scale of 1 to 7, and the data were uploaded to a secure server.

Researchers blind to treatment assignment completed assessments of patients at baseline, 12 weeks, and 22 weeks. The primary outcome of the study was feasibility, which was assessed in terms of uptake (the proportion of eligible participants consenting to the study), attrition, the proportion of participants completing user and alert-initiated data entries across participants (>33% data points), and the proportion continuing for 12 weeks. During the assessments, the researchers asked participants about the frequency, intensity, and distress of psychotic symptoms; health status and health-related quality of life; and more.

Overall, the study showed that Actissist was “feasible” (75% participants used Actissist at least once/day, “acceptable” (97% participants remained in the trial), and “safe” (0 serious adverse events), with high levels of user satisfaction and indications of a beneficial effect that surpassed that of the control group. Additional analysis suggested that there were improvements in key outcome measures, including PANSS negative score and general and total scores, in the Actissist group relative to the control group after treatment ended. While effects were not fully sustained at 22-week follow-up, the patients did not decline on any of the clinical outcomes measured.

“Smartphone-extended care could drive improvements in quality, efficiency, cost, and access to treatment, while enhancing patient experience,” the authors wrote. “Our findings suggest that the Actissist system may confer additional benefits over routine mobile symptom monitoring in the short term. Participants were engaged, active, and adherent with the system.”

For related information on digital interventions, see the Psychiatric Services articles “Using Digital Media Advertising in Early Psychosis Intervention” and “A Hierarchical Framework for Evaluation and Informed Decision Making Regarding Smartphone Apps for Clinical Care.”

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Eligible ABPN Diplomates Invited to Enroll in Pilot Test for MOC Part III Alternative

The American Board of Psychiatry and Neurology (ABPN) is piloting a new open-book, journal article–based assessment beginning in 2019 as an alternative to the proctored 10-year Part III Maintenance of Certification (MOC) examination. ABPN sent out an email last week inviting diplomates who are eligible to participate in the pilot to enroll in the program by May 1; participation is optional.

Participants in the pilot program will be required to read and answer questions on between 30 and 40 journal articles. They may choose from a library of articles that have been selected for the test by the ABPN Pilot Project Test Writing Committees. The pilot project will run for three years, from 2019-2021. If approved by the American Board of Medical Specialties (ABMS), the ABPN plans to transition diplomates into this program in 2022 as a permanent alternative to the secure MOC examination.

Diplomates who are eligible to participate in the pilot program are those who are currently certified and who fall into one of two categories: those who have earned ABPN certification or who passed the MOC examination in the years 2012, 2013, or 2014 in psychiatry, child and adolescent psychiatry, neurology, or child neurology; or those whose certificate is expiring in 2019, 2020, or 2021 in psychiatry, child and adolescent psychiatry, neurology, or child neurology.

Here are enrollment instructions for diplomates who are eligible to participate:

• Log in to your ABPN Physician Folios account.
• Click on the “Part III Pilot” tab in the Maintenance of Certification section.
• Review and respond to the MOC Pilot Project Enrollment Agreement.
• Respond Yes/No to Pilot Project enrollment by May 1.

APA leaders said that the article-based, open-book test option is an important step in making MOC more flexible.

“Requirements around Maintenance of Certification are among the most prominent concerns of our members, and many have been asking for an alternative to the 10-year, secure, proctored exam,” APA President Anita Everett, M.D., told Psychiatric News. “APA has been advocating for something similar to the open-book, journal article–based assessment, and we hope it provides an attractive option for members to consider.”

APA CEO and Medical Director Saul Levin, M.D., said the new program “provides more flexibility in terms of diplomates being able to select articles that are relevant to their own practice. It allows diplomates to read the articles and complete the test at their own pace.”

Additional information about the pilot program is posted on ABPN’s website. Those who have questions about enrollment or the program should send them to questions@abpn.com or call (847) 229-6512.

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Individuals With Aggression-Related Diagnoses Are More Likely to Have Had Mild Head Injuries

Clinicians evaluating individuals with intermittent explosive disorder or self-directed aggression should be sure to ask them about a history of head injury, concluded a study published earlier this month in the Journal of Neuropsychiatry and Clinical Neurosciences.

Individuals with intermittent explosive disorder, as well as people with a history of suicidal or self-injurious behavior, were found to be twice as likely to have a history of mild traumatic brain injury (mTBI) than those with other psychiatric disorders or healthy controls, according data from a study by Emil F. Coccaro, M.D., of the University of Chicago and Caterina Mosti, Ph.D., of Drexel University.

Mild TBI is highly prevalent, with more than 1.3 million injuries occurring in the United States each year. Additionally, some 15% of returning military service personnel are estimated to have sustained an mTBI. Since many people who experience mild head injury do not seek medical treatment, this is likely a significant underestimation, the authors wrote. While the resulting cognitive, physical, and emotional consequences typically resolve within three months of the injury, a growing body of research suggests that 10% to 31% of those with mTBI injuries suffer lingering physical symptoms and mood disturbances.

To explore the relationship between history of mTBI and aggression, the researchers interviewed 1,634 physically healthy adults (this group included 695 participants with intermittent explosive disorder, 486 participants with a current/lifetime diagnosis of a psychiatric disorder that was not intermittent explosive disorder, and 453 with no psychiatric disorder). During these interviews, study participants were asked to report any history of mTBI (defined as a blow to the head associated with mild neurological symptoms including any of the following: dizziness, disorientation, memory difficulties lasting less than 24 hours, or loss of consciousness of less than 30 minutes). The participants were also asked questions about aggressive and impulsive behaviors.

Among patients who had a mTBI, 11% had no evidence of psychiatric disorder, 12% had a psychiatric or personality disorder (other than bipolar or schizophrenia/psychotic disorders), and 24% had intermittent explosive disorder. About 25% of those with mTBI had suicidal and/or self-injurious behavior. Participants reporting two or more loss of consciousness episodes had the highest aggression scores of all groups.

“On the basis of these data alone, we cannot say whether the presence of high trait impulsivity and aggression led IED [intermittent explosive disorder] participants to be in circumstances that increase risk for mTBI or whether history of mTBI altered the brains of mTBI participants, leading to an increase in aggressive and impulsive behavior post-mTBI,” the authors wrote. “That said, impulsive-aggressive behaviors are present from very early life, and individuals with this temperament are likely to place themselves in circumstances associated with bodily injury, including mTBI.”

For related information on aggression following TBI, see the Psychiatric News article “Amantadine May Reduce Aggression in TBI Patients.”

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Review Examines Evidence to Support Use of Prenatal Supplements to Prevent Mental Illness

Previous studies suggest that certain prenatal supplements can enhance fetal brain development, but less is known about whether these supplements decrease the subsequent risk of mental illness in offspring. A review published Wednesday in AJP in Advance suggests that while prenatal nutrients may offer some protective mental health benefits to the offspring, there are some health risks.

AJP Editor Robert Freedman, M.D., of the University of Colorado School of Medicine and colleagues conducted a literature search for human studies that included the keyword “micronutrients” combined with “pregnancy” or “fetal development” that were published between 1990 and 2017. Thirty-five human studies and trials of individual nutrients were identified that included reports on subsequent child behavior, emotion, or cognition in one or more articles. Freedman and colleagues identified four supplements as a result of this literature review: folic acid, omega-3 fatty acids, phosphatidylcholine, and vitamins D and A.

Key findings of the review included the following:

• Folic acid and phosphatidylcholine supplements appear to reduce social and emotional problems in young children that are associated with later mental illness. More research is needed to establish whether these supplements can reduce the risk of psychiatric disorders such as schizophrenia.
• Vitamin A and D supplements appear to decrease the risk for schizophrenia and autism. However, at higher doses these vitamins can be toxic to both mother and child. The authors wrote, “Supplementation should not be greater than the amount in standard multivitamins.” (The daily recommendation in the United States for vitamin D is 600 IU for pregnant women and 400 IU for infants.)
• Omega-3 fatty acid supplements during pregnancy appear to increase the risk for schizophrenia and attention-deficit/hyperactivity disorder (ADHD) symptoms; however, other studies show that omega-3 supplements can substantially reduce the risk of premature birth, which is also a risk factor for ADHD.

Freedman and colleagues noted that more research is needed to understand the relationship between prenatal nutrients and mental health of offspring; of the 35 studies they analyzed for the review, only five were randomized, controlled clinical studies. “To obtain [substantive] evidence for any nutrient will require new research agendas that emphasize prenatal clinical trials of interventions, early biomarkers of their effectiveness developed in translational models, and then longer-term follow-up through childhood developmental stages into adulthood,” the authors wrote.

“In the absence of definitive evidence, parents currently planning pregnancy now have difficult decisions about nutrient supplements,” the authors continued. “The mother is unlikely to receive fully effective levels of the currently studied nutrients from diet alone. Adverse effects of supplements are few at the doses studied, but it would be premature to conclude that they are nonexistent. Conversely, there is only one opportunity in each child’s life for intervention to enhance fetal brain development and protect the child against developmental risks that arise in this period.”

To read more about this topic, see the Psychiatric News article “Long Career Studying Choline Leads to Public Health Payoff.”

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Study Offers Clues About Neural Biomarkers of Resilience to Depression

While numerous studies have examined risk factors for the transmission of familial depression, fewer have explored the factors that might protect individuals from developing this disorder. A report published today in JAMA Psychiatry suggests adolescent girls who appear resilient to depression may have greater connectivity in brain networks known to play a key role in the processing and regulation of emotion, motivation, and self-awareness.

For this longitudinal study, Adina S. Fischer, M.D., Ph.D., of Stanford University and colleagues conducted clinical and behavioral assessments every 18 months on a group of girls from age 9 to 18. Half of the girls had a mother who had recurrent major depressive disorder (MDD) episodes during her daughter’s lifetime (high risk); the other half had mothers with no history of depression (low risk). Approximately six years after the start of the study, adolescents in the high-risk and low-risk groups received a resting-state functional magnetic resonance imaging (fMRI) scan.

Fischer and colleagues compared data from the fMRI scans of 20 adolescents in the high-risk group who did not develop MDD (resilient) with 20 in the high-risk group who developed MDD (converted) and 25 adolescents in the low-risk group who did not develop depression (control).

Compared with adolescents who developed depression and those in the control group, adolescents in the resilient group had greater connectivity between the amygdala and prefrontal cortex—two regions known to be involved with emotion processing and regulation. Resilient adolescents also had greater connectivity between regions of the executive control network (implicated in explicit emotion regulation, including cognitive reappraisal and impulse control) than did adolescents who developed depression and the control peers. Both high-risk groups (resilient and converted) differed from controls in salience network connectivity, with the strongest salience network connectivity in the converted group. (The salience network is implicated in self-awareness and integrating stimuli.)

“Our findings suggest that high-risk adolescent females in the resilient group have greater ‘top-down’ control over emotions and behavior than do high-risk adolescent females who develop depression. … [T]his provides a possible mechanism and target through which therapeutic interventions aimed at strengthening these connections could increase resilience in high-risk populations.”

In an accompanying editorial, Scott A. Langenecker, Ph.D., and colleagues at the University of Illinois at Chicago wrote, “The work of Fischer and colleagues provides an important foundation for studying neurobiological factors, such as functional connectivity, that may reflect resilience for daughters of depressed mothers. … This type of work ultimately increases our understanding of promotive factors that can be strengthened, existing techniques that facilitate resilience, and the ways in which these techniques might be improved and more widely disseminated.”

For related information on resilience to psychiatric disorders, see the American Journal of Psychiatry article “The Role of Intrinsic Brain Functional Connectivity in Vulnerability and Resilience to Bipolar Disorder.”

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Survivors of Self-Harm at High Risk of Repeat, Suicide Over Following Year

Teenagers and young adults who deliberately hurt themselves are at markedly increased risk of suicide within one year, especially if the original self-harm incident involved violent methods such as using firearms, according to a report published Monday in Pediatrics.

According to lead author Mark Olfson, M.D., M.P.H. (pictured left), and colleagues, the results speak to the need for urgent clinical attention to young people who self-harm. “Clinical priority should be given to ensuring the safety of young people after self-harm, which may include treating underlying psychiatric disorders, restricting access to lethal means, fortifying psychosocial supports, and close monitoring for emerging suicidal symptoms,” they wrote.

Olfson and colleagues analyzed a cohort of 32,395 Medicaid patients aged 12 to 24 who had been diagnosed with deliberate self-harm. The cohort was followed from their index self-harm until the end of a 365-day follow-up period, date of death, or end of available data, whichever came first. The primary outcomes of interest were repeat, nonfatal self-harm and suicide.

Within a year after the initial self-harming incident, teenagers and young adults were at 26.7 times higher risk of suicide than those in the general population matched for age, sex, or race and/or ethnicity. Approximately 17% of the self-harm patients (n=5,545) had another incident of non-fatal self-harm during the follow-up year.

For self-harm patients who initially used firearms, the risk of suicide during the following year was 35 times greater than for those who harmed themselves by nonviolent means. Additionally, the odds of suicide were more than five times higher for American Indian and Alaskan native patients than for white non-Hispanic patients.

“For high-risk young people with access to firearms, distributing trigger locks and urging family members to store firearms away from the patient’s home can be a lifesaving precautionary measure,” Olfson and colleagues wrote.

For more information on self-harm, see the Psychiatric News article “Upping Our Game to Prevent Suicide,” by APA President Anita Everett, M.D., and the Psychiatric Services article “Denial of Suicide Attempt Among Hospitalized Survivors of a Self-Inflicted Gunshot Wound.”

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Childhood TBI Increases Risk of ADHD for Several Years

Traumatic brain injury (TBI) during early childhood is known to increase the risk of developing attention-deficit/hyperactivity disorder (ADHD) in the first two years following the injury; this is known as secondary ADHD (SADHD). A study published today in JAMA Pediatrics now shows that the risk for SADHD can extend for at least seven years after the TBI.

These findings “suggest that physicians and other clinicians should continue to be vigilant in monitoring attention problems in patients with a history of brain injury, even if it has been a number of years since the injury, the injury was moderate in nature, or the patient experienced a predominantly positive recovery,” wrote Megan Narad, Ph.D., of Cincinnati Children’s Hospital Medical Center and colleagues. This vigilance will aid in more timely identification of SADHD cases, the authors continued, which could reduce the functional impairments these children may face.

Narad and her team enrolled 187 children between the ages of 3 and 7 who were hospitalized overnight with either a TBI (81 children) or an orthopedic injury  (106 children; the control group). All participants were periodically assessed for SADHD until they reached middle school. The final assessments took place an average of 6.8 years after the initial injury.

Of the 187 children, 48 (25.7%) met the researchers’ definition of SADHD by the study’s end. These included 13 children with severe TBI at enrollment, 6 with moderate TBI, 13 with complicated mild TBI, and 16 with an orthopedic injury. Almost half of the children with TBI who later developed SADHD (15 of 32) did so more than one year after their injury.

An analysis of these outcomes revealed a 3.62-fold increased risk of SADHD among children with severe TBI compared with children with an orthopedic injury. Children with mild or moderate TBI had about a 1.7-fold increased risk of SADHD, but these data were not statistically significant. The authors also found that among children with TBI, family dysfunction was associated with a statistically significant 4.24-fold increased risk of SADHD.

“Findings about the association of family functioning with the development of attention problems after TBI also support previous research highlighting the importance of allocating resources to the injured child’s family throughout recovery,” Narad and colleagues concluded. “Assessing family functioning, identifying families at risk, and developing programs to promote healthy family functioning to foster positive outcomes should be integrated into clinical practice when working with patients and families with a history of TBI.”

To read more about TBI, see the Psychiatric News article “FDA Clears the Way for First Blood Test to Evaluate Head Injuries.”

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Adolescents With Mental Health Conditions More Likely to Transition to Long-Term Opioid Therapy, Study Finds

Adolescents with preexisting mental health conditions may be more likely than their peers to transition from a first opioid prescription to long-term opioid therapy, according to a study published this week in JAMA Pediatrics.

“Given the limited support for the efficacy of opioid therapy for chronic pain among youths, research is needed to understand potential adverse effects of LTOT [long-term opioid therapy] among adolescents as well as the role that preexisting mental health conditions may play in harmful outcomes,” lead author Patrick D. Quinn, Ph.D., of Indiana University and colleagues wrote.

For the study, Quinn and colleagues analyzed data from the 2003-2014 Truven Health MarketScan Commercial Claims and Encounters (MarketScan) databases of commercial health care insurance claims. The researchers identified a cohort of more than 1.2 million adolescents aged 14 to 18 who received opioids for the first time during this period. The researchers then tracked this group from their first prescription until their first disenrollment or December 31, 2014 (whichever occurred first), to examine subsequent long-term opioid therapy (defined as more than 90 days’ supply within a six-month window having no gaps in supply of more than 32 days).

Associations between preexisting mental health conditions and treatments and any opioid receipt were examined by comparing adolescents who received any opioid analgesic with those who did not matched on sex, calendar year and years of age of first enrollment, and months of enrollment.

The authors found that 3.0 per 1,000 opioid recipients transitioned to long-term opioid therapy within three years of fulfilling an initial opioid prescription. “Although adolescents with a wide range of preexisting mental health conditions and treatments were modestly more likely than adolescents without those conditions or treatments to receive an initial opioid, the former had substantially higher rates of subsequent transitioning to LTOT [long-term opioid therapy],” the authors wrote. 

“There is a clear need for mental health assessment among adolescents being considered for opioid therapy. Such an assessment may help inform decision making regarding pain treatment as well as illuminate the possible value of concomitant mental health interventions,” they concluded.

In an accompanying editorial, Michael J. Mason, Ph.D., of the University of Tennessee, Knoxville, wrote, “These findings are important clinically and provide a foundation for future research to test the efficacy and potential adverse effects of long-term opioid therapy for adolescents with and without comorbid diagnoses. This research has highlighted the need to address comorbidity by addressing the accompanying risk and protective factors—a challenging task but one that would provide immediate translational guidance for pediatric practitioners.” 

For related information, see the Psychiatric News article “Many Prescription Opioids Go to Adults With Depression, Anxiety.”

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Nondisclosure of Suicidal Intent Following Gunshot Wound Presents Barrier to Care, Study Finds

Some survivors of self-inflicted gunshot wounds falsely deny their injuries are a result of a suicide attempt. According to a study published today in Psychiatric Services in Advance, these patients are far less likely to receive inpatient psychiatric care following their injury than those who disclose suicidal intent.

The results highlight the importance of increased assessment, intervention, and psychoeducation for survivors of self-inflicted gunshot wounds, particularly while they are hospitalized on medical floors, wrote Michael Matthew McClay, M.S., of Western Kentucky University, Stephen S. O'Connor, Ph.D., of the University of Louisville, and colleagues. Because survivors of suicide attempts are at high risk of recurrence, correctly identifying these individuals is critical so treatment and prevention efforts can ensue, wrote the authors.

About 44,000 people die by suicide every year in the United States, making it the 10th most common cause of death. Suicide attempts occur at an even greater rate and result in more than 316,000 hospital admissions and $51 billion in combined costs of medical care and loss of work each year, the authors wrote.

The researchers examined electronic medical record data from 128 survivors of self-inflicted gunshot wounds at a trauma center in Tennessee; more than 25% of these patients were known to have made a prior suicide attempt.

Overall, 71% of the survivors of self-inflicted gunshot wounds disclosed that it was a suicide attempt, and 29% denied it. Of patients who denied the suicide attempt, about 40% (16 patients) were flagged during a psychiatric consultation as presenting under circumstances suspicious of a suicide attempt. Suicide attempt was suspected in some cases due to reports from witnesses or conflicting stories by the patients regarding the circumstances of their injury, for instance.

Patients who denied their suicide attempt were more than 10 times more likely to be discharged to home than to inpatient care, compared with patients who disclosed an attempt, the study found.

“Within acute care center settings, the desire to avoid inpatient psychiatric hospitalization and documentation in the medical record may be barriers to reporting that a self-inflicted gunshot wound was intentional,” the researchers wrote. “[T]he results indicate a need for further reflection on ways in which usual care in health systems (such as inpatient hospitalization) may present a barrier for eliciting honest reports from suicide attempt survivors due to a fear of hospitalization.”

For related information, see the book Gun Violence and Mental Illness, co-edited by Liza Gold, M.D., and Robert I. Simon, M.D.

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Adults Who Play Violent Video Games Appear No More Aggressive Than Those Who Don’t

Frequently playing violent video games does not appear to promote aggression, reduce empathy, or alter mood and cognition in healthy adults, according to a study published Tuesday in Molecular Psychiatry.

These “results provide strong evidence against the frequently debated negative effects of playing violent video games,” wrote Simone Kühn, Ph.D., of the Max Planck Institute for Human Development in Berlin, Germany, and colleagues. The authors noted that this debate has been largely fueled by studies showing short-term effects when tests were administered immediately after game playing.

“[I]n our view, the question that society is actually interested in is not: ‘Are people more aggressive after having played violent video games for a few minutes? And are these people more aggressive minutes after gameplay ended?’ but rather ‘What are the effects of frequent, habitual violent video game playing? And for how long do these effects persist (not in the range of minutes but rather weeks and months)?’” Kühn and colleagues wrote.

To investigate the long-term behavioral effects of playing violent video games, Kühn and colleagues randomly assigned 90 healthy adults who reported little or no video game use in the past six months to one of three groups: violent video games, nonviolent video games, or no video games. Participants assigned to the violent and nonviolent game groups were instructed to play Grand Theft Auto V and Sims 3, respectively, on a PlayStation 3.

Before the video game training period, all participants completed questionnaires and computerized tests assessing aggression, impulsivity, empathy, symptoms of depression and anxiety, and executive control. These tests were repeated after the video game training period and again two months later.

“No significant changes were observed, neither when comparing the group playing a violent video game to a group playing a nonviolent game, nor to a passive control group. Also, no effects were observed between baseline and posttest directly after the intervention, nor between baseline and a follow-up assessment two months after the intervention period had ended,” Kühn and colleagues wrote.

While the authors noted that these findings stand in contrast with the results of some short-term studies of violent video games, they wrote that more research is needed to determine whether playing violent video games during childhood leads to similar or different long-term behavioral effects.

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Severe Asthma in Adolescents May Increase Risk of Bipolar Disorder, Schizophrenia

Adolescents whose asthma required hospitalization may be at a greater risk of developing bipolar disorder or schizophrenia, according to a report in Schizophrenia Bulletin. The cohort study of more than 2 million Swedish children and their parents also revealed an association between asthma in the mothers and/or fathers and bipolar disorder in the children.

“As far as we are aware, this is the first study to find increased risk of bipolar disorder in children of individuals with asthma,” wrote Joseph Hayes, M.D., of University College London and colleagues. “Asthma admissions before aged 11 do not appear to be linked to bipolar or schizophrenia spectrum disorders.”

Hayes and colleagues collected data from Swedish registers from 1973 through 2011. These registers contain sociodemographic and medical information on each resident of Sweden, and parents can be linked to children via a unique identifier. The researchers included all children born in Sweden from 1973 to 1995 and their parents in the study cohort.

Children were grouped according to the age of first inpatient admission for asthma: at 5 years of age or younger, 6 to 10 years of age, and 11 to 15 years of age. Hospital admissions of the mothers and fathers for asthma prior to the birth of the children were also recorded.

Of the more than 2 million individuals born in Sweden between 1973 and 1995, 40,187 (1.78%) children were admitted with asthma before the age of 15, and 9,892 (0.44%) children were born to mothers who were hospitalized for asthma before their birth.

Following adjustment for confounding factors, the researchers found that there was an association between asthma admission between age 11 and 15 and both bipolar disorder (hazard ratio [HR] = 1.73) and schizophrenia spectrum disorder (HR = 1.62). There was no association between asthma and bipolar disorder and schizophrenia in children who were admitted for asthma before age 11. Additional analysis also revealed an association between both maternal and paternal asthma and bipolar disorder, but not between parental asthma and schizophrenia spectrum disorders.

“Taken together, our results do not suggest a straightforward link between asthma and severe mental illness via neurodevelopmental effects of inflammation, but potentially there is shared genetic vulnerability,” the authors wrote. “This finding has implications for understanding the differential pathogenic mechanisms of bipolar and schizophrenia spectrum disorders.”

For related information, see the Psychiatric News article “When Should Psychiatrists Manage [Other] Medical Conditions.”

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Light Therapy for Bipolar Depression Poses Minimal Risk of Mania Switching

Light therapy has been shown to be an effective treatment for bipolar depression, but there have been concerns that light therapy might increase the risk of triggering mania or hypomania in patients with bipolar disorder.

A meta-analysis published in the March issue of Psychiatry Research suggests that the risks of switching into mania during light therapy are quite low—roughly the same risk of switching among patients with bipolar disorder taking placebo medications in clinical studies.

Francesco Benedetti, M.D., of the Scientific Institute Ospedale San Raffaele in Milano, Italy, analyzed data from 41 studies evaluating the effects of light therapy on patients with bipolar depression. Of the 799 patients included in these studies, only 7 (0.9%) switched into mania and 11 (1.4%) switched into hypomania. Three of the patients who switched into mania had rapid-cycling bipolar disorder, which the authors noted is a risk factor for switching.

Further analysis of the data showed that the risk of switching was independent of the treatment design (for example, light intensity or time of day of treatment). However, the rate of switching varied based on how the investigators screened for mania symptoms. Among studies that used a mental state examination to assess mania, the identified switching incidence was 0.8%, while in studies that used clinical rating scales, the incidence was 3%.

Benedetti noted that the 3% risk of a patient switching into mania following light therapy is still a lower risk than most other treatment options. Current estimates suggest mania emerges in about 4% of bipolar patients taking a placebo medication, 6% to 8% of unipolar depression patients taking antidepressants, and 15% to 40% of bipolar depression patients taking antidepressants.

Benedetti cautioned that since the 41 studies included in the meta-analysis were quite different in their protocols, more well-designed trials are required to investigate the optimal intensity and frequency of light therapy for bipolar depression. “Overall, these observations do not justify specific safety concerns for the risk of manic switches when using this treatment option in patients with bipolar depression,” he concluded.

To read more about this topic, see the Psychiatric News article “Adjunctive Light Therapy Found Effective for Bipolar Depression.”

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ECT Does Not Appear to Increase Risk of Dementia

Electroconvulsive therapy (ECT) does not appear to increase long-term dementia risk in patients, according to a study published online this week in Lancet Psychiatry.

“The findings from this study support the continued use of ECT in patients with severe episodes of mood disorders, including those who are elderly,” wrote Merete Osler, D.Msc., of the Center for Clinical Research and Prevention at the Bispebjerg and Frederiksberg Hospitals in Denmark and colleagues.

ECT is considered a highly effective treatment for severe episodes of mood disorder, particularly major depression, the authors noted. Temporary memory loss is a common side effect, especially with bilateral lead placement and increasing number of treatments. Although such memory loss tends to resolve within weeks, few studies have examined whether patients who receive ECT have a greater risk of long-term adverse cognitive outcomes.

For the study, researchers identified about 168,000 patients aged 10 or older in the Danish National Patient Registry who were hospitalized with a first-time diagnosis of affective disorder from 2005 through 2015. Of these patients, nearly 6,000 (3.5%) underwent at least one ECT during the median 5-year follow-up, with the percentage highest among middle-aged patients. ECT was most common in those with severe depression, comorbid schizophrenia, or in those who used antidepressants or antipsychotic medication.

Of patients who underwent ECT, 3.6% developed dementia. Of some 162,000 patients not treated with ECT, 3.1% developed dementia. Researchers found that after adjusting for the potential effect of patient selection or competing mortality, ECT was not associated with risk of dementia.

In patients younger than 69 years old, ECT was not associated with an increased risk of dementia, compared with age-matched patients who were not given ECT. In patients aged 70 years and older, ECT was associated with a decreased rate of dementia. Furthermore, the risk of developing dementia was lower for patients aged 70 and older who had more than ten sessions of ECT.

“The potential adverse effects of ECT on cognitive function might have fueled the fear of dementia in patients and clinicians, and for that reason they might hesitate to choose ECT as a treatment,” the authors wrote. “The findings from this study show that notwithstanding other possible adverse long-term cognitive effects, ECT did not increase the risk of dementia, and support the continued use of ECT in patients with severe episodes of mood disorders, including those who are elderly.”

For related information, see the Psychiatric News article “High-Dose, Unilateral ECT Found as Effective as Bilateral ECT.”

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FDA Approves Latuda for Treatment of Youth With Bipolar Depression

The Food and Drug Administration (FDA) has approved Latuda (lurasidone HCl) for the treatment of depressive episode associated with bipolar I disorder (bipolar depression) in youth ages 10 to 17.

Latuda is already approved as a monotherapy or adjunctive therapy with lithium or valproate for the treatment of adults with bipolar depression. The medication is also approved for the treatment of adults and adolescents (ages 13 to 17) with schizophrenia.

According to a press release by Sunovion Pharmaceuticals, which manufactures Latuda, the approval for the expanded indication of Latuda was based on data from a six-week, phase 3 clinical study of 347 children and adolescents with bipolar depression. After six weeks, the participants who received once-daily Latuda (20-80 mg/day) showed statistically significant improvements in depression symptoms compared with those taking placebo—as indicated by change from baseline on Children’s Depression Rating Scale, Revised (CDRS-R) total scores and Clinical Global Impression-Bipolar Version, Severity of Illness (CGI-BP-S) depression score.

The medication was generally well-tolerated, with nausea, weight gain, and insomnia being the most common treatment-related adverse effects.

“The FDA approval of this medicine for the treatment of pediatric patients with bipolar depression is significant for several reasons,” said Robert Findling, M.D., M.B.A., the director of child and adolescent psychiatry at the Johns Hopkins University School of Medicine in Sunovion’s press release. “First, it is a new treatment option for this vulnerable group of young people. Also, it is the first single-agent formulation to receive regulatory approval for this pediatric indication.”

To read more about this topic, see the Psychiatric News PsychoPharm article “Lurasidone May Work Better as Monotherapy in Older Patients With Bipolar Depression.”

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Women With Schizophrenia May Be at Greater Risk of Breast Cancer, Meta-Analysis Finds

Women with schizophrenia may be at a 30% higher risk of breast cancer than women without schizophrenia, according to a meta-analysis published today in JAMA Psychiatry.

“Because breast cancer is the most common cancer in women, affecting 1 in 9 women during their lifetime, our findings highlight that intensive prevention and treatment against breast cancer are warranted for women with schizophrenia,” wrote study authors Chuanjun Zhuo, M.D., Ph.D., of Tianjin Medical University in China and Patrick Todd Triplett, M.D., of Johns Hopkins School of Medicine.

Zhuo and Triplett conducted a systematic search of PubMed and EMBASE databases; twelve cohort studies that included 125,760 women were included in the meta-analysis. The number of women with schizophrenia included in each study varied from 1,388 to 46,447, and the number of the breast cancer cases ranged from 42 to 1,042.

The meta-analysis revealed that schizophrenia was associated with a significantly increased risk of breast cancer incidence in women (standardized incidence ratio, 1.31); however, there were significant differences between the studies included in the meta-analysis.

“Future studies are needed to determine the association between schizophrenia and the different pathologic subtypes of breast cancer as well as whether the association may be affected by the woman’s age at breast cancer onset, antipsychotic medications used, and the cancer subtype,” Zhuo and Triplett wrote.

Despite the limitations of the meta-analysis, the authors noted the results indicate that women with schizophrenia deserve focused care for breast cancer screening and treatment.

“For the early prevention of breast cancer, an initial evaluation is needed to stratify the risk of breast cancer in women with schizophrenia. Subsequently, antipsychotics that may increase the prolactin level and produce a higher breast cancer risk should be avoided in high-risk women. Regular screening, including imaging or biomarker tests, should be performed. If an early diagnosis of breast cancer is made in women with schizophrenia, collaborations with oncologists are needed for clinical psychiatrists to make an optimal treatment recommendation,” they wrote.

For related information, see the Psychiatric News PsychoPharm article “Expert’s Corner: Best Practices for Treating Cancer Patients With Psychiatric Symptoms,” by Philip Bialer, M.D., of Memorial Sloan Kettering Cancer Center and the Psychiatric Services article “Mammography Among Women With Severe Mental Illness: Exploring Disparities Through a Large Retrospective Cohort Study.”

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Lithium, LAI Antipsychotics Found Best to Prevent Rehospitalization in Patients With Bipolar Disorder

Lithium appears to be the most effective medication for preventing rehospitalization for any reason among patients with bipolar disorder and should be the first-line of treatment, according to a report in JAMA Psychiatry. The study also revealed that long-acting injectable (LAI) antipsychotics were associated with substantially better outcomes compared with identical oral antipsychotics.

“When a patient with bipolar disorder uses an LAI, the patient’s risk of relapse leading to psychiatric hospitalization as well as all-cause hospitalization owing to mental or somatic illness is about 30% lower than during time periods when the same patient uses an identical oral antipsychotic,” Marrku Lähteenvuo, M.D., Ph.D., of the University of Eastern Finland and colleagues wrote. “Although more research is needed to support the notion, LAIs might offer a safe and effective option for relapse prevention in bipolar disorder for patients for whom lithium is not suitable."

Lähteenvuo and colleagues used Finnish national registry databases to examine the risk of psychiatric, cardiovascular, and all-cause hospitalization from January 1987 through December 2012 in patients in Finland who had been hospitalized for bipolar disorder. These databases include information on incidences, duration, and reasons for rehospitalization as well as information on reimbursed medications dispensed from pharmacies.

Among a cohort of more than 18,000 patients, 9,721 patients (54.0%) had at least one psychiatric rehospitalization during the study period. Of all medications studied, lithium was associated with the lowest risk of rehospitalization for any reason, with a hazard ratio (HR) of 0.71. Quetiapine fumarate, the most frequently used antipsychotic treatment, showed only modest effectiveness in reducing risk of all-cause rehospitalization (HR, 0.93).

Long-acting risperidone was associated with the lowest risk of psychiatric rehospitalization (HR, 0.58). The researchers also observed a marked association for reduced risk of psychiatric hospitalization with lithium (HR, 0.67).

“The main results of our study indicate that lithium is superior to other mood stabilizers and that LAIs are markedly better than identical oral formulations of antipsychotics.”

For related information see the Psychiatric News article, “Lithium Protects Against Suicide inBipolar Disorder, Study Finds.”

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