Clinicians Develop New Rating Scale for Perimenopausal Depression

Key differences in depressive symptoms that arise during perimenopause (the period immediately before menopause) suggest that perimenopausal depression may be a distinct subtype of depression, but scales to measure or monitor symptoms of perimenopausal depression are lacking. A report published yesterday in Translational Psychiatry describes the development and validation of a questionnaire that clinicians or patients can use to rate the severity of perimenopausal depression symptoms.

“Having a reliable tool to aid in the diagnosis of perimenopausal depression is very important in research of this relatively neglected area of women’s health,” wrote Jayashiri Kulkarni, M.D., and colleagues at Monash University in Melbourne, Australia. “Clinically, it is very important to accurately detect and diagnose perimenopausal depression as early as possible to enable more specific treatments, such as hormone treatment strategies.”

Kulkarni and colleagues conducted an extensive literature review and relied on clinical observation and focus groups (including perimenopausal women and clinicians) to identify key perimenopausal depression symptom areas. From this research, they created a 12-item questionnaire, called the Meno-D, which asked patients to rate the severity of the following symptoms on a scale of 0 to 4: anxiety, concentration, energy, irritability, isolation, memory, paranoia, self-esteem, sexual interest, sleep, somatic symptoms, and weight changes.

The Meno-D was then administered to 93 women experiencing symptoms of perimenopausal depression, 82 of whom completed the questionnaire. While the women varied significantly in their total Meno-D scores, despite all having perimenopausal depression, they generally had above average scores related to somatic (somatic symptoms and weight), cognitive (memory and concentration), self (self-esteem, paranoia, isolation, and anxiety), sleep (sleep disturbances and irritability), and/or sexual (sexual interest and energy) symptoms.

“Previous studies have reported that women experiencing perimenopausal depression complain about physical symptoms more than cognitive ones, which are not typically included in previous scales assessing for major depressive disorder,” Kulkarni and colleagues wrote. “This may explain why perimenopausal depression is often overlooked or left undiagnosed.”

They concluded, “The Meno-D will support a growing research field, interfacing both psychiatry and endocrinology, which indicates that perimenopausal depression is a unique subtype of depression requiring a different management approach.”

To read more about this topic, see the Psychiatric News article “Discontinuing Hormone Therapy May Increase Risk of Depression in Some Women.”

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Repetitive Transcranial Magnetic Stimulation Appears No Better Than Sham in Veterans With Depression

Repetitive transcranial magnetic stimulation (rTMS) helped more than 40% of veterans with treatment-resistant depression (TRD) to reach remission, but this remission rate was about the same as the benefit seen in veterans who received sham treatments, according to a study published yesterday in JAMA Psychiatry.

Jerome A. Yesavage, M.D., of the Department of Veterans Affairs (VA) and colleagues recruited 164 veterans with TRD (defined as failure to respond to two prior antidepressants) from nine VA medical centers. The study participants had a mean age of 55 years, 81% were men, and 77% were white. These participants were randomized to receive either left prefrontal rTMS treatment (10 Hz, 120% motor threshold, 4,000 pulses/session) or sham treatment for up to 30 treatment sessions. For both groups, treatment was delivered in five-session blocks over a period of five to 12 days. Participants who experienced remission received another six additional taper sessions over a three-week period.

At the end of the acute treatment phase, 41% of the participants in the active treatment group who finished rTMS treatment experienced remission of depressive symptoms compared with 37% in the sham group, which researchers found not to be a statistically significant difference. At the end of the six-month follow-up phase, 20% of the active treatment group sustained remission compared with 16% of the sham treatment group.

“These high remission rates suggest that veterans’ expectations of improvement and extensive attention provided by their TMS treatment team may have played a large role in the significant clinical improvements they experienced,” Yesavage and colleagues wrote.

They continued, “Achieving remission rates of 40% and over in treatment-resistant veterans is a clinically meaningful result warranting evaluation of such comprehensive approaches to treatment of patients with difficult-to-treat MDD [major depressive disorder] within the VA. Future work with rTMS may show an enhanced effect when newer coil models, better stimulus targeting, biological markers of response, higher frequency rates of stimulation, and longer duration of treatment are implemented.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Noninvasive Brain Stimulation: Challenges and Opportunities for a New Clinical Specialty.”

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Depression Severity May Predict Akathisia Risk With Aripiprazole Augmentation in Older Adults

Adding the antipsychotic aripiprazole to an antidepressant regimen can benefit older patients with treatment-resistant depression, but the strategy comes with risks: aripiprazole augmentation can cause extrapyramidal symptoms, such as akathisia and parkinsonism, according to a study in the Journal of Clinical Psychiatry. Thus, clinicians need to pay close attention when prescribing aripiprazole to older patients with more severe depressive symptoms.

Jonathan H. Hsu, M.D., of the University of Toronto, and colleagues analyzed data collected during a randomized, controlled trial evaluating the efficacy and safety of aripiprazole augmentation for adults aged older than 60 years with treatment-resistant depression. Patients who did not achieve remission after receiving venlafaxine extended-release (up to 300 mg/day) for 12 weeks were randomly assigned to receive aripiprazole augmentation (maximum dose 15 mg/day) or placebo for 12 weeks. Throughout the trial, the researchers assessed patients for extrapyramidal symptoms.

Forty (44%) of the 91 participants randomly assigned to aripiprazole achieved remission compared with 26 (29%) of 90 randomly assigned to placebo—a significant difference. Akathisia was the most common adverse effect of aripiprazole; 24 (26.7%) developed akathisia compared with 11 (12.2%) of participants assigned to placebo. Those who developed akathisia had higher depression severity at baseline. Aripiprazole was also associated with more parkinsonism; 15 people in the aripiprazole group (16.5%) developed parkinsonism compared with 2 (2.2%) in the placebo group. No clinical predictors or correlates for parkinsonism were identified. The researchers noted that most participants who developed akathisia improved over time, especially when aripiprazole dose was lowered.

“Fortunately, most older depressed patients who are prescribed aripiprazole will not develop akathisia, yet the emergence of these symptoms should be assessed carefully, particularly during initial dosage titration,” Hsu and colleagues concluded.

For related information, see The American Psychiatric Association Publishing Textbook of Psychopharmacology.

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Mobile App May Improve Mood, Motivation in Young People With Schizophrenia

Regular use of a mobile-based intervention may benefit young people with recent-onset schizophrenia spectrum disorders by improving their mood and motivation, according to a small study published in Schizophrenia Bulletin.

For the study, Danielle A. Schlosser, Ph.D., of the University of California, San Francisco, and colleagues recruited people aged 16 to 36 who had received a diagnosis of schizophrenia, schizophreniform, or schizoaffective disorder within the past five years. A total of 43 participants were randomly assigned to use a mobile intervention called PRIME (personalized real-time intervention for motivational enhancement) or to a wait-list group for 12 weeks. PRIME is a mobile app through which participants work toward self-identified goals (in areas of health and wellness, social relationships, and more) with the support of a virtual community of age-matched peers with schizophrenia spectrum disorders as well as motivation coaches. Participants in the PRIME group were encouraged to use the app daily, whether it be to message with coaches and/or peers or complete challenges.

Compared with the participants in the wait-list group, those who used PRIME experienced significant improvements in depression, defeatist beliefs, self-efficacy, and components of motivation, such as reward learning and anticipated pleasure. Over a 12-week period, participants were highly engaged in the platform, the authors reported. On average, participants logged in over four days/week and 5,152 direct messages were sent from participants to coaches. In terms of peer-to-peer interactions, participants initiated interactions with each other a total of 497 times.

“Many participants noted that it was the first time they had seen or interacted with other young people with an SSD [schizophrenia spectrum disorder], and they particularly appreciated being able to have on-demand coaching, as demonstrated by the qualitative feedback and this feature being rated as the most satisfying,” Schlosser and colleagues wrote. “[P]RIME may act as an important adjunctive intervention to treatment approaches that are usually more focused on treating the positive psychotic symptoms and offer a more holistic approach to improving outcomes for people with an SSD.”

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Mantram Therapy Found to Benefit Veterans With PTSD

A mindfulness-based therapy in which individuals learn to repeat personalized mantras to relax their thoughts appears to be more effective at reducing posttraumatic stress disorder (PTSD) symptoms than a problem-solving psychotherapy known as present-centered therapy, reports a study in AJP in Advance.

Mantram therapy is based on the premise that silently repeating a personally meaningful word or phrase (mantra) promotes relaxation, increases emotional regulation, and reduces stress. Present-centered therapy is a psychotherapy that focuses patients on the present to help them actively target daily challenges related to their past trauma and PTSD symptoms.

“Mantram therapy may be a valuable addition to current PTSD treatments because it incorporates some components of evidence-based treatments, yet without the trauma focus that can deter some clients,” wrote Jill Bormann, Ph.D., R.N., of the University of San Diego and colleagues.

Previous uncontrolled studies of veterans have suggested that mantram therapy can reduce PTSD symptom severity, help veterans manage sleep disturbances, and more. For the current study, Bormann and colleagues compared PTSD outcomes in veterans who were randomly assigned to either mantram therapy or present-centered therapy. A total of 173 veterans from two Veterans Affairs outpatient clinics diagnosed with military-related PTSD were assigned to receive eight individual weekly one-hour sessions of either mantram or present-centered therapy.

The mantram group experienced significantly greater improvements in their symptoms as assessed by the Clinician-Administered PTSD Scale at both the end of the study and at a two-month follow-up. Additionally, 59% of participants in the mantram group who completed the two-month follow-up no longer met criteria for PTSD, which was significantly higher than the 40% rate in the present-centered group. Participants who received mantram therapy also reported greater reductions in insomnia, a common occurrence in patients with PTSD, compared with those who received present-centered therapy.

Bormann and colleagues acknowledged that the study did not compare mantram therapy with either cognitive processing therapy or prolonged exposure, two evidence-based PTSD therapies currently used by the Veterans Health Administration. “It would be premature to draw any conclusions about the efficacy of mantram therapy compared with these established treatments, or other treatments, without head-to-head trials,” they wrote.

“Further assessment of mantram therapy in trials and real-world settings is clearly desirable, especially because mantram therapy may appeal to some veterans who may prefer therapies that are not trauma-focused, that include some element of spirituality, or that reduce sleep disturbances,” they concluded.

To read more about treatments for PTSD, see the Psychiatric News article “Propranolol Combined With Reactivation Therapy May Reduce PTSD Symptoms.”

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Police Shootings of Unarmed Blacks Adversely Impact Mental Health in Black Community

Police shootings of unarmed black Americans have adverse effects on the mental health of other black Americans in the general population, according to a study published Thursday in The Lancet. The report was released just two days after a police officer shot and killed Antwon Rose, an unarmed black teen who was fleeing a traffic stop in Pittsburgh.

Exposure to one or more police killings within a three-month period was associated with a 0.35 day increase in poor mental health days, according to the report, which combined data on police shootings with individual-level data from a nationally representative self-report survey on health. Adverse mental health effects were not observed among white respondents and resulted only from police killings of unarmed black Americans (not unarmed white Americans or armed black Americans).

“The observed adverse mental health spillover effects of police killings of unarmed black Americans could result from heightened perceptions of threat and vulnerability, lack of fairness, lower social status, lower beliefs about one’s own worth, activation of prior traumas, and identification with the deceased,” Jacob Bor, Sc.D., of Boston University School of Public Health and colleagues wrote. 

The researchers used self-reported race to identify black American respondents to the U.S. Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative telephone survey that collects health data from U.S. adults. Information collected from the 2013-2015 BRFSS was combined with available data with the timing of police killings as reported in the Mapping Police Violence database, which has tracked police killings in the United States since 2013.

The primary exposure was the number of police killings of unarmed black Americans occurring in the three months prior to the BRFSS interview within the same state. The primary outcome was the number of days in the previous month in which the respondent’s mental health was reported as “not good.”

A total of 38,993 of the 103,710 black American respondents were exposed to one or more police killings of unarmed black Americans in their state of residence in the months prior to the survey. Each additional police killing of an unarmed black American in the respondent’s state of residence in the months prior to interview was associated with a 0.14 day increase in the number of poor mental health days. “Specifically, our estimates imply that police killings of unarmed black Americans could contribute 1.7 additional poor mental health days per person per year, or 55 million excess poor mental health days per year among black American adults in the [United States],” Bor and colleagues wrote. “Interventions are needed to reduce the prevalence of these killings and to support the mental health of communities affected when they do occur.”

Rahn Bailey, M.D.(pictured at above), the APA Assembly representative for the Caucus of Black Psychiatrists, told Psychiatric News he believes the study confirms what he and other black psychiatrists have observed anecdotally, both professionally and personally. “The study is timely and convincing and has real-world impact.” 

APA Urges Members to Maintain Pressure on Administration Regarding Child Detentions

In an about-face, President Donald J. Trump signed an Executive Order yesterday halting his administration’s policy of separating migrant children from their parents who illegally cross the U.S. southern border. But Trump’s decision to continue his “zero tolerance” policy of border crossing will still place families into prison-like detention centers, perhaps long term.

It remains unclear what will happen to the more than 2,300 migrant children who have been separated from their parents since mid-May. Images of young children confined in steel cages and sleeping en masse on thin pads on concrete floors with aluminum-foil-like blankets sparked condemnation around the world, including from Pope Francis and all four living former first ladies.

APA led a coalition of mental health organizations in lobbying the administration to immediately halt its cruel policy of separating children from their parents at the U.S. border. “Children are dependent on their parents for safety and support. Any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder,” wrote APA and 17 mental health organizations, including the American Association of Child & Adolescent Psychiatry and the American Psychoanalytic Association, in a letter sent yesterday to the departments of Justice, Homeland Security, and Health and Human Services.

“This is not an acceptable policy to counter unlawful immigration, and the administration must immediately rescind this course of action,” the letter continued. “We support practical, humane immigration policies that take into account what we know about the harmful, long-term psychological effects of separation on children and their families.”

The government, under a federal court order known as the Flores settlement, is prohibited from keeping migrant children in detention for more than 20 days. But Trump’s Executive Order instructs Attorney General Jeff Sessions to file a request to modify Flores so it can detain families long term while adjudicating the criminal proceedings of the parents for improper entry. When combined with asylum claim evaluations, such proceedings can take months or years to resolve.

“Many families crossing the United States border are fleeing war and violence in their home countries and are already coping with the effects of stress and trauma,” APA President Altha Stewart, M.D., said in a statement opposing the separation of children from parents at the border released May 30.

APA is calling on its members to keep up the pressure and prevent further trauma from being inflicted on these children and families. APA has posted a form in its Action Center that psychiatrists can use to urge the administration to halt its destructive immigration policies immediately. Access the Action Center form now.

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Highlights From APA’s 2018 Annual Meeting: Issue #2

Stewart to Focus on APA’s Being a Leader on Issues of Diversity and Inclusion
Discrimination and implicit bias affect the psychological and physical health of not only psychiatry’s patients but also psychiatrists.

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Schatzberg Honored for Research Connecting Cortisol and Psychotic Depression
One of psychiatry’s leading researchers recounts the biopsychosocial work with which he has been involved in the search for more effective treatments.

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Most Americans Agree That Gun Violence Is Public Health Problem, Call for Action
Regardless of whether they are Democrats or Republicans, Americans believe Congress should take action to prevent mass shootings.

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Ensuring Patient, Staff Safety Begins With Supportive Management, Staff Training
Psychiatric hospitals with the best patient safety records spend time training nurses, use physical restraints as a last resort, and pay careful attention to staff involved with suicide watches.

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Digital Psychiatry Apps May Create New Burdens, Have Limited Efficacy Data
While mental health apps are proliferating, experts caution that they may create new legal responsibilities and question whether the hype is getting ahead of evidence supporting their use.

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Parent-Child Psychotherapy Leads to Improvements in Young Children With Depression

An adapted parent-child psychotherapy proven to help children with disruptive disorders may also reduce symptoms of depression in very young children, according to a study published today in AJP in Advance.

“The study provides very promising evidence that an early and brief psychotherapeutic intervention that focuses on the parent-child relationship and on enhancing emotion development may be a powerful and low-risk approach to the treatment of depression,” lead author Joan L. Luby, M.D., of Washington University School of Medicine in St. Louis said in a press release.

In standard parent-child interaction therapy (PCIT), a therapist first educates parents on ways to successfully interact with their child and then coaches parents as they practice these techniques with their child in an office setting. Previous studies show that PCIT is an effective way to treat disruptive behavior disorders in young children. Luby and colleagues wanted to know if adapting PCIT to focus on enhancing a child’s emotional competence and emotion regulation could reduce symptoms of depression in very young children with major depressive disorder.

Children aged 3 to 6 who met criteria for early childhood depression and their parents were randomly assigned to Parent Child Interaction Therapy–Emotion Development (PCIT-ED, n=114) or a waitlist group (n=115). In addition to depression, some of the children in the study met criteria for comorbid anxiety, attention-deficit/hyperactivity disorder, and/or oppositional defiant disorder at baseline. After the parent-child PCIT-ED pairs completed 12 PCIT sessions, they received training during which parents were taught how to validate their child’s emotions and help the child regulate these emotions. The researchers interviewed children and parents at the beginning and end of the 18-week study to assess the children’s psychiatric symptoms, ability to regulate emotions, and level of impairment and functioning. They also asked parents about how they coped with their child’s negative emotions and their own levels of stress and depression.

Compared with those in the waitlist group, children in the PCIT-ED group were found to have lower rates of depression, lower depression severity, and lower impairment at the end of the study. In addition, rates of comorbid disorders at trial completion, including anxiety disorders and oppositional defiant disorder, were significantly lower in the PCIT-ED group.

The therapy also appeared to have positive effects on the parents of the children with depression, Luby and colleagues reported. “Parents who received the active treatment displayed more emotionally focused parenting techniques and reported marked reductions in stress and a greater sense of positive responsiveness from their child. Also notable was that the treatment resulted in significant reductions in parental depression, even though this was not a direct target of treatment,” they wrote.

“The study findings suggest that early intervention for depression may be a window of opportunity to modify emotional functioning, utilizing the powerful influence of the parent-child relationship during this relatively neuroplastic developmental period to remediate depressive symptoms,” the authors concluded. “Given that depression is a chronic and relapsing disorder, these findings on an early, low-cost, low-risk psychotherapeutic intervention suggest that early identification and treatment of depressive disorders should become a public health priority.”

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Methadone, Buprenorphine After Opioid Overdose Associated With Lower Risk of Death

Treating patients who survive an opioid overdose with either methadone or buprenorphine appears to significantly reduce their risk of death for at least 12 months, but only a third of opioid overdose survivors may be receiving these medications, according to a report in the Annals of Internal Medicine.

“These findings suggest meaningful opportunities to improve engagement and retention in treatment of opioid use disorders after a nonfatal overdose,” wrote Marc Larochelle, M.D., M.P.H., of Boston Medical Center and colleagues.

Using the Massachusetts All-Payer Claims Database and several other linked Massachusetts state databanks, Larochelle and colleagues identified adults aged 18 and older who survived an opioid overdose between January 2012 and December 2014. The researchers also identified those who received medication for opioid use disorder, including methadone maintenance treatment (MMT), buprenorphine, or naltrexone.

In the 12 months after a nonfatal overdose, 2,040 people (11%) enrolled in MMT for a median of five months, 3,022 people (17%) received buprenorphine for a median of four months, and 1,099 persons (6%) received naltrexone for a median of one month.

Over 12 months of follow-up, 807 participants died of any cause and 368 died of an opioid-related overdose. Compared with individuals who received no treatment for opioid use disorder, those who received MMT or buprenorphine were less likely to die of any cause or of an opioid-related cause; reliable associations between treatment with naltrexone and all-cause and opioid-related death could not be ascertained owing to the small number of patients receiving naltrexone—a limitation to the study the researchers acknowledged.

Larochelle and colleagues noted that rates of treatment initiation are inversely proportional to the lag in time between being offered treatment and being able to start. “New models that offer treatment initiation and linkage to care from emergency department and inpatient settings have demonstrated increased treatment engagement,” they wrote. “Our findings also show that treatment initiation without retention undermines benefits.”

In an accompanying editorial, Nora Volkow, M.D., and Eric Wargo, Ph.D., of the National Institute on Drug Abuse, offered several strategies to increase medication-assisted therapy delivery to people at risk for opioid overdose. “A great part of the tragedy of this opioid crisis is that, unlike in previous such crises America has seen, we now possess effective treatment strategies that could address it and save many lives, yet tens of thousands of people die each year because they have not received these treatments,” they wrote. “Ending the crisis will require changing policies to make these medications more accessible and educating primary care and emergency providers, among others, that opioid addiction is a medical illness that must be treated aggressively with the effective tools that are available.”

For related information, see the Psychiatric News article “Why Aren't More Physicians Prescribing Buprenorphine?” and the Psychiatric Services article “Three-Year Retention in Buprenorphine Treatment for Opioid Use Disorder Among Privately Insured Adults.”

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Autistic Traits Associated With Elevated Depression in Youth Aged 10 to 18

At age 10, children with autism spectrum disorder (ASD) and those with high levels of autistic traits have more depressive symptoms than children in the general population, reports a study published in JAMA Psychiatry. These elevated depressive symptoms persist in the children until they are 18 and are significantly influenced by bullying.

“[F]urther research into the role of traumatic experiences, such as bullying, and the utility of interventions to reduce bullying or address its adverse effects could have the potential to reduce the burden of depression in this population,” wrote lead author Dheeraj Rai, Ph.D., of the University of Bristol and colleagues. 

For this study, Rai and colleagues assessed data from the Avon Longitudinal Study of Parents and Children (ALPSAC), which tracked over 15,000 children born in the Bristol area between 1990 and 1992 and their parents until the children turned 18. As part of ALSPAC, investigators conducted periodic clinical assessments and had parents and children complete self-report questionnaires for a range of behavioral issues, including ASD and depression.

The final dataset for the study included 8,087 children. Of this group, 96 children were diagnosed with ASD, 546 had social communication impairments, 526 had problems with speech coherence, 419 displayed repetitive behaviors, and 801 had poor social temperament.

Children with ASD or any of the four autistic traits had higher depressive symptom scores than the general population at age 10, as assessed by the Short Mood and Feelings Questionnaire (SMFQ). The SMFQ scores continued to rise over time, though by age 18 only those with social communication impairments had a significantly higher rate of diagnosed depression than the youth in the general population (1.68 times the risk).

At age 10, the children with ASD and autistic traits who reported being bullied had the highest average SMFQ scores; likewise, youth with social communication impairments who reported being bullied in childhood or adolescence were more likely to have a diagnosis of depression at age 18.

“These findings add to the evidence highlighting a higher burden of depression and also suggest a potentially modifiable pathway, through bullying,” Rai and colleagues wrote. “However, gaps remain in our understanding of the measurement and phenomenology of depression in individuals with autism, which could be a priority for future research. Further work could also focus on improvements in psychological and pharmacological management of depression in ASD.”

To read more about this topic, see the Psychiatric News article, "Social Skills Therapy for ASD Shows Modest Benefits in Routine Settings."

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Highlights From APA’s 2018 Annual Meeting: Issue #1

Everett Sums Up State of Psychiatry in America and Where Profession Is Headed
One of the keys to psychiatry’s future is the development of innovative technologies that will reduce administrative burdens and improve patient care.

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Talking About Firearms With Patients Necessary, But Examine Your Beliefs First
When talking with patients about gun ownership and storage issues, proceed with respect and neutrality.

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APA Poll Finds Americans’ Anxiety Is Increasing, Especially About Health, Safety, and Finances
Many Americans are dealing with stress and anxiety in various areas of their lives, especially with regard to money and paying bills, finds an APA poll.

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Familial History of Psychiatric Disorders Key in Predicting Postpartum Risk
An AJP study reports that the risk of experiencing a postpartum psychiatric episode was highest when mothers had a first-degree relative with bipolar disorder.

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Online Support Shows Potential of Tech-Based MH Care, Insel Says
Online counseling networks show how simple technological approaches can reduce delays in care and build online help communities.

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Rapid Weight Gain, Decreased Insulin Sensitivity Found in Youth Taking SGAs for First Time

Within 12 weeks of starting treatment with low-dose aripiprazole, olanzapine, or risperidone, youth with disruptive behavioral disorders experienced significant increases in total body fat, according to a study published today in JAMA Psychiatry. The study also found that youth treated with these second-generation antipsychotics (SGAs) experienced decreases in insulin sensitivity over the 12-week period.

The findings point to the importance of continued monitoring for metabolic abnormalities when treating youth with antipsychotics.

For the study, Ginger E. Nicol, M.D., of the Department of Psychiatry at Washington University School of Medicine in St. Louis and colleagues recruited antipsychotic-naïve youth aged 6 to 18 with one or more psychiatric disorders and clinically significant aggression. A total of 144 youth were assigned to aripiprazole, olanzapine, or risperidone for 12 weeks. (According to the study authors, mean final antipsychotic doses were representative of pediatric practice patterns and below the doses typically used to treat psychosis: aripiprazole, 6.0 mg; olanzapine, 6.3 mg; risperidone, 1.0 mg.)

The authors used dual X-ray absorptiometry (DXA) and magnetic resonance imaging (MRI) scans to assess changes in total body fat and abdominal fat over the course of the trial. At baseline and 12 weeks, the youth also received an insulin sensitivity test and answered questions about their symptoms.

Although the youth experienced clinically and statistically significant improvements in irritability, aggression, and overall symptoms over the course of the study, the mean DXA percentage total body fat of the youth increased significantly during 12 weeks for all study treatments—1.66% for aripiprazole, 4.12% for olanzapine, and 1.18% for risperidone. Abdominal fat measured by MRI also “increased significantly in visceral and subcutaneous compartments, … [with] greater subcutaneous mean fat increase with olanzapine compared with risperidone and aripiprazole,” Nicol and colleagues wrote. The researchers also found insulin sensitivity decreased significantly from baseline in the pooled study sample.

“These findings confirm previous reports … which showed rapid-onset obesity and glucose dysregulation in children using SGA medications, as well as the greatest weight gain and adverse changes in glucose metabolism in those treated with olanzapine,” Marc De Hert, M.D., Ph.D., and Johan Detraux, M.Psy., of Katholieke Universiteit Leuven in Belgium wrote in an accompanying editorial. They emphasized the importance of routine weight, glucose, and lipid monitoring when prescribing antipsychotics to youth.

“Although no SGA regimen is absolutely free from metabolic consequences, preference should be given to an SGA drug with a low to moderate metabolic risk (thus avoiding olanzapine), and clinicians should aim for the shortest necessary treatment duration in the case of off-label use,” De Hert and Detraux concluded.

For related news, see the Psychiatric News article “Survey Finds Poor Compliance With Guidelines For Monitoring SGAs in Kids.”

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Psychiatrist Patrice Harris, M.D., M.A., Elected President-Elect of the AMA

APA member Patrice Harris, M.D., M.A., a former APA board member and AMA board member, was elected today as president-elect of the AMA during the AMA’s House of Delegates meeting in Chicago. 

“I believe our American Medical Association has well-crafted policy concerning the changing health care environment in this country,” Harris said in an address to the House following her election. “It will be my honor to represent our AMA in the venues where important issues will be debated. I am committed to preserving the central role of the physician-patient relationship in our healing art.”

Harris is the first African-American woman to hold the office.

Harris served on the AMA Board of Trustees beginning in 2011 and served as secretary for the 2014-2015 term and as chair of the board for the 2016-2017 term. As a practicing psychiatrist trained in child/adolescent and forensic psychiatry, she consults with both public and private organizations on health service delivery. She is also chair of the AMA Task Force to Reduce Opioid Abuse and is an adjunct assistant professor in the Department of Psychiatry and Behavioral Sciences at Emory University. 

“I’m elated that Dr. Harris has been elected president of the AMA,” said APA President Altha Stewart, M.D. “This is a great day for APA and for psychiatry. The APA Board of Trustees looks forward to continuing to work with her as both organizations collaborate to increase patient access to care and improve the practice of medicine.”

Harris previously served as the director of health services in Fulton County, Ga., and the head of the Fulton County Department of Behavioral Health and Developmental Disabilities. As chief health officer for Fulton County, she spearheaded efforts to integrate public health, behavioral health, and primary care. She is a past president of the Georgia Psychiatric Physicians Association.

“We are delighted to have a psychiatrist and a former APA Board of Trustees member leading the house of medicine as president-elect of the AMA,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Her election demonstrates how psychiatrists can be leaders in medicine. We look forward to working with Dr. Harris on continued advocacy for improving the quality of care and integrating psychiatry and mental health within medicine.”

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APA Calls on Administration to Defend Patient Protections in ACA

APA has strongly condemned the recent decision by the Department of Justice to not defend the patient protections provided in the Affordable Care Act (ACA) in the case Texas v United States.

Since the ACA took effect in 2013, the uninsured rate among nonelderly adults has dropped 40 percent (from 20.5% in 2013 to 12.2% in 2016), according to the Kaiser Family Foundation. The Justice Department’s decision opens the door for insurers to deny health care coverage to the 130 million individuals with preexisting conditions and allows insurers to raise the premiums for Americans with disabilities, senior citizens, and those who have a history of using more health care.

“We strongly condemn the Administration’s decision not to defend the patient protections provided in the Affordable Care Act, an established law of the land,” APA President Altha Stewart, M.D., said in a statement released Friday. “This is harmful to the health of Americans and is very short-sighted, considering the nation is in the midst of an opioid epidemic and a 30 percent rise in suicide rates. We call upon the administration to reverse this decision and defend the rights of our patients.”

APA also signed on to a similar statement released Saturday with five other medical organizations representing more than 560,000 physician and medical student members. It read, “We strongly urge the Department of Justice to reconsider its decision in Texas v United States and that we all seek policy solutions that increase access to affordable health care that provides all individuals, regardless of their gender, race, and health status, reasonable protections against discrimination in coverage and pricing.”

The Supreme Court had previously upheld the ACA’s individual mandate that required most people to carry minimum essential health insurance, but only in so far as it was a tax provision that yielded at least some revenue for the federal government. But because the Tax Cut Jobs Act eliminates the ACA’s tax/penalty provision of the individual mandate starting in 2019, the Justice Department determined that it will no longer be constitutional as of January 1, according to a memorandum filed June 7. Texas, along with 19 other states, had filed a federal lawsuit in February challenging the individual mandate and other patient protections in the law.

The Justice Department did not uphold the ACA’s “guaranteed issue” and “community rating” provisions. These provisions required insurance companies to provide coverage to those with preexisting conditions and provide the same premiums regardless of medical history.

The Department of Justice’s brief in the case is posted at https://www.justsecurity.org/wp-content/uploads/2018/06/ACA.Azar_.filing.pdf.

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APA Reacts to CDC Report on Uptick in Suicides Across United States

A report released yesterday by the CDC found suicide rates increased significantly in most states between 1999 and 2016, with 25 states experiencing increases of greater than 30%. The report also suggested that more than half of people who died by suicide did not have a known mental health condition.

“Suicide is a critical issue for all of us who work in health care,” APA President Altha Stewart, M.D., said in statement released today. “We know from other research that most people who die by suicide have mental health conditions, though they may not have been formally diagnosed or treated. People should know that suicide is preventable. Anyone contemplating suicide should know that help is available, and that there is no shame in seeking care for your mental health.”

The National Suicide Prevention Hotline is available 24 hours/7 days a week. For those seeking help, please call 1-800-273-8255.

“Suicide is rarely caused by any single factor, but rather, is determined by multiple factors,” including mental illness and prior suicide attempts, as well as social and economic problems, access to lethal means, and poor coping and problem-solving skills, lead author Deborah Stone, Sc.D., of the CDC and colleagues wrote. “Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning.”

Stone and colleagues used data from National Vital Statistics System to calculate national and state-level suicide rate estimates for people aged 10 and older from 1999 to 2016. Suicide rates increased in all states except Nevada, where the rate was consistently high (above 21 per 100,000 people) throughout the study period; the absolute increases in suicide rates ranged from 0.8 per 100,000 people in Delaware to 8.1 per 100,000 people in Wyoming.

The researchers also compared the characteristics of people who died by suicide, with and without known mental health conditions, in the 27 states with complete data in CDC’s National Violent Death Reporting System in 2015. Their analysis revealed that 54.0% of those who died by suicide did not have known mental health conditions (disorders and syndromes listed in DSM-5). While most of the people who died by suicide were male (76.8%) and non-Hispanic white (83.6%), those without known mental health conditions were more likely to be male (83.6% versus 68.8%) and belong to a racial/ethnic minority than those with known mental health conditions.

“Today's report on suicide reinforces the need to fund and enforce laws ensuring access to mental health services,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Early identification of mental illness is essential, and we are ready to work with Congress and other stakeholders to ensure that Americans can receive treatment when needed.”

For related information, see the Psychiatric News article “How to Reduce Risk of Suicide by Firearms,” by Liza Gold, M.D.

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Alcohol Use Intervention in ED Shows Promise in Reducing Dating Violence, Depression

A single motivational interviewing-based brief intervention used in the emergency department to curb underage drinking may also reduce short-term dating violence and depression, according to a study in the June issue of Pediatrics.

For this study, Quyen M. Ngo, Ph.D., of the University of Michigan Medical School and colleagues analyzed data collected as part of the U-Connect trial. A total of 836 adolescent patients in the emergency department (aged 14 to 20) who screened positive for risky drinking on the Alcohol Use Disorders Identification Test were randomly assigned to a computer-led brief intervention, a therapist-led brief intervention, or a control group that received “enhanced usual care” (staff reviewed a resource brochure with participants). 

In addition to assessing drinking behaviors at three-, six-, and 12-month follow-ups, the researchers asked the participants about exposure to dating violence (using the modified Conflict in Adolescent Dating Relationships Inventory) and symptoms of depression (using the Brief Symptom Inventory).

At three months, patients who received either computer or therapist brief intervention had a 15% lower incidence rate for depression. At six months, computer brief intervention resulted in a reduction of dating violence perpetration (48% lower than control) and depression symptoms (22% lower than control). At the 12-month follow-up, therapist-led brief intervention resulted in a significant reduction of dating violence perpetration (47% lower than that of the control group).

“Currently, no ED-based alcohol interventions have been tested that are also used to address multiple detrimental outcomes, including dating violence perpetration and depression symptoms,” Ngo and colleagues wrote. “Even when controlling for baseline alcohol consumption, we found that these are notable risk reductions, especially given that the intervention was not explicitly focused on dating violence or depression. … With our findings, we suggest that participating in an alcohol BI [brief intervention] may have a broader impact beyond alcohol consumption, including dating violence and depression secondary outcomes.”

For other information on alcohol use in adolescence, see the American Journal of Psychiatry article “Neural Predictors of Initiating Alcohol Use During Adolescence.”

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Internet Addiction May Increase Risk of Suicidality, Meta-Analysis Finds

People with internet addiction appear to be at a higher risk of suicidal behaviors than those with healthy internet use, according to a meta-analysis in the Journal of Clinical Psychiatry.

“We suggest screening individuals with internet addiction for the risk of suicide even if they do not have depression, as other factors may increase the risk of suicide in those with internet addiction,” Yu-Shian Cheng, M.D., of Tsyr-Huey Mental Hospital in Kaohsiung, Taiwan, and colleagues wrote.

While internet addiction disorder is not included as a formal diagnosis in DSM-5, the consequences of pathological internet use continue to attract increasing attention, according to the study authors. (Internet gaming disorder—the persistent and recurrent use of the internet to engage in games, leading to clinically significant impairment or distress—is listed as a condition for further study in DSM-5.) Several studies have suggested that internet addiction is associated with higher rates of suicidal behaviors, but whether this association is driven by other factors, such as depression, remains unclear.

To examine the strength of the association between suicidality and internet addiction, as well as the influence of other suicide risk factors, Cheng and colleagues performed a systematic review and meta-analysis of observational studies that investigated the association between internet addiction and suicidality. A total of 23 cross-sectional studies (n = 270,596) and two prospective studies (n = 1,180) were included in the analysis.

The authors found that prevalence rates of suicidal ideation, planning, and attempts were all significantly higher in study participants with internet addiction than in the controls (odds ratios [OR] of 2.952, 3.172, and 2.811, respectively). When the authors only used data from studies that adjusted for demographics and depression, they found that the prevalence rates of suicide attempts and ideation, though reduced, remained significantly higher in the participants with internet addiction than in the controls (attempts: adjusted OR = 1.559; ideation: adjusted OR = 1.490).

Further analysis “showed higher rates of suicidal behaviors in adolescents compared with adults and also showed a trend of higher prevalence rates of suicidal ideation in those with internet gaming disorder compared with those with internet addiction including any type of internet activity,” Cheng and colleagues wrote.

For related information, see the AJP Residents’ Journal article “Facebook Addiction: An Emerging Problem.”

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Firearm Seizure Laws Appear to Reduce Firearm-Related Suicides, Study Shows

States that have laws allowing police to temporarily seize firearms from people deemed to be at risk of danger to self or others have experienced a decrease in the number of suicides involving firearms, according to a report in Psychiatric Services in Advance.

In recent years, several states have enacted laws allowing time-limited seizure of firearms, with a level of judicial oversight and due process, from people deemed to be at risk. In 1999, Connecticut became the first state to do so following a mass shooting at the state lottery headquarters. Indiana followed suit in 2005 after the fatal shooting of a police officer in Indianapolis.

Aaron J. Kivisto, Ph.D., and Peter Lee Phalen, M.A., of the University of Indianapolis, analyzed the effects of Connecticut and Indiana’s firearm seizure laws on firearm and non-firearm suicide rates. They used suicide data from 1981 to 2015 in all 50 states to construct a synthetic model of characteristics and suicide trends prior to enactment of the firearm seizure law to compare with trends after enactment.

The authors found that Indiana’s firearm seizure law was associated with a 7.5% reduction in firearm suicides in the first decade following its enactment. Enactment of Connecticut’s law was associated with a 1.6% reduction in firearm suicides shortly after its passage; after the mass shooting at Virginia Tech University in April 2007, after which enforcement of the Connecticut law increased substantially, there was a 13.7% reduction in firearm suicides.

“Whereas Indiana demonstrated an aggregate decrease in suicides, Connecticut’s estimated reduction in firearm suicides was offset by increased nonfirearm suicides,” Kivisto and Phalen wrote. 

“Even though risk-based firearm seizure laws have typically been enacted in response to mass homicides, the laws have functioned primarily as a means of seizing firearms from suicidal individuals,” they concluded. 

For related information, see the Psychiatric News article “How to Reduce Risk of Suicide by Firearms,” by Liza Gold, M.D.

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Data Contained in Electronic Health Records May Help Identify Short-Term Suicide Risk

Combining patient responses to the Patient Health Questionnaire (PHQ-9) with clinical information available on electronic health records (EHRs) may someday help clinicians better predict which patients are most likely to attempt suicide, reports a study published in AJP in Advance.

Multiple studies have shown that health data can be helpful in identifying at-risk patients, but most patients do not show any obvious warning signs. Gregory Simon, M.D., M.P.H., of Kaiser Permanente and colleagues tested whether a comprehensive EHR analysis that includes data from the PHQ-9—a simple but effective depression screening tool—might improve prediction accuracy.

Simon and colleagues collected data from nearly 3 million patients aged 13 and older who had a specialty mental health visit or primary care visit and was diagnosed with a mental health disorder between January 1, 2009, and June 30, 2015. The patients were enrolled in one of seven large health systems: HealthPartners in Minnesota and Wisconsin; the Henry Ford Health System in Detroit; and the Colorado, Hawaii, Northwest, Southern California, and Washington regions of Kaiser Permanente. Within this group, the study authors identified 24,133 suicide attempts and 1,240 suicide deaths within 90 days of a primary care or specialty mental health visit.

The authors then stratified the patients by suicide risk using 313 demographic and clinical characteristics—including age, race, income, substance use, psychiatric medications dispensed, use of inpatient or emergency department care, and PHQ-9 results (both total score and answers to item 9, which asks about suicide or thoughts of self-harm).

Of the patients who scored in the top 5% of having the most risk factors out of the 313 that the researchers had identified, 5.4% attempted suicide and 0.26% died by suicide within 90 days. Patients who scored in the top 5% after a mental health specialty visit accounted for 43% of subsequent suicide attempts, while those in the top 5% after a primary care visit accounted for 48% of suicide attempts. This is an improvement over existing suicide prediction models, which identify on average 25% to 33% of subsequent suicide attempts, according to the authors.

The strongest predictors of suicide attempt were similar in mental health specialty and primary care patients: prior suicide attempt, mental health and substance use diagnoses, responses to PHQ-9 item 9, and prior inpatient or emergency mental health care.

“Prediction models cannot replace clinical judgment, but risk scores can certainly inform both individual clinical decisions and quality improvement programs,” the authors concluded. “Accurate risk stratification can also inform providers’ and health systems’ decisions regarding frequency of follow-up, referral for intensive treatment, or outreach following missed or canceled appointments.”

To read more about this topic, see the Psychiatric News article “Study Points to Risk Factors Predictive of Suicide After Emergency Visit.”

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