Specialized Psychotherapy Found to Reduce Severity of Delusions in Patients With Schizophrenia

Participating in a brief course of individualized metacognitive training—a psychotherapy designed to specifically target delusional beliefs—can reduce the severity of delusions and positive symptoms in patients with schizophrenia, according to a study published Tuesday in Schizophrenia Bulletin.

The study found that patients who received metacognitive training had significant reductions in delusional thinking compared with patients who received cognitive remediation, a program designed to improve cognitive abilities. These improvements were maintained at six months.

The findings “suggest that even brief psychotherapy can help to ameliorate the symptoms of psychosis,” Ryan P. Balzan, Ph.D., of Findlers University in Adelaide, Australia, and colleagues wrote.

Patients aged 18 to 65 with a schizophrenia spectrum diagnosis and delusional beliefs were recruited for the study. Of the 54 patients included in the trial, 52 were taking antipsychotic medications; these patients continued to receive their medication throughout the study.

The patients were randomly assigned to metacognitive training or cognitive remediation. Patients in the metacognitive training group completed four two-hour sessions with a therapist over one month, where they learned techniques for increasing awareness of their own cognitive biases that may contribute to the formation and maintenance of their delusional beliefs (for example, overconfidence and belief inflexibility). Patients in the cognitive remediation group completed four therapist-led, 90-minute to two-hour sessions over the same timeframe, during which they focused on improving working and verbal memory, processing speed, problem-solving, and attention—cognitive domains commonly impaired in patients with schizophrenia.

The researchers assessed the patients’ delusions, positive symptoms, performance in several cognitive domains, and clinical insight (awareness of and attitudes toward mental illness) at the start of the trial, following the completion of the four therapy sessions, and six months later. Two patients did not complete the six-month assessment.

Patients in the metacognitive training group showed significant reductions in delusional and overall positive symptom severity and improved clinical insight relative to patients in the cognitive remediation group. In contrast, compared with those in the metacognitive training group, patients in the cognitive remediation group showed moderate improvement in problem-solving ability but in no other cognitive domains. The authors wrote that this suggests “more CR [cognitive remediation] might be required to be effective in these domains.”

In conclusion, the authors wrote, “While larger multisite trials investigating MCT+ [metacognitive training] are warranted, the present study adds to the growing literature that psychological interventions can be effective in people with psychosis.”

For related information, see the American Journal of Psychotherapy article “Application of Integrative Metacognitive Psychotherapy for Serious Mental Illness.”

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What Can Physicians Do to Prevent Firearm Violence?

Physicians should routinely ask patients about firearms in their home and whether guns are locked and safely stored, writes James S. Kahn, M.D., a professor of medicine at Stanford University, in an editorial published today in the Annals of Internal Medicine. The editorial was published alongside a position paper from the American College of Physicians on reducing firearm injuries and deaths in the United States.

“Firearm-related violent death is an extraordinary problem made even more alarming by the prevalence of guns in the households of persons with dementia and the variation in firearm injuries related to racial disparities,” Kahn writes. “Yet, many physicians have been unengaged or silent during this epidemic. Why? Perhaps we think firearm violence is outside our realm of influence.”

Yet Kahn says physicians routinely ask patients about their unsafe activities, risky exposures, and addictions. “Nicotine abatement programs, alcohol reduction plans, and HIV prevention efforts begin with questions … about a person’s behavior and are successful when physicians provide information to empower patients, motivating them to prevent disease and avoid disability or death. Guns should be no different.”

Kahn recommends the following advice to patients about creating a safe environment when guns are in the home: 

• Remove the ammunition from the gun and lock the gun in a secure location.
• Lock the ammunition in a separate location from the gun.
• Store the keys in a different area from household keys and keep the keys out of reach of children.
• Lock up gun-cleaning supplies.
• Never leave a gun unattended after removing it from a safe storage place.

Kahn urges physicians to begin the conversation simply by asking, “Do you have guns in the home?” If a patient answers “yes,” the physician can follow up with a question such as “How or where do you typically store your guns?”

“If my patients say their guns are not secured or locked, then we can talk about how they might protect themselves and others from unintentionally finding and firing the guns,” Kahn writes. “We discuss what to teach children to do if they encounter a gun: Stop what they are doing, never touch the gun, leave the area, and tell an adult right away.” 

“It would be so easy to normalize this line of inquiry and add these questions to an electronic medical record along with questions about alcohol consumption, drug use, and sexual practices,” Kahn writes. “And it is not difficult to learn how to talk to patients about guns and how to counsel them about safety. We need to routinely ask, ‘Do you have guns in the home?’”

For related information, see the Psychiatric News article “Talking to Patients About Guns Necessary, But Examine Your Beliefs First.”

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Augmenting Interpersonal Therapy Early May Speed Improvement in Youth With Depression

Psychiatrists who treat adolescents with depression with interpersonal psychotherapy (IPT-A) should consider augmenting the treatment if there is no significant response to therapy within four weeks, suggests a small study published in the Journal of American Academy of Child & Adolescent Psychiatry.

“Waiting too long to decide whether to change treatment for an insufficient responder could mean prolonged experience of depressive symptoms and associated functional impairments,” wrote Meredith Gunlicks-Stoessel, Ph.D., of the University of Minnesota and colleagues. “On the other hand, augmenting treatment too soon might mean adding treatments that could increase risk of side effects or other burdens before giving the initial treatment sufficient time to work.”

For the study, Gunlicks-Stoessel and colleagues tracked 40 adolescents aged 12 to 17 with depression receiving 12 IPT-A sessions over a 16-week period. The participants were randomly assigned to receive a clinical evaluation after either four weeks or eight weeks, at which point treatment could be augmented if needed. Adolescents who showed an insufficient response to IPT-A (defined as less than a 20% reduction in depression symptom scores after four weeks or less than 40% reduction in depression symptom scores after eight weeks) were randomly assigned to four additional IPT-A sessions or daily fluoxetine (10 mg to 40 mg).

The authors found that the adolescents who received a clinical evaluation after four weeks had lower average depressive symptoms, as measured by the Children’s Depression Rating Scale-Revised, or CDRS-R, after 16 weeks compared with those who received the evaluation at eight weeks.

Additional analysis revealed that adolescents who received additional IPT-A sessions or adjunct fluoxetine beginning at week 4 saw statistically similar symptom improvements at week 16, the authors noted. Adolescents who received additional IPT-A sessions after four weeks saw greater symptom improvements compared with those who received the additional sessions after eight weeks. Adolescents who received fluoxetine experienced similar improvements regardless of when they began the augmentation.

“It may be that the timing of adding fluoxetine is not critical in the way that it appears to be for increasing the dose of IPT-A,” the authors wrote. “At week 4, the adolescent is about to initiate working on the interpersonal problem area and learning new communication and interpersonal problem-solving skills. It may be that meeting twice per week at this time is particularly good timing, as it provides more concentrated skill building and opportunities for engaging in interpersonal experiments in between sessions.”

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

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Cardioprotective Treatments After Heart Attack Increase Lifespan of Patients With Schizophrenia

The increased risk of mortality in patients with schizophrenia can be reduced with cardioprotective medication, such as antiplatelets, β-blockers, and statins, after a heart attack, suggests a study published in JAMA Psychiatry.

Previous studies have found that patients with schizophrenia die 10 to 15 years younger and have worse outcomes from coronary artery disease than those in the general population.

“Our study suggests that patients with schizophrenia who are treated with cardioprotective treatment after MI [myocardial infarction] have a lower mortality risk compared with patients who are not treated, similar to those treated in the general population,” wrote Pirathiv Kugathasan, M.D., of Aalborg University in Denmark and colleagues. “Cardioprotective medication after myocardial infarction should be carefully managed to improve prognosis.”

The researchers studied all adults aged 30 and older who were treated in Denmark public hospitals with first-time myocardial infarction (MI) during a 20-year period, involving 105,018 individuals, including 684 patients with a prior diagnosis of schizophrenia. The researchers followed patients up to 20 years and collected data on prescriptions received and defined five cardioprotective therapeutic drug groups: antiplatelets, vitamin K antagonists, β-blockers, angiotensin-converting enzyme inhibitors, and statins. The researchers noted use of monotherapy (treatment with one these medication groups), dual therapy (use of two), and triple therapy (use of three or more) as well as the time to all-cause mortality during the follow-up.

Compared with patients in the general population, patients with schizophrenia were less likely to receive prescriptions for cardioprotective medications after MI. Such patients were nearly nine times more likely to die compared with the general population treated; moreover, even those who received treatment were still nearly twice as likely to die as those treated in the general population.

The triple therapy provided the greatest benefit for patients, however, and patients with schizophrenia who received any combination of triple therapy had mortality rates similar to those observed of the general population who received the same treatment.

“Cardiovascular medications are a mainstay for ensuring health and preventing recurrent cardiovascular events after myocardial infarction,” Benjamin G. Druss, M.D., M.P.H., of Emory University wrote in an accompanying editorial. “The findings of the study by Kugathasan et al suggest that these medications can also play a critical role in reducing mortality among individuals with schizophrenia.”

For related information, see the Psychiatric News article “Patients With Serious Mental Illness Need Better Primary Care Integration, Health Advocacy.”

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Children With Anxiety Disorders Face Higher Risk for Self-Harm, ER Visits, Hospitalization

Children with newly diagnosed anxiety disorders were significantly more likely to experience serious medical events requiring treatment in the emergency room (ER) or inpatient hospitalization than children who did not have these disorders, according to a study published in Depression and Anxiety.

“Within two years following a new anxiety disorder diagnosis, a significant proportion of children have a mental health–related hospitalization, inpatient treated self-harm event, or ER visit, which translates to a sizable number of children, given the prevalence of anxiety disorders,” wrote author Greta A. Bushnell, Ph.D., a postdoctoral fellow in the Department of Epidemiology at Columbia University Mailman School of Public Health, and colleagues. Some 54 million children worldwide are estimated to have an anxiety disorder, according to the Global Burden of Disease Pediatrics Collaboration.

For the study, Bushnell and colleagues identified nearly 200,000 commercially insured children (aged 3 to 17) who were newly diagnosed with anxiety disorder in an office setting and had not received treatment for anxiety. The authors then examined the incidence of mental health–related hospitalization, inpatient treatment for suicide and self-inflicted injury, suicidal ideation, and ER visits in these children over a two-year period. They also examined the incidence of these events in children without an anxiety diagnosis (matched by age, sex, geographical region).

Within two years of diagnosis with anxiety, the children were three times more likely to have had a mental health related–hospitalization than children without an anxiety diagnosis (3.2% vs. 0.9%). Nearly one-third of the children with an anxiety diagnosis were treated in the ER (31.9%) versus about one-fifth of the children without an anxiety diagnosis (21.8%). Children with anxiety were also more than three times more likely to have suicidal ideation (1.7% vs. 0.4%) or receive inpatient treatment for self-harm (0.13% vs. 0.03%).

The rate of serious events were even higher than expected by researchers, Bushnell told Psychiatric News. “For example, more than 3% of youth aged 14 to 17 years had a mental health–related hospitalization in the year following a new anxiety diagnosis. An important next step would be to examine how we can improve follow-up care and treatment to reduce these events,” she said.

“The findings can help inform discussions providers have with patients and caregivers when a child is newly diagnosed with anxiety, including discussions on monitoring anxiety symptoms and when to seek additional care to prevent serious events,” Bushnell added. “Our results draw attention to the importance of follow-up care, particularly in older children with psychiatric comorbidities.”

For related information, see the Psychiatric News article “Peer Program Helps High Schoolers Handle Depression, Anxiety.”

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Support at Home, in Community May Protect Against Emotional Distress, Substance Use in Transgender Youth

Transgender and gender-diverse youth who feel close with their parents are less likely to experience emotional distress and engage in substance use compared with those reporting less connected relationships with parents, according to a study in the American Journal of Preventive Medicine. The study also found that youth who feel safe at school and have stronger relationships with teachers and other adults are less likely to experience depression, suicidality, and engage in substance use.

“Given that transgender and gender-diverse [TGD] youth report lower levels of connectedness and safety, bolstering an explicitly transgender and gender-diverse−friendly network of caring parents, safe and supportive schools, and connections to adults in the community may support efforts to eliminate disparities in depression, suicidality, and substance use,” Amy L. Glower, Ph.D., of the University of Minnesota and colleagues wrote.

For the study, Glower and colleagues examined data from the 2016 Minnesota Student Survey—a survey that asks students about school climate, bullying, out-of-school activities, health and nutrition, emotional and mental health, relationships, substance use, and more. As part of the survey, students in the ninth and 11th grades were asked, “What is your biological sex?” (response options: male/female) and whether they “identify as transgender, genderqueer, genderfluid, or unsure about their gender identity” (yes/no).

The researchers examined associations between eight protective factors (connectedness to parents, adult relatives, friends, adults in the community, and teachers; youth development opportunities; and feeling safe in the community and at school) and depression, suicidality, and substance use (alcohol, binge drinking, marijuana, nicotine) among 2,168 adolescents who identified as transgender, genderqueer, genderfluid, or questioning their gender.

Of the 2,168 included in the analysis, 57.9% met the cutoff score for additional depression screening using the Patient Health Questionnaire-2, 44.9% reported suicidal ideation, and 16.7% reported a suicide attempt; substance use ranged from 11.2% (binge drinking) to 25.9% (any nicotine use). Feeling more connected to parents was related to significantly lower odds of all indicators of emotional distress and substance use relative to those reporting less connected relationships with parents, the authors reported.

“Given that TGD youth report less connectedness with their parents than their cisgender peers, increasing investment in programs offering support and guidance to parents of TGD youth and linking parents to existing supports (e.g., through health care, schools, religious institutions) may be effective ways to bolster the development of these caring relationships,” the authors concluded.

For related information, see the Psychiatric News article “Psychiatrists Need to Prepare to Care for Gender-Variant Patients” and the Psychiatric Services article “Affirming Gender Identity of Patients With Serious Mental Illness.”

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Haloperidol, Ziprasidone Found Ineffective in Treating Patients With Delirium in the ICU

Neither haloperidol nor ziprasidone, medications commonly used to treat psychosis, had any benefit over placebo in treating patients for delirium in the intensive care unit (ICU), according to a study published Monday in the New England Journal of Medicine.

“For more than 40 years, intravenous antipsychotic medications have been used to treat delirium in hospitalized patients,” wrote E.W. Ely, M.D., of the Vanderbilt University Medical Center and colleagues. “In this double-blind, randomized, placebo-controlled trial of intravenous antipsychotic medications for the treatment of delirium in the ICU, there was no evidence that either haloperidol or ziprasidone led to a shorter duration of delirium and coma.”

The study involved patients with acute respiratory failure or shock who developed hypoactive or hyperactive delirium at 16 U.S. medical centers. Of the 566 patients who developed delirium during the trial, 192 were randomly assigned to receive haloperidol (maximum intravenous dose, 20 mg daily), 190 received ziprasidone (maximum intravenous dose, 40 mg daily), and 184 received placebo. Patients were discontinued from drug or placebo after 14 days or at ICU discharge, whichever occurred first.

Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). The primary endpoint was the number of days alive without delirium or coma during the 14-day intervention period. A secondary endpoint was duration of delirium.

The researchers found no significant difference between the treatment groups on the primary endpoint: the median number of days alive without delirium or coma was 7.9 in the haloperidol group, 8.7 in the ziprasidone group, and 8.5 in the placebo group. Neither haloperidol nor ziprasidone led to a shorter duration of delirium compared with placebo.

“Why did the trial fail to show benefit? It is likely that our concept of delirium is flawed,” suggested Thomas P. Bleck, M.D., of the Department of Neurological Science at Rush Medical College, Chicago, in an accompanying editorial.

“The neurochemistry of sudden alteration in mentation [mental activity] is complex and involves several neurotransmitters as well as structural, immunologic, and network alterations and possible brain infection that is not clinically evident,” he wrote. “The investigators deserve credit for conducting a difficult trial, but it would have been astounding if there were a single magic bullet for the restitution of normal brain function in ICU patients with delirium.”

For related information, see the Psychiatric News article “Point-of-Care EEG Device Could Ease Efforts to Detect Delirium.”

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Patients With OUD Who Receive Extended-Release Naltrexone May Be More Likely to Stay in Treatment

Naltrexone is a proven treatment for opioid use disorder (OUD), but its clinical usefulness, when taken orally, has been limited by poor adherence among patients, according to several studies. A study in AJP in Advance now suggests that patients with OUD may be twice as likely to stay in therapy if they receive monthly injections of extended-release naltrexone (XR-naltrexone) following opioid withdrawal compared with daily oral naltrexone.

“These study findings have immediate clinical relevance for treatment of opioid use disorder at a time when an opioid epidemic continues unabated in the United States,” wrote Maria Sullivan, M.D., Ph.D., of Columbia University and colleagues. “Given that postdetoxification outpatient treatment without pharmacotherapy yields poor completion rates, high (60%−90%) relapse rates, and heightened risk of overdose and death, XR-naltrexone may be a viable alternative to prevent relapse in patients seeking treatment for opioid use disorder who do not prefer an agonist approach [such as methadone or buprenorphine].”

Sullivan and colleagues enrolled 60 adults aged 18 to 60 who met DSM-IV criteria for opioid dependence in the study. All participants completed an inpatient medication-assisted opioid withdrawal program and were transitioned to naltrexone therapy. Thirty-two patients were randomly assigned to treatment with oral naltrexone (50 mg/day) and 28 were assigned to treatment with XR-naltrexone (380 mg per injection every four weeks) for 24 weeks.

All participants were asked to visit the clinic three times per week for the first two weeks and then twice weekly for the remainder of the 24-week study. During each clinic visit, the patients took a urine test, discussed any recent substance use, and received a behavioral therapy session. The goal of the behavioral therapy was to educate, motivate, and support patients through the process of opioid detoxification, naltrexone induction, and successful naltrexone maintenance. Therapy goals were reinforced with a reward system whereby patients could win gift vouchers after achieving goals or milestones.

After six months, 12 of the 28 (43%) patients receiving XR-naltrexone had dropped out of treatment, compared with 23 of 32 (72%) patients in the oral naltrexone group. There were no significant differences in side effects between the two groups, other than a higher rate of insomnia among patients taking oral naltrexone. There were nine serious adverse events, but only one was found to be related to medication: one patient receiving XR-naltrexone developed allergic hives and was removed from the study.

“These results support the use of XR-naltrexone combined with behavioral therapy as an effective treatment for patients seeking opioid withdrawal and nonagonist treatment for preventing relapse to opioid use disorder,” the researchers concluded.

To read more about naltrexone, see the Psychiatric News article “Low-Dose Naltrexone May Mitigate Severity of Opioid Withdrawal During Detox.”

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Giving Patients Choice of PTSD Treatment Yields Significant Benefit, Study Finds

Adults with posttraumatic stress disorder (PTSD) given a choice between sertraline or prolonged exposure therapy opted for prolonged exposure almost two to one; and while both treatments conferred significant benefits, prolonged exposure provided some advantage over sertraline, reports a study published today in AJP in Advance.

The study aimed to determine whether giving patients diagnosed with PTSD their choice of treatment would affect patient outcomes, wrote Lori A. Zoellner, Ph.D., of the Department of Psychology at the University of Washington and colleagues. According to the authors, the study was the first large-scale trial directly comparing the efficacy of sertraline and prolonged exposure therapy for PTSD.

Some 200 patients with PTSD watched videotaped treatment rationales for both treatments and then indicated a preference for either sertraline or prolonged exposure. They were then randomly assigned to having a choice between treatments or to no choice of treatment. Both groups received up to 10 weeks of acute treatment and up to 24 months of follow-up.

Participants showed a strong preference for prolonged exposure therapy over the medication: of 97 participants given a choice of treatment, 63% chose prolonged exposure therapy and 37% chose sertraline. Participants in the prolonged exposure group received 10 weekly, 90- to 120-minute sessions led by a therapist. Responders were offered continued sertraline up to 24 months or up to two prolonged exposure booster sessions during the follow-up period.

The primary outcome measure was interviewer-rated PTSD symptoms, as measured by the PSS-I—a 17-item interview that uses DSM-IV symptom criteria and yields a severity rating (range, 0–51) and a diagnosis (yes/no). Additional measures included several standard self-assessments for depression, anxiety, and disability.

Both treatment groups showed large gains that were maintained during the 24-month follow-up; however, patients treated with prolonged exposure were significantly more likely to lose their PTSD diagnosis.

The authors noted that patients who received their preferred treatment were more likely to complete treatment (73% vs. 49%), and were more likely to lose their PTSD diagnosis, achieve responder status, and have lower self-reported PTSD, depression, and anxiety symptoms.

“Notably, preference effects were as strong as, if not stronger than, treatment modality effects, which suggests that accommodating patients’ preferences in treating PTSD is as important as, if not more so, than the specific choice of an empirically supported treatment,” the researchers wrote. “Accommodating patient preferences … and developing strategies for enhancing patient buy-in are important next steps in facilitating access, initiation, adherence, and completion of empirically supported treatment for PTSD.”

For related information, see the Psychiatric News article “Propranolol Combined With Reactivation Therapy May Reduce PTSD Symptoms.”

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Several Symptoms May Point to Suboptimal Medication Adherence in Patients With Depression

Despite the proven efficacy of antidepressants, a significant number of patients with depression fail to take these medications as prescribed, which can increase the risk of depression relapse, hospitalization, and more. A study in Depression & Anxiety now suggests that patients with major depression who have more severe symptoms, suicidal thoughts, and/or report physical pain may be most likely to report not taking their medications as prescribed.

Carolina Baeza-Velasco, Ph.D., of the University of Paris Descartes and colleagues examined data extracted from hospital admissions at the Department of Emergency Psychiatry and Acute Care of the University Hospital of Montpellier, France, between May 2012 and July 2015. A total of 360 adults aged 18 to 77 who met DSM-IV criteria for a current major depression episode and filled out the Medication Adherence Rating Scale (MARS) questionnaire were included in the study.

The MARS questionnaire asks patients to answer yes or no to 10 questions/statements on medication adherence behavior, beliefs/attitudes about taking medication, and side effects of medication. The researchers divided the study participants into two groups according to how they responded to the four MARS questions on medication adherence behavior—the “optimal adherence group” and the “suboptimal adherence group.” Patients in the optimal adherence group responded no to all four questions, including “Do you ever forget to take your medication?” and “When you feel better, do you sometimes stop taking your medication?”. Of the 360 patients included in the study, 107 (29.7%) were found to be optimally adherent to their medication.

The researchers next compared the responses of patients in the two groups to questions regarding depressive symptoms and suicidal thoughts; history of abuse and/or neglect during childhood; physical pain intensity; and psychiatric history. The number of psychiatric hospitalizations, the score of depression severity, suicidal ideation, reports of negative side effects from medication, and pain were significantly higher in the patients in the suboptimal adherence group compared with those in the optimal adherence group. Patients in the suboptimal adherence group also had less favorable attitudes toward medication and were less likely to be married/living with a partner than patients in the optimal adherence group.

“These results suggest a vicious circle in which more vulnerable patients are less adherent to medication, which could worsen the clinical picture maintaining, in turn, low adherence,” the researchers concluded.

For related information, see the Psychiatric News article “Motivational Pharmacotherapy Can Improve Medication Adherence,” by Roberto Lewis-Fernández, M.D., of Columbia College of Physicians and Surgeons.

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Older Adults Who Engage in Self-Harm Are Often Not Referred to Mental Health Services, Study Finds

Most older adults who engage in self-harm are not referred to mental health services, according to the results of a study conducted in the United Kingdom. The findings, which were published in Lancet Psychiatry, suggest these patients are 20 times more likely to die from unnatural causes within a year compared with older adults who do not engage in self-harm.

“We have identified a group at high risk of premature unnatural death and identified areas of improvement for clinical management of older-aged adults in primary care,” wrote Catherine Morgan, M.D., of the University of Manchester, U.K., and colleagues. “Health care professionals should take the opportunity to consider the risk of self-harm when an older person consults with other health problems, especially when major physical illnesses and psychopathology are both present, to reduce the risk of an escalation in self-harming behaviour and associated mortality. “

Morgan and colleagues analyzed data from the UK Clinical Practice Research Datalink, which contains anonymous patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. They identified 4,124 adults aged 65 years and older with a self-harm episode recorded during calendar years 2001 to 2014. Of these episodes, 3,327 (80.7%) involved ingestion of drugs and 234 (5.7%) involved self-cutting.

For their analysis, the researchers focused on the 2,854 adults with at least 12 months of follow-up data. They examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. They compared the self-harm cohort with a group of similarly aged patients who did not engage in self-harm.

Within 12 months of their initial self-harm episode, just 335 (11.7%) of 2,854 older adults were referred to mental health services, 1,692 (59.3%) were prescribed an antidepressant, and, of these, 336 (11.8%) received a tricyclic antidepressant, which can be fatal when taken in overdose.

In the year after the first self-harm episode, 412 (14.4%) individuals had another self-harm episode, of whom 344 (83.5%) had one repeat episode and 68 (16.5%) had two or more episodes. A total of 908 (37.0%) deaths occurred in the self-harm cohort compared with 12,683 (25.9%) deaths in the comparison cohort, of which 54 (5.9%) were unnatural deaths and 36 (4.0%) were deaths by suicide in the self-harm cohort versus 275 (2.2%) unnatural deaths and 12 (<0.1%) deaths by suicide in the comparison cohort, the authors reported.

“After self-harm in an older adult, improvement of referral rates [to specialty mental health care] and consideration of possible alternative medication, with particular avoidance of TCAs [tricyclic antidepressants], might reduce the risk of escalating self-harm behavior and associated mortality risk,” the authors wrote.

For related information, see the American Journal of Psychiatry article “Suicide Following Deliberate Self-Harm.”

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Methylphenidate May Lead to Improvements in Youth With Disruptive Behavior Disorder, Study Suggests

Methylphenidate (MPH) may be a potential treatment option for youth with disruptive behavior disorder, suggests a study published in the Journal of the American Academy of Child & Adolescent Psychiatry.

Research has shown that youth with disruptive behavior disorder are less likely than others to anticipate the negative consequences of their behaviors, which may contribute to behavioral problems. Studies also show that people with disruptive behavior disorder tend to have lower activity in the amygdala—a brain region known to be involved in emotional learning, including fear response.

Koen Van Lith, M.D., of the Vrije Universiteit Amsterdam and colleagues tested whether MPH might increase amygdala activity in youth with disruptive behavior disorder, including oppositional defiant and/or conduct disorder. The researchers chose MPH since this medication is known to increase amygdala activity in children with attention-deficit/hyperactivity disorder.

Van Lith and colleagues conducted a clinical study of 42 boys aged 14 to 17 who were diagnosed with disruptive behavior disorder. The adolescents completed a fear-learning task (learning to associate a visual stimulus with a mild electric shock) 90 minutes after taking either a single dose of MPH (0.3 mg/kg to 0.4 mg/kg) or placebo. Twenty-one adolescents with no behavioral problems were also included as a comparison group; these participants were given no medication before testing. All the participants underwent functional MRI scanning while performing the fear-learning task to measure amygdala activity.

The adolescents with disruptive behavior disorder who took placebo had much lower amygdala activity during the fear-learning task compared with healthy controls. In contrast, the adolescents with disruptive behavior disorder who took MPH had amygdala activity that was similar to the adolescents with no behavioral problems.

“This is promising for MPH as a possible treatment option in DBD [disruptive behavior disorder],” Van Lith and colleagues wrote. “Because amygdala functioning is important for decision making and moral judgment, MPH might improve clinical outcomes, although future studies should establish whether increased amygdala function after MPH administration indeed improves behavioral outcomes.”

To read more about treating disruptive behaviors in youth, see the Psychiatric News article “Experts Search for Meds to Help Youth With DMDD.”

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Candidates Announced for APA's 2019 Election

The APA Nominating Committee, chaired by APA Immediate Past President Anita Everett, M.D., today announced the candidates for the Association's 2019 election.




President-Elect
Jeffrey Geller, M.D., M.P.H.
Philip Muskin, M.D., M.A.

Secretary
Jeffrey Akaka, M.D.
Sandra DeJong, M.D., M.Sc.
Ramaswamy Viswanathan, M.D., D.M.Sc.

Minority/Underrepresented (M/UR) Trustee
Rahn Bailey, M.D.
Robert Cabaj, M.D.

Area 3 Trustee
Kenneth Certa, M.D.
Barry Herman, M.D.
Roger Peele, M.D.

Area 6 Trustee
Barbara Weissman, M.D.
Melinda Young, M.D.

Resident-Fellow Member Trustee-Elect
Lisa Harding, M.D.
Daniel Hart, M.D.
Michael Mensah, M.D., M.P.H.

The deadline for candidates who wish to run by petition is November 15. All candidates and their supporters are encouraged to review APA's Election Guidelines. For more election information, please visit the Election section on APA's website or email election@psych.org.

The slate of candidates who have been nominated is considered public but not official until it is approved by the APA Board of Trustees at its December meeting. APA members may cast their ballots from January 2 to January 31, 2019.

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Heart Valve Surgery May Lead to Postoperative Cognitive Deficits

Patients who undergo heart valve surgery are at a heightened risk of cognitive decline in the first few months after surgery, suggests a paper published yesterday in the Journal of the American Geriatrics Association.

“Aortic valve surgery, which is performed more commonly in older adults, entails greater risk of early cognitive dysfunction within the first month after surgery than mitral valve surgery, but cognition in both groups appears to converge by six months,” wrote Mark Oldham, M.D., of the University of Rochester Medical Center and colleagues.

Oldham and colleagues conducted a meta-analysis of 12 clinical studies that had assessed the cognitive scores of adults before and after undergoing heart valve surgery. A total of 12 clinical studies, which included 450 patients who had early cognitive assessments (one week to one month after surgery) and 722 patients with intermediate assessments (two to six months after surgery), were included in the analysis. The researchers identified no studies that explored long-term cognitive changes after heart valve surgery, which they noted is a major research gap.

The analysis revealed that patients who underwent heart valve surgery experienced moderate cognitive decline in the first month after surgery that improved slightly by six months out. Patients who underwent mitral valve surgery experienced mild but progressive decline over six months, while those who underwent aortic valve surgery had greater early cognitive dysfunction, followed by partial recovery. The authors noted that patients receiving aortic valve surgery were about 11 years older on average, which could have influenced these outcomes.

“These findings call for further investigation aimed at refining risk stratification and prevention strategies in this group, in which cognitive vulnerability is widely underrecognized,” Oldham and colleagues concluded.

To read more about this topic, see the Psychiatric News article “Escitalopram May Reduce Risk of Heart Problems.”

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Shared Decision Making With Patients Can Improve Treatment Engagement, Medication Adherence

Providing patients with a computer-based, shared decision-making tool may promote ongoing treatment engagement and adherence to antipsychotic medication regimens, according to a study in Psychiatric Services in Advance.

Shared decision making is a model of patient-provider communication that requires the active participation of both patient and clinician in information sharing, leading to a treatment decision made and agreed upon by both parties. It combines evidence on treatment options with the values and preferences of patients and their families.

This study focused on a specific tool called CommonGround, an offering on the My Collaborative Health Outcomes Information System (MyCHOIS), a web-based platform developed by the New York State Office of Mental Health (NYSOMH). Molly T. Finnerty, M.D., of NYSOMH and colleagues examined the effects of MyCHOIS-CommonGround on treatment engagement, and for patients with schizophrenia, adherence to antipsychotic medication regimens.

Some 472 Medicaid patients completed shared decision-making reports using MyCHOIS-CommonGround, summarizing their symptoms, functioning, and concerns, with the help of peer staff. Later, during a medication appointment, the clinician and patient reviewed the report and worked together to develop a shared decision. Also studied were 944 similar Medicaid patients who did not use the program. Among participants, schizophrenia was the most prevalent diagnosis (40%), and about one-third of the patients had a comorbid substance use disorder.

While there were no differences between the two groups at baseline, during the follow-up year, the MyCHOIS–CommonGround users had a higher level of ongoing engagement in outpatient mental health service compared with the control group (months with use of a service, 8.54 versus 6.95), the researchers wrote. Furthermore, at the one-year follow-up, there was a significant increase in ongoing treatment engagement for the MyCHOIS–CommonGround users group and a significant decrease in engagement for the control group. Patients with schizophrenia who used MyCHOIS-CommonGround were also found to be significantly more adherent to their antipsychotic regimen during the follow-up year than those in the control group (9% more days with medication).

“It is important to establish the benefit of shared decision making beyond the ethical considerations upon which it was founded, in part to inform implementation decisions. Implementation of shared decision-making programs, such as CommonGround, can be challenging and requires leadership and staff commitment and upfront and ongoing resources,” Finnerty and colleagues wrote. “Shared decision making is a promising approach to enhancing patient-centered care, improving the use of services, and ultimately improving outcomes of care.”

For related information, see the Psychiatric Services article “Consumer Outcomes After Implementing CommonGround as an Approach to Shared Decision Making.”

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Mental Health Problems Predict Tobacco Use in Youth

Youth and young adults with internalizing problems such as depression and anxiety and externalizing problems such as attention-deficit/hyperactivity disorder may be more likely to begin using tobacco products than those without these disorders, according to a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

“[T]he need for early and specific tobacco product use screening, as well as screening across the spectrum of mental health problems, as tools to prevent tobacco product use onset is apparent,” wrote Wilson Compton, M.D., M.P.E., deputy director of the National Institute on Drug Abuse, and colleagues. “Providing incentives to providers to link these two screening mechanisms could increase the overall integration of these services in clinical practice.”

For the study, Compton and colleagues relied on data obtained from youth and young adults who were participants in the longitudinal Population Assessment of Tobacco and Health (PATH) Study. Specifically, the authors analyzed data from 9,067 youth (12 to 17 years) and 1,466 young adults (18 to 24 years) who reported having never used tobacco products at the beginning of the study (Wave 1).

At Wave 1, the study participants completed the Global Appraisal of Individual Needs-Short Screener, which assesses internalizing and externalizing problems, and answered questions about drug and alcohol use. At Wave 2 (approximately one year later), the participants were again asked about their use of tobacco products (including cigarettes, electronic nicotine delivery systems, traditional cigars, cigarillos, filtered cigars, pipe, hookah, smokeless tobacco, snus pouches, bidis, kreteks, and dissolvable tobacco) over the past 12 months.

After adjusting for sociodemographics, alcohol or drug use, and externalizing problems, youth and young adults with high severity internalizing problems were found to be 1.5 times more likely to begin use of any tobacco product compared with those with no/low/moderate severity internalizing problems. Youth and young adults with high severity externalizing problems were 1.3 times more likely to begin use of any tobacco product compared with those with no/low/moderate severity externalizing symptoms.

Additional analysis revealed that youth and young adults with high severity internalizing problems were about 1.8 times more likely to report new use of multiple tobacco products. The “findings of a dose-response relationship between internalizing problems and onset of exclusive and poly-tobacco use, respectively, suggest that youth and young adults with internalizing problems were not only more likely to begin using tobacco products compared to those without internalizing problems, but were also more likely to begin using with multiple tobacco products,” the authors wrote.

They concluded, “This study demonstrates that mental health problems predict the onset of tobacco use among youth and young adults in a nationally representative sample, and across a wide range of tobacco products beyond cigarettes. … In addition to screening for tobacco product use, health care providers should screen for a range of mental health problems as a predictor of tobacco use.”

For related information, see the Psychiatric News article “FDA’s ‘Real Cost’ Campaign Cuts Cigarette Smoking by Teens.”

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Women’s Psychiatry Expert Discusses Importance of Addressing Patients’ Sexual Harassment

Asking patients about their history with sexual harassment and abuse should be a routine part of psychiatric care, said APA Past President Nada Stotland, M.D., during her presentation at this year’s IPS: The Mental Health Services Conference. The comments were part of a wide-ranging lecture about important social issues facing women psychiatrists today.

Stotland, who is an expert on reproductive psychiatry and women’s issues, told the audience that psychiatrists can play key roles in helping people deal with and recover from their experiences of sexual harassment and/or sexual abuse. While she noted that identifying a patient’s sexual harassment history is important, she emphasized that such questions must be asked with empathy and sensitivity. If a patient has had such an experience, the psychiatrist’s focus should be on helping the patient deal with her reactions to her experience, such as self-recrimination, shame, guilt, and/or rage. “We need to validate their reactions,” she said.

Stotland recommended that psychiatrists should primarily use psychotherapy during the early stages of therapy and prescribe medications to patients with severe, acute symptoms. Once a good rapport has been reached, medications can be given on a case-by-case basis.

Risk of sexual harassment is not limited to patients, and Stotland also provided some suggestions for women psychiatrists to help protect themselves.

“Before accepting any job, get as much information as possible about the power structure of the employer and its sexual harassment history,” she stressed. Stotland added that women should also be aware of what support services are available at the institution or in the surrounding area should any problems arise.

To read more about sexual harassment in psychiatry, see the Psychiatric News article “Sexual Harassment Still Occurs in Psychiatry, Says Women’s Caucus Leader” and the Psychiatric Services article “Gold Award: Integrated Psychiatric Treatment for Survivors of Intimate Partner Violence at the Bronx Family Justice Center.”

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More African Americans With Schizophrenia Could Receive Clozapine Despite Lower White Blood Cell Counts

More African Americans with schizophrenia who are not prescribed the antipsychotic clozapine because of low white blood cell counts could potentially use the drug safely, according to Deanna Kelly, Pharm.D., and Gopal Vyas, D.O.

Kelly is the director of the Treatment Research Program at the Maryland Psychiatric Research Center (pictured left), and Vyas is a psychiatrist at the Treatment Research Center. They spoke yesterday at APA’s IPS: The Mental Health Services Conference in Chicago.

Clozapine has been shown repeatedly to be the best medication for treatment-resistant schizophrenia. Yet Kelly and Vyas explained that African Americans with schizophrenia are much less likely to receive clozapine and more likely to have the medication discontinued because of neutropenia, or low white blood cell counts. Clozapine is known to increase the risk for agranulocytosis—a condition of extremely low white blood cell counts that can be life threatening—and patients using clozapine are required to undergo periodic blood monitoring. Many African-American patients who never received the drug or were taken off it, however, may have benign ethnic neutropenia (BEN), a condition that occurs in about 25% to 50% of people of African ancestry and up to 38% of people of Middle-Eastern descent.

Kelly and Vyas said that the standards for determining when a patient has neutropenia have largely been drawn from European Caucasian populations.For instance, up until 2015, the Food and Drug Administration required clozapine to be discontinued when neutrophil counts fell below 1500/uL. But individuals with BEN are liable to have naturally occurring neutrophil counts that fall below that standard and are not at greater risk of agranulocytosis.

In 2015, the FDA lowered the threshold for interrupting clozapine treatment from an absolute neutrophil count of 1,500/uL to 1,000/uL. New guidelines have been issued for patients believed to have BEN, which are intended to make it easier to prescribe and continue clozapine use for these patients.

“Clozapine is underutilized due to many reasons, and its use in African-descent patients is very low,” Kelly said. “The underuse most likely is attributed to BEN, but clozapine use in BEN does not increase the risk for agranulocytosis or infection related to using clozapine.”

For related information see the Psychiatric News article “New Clozapine Guidelines Likely to Limit Treatment Interruptions.”

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APA Praises Congressional Passage of Opioid Treatment and Prevention Package

A bipartisan legislative package passed yesterday by Congress takes many important steps toward combating the opioid crisis with a broad range of opioid treatment and prevention programs, said APA in a statement.

“Opioid use disorder has taken a heavy toll on the health and well-being of Americans,” commented APA President Altha J. Stewart, M.D. “APA is grateful to see bipartisan support for increased access to treatment for substance use disorders [SUD], including expanded access to residential treatment and medication-assisted treatment.”

APA was disappointed, however, that the bill failed to include a critical revamp of a federal regulation known as 42 CFR Part 2 to align it with the Health Insurance Portability and Accountability Act. The changes for which APA had lobbied would have allowed for better care coordination, improved patient safety, and reduced stigma for SUD treatment while still preserving patient confidentiality, Stewart said. These measures are contained in the OPPS Act (HR 6082), which passed the House with overwhelming bipartisan support earlier this year. “We urge the Senate to hold a separate vote on the OPPS Act to ensure that these reforms become law.”

After passing the Senate 98 to 1, the legislation—The SUPPORT for Patients and Communities Act (HR 6)—now awaits President Trump’s signature. One year has passed since President Trump declared the opioid epidemic a national emergency, yet overdose deaths continue to climb, surpassing 72,000 in 2017, according to the latest provisional government estimates. That number represents a nearly 10 percent increase from the previous year.

HR 6 includes a number of provisions for which APA had lobbied, including the following:

Telemedicine: eliminates telehealth facility fees and waives geographic requirements for treatment of SUD for Medicare patients; also directs the Attorney General to issue final regulations within one year specifying the limited circumstances in which a special registration to use telemedicine to treat SUD may be issued and the procedure for obtaining a special registration.

Mental health and substance use treatment parity: mandates coverage of mental health and substance use disorder services for the 9.4 million low-income children enrolled in the State Children’s Health Insurance Program.

Workforce investment: creates a new student loan repayment program for SUD treatment providers (up to $250,000 per individual) who agree to serve for six years in underserved areas or areas with higher-than-average overdose rates.

Pain management: supports innovative medical research at the National Institutes of Health to combat the opioid crisis.

The legislation also lifts the ban on states from using Medicaid funds to treat SUD patients in larger residential facilities. States will now be able to amend their plans to cover institutional SUD treatment for up to 30 days per patient in a 12-month period.

The opioid package does not allot funding for its measures. In a separate measure last week, a FY2019 appropriations package provided $3.8 billion for the opioid crisis, a $206 million increase from 2018 funding levels.

For related information, see “APA Praises Congress for Passing Bill That Funds Mental Health and Substance Use Services.”

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