Suicide Risk Factors May Be Overlooked in Older Veterans, Study Suggests

General health professionals may be missing key opportunities to assess suicidal risk and prevent suicide attempts in veterans aged 50 or older. A study in the American Journal of Geriatric Psychiatry found that veterans aged 50 and older who later attempted suicide were less likely to be asked about impulsivity and firearms access during their last visit prior to the attempt than younger veterans who later attempted suicide. The older veterans were also less likely to receive mental health referrals than their younger peers.

Kelsey Simons, Ph.D., L.M.S.W., of the Veterans Administration VISN 2 Center of Excellence for Suicide Prevention in Canandaigua, N.Y., and colleagues used electronic health records to examine differences in suicide risk screening among 93 patients who attempted suicide and who had visited VA medical facilities within a year before the attempt. The researchers also looked at differences in mental health referrals made by general health professionals. All patients were veterans who had survived a suicide attempt within 48 hours before hospitalization. Thirty-seven patients were age 50 or older, and 56 were 18 to 49.

Among all patients, the last visit to a VA medical facility occurred at an average of about 27 days before a suicide attempt, and most visits occurred in an outpatient setting. Although general health professionals screened both groups of patients equally for risk factors such as depression and suicidal ideation, they were less likely to screen older patients for impulsivity or access to firearms. Furthermore, just 16.2% of older patients who saw a general health professional received a referral to a mental health professional, compared with 46.4% of the younger veterans.

The researchers noted that their study was limited by the number of patients and the number of facilities involved, and that the study may not generalize to all veterans or to non-veterans. However, they noted the need for more screening among older veterans.

“Despite these limitations, our findings are important as they emphasize primary care as a key site for suicide prevention among older veterans, informing both research and program development,” Simons and colleagues wrote. “Interventions that capitalize on primary care for reaching older patients at risk for suicide (e.g., collaborative and integrated care) have the potential to improve prevention efforts in this population.”

For related information, see the Psychiatric News article “Suicide Deaths Climb Dramatically in U.S., Nearly Double for Women.”

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Initiating Aripiprazole Similar to Other Antipsychotics When It Comes to Risk of Treatment Failure, Study Suggests

Patients who begin taking the antipsychotic aripiprazole after being treated with other antipsychotics do not appear to be at greater risk of hospitalization, self-harm, or suicide than those initiating other antipsychotics after previous antipsychotic exposure, according to a study reported today in JAMA Psychiatry.

Aripiprazole is an effective antipsychotic medication that is often used because it has fewer side effects compared with other antipsychotic medications, explained François Montastruc, M.D., Ph.D., of the Jewish General Hospital in Quebec and colleagues. Recently, however, there have been reports that in patients already exposed to antipsychotic medication, aripiprazole can result in worsening of symptoms and treatment failure.

“We found no evidence of an increased rate of psychiatric treatment failure associated with initiating aripiprazole use compared with initiating use of other antipsychotic drugs in patients previously exposed to antipsychotic medications,” Montastruc and colleagues wrote.

They analyzed data from the United Kingdom Clinical Practice Research Datalink (CPRD) on 1,643 patients who were starting aripiprazole (either as a switch from or add-on to a previous antipsychotic medication) and another 1,643 patients who were starting on other oral antipsychotic medications under similar circumstances. The CPRD is one of the world’s largest computerized databases of anonymous primary care medical records, containing the data of more than 15 million patients enrolled with more than 700 general practices in the United Kingdom. Patients included those with diagnoses of schizophrenia, bipolar disorder, depression, “other psychiatric diseases,” or unknown.

Patients in both groups were matched on the basis of calendar year of cohort entry, time since first antipsychotic prescription, psychiatric disease history, age, and other factors. They were followed for one year or until psychiatric treatment failure or death from any cause other than suicide, whichever occurred first. The primary outcome was the first psychiatric treatment failure, defined as hospitalization for a psychiatric event, episode of self-harm, or suicide.

The researchers found that initiation of aripiprazole was not associated with an increased rate of overall psychiatric treatment failure, psychiatric hospitalizations, self-harm, or suicide compared with initiation of another antipsychotic medication.

“Switching to or adding aripiprazole may be associated with psychiatric worsening in some patients, but the findings suggest that these exacerbations do not lead to serious psychiatric treatment failure,” Montastruc and colleagues wrote. “These findings warrant replication in large observational studies.”

For related information, see the Psychiatric News article “Aripiprazole May Reduce Some Side Effects of Antipsychotics in Women.”

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Potent Dopamine D2 Antagonists Found to Block Reward-Enhancing Effects of Nicotine in Smokers With Schizophrenia

Many people with schizophrenia smoke cigarettes—a behavior that has been linked to worse symptoms and early mortality. A study in Schizophrenia Bulletin points to why some patients with schizophrenia who take certain antipsychotics may smoke more than patients with schizophrenia who take other antipsychotics. Chlorpromazine, fluphenazine, haloperidol, olanzapine, paliperidone, and risperidone may reduce some of the positive feelings that smokers associate with nicotine, the study suggests.

Previous studies have found that patients with schizophrenia who take first-generation antipsychotics, many of which block dopamine D2 receptors in the brain, have a hard time with smoking cessation, wrote Alexis E. Whitton, Ph.D., of McLean Hospital and colleagues. “Because these medications are foundational to the management of schizophrenia, an important question is whether dopamine D2 receptor antagonists modulate nicotine’s reinforcing effects.”

Whitton and colleagues recruited 184 chronic tobacco smokers with schizophrenia to examine the effects of smoking on reward learning (the process by which a behavior is modified based on prior reward). As part of the study, all participants performed a computer task where they had the chance to win money for correctly identifying differences between faces on a screen. Each participant performed this task before and after smoking a cigarette.

Of the 98 participants who completed the task, 71 reported taking chlorpromazine, fluphenazine, haloperidol, olanzapine, paliperidone, or risperidone (medications the authors noted are known to fully block dopamine D2 receptors) and 27 reported taking aripiprazole, clozapine, or quetiapine (medications that do not fully block dopamine D2 receptors). The researchers found that smoking increased reward learning in participants taking aripiprazole, clozapine, or quetiapine, but not in those taking the other antipsychotics.

“These findings point to a potential mechanistic explanation for increased smoking in individuals with schizophrenia who are treated with potent [dopamine] D2 receptor antagonists. Specifically, these antagonists appear to diminish the effects of tobacco smoking on reward processing,” Whitton and colleagues wrote. “Although not directly assessed in this study, we suggest that this may be a factor that drives compensatory increases in smoking behavior in order to achieve the same level of reward/stimulation.”

They continued, “Our findings have important clinical implications for treating individuals with schizophrenia and co-occurring nicotine dependence. All patients with schizophrenia should be advised to quit and offered pharmacologic assistance with quitting. If a patient is unable to quit with evidence-based cessation treatment and is taking a potent [dopamine] D2 receptor antagonist, switching to a different antipsychotic with lower affinity [dopamine] D2 antagonism (for example, clozapine) or partial [dopamine] D2 agonism (for example, aripiprazole) may be appropriate prior to a second trial of evidence-based cessation treatment.”

For related information, see the Psychiatric News article “Schizophrenia Patients Show Cognitive Improvements After Smoking Cessation” and the American Journal of Psychiatry study “Association Between Smoking Behavior and Cognitive Functioning in Patients With Psychosis, Siblings, and Healthy Control Subjects: Results From a Prospective 6-Year Follow-Up Study.”

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Slower Development of Young Children May Be Linked to Excess Screen Time

Children aged 2 and 3 years who spend a greater amount of time watching TV or playing on a smartphone or computer than their peers may be less likely to meet developmental milestones by age 5, suggests a study published today in JAMA Pediatrics.

“To our knowledge, the present study is the first to provide evidence of a directional association between screen time and poor performance on development screening tests among very young children,” wrote Sheri Madigan, Ph.D., of the University of Calgary and colleagues. “As technology use is entrenched in the modern-day lives of individuals, understanding the directional association between screen time and its correlates and taking family-based steps to engage with technology in positive ways may be fundamental to ensuring developmental success of children growing up in a digital age.”

Madigan and colleagues analyzed data from more than 2,400 typically developing children and their mothers who were part of the All Our Families study. The study included assessments when the children were 24, 36, and 60 months of age. At each assessment, the mothers reported their child’s average weekly screen time and completed the Ages and Stages Questionnaire, Third Edition (ASQ-3)—a questionnaire that tracks progress in five developmental areas: communication, gross motor skills, fine motor skills, problem solving, and personal-social behavior.

On average, children aged 24, 36, and 60 months in the study viewed screens approximately 17, 25, and 11 hours per week or approximately 2.4, 3.6, and 1.6 hours of screen time per day, respectively. The researchers identified a statistically significant association between above-average screen time at 24 months and 36 months and lower developmental questionnaire scores at 36 months and 60 months, respectively. In contrast, lower than average developmental scores at 24 months and 36 months were not associated with higher levels of screen time at 36 months and 60 months.

Many factors may influence the amount of time a child spends in front of a screen and “buffer the negative effects of screen time on child development,” the researchers added. “Future longitudinal research examining the differential susceptibility of children to screen time exposure, as well as risk and protective factors, will be necessary to identify when and for whom screen time is particularly problematic for child development,” they concluded.

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Buprenorphine/Naloxone May Be More Effective Than SSRIs for Patients With PTSD

Buprenorphine/naloxone may help decrease symptoms of posttraumatic stress disorder (PTSD) more than selective serotonin reuptake inhibitors (SSRIs) or opioids alone, according to a study published in the American Journal on Addictions.

Elizabeth P. Lake, Pharm.D., B.C.P.P., of the Central Arkansas Veterans Healthcare System in North Little Rock, Ark., and colleagues conducted a retrospective chart review of 165 patients with PTSD who were treated at the Michael E. DeBakey Veterans Affairs Medical Center between June 1, 2010, and June 30, 2016. The researchers divided the patients into three groups: those taking buprenorphine/naloxone, those taking an SSRI, and those taking other opioid medications. There were 55 patients in each group.

The researchers compared the patients’ initial scores on the PTSD Checklist for Clinicians, VA Primary Care PTSD Screen, or both, with the patients’ last scores for the study period. They found that patients in the buprenorphine/naloxone group had significantly decreased symptoms compared with those in the SSRI group. There were no significant differences in symptoms between the buprenorphine/naloxone group and the opioid group or between the opioid group and the SSRI group.

When looking at the patients’ initial and final PTSD scores, the researchers found that those in the buprenorphine/naloxone group experienced a 24% decrease in symptoms since their first evaluation, compared with a 16.2% decrease for those in the opioid group. However, PTSD symptom scores increased 1.16% in those taking SSRIs.

“Buprenorphine/naloxone showed both a statistically significant and clinically significant change in PTSD scores as compared to SSRIs, which are the current mainstay of pharmacotherapeutic treatment for PTSD,” Lake and colleagues wrote.

The researchers cited several limitations to the study, notably that confounding factors such as comorbid conditions were not included in the statistical analysis because of constraints in the modeling software. The researchers also did not assess whether patients were undergoing psychotherapy for PTSD or a substance use disorder or had a concurrent diagnosis for opioid use disorder.

“Prospective randomized trials utilizing current PTSD symptom scales are warranted to evaluate if buprenorphine/naloxone may represent a potential pharmacotherapeutic option for the treatment of PTSD,” they concluded.

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

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APA Calls for Protection of Transgender Rights After Supreme Court Allows Military Service Ban

APA has denounced a Supreme Court decision handed down earlier this week that gave a green light to the U.S. military to restrict service by individuals who are transgender.

A sharply divided high court handed the Trump administration the victory for its policy banning transgender military service by a vote of 5-4, without discussing the merits of the case. In response, APA issued a statement calling for the protection of transgender individuals’ civil rights and expressing great disappointment in the decision to lift the injunctions on the transgender service ban imposed by a lower courts.

After President Donald Trump signed the ban last March to disqualify individuals who are transgender from military service except under certain limited circumstances, four federal courts issued preliminary injunctions to block it. The Supreme Court decision lifts the injunctions and allows the ban to take effect while the cases challenging the policy continue to wind their way through the courts.

“We are extremely concerned that the military will discriminate against transgender Americans who want to serve their country while these lower court cases are being decided,” said APA President Altha Stewart, M.D., in a statement issued to the media. “Banning transgender service members from serving our country harms not just those transgender Americans who have dedicated themselves to service of others, but it unfairly casts a pall over all transgender Americans. And as psychiatrists, we know all too well the negative impact that discrimination has on the mental health of those targeted.”

“Losing highly qualified transgender military personnel does not benefit the military or the nation,” added APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We firmly believe the United States should be more inclusive and stand against discrimination of any minority group.”

Trump’s policy bans individuals who have transitioned from their gender assigned at birth from joining the military. It also requires current troops to serve as members of their gender assigned at birth, with an exception for those who began a gender transition under Obama administration rules. Trump cited “tremendous medical costs and disruption” as reasons for the ban when he first announced the policy, by tweet, in July 2017.

The Supreme Court decision effectively reverses an Obama administration decision in June 2016 granting transgender service members the right to serve openly. The decision had also allowed transgender servicemembers to undergo gender transition if they were diagnosed with gender dysphoria. The reasons cited for the decision were the need to recruit and retain the best talent, provide clearer guidance to existing service members who are transgender, and a matter of principle.

A Rand Corporation review commissioned by the Obama administration in 2016 estimated the cost impact of providing gender transition services to service members who are transgender would be minimal, largely because there are so few, only about 2,500 to 7,000 of the 1.3 million of those on active duty.

For related information, see the Psychiatric News article “APA Opposes Ban on Transgender Military.”

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Olanzapine May Help Adults With Anorexia Gain Weight

Many patients who take the antipsychotic olanzapine for psychiatric disorders are known to experience significant weight gain. A study in AJP in Advance now suggests that olanzapine may be able to help adults with anorexia gain some weight, but it does not appear to reduce psychological symptoms associated with the disorder.

“We found a weight gain effect associated with olanzapine, but it was more modest than the significant, usually undesirable, weight gain seen when olanzapine is used to treat other disorders,” Evelyn Attia, M.D., of Columbia University Irving Medical Center and colleagues wrote. The findings are “notable, as achieving change in weight is notoriously challenging in this disorder,” they added.

For the study, which was carried out at five North American sites, Attia and colleagues randomly assigned 152 adults aged 18 to 65 with anorexia (96% women; mean body mass index [BMI]: 16.7) to olanzapine or placebo for 16 weeks. Patients were excluded from the trial if they had a general medical or psychiatric condition that required immediate attention; a current diagnosis of substance abuse or dependence, schizophrenia, schizophreniform disorder, or bipolar illness; a neurological problem; or an allergy to olanzapine or a documented failure to respond to or inability to tolerate olanzapine at 10 mg/day. Medication was initiated at 2.5 mg/day for two weeks, then increased to 5 mg/day for two weeks, and up to 10 mg/day for the rest of the trial.

All participants met weekly with a study psychiatrist to discuss symptoms and possible side effects from their assigned treatment. Height and weight were measured at baseline, and weight was measured at each weekly assessment. The researchers used the Yale-Brown Obsessive Compulsive Scale (YBOCS) interview and several other assessments to assess participants’ obsessionality, eating disorder severity, and other factors over the course of the trial.

The researchers found that olanzapine was associated with a significantly greater rate of weight gain than placebo (approximately 1 lb per month for a woman of average height, or 5 feet 5 inches). There was no significant difference between treatment groups in rate of change in YBOCS total score or YBOCS subscale scores.

“[O]ur results suggest that olanzapine may provide a modest therapeutic benefit for adult outpatients with anorexia nervosa, a group much in need of effective treatment strategies. Olanzapine alone clearly does not constitute a sufficient treatment intervention and should be provided in the context of appropriate psychological and behavioral therapy,” Attia and colleagues wrote. “Future studies should examine how best to combine olanzapine with other treatment interventions and assess longer-term outcomes. More broadly, this study underscores the challenges of treating anorexia nervosa and the need for research to improve our understanding of its relative refractoriness to both psychological and pharmacological treatments.”

For related information, see the book Handbook of Assessment and Treatment of Eating Disorders from APA Publishing.

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Guanfacine May Enhance Effects of Social, Cognitive Therapy for Patients With Schizotypal Personality Disorder

Guanfacine, a medication believed to help enhance cognitive function, appears to improve reasoning and problem solving among patients with schizotypal personality disorder when combined with cognitive and social skills training, according to a report in AJP in Advance.

Schizotypal personality disorder is characterized by a pattern of social and interpersonal deficits including eccentric behavior and unusual thoughts. Cognition, the ability to think and reason, has been shown to be highly correlated with functional outcome in patients with schizophrenia spectrum disorders, including schizotypal personality disorder.

“[T]hese results suggest that this agent [guanfacine], which is hypothesized to enhance an individual’s attentional ability, augments the results of cognitive remediation and social skills training,” wrote Margaret McClure, Ph.D., of Mt. Sinai Icahn School of Medicine and colleagues.

The researchers randomly assigned 28 patients with schizotypal personality disorder to either guanfacine (2.0 mg/day) or placebo combined with cognitive remediation and social skills training for eight weeks. Cognitive remediation was administered using a multimedia computer software program with problem-solving exercises. Twice-weekly social skills training groups were led by a doctoral-level clinical psychologist.

The researchers measured five domains of cognition—speed of processing, working memory, verbal learning, visual-spatial learning, and reasoning and problem solving—using the MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery (MCCB). Four domains of functioning—comprehension/planning, finance, communication, and transportation/mobility—were also assessed using the University of California San Diego Performance-Based Skills Assessment (UPSA). Patients in the study also participated in the Movie for the Assessment of Social Cognition (MASC), which involves watching a 15-minute movie about four characters getting together for a dinner party. Throughout the movie, the video is paused to ask participants questions concerning the characters’ feelings, thoughts, and intentions.

Participants treated with cognitive remediation, social skills training, and guanfacine demonstrated statistically significant improvements in reasoning and problem solving, as well as in functional capacity, compared with those treated with cognitive remediation, social skills training, and placebo. Patients in the guanfacine group also performed better on the MASC assessment, though the results fell short of statistical significance.

“The results of our study suggest that cognitive remediation and social skills training are an effective intervention for improving cognitive performance and functional skills in individuals with schizophrenia spectrum disorders and that guanfacine is a promising agent for enhancing the effectiveness of the intervention,” McClure and colleagues wrote. “Because cognitive impairments are closely linked to functional outcomes for individuals across the schizophrenia spectrum, this augmented therapy is an important next step in improving real-world outcomes for individuals with these disorders.”

For related information, see the Psychiatric News article “Handgrip Linked to Cognition in Mood Disorders, Schizophrenia.”

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Calls, Texts May Help Patients With Schizophrenia, Bipolar Disorder Stick to Their Medications

Phone calls and texts may help adults with severe mental illness maintain their medication regimens, according to a study published Thursday in Psychiatric Services in Advance.

In a clinical trial of 120 patients with schizophrenia or bipolar disorder, Lara N. Schulze of the University of Greifswald in Germany and colleagues randomly assigned participants to the intervention or control group. Both groups received care as usual, defined as basic medical care that included occasional visits to physicians. The intervention group also received regular telephone calls every other week for six months.

During the calls, trained nurses spoke with the patients about the patients’ mood; events in the patients’ lives since the previous call; personal aspects of the patients’ lives such as jobs, family, and hobbies; and whether the patients had trouble taking their medications. The nurses also asked questions to detect whether patients had suicidal thoughts. Patients in the intervention group were also offered the option of receiving short, weekly text messages about topics discussed in their calls. Of the 42 patients that remained in the intervention group throughout the trial, 20 received phone calls only.

The researchers followed up with participants at three months and six months by telephone. Throughout the study 16 patients in each group dropped out, leaving 88 available for the six-month follow-up. Although the intervention did not appear to have an effect on medication adherence at three months, at six months patients in the intervention group were on average four times more likely to be medication adherent than those in the control group. The researchers found that the patients’ diagnosis or medications did not affect the results.

“We showed that our telemedicine intervention for patients with severe mental illness could partly compensate for a critical gap in medical care. Personalized communication led to a promising improvement in medication adherence,” the researchers wrote.

For related information, see the Psychiatric News article “How Might Technology Change Mental Health Care?”

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Punitive Discipline May Work in Short Term but Could Cause Long-Term Emotional Damage

Young children whose parents employed punitive discipline styles, such as smacking or shouting at them, tended to have fewer conduct problems and less hyperactivity, but it came at a high cost: they tended to develop more emotional problems and less prosocial behaviors at age 11, according to a study published in the January issue of the Journal of the American Academy of Child & Adolescent Psychiatry.

The findings offer yet another example of why parents should avoid physical punishment and verbal abuse of children, as was recently emphasized in an updated policy statement against corporal punishment by the American Academy of Pediatrics.

Pryia Rajyaguru, M.R.C.Psych, of Bristol Medical School and colleagues analyzed data from nearly 5,000 mothers who were participating in the UK Millennium Cohort Study, a national longitudinal study monitoring the lives of children born in 2000 and 2001 in the United Kingdom. The mothers completed a questionnaire on their parenting styles when their children were 3 years old, which quantified their use of “active” punishment (such as smacking, shouting, and telling off) and “withdrawal of reward” styles of discipline (such as ignoring, removal of privileges, and sending children to their bedroom). Additionally, the mothers completed a brief questionnaire called the Strengths and Difficulties Questionnaire (SDQ), which asked them to evaluate emotional and behavioral problems in the 3-year-olds; the mothers repeated this assessment when the children were aged 11.

Older mothers used relatively less discipline overall, whereas those who were educated and of higher socioeconomic status used relatively more withdrawal of rewards and less active punishment approaches, the study found. Children subjected to both active punishment and withdrawal-of-reward approaches had fewer conduct problems from age 3 to 11, the researchers wrote. However, those subjected to active punishment developed increased emotional problems not seen with the withdrawal-of-rewards discipline style.

Both approaches, however, increased child-reported emotional symptoms, as measured by a six-item questionnaire completed by the children at age 11. This suggests that both active punishment and withdrawal of rewards might negatively influence the child’s mood.

“This study demonstrates that for those mother-child dyads in which discipline is frequent, the type of approach used appears important with distinct later childhood mental health outcome,” Rajyaguru and colleagues wrote. “[I]f mothers adopted more withdrawal and less active approaches, then later emotional and behavioral problems might be decreased.”

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Individuals With a Mental Disorder at Increased Risk for Subsequent Diagnoses

About 30% of men and 40% of women diagnosed with depression before age 20 will be diagnosed with an anxiety disorder within five years, and 40% of men and 50% of women will be diagnosed within 15 years, reports a study published today in JAMA Psychiatry. This strong association between depression and later anxiety was just one of many comorbidities identified in this study—one of the largest and most detailed examinations of comorbidity of mental disorders to date.

“To our knowledge, this is the first study to provide a comprehensive set of age- and sex-specific estimates of absolute risks associated with comorbid mental disorders,” lead author Oleguer Plana-Ripoll, Ph.D., of Aarhus University and colleagues wrote. “Our findings provide new insights into the complex nature of comorbidity, and the comprehensive nature of the analysis will provide an important foundation for future research.”

Plana-Ripoll and colleagues used health registry data from all individuals born in Denmark and residing in the country between 2000 and 2015; this encompassed 5.94 million individuals and about 84 million years of medical data. They grouped all ICD diagnoses within 10 categories of mental illness: behavioral disorders, developmental disorders, eating disorders, intellectual disability, mood disorders, neurotic disorders, organic disorders (for example, dementia), personality disorders, schizophrenia disorders, and substance use disorders. Next, they calculated the risks of an individual having a disorders within any two separate categories.

Overall, the presence of comorbidity was pervasive, with some categories of disorders having exceptionally strong odds of occurring together. For example, compared with an individual not diagnosed with a mental disorder, an individual diagnosed with a mood disorder was 30 times more likely to be diagnosed later with a personality disorder or a developmental disorder, and 20 times more likely to be diagnosed with schizophrenia or a substance use disorder.

The investigators also found that the risk of being diagnosed with a second mental illness is highest in the first six months after the diagnosis of the first disorder, and the increased risk persists for at least 15 years after the initial diagnosis.

Given this vast amount of data, the researchers developed an interactive visualization tool highlighting these various connections, which they hoped would assist clinicians in monitoring potential emerging comorbidity over time.

For related information, see the Psychiatric News article “Study Examines Connections Between Psychiatric, Neurological Disorders.”

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Parents Often Unaware of Adolescents’ Suicidal Ideation, Study Shows

Parents are often unaware that their adolescent children are thinking about suicide or death, according to a report in the journal Pediatrics. Moreover, when parents do believe their children are having such thoughts, the children often deny them.

Given these findings, it is apparent that brief screens used at routine checkups are not detecting many adolescents at risk for suicide, wrote Jason D. Jones, Ph.D., of the Department of Child and Adolescent Psychiatry at Children’s Hospital of Philadelphia. “This highlights the urgent need for continued training of pediatric primary care physicians in the evaluation and management of suicidal ideation and the importance of collecting information from multiple informants and rectifying discrepant reports.”

Jones and colleagues analyzed data on more than 5,000 adolescents and their parents or stepparents from the Philadelphia Neurodevelopmental Cohort. The latter is a research initiative combining genetic, neurodevelopmental, neuroimaging, and behavioral data on more than 9,000 adolescents aged 11 to 21 recruited from a large pediatric health network.

During a computerized, structured clinical interview, adolescents were asked these questions: “Have you ever thought about killing yourself?” and “Have you ever thought a lot about death or dying?” Parents answered the same questions about their adolescents’ suicidal thoughts and thoughts of death.

Half of all parents were unaware of their adolescents’ suicidal thoughts, and three-quarters of the parents were unaware that their children harbored recurrent thoughts of death. Moreover, when parents did report that their adolescent children had thoughts of suicide or death, the children frequently denied it: 48.4% of adolescents denied thinking about killing themselves, and 67.5% denied thoughts of death reported by parents. Age and previous psychiatric treatment were associated with better parent-child agreement.

In an accompanying editorial, Khyati Brahmbhatt, M.D., and Jacqueline Grupp-Phelan, M.P.H., M.D., of San Francisco Benioff Children’s Hospital, agreed with the recommendations that multi-informant assessments should be used and disagreements should be carefully explored.

“Including parents and other sources of information in assessments may help capture a larger percentage of adolescents who are at risk,” they wrote. “Further research to improve our understanding of factors driving the denial of symptoms by adolescents and its relation to the risk for suicide attempts is needed. It may help inform screening as well as interventions and ultimately enhance our ability to effectively address suicide in adolescents.”

For related information see the Psychiatric News article "Irritability in Childhood May Point to Teens at High Risk for Suicide."

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Study Suggests Actions to Improve Compliance With Depression Treatment

Treatment guideline recommendations are not being followed for a large proportion of patients with major depressive disorder, suggests a study published today in Psychiatric Services in Advance. The authors suggest that improvement in multiple areas—such as treatment practices and health insurance coverage—are needed.

“Our research found that most patients were not receiving antidepressants or psychotherapy after the first five months following their initial diagnosis of major depressive disorder,” wrote Fraser W. Gaspar, Ph.D., M.P.H., of MDGuidelines, a health care consulting organization, and colleagues. “Furthermore, when treatment was utilized, antidepressant and psychotherapy adherence was low, and the starting antidepressant dosages were often outside guideline recommendations.”

The study analyzed claims data from the 2007-2016 records of IBM MarketScan research databases for nearly 25,000 patients whose ICD (International Classification of Diseases) code indicated a diagnosis of “single-episode, major depressive disorder.” The MarketScan population is drawn from a sample of employees who mostly work for larger employers and have employer-provided health insurance. Researchers tracked use of pharmacotherapy and psychotherapy and analyzed drug codes attached to each participant’s pharmaceutical claims to determine the strength and class of prescribed antidepressants.

The study’s major findings include the following:

• Most patients (55%) had discontinued all treatment, both psychotherapy and medication, by the fifth month after being diagnosed with major depressive disorder.
• A shorter time from diagnosis to treatment and a lower percentage of out-of-pocket costs paid by the patient were associated with increased medication adherence and intensive psychotherapy use. In contrast, participants in high-deductible and consumer-driven health plans were most likely to receive no treatment or treatment with a prescription only.
• About one-third of patients were prescribed dosages outside of the dosing regimen noted in the APA Practice Guideline for the Treatment of Major Depressive Disorder, with more dosages below the recommendation (23%) than above (11%). However, the authors noted some of the variance might reflect off-label use of the medications.
• Less than half of patients with depression were adherent to antidepressant treatment in the acute and continuation phases (defined as approximately the first four months and eight months, respectively, after starting treatment). Patients with greater depression severity had significantly lower adherence rates, the authors noted.

“Modifiable characteristics, such as starting treatment immediately after diagnosis of major depressive disorder and lowering out-of-pocket expenses, were associated with antidepressant adherence and intensive psychotherapy utilization. Furthermore, patients who used mail-order prescriptions for antidepressants had higher odds of adherence,” the authors wrote. Since increased cost sharing cut pharmaceutical adherence, health policymakers should consider expanding mental health benefits to improve overall savings attributable to improved health outcomes, the authors noted.

For related information, see the Psychiatric News article “Refusal, Dropout Rates Differ Between Patients Receiving Psychotherapy, Pharmacotherapy.”

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Some Common Medications Found to Help People With Serious Mental Illness

Common medications used to fight cholesterol, high blood pressure, and diabetes may be useful in lowering risk of self-harm and psychiatric hospitalization for people with a serious mental illness (SMI) such as bipolar disorder, schizophrenia, or nonaffective psychosis, according to a study published yesterday in JAMA Psychiatry.

In the study, Joseph F. Hayes, Ph.D., of University College London and an international team of colleagues analyzed data from the health records of 142,691 Swedish patients aged 15 and older who had an SMI and were treated with psychiatric medication from October 2005 through December 2016. The data also included whether the patients were treated with statins for cholesterol, L-type calcium channel blockers for high blood pressure, or metformin for type 2 diabetes. The researchers then compared rates of self-harm and psychiatric hospitalization in these patients to determine whether they had been taking one of the three types of medications at the time of harming themselves and/or psychiatric hospitalization.

The researchers found that patients who had bipolar disorder and were taking one of the three types of medications were 8% to 20% less likely to experience psychiatric hospitalization and 19% to 27% less likely to harm themselves. Patients with schizophrenia who were taking one of the three types of medications were 20% to 27% less likely to experience psychiatric hospitalization and 36% to 70% less likely to harm themselves. Patients with nonaffective psychosis who were taking statins or metformin were 20% and 15% less likely to experience psychiatric hospitalization, respectively, and those taking L-type calcium channel blockers were 44% less likely to harm themselves.

“Each of these drugs has a theoretical basis for effectively reducing psychiatric symptoms,” Hayes and colleagues wrote. They noted that the three types of medications work on some of the processes thought to cause psychiatric disorders. For example, systemic and neuroinflammation are linked to psychiatric disorders, and statins are anti-inflammatory. Additionally, high cholesterol, high blood pressure, and diabetes are more common in people with SMI, they noted.

“If substantiated, this study has considerable implications for clinical practice and drug development. The study drugs … are globally licensed, commonly used, cheap, and relatively safe medications. They are therefore ideal candidates for repurposing,” Hayes and colleagues wrote. “Understanding their mode of action on the central nervous system may facilitate better understanding of the pathophysiology of SMI and offer opportunities for innovative pharmacotherapy development.”

For related information, see the Psychiatric News article “Psychiatrists Face Barriers to Managing Common Medical Conditions.”

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FDA Approves Marketing of Eye-Tracking Test for Detecting Concussion

The Food and Drug Administration has cleared for marketing an eye-tracking test that can help determine whether a patient has experienced a concussion.

The device, known as EyeBOX, uses a camera to measure a patient’s eye movements in response to a stimulus. Such information can help physicians and other health care professionals better assess the extent of a patient’s brain injury.

“Other diagnostics require a baseline test, typically generated at the beginning of a sport season, pre-injury, [which] is compared to subsequent test results at the time of a suspected concussion. In many situations, a baseline concussion assessment is not feasible, especially when evaluating trauma patients in the emergency room,” according to a press statement by Oculogica, the manufacturer of the device. “EyeBOX’s unique eye-tracking algorithm enables it to be baseline-free, a major advancement for the field.”

The FDA’s decision to approve the test for marketing was based in part on the results of a trial of 282 patients who presented with a suspected head injury to the emergency departments and sports medicine clinics at six independent clinical sites. The researchers compared the results of the EyeBOX test with those of a clinical reference standard for concussion. According to Oculogica, “The study showed that the EyeBOX had high sensitivity to the presence of concussion and that a negative EyeBOX result is consistent with a lack of concussion, thus providing objective data for health care providers to aid in the evaluation of patients with suspected TBI.”

EyeBOX is intended for patients aged 5 to 67 years, according to Oculogica.

For related information, see the Psychiatric News article “FDA Clears the Way for First Blood Test to Evaluate Head Injuries” and the Journal of Neuropsychiatry and Clinical Neurosciences article “Saccadic Impairment Associated With Remote History of Mild Traumatic Brain Injury.”

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Cancer Patients at Increased Risk for Suicide Within a Year After Diagnosis

Patients with cancer are at an increased risk of suicide in the first year after diagnosis compared with the general population,according to a report in the journal Cancer. The risk differs by type of cancer, with pancreatic and lung cancer having the highest risk.

“After the diagnosis, it is important that health care providers be vigilant in screening for suicide and ensuring that patients have access to social and emotional support,” wrote Anas M. Saad, M.D., of Ain Shams University, Cairo, and colleagues.

Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, the researchers calculated observed/expected (O/E) risk ratios for more than 4 million patients diagnosed with cancer between 2004 and 2014 in the United States. The O/E risk ratio represents the observed number of patients who died from suicide in the first year after diagnosis compared with a demographically similar population within the same period. Mortality data for the general population were collected by the National Center for Health Statistics.

A total of 1,005,825 cancer patients died within the first year after their diagnosis. Suicide was the cause of death for 1,585 of these patients (0.16%). The O/E risk ratio for cancer patients was 2.52, representing a more than two-and-a-half times greater risk of suicide than in the general population.

The patients with the highest increases in suicide rates were those who had been diagnosed with pancreatic cancer or lung cancer: their O/E ratios were 8.01 and 6.05, respectively.

“Social support for patients with cancer plays an integral role in suicide prevention,” Saad and colleagues wrote. “The most effective forms of support seem to be peer support, partner support, and one-to-one professional support. Discussing the quality of life after the diagnosis, the effectiveness of therapy, and the prognosis of the disease and maintaining a trusting relationship with health care professionals all decrease the likelihood of suicide immediately after a diagnosis of cancer.”

For related information, see the Psychiatric News article “Researcher Looks at Improving Well-Being of Families Affected by Cancer.”

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Some Levels of Alzheimer’s Biomarkers May Differ Between African Americans, Whites

African-American individuals on average have lower levels of the tau protein compared with white individuals, reports a study published today in JAMA Neurology. Tau, along with amyloid beta, are two proteins strongly associated with Alzheimer’s disease (AD) and considered key biomarkers for diagnosing AD.

“To our knowledge, our study is the first to examine racial differences in molecular biomarkers of AD in which the cohort contributed data for both amyloid concentrations as seen on PET scan and CSF [cerebrospinal fluid] concentrations of [amyloid and tau],” wrote lead author John C. Morris, M.D., of the Knight Alzheimer Disease Research Center at Washington University School of Medicine in St. Louis and colleagues. “Caution is needed in interpreting our results until they can be confirmed (or refuted) with subsequent analyses in larger cohorts to carefully explore the influences of socioeconomic status, comorbid diseases, and other factors that may contribute to racial differences.”

Morris and colleagues analyzed data from 1,255 adults who were participating in Alzheimer’s studies at the Knight Research Center; this sample included 173 African Americans. As part of these studies, the participants received brain scans and CSF samples were taken to assess for Alzheimer’s biomarkers. In both African-American and white participants, about two-thirds of individuals had normal cognition while the other one-third had Alzheimer’s or some other cognitive impairment.

The researchers found no racial differences in the average brain or CSF levels of amyloid beta among the participants. However, African-American participants had significantly lower CSF tau levels compared with white participants. Average CSF concentrations of tau were 293.65 pg/mL for African Americans and 443.28 pg/mL for whites. The discrepancy in tau levels between African Americans and whites was much larger among participants who had the ε4 allele of the APOE gene; APOEε4 is considered a genetic risk factor for Alzheimer’s.

“Given recent evidence that APOEε4 influences tau pathogenesis and tau-mediated neurodegeneration independent of [amyloid beta], … it is possible that the interactions of APOEε4 with tau in African-American individuals differs from its interactions with tau in white individuals,” Morris and colleagues wrote.

“Older African-American individuals, a population that is rapidly growing, are at greater risk of AD than are older white individuals, but are underrepresented in clinical research studies,” wrote Lisa Barnes, Ph.D., of Rush University Medical Center in an editorial accompanying the study. “[A]s the field moves toward a biological definition of AD, the underinclusion of minority populations in AD research will significantly hinder our progress as a field, and the race to end AD will not be shared with our most vulnerable, at-risk populations.”

For related information, see the Psychiatric News article “Are Amyloid and Tau Good Biomarkers For Alzheimer’s Disease?

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Perinatal and Postpartum Distress Increases Risk for Developmental Delays

Children born to mothers who have persistent anxiety from late pregnancy to three years postpartum have an increased risk of delays in communication and personal-social development, according to a study in the Journal of Affective Disorders. The findings suggest the need for increased efforts to identify mothers with perinatal and postpartum distress in an effort to mitigate the associated developmental delays.

Muhammad Kashif Mughal, M.B.B.S., Ph.D., of the University of Calgary and colleagues evaluated data from the three-year follow-up to the All Our Families (AOF) study, an ongoing study of mothers and children in Calgary, Alberta, Canada. The AOF study, begun in 2008 as the All Our Babies study, includes self-reported assessments of mothers’ distress at multiple time points ranging from before the 25th week of gestation up to three years postpartum. Also included are parent-reported tools to measure child development at age 3 across five domains: communication, gross motor, fine motor, problem solving, and personal-social. For the current study, the researchers analyzed data from 1,983 mother-child pairs.

Overall, 4.7% to 6.4% of the mothers reported depressive symptoms at four time-points: <25 weeks gestation, 34 to 36 weeks gestation, 4 months postpartum, and one year postpartum. Also, 13.8% to 18.5% of mothers reported anxiety symptoms at six time points: <25 weeks gestation, 34-36 weeks gestation, 4 months postpartum, one year postpartum, two years postpartum, and three years postpartum. After applying statistical models, the researchers found that persistent subclinical and high anxiety symptoms were associated with an increased risk of communication delay at age 3 years. They also found that persistent high anxiety symptoms and early postpartum depression were associated with an increased risk of personal-social delay at age 3 years.

The researchers chose to evaluate multiple time points for a more complete picture of risk over time. “[F]ocusing on maternal distress at one time point is problematic because recent studies characterizing perinatal mental health problems suggest that mental health symptoms are not isolated incidents and tend to recur or continue for a majority of women,” Mughal and colleagues wrote.

The results suggested an insignificant association between maternal distress and the remaining domains of child development (gross motor, fine motor, and problem solving). However, the researchers identified other risk factors for these domains, such as maternal age greater than 35 years, male sex, and preterm birth for gross motor delays; low maternal education and male sex for fine motor delays; and low family income and preterm birth for problem-solving delays. Having a family with two or more children was a protective factor for fine motor development.

“The study provides evidence for redefining ‘at-risk’ women as those traditionally identified as high risk as well as those identified as having subclinical symptoms over time,” Mughal and colleagues concluded. “As such, these findings call for a shift in the current model of health care … to approaches that capture the spectrum of chronicity and severity to ensure appropriate care that supports the improvement of maternal mental health outcomes and development in preschool children.”

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