Prevalence of Mental Disorders Higher in Patients With Head, Neck Cancers After Cancer Diagnosis

Patients with cancers of the head and neck are more likely to have an increased prevalence of mental health disorders after their cancer is diagnosed compared with the general population, according to a report published today in JAMA Otolaryngology-Head and Neck Surgery.

There appears to be an especially strong association between mental health disorders and cancers of the trachea. Additionally, patients who received multimodal therapy—radiotherapy, chemotherapy, and/or surgery—have a higher risk of developing mental health disorders compared with those who receive only surgery, according to the report.

“High mortality and morbidity associated with HNCs [head and neck cancers] may predispose these patients to MHDs [mental health disorders],” wrote Neerav Goyal, M.D., M.P.H., of Pennsylvania State University and colleagues. “In addition, morbidity is associated with the treatment.”

Goyal and colleagues analyzed data from the Truven Health Market Scan Commercial Claims and Encounters database from January 1, 2005, through December 31, 2014. They tracked diagnostic codes from ICD-9-CM associated with head and neck cancers and mental health disorders. Head and neck cancers included cancer of the lip, tongue, oral cavity, oropharynx, nasopharynx, hypopharynx, nasal cavity and sinus, larynx, trachea, mandible, Kaposi sarcoma of the palate, and malignant neoplasm of the head and neck. Mental health disorders included episodic mood disorders, including depression, anxiety, nonalcohol drug dependence, adjustment reaction, and depressive disorder not otherwise specified.

The researchers measured the prevalence of mental health disorders and compared points before and after the diagnosis of head and neck cancers. In this cohort study of 52,641 patients with a diagnosis of head and neck cancer, the proportion with mental health disorders at baseline was 20.6% compared with the national average of 17.9%, as estimated by the National Survey on Drug Use and Health. After diagnosis, the prevalence rose to 29.9%. Patients with tracheal cancers had twice the odds of developing mental health disorders compared with patients with oral cavity cancer.

A total of 15.2% of the cohort received radiotherapy, chemotherapy, and surgery; 12.9%, radiotherapy and surgery; and 2.9%, chemotherapy and surgery. Patients who received all three treatments were more likely to develop mental health disorders than those who had only surgery.

Patients with head and neck cancer should be monitored for mental health issues, Goyal and colleagues wrote. “Our results further support the importance of addressing psychosocial needs in routine treatment discussions.”

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

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Children Separated From Families at Border Could Suffer Long-Term MH Consequences, Says APA President

Children separated from their families at the border suffer from “toxic stress,” and some of these children will be significantly impaired for the rest of their lives, APA President Altha J. Stewart, M.D., testified on behalf of APA at a House Appropriations subcommittee today. Some of the factors that she said influence the children’s outcomes are dependent on their age, previous adversity, and the duration of the separation.

APA was among the first organizations to speak out last spring when it became clear that the administration’s “zero tolerance” policy of referring those crossing the border for federal criminal prosecution would result in the widespread separation of children and families.

“As the physician experts in mental health, we will continue to oppose such family separation policies,” Stewart said. “Children depend on their parents or other trusted adults for their comfort, safety, and support. Any forced separation is highly stressful for children and can cause lifelong trauma, as well as increased risk of mental illness, such as depression, anxiety, substance use, and posttraumatic stress disorder.”

Stewart’s goal in testifying was to give lawmakers an overview of the trauma caused by the forced separation of children and warn of the potential for lasting negative outcomes, she said at the hearing held by the Subcommittee on Labor, Health and Human Services, Education, and Related Agencies. She pointed out the need for providing the children with trauma-informed care and access to services and supports for their clinical care after reunification with their families. Trauma-informed care, she said, shifts the dialogue from asking “what’s wrong with you” to “what has happened to you.”

Stewart also explained the concept of Adverse Childhood Experiences (ACEs) and the longstanding body of research about their impact on future health status. Examples of ACEs are physical, sexual, or emotional abuse or neglect; household exposure to mental illness or substance use disorder in parents and caregivers; as well as incarceration itself. “When a child is exposed to such chronic stress and trauma, their underdeveloped brain remains in a very elevated state, and ultimately this consistent exposure to this heightened stress and trauma changes their emotional, behavioral, and cognitive functioning.”

The Flores agreement and subsequent court rulings require the federal government to quickly place immigrant children detained at the border in safe, supportive homes with family members, said Subcommittee Chair Rep. Rosa DeLauro (D-Conn.). “Executing this lawful mission has not been this administration’s approach, however,” she said. “Instead, it has attempted to turn Health and Human Services into an immigration enforcement agency.” In fact, she noted, tens of thousands of children have been held for many months, and the average length of child detentions has nearly tripled.

A full report of the hearing and the testimony of other witnesses will appear in a future issue of Psychiatric News.

For related information, see the Psychiatric News article “APA Maintains Pressure on Administration Regarding Welfare of Migrant Children.”

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Adolescent Opioid Misuse Linked to Parental Misuse

Parental and adolescent misuse of prescription opioids are significantly associated with each other, according to a study published yesterday in Pediatrics.

Pamela C. Griesler, Ph.D., of the New York State Psychiatric Institute and colleagues analyzed data from the National Survey on Drug Use and Health from 2004 to 2012 involving 35,000 parents (nearly two-thirds of whom were mothers) who had an adolescent aged 12 to 17 living in their household. As part of the survey, parents and adolescents were asked if they had ever used one of 21 prescription opioids without a doctor’s prescription or if they took the drug “only for the experience or feeling it caused.” They were also asked questions about lifetime depressive episodes and their use of cigarettes, alcohol, or other drugs.

About 14% of parents had ever misused a prescription opioid; white parents reported higher rates of use (16%) than African American parents (10%) and Hispanic parents (9%). About 9% of adolescents reported opioid misuse, with boys and girls as well as children from various races and ethnic backgrounds all reporting similar rates of use. Misuse increased with age—from 4% among 12-year-olds to 15% among 17-year-olds.

Adolescents were nearly twice as likely to misuse opioids when at least one of their parents had done so: nearly 14% of adolescents had misused opioids in their lifetime when a parent had also done so, compared with 8% when a parent had not. However, the associations differed with the sex of the parent: only mothers’ opioid misuse was significantly associated with that of their adolescents.

The researchers identified several parental factors that were associated with adolescents’ misuse of prescription opioids, including lifetime smoking and high levels of parent-adolescent conflict. Adolescents were more likely to misuse opioids if they smoked cigarettes, used marijuana, were depressed, or perceived that most of their classmates used drugs.

“Similar to other types of parental substance use, parental NMPO [nonmedical prescription opioid] use is associated with offspring use and should be considered in efforts to reduce adolescent NMPO use,” the researchers concluded. “Smoking should also be the target of interventions; there are significant links between parental and adolescent smoking and adolescent NMPO use. Parent-based interventions targeted at NMPO use among youth should not only address parental NMPO use but should also promote positive parenting practices...”

For related information, see the American Journal of Psychiatry article “Improving Our Understanding of Substance Use Disorders.”

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Patients Not Fully Responsive to Antidepressants, CBT Alone Found to Improve With Combined Therapies

A study published in AJP in Advance shows that the success of combined cognitive-behavioral therapy (CBT) and antidepressant therapy is just as likely regardless of which treatment—medication or CBT—is initiated first.

“The sequential combination of CBT or antidepressant medication for patients who do not achieve remission with monotherapy is an effective approach for outpatients with major depression, and the sequence in which the treatments are applied does not appear to affect end-of-treatment outcomes,” wrote lead author Boadie Dunlop, M.D., of Emory University and colleagues.

The findings were based on the second phase of the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study. In the first phase of PReDICT, Dunlop and colleagues randomly assigned 344 adults with depression to 12 weeks of treatment with escitalopram, duloxetine, or 16 one-hour individual sessions of CBT. Patients who did not achieve remission of their depression after 12 weeks (defined as a score of 7 or lower on the Hamilton Depression Rating Scale, or HAM-D) were invited to continue in the second phase of the study—a 12-week treatment period in which they received a combination of medication and CBT. In this second phase, patients who initially received escitalopram or duloxetine (n=75) continued their medication and received 16 sessions of CBT. Patients who initially received CBT (n=37) continued receiving monthly CBT sessions and began taking escitalopram daily.

By the end of second phase of the study, 64.9% (24/37) of the patients initially assigned to CBT and 60% (45/75) of those initially assigned to an antidepressant achieved remission. The rate of remission following combination therapy was significantly higher among patients who showed some response to monotherapy in phase 1 of the study (61%) than among patients who did not respond at all to monotherapy during phase 1 (41%).

Dunlop and colleagues also found that, as in previous research, more severe depression at baseline was associated with a lower chance of achieving remission. However, after controlling for severity of depression, the researchers found that higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups.

“These results suggest that previous studies that identified depression severity as a negative predictor of outcome should be reanalyzed to examine whether the results persist after controlling for anxiety,” they wrote.

To read more about the PReDICT study, see the Psychiatric News article “CBT, Antidepressants Are Equally Effective in Treatment-Naïve Patients” and the American Journal of Psychiatry article “Effects of Patient Preferences on Outcomes in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) Study.”

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Percentage of Older Adults Taking Insomnia Medications Exceeds Those Diagnosed With Disorder

Far more Medicare patients take insomnia medications than are actually diagnosed with insomnia by a physician, suggesting that insomnia is significantly underdiagnosed in this population despite treatment, according to a study in the American Journal of Geriatric Psychiatry.

Jennifer S. Albrecht, Ph.D., of the University of Maryland School of Medicine and colleagues analyzed data from a random sample of 5% of patients who had at least 10 months of continuous Medicare coverage between 2006 and 2013. They found that over the eight years studied, insomnia diagnoses in this population increased from 3.9% to 6.2%. They also found that insomnia medication use (defined as at least one prescription fill) increased from 21% to 29.6%.

“Annual prevalence of insomnia medication use was up to four times higher than insomnia diagnoses and remained steady over time,” Albrecht and colleagues wrote. “Our data suggest that insomnia is commonly treated but infrequently diagnosed. Future research should seek to understand the consequences and causes of this discrepancy.”

The most common insomnia prescriptions filled were sedating antidepressants, nonbenzodiazepine sedating hypnotics, hydroxyzine, and benzodiazepines. Among these medications, benzodiazepines had the greatest increase in usage between 2012 and 2013; the number of filled prescriptions jumped from 1.1% to 17.6%.

“The increase in prevalence of benzodiazepine use from 2012−2013 came at a time when nursing homes were mandated to reduce antipsychotic use and may reflect substitution of benzodiazepines for antipsychotics to control behavioral symptoms in that population,” Albrecht and colleagues wrote. They added that benzodiazepines are on the Beers list of medications to be avoided in older adults and stated that their use should be monitored closely in this population.

In their conclusion, the researchers noted that they were not able to learn why these medications were prescribed for the patients.

“Because some medications used for the treatment of insomnia (e.g., sedating antidepressants, benzodiazepines) have other indications, it is possible that our results overestimate insomnia medication use,” they wrote. Nonetheless, the study “raises important questions about insomnia diagnosis, prescribing practices, and medication interactions.”

For related information, see the Psychiatric News article “Self-Reports of Poor Sleep Not Always Accurate.”

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Antipsychotic Polypharmacy May Reduce Long-Term Rehospitalization Risk, Study Finds

A combination of clozapine plus aripiprazole was associated with the lowest risk of psychiatric rehospitalization among patients with schizophrenia who were followed for up to 20 years in Finland, according to a study published Wednesday in JAMA Psychiatry.

As many as 30% of patients with schizophrenia are treated with a combination of antipsychotics, although the practice is controversial because of its lack of evidence of tolerability, safety, and efficacy, wrote Jari Tiihonen, M.D., Ph.D., of the Karolinska Institutet in Sweden and colleagues.

In this study on the long-term use of antipsychotic polypharmacy in schizophrenia, researchers examined seven monotherapies and 22 antipsychotic combinations, excluding polypharmacy periods shorter than 90 days.

Researchers analyzed data on all Finnish patients with schizophrenia treated in an inpatient setting from 1972 to 2014, and the 62,250 patients were followed for a median of 14 years, with researchers pulling data on their dispensation of antipsychotic medication. The primary outcomes studied were the number of psychiatric rehospitalizations, with hospitalizations due to physical illnesses and deaths serving as secondary outcomes.

During that time 58% of participants were readmitted for psychiatric inpatient care.

The study findings include the following:

• Nearly 60% of participants used antipsychotic polypharmacy for at least 90 days. This practice was associated with a 13% lower risk of psychiatric rehospitalization compared with monotherapy.
• The treatment associated with the best outcome in terms of psychiatric or all-cause hospitalization was clozapine plus aripiprazole. Patients taking this combination had a 14% lower risk of psychiatric rehospitalization than those taking clozapine alone, which was the monotherapy associated with the best outcome.
• The advantage of the clozapine plus aripiprazole combination was greater for patients with first-episode schizophrenia, who were 23% less likely to be rehospitalized than other patients with first-episode schizophrenia.
• Among the 29 therapies examined, patients taking quetiapine monotherapy had highest risk of psychiatric rehospitalization, but adding on any another antipsychotic resulted in a better outcome.

The researchers concluded that certain types of polypharmacy may be beneficial in the treatment of schizophrenia. “Although the results do not indicate that all types of polypharmacy are beneficial, the current treatment guidelines should modify their categorical recommendations discouraging all antipsychotic polypharmacy in the maintenance treatment of schizophrenia,” they wrote.

For more information, see the Psychiatric Services article “Addressing Barriers to Clozapine Underutilization: A National Effort” and the Psychiatric News article “Clozapine, LAI Antipsychotics Found Best at Preventing Relapse.”

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Substance Use Disorder, Borderline Personality Disorder Common in Patients With Eating Disorders

More than half of patients with eating disorders have at least one other psychiatric condition such as substance use disorder (SUD) or borderline personality disorder, suggests a study in the International Journal of Eating Disorders. In addition, symptoms of eating disorders are more severe in those who have either SUD or borderline personality disorder.

Thomas J. Weigel, M.D., of McLean Hospital in Belmont, Mass., and colleagues analyzed the records of 479 patients who were in a residential treatment program for an eating disorder for at least 30 days between mid-November 2010 and mid-September 2014. Patients completed surveys to screen for SUDs and borderline personality disorder when they entered treatment. They also took the Eating Disorder Examination-Questionnaire (EDE-Q)—which evaluates the severity and frequency of eating disorder symptoms—when they entered treatment and every two weeks until they were discharged.

The researchers found that 55% of the patients with an eating disorder screened positive for SUD and/or borderline personality disorder when entering treatment. Among all patients, 41.3% screened positive for SUD, 33.2% screened positive for borderline personality disorder, and 19.4% screened positive for both. Furthermore, those with another condition in addition to an eating disorder had higher scores on the EDE-Q.

The researchers also tracked how the patients’ eating disorder symptoms changed as treatment progressed. They found that symptoms improved faster for patients with SUD than for patients with borderline personality disorder or an eating disorder without any other conditions.

“Abstinence from substances may diminish their adverse mood and food intake effects, both of which contribute to ED symptoms,” Weigel and colleagues wrote.

In addition, symptoms improved faster for patients with both SUD and borderline personality disorder than for patients with borderline personality disorder.

“This is perhaps because while access to substances is removed in residential treatment, [borderline personality disorder] symptoms represent chronic cognitive and behavioral patterns, such that participants are likely to remain symptomatic of [borderline personality disorder] during residential care,” they added.

The researchers noted a few limitations to their study, notably that it was conducted in only one treatment program and that they did not have information about the patients’ eating disorder diagnoses.

For related information, see the Psychiatric News article “Brief Update and Review on Treating Eating Disorders.”

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Tamoxifen May Reduce Mania in Patients With Bipolar Disorder But Questions Remain

Tamoxifen, a medication commonly used to treat breast cancer, appears to hold some promise as a treatment for mania, according to a systematic review and meta-analysis appearing in the Journal of Psychopharmacology.

Tamoxifen has been proposed as a treatment for bipolar disorder because it acts on cells in a way similar to lithium and valproate—both of which are effective medications for bipolar disorder. However, the current review found most studies focused on the effect of tamoxifen on mania, not on bipolar disorder, and its effects on depression are unknown.

“Tamoxifen appears to be a promising potential treatment for episodes of mania,” wrote Jorge Palacios, M.D., of King’s College, London, and colleagues. “However, the total number of participants in trials to date remains relatively low … and there has been a lack of study of its effects on depressive mood.”

Palacios and colleagues performed a literature search using the Cochrane Central Register of Controlled Trials and other resources for randomized, controlled trials (RCTs) of tamoxifen for bipolar disorder. They identified five placebo-controlled RCTs of tamoxifen in the treatment of acute mania in adults. There were no randomized trials of the agent for bipolar depression or for relapse prevention.

The five placebo-controlled RCTs included in the meta-analysis ran for a duration of three to six weeks and included a total of 164 participants. Tamoxifen was studied as a monotherapy in two of the studies and as an adjunct to lithium or valproate in the other three.

Tamoxifen was found to be superior to placebo in lowering mania scale scores, with greater improvements when used as a monotherapy. Response rates (defined as at least a 50% reduction in the mania rating scale score from baseline to end of treatment) were also higher for patients randomized to tamoxifen, and the overall acceptability (measured by overall drop-out rates) was similar to placebo.

“Tamoxifen has been recommended as an option for pharmacological treatment of acute mania in some, but not all recent guidelines,” the authors wrote. “There remain important unanswered questions to clarify its appropriate use. Future studies could investigate the effects of tamoxifen as an adjunct to dopamine antagonist medications for improved antimanic efficacy and establish its longer-term effects on mood, particularly depression, and relapse.”

For more information, see the Psychiatric News article “Researchers Sum Up Current Knowledge of Bipolar Disorder, Call for More Study.”

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Teen Marijuana Users Face Higher Risk of Adult Depression, Suicidality, Meta-Analysis Suggests

Teenagers who use cannabis are at a significantly higher risk of developing major depression and suicidality as young adults, including a three-times greater risk of attempting suicide, according to a meta-analysis published yesterday in JAMA Psychiatry.

“Cannabis is the mostly commonly used drug of abuse by adolescents in the world,” wrote Gabriella Gobbi, M.D., Ph.D., of McGill University in Montreal, Canada, and colleagues. The authors systematically selected studies that assessed participants’ cannabis use when they were younger than 18 years old; adjusted for depression, anxiety, and/or suicidality at baseline; and tracked development of depression in young adulthood (age 18 to 32 years). The meta-analysis included seven studies for depression, three for anxiety, three for suicidal ideation, and three for suicide attempts, totaling some 23,000 participants.

The odds of developing depression in young adulthood was more than one-third higher among adolescents who used cannabis before age 18 (odds ratio [OR] = 1.4), compared with those who had not. The effect was more dramatic for suicidality: adolescents who used cannabis before age 18 were 50% more likely to think about suicide (pooled OR of 1.5) and more than three times more likely to have attempted suicide (pooled OR of 3.5) as young adults.

Younger users of cannabis, age 14 and 15, were at significantly higher risk of suicidal behaviors, according to the report, and girls seemed more susceptible than boys to develop adult depression if they smoked cannabis in adolescence, the researchers reported. “Two trajectory studies demonstrated that quitting cannabis by the end of adolescence did not protect people from some of the serious effects of the drug,” the authors added.

More than one-third of high school seniors reported using marijuana in 2018 (36%), with vaping of THC (the active ingredient in marijuana) rising at record levels, according to an annual National Institute on Drug Abuse-funded survey. At the same time, perceptions of harm and disapproval of marijuana use have trended down in recent years, with only 1 in 4 seniors agreeing that regular marijuana use poses a great risk—less than half of what it was 20 years ago. Ten states plus the District of Columbia have now legalized recreational use of marijuana for adults in 2019.

“These findings highlight the importance of initiatives aiming to educate teenagers on the risks associated with using cannabis and teach them skills to resist peer pressure,” Gobbi and colleagues concluded from their study. “Given the likelihood of a window of risk during adolescence when the deleterious effects of cannabis are most pronounced, the findings in this meta-analysis suggest that cannabis is a serious public health concern and there is an urgent need to implement better drug use prevention programs targeting the use of cannabis among adolescents and interventions aimed at educating adolescents to develop the skills to resist peer pressure on drug consumption.”

For more information, see the Psychiatric News article “Teen Vaping Surges While Use of Most Other Substances Flat” and the American Journal of Psychiatry article “A Population-Based Analysis of the Relationship Between Substance Use and Adolescent Cognitive Development.”

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FDA Advisory Panel Gives Nod to Esketamine Nasal Spray, Paving Way for FDA Approval

An independent advisory panel to the Food and Drug Administration (FDA) on Tuesday endorsed the esketamine nasal spray Spravato for the treatment of adults with treatment-resistant depression. The rapid-acting antidepressant was developed by the Janssen Pharmaceutical Companies of Johnson & Johnson. While the FDA is not required to follow the recommendation of the panel, the agency does take its advice into consideration.

In a 14-2 vote with one abstention, the Psychopharmacologic Drug Advisory Committee and Drug Safety and Risk Management Advisory Committee concluded the benefits of esketamine outweigh the risks.

The committees’ vote on the safety and effectiveness of esketamine was based in part on the results of five phase 3 studies of esketamine in patients with treatment-resistant depression. As described in background materials made available on the FDA website ahead of the meeting, these studies included three short-term, double-blind, placebo-controlled studies; one randomized withdrawal maintenance-of-effect study; and one long-term, open-label safety study. To participate in these studies, patients were required to have failed at least two prior antidepressant trials at study entry. In each trial, patients were assigned to receive esketamine or placebo in addition to a newly initiated oral antidepressant.

According to the FDA briefing document, the evidence in support of esketamine’s effectiveness derives primarily from two positive phase 3 trials, which showed that treatment with esketamine nasal spray plus a newly initiated oral antidepressant was associated with rapid reduction of depressive symptoms and delayed time to relapse of symptoms of depression compared with placebo nasal spray plus a newly initiated antidepressant.

The safety profile of esketamine was evaluated in both short- and long-term trials, which concluded that the medication was generally tolerable in patients with treatment-resistant depression. The most common adverse events reported by patients in the trials included sedation, dissociation, and increases in blood pressure, with the symptoms most commonly presenting in the two hours following drug administration.

Because esketamine is a similar compound to ketamine—a drug known to be popular for recreational use for its ability to produce “out-of-body” experiences and hallucinations—some experts have expressed concerns about the risks of misuse and abuse. In briefing materials submitted by Janssen ahead of yesterday’s meeting, the company stated, “While the potential for abuse, misuse, and diversion exists for esketamine due to its similar pharmacologic profile to ketamine, no evidence of abuse, misuse, or overdose was observed in the esketamine development program with a [treatment-resistant depression] population (note, patients with moderate to severe substance use disorder were excluded from the studies), and possible diversion was minimal (<0.1% clinical supply kits unaccounted for in the Phase 3 studies).”

The FDA is proposing a Risk Evaluation and Mitigation Strategy (REMS) to ensure safe use of esketamine. “Among the key elements of the proposed REMS, esketamine administration would occur only in certain health care settings where the patient could be monitored for two hours after administration, the drug would not be dispensed directly to patients, and patients would be enrolled in a registry to better characterize the risks associated with esketamine administration,” the FDA briefing document noted.

Esketamine, an antagonist of the N-methyl-D-aspartate (NMDA) receptor, was first granted an FDA breakthrough therapy designation for treatment-resistant depression in 2013 and for major depressive disorder with risk of suicide in 2016. According to Janssen, the decision by the FDA on whether to approve the medication is expected by March 4.

For related information, see the American Journal of Psychiatry article “Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide: Results of a Double-Blind, Randomized, Placebo-Controlled Study.”

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APA Announces Results of 2019 Election

APA’s Committee of Tellers has approved the following results of APA’s 2019 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting on March 9 and 10 in Washington, D.C.



President-Elect
Jeffrey Geller, M.D., M.P.H.

Secretary
Sandra DeJong, M.D., M.Sc.

Minority/Underrepresented Trustee
Rahn Kennedy Bailey, M.D.

Area 3 Trustee
Kenneth Certa, M.D.

Area 6 Trustee
Melinda Young, M.D.

Resident-Fellow Member Trustee-Elect
Michael Mensah, M.D., M.P.H.

Complete results of the election will be reported in the March 1 issue of Psychiatric News.

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Text Messaging May Enhance Postpartum Depression Screening

Using text messages to ask questions and educate women with a new baby about postpartum depression is a practical and feasible approach to improve postpartum depression screening, reports a study in Psychiatric Services in Advance.

“This cost-effective, innovative technology has excellent potential to be used in mental health care for universal screening purposes and as a first step in the pathway to treatment,” wrote Andrea Lawson, Ph.D., of Mount Sinai Hospital in Toronto and colleagues.

The researchers recruited 937 new mothers to participate in a 12-week long assessment of a text-based screening. Every two weeks, the women were asked by text to rate how often they had experienced little interest or pleasure in doing things over the past two weeks and how often they had felt depressed or hopeless. The participants also received three text messages per week aimed at increasing awareness about postpartum depression and encouraging self-care.

Women who screened positive for depression based on their responses to the biweekly text-based screening were contacted by a researcher who administered the Edinburgh Postnatal Depression Scale—a 10-item screen considered the gold-standard postpartum diagnosis tool—via telephone. A subset of women who screened negative on the text-based screening were also screened using the Edinburgh Postnatal Depression Scale to help determine the accuracy of the text-based approach.

By comparing the results of the screening texts with the Edinburgh Postnatal Depression Scale diagnoses, the researchers found that the text-based screening was moderately accurate; 18% of the women who screened positive for depression based on their text answers and 10% who screened negative were misclassified.

While Lawson and colleagues acknowledged that the 18% false-positive rate of the text-based screening “was not ideal,” they noted that avoiding false-negatives is more important for this initial screening whose aim is not diagnosis but rather identification of women who need further follow-up.

The text-based screening was well-received; of the 937 participants who completed the study, 930 (99%) responded to a minimum of one of the six texted screens, and 632 (67%) responded to all six. A post-study survey also showed that 78% of the participants would recommend using text messages to screen for postpartum depression.

“We believe the reasons for the high rate of responsivity to the screen were its brevity and the fact that in-person attendance was not a requirement for completion,” the authors wrote. “The postpartum stage is a very difficult time for a mother, frequently characterized by sleep deprivation and high stress levels. Completing lengthy assessment tools in-person at this time can be challenging, particularly among mothers who are experiencing symptoms of depression.”

To read more about postpartum depression screening, see the Psychiatric News article “Researchers Turn to Smartphone Apps to Learn About Postpartum Depression.”

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Chronic Sinusitis Linked to Depression, Anxiety, Study Finds

People who have chronic rhinosinusitis (commonly referred to as chronic sinusitis and characterized by inflammation of nasal passages lasting more than 12 weeks) may be more likely to have depression and anxiety, according to a study published yesterday in JAMA Otolaryngology–Head & Neck Surgery.

Jong-Yeup Kim, M.D., Ph.D., of Hallym University College of Medicine, in South Korea and colleagues analyzed the health insurance records of 16,244 South Korean patients who received inpatient and outpatient care for chronic rhinosinusitis from January 2002 through December 2004. Each patient was tracked until December 31, 2013, or until the occurrence of depression and anxiety. The researchers then compared the rates of depression and anxiety in this group with those of 32,448 patients who did not have chronic rhinosinusitis in that period.

During the follow-up period, there were 24.2 incidences of depression per 1,000 person-years in the chronic rhinosinusitis group, compared with 16 in the control group. There were 42.2 incidences of anxiety per 1,000 person-years in the chronic rhinosinusitis group, compared with 27.8 in the control group.

In their discussion, the researchers noted that although people with chronic rhinosinusitis have higher rates of depression and anxiety, the relationship between chronic rhinosinusitis and these conditions remains unclear: “Despite its clinical importance, the causal association between [chronic rhinosinusitis] and psychiatric comorbidities is not fully understood. For example, whether depression and anxiety amplify the symptoms of [chronic rhinosinusitis] or whether these conditions are the consequence of [chronic rhinosinusitis] is unknown,” they wrote.

In an accompanying editorial, Edward D. McCoul, M.D., M.P.H., of the Ochsner Clinic in New Orleans noted that it may be helpful for physicians to keep depression and anxiety in mind when treating patients with chronic rhinosinusitis.

“Given the current state of knowledge, the physician may choose to screen patients with newly diagnosed [chronic rhinosinusitis] for the presence of depression or anxiety disorders. Brief, patient-reported questionnaires are a low-cost measure that may reduce morbidity in the long term and improve the success of treatments directed at [chronic rhinosinusitis],” he wrote.

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Intervention for Suicidal Adolescents May Reduce Long-Term Mortality

Suicidal adolescents who took part in a program for which they chose several “caring adults” who stayed in regular contact with them and were supportive of their treatment were nearly seven times less likely to die during the follow-up of 11 years to 14 years, according to a study published Wednesday in JAMA Psychiatry.

The intervention is believed to be among the first aimed at suicidal adolescents that has shown a reduction in mortality, according to lead author Cheryl A. King, Ph.D., of the University of Michigan and colleagues.

The study was a secondary analysis of a trial involving more than 400 adolescents, aged 13 to 17, who were hospitalized on a psychiatric unit for serious, frequent thoughts about killing themselves or a suicide attempt. The original study comparing adolescents who received Youth-Nominated Support Team–Version II (YST)—a psychoeducational, social support intervention—with those in a control group found that YST was associated with a significant reduction in suicidal ideation.

With YST, the adolescents nominated three or four “caring adults,” such as parents, grandparents, coaches, teachers, parents of friends, and youth group leaders who attended a one-hour psychoeducational session. During the session, the adults learned about the youth’s treatment plan, suicide warning signs, how best to communicate with the adolescents, and ways to increase the likelihood of youth’s adherence to their treatment plan. The adults received weekly supportive calls from YST staff for three months and engaged in regular contact with the youth.

For the current study, King and colleagues examined the National Death Index and found there were 13 deaths among participants in the control group, compared with two deaths in the YST group, meaning that those in the control group had a nearly sevenfold higher risk of dying within the 11 years to 14 years of follow-up. The authors noted that although the confidence interval was wide (1.5-29.3), reflecting the relatively small number of deaths, even the lower end of the confidence interval indicated a 50% higher mortality in the control group. All deaths occurred when participants were between the ages of 18 years and 28 years.

When the authors looked only at suicide, there was not a significant difference between the groups (three suicides in the control group versus one suicide in the YST group). Most of the deaths in the control group (nine) were drug related or caused by drug overdose.

“Although YST was not associated with fewer deaths coded as suicides…, this secondary analysis of mortality outcomes indicates that YST may be associated with positive youth trajectories and reduced mortality. Future studies are needed to replicate our study findings and examine YST’s mechanisms of action, which are suggested by its psychoeducational component, its underlying social support conceptual model, and the study results indicating that YST was associated with more outpatient psychotherapy, medication follow-up, and drug treatment,” King and colleagues wrote.

For related information, please see the American Journal of Psychiatry article “Suicide Attempt Prevention: A Technology-Enhanced Intervention for Treating Suicidal Adolescents After Hospitalization.”

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Children of Dads With Psychological Distress May Be More Likely to Show Behavioral Problems

Children whose fathers are experiencing greater feelings of hopelessness, worthlessness, and depression may be more likely to display behavioral problems compared with children whose fathers are experiencing fewer of these symptoms, according to a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

“Our study … clearly suggests that interventions to prevent and treat psychological distress in fathers may have much benefit for their children,” wrote Eirini Flouri, Ph.D., of the University College London. “The first step in doing that is increasing awareness of the role that paternal psychological distress can have in child development.”

For the study, Flouri and colleagues analyzed data from the Millennium Cohort Study (MCS), an ongoing population study of children born in 2000-2002 in the United Kingdom. As part of the MCS, parent-reported data were collected through interviews and questionnaires when children were 9 months, 3 years, 5 years, 7 years, 11 years, and 14 years. Beginning at the age 3 assessment, parents were asked to fill out the Strengths and Difficulties Questionnaire—which asks questions about a child’s emotions, interactions with peers, attention, and more over the past six months. Parents also completed the Kessler six-item psychological distress scale, which asks participants to reflect on distress over the past month, with such questions as “How often did you feel so depressed that nothing could cheer you up?” and “How often did you feel hopeless?”

A total of 13,442 children, whose mothers and fathers had valid data on psychological distress in at least one of these time points were included in the study sample.

After adjusting for maternal psychological distress, paternal psychological distress predicted all four domains of child problem behaviors examined (hyperactivity and conduct, emotional, and peer problems). High levels of paternal psychological distress predicted some problems (emotional symptoms and hyperactivity) more strongly in boys than girls, they added.

“[O]ur study showed that paternal psychological distress was related to several aspects of child problem behavior. … A priority for future studies should be to examine the mechanisms of this effect, which are likely both genetic and environmental,” they concluded.

For related information, see the American Journal of Psychiatry article “Offspring of Depressed Parents: 30 Years Later.”

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Hyperactive Brain Cells May Explain Why Some Patients Don’t Respond to SSRIs

Not everyone with depression responds to treatment with selective serotonin reuptake inhibitors (SSRIs), and now a report in Molecular Psychiatry provides a possible explanation: brain cells in people who do not respond to SSRIs may become hyperactive in the presence of serotonin in a way that the brain cells of people who respond to SSRIs do not.

“This is a promising step toward understanding why some patients don’t respond to SSRIs and letting us better personalize treatments for depression,” said senior author Rusty Gage, M.S., Ph.D., of the Salk Institute in a statement.

SSRIs acutely increase serotonin levels in the brain by binding to serotonin transporters of a neuron and blocking serotonin reabsorption, or “reuptake.” Following SSRI treatment, serotonin concentrations increase in target brain regions, but it remains unclear what other effects might contribute to SSRI resistance in depressed patients.

For the study, Gage and colleagues examined how a group of 803 patients with major depressive disorder responded to eight weeks of treatment with the SSRIs citalopram or escitalopram. From this group, they selected three patients who achieved complete remission of their depression symptoms with the SSRIs (SSRI responders) by eight weeks and three patients who did not experience symptom improvements (SSRI nonresponders).

The researchers isolated skin cells from these patients and from three individuals with no history of depression (control subjects). They used stem cell reprogramming techniques to turn the skin cells into “induced pluripotent stem cells,” which they then programmed to become neurons. Next, they compared how the neurons from the SSRI responders, SSRI nonresponders, and controls responded when exposed to increasing levels of serotonin.

In the presence of serotonin, neurons derived from the SSRI nonresponders had significantly higher activity on average compared with the neurons of healthy individuals or SSRI responders, the researchers reported. They also found that when two particular serotonin receptors (5-HT2A and 5-HT7) were chemically blocked, the neurons of nonresponders were no longer hyperactive in the presence of serotonin. This suggests that medications targeting these receptors may be effective alternatives to SSRIs in some patients, but more research is needed, the authors wrote.

“I hope this opens the door to many more studies of individuals who are extreme cases in terms of how they respond to treatments,” said Krishna Vadodaria, Ph.D., first author of the paper and a scientist at the Salk Institute. “In turn, that will help us understand major depression in the broader population.”

For related information, see the Psychiatric News article “Brain Scans May Indicate Optimal Treatment for Depression” and the American Journal of Psychiatry article “Getting Personalized: Brain Scan Biomarkers for Guiding Depression Interventions.”

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Physical Problems Exacerbate Severity of Post-Concussive Depression in Former NFL Players

A history of football-related concussions is more likely to lead to depression in former NFL players who also have physical problems such as body pain, headaches, and dizziness, reports a study published in the Journal of Neuropsychiatry and Clinical Neurosciences.

“These results suggest that medical professionals should be especially attentive to a retired athlete’s comorbid medical history and physically related conditions,” wrote Benjamin Brett, Ph.D., of the Vanderbilt Sports Concussion Center and colleagues. “If a retired athlete reports an extensive history of SRC [sport-related concussion] and somatic or depressive symptomatology, referral to a sports psychiatrist or clinical neuropsychologist is recommended for further assessment … and to differentiate depressive symptoms as purely somatic, psychiatric, or mixed.”

Brett and colleagues assessed data from 43 retired NFL players who had received comprehensive neuropsychological exams as part of a large neurological study. The exams included the Beck Depression Inventory II (BDI-II) to screen for depression and the Patient Health Questionnaire-15 (PHQ-15) to screen for somatic symptoms. The players self-reported an average of 8.7 sport-related concussions.

Of the 43 players, 29 reported minimal depressive symptoms, nine reported symptoms of mild depression (BDI-II score of 14 to 19), three reported symptoms of moderate depression (BDI-II score of 20 to 28), and two reported symptoms of severe depression (BDI-II score of 29 to 63). The average PHQ-15 score was 5.35.

Brett and colleagues found that there was no connection between concussion history and depressive symptoms in the players whose PHQ-15 scores were below average. In contrast, former players with average PHQ-15 scores did tend to have worse depression with greater somatic symptoms, and this association between concussion history and current depression was even greater among players with above-average PHQ-15 scores. The researchers also calculated that the presence of somatic symptoms contributed about twice as much to an individual’s depression as the concussions.

“Our results allow us to conclude that there are moderating factors that can affect the strength and nature of the relationship between [sport-related concussion] and depression,” the researchers concluded. “If somatic symptoms can be mitigated, it is possible that the risk and/or severity of depression may be decreased.”

For related information, see the Psychiatric News article “Can Sertraline Help Prevent Depression Following a TBI?”

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Prior Mental Health Problems May Increase Risk of PTSD, MDD Following mTBI

Certain patients who experience mild traumatic brain injury (mTBI) may be at especially increased risk for developing posttraumatic stress disorder (PTSD) or major depressive disorder (MDD) following injury, according to a study published this week in JAMA Psychiatry.

“We observed that having an antecedent mental health problem prior to TBI [traumatic brain injury] was an exceptionally strong risk factor for having PTSD or MDD postinjury,” wrote author Murray B. Stein, M.D., M.P.H., of the University of California, San Diego and colleagues. “[T]his finding underscores the importance of clinicians being aware of the mental health history of their patients with mTBI, as this information is central to expectations regarding both short-term and long-term outcome.”

For this large, multisite study, Stein and colleagues included some 1,200 civilian patients whose head injury occurred within 24 hours of emergency department admission, who received a CT scan, and who scored 13 to 15 on the Glascow Coma Scale. About 20% of these patients reported having a psychiatric history (patients with what the authors referred to as “major debilitating mental disorders—for example, schizophrenia, bipolar disorder”—were excluded from the trial). Patients took the PTSD Checklist for DSM-5 (PCL-5) and the Patient Health Questionnaire-9 (PHQ-9) at the start of the trial and again at two weeks and three, six, and 12 months postinjury. The researchers also included a comparison group of 230 patients who experienced orthopedic trauma, but not head injury; six months of follow-up data on this group was included in the analysis.

Nearly 1 in 5 participants with mTBI had probable PTSD (19%) six months postinjury, compared with 8% of those with orthopedic injuries. Major risk factors for PTSD at six months after an mTBI included being black, having an mTBI caused by assault or violence, or history of psychiatric disorder—each of which was associated with a four to five times greater risk of PTSD.

About 9% of those with mTBI had probable MDD six months postinjury, compared with 3% of those with orthopedic injuries. Major risk factors for MDD at six months after an mTBI included being black and having a history of psychiatric disorder—each of which was associated with a three to four times greater risk of moderately severe to severe depression.

Stein and colleagues noted that they were uncertain how to characterize the finding that black patients were at increased risk for PTSD and MDD following a mTBI, but wrote that it did not appear to be due to the cause of injury or socioeconomic status, such as education, employment status, or health insurance status. They called for further study of this finding.

“Some individuals, on the basis of antecedent mental health status and—in the case of PTSD—context of injury (i.e., assault or other violence), are at substantially increased risk of mental health problems following mTBI,” Stein and colleagues concluded. “These findings should influence recognition of at-risk individuals following mTBI and inform efforts at surveillance and intervention.”

For related information, see the Psychiatric News article “Sertraline May Help Prevent Depression Following Traumatic Brain Injury.”

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