Taking Antidepressants After Age 60 May Increase Dementia Risk, Study Finds

People who take antidepressants after age 60 may face a greater risk of dementia than those who don’t take antidepressants, a study in the American Journal of Geriatric Psychiatry has found.

Arad Kodesh, M.D., of the University of Haifa in Israel and colleagues analyzed the health records of 71,515 people aged 60 years or older from Israel. As far back as 2002, the participants had no diagnosis of dementia or record of taking medications for dementia. No participants had taken an antidepressant in 2012. The researchers then followed the participants from May 2013 to October 2017.

During follow-up, 3,688 participants had received and filled prescriptions for an antidepressant for at least 60 days. Of those, 11% developed dementia. In contrast, only 2.6% of those who did not take antidepressants developed dementia. After adjusting for other conditions linked to dementia risk, the researchers found that the risk of dementia in those who took an antidepressant was 3.43 times greater than those who did not.

“This is a considerable increase in risk and may be compared to other risk factors for dementia that have around a 1.6-fold increased dementia risk, e.g., smoking, and BMI [body mass index],” Kodesh and colleagues wrote.

The researchers found the increased risk to be consistent across different classes of antidepressants, with two notable exceptions: Compared with those who did not take antidepressants, those who took amitriptyline had twice the risk of developing dementia, and those who took paroxetine had more than five times the risk.

In noting the limitations of their study, the researchers wrote that their results could “mimic the [known] association between depression and dementia rather than the effect of taking an antidepressant.”

Nonetheless, they emphasized the importance of careful prescribing in older patients.

“Clinicians, caregivers, and patients may wish to consider this potential negative consequence of antidepressant exposure with the objective of balancing the adverse events and symptomatic benefits of monotherapeutic antidepressant medication in old age,” they wrote.

For related information, see the Psychiatric News article “Percentage of Americans Taking Antidepressants Climbs.”

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Initial Hospital Length of Stay, Transfers May Predict Likelihood of 30-Day Readmission of Bipolar Patients

Individuals with bipolar disorder are known to be at risk of comorbid medical illnesses and psychiatric hospital readmissions. A study in Psychosomatics suggests machine learning models may offer one way to identify patients with comorbid bipolar disorder and medical illness most likely to be readmitted to the hospital for psychiatric needs within 30 days following discharge from a hospital.

For the study, Juliet Edgcomb, M.D., Ph.D., of the University of California, Los Angeles, and colleagues analyzed electronic health record data of patients seen in the emergency department within the University of California Health Care System between 2006 and 2016. Specifically, the researchers focused on patients aged 18 and older with bipolar disorder, a comorbid medical illness, and at least one hospitalization during the study period.

In total, 552 patients with bipolar disorder and serious comorbid medical illness with 1,250 hospital admissions were included in the analysis. The researchers used a machine learning model to identify potential predictors of 30-day psychiatric readmission across these 1,250 hospital admissions.

The model predicted 30-day readmission with high accuracy, the authors reported. Predictors of readmission included the initial hospitalization length of stay, transfers between medical and psychiatric services, circumstances of discharge, and use of health services in the year prior to the index hospitalization.

“[I]ndividuals with short length of stay and rapid transfer may be more vulnerable to gaps in care and subsequent decompensation,” Edgcomb and colleagues wrote. “For these patients, interventions such as early consultation with psychiatry, involvement of interdisciplinary teams to address psychosocial needs, ongoing medical care during psychiatric hospitalization, and coordination of robust psychiatric and medical aftercare services may be particularly important to mitigate this vulnerability.”

For related information, see the Psychiatric Services article “Outpatient Follow-Up Care and Risk of Hospital Readmission in Schizophrenia and Bipolar Disorder.”

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Vraylar Now Approved for Full Spectrum of Bipolar I Disorder Symptoms

Yesterday the Food and Drug Administration (FDA) approved Vraylar (cariprazine) for the treatment of depressive episodes in adults with bipolar I disorder. This expanded indication means Vraylar, a dopamine and serotonin partial agonist, is now approved to treat depressive, manic, and mixed episodes of bipolar I disorder. Vraylar, which is manufactured by Allergan, is also approved for the treatment of schizophrenia in adults.

The drug’s expanded indication is based on results from three clinical trials (RGH-MD-53, RGH-MD-54, and RGH-MD-56), which evaluated Vraylar once daily versus placebo in adults with bipolar depression. The primary outcome was change in the Montgomery-Åsberg Depression Rating Scale (MADRS) after six weeks of treatment.

For the three Vraylar dosages studied, the trials found that patients treated with 1.5 mg/day experienced significant improvements in their MADRS score versus placebo. One trial confirmed similar significant findings for the 3 mg daily dose.

“Treating bipolar disorder can be very difficult because people living with the illness experience a range of depressive and manic symptoms, sometimes both at the same time, and this FDA approval gives health care providers a new option to treat the full spectrum of bipolar I disorder symptoms … with just one medication,” Stephen Stahl, M.D., Ph.D., a professor of psychiatry at the University of California, San Diego, said in a press release from Allergan.

The most commonly reported adverse events in the three trials were nausea, akathisia (an uncontrollable urge to move), restlessness, and other extrapyramidal symptoms (such as muscle spasms, rigidity, slowness of movement, and irregular movements).

FDA approved Vraylar 1.5 mg/day or 3 mg/day for the treatment of depressive episodes in bipolar I disorder. Vraylar 3 mg/day to 6 mg/day is approved for the acute treatment of manic or mixed episodes.

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

NOTE: The clinical trial results for RGH-MD-54 and RGH-MD-56 were published in the American Journal of Psychiatry. The results for RHG-MD-53 have not been published yet.

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APA, Medical Partners Protest Proposed Rule That Could Deny Care to LGBTQ, Women Patients

APA and five other medical specialty organizations issued a statement today protesting a proposed rule by the U.S. Department of Health and Human Services that would weaken nondiscrimination protections for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals under Section 1557 of the Affordable Care Act.

Section 1557 prohibits discrimination in health coverage and care on the basis of race, color, national origin, sex, age, and disability in health programs and activities that receive federal funding. These include most health care facilities, including hospitals and physician offices, and most health insurance companies. Under a 2016 rule from the Obama administration, discrimination on the basis of sex includes gender identity.

In addition to weakening protections for LGBTQ patients, the rule would allow religious exemptions that could restrict women’s access to reproductive health care and weakens requirements that have enabled millions of patients with disabilities and limited English proficiency to access services, the groups noted.

“Rolling back gender discrimination protections as the rule proposes would impede access to care and sanction discrimination against already vulnerable patient populations,” APA and its coalition partners said. “We oppose any laws and regulations that discriminate against transgender and gender-diverse individuals. We oppose any medically unnecessary restrictions placed on women’s access to reproductive health care. Instead, we urge the administration to eliminate this policy change and work with us to ensure patients have access to the quality care they need.”

The five other groups are the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, and the American Osteopathic Association. The coalition represents nearly 600,000 physicians and medical students nationwide.

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

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Deep Transcranial Magnetic Stimulation Effective in Treating OCD, Study Suggests

People with obsessive-compulsive disorder (OCD) who don’t achieve adequate relief from medication and cognitive-behavioral therapy may benefit from deep transcranial magnetic stimulation (dTMS), a study in AJP in Advance suggests.

During dTMS treatment, a cap containing coils delivers magnetic pulses to stimulate nerve cells in the brain. The study compared active dTMS treatment with sham (inactive) treatment in 87 people with OCD, with participants in the active treatment group experiencing greater improvement in symptoms at the end of treatment and at a follow-up assessment four weeks later.

The study, led by Lior Carmi, Ph.D., of Tel Aviv University, included participants aged 22 to 68 years who were receiving outpatient treatment at 11 centers in the Canada, Israel, and the United States. All participants had a baseline score of 20 or higher on the Yale-Brown Obsessive Compulsive Scale (YBOCS), indicating that they were experiencing at least moderate symptoms of OCD despite treatment. Participants received 29 treatment sessions of active or sham treatment over a span of six weeks. The caps worn by those in the sham treatment group caused sensations in the participants’ scalps but delivered no magnetic pulses.

Before each treatment, the researchers guided the participants through a list of ideas that would provoke obsessive thoughts to activate the parts of the brain involved in OCD. A few minutes into treatment the researchers reminded participants to keep thinking those thoughts (for example, “Please keep thinking about the dirty handle”).

At the end of six weeks, YBOCS scores dropped an average of 6 points in the active treatment group, compared with 3.3 points in the sham treatment group. At the four-week follow-up, YBOCS scores were 6.5 points lower than baseline in the active treatment group, compared with 4.1 points in the sham treatment group. At both study’s end and the follow-up assessment, more participants in the active treatment group had achieved a full response, defined by a reduction of at least 30% in YBOCS score, than in the sham treatment group.

Participants in both groups experienced adverse events. The most common adverse event was headache, experienced by 37.5% in the active treatment group and 35.3% in the sham treatment group. The researchers noted that similar adverse effects were reported in prior studies.

“Although [triggering patient’s symptoms prior to the intervention may be] considered brief exposure therapy, the fact that both groups underwent the same exposure procedure suggests that the observed clinical effects were due only to stimulation,” the researchers wrote.

For more information, see the Psychiatric News article “FDA Clears Deep TMS Device for Treatment of Obsessive-Compulsive Disorder.”

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Experts Argue for Addition of Suicide-Specific Diagnoses in DSM

A discrete, specific diagnosis of suicidal behavior disorder is included in DSM-5 Section III, which contains “conditions for further study.” Such a diagnosis could be enormously clinically useful, helping to identify at-risk patients for treatment and aiding in research on suicide, according to former APA President Maria A. Oquendo, M.D., Ph.D. (pictured at left), chair of the Department of Psychiatry at the University of Pennsylvania Perelman School of Medicine and a director on the National Board of the American Foundation for Suicide Prevention. She was the chair and a presenter at the Tuesday Annual Meeting session “The Argument for Suicide-Specific Diagnoses in the DSM.”

Inclusion of a diagnosis for suicidal behavior disorder would help solve a number of clinical and systemic problems associated with identifying patients at risk for suicide. Oquendo said that during an assessment, clinicians seek to make the primary diagnosis responsible for the chief complaint and use overview questions to identify comorbid conditions. If they do not find evidence for a major depressive episode or borderline personality disorder—two conditions for which DSM criteria specifically note a risk of suicide—questions about suicidal behavior may not be asked.

“While institutions today generally require suicide screening for psychiatric cases, many patients are seen in other settings that may not,” she said.

Moreover, since the Mental Status Examination targets the patients’ present condition, those denying suicidal ideation may not be asked about past suicidal acts, which results in underestimating the number of suicidality cases. In addition, current diagnostic algorithms may lead clinicians to overlook suicidal ideation or behavior in high-risk individuals, especially those with posttraumatic stress disorder or alcohol use disorder.

Most important, clinical studies demonstrate that suicide risk is often lost when patients are “handed off” in inpatient settings—that is, when a patient is passed from one treatment team or clinician to another. She also pointed out that electronic medical records encourage stilted, standardized patient descriptions, leading clinicians to rely more heavily on diagnostic codes in devising treatment plans.

Oquendo said the existence of a suicide-specific diagnosis would compel clinical and administrative structures to determine the suicide risk status of individuals assessed in psychiatric settings. “The presence of suicidal behavior can be documented in the medical record with the prominence that it deserves in written reports, allowing for treatment planning for vulnerable patients,” she said.

“For research purposes, a diagnosis would more reliably identify cases and controls or predictors of suicidal behavior in big-data analyses based on claims data or electronic medical records,” Oquendo added. “It would help to harness large cohorts with genomic and biologic data to study suicide and facilitate development of a registry to more accurately estimate the number of suicide attempters in specific cohorts to inform policy and prevention strategies.”

She was joined at the session by Igor Galynker, M.D., Ph.D., a professor of psychiatry at the Icahn School of Medicine at Mount Sinai, who described a proposal to include criteria for suicidal crisis syndrome in DSM. Thomas Joiner, Ph.D., a professor of psychology at Florida State University, outlined the case for creating the diagnosis of acute suicidal affective disorder. Both proposed diagnoses would be distinct from suicidal behavior disorder; they describe a discrete, highly acute and extremely high-risk pre-suicidal mental state marked by “frantic anxiety” and a feeling of entrapment, among other symptoms.

For related information, see the Psychiatric News article “Preventing Suicide Begins With Regular Assessments” and the book Clinical Manual for the Assessment and Treatment of Suicidal Patients, Second Edition, by APA Publishing.

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Highlights From APA Annual Meeting: Day Five

The final day of APA’s Annual Meeting featured an animated, case-based session on ECT and a review of strategies to help prevent suicide in youth. Experts also offered practical guidance on how to treat pregnant women with psychiatric conditions and important insights on why migrant children face a long, slow recovery when they are separated from their families.

Look for future coverage of APA’s 2019 Annual Meeting in upcoming issues of Psychiatric News.

Expert Outlines Practical Tactics Parents, Practitioners Can Use to Help Teens Overcome Suicidal Urges

Increasing suicide rates among adolescents call for immediate approaches to reducing the risk. Michele Berk, Ph.D., offers seven practical tactics that parents and psychiatrists can use today.
Read More >

Panelists Discuss Difficult ECT Questions, From Patient Selection to Treatment Completion

In a lively, interactive session on Wednesday participants debated patients most likely to benefit from ECT, how to place electrodes, and whether to use lithium before and after treatment.  Read More >

Nine Tips for Managing Psychiatric Conditions Before, During, and After Pregnancy

Four perinatal psychiatry experts remind that treatment during pregnancy requires a risk-risk discussion with women: the risks of treating versus not treating.
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NIMH Research Seeks to Harness Power of Technology, says Gordon

Applying machine learning and other technologies to better understand risk factors for suicide were among the topics addressed by NIMH director Joshua Gordon, M.D., Ph.D., during the 175th History Track session.
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Considerations for Treating Migrant Children Separated From Parents

Building trust is an important first step to helping migrant children separated from parents begin a path to recovery, says child trauma expert Alicia Lieberman, M.D. Read More >

Panel Questions Evidence on Deep Brain Stimulation for Depression

While some studies show DBS to be effective, experts warn against “therapeutic enthusiasm,” saying the body of evidence does not sufficiently support the treatment. Read More >

From Patient to Inmate: Session Highlights Complex Interactions Between Social Policies and Mental Health Care Delivery

Experts explore how upstream social institutions and policies on homelessness and incarceration can drive downstream breakdowns in the delivery of public mental health services. Read More >

Join Us Next Year in Philadelphia

Be sure to save the date for next year's Annual Meeting, April 25 through 29, 2020, in Philadelphia, the city where APA was founded.

Highlights From APA Annual Meeting: Day Four

Day four of APA’s Annual Meeting included the release of an AJP study and commentary on esketamine, an inspiring lecture by the winner of this year’s Fryer Award, and a discussion on psychiatric assessment of patients seeking physician-assisted death in states where it is legal.

Through May 22, Psychiatric News will deliver an evening digest of important highlights from the meeting.

800 Psychiatrists and Guests Celebrate APA’s 175th Anniversary in Historic Venue

APA celebrated its place in history as the country's first medical association at a party that won't soon be forgotten.
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Intranasal Esketamine Found to Be Safe, Effective but Questions Remain

Findings from an AJP study released at the Annual Meeting Tuesday confirm that the controversial drug improves symptoms in treatment-resistant depression, but when should it be used and for how long?  Read More >

NIDA Director Outlines Institute’s Efforts to Improve Pain Management, OUD Treatment

Nora Volkow, M.D., described the agency’s efforts to diversify treatments for opioid use disorder (OUD), integrate OUD care into a variety of settings, and incentivize pharmaceutical companies to develop new drugs to treat pain.
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Measuring Capacity in Cases of Physician-Assisted Dying: Advice to Psychiatrists

Faced with a request for PAD, psychiatrists must go beyond the traditional consent criteria and develop a “decision-optimizing” relationship with the patient.
Read More >

Fryer Award Winner Urges Continued Advocacy for LGBTQ Community

Shannon Minter, Esq., commends mental health experts for their role in successes achieved through the modern LGBTQ rights movement and warns why today more than ever we need the courage and commitment of John Fryer to protect those gains. Read More >

Family-Centered Program Reduces Stigma, Speeds Recovery of Patients With Borderline Personality Disorder

Psychiatrists are increasingly realizing that a critical element of treatment for BPD is a family commitment to improving their interpersonal relationships. Read More >

Intimate Partner Homicide Least Studied, Most Common Form of Family Murder

Up to half of murdered women are killed by a past or present male intimate partner. In one of the Annual Meeting's most popular sessions, experts dove into the psychopathology and risk factors for these crimes. Read More >

Interventions That Promote Wisdom May Help Patients With Psychiatric Conditions

While the study of wisdom is still in its infancy, researchers believe understanding the biological and psychosocial variables associated with wisdom can inform treatments. Read More >

Experts Highlight Community-Based Solutions to Help Break Cycle of Gun Violence

Gun control measures may be an essential part of the solution, but communities can initiate locally driven, disruptive approaches today that have been proven to reduce gun violence. Read More >

Highlights From APA Annual Meeting: Day Three

Day three of APA’s Annual Meeting included a call to psychiatrists to lead in efforts to improve the lives of children, the release of APA poll results showing mental health stigma remains a major challenge in the workplace, and conversation around the ways psychiatrists can help people of differing political backgrounds find common ground.

Through May 22, Psychiatric News will deliver an evening digest of important highlights from the meeting.

Kellogg CEO Urges Psychiatrists to Advocate for Trauma-Informed Care for Children

During the William C. Menninger Memorial Lecture on Monday, La June Montgomery Tabron called on psychiatrists to promote racial healing and to integrate social determinants of health into medical care so all people have an equal opportunity to living a healthy life.
Read More >

Poll Draws Attention to Mental Health Stigma in Workplace, Concerns Over Social Media

Although most respondents to a national poll by APA said they know how to access mental health services through work, more than one-third worry that seeking mental health care might impact their job. Those surveyed also agreed that social media may be contributing to feelings of loneliness and social isolation. Read More >

Simpler Blood Monitoring, Sharing Clinical Experiences Critical to Expanding Clozapine Use

Speaking to a packed house, schizophrenia experts share their experiences with clozapine to increase psychiatrists’ comfort in using the highly effective but underutilized treatment.
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Black Psychiatrists Persevered Despite Discrimination in Education, Organized Medicine

Speakers at a 175th Anniversary History Track session described how black psychiatrists sought equal treatment and the need to continue working to eliminate racial discrimination.
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Women Making Strides in Academic Psychiatry but Gender Bias, Discrimination Still Too Common

The number of women entering psychiatry continues to increase, but a gender gap persists in compensation, advancement, and research funding. Session attendees offer up several practical solutions. Read More >

Factors to Keep in Mind When Prescribing to Pregnant Patients

Most psychiatric medications can be safely continued in pregnancy, but changes that occur during pregnancy may affect absorption, distribution, and metabolism of these medications. Read More >

Psychiatrists Have Role to Play in Building Bridges Between Today’s Polarized Society

A sociologist explores the psychological reasonings that fuel the divergent views of those on the right and the left. Read More >

Stay Tuned for Coverage of 175th Anniversary Gala

APA’s 175th Anniversary Gala at the magnificent San Francisco City Hall got under way as this issue of the APA Daily went to press. More than 700 people were expected to attend. Proceeds will support the work of the APA Foundation. Coverage of the gala will appear in a future issue.

Highlights From APA Annual Meeting: Day Two

Day two of APA’s Annual Meeting included an address by psychiatrist and incoming AMA President Patrice Harris, M.D., to APA’s Board of Trustees; a discussion of the challenges that international medical graduate students face; and a recommendation that psychiatrists consider ways their own mindfulness could benefit their patients.

Through May 22, Psychiatric News will deliver an evening digest of important highlights from the meeting.

Incoming AMA President and Former APA Board Member Lays Out Plans for Presidential Year

Psychiatrist Patrice Harris, M.D., told trustees that the integration of mental health and general medical care and promoting diversity across organized medicine would be among her priorities for the year.
Read More >

Valerie Jarrett Shares Insights From Her Years in the White House

In a wide-ranging “fireside chat” with APA President Altha Stewart, M.D., Valerie Jarrett talked about the experience of serving as President Obama’s longest-serving senior adviser. Read More >

Childhood Trauma Changes Biology of Brain

Advances in neurobiology and genetics explain the links between early life adversity and increased risk for psychiatric and medical conditions later in life, but how and when does psychiatry intervene?
Read More >

Why Psychiatrists Must 'Mindfully' Embrace Nutritional Wellness for Themselves and Their Patients

As the obesity epidemic expands, psychiatrists must go beyond telling patients how to lose weight to helping them live a healthy and fit life. Applying mindfulness to eating is one technique both physicians and their patients can benefit from.
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History Track Session Focuses on Challenges Faced by IMGs

A panel discussion of IMGs described the insensitivity and isolation—ranging from cultural misunderstandings to frank discrimination—that these trainees face in the workplace. Read More >

Overlap Between PTSD, TBI Symptoms Creates Challenges for Diagnosing Patients

Experts on Saturday discussed similarities in the causes and symptoms of PTSD and TBI, which can be critical for the determination of disability. Read More >

Winners of Resident/Medical Student Poster Competition Announced

Winners were recognized for their research focused on building resilience and addressing burnout in medical students and residents, reducing agitation, and more. Read More >

Highlights From APA’s 2019 Annual Meeting Day One

Welcome to San Francisco!

APA’s 2019 Annual Meeting began in San Francisco Saturday. From now through May 22, Psychiatric News will deliver an evening digest of some of the day’s highlights. Whether you are here in San Francisco or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

Stewart Brings a Robust and Eventful Presidential Year to a Close

During the Opening Session on Saturday, Altha Stewart, M.D., described how APA renewed its global reach while laying the groundwork for a more diverse and inclusive profession and responding to several national emergencies.
Read More >

Schwartz: APA Must Lead the Way to End Stigma, Improve Care

Incoming APA President Bruce Schwartz, M.D., vowed during his Opening Session address on Saturday to focus on three crucial areas: increasing access to care, improving quality of care, and continuing the fight against the stigma and discrimination attached to mental illness. Read More >

Levin Speaks to Future of a 'Noble' Profession

The 2019 APA Annual Meeting can offer a blueprint for the future, said APA CEO and Medical Director Saul Levin, M.D., M.P.A., during the Opening Session on Saturday. “For all the progress we’ve made, there are still some areas where we must improve as we work toward our next milestones—the 200th and 225th anniversaries,” he said.
Read More >

MindGames Playoffs Offer Double Treat to Meeting Attendees

MindGames has become one of the most popular Annual Meeting attractions, and this year, attendees got two versions—the traditional resident competition and a special history version in honor of APA's 175th Anniversary.
Read More >

The Lincolns: Retrospective Diagnosing Raises Questions Worth Pondering

Studying the putative psychiatric symptoms of historical figures raises important questions about the nature of psychiatric diagnosis, how those diagnoses are viewed through various cultural lenses, and how they may change over time. Read More >

Medications for Cannabis Use Disorder May Ease Withdrawal But Fail to Achieve Abstinence

Treatments to manage withdrawal or block the positive effects of cannabis offer limited benefit, but an over-the-counter supplement may reduce drug-seeking behavior in youth. Experts question whether treatment goals should focus on curbing consumption versus total cessation. Read More >

APA Raises $15,000 for Center Serving Disadvantaged Women

As part of the APA’s annual “APA Gives Back” program, APA President Altha Stewart, M.D., presented a donation today of $15,000 to this year’s recipient, the Young Women’s Freedom Center. For 25 years, this center has been providing support, advocacy, and opportunities for healing for women and girls of color who are impacted by poverty or who were formerly incarcerated. Read More >