Acetaminophen Use During Pregnancy Associated With Increased Risk of ASD, ADHD in Children

Using acetaminophen during pregnancy may increase the risk of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in children, according to a report published Wednesday in JAMA Psychiatry.

For this study, Yuelong Ji, Ph.D., of the Johns Hopkins Bloomberg School of Public Health and colleagues measured the levels of acetaminophen in umbilical cord blood taken after childbirth from 996 women who were part of a study called the Boston Birth Cohort. The study had a 21-year follow-up period.

Of the 996 children of these women, 257 were subsequently diagnosed with ADHD, 66 were diagnosed with ASD, 42 were diagnosed with both ADHD and ASD, 304 were diagnosed with another developmental disorder, and 327 had no developmental disorders.

The researchers found that the children who were exposed to more acetaminophen in the womb (as reflected by higher acetaminophen concentrations in cord blood) were more likely to have ADHD or ASD. The risk of either disorder was dose-dependent; that is, higher concentrations of acetaminophen in the cord blood equated to greater ADHD or ASD risk.

“Our findings support previous studies regarding the association between prenatal and perinatal acetaminophen exposure and childhood neurodevelopmental risk and warrant additional investigations,” Ji and colleagues wrote.

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Substance-Induced Psychosis Associated With Increased Risk of Schizophrenia, Meta-Analysis Finds

People who experience psychosis following the use of cannabis, hallucinogens, or amphetamines (known as substance-induced psychosis) may be at a greater risk of developing schizophrenia, according to a meta-analysis in Schizophrenia Bulletin. This risk was found to be only slightly less than that observed for patients who presented with other brief psychotic disorders.

“These findings have important implications for mental health care and services. Substance-induced psychoses are common reasons for seeking mental health care,” wrote Grant Sara, M.B., of the University of Sydney and colleagues. “Yet despite this, people with substance-induced psychoses are often excluded from early psychosis services or assertive mental health care due to a perception that these are benign or self-limiting conditions.”

Sara and colleagues searched MEDLINE, PsychINFO, and Embase for peer-reviewed, English-language studies published between 1980 and 2018 that looked at how often patients with substance-induced psychoses were later diagnosed with schizophrenia. They compared this group with those who had an initial diagnosis of “brief psychosis,” “atypical psychosis,” “schizophreniform psychosis,” or “psychosis not otherwise specified” who were later diagnosed with schizophrenia.

The researchers identified 50 studies, which included more than 40,500 people. Of these studies, 25 looked at later diagnosis of schizophrenia among people who had substance-induced psychosis (following use of cannabis, hallucinogens, amphetamines, alcohol, sedatives, or opioids).

Overall 25% of people with substance-induced psychosis were later diagnosed with schizophrenia, compared with 36% of people who first presented with brief, atypical, and not otherwise specified psychoses. Among the 25 studies that looked at substance use-induced psychosis, transition to schizophrenia was highest (34%) for cannabis-induced psychoses.

“The importance of assertive intervention in this group is underlined by evidence that integrated care, which addresses substance use disorders and psychosis, can have a significant impact on course,” the researchers wrote. “Such care can double the likelihood of remission in early psychosis; reduce the risk for hospital re-admission; and lead to better symptomatic, drug use, and functional outcomes at 10-year follow-up.”

For more information, see the Psychiatric News article “Substance-Induced Psychosis Associated With Later Schizophrenia, Bipolar Disorder.”

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Cannabinoids for Psychiatric Disorders? Evidence of Effectiveness is Lacking, Report Concludes

There is little evidence that the use of cannabinoids can improve symptoms of anxiety, attention-deficit/hyperactivity disorder (ADHD), depression, posttraumatic stress disorder (PTSD), psychosis, or Tourette syndrome, according to a report in Lancet Psychiatry.

“Cannabinoids are often advocated as a treatment for various mental disorders,” wrote Nicola Black, Ph.D., of the University of New South Wales and colleagues. Doctors and patients “need to be aware of the low quality and quantity of evidence for the effectiveness of medicinal cannabinoids in treating mental disorders and the potential risk of adverse events,” they added.

Black and colleagues searched several databases including MEDLINE, the Cochrane Central Register of Controlled Clinical Trials, and the Cochrane Database of Systematic Reviews for studies published between 1980 and 2018 that examined changes in symptoms and/or remission following the use of medicinal cannabinoid for treating adults with anxiety, ADHD, depression, PTSD, psychosis, or Tourette syndrome, either as the primary condition or secondary to other medical conditions. The researchers also searched for unpublished or ongoing studies on ClinicalTrials.gov, the EU Clinical Trials Register, and the Australian and New Zealand Clinical Trials Registry.

They identified 83 studies, including 40 randomized, controlled trials (RCTs), for the analysis. Most of the RCTs were very small (with median sample sizes of 10 to 39 participants) and had short follow-up periods (median trial length of four to five weeks), the authors noted.

“We found little evidence for the effectiveness of pharmaceutical CBD [cannabidiol] or medicinal cannabis for the treatment of any of [the examined] mental disorders,” Black and colleagues wrote. “Some very-low quality evidence was found for the use of pharmaceutical THC [tetrahydrocannabinol] (with or without CBD) in treating anxiety symptoms among individuals with other medical conditions, such as chronic noncancer pain and multiple sclerosis.”

In an accompanying commentary, Deepak Cyril D’Souza, M.B.B.S., M.D., of Yale University cautioned, “The process of drug development in modern medicine is to first demonstrate efficacy and safety in clinical trials before using the drug clinically. With cannabinoids, it seems that the cart (use) is before the horse (evidence). If cannabinoids are to be used in the treatment of psychiatric disorders, they should first be tested in randomized, controlled trials and subjected to the same regulatory approval process as other prescription medications.”

For more information on this topic, see the Psychiatric Services article “The CBD Dialectic in Mental Health: Benign and Powerful?”

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Use of Telepsychiatry Nearly Doubles From 2010 to 2017, Study Finds

Nearly twice as many mental health facilities in the United States offered telepsychiatry in 2017 than in 2010, according to a study published in Psychiatric Services. Telepsychiatry was most commonly offered by facilities in underserved and rural areas.

“Facilities with telepsychiatry offer a variety of services to a wide range of populations, and the increased use of these services among populations with greater barriers to access, such as those residing in rural and underserved areas, continues to [show] promise that such services will be made available to patients with the greatest need,” wrote Stanislav Spivak, M.D., of Johns Hopkins University School of Medicine and colleagues.

Spivak and colleagues analyzed national data from the Substance Abuse and Mental Health Services Administration’s National Mental Health Services Survey (NMHSS) collected between 2010 and 2017. The survey asked facilities that provide mental health treatment if they provided telepsychiatry—defined as “the ability for health care providers, working from a distance using telecommunications technology, to communicate with patients, diagnose conditions, provide treatment, and discuss health care issues with other providers to ensure quality health care services are provided.” The researchers compared the ownership, licensing, funding, and treatment setting of those facilities that reported offering telepsychiatry in 2017 with those that did not. They also asked state mental health agency officials whether telemedicine was reimbursed by state funds and/or Medicaid funds, and if the state had initiatives to expand the use of telemedicine.

In 2010, 15.2% (n=1,580) of the facilities surveyed reported using telepsychiatry; in 2017, that number grew to 29.2% (n=3,385) of the facilities surveyed. But the authors noted “considerable variability” among states, with less than 15% of facilities offering telepsychiatry in some states compared with over 60% in others. The increase in the proportion of facilities with telepsychiatry from 2010 to 2017 was highest in states with a rural population of 40% or more, the authors noted.

“Facilities that offered telepsychiatry had higher odds of being funded by federal and local government sources, as well as by private insurance, self-pay, and grant funding compared with facilities without telepsychiatry,” Spivak and colleagues wrote. In contrast, facilities offering telepsychiatry were less likely to be funded by Medicaid than those without telepsychiatry—a finding the authors described as “puzzling, as the federal Medicaid statute allows reimbursement of telemedicine as a regular service.” The lower odds of facilities using telepsychiatry receiving funding from Medicaid “may reflect the effect of state Medicaid regulatory hurdles,” they wrote.

State funding may also explain the variability in telepsychiatry from state to state. States that did not provide direct state funding for telemedicine had lower odds of offering telepsychiatry services (19.3% vs. 29.8%), the authors noted.

For related information, see the Psychiatric News article “Telepsychiatry: Who, What, Where, and How.”

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Limiting Flavored Tobacco Sales May Cut Use in Youth

Restricting the sale of flavored tobacco products may cut tobacco use among adolescents, a study in the American Journal of Preventive Medicine has found.

Melody Kingsley, M.P.H., of the Massachusetts Department of Public Health and colleagues compared tobacco use among youth in two Massachusetts towns, Lowell and Malden. In 2016, Lowell enacted a policy that restricted the sale of flavored tobacco products—those meant to taste like fruit, candy, honey, etc.—to tobacco retail stores such as smoking bars, vape shops, and tobacconists that only sell to adults aged 21 years and older. Malden did not have such a policy at the time of the study.

Researchers used retailer inventory data collected by Massachusetts Tobacco Control Program educators to compare the availability of flavored tobacco products in both towns in September 2016, before Lowell’s flavored tobacco restriction policy took effect, and six months later. More than 500 adolescents in Lowell high schools and more than 600 adolescents in Malden high schools took surveys about their tobacco use in September 2016 and again six months later.

During that timeframe, the percentage of stores where flavored products were available in Lowell dropped from 77.3% to 7.3%, whereas the availability of flavored tobacco products in Malden did not change significantly. Adolescent use of flavored tobacco products dropped 2.4% in Lowell but increased 3.3% in Malden. Adolescent use of non-flavored tobacco products dropped 1.9% in Lowell but increased 4.3% in Malden.

The researchers acknowledged that the surveys did not include all of the same adolescents at both time points, so they were unable to determine whether tobacco use for each adolescent in the study changed over time. Nevertheless, they concluded that overall Lowell’s policy appeared to curb tobacco use in youth.

“With a longer follow-up time, [we] expect these trends will continue, and the policy may begin to impact and reduce flavored tobacco initiation, as exposure to flavored tobacco among younger students continues to decline,” they wrote.

For related information, see the Psychiatric News articles “FDA Seeks Information on Role of Flavors in Initiation, Cessation of Tobacco Use” and “FDA Warns Some E-Cigarette Users Having Seizures, Particularly Youth.”

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ADHD Medication May Reduce Risk of Injuries in Youth With Co-Occurring Developmental Disorders

ADHD medication may reduce the risk of unintentional injuries in youth with ADHD and co-occurring neurodevelopmental disorders, such as autism, suggests a study in the Journal of Child Psychology and Psychiatry.

While previous studies have found a negative association between ADHD medication use and risk of injuries in children and adolescents, this is the first observational study exploring risk in children with ADHD and a co-occurring neurodevelopmental disorder, wrote Laura Ghirardi, M.Sc., of the Karolinska Institutet in Stockholm and colleagues.

Ghirardi and colleagues used data from Sweden’s Total Population Register and National Patient Register to identify individuals aged 5 to 18 who had received an ADHD diagnosis between 2006 and 2013, including those who had also been diagnosed with the following neurodevelopmental disorders: autism spectrum disorder, communication disorders, intellectual disability, learning disorders, and motor disorders. They then gathered information from the Prescribed Drug Register on the patients’ use of ADHD medications, including methylphenidate, amphetamine, dexamphetamine, lisdexamphetamine, and atomoxetine.

The researchers tracked the youth’s inpatient and outpatient visits reporting injury until the end of 2013, the youth aged out of the study, or death, whichever came first. They then compared the rate of injuries during periods when the youth were taking ADHD medication with the rate of injuries during periods they were not taking medication.

Of the 9,421 children and adolescents with ADHD included in the analysis, 2,986 had a co-occurring neurodevelopmental disorder; 1,390 had autism spectrum disorder. The rate of any unintentional injury and traumatic brain injury was lower during periods when the youth were taking ADHD medication compared with when they were not taking ADHD medication. Youth with co‐occurring neurodevelopmental disorders were 12% less likely to have an unintentional injury and 73% less likely to have a traumatic brain injury when taking ADHD medication.

The findings have “clinical and public health relevance, considering the high rate of comorbidity among [neurodevelopmental disorders] and the fact that unintentional injuries are relatively common among children and adolescents,” the authors wrote.

For related news, see the Psychiatric News article “Many Youth With ADHD Fail to Take Stimulants as Prescribed.”

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Aripiprazole Found to Have Fewer Side Effects in Teens With First-Episode Psychosis

Young people with first-episode psychosis (FEP) who are treated with extended-release quetiapine gain more weight and experience worse metabolic effects—including increased lipids, insulin, triglycerides, and total cholesterol—than patients treated with aripiprazole, according to a report in the Journal of the Academy of Child and Adolescent Psychiatry.

“These differences emerged early, are clinically relevant, and should inform treatment choice for youths with early onset psychosis,” especially since studies have shown the two medications are equally effective in treating symptoms, say Karsten Gjessing Jensen, M.D., Ph.D., of the University of Copenhagen and colleagues.

The researchers analyzed data on 113 youth aged 12 to 17 with FEP who were randomized to 12 weeks of extended-release quetiapine (quetiapine-ER) or aripiprazole as part of the Tolerability and Efficacy of Antipsychotics trial. The trial was conducted from June 2010 to April 2014 in seven university child and adolescent psychiatry departments across Denmark.

The primary outcome was change in body weight; secondary outcomes were changes in body mass index (BMI), waist circumference, blood pressure, heart rate, and lipid and glucose metabolism measures. Patients were assessed and blood samples taken at 4 and 12 weeks. The researchers also examined family history for factors that might predict how youth would respond on weight and metabolic measures.

Treatment with quetiapine-ER was associated with greater weight gain at 4 and 12 weeks (2.24 kg and 4.88, respectively) than aripiprazole (0.45 kg at 4 weeks and 1.97 kg at 12 weeks). Patients treated with quetiapine-ER also had increased metabolic measures—including cholesterol, triglycerides, and hyperinsulinemia—than patients treated with aripiprazole. Of the patients in the quetiapine-ER group, 14% had metabolic syndrome at week 12 compared with 8.3% in the aripiprazole group. Family factors that predicted weight gain and BMI in youth were early weight gain, obesity, or type 2 diabetes.

The researchers noted that, aside from the health effects, weight gain is likely to be stigmatizing for young people who may already be marginalized because of their psychosis. “Youths with psychotic disorders are a highly vulnerable patient group who may already feel marginalized by their peers, so that a weight gain of 5 kg may be yet another cause of (self-)stigmatization that may increase the risk of treatment discontinuation and that may impair the alliance between patients and health care providers,” they wrote.

For related information, see the Psychiatric News article “SGAs Increase Teens’ Abdominal Fat, Decrease Insulin Sensitivity.”

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Experts Outline Keys to Helping People Manage Prolonged, Disabling Grief

While all bereaved people can benefit from compassionate support, patients who experience intense, persistent, and disabling grief following the death of a loved one may require additional interventions. One intervention that may help is complicated grief therapy, wrote Alana Iglewicz, M.D., of the Veterans Affairs San Diego Healthcare System and colleagues in a paper in Depression & Anxiety.

“While everyone grieves in their own way, bereaved individuals often feel a sense of disconnection from themselves; their past, present, and future; and especially from the person who died,” Iglewicz and colleagues wrote. “[O]ver time, most adapt to their loss by accepting its finality and consequences.” Some people, however, may find themselves struggling with a prolonged grief the authors describe as complicated grief (the authors noted that various other terms have been used to describe this condition, including prolonged grief disorder in ICD-11). These people may be at greater risk of psychiatric and general medical conditions, the authors noted.

“[Complicated grief therapy] is based on the premise that grief emerges naturally after a loss and finds a place in our lives as we adapt to the loss,” the authors wrote. “Adapting entails coping with problems as well as envisioning and finding ways to bring joy and satisfaction into ongoing life. When doing [complicated grief therapy], grief is not an intervention target. Rather we seek to facilitate coping and personal growth and to resolve any impediments to this process.”

The authors outlined how mental health professionals can create a space to engage the patient using the following evidence-based guidance:

• Understanding and accepting grief: For example, remind the patient that grief is normal and that he or she is not alone.
• Recognizing painful emotions: For example, encourage the patient to pay attention to how his or her grief changes over the course of the day and what triggers these changes.
• Thinking about a meaningful and fulfilling future: For example, work with the patient to create goals and formulate steps toward reaching these goals.
• Reconnecting with others: For example, encourage the patient to identify at least one confidant.
• Telling the story of loved one’s death: For example, invite the patient to tell the story of his or her loved one’s death repeatedly over several sessions.
• Learning to live with reminders of the deceased: For example, create a list of activities that the patient has been avoiding and encourage the patient to gradually revisit these activities.
• Establishing an enduring connection with memories of the person who died: For example, remind the patient of the role that memories play in relationships with loved ones, even when they are no longer alive.

“We suggest each clinician adapts the principles and procedures of complicated grief therapy in the way that fits their work best. Our experience suggests that patients can benefit greatly from a simple intervention that includes the seven core themes described above,” the authors concluded.

For related information, see the Psychiatric News article “Citalopram May Offer Limited Benefit for Patients With Complicated Grief.”

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Prescribing Lithium During Pregnancy Requires Careful Balancing of Benefits, Risks

The risk of giving birth to a child with birth defects may be slightly higher in women with bipolar disorder who take lithium compared with those who do not take lithium, suggests a meta-analysis in AJP in Advance. However, these slight risks may be outweighed by the dangers to mother and child of relapse of illness episodes (either depressive or manic), the authors of the analysis caution.

“Pregnancy should not be considered an absolute contraindication to lithium prescription, given the relatively small increase in risk for any malformation or cardiac malformations, and given that such events, fortunately, remain rare,” wrote Michele Fornaro, M.D., Ph.D., of the University of Naples Federico II School of Medicine and colleagues. In comparison, women with bipolar disorder who are not in treatment may experience frequent relapse of mood episodes during pregnancy and the postpartum period. These episodes themselves can harm the health of the mother and the fetus or newborn.

Fornaro and colleagues compiled data from 29 studies that assessed the efficacy and safety outcomes of lithium treatment during pregnancy and the postpartum period. They found that lithium exposure was not associated with any risk of preterm birth or low birth weight. Compared with women who were not prescribed lithium, however, those who took lithium any time during pregnancy had 1.81 times greater odds of giving birth to a child with a congenital defect and 1.86 times greater odds of giving birth to a child with a cardiac birth defect; these risks were slightly higher for women who started taking lithium in the first trimester (1.81 times for any congenital defect and 1.96 times for a cardiac defect). Women who took lithium in the first trimester also had 3.77 times greater odds of a miscarriage. When the comparisons were limited to women with bipolar disorder, however, women who took lithium did not have any increased risk of miscarriage compared with those who did not, and no increased risk of cardiac birth defects when lithium was taken in the second and/or third trimester.

Women with bipolar disorder who took lithium were 84% less likely to relapse during the postpartum period than women with bipolar disorder who did not take lithium during pregnancy.

To read more on this topic, see the Psychiatric News article “How to Manage Meds Before, During, and After Pregnancy.”

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Risk of Heart Disease Quadruples in Women Hospitalized for Bulimia

The risk of cardiovascular disease skyrockets for women who have been hospitalized for bulimia nervosa, a study in JAMA Psychiatry reports. The risk is greatest in the first two years after hospitalization and remains high for another three years before disappearing at the 10-year mark.

“Our findings suggest that women with a history of bulimia nervosa should be informed of an increased risk of cardiovascular disease and death in the first decade after the index admission for bulimia,” wrote Rasmi M. Tith, R.D., M.P.H., of the University of Waterloo in Ontario and colleagues. “These women may benefit from screening for prevention and treatment of cardiovascular risk factors.”

The study followed more than 416,000 women for up to 12 years from 2006 to 2018. Of the patients, 818 were hospitalized for bulimia, and the rest were hospitalized for pregnancy-related events such as delivery of a live or stillborn infant, abortion, or pregnancy outside the uterus (ectopic pregnancy). The average age of the women at hospitalization was 28 years.

“The comparison group was representative of most women in the province … because 99% of deliveries and a significant proportion of other pregnancy events occur in hospitals,” the researchers wrote.

Compared with women who had been hospitalized for pregnancy-related events, women who had been hospitalized for bulimia had nearly 22 times the risk of heart attack within two years of hospitalization and more than 14 times the risk at five years. Over the entire follow-up, they had more than four times the risk of any cardiovascular disease, including six times the risk of heart attack, seven times the risk of ischemic heart disease (heart problems caused by narrowed heart arteries), and seven times the risk of atherosclerosis. They also had five times the risk of death. Those who had multiple hospitalizations for bulimia had a higher risk of cardiovascular disease and death than those who had been hospitalized only once.

The researchers noted that bulimia has been associated with metabolic changes such as changes in lipids that may affect the risk of cardiovascular disease. They added that bulimia may cause endocrine abnormalities such as low estrogen levels, which may also increase cardiovascular risk.

“Although more studies are needed, the findings from the present study suggest that bulimia nervosa, especially bulimia that requires multiple hospitalizations for treatment, may be associated with a range of cardiovascular disorders,” the researchers concluded. “Bulimia nervosa may be an important contributor to premature cardiovascular disease in women.”

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

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Transcranial Direct Current Stimulation May Effectively Treat Negative Schizophrenia Symptoms

Transcranial direct current stimulation (tDCS) appears to be an effective and safe add-on treatment for ameliorating negative symptoms in schizophrenia, such as loss of interest in everyday activities and emotional withdrawal, according to a study published yesterday in JAMA Psychiatry. This noninvasive therapy delivers weak, direct currents into the brain via electrodes placed on the scalp.

“There is an unmet clinical need for the treatment of negative symptoms in schizophrenia,” wrote Leandro da Costa Lane Valiengo, M.D., Ph.D., of the Instituto Nacional de Biomarcadores em Neuropsiquiatria Faculdade de Medicina in São Paulo, Brazil, and colleagues. “[G]iven its acceptability, tolerability, and short treatment protocol, tDCS could be evaluated as an add-on intervention for patients with schizophrenia with negative symptoms in outpatient settings.”

The double-blind, placebo-controlled, randomized trial took place from September 2014 to March 2018 in two São Paulo outpatient clinics. The 100 participants aged 18 to 55 were all diagnosed with schizophrenia using the Portuguese version of DSM-IV, had Positive and Negative Syndrome Scale (PANSS) negative symptom scores of 20 or more, and had stable positive and negative symptoms for four weeks or more. Participants received tDCS in twice-daily, 20-minute sessions over five consecutive days. A sham group went through the same procedure without receiving tDCS. A total of 95 patients completed the trial.

The participants’ symptoms were assessed at baseline, five days, two weeks, four weeks, six weeks, and 12 weeks after the treatment began. After 12 weeks, there was a 4.5-point improvement in the mean PANSS negative symptoms subscale score for patients who received tDCS, compared with a 1.8-point improvement in the sham group. Forty percent of those in the tDCS group achieved treatment response (a 20% or greater improvement in negative symptoms), compared with only 4% in the sham group. The participants had no serious adverse effects, such as acute psychosis or hospitalization, though those who received tDCS reported a burning sensation over the scalp.

“Our findings encourage the use and optimization of this technique in patients with psychotic disorders,” the authors concluded.

For related information, see the American Journal of Psychiatry article “Low-Intensity Transcranial Current Stimulation in Psychiatry.”

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APA Celebrates 175th Anniversary Today

APA is 175 years old today.

On October 16, 1844, 13 superintendents of U.S. institutions for people with mental illness came together in Philadelphia for a four-day meeting that led to the creation of the Association of Medical Superintendents of American Institutions for the Insane. In 1892, the Association’s name was changed to the American Medico-Psychological Association, and in 1921 it became the American Psychiatric Association.

“APA’s founders were determined to provide their patients with psychosocial care in a humane environment,” said APA President Bruce Schwartz, M.D. “They gathered to talk about the common challenges they faced and to advance treatments to improve the lives of their patients. In the 175 years since, APA and its members have worked to promote the highest quality of care for individuals with mental illness and substance use disorders.”

Over the past 175 years, APA has advanced the field of psychiatry by promoting research, advocating at the federal and state levels for equitable treatment of people with mental illness and substance use disorders, standing up for the rights of people with mental illness in the courts, and educating the public about mental illness and the effectiveness of treatment. Documents and other resources related to APA’s rich history are preserved in the Melvin Sabshin, M.D. Library & Archives at APA headquarters in Washington, D.C.

Highlights of APA’s history include the following:

• In 1917 the American Medico-Psychological Association, working with the National Committee for Mental Hygiene, created a formal system for classifying mental illnesses. This would later become the Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952. Further revisions, most recently in 2013 with DSM-5, reflect significant scientific advances in understanding and diagnosing mental illness.
• Throughout the 1970s and 1980s APA was instrumental in confronting the former Soviet Union over its use of psychiatric hospitals to detain political dissidents; APA has also advocated for civil rights of people with mental illness in Chile, Cuba, South Africa, and China.
• In 1981 American Psychiatric Publishing Inc., APA’s publishing company, was created to produce books, journals, and multimedia to provide cutting-edge information to medical students, residents, and practicing psychiatrists. (APA members may access the American Journal of Psychiatry from its beginnings as the American Journal of Insanity in 1844.)
• In 1992 APA created the American Psychiatric Association Foundation to advance mental health through educational programs in schools, workplaces, correctional institutions, and the broader community.
• In 2008 Congress passed the Mental Health Parity and Addiction Equity Act, requiring insurers to provide coverage for treatment of mental illness and substance use disorders on the same par as that provided for general medical and surgical treatments. APA was a leading advocate for this legislation and has continued to work on ensuring the law’s enforcement.

APA kicked off celebrating its 175th anniversary during its Annual Meeting earlier this year in San Francisco. The year of commemoration concludes at the organization’s next Annual Meeting in Philadelphia in April 2020.

“We are proud to recognize our rich and deep history,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “By exploring our past, we can see how far we have come as a medical organization and the great potential we have moving forward.”

For information on APA’s founding, see the Psychiatric News article “APA’s Origins Reflected Enlightened Thinking About Care for People With Mental Illness.”

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Suicide Attempts by Black Adolescents Rising, Report Suggests

Between 1991 and 2017, the rate of black adolescents who reported attempting suicide rose, according to a report published Monday in Pediatrics. This trend was not seen in adolescents who identified as white, Hispanic, Asian American or Pacific Islander, or being of multiple races.

“Examining trends in suicidal ideation and behaviors over time by sex and race and ethnicity allows us to determine where to focus prevention and intervention efforts,” wrote Michael A. Lindsey, Ph.D., M.S.W., M.P.H., of New York University and colleagues.

Lindsey and colleagues analyzed data from the Youth Risk Behavior Survey (YRBS)—a national survey administered to high schoolers across the United States—from 1991 through 2017. As part of this survey, youth were asked to report suicidal thoughts and behaviors; such questions included the following: “During the past 12 months, did you make a plan about how you would attempt suicide?”; “During the past 12 months, how many times did you actually attempt suicide?”; and “Did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?”

The sample included 198,540 high school students. During the study period, the weighted overall prevalence rates of suicidal ideation, plan, attempt, and injury by attempt were 18.8%, 14.7%, 7.9%, and 2.5%, respectively, Lindsey and colleagues reported. While the analysis revealed that the rates of suicidal ideation and suicide plans by the adolescents trended downward over time across all sex and racial and ethnic groups, black adolescents experienced an increase in rates of suicide attempts.

Additional analysis revealed that self-reported suicide attempts increased at an accelerating rate in black girls (even as suicide attempts among adolescent girls overall declined), and there was a significant increase in injuries from self-reported suicide attempts in black boys.

“[O]ver time, black youth have experienced an increase in suicide attempts, which is the most prominent risk factor associated with suicide deaths,” Lindsey and colleagues wrote. They suggested that this finding may be related to disparities in access to mental health treatment and social factors disproportionately experienced by black youth, such as racial discrimination.

“Despite the recent increases in rates of suicide, black adolescents continue to have a lower suicide rate than white adolescents,” noted Benjamin N. Shain, M.D., Ph.D., of the University of Chicago in an accompanying commentary. Nonetheless, he wrote, “the increases in rates of suicide and suicide attempts by black adolescents are concerning and should influence prevention and intervention efforts. Future research should be aimed at delineating the reasons for the increases and suggesting approaches useful for clinicians, schools, and leaders in charge of health care and social policy.”

For related information, see the Psychiatric News article “Mental Health Needs of Blacks Not Being Met, Says APA President.”

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Candidates for APA's 2020 Election Announced

The APA Nominating Committee, chaired by immediate past President Altha Stewart, M.D., reports the following slate of candidates for APA’s 2020 election. This slate is considered public, but not official, until the Board of Trustees approves it at its December 2019 meeting.



President-Elect
David C. Henderson, M.D.
Vivian B. Pender, M.D.

Treasurer
Ann Marie T. Sullivan, M.D.
Richard F. Summers, M.D.

Trustee-At-Large
Frank Clark, M.D.
Mark Komrad, M.D.
Michele Reid, M.D.

Area 2 Trustee
James P. Kelleher, M.D., M.B.A.
Glenn A. Martin, M.D.

Area 5 Trustee
Jenny Boyer, M.D., Ph.D., J.D.
Philip L. Scurria, M.D.

Resident-Fellow Member Trustee-Elect
Mariam Aboukar, D.O.
Aatif Mansoor, M.D.
Sanya Virani, M.D., M.P.H.

The deadline for candidates who wish to run by petition is November 15. All candidates and their supporters are encouraged to review APA’s Election Guidelines. Candidates’ photos and the addresses of their personal websites will be published in the December 20 issue of Psychiatric News.

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Changes in Depressive Symptoms at Two-Week Treatment Mark May Predict 12-Week Remission Outcomes

Whether patients with major depressive disorder show improvement (or lack thereof) at the end of their second week on an antidepressant medication may predict whether they will ultimately achieve remission at the end of 12 weeks, a study published in Psychiatric Research & Clinical Practice found.

“For any antidepressant medication trial, it is important to identify as early as possible whether the patient is likely to achieve remission …,” wrote Paul B. Hicks, M.D., Ph.D., of Texas A&M College of Medicine and colleagues. “The present study bolsters the proposed use of the lack of early improvement as a predictor of failure to achieve remission with the current medication.”

The researchers conducted a secondary analysis of data from the Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) study, which involved 1,552 veterans aged 18 and older whose major depressive disorder was unresponsive to at least one course of antidepressant treatment. The study participants were randomly assigned to one of three medication treatment groups: augmentation with bupropion sustained release, augmentation with aripiprazole, or switch to a different antidepressant. The dosage remained relatively constant throughout the trial, though the researchers allowed adjustments to doses as early as the end of the first week. The researchers evaluated participants at baseline and at the end of weeks 1, 2, 4, 6, 8, 10, and 12.

Early improvement was defined as a drop from the baseline depression severity score of 20% or more, as measured by the Quick Inventory of Depressive Symptomatology-Clinician Rated (QIDS-C), within the first two weeks of the treatment modification. The researchers then calculated positive and negative predictive values by evaluating whether the participants showed early improvement by the end of the second week and whether they then achieved remission by the end of week 12. The values were determined by categorizing participant outcomes based on whether the patient had a true positive (they showed early improvement and achieved remission), false positive (they showed early improvement but did not achieve remission), true negative (they neither achieved early improvement nor remission), and false negative (they did not show early improvement but achieved remission).

The researchers found that early improvement in patients resulted in a positive predictive value of 38.2% and a negative predictive value of 92.6%; the latter means that if the patient does not show improvement by the end of the second week on a medication, the chance of achieving remission at the end of the 12th week is less than 8%. “The odds of achieving remission, response, and greater than minimal improvement was higher among individuals who exhibited early improvement,” the authors wrote.

They noted, however, that it is also important to analyze the characteristics of the patients who did not experience early improvement but did ultimately achieve remission by the end of the 12 weeks. Those patients were more likely to have lower baseline scores, fewer adverse childhood experiences, lower baseline Beck Anxiety Inventory Score, lower Columbia-Suicide Severity Rating Scale scores, and a higher baseline quality of life.

“A lack of early improvement at the end of week 2 of antidepressant therapy can be used to inform clinical decisions on the likelihood of nonremission of depression during the subsequent 10 weeks, even when dosage optimization is incomplete,” the authors concluded.

For related information, see the American Journal of Psychiatry article “General Predictors and Moderators of Depression Remission: A VAST-D Report.”

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Bacterial Infection in Pregnancy Linked to Psychosis in Offspring as Adults

Children of mothers who contract a bacterial infection such as pneumonia during pregnancy are significantly more likely to have a psychotic disorder in adulthood compared with those not exposed to infection in utero, according to a report in AJP in Advance.

The risk of psychosis in adulthood is even greater when pregnant women have an infection that impacts multiple body systems such as sepsis and is especially high for males.

Lead author Younga H. Lee, Ph.D., of Brown University and colleagues said more research with larger sample sizes could help uncover how gestational bacterial infection may directly or indirectly cause adult psychosis. “If replicated, our findings would also call for public health and clinical efforts that focus on preventing and managing bacterial infection in pregnant women,” they wrote.

Lee and colleagues analyzed data on 15,421 live births between 1959 and 1966 in Boston and Providence, R.I., as part of the Collaborative Perinatal Project (now known as the New England Family Study). Information about exposure to bacterial infection was recorded during perinatal visits beginning at the time of registration for prenatal care, at intervals of four weeks during the first seven months of pregnancy, every two weeks at 8 months, and every week thereafter until birth.

Of 15,421 cohort mothers in the sample, 3,499 (23%) had bacterial infection; of these, 3,191 (21%) had localized infections, 399 (3%) had multisystemic infections, and 91 (<1%) had both. Localized bacterial infections included tuberculosis (n=8); pneumonia (n=83); syphilis (n=66); gonorrhea (n=15); and kidney, ureter, and bladder infections (n=1,203); and vaginitis (N=2,136).

A total of 116 offspring were diagnosed with a psychotic disorder in adulthood.

Offspring of mothers who experienced a multisystemic infection were almost three times as likely to have a psychotic disorder in adulthood compared with those whose mothers experienced no infection. Offspring of mothers who had any kind of infection during pregnancy—localized or multisystemic—were 1.8 times as likely to have a psychotic disorder as those whose mothers had no infection.

The risk was especially high for males; male offspring of mothers who experienced a multisystemic infection during pregnancy had a five times greater risk of psychosis than males whose mothers did not have infection, and nearly three times the risk of psychosis when mothers had had any kind of bacterial infection.

A large body of research has implicated viral infections during pregnancy in psychosis among offspring; the new AJP study extends that work to bacterial infections. “These findings could be an important first step to motivating large-scale national register-based investigation” of the role of both viral and bacterial infections in psychosis, the researchers wrote.

For related information, see the Psychiatric News article “Maternal Infection, Later Childhood Infection Linked to Psychosis in Offspring.”

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Study Highlights Long-Term Benefits of Deep Brain Stimulation for Refractory Depression

Deep brain stimulation (DBS) of a region called the subcallosal cingulate appears to be safe and effective at reducing symptoms of depression in patients with treatment-resistant depression over time, according to a small study in AJP in Advance.

Previous studies suggest that up to one-third of all patients with major depression have treatment-resistant depression (that is, they fail to experience symptom improvements during two or more antidepressant trials). “Given that patients with treatment-resistant depression are highly susceptible to recurrent depressive episodes, the ability of DBS or any treatment to support long-term maintenance of antidepressant response and prevention of relapse in severe and intractable depression would be an important treatment advance,” wrote Andrea Crowell, M.D., of Emory University School of Medicine and colleagues.

Crowell and colleagues analyzed long-term follow-up data from an open-label trial of 28 patients aged 27 to 65 who underwent subcallosal cingulate DBS surgery. (The subcallosal cingulate is a small brain region rich in serotonin transporters that is believed to be a key regulator of mood.) Of this group, 20 had been diagnosed with major depressive disorder, and seven had been diagnosed with bipolar II disorder; one patient in the major depression subgroup was later reclassified as having bipolar II disorder. To be included in the trial, patients were required to have a score ≥20 on the 17-item Hamilton Depression Rating Scale (HAM-D) and a score <50 on the Global Assessment of Functioning Scale (GAF). Patients with a history of psychosis, personality disorders, or imminent risk for suicide were not included in the trial.

A psychiatrist evaluated study participants weekly for 32 weeks, beginning about four weeks prior to DBS surgery. After this point, a psychiatrist assessed study participants every six months for two to eight years. All 28 participants who underwent DBS surgery completed at least one year of follow-up. Fourteen participants completed at least eight years of study participation.

After two years, the average HAM-D scores of the patients dropped by over 50% (from about 23 to 10) and remained steady over the remaining years. Likewise, the average GAF score rose from about 34 (indicating major impairment in several areas of functioning) to 70 (indicating mild symptoms but with overall good functioning) after two years and remained steady. Crowell and colleagues noted that 20 participants (71%) “demonstrated consistent improvement of ≥25% from baseline depression severity ratings throughout the study. … Among the eight patients with bipolar disorder, five showed a favorable response pattern, and three exhibited limited antidepressant response over time.”

While no adverse events were attributable to acute or chronic stimulation, 19 serious adverse events were related to surgery, or 0.7 events per participant—a medical complication rate “comparable to that seen with DBS for other indications,” they continued.

Crowell and colleagues concluded, “Identifying factors associated with long-term response is an important next step in [subcallosal cingulate] DBS research. … Beyond this, more qualitative studies of DBS patient characteristics and the quality of patients’ experience of depression before and after DBS are needed in order to optimize patient selection for DBS in the [subcallosal cingulate] and other brain targets.”

For more on deep brain stimulation, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Deep Brain Stimulation and Cognitive Outcomes Among Patients With Parkinson’s Disease: A Historical Cohort Study.”

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Psychiatrists Can Do More to Help Patients Quit Smoking, Addiction Experts Say

Several medications are proven to help people stop smoking, but few patients with tobacco use disorder are being offered them, according to addiction experts at APA’s IPS: The Mental Health Services Conference in New York.

Despite the higher rates of smoking by people with mental illness compared with those without mental illness, only a quarter of facilities that treat patients with substance use disorders in the United States offer nicotine replacement therapy or medication treatment, and two-thirds allow tobacco use on their grounds, explained session chair Michael Brus, M.D., a clinical instructor of psychiatry at Icahn School of Medicine at Mount Sinai, during the session “The Deadliest Drug Epidemic: How Psychiatrists and the Media Miss the Boat on Tobacco Addiction, and What to Do About It.” Brus called for psychiatrists to do more to address tobacco use in this population.

To help patients successfully quit tobacco, Jill Williams, M.D., director of the Division of Addiction Psychiatry at the Rutgers University-Robert Wood Johnson Medical School, said psychiatrists should regularly ask patients about their tobacco use, and if they do use tobacco, advise patients on the risks of such use and refer them to treatment such as behavioral counseling.

Psychiatrists should also strongly consider prescribing smoking cessation medications, including varenicline, which is underused despite strong evidence of safety and efficacy.

Brus highlighted a 2016 study known as EAGLES that found varenicline to be superior to bupropion and the nicotine patch in helping smokers achieve abstinence (the study did not show a significant increase in adverse psychiatric events in patients taking varenicline compared with those with nicotine patch or placebo). Yet in the three years since that study, prescription rates of varenicline have ticked up only marginally, Brus said.

Williams highlighted another study that found that varenicline could promote smoking abstinence even in patients whose initial goal was only to reduce their smoking levels. “There’s also evidence that varenicline can lessen dependence and reduce withdrawal symptoms, so prescribing this medication can be a useful harm-reduction strategy even in people not looking to quit,” she said.

For psychiatrists who may still have concerns with varenicline, Brus and Williams pointed out that combination nicotine replacement (combining a long-acting patch with rapid-acting lozenges or gum) has been shown to be as effective as varenicline when combined with counseling. The current data are inconclusive about whether a combination of varenicline plus nicotine replacement therapy promotes better abstinence than either treatment alone. There is emerging evidence that varenicline plus bupropion may elevate quit rates, but more research is needed.

For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco” and the Psychiatric Services article “Low-Burden Strategies to Promote Smoking Cessation Treatment Among Patients With Serious Mental Illness.”

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