Eating Disorders Associated With Increased Risk of Pregnancy, Neonatal Complications

Women who have or had an eating disorder are at increased risk of adverse outcomes during pregnancy compared with women without an eating disorder, suggests a meta-analysis in JAMA Psychiatry. Such outcomes include anemia, hyperemesis (characterized by severe nausea and dehydration), and pre-birth hemorrhage. Women with an eating disorder were also found to be at an increased risk of preterm birth and delivering a baby with microcephaly (a smaller than normal head circumference).

“Women with eating disorders should … be recognized as a high-risk population among pregnant women,” wrote Ängla Mantel, M.D., Ph.D., of Karolinska University, Sweden, and colleagues. “[T]hese findings emphasize the importance of developing a reliable antenatal routine enabling identification of women with ongoing or previous eating disorders… .”

Mantel and colleagues analyzed data from the Swedish Medical Birth Registry and other Swedish national health registers looking at demographic data, comorbidities, and complications during pregnancy, delivery, and the neonatal period. The analysis included more than 1 million women who gave birth between January 1, 2003, and December 31, 2014, comprising almost all singleton births in Sweden during this period.

A total of 7,542 women with eating disorders were compared with 1,225,321 women without eating disorders. Eating disorder diagnoses included anorexia, bulimia, and eating disorders not otherwise specified (EDNOS). Women with any of the disorders were further stratified into two groups: those with current eating disorders and those who were diagnosed with eating disorders more than one year before conception.

The analysis revealed the following:

• Women with any eating disorder had nearly twice the risk of hyperemesis.
• Women with anorexia nervosa had a 60% increased risk of pre-birth hemorrhage.
• Women with anorexia had twice the risk of anemia compared with women without eating disorders.
• Women with anorexia nervosa had a 60% increased risk of preterm birth (defined as less than 37 gestational weeks). The risk was smaller for women with bulimia nervosa and women with EDNOS, but significantly higher than in women without an eating disorder.
• The risk of having a baby who was below the sex-specific average weight at birth was increased among women with anorexia nervosa and women with EDNOS compared with women without an eating disorder.
• Women with anorexia nervosa had an almost twofold risk of having a baby with microcephaly. The risk was smaller for women with bulimia nervosa and women with EDNOS, but significantly higher than in women without an eating disorder.

In general, the risks for pregnancy and neonatal complications were higher for women with current eating disorders than those with a history of eating disorders. “Important future research tasks should focus on identifying mechanisms behind the impaired outcomes for women with eating disorders as well as addressing long-term outcome,” the researchers wrote.

For related information, see the Psychiatric News article “Anorexia’s Complex Etiology Opens Path to New Treatments.”

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U.S. Life Expectancy Falls as Rates of Death From Drug Overdose, Suicide Rise

Life expectancy among people living in the United States has fallen in recent years, driven in part by an uptick in deaths among young and middle-aged adults from drug overdose, alcohol consumption, and suicide, according to a report published today in JAMA.

“The implications of increasing midlife mortality are broad, affecting working-age adults and thus employers, the economy, health care, and national security. The trends also affect children, whose parents are more likely to die in midlife and whose own health could be at risk when they reach that age, or sooner,” wrote Steven Woolf, M.D., M.P.H., and Heidi Schoomaker, M.A.Ed., of Virginia Commonwealth University.

Woolf and Schoomaker analyzed life expectancy data collected by the Centers for Disease Control and Prevention and cause-specific mortality rates listed in the U.S. Mortality Database from 1959 to 2017.

The analysis revealed that from 1959 to 2014, U.S. life expectancy increased from 69.9 years to 78.9 years. The rate of increase was greatest from 1969 to 1979, plateaued in 2011, and decreased after 2014, the authors noted. From 2010 to 2017, age-adjusted all-cause mortality rates increased by 6% in those aged 25 to 64 years (defined by authors as midlife adults). The authors noted several changes in rates of midlife mortality:

• From 1999 to 2017, midlife mortality from drug overdoses increased by 386.5%.
• During this same period, death rates from alcoholic liver disease increased by 40.6%.
• Similarly, the suicide rate among individuals aged 25 to 64 years increased by 38.3%, and 55.9% among individuals aged 55 to 64 years. (Suicide rates also increased among those younger than 25 years.)
• The midlife mortality rates for hypertensive diseases increased by 78.9% and 114.0% for obesity.

“Multidisciplinary approaches can address mortality linked to the disturbing triad of alcohol-related conditions, drug overdoses, and suicide, recently proposed as ‘deaths of despair,’” wrote Howard K. Koh, M.D., M.P.H., of the Harvard T.H. Chan School of Public Health in an accompanying editorial. “[P]olicies including the 2008 Mental Health Parity and Addiction Equity Act have elevated conditions affecting mental and emotional well-being, long overlooked, to a level equivalent to physical well-being. Stricter enforcement of the law, a major limitation to date, will be required to realize its vision.”

They concluded, “The study by Woolf and Schoomaker, detailing years of cumulative insults to the nation’s health, represents a call to action. Further research must explore how income inequality, unstable employment, divergent state policies, and other social dimensions affect disease.”

For related information, see the Psychiatric News article “Mental Health Parity May Hold Key to Solving Suicide and Opioid Crises.”

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Patients With Major Depressive Disorder May Benefit From Interpersonal and Social Rhythm Therapy

Psychotherapy that includes social rhythm therapy—which helps people develop regular patterns in their daily activities such as work, eating, and sleeping—has been shown to be an effective treatment for patients with bipolar disorder. This disorder typically creates disruptions in the circadian clock, and social rhythm therapy can help reset this clock. A small study published in the American Journal of Psychotherapy now suggests that combining interpersonal psychotherapy and social rhythm therapy can help patients with unipolar depression as well.

The analysis included 30 patients who received 12 months of interpersonal psychotherapy, which focuses on a person’s family and social relationships, coupled with social rhythm therapy; 19 patients had bipolar disorder and 11 had major depressive disorder. For the first 10 to 12 weeks, the participants received weekly sessions followed by sessions every two weeks and then monthly. These patients were part of larger clinical trial at the University of Otago Christchurch in New Zealand exploring whether add-on cognitive therapy can make interpersonal and social rhythm therapy (IPSRT) more effective.

The researchers assessed both depression severity (using the Quick Inventory of Depressive Symptoms–Self-Reported [QIDS-SR] scale and the Longitudinal Interval Follow-Up Evaluation) and social impairment (using the Social Adjustment Scale) in the participants; the assessments were done at the beginning and end of the study. The researchers found that the patients with major depression showed large reductions in both their depressive symptoms and social impairment. For example, their QIDS-SR scores dropped from an average of 13.1 to 6.8, which is considered a strong improvement.

“The emphasis on both the stabilization of the social rhythms that underpin circadian rhythms and the treatment of interpersonal issues may have contributed to the improvement in both mood and functioning,” wrote Marie Crowe, R.N., Ph.D., of the University of Otago Christchurch and colleagues.

“Improvement in social functioning is important because these improvements do not automatically follow [improvement in] depressive symptoms,” the authors continued. “This is of particular interest because psychosocial impairment is a risk factor for recurrence of mood episodes.”

To read more on this topic, see the Psychiatric News article “Could Chronotherapy Provide Relief to Patients With Mood Disorders?”

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Monthly Buprenorphine May Improve OUD Patients’ Sense of Well-Being, Satisfaction With Treatment

A study in the Journal of Substance Abuse Treatment has shown that treating patients with opioid use disorder (OUD) with monthly injections of extended-release buprenorphine may result in measurable improvements in patients’ quality of life and sense of well-being. This represents a departure from standard research on OUD treatment, which largely focuses on how long patients remain in treatment and whether they abstain from illicit opioid use, according to the researchers.

“Outcomes that are easily measurable during office visits can help clinicians assess life changes reflective of a person’s recovery—a lifestyle characterized not only by abstinence but also health and return to normality,” wrote Walter Ling, M.D., of the University of California, Los Angeles, and colleagues.

In the 12-month study, 206 patients between 18 and 65 years old with moderate to severe OUD received monthly injections of extended-release buprenorphine. Researchers used standard assessment tools and questionnaires at various intervals throughout the study to measure how the patients felt about their own well-being. These tools included the following:

• The EQ-5D-5L to measure the patients’ sense of health such as mobility, self-care, daily activities, pain and discomfort, and anxiety and depression.
• The SF-36v2 to measure the patients’ sense of health-related quality of life and physical and mental health.
• The Treatment Effectiveness Assessment to assess the patients’ perception of treatment effectiveness.
• The Addiction Severity Index-Lite to assess challenging treatment areas, medical, family/social, or psychiatric issues, employment/support status, alcohol use, drug use, and legal issues.
• The Medication Satisfaction Questionnaire to assess the patients’ satisfaction with their treatment.

At the end of the study, the patients’ scores had remained stable on the EQ-5d-5L and the physical component of the SF-36v2. However, their scores rose in the mental health component of the SF-36v2, which suggests that they felt their mental health had improved. The patients’ scores also rose an average of 9 points on the Treatment Effectiveness Assessment, which suggests that they felt the treatment was working. Their scores on the Addiction Severity Index-Lite improved for every measure except alcohol use, and their employment rate increased 7%. At the end of the study, 89% of participants stated they were satisfied with treatment on the Medication Satisfaction Questionnaire.

The researchers noted one important caveat in their study: 412 patients had originally enrolled, but half had withdrawn before the study was over. However, the researchers added that this dropout rate was comparable to that of 11 other studies on buprenorphine treatment.

“Results from this long-term study show positive patient-centered outcomes and high treatment satisfaction for participants initiating and receiving up to 12 months of [extended-release buprenorphine] treatment during the open-label study, demonstrating that meaningful life changes are measurable during a person's recovery journey,” they concluded.

For related information, see the Psychiatric News article “Multidisciplinary Teams Knock Down Barriers to Medication Treatment for OUD.”

This work was funded by Indivior Inc., who manufactures Sublocade, the extended-release buprenorphine medication used in this trial.

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High-Dose Omega-3 Fatty Acid May Improve Attention, Vigilance in Children With ADHD

Taking a high dose of the omega-3 fatty acid eicosapentaenoic acid (EPA) may help to improve attention in youth who have attention-deficit/hyperactivity disorder (ADHD) and low levels of EPA, suggests a study published in Translational Psychiatry.

“A deficiency of omega-3 polyunsaturated fatty acids (n-3 PUFAs) may play a role in the pathogenesis of attention-deficit/hyperactivity disorder (ADHD),” wrote Jane Pei-Chen Chang, M.D., of King’s College London and colleagues.

Chang and colleagues conducted a 12-week, double-blind, placebo-controlled trial comparing the effects of high-dose EPA with placebo in youth aged 6 to 18 years with ADHD. All participants were either drug naïve or had not been on medications for the previous six months and had been referred to the Department of Psychiatry at China Medical University Hospital in Taiwan.

The participants were randomized into the EPA (1.2 grams per day) group or placebo (1.2 grams per day of soybean oil) group. The researchers assessed the youth on the following four items of the Continuous Performance Test at the beginning and end of the trial: focused attention, impulsivity, sustained attention, and vigilance. They also took blood samples from the youth at the start of the trial and again at week 12 to determine baseline EPA levels and changes to these levels over the course of the study. Of the 103 youth who were randomized to the two groups, 92 completed the 12-week trial.

Youth in the EPA group improved more than those in the placebo group in focused attention, while those who received the placebo showed more improvement in the impulsivity measure. The researchers noted there were no other significant differences between the groups on the cognitive measures examined as part of the Continuous Performance Test.

Additional analysis revealed that youth with low endogenous EPA levels showed further improvement in an additional measure of attention and vigilance compared with those in the placebo group.

“[O]ur study shows some benefits of EPA monotherapy on cognitive symptoms of ADHD,” the authors concluded. However, they advised against EPA supplementation in youth who have high endogenous levels of EPA.

For related news, see the American Journal of Psychiatry article “Nonpharmacological Interventions for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments.”

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Study Examines Efficacy of Esketamine-Antidepressant Combo in Older Adults With Treatment-Resistant Depression

A subset of individuals 65 years or older with treatment-resistant depression who took a new oral antidepressant plus intranasal esketamine showed greater improvement of symptoms than those who took an antidepressant and intranasal placebo, according to a report in the American Journal of Geriatric Psychiatry. However, the overall difference between the esketamine and placebo groups in symptom score reduction was not statistically significant, indicating a need for further research, wrote lead author Rachel Ochs-Ross, M.D., of Janssen Research & Development and colleagues.

The study was funded by Janssen, who markets intranasal esketamine. (The drug was approved by the Food and Drug Administration earlier this year for treatment-resistant depression.)

The researchers randomly assigned 138 patients 65 years or older with treatment-resistant depression to take intranasal esketamine or placebo twice weekly in addition to a new oral antidepressant daily for four weeks. Patients initially received 28 mg of esketamine or the placebo nasal spray, but the investigators increased the esketamine dose to 56 mg or 84 mg based on the patients’ response to the treatment. The primary endpoint was change in the Montgomery- Åsberg Depression Rating Scale (MADRS) from baseline to day 28. Secondary measures included the percentage of patients who showed a treatment response (defined as a 50% or greater reduction in MADRS score) and rates of remission (defined as a MADRS score of 12 or less).

The average change in MADRS score for patients taking antidepressant plus esketamine was 10 points compared with 6.3 for patients taking antidepressant plus placebo. Treatment response was observed in 27% of patients receiving esketamine and 13.3% receiving placebo. Remission rates were 17.5% in the esketamine group and 6.7% in the placebo group.

The difference between the esketamine and placebo groups on the primary endpoint of overall symptom reduction was not statistically significant. This failure to achieve statistical significance may be related to lower dosing required in older patients and a need for longer treatment duration, the researchers wrote.

Additional analysis revealed that there was a greater reduction in total symptom scores among individuals aged 65 to 74 treated with esketamine compared with placebo that was not observed in patients aged 75 years or older, suggesting that the combination may benefit a younger subset of seniors.

“Given the need for treatments for [treatment-resistant depression in older adults] and the potential role of esketamine, future studies are needed to establish if esketamine is effective in [treatment-resistant depression in older adults] and if so the optimal induction/optimization/maintenance dosing and duration of treatment,” Helen Lavretsky, M.D., M.S., of the Semel Institute for Neuroscience and Human Behavior at UCLA and Steven P. Roose, M.D., of New York State Psychiatric Institute, wrote in an accompanying editorial. “There is much work to do but the exciting news is that studies are underway and hopefully new esketamine studies will be initiated that will provide the clinician with the information necessary to alter the deleterious trajectory associated with this high-risk population and difficult to treat population,” they wrote.

For related information, see the Psychiatric News article “Esketamine Approved For Treatment-Resistant Depression.”

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Ketamine Found to Rapidly Reduce Suicidal Thoughts in Depressed, Suicidal Patients in ER

Patients presenting to an emergency room with complaints of suicidal thoughts may experience relief from these thoughts within 90 minutes of a single, low-dose infusion of ketamine, suggests a small study in Depression & Anxiety.

While previous studies have demonstrated the potential of ketamine to reduce suicidal thoughts in patients with depression (including this 2017 paper published in the American Journal of Psychiatry), this new study examined the effectiveness of a low-dose infusion administered in an emergency department. “A single infusion of ketamine, administered in the emergency department, is a safe and feasible treatment option for depressed, suicidal patients,” wrote Yoav Domany, M.D., of Tel Aviv University and colleagues.

The study included 18 depressed patients aged 18 to 65 who were hospitalized after reporting suicidal ideation in an emergency room setting. After completing baseline assessments, the patients were randomly assigned to receive ketamine (0.2 mg/kg) or placebo (saline) intravenously over five minutes, under the supervision of an emergency department physician. The researchers evaluated the severity of the patients’ suicidal ideations (using the Beck Scale for Suicidal Ideation and item 10 of the Montgomery–Åsberg Depression Rating Scale, or MADRS), feelings of depression and anxiety (using the MADRS and Beck Anxiety Index), dissociative symptoms, blood pressure, and more 15, 30, 60, 90, 120, 180, and 240 minutes after the infusion. The patients were evaluated again 1, 2, 3, 7, and 14 days later.

Domany and colleagues found that patients in the ketamine group reported fewer suicidal thoughts than those in the placebo group 90 to 180 minutes after the infusion. “Notably, 90 minutes after infusion, 88% of the ketamine‐receiving subjects were no longer actively suicidal compared with 33% of the controls,” the authors wrote. A total of 22% of patients in the ketamine group experienced what the authors referred to as “transient elevated systolic blood pressure” (higher than 140 mm/Hg), compared with 11% in the placebo group. There were no differences in psychiatric symptoms or dissociative symptoms between the two groups at any time point following the infusion.

“Our findings are consistent with others who demonstrated the antisuicidal effect of ketamine. … We, however, suggest here a more feasible way of administration, which is more appropriate for an emergency department setting (even before administration to psychiatric ward),” they wrote.

The authors noted the main limitation of the study was the small sample size of the trial and called for additional studies to examine the effectiveness of ketamine for reducing suicidal thoughts in this patient population.

For related news, see the Psychiatric News article “Ketamine Shown to Reduce Suicidal Ideation in Severely Depressed Patients” and the American Journal of Psychiatry article “Ketamine for Rapid Reduction of Suicidal Thoughts in Major Depression: A Midazolam-Controlled Randomized Clinical Trial.”

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Many Women With Schizophrenia Do Not Receive Mammograms, Meta-Analysis Suggests

Women with schizophrenia are only half as likely as women in the general population to receive mammograms, reports a meta-analysis published in Psychiatric Services in Advance.

“Lower screening rates could explain why women with schizophrenia and other serious mental illnesses are found to have more advanced breast cancer at time of diagnosis,” wrote Alison Hwong, M.D., Ph.D., and colleagues at the University of California, San Francisco. “Given the high prevalence of breast cancer and the promising prognosis of breast cancer if detected early, mammography screening is a key first step in improving diagnosis and treatment for people living with schizophrenia.”

Hwong and colleagues compiled data from 11 clinical studies that looked at mammography screening rates in women with schizophrenia or other psychotic disorders. The 11 studies were conducted in four countries with diverse health care systems (United States, Canada, England, and Denmark) and totaled more than 470,000 women; this included 25,447 women with a diagnosis of schizophrenia or other psychotic disorders.

“With time constraints, primary care providers and psychiatrists may not prioritize cancer screening for patients with serious mental illness,” Hwong and colleagues wrote. Physicians may focus on psychiatric and metabolic symptoms first, which “may lead to deferring routine preventive screening discussion for future visits, but the future discussion never occurs.”

The authors called for research on the inequity in breast cancer screening and the development of novel strategies to promote mammography screening of these women.

To read more on this topic, see the Psychiatric News article “UCSF Psychiatrists Bring OB-GYN Care to Patients With SMI.”

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Ketamine Infusion Combined With Mindfulness Program May Improve Cocaine Abstinence

Adding a single infusion of ketamine to a program of mindfulness-based relapse prevention (MBRP) may promote abstinence in patients who use cocaine, according to a study published in the November American Journal of Psychiatry.

In a five-week trial conducted by Elias Dakwar, M.D., of Columbia University Medical Center and colleagues, 55 patients who met the DSM-IV criteria for cocaine dependence were randomized to receive a 40-minute intravenous infusion of either ketamine or midazolam (a preoperative sedative). They received their infusions on the second day of a five-day hospitalization in a psychiatric research unit. During their hospitalization, they began MBRP, which includes cognitive-behavioral strategies that help patients become aware of feelings as they occur. The goal of MBRP is to enable patients to make choices that improve wellness rather than react automatically in ways that may be detrimental to their health and abstinence.

After their five-day hospitalization, patients returned to the hospital twice a week for four more weeks of MBRP sessions, physician visits, and drug testing. At the end of the five-week trial, researchers assessed the patients’ cravings to use cocaine. At six months, patients participated in a follow-up telephone interview.

During the last two weeks of the trial, 48.2% of patients in the ketamine group had remained abstinent from cocaine use, compared with only 10.7% in the midazolam group. At the end of five weeks, craving scores were 58.1% lower in the ketamine group than in the midazolam group. At the six-month follow-up interview, 12 patients in the ketamine group reported abstinence compared with none in the midazolam group.

“These sustained benefits, in some cases lasting several months, suggest the potential of ketamine for effecting long-term behavioral changes,” the researchers wrote. “Moreover, the integrated treatment framework was well tolerated, and MBRP appeared to enhance certain ketamine-related benefits, such as reductions in cocaine craving scores.”

The researchers noted several limitations to their study, namely that it was small, most of the patients belonged to the same race and sex (black males), and the patients tended not to have any other psychiatric conditions.

“While the selection of patients with no comorbidities might hamper the extension of our findings to a more psychiatrically complicated population, it is likely that cocaine-dependent individuals with depression or anxiety would respond even more robustly to ketamine given [prior] evidence supporting its psychiatric efficacy,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “Searching for Treatments for Cocaine Use Disorder: The Quest Continues.”

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Genetic Data Can Improve Psychosis Prediction Tool

Incorporating genetic data into a clinical tool that predicts whether a person will develop schizophrenia can improve the accuracy of this tool, according to a study appearing in AJP in Advance.

Diana Perkins, M.D., M.P.H., of the University of North Carolina and colleagues assessed whether polygenic risk scores (PRS) could be used as part of a clinical assessment of schizophrenia risk. A PRS reflects how many individual genetic variants associated with schizophrenia a person has; the higher an individual’s PRS, the greater his or her genetic risk of developing schizophrenia. They looked at health data from 764 young adults (average age 18) considered at high risk for developing psychosis. These young adults were participants in the North American Prodrome Longitudinal Study (NAPLS 2). As part of the NAPLS 2, these individuals were prospectively followed for two years to identify traits that might help predict the onset of schizophrenia.

On the basis of NAPLS 2 data, the researchers developed a risk calculator that was able to predict which high-risk youth might develop schizophrenia with about 70% accuracy. The risk calculator included variables such as age, history of trauma and stressful life events, family history of psychotic disorders, the degree of disordered thoughts, and performance on tasks assessing verbal learning and information processing speed.

The NAPLS 2 participants also provided blood samples, and Perkins and colleagues used these to extract DNA and compute PRS scores for each participant. They found that PRS scores by themselves could predict schizophrenia onset with about 62% accuracy in Europeans and 57% accuracy in non-Europeans. When added to the risk calculator, however, PRS improved the accuracy of these tools.

“Use of a schizophrenia PRS in clinical practice hinges on improved accuracy, especially in persons of non-European ancestry, and [genetic studies] that include individuals from diverse populations are essential,” Perkins and colleagues wrote. “With further improvements and given the relatively low cost and wide availability of genotyping, potential applications of the genetic risk scores to individualized psychosis risk screening warrant further investigation,” they concluded.

For related information on predicting patients most likely to develop psychosis, see the Psychiatric News article “Imaging Advances Could Aid Prediction of Outcome in High-Risk Patients.”

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Concussions May Raise Risk of Suicide in High School Students

Having a concussion within the past year may raise the risk of suicidal ideation and behavior in high school students, according to a study in the Journal of Affective Disorders.

Dale S. Mantey, M.P.A., of the University of Texas School of Public Health and colleagues used data from more than 13,000 respondents in grades 9 through 12 who participated in the 2017 Youth Risk Behavior Surveillance Survey (YRBSS). The national YRBSS is conducted every two years by the Centers for Disease Control and Prevention to monitor health behaviors that contribute to the leading causes of death, disability, and social problems among youth and adults in the United States.

For this study, researchers analyzed the respondents’ answers to the question “During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?” They then compared those answers with answers to questions designed to determine whether over the past 12 months the students had depressive symptoms, suicidal ideation, planned suicide attempts, attempted suicide, and/or were treated by a doctor or nurse for an injury, poisoning, or overdose following a suicide attempt.

Overall, 15% of the respondents reported a sports-related concussion in the previous 12 months. Compared with their peers who did not report concussions, these participants were 20% more likely to have experienced depressive symptoms, 25% more likely to have had suicidal ideation, and 60% more likely to have attempted suicide. They were also more than twice as likely to have been treated by a doctor or nurse for a suicide attempt. The risk of a suicide attempt and a suicide attempt treated by a doctor or nurse were more pronounced in boys than girls: Boys with a history of concussion were twice as likely to have a suicide attempt and more than three times as likely to have been treated by a doctor or nurse for a suicide attempt than boys with no history of concussion.

“Though further research is needed to explore the relationship observed in this study, [the] findings suggest a critical need for expanded education, awareness, monitoring, and treatment of sports-related concussions,” the researchers wrote. “[S]uicide awareness, education, and prevention efforts should incorporate history of sports-related concussions (or other traumatic brain injuries) as risk factors for interventional programs. Furthermore, organized physical activities (e.g., sports) should ensure proper monitoring of suicidal risk factors (e.g., changes in mood) following the diagnosis of concussion in youth participants.”

For related information, see the Psychiatric News article “New Analysis Suggests There Is No Such Thing as Harmless Head Contact in Football.”

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Anxiety in Older Adults With MDD on Venlafaxine Doesn’t Reduce Chance of Remission, Study Finds

The presence of comorbid anxiety symptoms does not appear to predict the likelihood that older patients with major depressive disorder (MDD) will respond to the antidepressant venlafaxine, according to a study in Depression & Anxiety.

“[R]emission of depression was just as likely in more and less anxious participants,” Yasmina M. Saade, M.D., of Washington University in St. Louis and colleagues wrote.

Previous studies show that older depressed adults with comorbid anxiety often have more severe depression symptoms and cognitive decline and are at greater risk of suicide compared with older depressed adults without anxiety. To examine whether comorbid anxiety influences response to treatment in older adults, Saade and colleagues analyzed data from the Incomplete Response in Late‐Life Depression: Getting to Remission (IRL‐GRey) study, a large prospective antidepressant trial.

For the first phase of the IRL-GRey study, 468 adults aged 60 years or older with MDD received open‐label treatment with venlafaxine extended release, a selective serotonin and norepinephrine reuptake inhibitor. The participants were started at a dose of 37.5 mg/day and titrated up to 300 mg/day if they did not go into remission. Those who were taking a previously prescribed low-dose benzodiazepine were permitted to continue its use. Before starting on venlafaxine, the researchers evaluated the participants using Montgomery-Åsberg Depression Rating Scale (MADRS), the Brief Symptom Inventory anxiety subscale (BSI‐anxiety), the 19‐item Scale for Suicide Ideation (SSI), the Anxiety Sensitivity Index (ASI), and the Penn State Worry Questionnaire (PSWQ). The participants were reassessed using the MADRS, BSI-anxiety, and SSI weekly or biweekly throughout the 12- to 14-week open-label phase.

Baseline anxiety scores did not predict the likelihood of the participants’ remission of depressive symptoms (defined as a MADRS score ≤10 at both of the final two consecutive visits) on venlafaxine, the authors wrote. Similarly, the baseline anxiety scores did not predict time to remission. Participants who expressed some suicidality at baseline, however, tended to have more severe symptoms of depression and anxiety.

“In older adults with MDD, comorbid anxiety symptoms are associated with symptom severity but do not affect antidepressant remission or time to remission,” Saade and colleagues wrote. “The presence of comorbid anxiety should prompt an intensive course of treatment, including frequent follow‐up visits and maximizing the antidepressant dosage before declaring nonresponse. We also speculate that the use of a dual‐reuptake inhibitor may be preferable in depression with comorbid anxiety symptoms.”

For related information, see the American Journal of Psychiatry article “Norepinephrine Transporter Gene Variants and Remission From Depression With Venlafaxine Treatment in Older Adults.”

Pfizer contributed venlafaxine extended-release capsules for this study.

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Adverse Events in Childhood May Raise Health, Socioeconomic Risks in Adulthood

A study published this week in the Morbidity and Mortality Weekly Report adds to the growing body of evidence indicating that experiencing adverse events in childhood such as abuse or witnessing intimate partner violence increases the risk of numerous negative health and socioeconomic outcomes in adulthood.

Researchers from the Centers for Disease Control and Prevention used data from more than 144,000 respondents who participated in the Behavioral Risk Factor Surveillance System (BRFSS) from 2015 to 2017. The BRFSS is an annual state-based telephone survey of adults in which participants report on their health behaviors and whether health care professionals had ever diagnosed them with a health condition. The researchers drew the data from 25 states that had added questions to the BRFSS to assess participants’ exposure to eight types of adverse childhood experiences, including physical, emotional, or sexual abuse; household member substance misuse, incarceration, or mental illness; parental divorce; or witnessing intimate partner violence.

Overall, 60.9% of participants had been exposed to at least one type of adverse childhood experience, and 15.6% had been exposed to four or more. The more types of adverse childhood experiences participants were exposed to, the more likely they were to engage in risky health behaviors or have chronic health conditions or socioeconomic challenges as adults. For example, participants who were exposed to four or more types of adverse childhood events were five times more likely to have depression, roughly three times more likely to have chronic obstructive pulmonary disease or smoke, and nearly twice as likely to have coronary heart disease, drink heavily, or be unemployed compared with participants who reported no exposure to adverse childhood experiences.

The researchers noted that the prevalence of adverse childhood experiences was higher among people aged 34 years and younger, possibly because of differences in risk among people in that age group, their willingness to disclose their history, or their ability to recall adverse childhood experiences.

“Strategies to prevent adverse childhood experiences in the first place and to intervene with those who have been exposed to adverse childhood experiences might help to reduce prevalence of engaging in health risk behaviors [such as smoking or drinking] in young adulthood and subsequent negative health outcomes,” the researchers wrote. “These strategies might also help to break the multigenerational cycle of adverse childhood experiences as these age groups are most likely to start families or raise children.”

For related information, see the Psychiatric News article “Positive Childhood Experiences May Counteract Adverse Experiences” and the Psychiatric Services article “State Legislators’ Opinions About Adverse Childhood Experiences as Risk Factors for Adult Behavioral Health Conditions.”

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Web-Based Training May Increase Residents’ Treatment of Patients for Tobacco Use

Psychiatry residents were more likely to advise patients on tobacco use disorder and provide treatment after completing an online training course, according to a study published in Psychiatric Services in Advance.

Though tobacco use accounts for half of all deaths of individuals with mental illness or substance use disorder, “educational opportunities for psychiatrists and residents remain limited,” wrote Jill Williams, M.D., of Rutgers-Robert Wood Johnson Medical School in New Jersey and colleagues. The data suggest “that an online training opportunity, especially early in residency, may increase knowledge about tobacco use disorder and, more importantly, increase the frequency of behaviors likely to result in reduced tobacco use in the vulnerable populations these residents will treat,” they noted.

U.S. psychiatry residency program directors provided the researchers with the email addresses of current psychiatry residents; participation was not required. A total of 199 residents completed surveys that evaluated their attitudes toward tobacco treatment practices (such as monitoring patients' progress in attempting to quit and prescribing tobacco treatment medications) and estimated how frequently they applied such practices.

The residents then viewed three one-hour webinars on tobacco treatment, which covered topics such as the prevalence and consequences of tobacco use disorder among individuals with behavioral health conditions, as well as counseling strategies and pharmacological treatments. Of the 152 participants who completed the online course, 89 completed a follow-up assessment three months later.

There was “considerable variability” in residents’ ratings of tobacco treatment practices at baseline, the authors reported. Asking patients about their smoking status was the most highly reported treatment practice, with 47% of residents always asking, and 44% usually asking. Others, such as prescribing tobacco treatment medications or arranging follow-up visits to address smoking, were reported less frequently.

In the three-month follow-up, however, “[r]esidents reported a significant increase in their use of nine of the 12 tobacco treatment practices,” Williams and colleagues wrote. The findings include the following:

• Residents who said they always assess patients’ willingness to quit smoking increased from 15% at baseline to 23% at follow-up.
• Residents who said they usually refer patients who smoke to others for appropriate cessation treatment increased from 18% to 36%.
• Residents who said they usually refer smokers to a telephone cessation service like Quitline increased from 8% to 19%.

The authors found that residents who were earlier in their training (first- and second-year residents) were more likely to change their tobacco treatment practices than third- through fifth-year residents. “This finding may imply that educational efforts are more effective before residents have solidified their practice patterns, even though junior residents have less control over their own practice.”

For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco.”

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Hypothyroidism May Reverse After Lithium Is Discontinued, Study Suggests

People who develop hypothyroidism while using the mood stabilizer lithium may return to normal thyroid function after the drug is discontinued, according to a study in the Journal of Psychopharmacology.

Hypothyroidism—a condition in which the thyroid gland does not produce enough thyroid hormone—has long been known to be associated with the use of lithium. “In most patients lithium-associated hypothyroidism seems reversible once lithium has been discontinued,” wrote Ingrid Lieber, M.D., of Umea University in Sweden and colleagues. “Therefore, in such cases, TRT [thyroid replacement therapy] discontinuation could be attempted much more often than is currently done.”

Lieber and colleagues analyzed follow-up data on 85 patients who discontinued lithium because of hypothyroidism and were being treated with thyroid replacement therapy. They were enrolled in the Lithium–Study Into Effects and Side Effects, a large Swedish study of patients using lithium. The mean delay from starting lithium to starting thyroid replacement therapy was 2.3 years.

Of the 85 patients, 35 stopped thyroid replacement therapy at some point after discontinuation of lithium. Only six patients had to be placed back on thyroid replacement therapy.

Lieber and colleagues said that it is prudent to allow some weeks for the thyroid gland to recover before stopping thyroid replacement therapy. “Based on the limited evidence of our study, we can expect hypothyroidism to recur early after TRT discontinuation, if at all,” they wrote. “Thus, it is advisable to monitor thyroid function for three to six months. TRT reinsertion should then only be reconsidered if there are unambiguous signs of hypothyroidism … .”

For more information, see the chapter “Endocrine and Metabolic Disorders” in The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry, Third Edition.

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Newspapers Can Do More to Change Public Perception of Suicide, Report Suggests

Regional and national newspapers in the United States are falling short of meeting guidelines for reporting on suicide deaths, suggests a report in JAMA Network Open. An analysis of coverage following the deaths of Kate Spade and Anthony Bourdain in June 2018 in print newspapers with a minimum circulation of 200,000 shows that the publications adhered to only about half of the national recommendations for reporting on suicide, such as avoiding details of lethal means or use of a sensational headline.

“News media coverage of suicide is associated with an increased risk of subsequent suicides, with the strongest associations following newspaper reporting of celebrity suicides,” wrote Arielle H. Sheftall, Ph.D., of the Ohio State University College of Medicine and colleagues. To educate the media about these risks, leading experts in suicide prevention, public health, and media from the American Foundation for Suicide Prevention, Annenberg Public Policy Center, Columbia University Department of Psychiatry, government agencies, and more in 2001 published the guideline “Recommendations for Reporting on Suicide.”

“Risk of additional suicides increases when the story explicitly describes the suicide method, uses dramatic/graphic headlines or images, and repeated/extensive coverage sensationalizes or glamorizes a death,” according to this document. “Covering suicide carefully, even briefly, can change public misperceptions and correct myths, which can encourage those who are vulnerable or at risk to seek help.”

Sheftall and colleagues analyzed the coverage of the deaths of Spade and Bourdain in the following newspapers: The Chicago Tribune, Denver Post, Houston Chronicle, Los Angeles Times, New York Times, Seattle Times, Tampa Bay Times, USA Today, Wall Street Journal, and Washington Post. Specifically, the authors assessed guideline adherence by the newspapers in the days following the deaths using 14 items derived from “Recommendations for Reporting on Suicide.” These items included avoiding details of notes left behind or location of death, providing information about warning signs of or risk factors for suicide, and listing the National Suicide Prevention Lifeline phone number. The researchers scored the articles by adherence to each guideline (1 for yes; 0 for no; total score: 14).

Overall, the newspapers adhered to a mean of 7.4 of the 14 specific guidelines; none of the newspapers adhered to 80% of the specific guidelines. All of the newspapers adhered to the two following guidelines: “avoided single-cause explanation of suicide death” and “avoided referring to suicide as a growing problem, epidemic, or skyrocketing.” In contrast, none followed recommendations to “share a hopeful message that suicide is preventable” or to “convey that suicidal behaviors can be reduced with mental health support and treatment,” according to the authors.

The findings point to “widespread opportunities for improvement,” Sheftall and colleagues wrote. They noted that steps taken in Canada in April 2014 to establish reporting guidelines for suicide and create checklists for journalists to promote adherence were associated with increased adherence to these guidelines following the death of Robin Williams by suicide in August 2014. “A collaboration between U.S. media staff, governmental agencies, and other stakeholders when updating and disseminating the recommended reporting guidelines for suicide may increase adherence, which in turn might reduce preventable harm,” they concluded.

For related information, see the Psychiatric News article “Preparing for a Sequel: ‘13 Reasons Why’ and Suicide Contagion” by Michael Fadus, M.D., and the Psychiatric Services article “Increases in Demand for Crisis and Other Suicide Prevention Services After a Celebrity Suicide.”

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Symptoms of Grandiosity May Point to Higher Risk of Relapse on Oral Antipsychotic

Schizophrenia patients with severe grandiosity (an inflated sense of self) may be more likely to relapse when taking daily oral antipsychotics compared with patients without such delusions of grandeur, according to a report in Schizophrenia Research. This symptom profile did not affect relapse risk in patients taking long-acting injectable (LAI) risperidone. In addition, many patients who relapsed showed worsening emotional withdrawal as early as eight weeks prior to the relapse event.

“While it is unclear whether this symptom worsening is a predictor of relapse or a part of a relapsing process, this timeline may offer a window for possible interventions in an effort to avert relapses,” wrote Yuta Saito, M.D., of Keio University School of Medicine in Tokyo and colleagues.

These findings come from a secondary analysis of a clinical trial known as PROACTIVE. This trial followed 305 outpatients with schizophrenia taking either biweekly LAI risperidone or daily oral second-generation antipsychotics for up to 30 months. PROACTIVE was conducted in eight clinical centers across the United States and had a primary goal of testing whether LAI risperidone was better than daily antipsychotics at preventing a relapse of schizophrenia symptoms. Researchers assessed schizophrenia symptom severity at the beginning of the study and then every two weeks until the end of the study. For this analysis, Saito and colleagues used that wealth of symptom data to see whether there were any signs that might predict future relapse.

Of the 305 patients in the study, 73 patients (41 receiving LAI risperidone and 32 taking oral antipsychotics) experienced at least one relapse of their schizophrenia symptoms. No individual symptom was associated with relapse in the LAI group; in the oral group, however, a greater initial score in grandiosity was associated with a 43% increased risk of relapse.

Saito and colleagues noted that previous research has shown that grandiosity decreases motivation and medication adherence, which may explain why this symptom increases relapse risk in patients who need to take an antipsychotic every day.

The investigators also found that patients who eventually relapsed were much more likely to experience emotional withdrawal in the weeks prior; significantly elevated emotional withdrawal relative to baseline was observed between two and eight weeks prior to the relapse date.

“[T]hese results point to the value of thorough evaluation of individual symptoms as well as overall symptomatology for relapse prevention among patients with schizophrenia,” Saito and colleagues concluded.

The PROACTIVE trial was funded by NIMH, and the authors reported no external funding for this secondary analysis. Some of the authors have received honoraria, speaker fees, or grants from Janssen, manufacturer of risperidone.

For related information, see the Psychiatric News article “Clozapine, LAI Antipsychotics Found Best at Preventing Relapse.”

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Sexual Minorities Found to Be at Elevated Risk for Eating Disorders

People who are homosexual, bisexual, or unsure of their sexual orientation have both a higher risk and a higher rate of eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder than people who are heterosexual, a study in the International Journal of Eating Disorders has found. Although prior research suggests that members of sexual minorities have a higher risk of eating disorder symptoms than heterosexuals, this study is believed to be the first to use data from a large number of people to determine how common eating disorders are among sexual minority members.

Rebecca C. Kamody, Ph.D., of Yale University School of Medicine and colleagues analyzed data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a survey of roughly 36,000 U.S. adults. The NESARC-III determined if participants had eating disorders based on whether their responses suggested that they met the DSM-5 criteria for eating disorders. They found that eating disorders occurred at the following rates among sexual minorities and heterosexuals:

• Anorexia nervosa occurred in 1.71% of members of sexual minorities, compared with 0.77% of heterosexuals.
• Bulimia nervosa occurred in 1.25% of members of sexual minorities, compared with 0.24% of heterosexuals.
• Binge eating disorder occurred in 2.17% of members of sexual minorities, compared with 0.81% of heterosexuals.
• Anorexia nervosa occurs in 3.78% of members of sexual minorities who experienced discrimination. There were no significant differences in the prevalence of bulimia or binge eating disorder in those who perceived discrimination

Compared with heterosexuals, members of sexual minorities may be nearly twice as likely to develop anorexia, more than three times as likely to develop bulimia nervosa, and more than twice as likely to develop binge eating disorder at some point in their lives, the study found.

“While there has been an impetus in recent years to increase diversity in [eating disorder] research, … the present study highlights the importance of diversifying further [eating disorder] research in order to inform the development of more responsive evidence-based interventions tailored to individual needs,” Kamody and colleagues wrote. “This may serve as a first step in reducing disparities and promoting health among sexual minority populations.”

For related information, see the Psychiatric News article “Brief Update and Review on Treating Eating Disorders,” by James Lock, M.D., Ph.D.

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