Thursday, December 31, 2020

Expert Offers Guidance on How to Talk With Patients About Getting Vaccinated for COVID-19

To end the COVID-19 pandemic, it is essential that citizens are willing to receive a vaccine. Yet vaccine hesitancy is becoming a growing problem. In an article in Psychiatric News, Joshua Morganstein, M.D., chair of the APA Committee on Psychiatric Dimensions of Disasters, outlined actions psychiatrists can take to prepare for and have conversations about COVID-19 vaccines with patients.

Check your pulse: After the challenges that 2020 has brought, health care professionals are increasingly tired and frustrated. Yet burnout and extreme stress will make it only more difficult to start tough conversations with patients about vaccinations. Psychiatrists must address their own physiologic needs—including those as basic as getting adequate sleep, nutrition, and hydration—to engage effectively with patients. “A brief check-in with a trusted family member, friend, or colleague can provide helpful feedback on the extent to which we are prepared to effectively navigate vaccination conversations with patients,” Morganstein wrote.

Know your audience: It is vital that psychiatrists understand their patients' perspectives on COVID-19 vaccines and adjust their approaches accordingly. Additionally, psychiatrists should ensure they understand cultural factors within their communities to help improve trust. Patients who are ready to receive a vaccine should be encouraged and have any questions answered. For patients who are hesitant, psychiatrists can employ motivational interviewing, in which they explore  patients’ concerns and discuss potential benefits and risks to receiving or not receiving a vaccine.

Psychiatrists should respect the perspectives of those patients who express a refusal to receive a vaccine, while informing them that receiving a vaccine is recommended and offering to speak more on the topic later, if the patient should so desire. Efforts to change the behavior of those who have already refused to get a vaccine are rarely successful, Morganstein wrote. In fact, those conversations may have the unintended consequence of deepening mistrust and reducing the chance that a common ground may be reached in the future.

Find the words: Morganstein recommended staying away from medical jargon when talking with patients, noting that “more understandable and down-to-earth language often serves to enhance trust and build rapport.” He also suggested using language that normalizes feelings, such as talking about concerns, rather than using clinical terms like anxiety.

Appealing to emotions rather than relying on data and statistics can also be effective, as can talking about universal values, such as family safety, rather than controversial topics like politics or religion. Sharing personal stories can humanize psychiatrists and strengthen the therapeutic bond, as well. “The use of guilt, shame, or criticism rarely motivates behavior change, may further entrench patients in or move them toward vaccine refusal, and should be avoided,” he wrote.

“Health care professionals and patients may not come to an agreement,” Morganstein wrote. “Ultimately, it is an individual’s choice whether or not to receive a vaccine, and it is essential that health care professionals respect patient autonomy.” But the actions he outlined, he continued, will help “move the needle” and encourage patients to get vaccinated during this crucial point in the global pandemic.




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Wednesday, December 30, 2020

Frail, Older Adults May Have Poorer Response to Antidepressant Treatment Than Non-Frail Adults

Older, depressed adults who are frail (experiencing deficits in strength and physical activity) may have a poorer response to antidepressant treatment than non-frail older adults with depression, according to a report in the Journal of Geriatric Psychiatry.

“Frailty in the context of late-life depression may mean that antidepressant medications are necessary but not sufficient for the adequate treatment of frail adults,” wrote Patrick Brown, Ph.D., of the Neurobiology and Therapeutics of Aging Division at the New York State Psychiatric Institute (NYSPI) and colleagues. Physical therapy, behavioral strategies, and/or exercise to improve energy, lower extremity strength, and greater overall activity levels may be necessary to improve outcomes.

Brown and colleagues compared outcomes of 49 frail adults and 51 non-frail or moderately frail adults over age 60 receiving treatment for late-life depression at the Clinic for Aging, Anxiety, and Mood Disorders at NYSPI. Frailty was determined using measures of gait speed, hand grip strength, physical activity, fatigue, and self-reported unintentional weight loss with clinically significant cutoff points: individuals were categorized as non-frail (0 deficits), intermediate frail (1-2 deficits), and frail (3 or more deficits). All participants had a diagnosis of either major depressive disorder or persistent depressive disorder and a score of 16 or higher on the 24-item Hamilton Depression Rating Scale (HRSD).

Participants were treated with antidepressant medication (escitalopram or duloxetine) either openly or in a placebo-controlled trial for eight weeks. Following the eight-week acute trial, participants were eligible to continue in open treatment for an additional 10 months.

After eight weeks of treatment, frail adults showed an average HRSD score 2.82 points higher than the non/intermediate frail adults; this difference persisted over the entire study follow-up period. Additional analysis revealed that weak grip strength and low physical activity levels were each associated with worse response to antidepressants, while slow gait speed, exhaustion, and significant weight loss were not. Participants with weaker grip strength had an average HRSD score 2.96 points higher at eight weeks of treatment, with this difference persisting over the entire follow-up period compared with those with stronger grip strength.

“These findings highlight the importance of comprehensively assessing adults with LLD [late-life depression] beyond the standard of psychiatric diagnosis and symptom severity ratings,” the researchers wrote. “Physical characteristics such as activity levels, strength, and mobility can provide important insight into the clinical trajectories of the patient [and] the identification of potential barriers to treatment implementation and may impact therapeutic decision making.”

For related information, see the Psychiatric News article “Purpose in Life Linked to Physical Function in Older Adults.”

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Tuesday, December 29, 2020

Women With Mental Illness Are Less Likely to Receive Mammograms, Study Finds

Despite access to free health care services, women with mental illness may be less likely to receive breast cancer screenings than those without mental illness, according to a study in the American Journal of Preventive Medicine. The report focused on women living in the United Kingdom, who are regularly notified to get a breast cancer every three years between the ages of 50 and 70.

Previous studies have suggested that U.S. women with mental illness, particularly serious mental illness, are less likely to get mammograms than those without mental illness. Less clear, however, has been whether this disparity extends to women living in a country where there is universal health care, wrote Emma Ross, Ph.D., of the Centre for Public Health at the Queen’s University Belfast and colleagues.

For this study, Ross and colleagues used 2011 census data to identify a cohort of 57,328 women eligible for free breast screening in Northern Ireland. The researchers then tracked these women over the course of a three-year period, examining whether mental illness impacted the odds of their getting screened for breast cancer. Women were considered to have mental illness if they received at least one prescription for a psychotropic medication in the three months preceding their notification for a breast cancer screening.

The authors reported that nearly one-third of the women in the study were prescribed a psychotropic medication during this timeframe. Women who received a psychotropic medication prescription were 15% less likely to get a breast cancer screening than those without such a prescription. Additional analysis revealed that breast cancer screening was particularly low for women prescribed anxiolytics and antipsychotics.

“The findings of this study provide novel evidence of variation in the magnitude of disparity in screening attendance according to the type of psychotropic medication prescribed. Notably, the inequality in uptake was greatest in individuals prescribed anxiolytics, for whom a 39% reduction in the odds of attending screening was observed,” Ross and colleagues wrote. “Although the underlying relationship between anxiety and screening attendance is yet to be elucidated, it is plausible that the avoidance behaviors that commonly develop as a coping mechanism in individuals with anxiety disorders predominantly explain this reduced participation.”

For related information, see the Psychiatric News article “Women With Schizophrenia Only Half as Likely to Receive Mammograms.” 

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Today Is Last Day to Purchase PPE Through Project N95

To help members who are having trouble acquiring PPE, APA is collaborating with Project N95, a nonprofit organization working to get critical equipment to COVID-19 frontline workers. This collaboration will provide a special opportunity for APA members to purchase N95 respirators, isolation gowns, and disposable face shields. You must register with Project N95 to be eligible to place an order. Orders must be placed and paid for by 3 p.m. ET today, Tuesday, December 29.

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Monday, December 28, 2020

Childhood Depression, Tobacco Use May Increase Risk of Opioid Use in Early Adulthood

Youth with a history of childhood depression and/or tobacco use are at a greater risk of using opioids by the age of 30 than those without such a history, according to a study published today in JAMA Pediatrics.

“Childhood tobacco use and chronic depression may be associated with impaired reward system functioning, which may increase young adults’ vulnerability to opioid-associated euphoria,” wrote Lily Shanahan, Ph.D., of the University of Zurich and colleagues. “Known evidence-based prevention strategies [for smoking and depression] could save lives, especially because mental health and substance use disorders are associated with opioid overdoses among the young.”

Shanahan and colleagues used data from the Great Smoky Mountains Study, a longitudinal study that enrolled over 1,400 children aged 9 to 13 years from 11 rural counties in western North Carolina in 1993 and periodically assessed them until age 30. The researchers specifically focused their analysis on data collected from 1,252 non-Black participants, including 342 American Indians, who had not used any opioids upon enrollment. (The sample of Black children was too small for inclusion in the study, the authors noted.) By age 30, 24.2% of the participants had used nonheroin opioids, 8.8% had used nonheroin opioids at least once a week, and 6.6% had used heroin.

The researchers identified several factors in childhood (defined as age 16 and younger) that increased the likelihood of future opioid use, including being male, using tobacco, using cannabis, and having depression. After adjusting for other variables, childhood tobacco use and depression had the strongest associations for future opioid use.

The risks were greatest in participants who had chronic depression (at least two years of symptoms) or dysthymia (persistent low mood). For example, participants with childhood dysthymia were 5.43 times as likely to have used nonheroin opioids, 8.89 times as likely to have used nonheroin opioids weekly, and 8.16 times as likely to have used heroin by age 30 as those without a history of childhood dysthymia.

“One possible reason childhood chronic depression increases the risk of later opioid use is self-medication,” Shanahan and colleagues wrote. “Opioids may offer a problematic antidote to depression-related difficulties detecting and experiencing reward or pleasure, debilitating low moods, and low self-esteem. Children with chronic depression may also later take opioids to alleviate the physical symptoms and pain that often accompany depression.”

To read more about this topic, see the Psychiatric News article “Opioid Prescribing in Rural Areas Far Outpaces Urban, CDC Finds.”

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Tomorrow Is Last Day to Purchase PPE Through Project N95

To help members who are having trouble acquiring PPE, APA is collaborating with Project N95, a nonprofit organization working to get critical equipment to COVID-19 frontline workers. This collaboration will provide a special opportunity for APA members to purchase N95 respirators, isolation gowns, and disposable face shields. You must register with Project N95 to be eligible to place an order. Orders must be placed and paid for by 3 p.m. ET tomorrow, Tuesday, December 29.

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Wednesday, December 23, 2020

Psychiatrists Outline Strategies to Achieve Antiracism in Medicine

From the devastating effects of COVID-19 on the Black community to the killings of Black Americans by police, 2020 is likely to be remembered in part for the stark reminder that racism and racist policies kill people. 

“Physicians’ responsibilities in addressing racism and racial violence toward Black Americans range from examining and taking steps to counter our own implicit and explicit biases to addressing policies and procedures that reproduce inequities within mental health delivery systems,” wrote psychiatrists Barbara Robles-Ramamurthy, M.D., Angela A. Coombs, M.D., Walter Wilson, M.D., and Sarah Y. Vinson, M.D., in a commentary in the Journal of the American Academy of Child & Adolescent Psychiatry.

Drawing from literature and their personal experience, the authors offered the following recommendations for the field of medicine, as it relates to the following roles:

Educators: “[I]t is incumbent upon us to change how we teach about race,” they wrote. This includes considering structural competence (the ways in which social structures affect patients’ health and well-being) as a core competency, as well as providing training about “how structural racism fuels inequities in child mental health.”

Clinicians: Clinicians should educate themselves about the over- and underdiagnosis of psychiatric disorders in Black youth and conduct chart reviews to see if there are inequities in diagnostic patterns within their practices. It is also important for clinicians to “seek to attain a basic understanding of the structural traumas experienced by communities we serve to better appreciate how it affects pediatric mental health and what helps or hinders families’ access to services,” they wrote.

Medical administrators: Medical administrators must take active and intentional steps to recruit, mentor, sponsor, promote, and retain Black physicians, clinicians, and staff at every organizational level; gather and address feedback from Black patients; and support antiracist work by clinicians, staff, and administrators with protected time and/or compensation.

The authors also outlined ways for individuals to address racial inequities through advocacy, including participation in partnerships with child advocacy groups, juvenile attorneys, law schools, advocacy groups, and educational systems to address educational and juvenile legal system inequities. Additionally, they recommended greater inclusion of clinicians on mobile crisis teams and equitable distribution of these teams “so that law enforcement officers are less likely to be involved when Black youth and families need crisis intervention.”

The authors concluded, “As clinicians serving children and families, we are well aware of how critical adult support, safety, and security are for children during times of uncertainty and unrest. Structural racism undermines each of these needs for Black youth. Knowledge of and a commitment to action against it is a prerequisite for serving them. Silence and inaction are complicity with the racist, harmful status quo. As clinicians who have taken an oath to do no harm, we must act.”

For related information, see the book Social (In)Justice and Mental Health from APA Publishing, edited by Ruth S. Shim, M.D., M.P.H., and one of the authors of this commentary, Sarah Y. Vinson, M.D.

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Purchase PPE Through Project N95

To help members who are having trouble acquiring PPE, APA is collaborating with Project N95, a nonprofit organization working to get critical equipment to COVID-19 frontline workers. This collaboration will provide a special opportunity for APA members to purchase N95 respirators, isolation gowns, and disposable face shields. You must register with Project N95 to be eligible to place an order. Orders must be placed and paid for by 3 p.m. ET on Tuesday, December 29.

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Tuesday, December 22, 2020

Congress Passes Legislative Package Including APA Model Parity Enforcement Bill

Congress yesterday passed the Strengthening Behavioral Health Parity Act (HR 7539), a bipartisan bill based on APA’s model legislation for improving compliance with the federal mental health parity law.

The bill was passed as part of a year-end funding package that combined annual appropriations legislation for federal agencies and a $900 billion COVID-relief package. The president is expected to sign the legislation later this week. 

HR 7539 gives the Department of Labor new powers to regulate and audit health plans to determine if they are in compliance with the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). The new legislation was introduced by Reps. Joe Kennedy (D-Mass.), Katie Porter (D-Calif.), Gus Bilirakis (R-Fla.), and Fred Upton (R-Mich.), and Sens. Chris Murphy (D-Conn.) and Bill Cassidy, M.D. (R-La.). It reflects language negotiated between the House and Senate related to the bipartisan Mental Health Parity Compliance Act. APA wrote the initial draft and worked with congressional champions to get it introduced and to build bipartisan support.

“This is tremendously good news for the millions of Americans with mental health and substance use disorders,” said APA President Jeffrey Geller, M.D., M.P.H., in a press statement. “Twelve years after mental health parity became the law of the land, the Strengthening Behavioral Health Parity Act will give the government important tools to stop health plans from discriminating against people with mental illness. APA expresses its gratitude to the bipartisan group of lawmakers who, with the support of many advocates, ensured that this act became law.”

The new law applies to federally regulated employer-sponsored (ERISA) plans as well as state-regulated insurance plans. It does the following:

  • Requires health plans to perform comparative analyses of mental health/substance use disorder to medical/surgical benefits and make them available to the U.S. Department of Labor (DOL) or a state insurance commissioner in response to complaints or violations or when the secretary or a commissioner deems appropriate.
  • Requires plans that DOL deems noncompliant with MHPAEA to inform plan beneficiaries of their noncompliance if they do not make necessary corrections within 45 days.  
  • Requires the secretary to send an annual report to Congress that identifies plans that are out of compliance.   

The combined year-end funding package and COVID relief package also contains support for other mental health and substance use-related programs and initiatives. These are among the many highlights:

  • $6 billion for the Substance Abuse and Mental Health Services Administration (SAMSHA) in annual appropriations and an additional one-time $4.25 billion in funding for SAMSHA as part of the COVID-relief package.
  • $600 million in new COVID-relief funds for Certified Community Behavioral Health Clinics (CCHBC) and extension of the CCBHC demonstration program by three years.
  • $16 million in funding for the Substance Use Disorder Treatment Workforce Program, a loan repayment program, through the Health Resources and Service Administration.
  • $1.47 billion for the National Institute on Drug Abuse, $390 million for the National Institute on Minority Health and Health Disparities, and $2 billion for the National Institute of Mental Health. 
  • $25 million for research related to firearm violence and prevention. 

“Passage of the Strengthening Behavioral Health Parity Act paired with this year-end funding package are essential in our efforts as we continue to face a mental health crisis in this country,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “This act is a good example of how Congress can work in a bipartisan manner to keep Americans’ mental health needs on their radars and invest in programs that help us navigate the pandemic.”

(Image: David Hathcox)

Monday, December 21, 2020

Bariatric Surgery May Increase Risk of Unhealthy Alcohol Use

Adults with no history of unhealthy alcohol use who undergo bariatric surgery to promote weight loss may be more likely to develop unhealthy alcohol use compared with adults who do not receive surgery, according to a study appearing today in JAMA Network Open.

“The clinical implications of these results suggest that patients undergoing bariatric surgical procedures should be cautioned that drinking alcohol can escalate after bariatric surgery, even in patients with no previous evidence of drinking alcohol above recommended limits,” wrote Matthew Maciejewski, Ph.D., of the Durham VA Medical Center and colleagues.

“[N]ot drinking alcohol is the safest option after a bariatric surgical procedure, given that blood alcohol concentration (and therefore the brain’s alcohol exposure) peaks at higher levels after a bariatric operation,” they continued. “Furthermore, all patients who undergo bariatric surgical procedures should be monitored long-term for unhealthy alcohol use.”

Previous controlled studies examining the relationship between bariatric surgery and drinking behaviors have mainly focused on women who have had Roux-en-Y gastric bypass (RYGB), not the laparoscopic sleeve gastrectomy (LSG)—the more popular bariatric surgery in the United States.

The researchers analyzed electronic health record data from 2,608 veterans (75% male) who underwent a bariatric surgical procedure between October 1, 2008, and September 30, 2016. (Since 2004, the U.S. Department of Veterans Affairs health system has required screening of all outpatients using the 3-item Alcohol Use Disorders Identification Test-Consumption, or AUDIT-C.) This sample included 1,684 patients who had had LSG procedures and 924 who had had RYGB procedures. Another 22,284 veterans who had not had bariatric surgery but had similar characteristics as the patients who did were included as matched controls.

The participants were further divided based on their scores on the AUDIT-C: Any veterans who reported AUDIT-C score of ≥3 (females) or ≥4 (males) in the two years prior to surgery were classified as having unhealthy alcohol use. About 92% of the participants had no history of unhealthy alcohol use.

The researchers evaluated alcohol use data collected until the participants’ death, eight years after the surgery, or the end of the study period (December 31, 2019), whichever came first.

The researchers estimated that among veterans without a history of unhealthy alcohol use, 7.9% and 9.2% were at risk of developing unhealthy alcohol use eight years following their LSG or RYGB surgery, respectively, compared with 4.5% and 4.4% of matched controls. Among veterans with a history of unhealthy alcohol use, 39.4% of veterans who received RYGB were at risk of postsurgical unhealthy alcohol use, compared with 25.7% of matched controls. The researchers identified no differences in post-LSG unhealthy alcohol use between veterans with a history of unhealthy alcohol use and matched controls (26.1% versus 28.9%, respectively).

“From these findings, we estimate that for every 21 patients who undergo an RYGB and every 29 patients who undergo an LSG, on average one from each group will develop unhealthy alcohol use,” Maciejewski and colleagues wrote.

To read more on this topic, see the Psychiatric News article “Many At-Risk Bariatric Patients Missed by Alcohol Screening Tools.”

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Purchase PPE Through Project N95

To help members who are having trouble acquiring PPE, APA is collaborating with Project N95, a nonprofit organization working to get critical equipment to COVID-19 frontline workers. This collaboration will provide a special opportunity for APA members to purchase N95 respirators, isolation gowns, and disposable face shields. You must register with Project N95 to be eligible to place an order. Orders must be placed and paid for by 3 p.m. ET on Tuesday, December 29.

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Friday, December 18, 2020

Depression, Anxiety Three Times More Likely in People with Cannabis Use Disorder

Rates of comorbid major depressive disorder and generalized anxiety disorder are three times higher in people who have cannabis use disorder, a meta-analysis in the Journal of Affective Disorders has found.

Vivian N. Onaemo, Ph.D., M.P.H., M.B.B.S., of the Government of Saskatchewan Ministry of Health in Reginia, Canada, and colleagues analyzed data from eight articles from six epidemiological surveys published from January 1980 through July 2020. There were approximately 177,000 respondents among all six surveys, and the surveys were largely conducted in the United States and Australia.

The odds of having major depression were 3.22 times higher in people with cannabis use disorder compared with those without cannabis use disorder. Onaemo and colleagues noted several possible reasons for this, including cannabis-induced changes in brain chemistry and genetic or environmental vulnerabilities that predispose some people to mental health problems and substance use disorders.

The odds of having generalized anxiety disorder were 2.99 times higher in people with cannabis use disorder compared with those without cannabis use disorder. The researchers wrote that chronic cannabis use could lead to the development of anxiety symptoms and that early cannabis use may affect cognitive function in adolescents, thereby predisposing them to the development of anxiety.

The researchers added that some people with depression or anxiety may self-medicate with cannabis for its calming or euphoric effect.

“However, irrespective of the pathway that led to the comorbid state and the high prevalence of the comorbidity, it does appear that once an individual has developed both [cannabis use disorder and depression or anxiety], a vicious cycle may be at play where each disorder maintains or exacerbates the other,” they wrote.

“Given the increasing prominence of cannabis use along with ongoing changes in many countries’ cannabis legalization, it is imperative to mitigate the serious health-related harms of [cannabis use disorder], such as increased risk of comorbid anxiety or depression; high risk of myocardial infarction, stroke, and transient ischemic attacks; increased [emergency department] visits and fatal car accidents; and crime,” the researchers concluded.

For related information, see the Psychiatric News article “Cannabis Use Disorder Linked to Increased Heart, Stroke Risk in Youth.”

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Purchase PPE Through Project N95

To help members who are having trouble acquiring PPE, APA is collaborating with Project N95, a nonprofit organization working to get critical equipment to COVID-19 frontline workers. This collaboration will provide a special opportunity for APA members to purchase N95 respirators, isolation gowns, and disposable face shields. You must register with Project N95 to be eligible to place an order. Orders must be placed and paid for by 3 p.m. ET on Tuesday, December 29.

LEARN MORE 




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Thursday, December 17, 2020

Parkinson’s Disease Associated With Increased Risk of Suicide, Study Finds

Suicide risk is about two times higher in patients with Parkinson’s disease than the general population, even after adjusting for physical and mental comorbidities, according to a study published Wednesday in JAMA Psychiatry

“Approximately 40% to 50% of patients with [Parkinson’s] are affected by depression, and 30% to 40% are affected by anxiety disorders,” wrote Ying-Yeh Chen, M.D., Sc.D., of the Taipei City Psychiatric Center in Taiwan and colleagues. “In addition to the long-established associations between mental disorders and suicide, the physical limitations caused by [Parkinson’s] and the well-known increased risk of suicide in older persons call for attention to the likelihood of suicide in [these] patients.”

Chen and colleagues conducted a cohort study using Taiwan’s National Health Insurance data, identifying 35,891 patients who received a Parkinson’s disease diagnosis between 2005 and 2014, with follow-up through 2016. Each patient with Parkinson’s was matched with four control participants (those who had not been diagnosed with Parkinson’s disease), for a total control cohort of 143,577. The researchers also analyzed whether the participants had been diagnosed with dementia, depression, or another mental disorder within one year prior to or after the onset of Parkinson’s. Data on suicides were obtained from the Taiwan Death Registry from 2005 to 2016.

In patients with Parkinson’s, the 11-year cumulative incidence of suicide was 66.6 per 100,000, compared with 32.3 per 100,000 among the control participants.

“The suicide risk elevation in [Parkinson’s] was only partially explained by comorbidity with depression and other mental disorders,” the authors wrote, adding that Parkinson’s in itself markedly escalated the risk of suicide.

Compared with the control participants who died by suicide, patients with Parkinson’s who died by suicide were more likely to be younger (the mean age among patients with Parkinson’s was 74 compared with 76 in the control participants) and reside in urban areas, the authors found.

The authors concluded by pointing to potential intervention measures, such as enhancing family and community connectedness for this population. “Integrating mental health care into primary care and [Parkinson’s] specialty care, along with socioenvironmental interventions, may help decrease the risk of suicide in patients with [Parkinson’s],” they wrote.

For related information, see the Psychiatric News article “Phone CBT Effective for Patients With Parkinson’s Disease.”

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Wednesday, December 16, 2020

Psychiatrists May Play Important Role in Facilitating Uptake of COVID-19 Vaccine by Patients With SMI

People with serious mental illness (SMI) should be among the high-priority groups to receive the COVID-19 vaccine, wrote Nicola Warren, M.B.B.S., of the University of Queensland, Australia, and colleagues in an editorial in JAMA Psychiatry.

In the article—appearing just days after health care workers in Europe, the United Kingdom, and the United States began receiving the first COVID-19 vaccines—the authors outline obstacles to immunization confronting people with SMI and strategies for overcoming them.

“Mental health clinicians have a key role in advocating for priority access to a COVID-19 vaccination for those with SMI, as well as facilitating its uptake,” Warren and colleagues wrote. To ensure people with SMI receive the COVID-19 vaccine, they suggested that experts look to what is known about how people with SMI access existing vaccination programs.

They noted that influenza vaccination rates among people with SMI are as low as 25%. This may be due to limited understanding of the benefits of the vaccine and where to access it, as well as misconceptions about risks. “Mental health professionals are uniquely skilled to deliver this education, being able to adapt for those with communication difficulties and balance factors influencing decision-making,” they wrote. “This highlights the importance of an individualized and clear message while enhancing capacity to consent.”

Additional hurdles to patients with SMI getting vaccinated include cost and transportation to vaccination clinics. “[U]se of existing physical health programs; co-location of vaccine administration with mental health services; and, where possible, actually delivering the vaccine may help increase uptake among individuals with SMI,” Warren and colleagues wrote. “Given that almost 80% of individuals without health insurance do not get vaccinated for influenza, any COVID-19 vaccine should be provided at no cost to the individual.”

They concluded, “It is vital to commence planning and development of appropriate policies to ensure rapid delivery of a COVID-19 vaccine when it becomes available.”

For related information, see the Psychiatric News article “Special Report: Patients With SMI in the Age of COVID-19—What Psychiatrists Need to Know.”

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Join Former AMA President, Psychiatrist in New Campaign on Black Women’s Health

The AMA has launched a new campaign with other medical organizations to support Black women in a movement for healthy blood pressure. A two-part interview with radio talk show host Tom Joyner is being aired to spread the word. Part one is posted here; the second part will be available today (Wednesday, December 16) at 8 p.m. ET. In this episode, Joyner will interview the AMA’s first Black president, psychiatrist Patrice A. Harris, M.D., M.A. The AMA has also posted a toolkit for physicians as part of the campaign.




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Tuesday, December 15, 2020

Youth Depression Associated With Somatic Diseases, Mortality

Children and adolescents with depression are at higher risk for a host of somatic diseases and premature death in early adulthood, according to a study published in JAMA Psychiatry.

These findings support the hypothesis that youth depression is linked to more than other psychiatric and neurologic disorders, impacting their quality of life and posing public health challenges, according to corresponding author Sarah E. Bergen, Ph.D., of the Karolinska Institutet in Sweden and colleagues. “Consequentially, clinical efforts to comprehensively manage both psychiatric and somatic diagnoses are needed.”

Bergen and colleagues conducted a cohort study of nearly 1.5 million Swedish individuals born between 1982 and 1996, with follow-up through 2013. Using data on clinical diagnoses from the National Patient Register and deaths noted in the Cause of Death Register, they compared outcomes in people who were diagnosed with depression between the ages of 5 and 19 (defined by authors as youth depression) with those who were not diagnosed with depression as youth. (The observation period began when patients were aged 5 because pediatric depression is rarely diagnosed during the first years of life, the authors wrote.) The patients’ age at the end of the follow-up period was between 17 and 31 years.

The authors specifically focused on causes of death and the diagnoses of 69 somatic diseases, including gastrointestinal, respiratory, and genitourinary diseases; autoimmune diseases; and endocrine and metabolic disorders.

In total, 360 patients (1.0%) with youth depression died during follow-up compared with 6,254 individuals (0.4%) in the group without history of depression. Intentional self-harm was the leading cause of death among those with youth depression. Those participants also had a significantly higher risk of being diagnosed with 66 of the 69 somatic diseases included in the study at any time after their first inpatient or outpatient recorded depressive episode.

The strongest risk for an injury was among females with youth depression, who were 14 times more likely to experience an injury from self-harm than females not diagnosed with youth depression. Females with youth depression also had a higher risk of genitourinary infections, while males had a higher risk for obesity, thyroid disease, and other endocrine gland disorders. Both sexes, however, had an increased risk for type 2 diabetes, viral hepatitis, kidney disease, and liver disease. When adjusted for psychiatric comorbidity, all the associations that the authors identified were weaker, but persisted.

“More research is needed to identify whether depression at a young age leads to adverse health outcomes or common causes underlie both,” the authors concluded. “Discovery of disease mechanisms that may serve as intervention targets in early life should be prioritized in light of the substantial disease burden associated with youth depression diagnoses.”

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Join Former AMA President, Psychiatrist in New Campaign on Black Women’s Health

The AMA has launched a new campaign with other medical organizations to support Black women in a movement for healthy blood pressure. A two-part interview with radio talk show host Tom Joyner is being aired to spread the word. Part one is posted here; the second part will be available tomorrow (Wednesday, December 16) at 8 p.m. ET. In this episode, Joyner will interview the AMA’s first Black president, psychiatrist Patrice A. Harris, M.D., M.A. The AMA has also posted a toolkit for physicians as part of the campaign.




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Monday, December 14, 2020

Depression, Not Burnout, Associated With Greater Suicidal Ideation in Physicians

Depression, but not burnout, appears to be associated with greater suicidal ideation in U.S. physicians, according to a study in JAMA Network Open. In contrast, burnout, but not depression, was associated with self-reported medical errors.

“Approximately 1 in 10 medical students, 1 in 4 interns, and 1 in 16 practicing physicians report some degree of suicidal ideation,” wrote senior author Mickey T. Trockel, M.D., Ph.D., of Stanford University School of Medicine and colleagues. “Addressing physician well-being and reducing suicide risk require understanding the associations between physician distress, including burnout and depression, and personal and professional outcomes.”

Previous studies have suggested burnout is a risk factor for depression and suicide in physicians and physicians in training. Few, however, have examined the association between burnout and suicidal ideation after adjusting for depression, according to Trockel and colleagues. To examine this association after accounting for concurrent symptoms of depression, the authors invited a random sample of U.S. attending and postgraduate trainee physicians to complete a survey assessing burnout, depression, and suicidal ideation. This cross-sectional study was conducted from November 12, 2018, to February 15, 2019.

The participants were evaluated using subscales of the Stanford Professional Fulfillment Index (PFI), Maslach Burnout Inventory–Human Services Survey for Medical Personnel, Mini-Z burnout survey, and the Patient-Reported Outcomes Measurement Information System (PROMIS) depression Short Form. In addition, the participants were asked about suicidal ideation, as well as any history of making medical errors and the types of errors made.

The authors analyzed the responses of 1,354 survey participants, 75 (5.5%) of whom reported having thoughts of taking their own life in the previous 12 months. Burnout was significantly associated with increased odds of suicidal ideation before but not after the data were adjusted for depression. In contrast, after the data were adjusted for overall burnout (PFI), sex, race/ethnicity, training status, and age category, each increase of one standardized point on the PROMIS depression scale was associated with 202% greater odds of suicidal ideation.

The authors found the opposite was true when examining the relationship between burnout, depression, and medical errors: Burnout, not depression, was associated with self-reported medical errors.

Trockel and colleagues noted several limitations to the study, including their inability to assess causality. “Future investigations are warranted to evaluate causal relationships between burnout, depression, suicidal ideation, and medical error,” they concluded.

For related information, see the Psychiatric News article “New Findings and Controversies in Physician Well-Being and Burnout” and the American Journal of Psychiatry article “The Elephant in the Room: What Burnout Is and What It Is Not.”

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Friday, December 11, 2020

Anxiety, Depression May Increase Risk of Acute Exacerbation in COPD

Patients with chronic obstructive pulmonary disease (COPD) may experience an acute exacerbation of their illness if they have depression and/or anxiety, suggests a study in the Journal of Affective Disorders.

Guangxi Li, M.D., Ph.D., of Guang'anmen Hospital at the China Academy of Chinese Medical Sciences in Beijing and colleagues interviewed 504 adults with COPD who visited the pulmonary clinic at the hospital from January 2012 through July 2013. The patients completed the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) to screen for depression and anxiety symptoms. Those with an SAS score of 50 or more were considered to have anxiety. Those with an SDS score of 53 or more were considered to have depression. The researchers defined an acute exacerbation of COPD as an acute event that worsened a patient’s respiratory symptoms of COPD beyond normal day-to-day variation and led to a change in at least one of three medications such as antibiotics, corticosteroids, or bronchodilators. The researchers determined acute exacerbations from the patients’ case records from February to August 2014.

Just over 54% of patients with anxiety experienced an acute exacerbation of their COPD compared with about 40% of patients without anxiety. About 52% of patients with depression experienced an acute exacerbation of their COPD compared with slightly more than 40% of those without depression. Overall, the risk of acute exacerbation was 60% higher in patients with anxiety and/or depression.

The findings suggest that health care professionals should pay attention to symptoms of anxiety and depression in patients with COPD, as these symptoms may be associated with worse outcomes, the researchers wrote. “[L]arger multi-center prospective cohort studies [could] explore the association between anxiety and/or depression and [acute exacerbation of] COPD, in order to reduce the additional burden of disease associated with these mental stresses, as well as discover new therapies or interventions to decrease the morbidity and mortality of acute exacerbation.”

For related information, see the Psychiatric Services article “Effects of Mental Health on the Costs of Care for Chronic Illnesses.”

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Thursday, December 10, 2020

Progesterone Modulator May Reduce Symptoms of Premenstrual Dysphoric Disorder

Ulipristal acetate (UPA), a progesterone-modulating medication used as an emergency contraceptive and treatment for uterine fibroids, might help alleviate the psychological symptoms of premenstrual dysphoric disorder (PMDD), according to a study published today in AJP in Advance. An estimated 3% to 5% of women of reproductive age are believed to experience PMDD, which is characterized by mood swings, irritability, anxiety, depression, and physical symptoms in the days preceding menstruation.

For the current study, Erika Comasco, Ph.D., of Sweden’s Uppsala University and colleagues recruited women aged 18 to 46 who were diagnosed with PMDD, as determined by scores on the Daily Record of Severity of Problems (DRSP) over a two-month period. This scale measures the time course and severity of 11 common PMDD symptoms. A total of 95 participants were then given either 5 mg UPA or placebo pills daily over the course of three menstrual cycles.

At the end of the study, DRSP scores (the average among the five days prior to menstruation) had fallen by an average of 41% among women taking UPA compared with 22% among women taking placebo. In addition, half of the women taking UPA achieved full remission (defined as no individual DRSP symptom above a score of 3) compared with 21% in the placebo group.

Among specific symptoms, women taking UPA reported greater improvements in symptoms of depression, anger, and fatigue relative to women taking placebo. UPA was not associated with improvements in anxiety or guilt, and it did not significantly improve any physical symptoms, such as headache or feeling bloated.

There were similar dropout rates in the UPA and placebo groups, and the only side effect more common in the UPA group compared with the placebo group was nausea. Some data have suggested that extended UPA use may cause liver damage (which is why UPA is not approved for fibroid therapy in the United States), but none of the participants experienced any liver issues during the study.

“As this proof-of-concept study is the first to evaluate UPA for treatment of PMDD, we cannot make any treatment recommendations at present,” Comasco and colleagues wrote. “Further studies to validate our findings, and positive outcomes from ongoing liver-safety studies, are needed.”

For related information, see the Psychiatric News article “Can Hormonal Treatments Help Your Patients?

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Wednesday, December 9, 2020

Consistent Use of Mental Health Services Uncommon Among Youth Treated Early for Anxiety

Anxiety is a chronic condition, yet only a little more than a third of young people who had received early evidence-based treatment for anxiety reported consistent use of services into early adulthood, according to a study in the Journal of the American Academy of Child and Adolescent Psychiatry.

Tara Peris, Ph.D., of the University of California, Los Angeles, and colleagues wrote that experience with quality mental health treatment early in life should encourage people to seek out such services when necessary as they grow older. “Findings from this large multi-site study indicate that this is not always the case. … On the whole, rates of service use for these youth did not appear to match their level of clinical need.”

Peris and colleagues assessed long-term use of mental health services by 318 young people who had received evidence-based anxiety treatment when they were 7 to 17 years old through the Child/Adolescent Anxiety Multimodal Study (CAMS). CAMS was a six-site, randomized, controlled trial that compared the effects of cognitive-behavioral therapy (CBT), sertraline (SRT), a combination of CBT and sertraline (COMB), and placebo (PBO) on youth with pediatric anxiety disorders.

“[CAMS] youth had generally favorable acute treatment outcomes, with 59.7% of those assigned CBT, 54.9% in SRT, and 80.7% of those in COMB [groups] demonstrating clinically significant response compared with only 23.7% of those receiving PBO,” they noted. However, when following up with these participants some 6.5 years later, the researchers found 58.3% met the criteria for an anxiety disorder.

Overall, 65.1% of participants endorsed ever receiving some form of anxiety treatment over the course of the follow-up period, with more youth reporting medication use than psychotherapy. These rates did not differ by original CAMS treatment assignment, acute treatment response, or remission status, other than that those who did not go into remission reported higher rates of SSRI usage than those in remission. Only 35.2% of participants reported consistent use of anxiety treatment across the course of the study, with no differences based on original treatment condition, response, or remission.

“This study provides the first view of long-term mental health service use among youth previously treated for anxiety,” the researchers wrote. “It suggests that the type of evidence-based treatment and initial response do not influence subsequent decisions about care, and it raises important questions about how to encourage continued engagement and improve outcomes for chronically ill youth.”

For related information, see the Psychiatric News article “Childhood Anxiety Can Be Treated—the Challenge is to Recognize It.”




Deadline to Submit New Research Posters for Annual Meeting Is Tomorrow

APA invites New Research poster submissions for the 2021 Annual Meeting. The deadline is Thursday, December 10, at 5 p.m. ET. The Scientific Program Committee encourages all submitters to keep in mind the Annual Meeting’s theme: “Finding Equity Through Advances in Mind and Brain in Unsettled Times.”

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Tuesday, December 8, 2020

PTSD, Depression May Increase Risk of Death in Women

Women with symptoms of posttraumatic stress disorder (PTSD) and depression are at an increased risk of death compared with women without trauma exposure or depression, according to a study in JAMA Network Open.

“Our findings are consistent with prior studies that found that co-occurring PTSD and depression are associated with worse health outcomes compared with either disorder alone,” wrote Andrea L. Roberts, Ph.D., of Harvard T.H. Chan School of Public Health and colleagues. For instance, previous studies show that people with PTSD are at an increased risk of chronic diseases, including cardiovascular disease and type 2 diabetes.

Although PTSD occurs at higher rates among women than men, most research examining the association between PTSD and increased risk of death have focused on men who are veterans, according to Roberts and colleagues. To examine the association between symptoms of PTSD, depression, and risk of death in women, the researchers analyzed data collected from participants in the Nurses’ Health Study II. This ongoing study involves 116,429 women who enrolled in 1989 at ages 25 to 42 years and are followed-up biennially.

In 2008, study participants aged 43 to 64 years were mailed a supplemental PTSD questionnaire, which asked whether they had ever experienced 15 potentially traumatic events (for example, a serious motor vehicle crash) and if so, which they considered to be the worst/most traumatic. They were then asked about PTSD symptoms in relation to this event (using the Short Screening Scale for DSM-IV PTSD) and past-week depressive symptoms (using the Center for Epidemiologic Studies Depression Scale-10, or CESD-10). The authors considered participants who reported six to seven symptoms of PTSD to have high PTSD symptoms; participants who scored 10 or above on the CESD-10 were considered to have probable depression.

Among 51,602 women (97% White) who completed the PTSD questionnaire in 2008, 2,093 women had high PTSD symptoms and probable depression, compared with 8,890 women with no trauma exposure and no depression. By 2017, 555 women in the study had died. The researchers found that women with high PTSD symptoms and probable depression were at nearly fourfold greater risk of death compared with women with no trauma exposure and no depression.

The researchers were able to obtain cause of death information for 109 deaths that occurred in women with any PTSD symptoms and probable depression and 124 deaths that occurred in women with no depression or PTSD. Compared with women with no PTSD or depression, women with PTSD symptoms and probable depression had higher rates of death from cardiovascular disease, diabetes, unintentional injury, suicide, and other causes of death. The rate of such deaths among women with PTSD and depression did not differ significantly compared with women with PTSD symptoms alone or probable depression alone, the researchers noted.

“Our findings additionally highlight the need for better access to and dissemination of effective treatments for comorbid PTSD and depression,” Roberts and colleagues wrote. “[T]reatment of PTSD and depression in women with symptoms of both disorders and efforts to improve their health behaviors may reduce this population’s increased risk of mortality.”

For related information, see the Psychiatric Research & Clinical Practice article “Psychobehavioral Responses, Post‐Traumatic Stress, and Depression in Pregnancy During the Early Phase of COVID‐19 Outbreak.”

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Only a Few Days Remain to Submit New Research Posters for Annual Meeting

APA invites New Research poster submissions for the 2021 Annual Meeting. The deadline is Thursday, December 10, at 5 p.m. ET. The Scientific Program Committee encourages all submitters to keep in mind the Annual Meeting’s theme: “Finding Equity Through Advances in Mind and Brain in Unsettled Times.”

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Monday, December 7, 2020

Selecting Antipsychotic Based on Genetic Screening Not Associated With Better Outcomes in Schizophrenia

Using pharmacogenetic data on metabolism status to guide antipsychotic prescribing for schizophrenia patients does not appear to improve symptoms or reduce side effects better than routine monitoring, according to a study published today in JAMA Network Open

Gesche J├╝rgens, M.D., Ph.D., of Zealand University Hospital in Roskilde, Denmark, and colleagues conducted a clinical trial involving 311 adults diagnosed with schizophrenia. The participants were screened to see which variants of the drug-metabolizing cytochrome P450 (CYP) enzymes they had; based on their pharmacogenetic profile, they were classified as poor drug metabolizers, intermediate metabolizers, extensive metabolizers, or ultrarapid metabolizers.

The participants were then randomly assigned to one of three treatment groups. In the CYP-guided group, the attending psychiatrists were given the patient’s pharmacogenetic results to guide medication choice and dosing strategy. In the structured clinical monitoring group, the patients’ primary clinical contact (such as a nurse or social workers) was not given CYP results, but at least once every three months, they systemically assessed the patient’s symptoms, medication adherence, and side effects. For the routine care group, the patients’ CYP results were not shared, and patients were not required to undergo symptom assessment on a fixed schedule. 

After one year, there was no difference in antipsychotic persistence among patients in the three groups; that is, the length of time that elapsed before patients’ medication or dose had to be changed. There was also no difference in antipsychotic persistence when only examining patients with extreme metabolism (either poor or ultrarapid metabolizers). Additionally, the groups were similar in terms of total improvements in patients’ hallucination or delusion symptoms and the frequency of adverse side effects.

“As a holistic approach, clinical monitoring can detect adverse effects and treatment failure, even when they are unrelated to the patient’s drug metabolism. In contrast, CYP genotyping mainly serves to identify patients at risk of relative underdosage or overdosage due to abnormal drug metabolism,” they authors wrote. “These results do not support routine use of genotyping for CYP2D6 and CYP2C19 polymorphisms in patients with schizophrenia.”

To read more on this topic, see the Psychiatric News article “Pharmacogenomic Tests in Psychiatry: Not Ready for Prime Time.”

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Only a Few Days Remain to Submit New Research Posters for Annual Meeting

APA invites New Research poster submissions for the 2021 Annual Meeting. The deadline is Thursday, December 10, at 5 p.m. ET. The Scientific Program Committee encourages all submitters to keep in mind the Annual Meeting’s theme: “Finding Equity Through Advances in Mind and Brain in Unsettled Times.”

LEARN MORE




Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.


Friday, December 4, 2020

New MOC Draft Standards to Be Released for Public Comment Next Spring

The release of new draft Standards for Board Continuing Certification by the American Board of Medical Specialties(ABMS), which had been scheduled for early next week, has been delayed until April 2021.

Despite the delay, APA is proactively alerting members to this important development and will be urging members to review the standards when they are released and to submit their comments directly to ABMS. The deadline for submission of public comments will be announced when the draft standards are released, and APA will inform members about the date and submission process.

These standards will shape the maintenance of certification (MOC) programs for all ABMS boards, including the American Board of Psychiatry and Neurology, for years to come. ABMS has not yet shared these standards with APA; however, as soon as the draft is available, APA will conduct a thorough analysis regarding how the revised MOC standards will impact physicians’ ability to practice medicine and care for patients. 

ABMS had been prepared to release the Draft Standards for Continuing Certification – Call for Comments on Monday, December 7, in accordance with the timeframes established in the Continuing Board Certification: Vision for the Future Commission. However, the recent surge in new COVID-19 cases, which has placed additional burdens on the already stressed health care system, prompted ABMS to postpone the opening of the public comment period. After consulting external and internal stakeholders, ABMS decided to move the opening of the Call for Comments to April, pending the status of the COVID-19 surge and the hospital caseload at that time.

“APA members have sent a message loud and clear that they want a lifelong learning and continuing certification process that is less burdensome, less expensive, and more relevant to their clinical practice,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., told Psychiatric News. “The new standards have the potential to impact all parts of ABPN’s maintenance of certification program and will directly impact all psychiatrists who are currently board certified. Our Division of Education and our advocacy staff will review the standards closely for how they will affect members immediately and in the future. 

“It is imperative that we make our voices heard during the public comment period.”

Look for further information as it unfolds about the draft ABMS standards in the Psychiatric News Alert and print version of Psychiatric News.

Thursday, December 3, 2020

Patients With Major Depression May Experience Insulin Resistance

Two biomarkers of insulin resistance appear to be associated with current, but not remitted, major depressive disorder (MDD), according to a study published in JAMA Psychiatry.

Insulin resistance “is a known risk factor for somatic and brain-based disorders, including cardiovascular disease, Alzheimer disease, and major depressive disorder,” wrote Kathleen Watson, Ph.D., of the Center for Neuroscience in Women’s Health at Stanford Medicine and colleagues. “However, there is little evaluation of how [insulin resistance] is associated with specific features of major depression.”

Watson and colleagues used data from 1,269 participants in the Netherlands Study of Depression and Anxiety who had provided blood samples as part of the study. The participants were divided into three diagnostic groups: those with current MDD, remitted MDD, and no history of the disorder. The researchers evaluated the participants’ levels of insulin resistance with two biomarkers: the quantitative insulin sensitivity check index (QUICKI) and the triglyceride to high-density lipoprotein (HDL) ratio. Depression status was assessed via the Composite International Diagnostic Interview, version 2.1; depression severity was assessed via the Inventory of Depressive Symptomatology; and depression chronicity over the preceding four years was assessed via the life chart interview.

Patients with current MDD were more likely to have insulin resistance compared with those with no history of the disorder. Patients in remission from MDD appeared no more likely to have insulin resistance than those with no history of the disorder, however. Further, both measures of insulin resistance were positively associated with depression severity among participants with current MDD.

The researchers also found that depression chronicity was associated with the triglyceride-HDL ratio, but not with the QUICKI. Additionally, the participants who were insulin resistant were older, less educated, and had higher body mass index than those who were insulin sensitive, the authors found.

The findings suggest that insulin resistance, “is a state, rather than a trait, biomarker of depression,” the authors wrote. “Taken together, these biomarkers of metabolic dysfunction represent simple, clinically accessible methods of identification of [insulin resistance] among currently depressed patients,” they concluded.

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

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