Friday, April 9, 2021

Study Identifies Risk Factors for Opioid Use Disorder, Overdose in Youth

Opioid use disorder (OUD) and overdose among young people who fill an initial opioid prescription are rare but more likely to occur in those who have other substance use disorders or who have mood or anxiety disorders, a study in Addiction has found.

Scott E. Hadland, M.D., M.P.H., M.S., of Boston University School of Medicine and colleagues analyzed data from the health insurance claims of more than 3.2 million youth aged 11 to 25 years who filled an initial opioid prescription between 2006 and 2016.

Within 12 months of first filling their opioid prescriptions, 0.3% of the patients either developed OUD or overdosed. Patients who had other substance use disorders were more than 20 times more likely to develop these complications than their peers who did not have a substance use disorder. Roughly 73% of those who developed OUD or overdosed had a comorbid substance use disorder. and of these, 33.4% used alcohol, 33% used cannabis, and 43.2% used nicotine.

Patients who had mood or anxiety disorders were 4.45 times more likely to develop either of these opioid-related complications than their peers who did not have the disorders.

“We do not advocate for withholding opioid prescriptions from youth with comorbid mental health conditions or substance use; however, clinicians might consider ensuring close follow-up … for youth identified as having comorbid mental health conditions or substance use to minimize the risk [of OUD or overdose],” the researchers wrote.

The researchers also found a link between formulations of opioids and increased risk of opioid-related complications. Taking long‐acting opioids more than doubled the risk of OUD or overdose compared with taking short-acting formulations. Similarly, taking opioids for 15 days or more doubled the risk compared with taking opioids for three or fewer days.

The researchers concluded that consistent with U.S. opioid prescribing guidelines for adults, opioid prescriptions for young people should be for short-acting formulations at the lowest dose and for a short duration.

For related information, see the Psychiatric News article “Polysubstance Use Common in SUD Patients.”

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Thursday, April 8, 2021

FDA Approves Once-Daily Nonstimulant for Treatment of ADHD

The Food and Drug Administration (FDA) has approved the selective norepinephrine reuptake inhibitor Qelbree (viloxazine extended-release) for the treatment of attention-deficit/hyperactivity disorder (ADHD) in youth 6 to 17 years of age. The nonstimulant drug, which is to be taken once a day, can be swallowed whole or opened and sprinkled into applesauce.

The efficacy of Qelbree was evaluated in three multicenter randomized, controlled trials. In the first trial, researchers randomly assigned 477 patients with ADHD aged 6 to 11 to receive Qelbree 100 mg, Qelbree 200 mg, or placebo once daily for six weeks. The patients were evaluated using the ADHD Rating Scale (ADHD-RS-5) and the Clinical Global Impression Improvement (CGI-I) scale at the start of the study and again at six weeks. Patients who received Qelbree 100 mg or Qelbree 200 mg experienced a greater reduction in ADHD-RS-5 total scores and improvements in CGI-I scores over the course of the trial compared with those who received placebo. The second trial involved 313 patients with ADHD aged 6 to 11 who were assigned to Qelbree 200 mg, Qelbree 400 mg, or placebo once daily for eight weeks. As seen in the first trial, patients who received Qelbree 200 mg or Qelbree 400 mg experienced greater reductions in ADHD-RS-5 total scores and improvements in CGI-I scores from baseline to the end of the study.

For the third trial, Qelbree was evaluated in patients aged 12 to 17 years: 310 youth with ADHD were randomly assigned to Qelbree 200 mg, Qelbree 400 mg, or placebo once daily for six weeks. As in the trials with the younger patients, these youth also experienced greater reductions in ADHD-RS-5 total scores and improvements in CGI-I scores from baseline to the end of the study.

“This approval offers a novel once-a-day sprinkleable nonstimulant that can be a great option for children and adolescents with ADHD,” Andrew J. Cutler, M.D., a clinical associate professor of psychiatry at SUNY Upstate Medical University, said in a press release from Supernus, maker of Qelbree. (Cutler has received consultant fees from Supernus.)

Qelbree’s label contains a boxed warning that the medication may increase the risk of suicidal thoughts and behaviors. Physicians are advised to monitor patients closely for “clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes.”

Data from the clinical trials suggest that the medication may induce manic or mixed episode in patients with bipolar disorder and/or increase blood pressure and heart rate. “Prior to initiating treatment with Qelbree, screen patients to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a personal or family history of suicide, bipolar disorder, and depression,” the label cautions. Assessing heart rate and blood pressure prior to initiating treatment as well as when increasing dosages is also advised.

According to the press release, the company plans to make Qelbree available in the United States later this year.




Webinars to Be Held Tonight on Impact of COVID-19 on MH of African Americans

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Wednesday, April 7, 2021

One-Third of COVID-19 Survivors May Develop a Neuropsychiatric Disorder Within Months of Infection

One-third of individuals diagnosed with COVID-19 developed a psychiatric or neurological problem within six months of their diagnosis, according to a study published Tuesday in The Lancet Psychiatry. The prevalence of a post-COVID neurologic or psychiatric diagnosis was even greater among individuals with severe illness who had required hospitalization.

“Given the size of the pandemic and the chronicity of many of the diagnoses and their consequences (for example, dementia, stroke, and intracranial hemorrhage), substantial effects on health and social care systems are likely to occur,” wrote Maxime Taque, Ph.D., of the University of Oxford and colleagues. “Our data provide important evidence indicating the scale and nature of services that might be required.”

Taque and colleagues used data from a multinational electronic health record (EHR) database to identify 236,379 patients diagnosed with COVID-19 on or after January 20, 2020, and who were still alive on December 13, 2020. This sample included 190,077 patients who did not require hospitalization and 46,302 who did (including 8,945 patients who required intensive care). For control groups, Taque and colleagues also examined the EHR records of patients diagnosed with influenza and patients diagnosed with any respiratory tract infection during the same period.

The researchers then investigated the occurrence of the following neuropsychiatric outcomes in the first 180 days after COVID-19 diagnosis: intracranial hemorrhage; ischemic stroke; Parkinson’s disease; Guillain-BarrĂ© syndrome; nerve, nerve root, and plexus disorders; neuromuscular disorders; encephalitis; dementia; psychotic disorders; mood disorders; anxiety disorders; substance use disorder; and insomnia.

Overall, 33.62% of COVID-19 patients received one of the above diagnoses within 180 days; this rate increased to 38.73% among patients who were hospitalized and 46.42% among patients admitted to intensive care. The rates of almost all these outcomes were higher in patients in the COVID-19 group compared with those in the influenza group or respiratory tract infection group. The exceptions were Parkinson’s disease and Guillain-BarrĂ© syndrome, which were similar in COVID-19 and influenza patients.

Anxiety disorders were the most common neuropsychiatric diagnoses among all patients, occurring in 17.39% of COVID-19 patients; they were followed by mood disorders in 13.66% of COVID-19 patients and substance use disorder at 6.58% of COVID-19 patients. Psychotic disorders were diagnosed in 1.40% of COVID-19 patients.

Compared with neurological disorders, the rates of mood and anxiety disorders did not significantly increase among hospitalized patients, Taque and colleagues noted. “This might indicate that their occurrence reflects, at least partly, the psychological and other implications of a COVID-19 diagnosis rather than being a direct manifestation of the illness,” they wrote.

For related information, see the Psychiatric News article “Expect a ‘Long Tail’ of Mental Health Effects From COVID-19.”

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Tuesday, April 6, 2021

Bipolar II Disorder Associated With Higher Prevalence of Seasonal Affective Disorder

Patients with early-onset bipolar II disorder may be more likely to experience seasonal affective disorder (SAD) than those with other mood disorders, according to a study published in Depression and Anxiety.

“SAD can co-occur with several psychiatric disorders, including mood disorders,” wrote Heon-Jeong Lee, M.D., Ph.D., of the Korea University College of Medicine, and colleagues. They noted that although there have been debates on separating SAD as an independent diagnosis, DSM-5 recognizes seasonality as a specifier of major depressive disorder, bipolar I disorder, and bipolar II disorder.

The authors recruited 378 participants from the Mood Disorder Cohort Research Consortium study, a multicenter observational study of individuals with early-onset mood disorders including major depressive disorder, bipolar I disorder, and bipolar II disorder. The participants had to be either under 25 years old or under 35 years old and treated for a mood disorder for less than two years. Participants completed the Korean language version of the Seasonal Pattern Assessment Questionnaire to determine overall seasonal impairment and the Mood Disorder Questionnaire to identify bipolarity. The authors also recruited 235 health control subjects.

Of the participants, 138 were diagnosed with major depressive disorder, 101 were diagnosed with bipolar I disorder, and 139 were diagnosed with bipolar II disorder. Participants with mood disorders had higher overall seasonal impairment than the healthy controls. About 10% of participants with major depressive disorder and bipolar I disorder also had SAD, compared with 23% of those with bipolar II disorder and only 6% of the controls. Participants with bipolar I disorder had the highest proportion of winter-associated SAD, while those with major depressive disorder had the highest proportion of summer-associated SAD. Participants with bipolar II disorder were between two and three times more likely to experience SAD compared with those with major depressive disorder.

Additionally, the authors noted that previous studies have shown that SAD is more common in females than males. Their study, however, did not identify sex as a risk factor for SAD, which they hypothesized may be due to the younger age of the study sample and suggests that risk factors for seasonality in patients with early-onset mood disorder may differ between age groups.

“It remains unclear and needs further investigation to understand why [bipolar II disorder] has the highest seasonality among the mood disorders,” the authors wrote. “Considering the close relationship between [bipolar II disorder] and SAD, it may be helpful for clinicians to screen for seasonality in [bipolar II disorder] and bipolarity in those suspected to have SAD.”

For related information, see the Psychiatric News article “This Winter, Pandemic May Intensify Seasonal Depression.”

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Monday, April 5, 2021

Psychotherapy Aimed at Social Engagement Reduces Depression Associated With Loneliness

A form of psychotherapy aimed at helping older adults feel more connected to other people reduced depression and improved quality of life for those who had reported they felt lonely and/or were a burden to people around them, according to a study in the American Journal of Geriatric Psychiatry.

“Social connection is essential for health and quality of life at all ages and may be an especially useful intervention target for promoting mental health in later life,” wrote Kimberly Van Orden, Ph.D., an associate professor of psychiatry at the University of Rochester, and colleagues.

The researchers adapted a manualized form of behavioral psychotherapy called Engage Psychotherapy to specifically target social connection among older adults at risk for suicide. Engage is designed to help patients reengage with the pleasant, physical, and/or social activities they may have stopped doing because of their depression. Participants create “action plans” that involve setting a goal, brainstorming ways to achieve the goal, and selecting specific actions to take before their next session. The form of Engage used in the study is called Social Engage, which includes psychoeducational materials to address the importance of social connection and instructions to therapists to focus action plans on social engagement.

Participating in the study were 62 adults aged 60 years or older who endorsed feeling lonely and/or feeling like a burden to others in the prior two weeks. Thirty-two individuals were randomly assigned to 10 sessions of Social Engage, and 30 were assigned to usual care. Follow-up assessments were at three weeks, six weeks, and 10 weeks.

Outcomes were measures of depression and suicidal ideation using the 16-Item Quick Inventory of Depressive Symptomatology (QIDS-C) clinician interview, the Geriatric Suicide Ideation Scale, and measures of social-emotional quality of life using the World Health Organization Quality of Life Scale.

Social Engage was associated with statistically significant improvements in depression at all timepoints and in social-emotional quality of life. It was not associated with a perceived sense of being a burden or belonging.

“[F]eedback from participants suggests that improvements may unfold over time, indicating a longer duration of intervention and follow-up may be needed to document improvement in subjective connection,” the researchers wrote. “[P]articipants reported increased insight and awareness of the importance of social connection, increased social engagement, and acquisition of skills to manage barriers to social engagement; however, it may take more time (and practice) to build/improve social connections that impact perceptions about social connection.”

For related information, see the Psychiatric News article “Loneliness Persists Even When Older Adults Live in Social Environments.

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Join APA for a two-part webinar series that will examine strategies and opportunities to improve the mental health of African Americans during the pandemic, while also raising awareness and building trust about the efficacy of the COVID-19 vaccine. The webinars will be held on April 8 beginning at 7 p.m. ET.

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Friday, April 2, 2021

Children of Parents With Bipolar Disorder at Risk of ADHD and Early Onset Bipolar, Study Suggests

Children who have a parent with bipolar disorder are more likely to develop attention-deficit/hyperactivity disorder (ADHD) during their preschool years than children with no family history of bipolar disorder, reports a study in Journal of the American Academy of Child and Adolescent Psychiatry. The study also found that these children were more likely to develop symptoms of bipolar disorder as they grew older.

“[Bipolar disorder] symptoms were scarce during the preschool years and increased throughout [early adolescence],” wrote Boris Birmaher, M.D., of the University of Pittsburgh School of Medicine and colleagues. “Developing early interventions to delay or, ideally, prevent [bipolar disorder] onset are warranted.”

Birmaher and colleagues recruited 116 children who had a parent with either bipolar I or II disorder (BD-I/II parents), 53 children of parents with a non-bipolar psychiatric disorder (non-BD parents), and 45 children of parents with no psychiatric disorder (healthy parents) for the study. All children were between the ages of 2 and 5 years at the start of the study and were periodically assessed for about 10 years using the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (KSADS-PL).

The researchers found that the children of BD-I/II parents were significantly more likely to have ADHD by age 5 (21.6% of children) than children of non-BD parents (3.8%) and children of healthy parents (2.2%). After age 5, children of BD-I/II parents and non-BD parents showed no statistical difference in rates of non-bipolar psychiatric disorders. However, compared with children of healthy parents, children of BD-I/II parents had elevated rates of anxiety, ADHD, and behavior problems after age 5.

During the study period, 17 of the children of parents with BD-I/II (about 15%) were diagnosed with bipolar disorder; four children developed BD-I/II and 13 developed BD-Not-Otherwise-Specified (BD-NOS), with an average age of onset of 11.4 and 7.4 years, respectively. (BD-NOS is typically diagnosed in people who show bipolar mood swings but the timing and/or intensity do not meet the full criteria of BD-I or BD-II.) None of the children in the other groups received a diagnosis of bipolar disorder during the study.

“Given that youth with BD-NOS exhibit as much psychosocial impairment, suicide risk, substance abuse, comorbid disorders, and family history of BD as youths with BD-I/II, and are at very high risk to transition into BD-I/II (particularly if they have family history of BD), the diagnosis of BD-NOS warrants significant clinical consideration,” Birmaher and colleagues wrote.

The researchers looked over the data to see which factors might help predict the youth who would develop bipolar disorder; the only significant risk factors they identified were an ADHD diagnosis before age 6 and having parents with early onset bipolar disorder.

To read more on this topic, see the Psychiatric News article “Study Sheds Light on Trajectory of Developing Bipolar Disorder.”

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APA Seeks Input on How Psychiatrists Can Address Racial Inequities

The APA Presidential Task Force to Address Structural Racism Throughout Psychiatry is fielding a new short survey. Help the task force inform its important work by responding to the survey by Wednesday, April 14. Learn more about the task force and view the results of its previous three surveys on the task force webpage.

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Thursday, April 1, 2021

Maternal Depression, Anxiety Worsened During Pandemic, Meta-Analysis Suggests

Postnatal depression and maternal anxiety appear to have increased worldwide during the COVID-19 pandemic, according to a meta-analysis published Wednesday in The Lancet Global Health.

“It is clear that pregnant individuals and babies have been subjected to harm during the pandemic, and the onus is on the academic community, health care providers, and policymakers to learn from it,” wrote Asma Khalil, M.D., of St. George’s University of London and colleagues.

Khalil and colleagues searched MEDLINE and Embase for studies published from January 1, 2020, to January 8, 2021, that compared maternal, fetal, and infant health outcomes before and during the pandemic. Studies that only included women infected with COVID-19 were excluded.

Of the 3,592 abstracts the authors screened, 40 studies from 17 countries were included in the analysis. Overall, the studies indicated increased maternal mortality, stillbirth, and maternal stress during the pandemic compared with before, with a particularly disproportionate impact on low- and middle-income countries.

Eleven studies compared maternal mental health outcomes before and during the pandemic, using such measurements as the Generalized Anxiety and Depression Scale, Inventory of Depression and Anxiety Symptoms, the Generalized Anxiety Disorder 7-item (GAD-7) Questionnaire, and the Edinburgh Postnatal Depression Scale, among others. Seven of these studies reported a statistically significant increase in postnatal depression, maternal anxiety, or both.

The authors hypothesized that the increase in adverse pregnancy outcomes could be attributed to reduced access to care. “Although maternal anxiety was consistently shown to [have] increased during the pandemic, health care providers around the world have reported reduced attendance for routine and unscheduled pregnancy care,” the authors wrote. “This reduction could be driven by concern about the risk of acquiring COVID-19 in health care settings, governmental advice to stay at home, or reduced public transport and childcare access during lockdowns.”

Other changes during the pandemic—including the reported increase in intimate partner violence, a rise in unemployment among women, and a greater burden of childcare responsibilities due to school closures—may also play a role in these adverse outcomes, the authors noted.

“Women’s health care is often adversely affected in humanitarian disasters and our findings highlight the central importance of planning for robust maternity services in any emergency response,” the authors concluded.

For related information, see the Psychiatric News articles “Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions” and “Pandemic Has Compromised Mental Health of New Moms.”

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