Youth Later Diagnosed With Psychotic Disorders May Show Up in Acute Care Settings First

Most people receiving a first diagnosis of a psychotic disorder have had some indication of mental health problem in the previous year. A study published today in AJP in Advance suggests that as many as two-thirds of adolescents and young adults who are diagnosed with psychotic disorder may have sought mental health care during the year prior to diagnosis.

While similar patterns of health care use were seen in patients who were later diagnosed with unipolar depression, the authors did find that people who would go on to develop a psychotic disorder received specialty mental health services in inpatient and emergency department settings more frequently. 

Gregory Simon, M.D., M.P.H., of Kaiser Permanente Washington Research Institute and colleagues reviewed the medical records of all diagnoses made in youth/young adults (aged 15 to 29) between Jan. 1, 2007, and Dec. 31, 2013, among participants in the Colorado, Northern California, Northwest, Southern California, and Washington regions of Kaiser Permanente. During this period, they identified 624 confirmed cases of a first diagnosis of a psychotic disorder, which included 105 diagnoses of a schizophrenia spectrum disorder, 78 diagnoses of a mood disorder with psychosis, and 441 diagnoses of other psychotic disorders. For comparison, they also examined data from 1,862 patients who had received a diagnosis of first unipolar depression and 1,851 control patients selected from all health plan members who had at least one outpatient visit during the study period.

Of the patients with a first diagnosis of a psychotic disorder, 29% had received mental health outpatient care in the previous year, 8% had received mental health inpatient care, 24% had received emergency department mental health care, and 29% made a primary care visit that involved a mental health diagnosis. 

Patients who received a first diagnosis of unipolar depression had similar rates of previous mental health outpatient or primary care visits, but the patients who later developed a psychotic disorder were far more likely to have received inpatient and emergency mental health services. Specifically, compared with patients receiving a first diagnosis of unipolar depression, those with a first diagnosis of psychosis were 2.96 times more likely to have received mental health inpatient care in the previous year, and 3.74 times more likely to have received mental health emergency department care. 

“The strong and specific association between use of acute care mental health services and subsequent presentation with psychotic symptoms suggests the potential value of assessment for prodromal or early psychotic symptoms in people receiving inpatient or emergency care for mental health concerns,” Simon and colleagues wrote. “Systematic assessment following emergency department or inpatient mental health care may hasten identification and engagement in appropriate specialty care.”

For more information, see the Psychiatric News article “Early Identification of People With Psychosis Linked to Educating Outpatient Providers” and the Psychiatric Services article “Is the Clinical High-Risk State a Valid Concept? Retrospective Examination in a First-Episode Psychosis Sample.”

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Computer-Assisted CBT for Depression Found Equivalent to Standard CBT

Patients with major depressive disorder who used a computer-assisted form of cognitive-behavioral therapy (CBT) in conjunction with visits with a therapist experienced similar remission rates as those who received traditional CBT for 16 weeks, according to a report in AJP in Advance.

The computer-assisted CBT (CCBT) entailed fewer visits with a therapist than standard CBT, theoretically increasing efficiency and lowering costs. “With increasing utilization of computers in society, improvements in broadband speed and access, and continued work on enhancing the quality of online CCBT programs, computer-assisted methods that reduce costs and improve the efficiency of psychotherapy offer a valuable means to make treatment available to larger numbers of people with depression,” wrote Michael Thase, M.D., of the Perelman School of Medicine at the University of Pennsylvania and colleagues.

The researchers randomized a total of 154 medication-free patients with major depressive disorder to either 16 weeks of standard CBT (up to 20 sessions of 50 minutes each over 16 weeks) or 16 weeks of CCBT using the “Good Days Ahead” (GDA) program, consisting of the nine Internet-delivered modules of GDA and 12 sessions with a therapist. The modules used a blend of video illustrations, psychoeducation from a psychiatrist-narrator, feedback to users, mood graphs to measure progress, interactive skill-building exercises that help users apply CBT methods in daily life, and quizzes to assess comprehension and promote learning. A clinician dashboard allowed therapists to assess progress, view learning exercises, and coordinate all aspects of treatment.

The CBT group received 8.3 more hours of therapist contact than the CCBT group, which corresponds to 10 fewer 50-minute visits across 16 weeks. Both groups experienced large improvements and similar rates of symptom reduction across the 16 weeks of treatment. Among those who completed treatment, remission rates (defined as a score ≤7 on the Hamilton Depression Rating Scale) at week 16 were 46.9% (30/64) for the CCBT group and 48.4% (30/62) for the CBT group. These improvements were maintained in both groups at follow-up visits three and six months later. Among the 55 participants who had remitted at week 16 and completed the follow-up, only six relapsed (11%), two in the CBT group (7%) and four in the CCBT group (16%).

“Because CCBT reduces the ‘dose’ of therapist time, it is possible that this form of treatment would be less effective than standard CBT for patients with higher symptom severity or more complex, long-standing depressions,” Thase and colleagues wrote. “We also did not enroll patients who wanted to receive concomitant antidepressant therapy, which may have skewed sampling toward a subset of patients who were more highly motivated for psychotherapy. It would be worthwhile in future research to study a wider range of depressed patients, including those who prefer combined treatment with antidepressants and those have not obtained an adequate response to pharmacotherapy.”

For related information, see the Psychiatric News article “Online CBT-I Program May Reduce Depression, Anxiety Symptoms” and the Psychiatric Services article “Technology in Mental Health: Creating New Knowledge and Inventing the Future of Services.”

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Methylphenidate Found to Reduce Apathy in Patients With Mild Alzheimer’s Disease

Methylphenidate appears to improve apathy in patients with mild Alzheimer’s disease (AD), according to a study of community-dwelling veterans with mild AD published in AJP in Advance.

Prasad Padala, M.D., an associate director for clinical programs at the Geriatric Research Education and Clinical Center at the Central Arkansas Veterans Healthcare System, and colleagues also found that methylphenidate improved cognition, functional status, caregiver burden, Clinical Global Impression (CGI) scores, and depression.

Padala and colleagues randomized 60 community-dwelling male veterans with mild Alzheimer’s disease to methylphenidate or placebo. All participants were started on 5 mg of methylphenidate or a look-alike placebo twice daily and titrated to 10 mg twice daily at two weeks. The protocol allowed the study physician to decrease the dose if adverse events were reported. Otherwise, participants continued to take 10 mg twice daily until 12 weeks, at which time the dose was tapered to 5 mg twice daily for three days and stopped.

The primary outcome measure was the score on the clinician-reported Apathy Evaluation Scale (AES-C). The secondary outcome measures were scores on the Modified Mini-Mental State Examination and instruments evaluating cognition and function, including ability to carry out daily activities, and depression.

Padala and colleagues found significant differences over time for apathy in the methylphenidate group but not in the placebo group. After adjusting for baseline scores on the AES-C, they found that the methylphenidate group had significantly greater improvement than the placebo group at four weeks, and apathy continued to improve at eight weeks and 12 weeks. The behavioral and cognitive domains improved by eight weeks, and the emotional domain finally improved at 12 weeks. 

“These results suggest that improvement in the emotional domain may be mediated by improvements in the cognitive and behavioral domains,” Padala and colleagues wrote.

They added, “Although the ideal duration of treatment with methylphenidate is unknown, a case for longer duration can be made because the results of these studies were proportional to the duration of treatment, with the highest improvement in apathy and cognition noted with 12-week treatment. Longer duration studies need to be conducted to investigate if the improvement in apathy continues with the duration of treatment or if it plateaus at a certain point.”

For related information, see the Psychiatric News article “Kunadlini Yoga Found to Enhance Cognitive Functioning in Older Adults.”

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