Study Identifies Some Predictors of Bipolar Disorder in At-Risk Youth

Among offspring of individuals with bipolar disorder, 25% were diagnosed with the disorder, according to a study published in AJP in Advance. The study found that childhood sleep and anxiety disorders may be important predictors of the illness.

Participants with childhood anxiety disorders or sleep disorders were nearly twice as likely to develop mood disorder, according to Anne Duffy, M.D., a professor in the Department of Psychiatry at Queen’s University in Canada, and colleagues. Children with depressive or manic symptoms were 2.7 times more likely and 2.3 times more likely, respectively, to develop mood disorder.

The study findings “underscore the importance of taking into account both the family history and the developmental trajectory of emerging psychopathology to improve earlier diagnostic precision in young people manifesting clinically significant symptoms and syndromes,” Duffy and colleagues wrote.

The prospective study included 279 “high-risk” participants (aged 5 to 25 years) who had one parent diagnosed with bipolar disorder I or II, and 87 comparison participants with similar socioeconomic backgrounds from Ottawa schools. Participants were followed for an average of about seven years. All participants completed research assessments administered by a psychiatrist at baseline and about every year thereafter, including a semistructured interview following the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-L) or the similar SADS-L.

The researchers observed bipolar spectrum disorders and psychotic spectrum disorders only in the high-risk offspring (25% and 11%, respectively) and not in the comparison group. There was no difference in the rate of bipolar disorder among participants based on whether their parent responded to lithium; however, psychotic disorders manifested almost exclusively among the offspring of lithium-nonresponsive parents (20% compared with 1%).

The researchers diagnosed major depressive disorder exclusively among the high-risk offspring (33% of high-risk group versus 5% of comparison group). A similar pattern emerged for sleep disorders (23% of high-risk group versus 1% of comparison group). Depressive episodes predominated during the early bipolar course.

The findings indicate the major role that anxiety and sleep disorders and major depression—especially with psychotic symptoms—may play in the development of bipolar disorder in young people with a familial risk. “Early clinical intervention and prevention efforts,” the researchers wrote, “should emphasize low-risk interventions addressing mood symptoms, anxiety and sleep disorders, and prevention of substance misuse.”

For related information, see the Psychiatric News article “Researchers Sum Up Current Knowledge of Bipolar Disorder, Call for More Study.”

(Image: iStock/Steve Debenport)

Follow Psychiatric News on Twitter!

Medicare Beneficiaries With Mental Illness May Be More Likely to Seek Care at Emergency Department

Studies show that a relatively small proportion of the population accounts for most health spending in the United States. By some estimates, 25% of Medicare beneficiaries account for 85% of Medicare costs. A study in Psychiatric Services in Advance now suggests that high-cost Medicare patients with mental health problems may be more likely to seek help at the emergency department (ED) than patients without mental conditions.

Jeffrey B. Weilburg, M.D., of Massachusetts General Hospital (MGH) and colleagues focused their analysis on high-cost Medicare patients who were enrolled in a Medicare Case Management for High-Cost Beneficiaries Demonstration Project (CMHCB-DP) at MGH for at least 12 months. Data were obtained from the following sources: the CMHCB database; the MGH ED information system, which provided ED visit–level data; the MGH comprehensive electronic medical record, which provided a list of diagnoses, procedures, and medications; and the hospital’s electronic billing system, which provided the diagnosis codes associated with the patient’s MGH clinic, hospital inpatient, and outpatient encounters.

All codes in DSM-IV-TR or the mental disorders section of ICD-9-CM were considered as diagnoses of behavioral health conditions. The codes were sorted into 11 categories: adjustment, affective, anxiety, axis II, eating, neuropsychiatric, other, psychosis, sleep, substance abuse, and unknown.

Overall, 1,341 of 3,620 (37%) patients had a total of 2,587 ED visits during their first 12 months of enrollment in CMHCB-DP. Patients who fell into two or more behavioral health categories or had two or more prescribed psychotropics had a significantly greater tendency to make at least one ED visit, compared with patients with no behavioral health diagnosis categories or medications, and were more likely to make four or more ED visits a year. In addition, patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those with other mental health problems to use the ED.

“Most other studies have found that medical severity and comorbidity are the most powerful predictors of ED use. Our findings suggest that this is also true for a high-cost, high-risk subpopulation,” Weilburg and colleagues wrote. “[F]uture studies are needed to address the impact of individual behavioral health diagnoses on ED use.”

For related news, see the Psychiatric Services article “Treating Patient Well-Being in a Psychiatric Emergency Room.”

(Image: iStock/MJFelt)

Follow Psychiatric News on Twitter!

Sleep Disorders May Be Missed in Patients With Psychosis

Sleep disorders appear to be common in patients with psychosis, but few appear to be receiving sleep assessments or treatment for such disorders, suggests a report in Schizophrenia Bulletin.

“Taking sleep disorders in psychosis seriously may have important benefits,” Sarah Reeve, D.Phil., of the University of Oxford and colleagues wrote. “Recent manipulation studies have demonstrated that simulating insomnia increases psychotic experiences, and, conversely, treating insomnia reduces psychotic experiences. … [B]y improving sleep it may be possible to improve psychosis, representing an exciting new treatment target.”

For the study, Reeve and colleagues recruited patients aged 18 to 30 who had received a diagnosis of nonaffective psychotic disorder and outpatient clinical services. The researchers used the Diagnostic Interview for Sleep Patterns and Disorders (DISP) and information obtained from sleep diaries and wrist-based activity monitoring devices to assess the presence of sleep disorders in these patients. If the patient met criteria for diagnosis or positive screen for a sleep disorder, they were then asked whether they had ever discussed the issue with a medical professional and whether they received treatment for the disorder.

Of the 60 patients included in the study, 48 (80%) received a positive screen or diagnosis for at least one sleep disorder. The most common sleep diagnoses were insomnia (n=30, 50%) and nightmare disorder (n=29, 48.3%), but as the authors noted, “there was a broad range of sleep issues presenting in this group and comorbidity was high, with an average of 3.3 sleep disorders per patient.”

Patients with at least one sleep disorder reported more severe paranoia, hallucinations, depression, and anxiety compared with those who did not report a sleep disorder (as assessed by Specific Psychotic Experiences Questionnaire and Depression Anxiety and Stress Scale). The researchers found that over half of the sleep disorders had been discussed with a clinician but almost three-quarters had received no treatment.

“Diagnostic systems such as DSM-5 recommend that sleep problems should be assessed and treated irrespective of other psychiatric comorbidities. This does not appear to be happening in psychosis services,” Reeve and colleagues wrote. “[I]ndependent of any relationship with psychotic experiences, our view is that the assessment and treatment of sleep disorders among those with psychosis merits greater clinical attention.”

For related information, see the Psychiatric News article “Brains of People With Insomnia Stay More Active During Sleep.”

(Image: iStock/FatCamera)

Follow Psychiatric News on Twitter!

FDA Recommends Lower Starting Dose for Popular Sleep Medication

The Food and Drug Administration
(FDA) has announced that it is recommending that health care professionals who prescribe the sleep medication eszopliclone (marketed as Lunesta) lower the current recommended starting dose due to risk of impairment the morning after use of the sleeping aid. The recommended starting dose has been decreased from 2 milligrams to 1 milligram.

The dose change is based in part on findings from a study of nearly 100 healthy volunteers, aged 25 to 40, who were given 3 milligrams of eszopliclone or placebo. The data showed that administration of 3 milligrams of eszoplicone was associated with severe next-morning memory and psychomotor impairment—which included driving skills—in both men and women up to 11 hours after taking the drug. According to the study, despite the long-lasting effects, patients were often unaware that they were impaired.

The FDA recommends that patients currently taking 2 milligram or 3 milligram doses of eszoplicone contact their physician to ask for instructions on how to continue to take their medicine safely at a dose that is best for them.

“Recently, data from clinical trials and other types of studies have become available, which allowed the FDA to better characterize the risk of next-morning impairment with sleep drugs,” commented Ellis Unger, M.D., director of the Office of Drug Evaluation I at the FDA. “To help ensure patient safety, health care professionals should prescribe, and patients should take, the lowest dose of a sleep medicine that effectively treats their insomnia.”

To read the FDA Safety Communication click here. To read more about sleep disorders, see the Psychiatric News articles, "Eating, Sleep Disorder Criteria Revised in DSM-5" and "Combining Insomnia, Depression Treatment May Improve Outcome."

FDA Wants Lower Dosage Recommendations for Zolpidem

The Food and Drug Administration (FDA) announced that it is requiring manufacturers of widely used sleep medications that contain zolpidem to lower current recommended dosages. The ruling will affect manufacturers of Ambien, Ambien CR, Edluar, and Zolpimist. New data show that zolpidem blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving.

The FDA informed the manufacturers that the recommended dosage of zolpidem for women should be lowered from 10 mg to 5 mg for immediate-release products (Ambien, Edluar, and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR). For men, the FDA said that the labeling should recommend that health care professionals consider prescribing these lower dosages (5 mg for immediate-release products and 6.25 mg for extended-release products). These products are available in both the higher and lower dosages.

Data show the risk for next-morning impairment is highest for patients taking the extended-release forms of these drugs. “To decrease the potential risk of impairment with all insomnia drugs, health care professionals should prescribe, and patients should take, the lowest dose capable of treating the patient’s insomnia,” said Ellis Unger, M.D., director, Office of Drug Evaluation I in the FDA's Center for Drug Evaluation and Research. “Patients who must drive in the morning or perform some other activity requiring full alertness should talk to their health care professional about whether their sleep medicine is appropriate.”

Ruth Benca, M.D., a professor of psychiatry and director of the sleep center at the University of Wisconsin School of Medicine, said the ruling is appropriate. “We have always known that zolpidem is a bit more potent in women than in men,” she told Psychiatric News. “It doesn’t mean that everyone should automatically cut their dose if they are doing okay with what they are taking, but clinically it is always good practice to start low and prescribe the lowest dose that is effective.”

For more information on treating sleep problems, see American Psychiatric Publishing's Clinical Manual for Evaluation and Treatment of Sleep Disorders. For purchasing information click here.

(Image: Warren Goldswain/shutterstock.com)

Zebra Fish May Teach Us Something About Sleep

David Prober, Ph.D., of the California Institute of Technology is using the zebra fish to find out why humans and animals sleep. He announced some of his results at a Brain and Behavior Research Foundation symposium held recently in New York City. For example, a deficiency in the neurotransmitter hypocretin has been strongly implicated in narcolepsy. So Prober and his colleagues switched off the gene that makes hypocretin in zebra fish and found that they slept about only half as much as normal. Thus hypocretin may be involved in normal sleep as well as in narcolepsy. Prober and his colleagues are also using the zebra fish as they search for new drugs to treat insomnia. They currently have some candidates.

"Unfortunately sleep research has been underrecognized and underfunded," Dennis Charney, M.D., dean of Mount Sinai School of Medicine, commented after Prober's talk. "The zebra fish is potentially a good model."

Researchers are also studying sleep behaviors as they relate to parasomnias and the significance of insomnia in mood-disorder patients. Read research on those topics in Psychiatric News here and here. Much more about sleep disorders can be found in American Psychiatric Publishing's Clinical Manual for Evaluation and Treatment of Sleep Disorders.

(Image: Vilmos Varga/Shutterstock.com)

Sleep Deprivation Can Heighten Anxiety

Sleep deprivation may amplify anxiety, a study reported June 10 at the  annual meeting of the Associated Professional Sleep Societies found. Eighteen healthy adults were exposed, first after a normal night's sleep and then after a night of sleep deprivation, to an anxiety-provoking situation. Their brains were imaged. In both instances, the exposure provoked activity in the amygdala—the brain's fear center—but that activity was especially pronounced after sleep deprivation.

Teens may be particularly susceptible to sleep deprivation. In another study of the issue, this one conducted by researchers at the Centers for Disease Control and Prevention, more than two-thirds of some 12,000 American teens were found to be getting too little sleep on a regular basis, and this lack of sleep was linked to several health-risk behaviors. More details about this study can be found in Psychiatric News.

To read much more about the consequences of sleep deprivation and the diagnosis and treatment of sleep problems, see American Psychiatric Publishing's Clinical Manual for Evaluation and Treatment of Sleep Disorders.

(Image: Lisa S./Shutterstock.com)

Kay Redfield Jamison Calls Grief 'Necessary'

APA's 2012 annual meeting in Philadelphia wraps up today. Here is more news from the meeting.

Kay Redfield Jamison Compares Grief and Depression
“Grief is not a disease, it’s necessary,” Kay Redfield Jamison, Ph.D., told a large and appreciative audience at APA’s 2012 annual meeting. She is a coauthor of Manic Depressive Illness: Bipolar Disorders and Recurrent Depression, the definitive book on the topic, and a best-selling memoir about her life experiences with mental illness, An Unquiet Mind. She gave a moving and eloquent presentation in which she described her perspective on the similarities and differences between grief and depression, having suffered the ravages of bipolar disorder as well as the 2002 loss of her husband. Read more.

Raise Your Energy and Performance With Sports Strategies
Sports psychiatrists are developing new strategies for athletes and nonathletes to counteract the ways in which competitive pressure degrades quality of life and performance, according to David McDuff, M.D. McDuff is a clinical professor of psychiatry at the University of Maryland School of Medicine and author of Sports Psychiatry: Strategies for Life Balance & Peak Performance by American Psychiatric Publishing. Read more.

Advances in Sleep Disorders: What’s New Under the Moon?
More than half of all psychiatric patients complain of disturbances of sleep and wakefulness. Sleep disorders are associated with impaired daytime functioning and predict a heightened vulnerability to psychiatric illness. They are also associated with physiological impairments and diminished lifespan. Their comorbid presence complicates psychiatric disorders, and their management may offer the potential for greater efficacy in the alleviation of emotional symptoms. These were some of the key points made by Karl Doghramji, M.D., a professor of psychiatry, neurology, and medicine at Thomas Jefferson University. Read more.