Friday, July 18, 2014

Study Finds That Common Lab Test Can Help Predict Antidepressant Treatment Response


Researchers have been studying the interaction between inflammation and depression for decades. Now a team of Canadian and European scientists report in AJP in Advance on a way to help predict treatment outcomes based on levels of C-reactive protein (CRP), a biomarker of systemic inflammation. The study was part of the Genome-Based Therapeutic Drugs for Depression (GENDEP) study and compared outcomes in patients randomized to the SSRI escitalopram (n=115) or the tricyclic antidepressant nortriptyline (n=126). GENDEP is a multinational study sponsored by the European Commission designed to identify genetic markers that can help physicians decide which antidepressant is likely to be effective in a particular patient.

Patients with low baseline levels of CRP improved more with escitalopram, while those with higher CRP levels did better with nortriptyline, as measured on the Montgomery-Åsberg Depression Rating Scale, reported Rudolph Uher, M.D., Ph.D., an associate professor of psychiatry at Dalhousie University in Halifax, Nova Scotia, and colleagues. “The effect size of the differential prediction met criteria for clinical significance, suggesting that the prediction can be meaningful in individual cases.”

The study must be replicated and tested with other antidepressants, said Uher. However, this exploration of the different effects of norepinephrine and serotonin on the immune system may open doors to predict how patients respond to treatments and perhaps narrow the trial-and-error process of finding the right antidepressant for each individual.

To read more about research on the connection between inflammation and depression, see the Psychiatric News articles, “Cytokine Antagonists May Help Some Depression Patients” and "Scientists Closer to Finding Tests for Depression Biomarkers."

(Image: Angellodeco/Shutterstock.com)

Thursday, July 17, 2014

APA Makes Recommendations to HHS Secretary About Community Mental Health Demonstration Programs


As the Department of Health and Human Services (HHS) prepares to implement a project called Demonstration Programs to Improve Community Mental Health Services, APA has forwarded several recommendations to HHS Secretary Sylvia Burwell that it believes will facilitate implementation of the project, whose goal is to bring comprehensive mental health treatment, especially for serious mental illness, to far more Medicaid beneficiaries who need such care. The demonstration program was included in PL-113-93, the Protecting Access to Medicare Act of 2014, which dealt with how physicians would be paid under Medicare for the next year.

In a July 11 letter, APA CEO and Medical Director Saul Levin, M.D., M.P.A., notes that chief among APA's concerns is ensuring that Community Behavioral Health Clinics (CBHCs), which will be established and certified as part of the program, "are structured to provide high-quality health care and that appropriate and efficacious quality metrics are built into the system" and that they will have a psychiatrist as medical director. The letter also addresses the need for child and adolescent psychiatrists in the CBHCs and discusses payment systems for the care provided in the CBHCs.

APA will be meeting with officials of the Centers for Medicare and Medicaid Services and the Substance Abuse and Mental Health Services Administration in the next month to discuss its recommendations in more detail.

Wednesday, July 16, 2014

Pre-Katrina Environment Was Critical in Children's Mental Health Outcomes, Study Finds


The social and economic circumstances surrounding children in New Orleans prior to Hurricane Katrina in 2005 more strongly affected what happened to them afterwards than did individual or personal factors, reported two sociologists in The Dialogue, according to a study published by the Substance Abuse and Mental Health Services Administration’s Disaster Technical Assistance Center.

"Disasters are often depicted as events that affect everyone indiscriminately, regardless of social status,” wrote Lori Peek, Ph.D., an associate professor of sociology and co-director of the Center for Disaster and Risk Analysis at Colorado State University, and Alice Fothergill, Ph.D., an associate professor of sociology at the University of Vermont. However, when pre-storm poverty, parental unemployment, poor housing, insecure neighborhoods, and unreliable access to health care and nutritious food were combined with exposure to life-threatening situations, the result was a “declining trajectory,” the researchers said. Children from poor families struggled later with increased behavioral problems, higher anxiety levels, and trouble concentrating in school, noted Peek and Fothergill. Those families often ended up in mass shelters, compared with middle-class children who could stay with family or friends outside the storm zone and had more resources to draw on as they recovered from the disaster. “Our work demonstrates how pre-existing disadvantage—the crisis before the crisis—and the profound disruption caused by a disaster like Katrina can send already vulnerable children on a downward spiral,” said the authors.

For more in Psychiatric News about the effects of disasters on vulnerable populations, see the article, “MH Recovery Effort Tailored To Diverse Needs of Sandy’s Victims.” More information can be found in the American Psychiatric Publishing book Disaster Psychiatry: Readiness, Evaluation, and Treatment.

(Image: Zack Frank/Shutterstock.com)

Tuesday, July 15, 2014

CBT, Psychodynamic Therapy Appear to Benefit Social Anxiety Disorder in Long Term, Study Finds


Both cognitive-behavioral therapy (CBT) and psychodynamic therapy appear to be efficacious in treating social anxiety disorder, in both the short term and long term, according to the report, "Long-Term Outcome of Psychodynamic Therapy and Cognitive Behavioral Therapy in Social Anxiety Disorder," published online yesterday in AJP in Advance.

German researchers, led by Falk Leichsenring, D.Sc., of the Clinic of Psychosomatics and Psychotherapy at Justus-Liebig University Giessen, last year reported the short-term results of a comparison of the two therapies in the American Journal of Psychiatry, in which both were found more effective than a wait-list control. In the current study, they assessed outpatients with social anxiety disorder who were treated with CBT (N=209) or psychodynamic therapy (N=207) in the previous study at six, 12, and 24 months after the end of therapy. Primary outcome measures were rates of remission and response.

For both CBT and psychodynamic therapy, response rates were approximately 70 percent by the two-year follow-up. Remission rates were nearly 40 percent for both treatment conditions. Rates of response and remission were stable or tended to increase for both treatments over the 24-month follow-up period, and no significant differences were found between the treatment conditions after six months.

“For psychodynamic therapy, improvements in interpersonal problems increased significantly during the follow-up period, suggesting that after the end of treatment, patients treated with psychodynamic therapy continued to work on their interpersonal problems,” the researchers said. “CBT appears to improve interpersonal problems faster, whereas in psychodynamic therapy, improvements seem to take time to emerge following the end of therapy, but eventually the same level of interpersonal problems as in CBT is achieved.”

To read more about research on CBT in patients with anxiety disorders, see the Psychiatric News article, "Imaging Helps Predict Anxiety Patients Who May Benefit From CBT."

(Image: Tashatuvango/shutterstock.com)

Monday, July 14, 2014

Parents of Veterans Who Died by Suicide Criticize VA's Mental Health Care


On Thursday, the House Veterans Affairs Committee listened to emotional stories from family members of soldiers who lost their lives as a result of what they say is inadequate mental health care provided by the Veterans Health Administration.

"We have held a full series of oversight hearings over the last several weeks to evaluate the systemic access and integrity failures that have consumed the VA health care system," said committee Chair Rep. Jeff Miller (R-Fla.) at the hearing's start. "Perhaps none of these hearings have presented the all-too-human face of the VA’s failure so much as today’s hearings will."

Three families and retired military personnel testified before the committee about the barriers uniformed men and women face in accessing effective mental health care. Susan Selke, mother of Marine Sgt. Clay Hunt, 28, who lost his life to suicide in 2011, said that her son was prescribed a brand-name antidepressant that worked well, but was forced to switch drugs because no generic equivalent of the original, and effective, antidepressant was available. Army Sgt. Josh Renschler, who was being treated for anxiety and other medical conditions resulting from a mortar blast in Iraq, explained that he was receiving excellent care through an integrative health initiative until VA "medical center leadership concluded that… [it] was too costly." Other topics discussed were lack of available mental health professionals, long waiting lists, and ineffective communication between the VA and Department of Defense as it concerns veterans’ health records.

"I think that today's hearings went well" said Selke, in an interview with Psychiatric News after her testimony. "I was very pleased at the level of interest, and hopefully some major responses are underway." Later that afternoon, Selke, along with her husband, Richard, and Rep. Tammy Duckworth (D-Ill.), an Iraq war veteran, announced the Clay Hunt Suicide Prevention for American Veterans Act, a bill that would provide suicide-awareness education for veterans and educational loan assistance to those seeking a career in mental health care at the VA.

For information on how to get involved in the push for better mental health care services for military men and women, visit APA’s Legislative Action Center. To read about the recent mental health issues concerning the Veterans Health Administration, see the Psychiatric News articles, "Pentagon, VA Lack Data to Assess PTSD Care Systems," and "Veterans Affairs Scheduling Scandal Leads to Turmoil at the Top."

(photo: Vabren Watts, Psychiatric News)

Friday, July 11, 2014

APA Hosts Meeting of the Mental Health and Faith Community Partnership


“My life today is built on a spiritual foundation, living in the sunlight of the spirit,” said former Congressman Patrick Kennedy in an address this morning at the headquarters of APA. Speaking at a remarkable gathering hosted by APA of more than 40 leaders from the faith and mental health communities, the former congressman and co-sponsor of the Mental Health Parity and Addiction Equity Act described his own recovery from alcohol and substance abuse and the important role that spirituality played in that recovery.

Today’s event at APA inaugurates the Mental Health and Faith Community Partnership, a collaboration between psychiatrists and clergy aimed at fostering a dialogue between the two fields, reducing stigma, and accounting for spiritual dimensions as people seek care. The convening organizations are APA, the American Psychiatric Foundation (APF), and the Interfaith Disability Advocacy Coalition (IDAC), a program of the American Association of People With Disabilities.

Also speaking this morning were Charles Nemeroff, M.D., who described the neurobiological and genetic basis of mental illness; Nancy Kehoe, R.S.C.J., Ph.D., a Roman Catholic nun and clinical psychologist who spoke about building bridges between faith and mental health; Curtis Ramsey Lucas, M.Div., managing director of resource development at American Baptist Home Mission Societies, who is coordinating IDAC’s partnership with APF, who spoke about current efforts within the faith community to reach out to those with mental illness; and Annelle Primm, M.D., M.P.H., director of APA’s Office of Diversity and Health Equity, who spoke about APA’s efforts to reach out to minority and faith communities.

"The agenda for this partnership is ambitious but reflects the scope of the challenges we face,” said APA President Paul Summergrad, M.D. “There is much to be done to reduce stigma, enhance education about, and address the prevalence of, mental illness in our society, so working together is imperative. This July also marks APA's Diversity Mental Health Month, which matters because studies have shown that many groups, such as Hispanics and African Americans, are more inclined to reach out to a member of their faith community than to a mental health professional when experiencing signs of mental illness. APA is deeply committed to entering into a respectful dialogue with faith-based leaders and to listen, learn, and provide the best evidence-based education about mental illness we can provide."

For more on the partnership, see the Psychiatric News article "APA, Foundation Partner With Interfaith Disability Coalition."

(image: Sylvia Johnson)

Thursday, July 10, 2014

APA Provides Resources in Conjunction With Diversity Mental Health Month


APA has designated July as Diversity Mental Health Month, a time to bring attention to mental health disparities and to focus on the mental health needs within diverse communities. "The richness of the United States is reflected in our great diversity. Likewise, APA is strengthened by our broad and diverse membership who come together to support the goals of improving patient care and scientific advances in psychiatry," commented APA President Paul Summergrad, M.D. "Diversity mental health month is a time for reflection on the respectful engagement we need to have with all who need our help."

In a video, APA CEO and Medical Director Saul Levin, M.D., M.P.A., introduces the concept behind Diversity Mental Health Month and the many resources that APA's Division of Diversity and Health Equity has put together for your use not only in July but on an ongoing basis. The video can be accessed at APA's Diversity Mental Health Month webpage here. Additional resources and an infographic on diverse populations are also posted on the webpage. There are also links to a special toolkit that members can download that includes fact sheets, brochures, and community outreach ideas, and educational videos about mental health issues in African-American and Latino populations.

"APA has designated July as the first annual Diversity Mental Health Month as part of our ongoing effort to enhance awareness about the mental health needs of individuals from diverse communities and promote the use of cultural competency in clinical practice and research among psychiatrists and other clinicians," said Levin. "This month is an opportunity to reflect on how we can provide optimal, high-quality care to every one of our patients, regardless of their race, ethnicity, sexual orientation, gender identity, socioeconomic status, religion, or other cultural attributes."

Wednesday, July 9, 2014

Methamphetamine-related Emergency Visits on Rise, SAMHSA Reports


A new report on emergency department (ED) visits for adverse health events associated with illicit use of methamphetamine, with its high potential for abuse and addiction, suggests that unlawful use of the drug is on the rise.

The Substance Abuse and Mental Health Services Administration (SAMSHA) conducted an analysis to assess the prevalence ED visits related to illicit use of methamphetamine from 2007 to 2011. Findings showed that ED visits jumped dramatically from 67,954 in 2007 to 102,961 in 2011. In addition, 62% of the methamphetamine-related ED visits in 2011 involved the use of at least one other substance. Marijuana (22%) and alcohol (16%) were the two substances most frequently associated with methamphetamine-related ED visits.

Director of SAMHSA’s Center for Substance Abuse Treatment H. Westley Clark, M.D., J.D., M.P.H., commented that “this report shows that methamphetamine use may be on the rise again, and we must do everything we can to address this serious public-health problem." Clark stressed that it is of utmost importance to use ED visits as a critical opportunity to talk and intervene with people who have a substance use disorder involving methamphetamine so that they can more fully understand its dangers and know where to they can turn to for help.

To read more about illicit use of methamphetamines and associated adverse health events, see the Psychiatric News articles, "Abused Substances Differ in Rural, Urban," and "Psychotic Symptoms Increase With More Frequent Meth Use."

Tuesday, July 8, 2014

Youth in Various Ethnic Groups Give Different Reasons for Receiving MH Treatment, Study Finds


Racial and ethnic minorities were more likely than whites to endorse externalizing or interpersonal problems and less likely to endorse internalizing problems as reasons for mental health treatment, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Researchers at Emory University and colleagues analyzed data from the 2005-2008 editions of the National Survey on Drug Use and Health on nearly 2,800 adolescent participants who experienced a major depressive disorder and received mental health treatment in the prior year. Racial/ethnic differences in endorsing each of 11 possible reasons for receiving treatment were examined and adjusted for sociodemographic characteristics, health and mental health status, treatment setting, and survey year.

The researchers found that despite similar depressive symptom profiles, Hispanic adolescents were more likely than whites to endorse “breaking the rules or physical fighting” as reasons for mental health treatment. Black adolescents were more likely than whites to endorse “problems at school,” but less likely to endorse “feeling afraid/anxious” or “trouble eating” as reasons for treatment. Asian adolescents were more likely to endorse “interpersonal problems” but less likely than whites to endorse “suicidal thoughts/attempt” and “feeling depressed” as reasons for treatment.

“These findings are not surprising," said Annelle Primm, M.D., APA deputy medical director and director of APA's Division of Diversity and Health Equity, who reviewed the study. "They illustrate that culture counts with respect to a group’s conceptualization of mental illness. Giving reasons of externalizing or interpersonal problems may represent a person's preference for embracing explanations that fit within the realms of cultural norms versus accepting pathological labels, which can be severely stigmatizing and humiliating in some cultural groups.”

For related information, see the Psychiatric News articles, "For Better Mental Health Care for Latinos, Look at Neighborhoods" and "How Americans' View of Black Men Affects Mental Health Care."

(Image: Christy Thomposon/shutterstock.com)

Monday, July 7, 2014

SAMHSA Sounds Alarm Over Teens' Combined Use of Alcohol, Drugs


A new report from the Substance Abuse and Mental Health Services Administration (SAMHSA) sheds light on a public-health concern regarding combined use of alcohol and drugs among adolescents.

SAMHSA’s Drug Abuse Warning Network (DAWN) gathered data from hospital emergency departments nationwide to assess the association between underage drinking and serious health outcomes in people aged 12 to 20. The analysis showed that nearly 188,000 alcohol-related emergency department visits involved youth in this age group—with 20 percent of the visits resulting in serious health outcomes including death. Of the alcohol-related hospital visits that resulted in serious health outcomes, 33% were associated with underage drinking and concurrent drug use, compared with 12% which were associated with underage drinking alone.

“The 9.3 million underage drinkers across America are putting their health and futures at risk—even more so when they combine alcohol with drugs,” stated SAMHSA Administrator Pamela Hyde, J.D. “The start of summer is a good opportunity for parents and other concerned adults to talk with teens and young adults about the dangers of underage drinking and drug use.”

As part of a stepped-up education effort focused on this problem, SAMHSA has started an underage drinking prevention campaign titled “Talk. They Hear You” to help parents and other caregivers initiate a dialogue with children and teenagers on the often-serious risks they face when they drink alcohol.

Information on SAMHSA’s prevention efforts to reduce underage drinking is posted here. To read about other research on alcohol and substance use in youth, see the Psychiatric News article, “News Is Mixed on Teenagers and Substance Use.” For more on this issue, see American Psychiatric Publishing's Clinical Manual of Adolescent Substance Abuse Treatment.


Thursday, July 3, 2014

Cognitive Remediation Therapy May Be Useful in Early-Onset Schizophrenia, Study Shows


Cognitive remediation therapy (CRT) appears to be an effective intervention for adolescents having cognitive impairments associated with early-onset schizophrenia (EOS), according to a report published online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Researchers in the Department of Child and Adolescent Psychiatry in Spain's conducted a randomized, controlled trial of individually delivered CRT plus treatment-as-usual compared with treatment-as-usual (TAU) alone. Fifty adolescents with EOS were randomly assigned to receive CRT or TAU. The researchers used a manualized model of CRT, a strategy-learning program involving tasks of progressive complexity implemented on an individual basis, using mainly paper-and-pencil tasks. Clinical symptoms and cognitive and functional performance were assessed before and after treatment in both groups and after three months in the CRT group. Cognitive domains were defined according to the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) consensus battery and averaged in a global cognitive composite score.

After CRT, significant improvements were found in verbal memory and executive functions, with medium-to-large effect sizes. This change was reliable in more than two-thirds of treated patients. Medium effect sizes were found for improvements after CRT in daily living and adaptive functioning, while large effect sizes were observed for improvements in family burden. With the exception of functional gains, these changes were maintained after three months. “Cognitive improvements can be achieved through CRT, although further research is warranted to determine the durability of functional gains,” the researchers state.

To read more about cognitive remediation in patients with mental illness, see the Psychiatric News article, "Cognitive Training Augments Benefits of Supported Employment."

(Image: pogonici/shutterstock.com)


Wednesday, July 2, 2014

Inflammation in Maternal Sera Linked to Schizophrenia in Offspring, Study Finds


Maternal inflammation as indicated by the presence in maternal sera of early gestational C-reactive protein—an established inflammatory biomarker—appears to be associated with greater risk for schizophrenia in offspring. That’s a key finding from the study, "Elevated Maternal C-Reactive Protein and Increased Risk of Schizophrenia in a National Birth Cohort," published online in AJP in Advance.

American and Finnish researchers conducted a case-control analysis of data from the Finnish Prenatal Study of Schizophrenia, a large, national birth cohort with an extensive serum biobank. They tested for the presence of C-reactive protein in the maternal sera of 777 offspring with schizophrenia and compared the findings with those from 777 control subjects. Maternal C-reactive protein levels were assessed using a latex immunoassay from archived maternal serum specimens.

They found that increasing maternal C-reactive protein levels were significantly associated with development of schizophrenia in offspring. This finding remained significant after adjusting for potential confounders such as parental history of psychiatric disorders, twin/singleton birth, urbanicity, province of birth, and maternal socioeconomic status.

“This is the first time that this association has been demonstrated, indicating that an infection or increased inflammation during pregnancy could increase the risk of schizophrenia in the offspring,” lead author Alan Brown, M.D. (shown in photo above), a professor of psychiatry and epidemiology at Columbia University, told Psychiatric News. “Inflammation has been shown to alter brain development in previous studies, and schizophrenia is a neurodevelopmental disorder,” he noted. “Thus, this study provides an important link between inflammation and schizophrenia and may help us to better understand the biological mechanisms that lead to this disorder.... To the extent that the increased inflammation is due to infection, this work may suggest that approaches aimed at preventing infection may have the potential to reduce risk of schizophrenia.”

To read more about research on potential schizophrenia risk factors, see the Psychiatric News article, "Link Found Between Childhood Infections, Later Psychosis."

Tuesday, July 1, 2014

HIgh Court Lets Law Banning Reparative Therapies for Minors Take Effect


The U.S. Supreme Court yesterday declined to hear the appeal of a case challenging California's law barring use of so-called "conversion therapies" or "reparative therapies" to change the sexual orientation of minors from homosexual to heterosexual. The Ninth Circuit Court of Appeals had upheld the constitutionality of the law in a ruling issued last August, finding that the ban on these therapies served the state's interest in protecting minors from harm and did not violate the free-speech rights of practitioners who want to use these interventions. By declining to hear an appeal of that decision from a Christian legal aid group known as Liberty Counsel, the High Court allowed the appeals court's ruling to stand and the state to begin enforcing the law. As is customary when it declines to hear an appeal, the Supreme Court gave no explanation for its decision. New Jersey Gov. Chris Christie signed a similar law last year, but it too is facing a legal challenge.

"The Supreme Court has cement shut any possible opening to allow further psychological child abuse in California," state Sen. Ted Lieu, the law's sponsor, said Monday. "The Court's refusal to accept the appeal of extreme ideological therapists who practice the quackery of gay conversion therapy is a victory for child welfare, science and basic humane principles."

Psychiatrist Jack Drescher, M.D., who in 2000 drafted APA's position statement opposing sexual orientation conversion or reparative therapies, told Psychiatric News that,"While legislation is not the ideal way to promote best clinical practices in psychotherapy settings, the reality of what is happening on the ground left few options. The fact is that vulnerable children are being brought by their parents to 'therapists' engaging in questionable practices in order to change their sexual orientation. APA and other mainstream health and mental health organizations have found no scientific basis for the efficacy of conversion therapies, and in refusing to hear an appeal of California's gay conversion 'therapy' ban for minors, the Supreme Court has rightly acknowledged that regulating what licensed professionals can say to their patients is not the same thing as regulating free speech."

APA's position statement on reparative and conversion therapies is posted here.

(image: Brandon Bourdages/Shutterstock)

Monday, June 30, 2014

Quetiapine Appears Effective in Treatment of Borderline Personality Disorder, Study Finds


A new study, "Comparison of Low and Moderate Dosages of Extended-Release Quetiapine in Borderline Personality Disorder: A Randomized, Double-Blind, Placebo-Controlled Trial," in AJP in Advance provides evidence for the antipsychotic quetiapine's use as a potential therapy for borderline personality disorder (BPD). A research team led by Donald Black, M.D. (photo at left), vice chair of education and a professor of psychiatry at the University of Iowa Carver College of Medicine, conducted a study comparing the efficacy and tolerability of low and moderate dosages of extended-release quetiapine in adults with BPD.

“A variety of psychotherapies have been developed [for BPD], and while research on the use of medication is ongoing, no drug has been approved in the United States or elsewhere for its treatment,” the researchers pointed out. “This study was designed to provide a rigorous test of extended-release (ER) quetiapine in the treatment of borderline personality disorder.”

They randomly assigned 95 participants who met DSM-IV criteria for BPD to receive low (150 mg/day) or high dosages (300 mg/day) of ER-quetiapine or to placebo for eight weeks. The Zanarini Rating Scale for Borderline Personality Disorder was used to analyze changes in BPD symptoms. The results showed that participants receiving both low and high dosages of ER-quetiapine had significant improvements in BPD symptoms compared with those receiving placebo. Adverse events associated with ER-quetiapine included sedation, change in appetite, and dry mouth. Participants taking high dosages were more likely to experience adverse events.

The researchers noted that "while quetiapine was effective in treating many symptoms of borderline personality disorder, its adverse effects must be taken into consideration." They concluded that their findings emphasize a need for more studies to be conducted to confirm the efficacy of quetiapine—both extended- and immediate-release forms—intended for BPD. Funding for the study was provided by AstraZeneca, which makes the Seroquel brand of quetiapine.

To read more about potential pharmacotherapies for BPD, see the Psychiatric News article, "Several Therapies Show Success in Treatment of Personality Disorders."

(Image: University of Iowa Carver College of Medicine)


Friday, June 27, 2014

Prenatal Exposure to Antidepressants Shows No Cardiac-associated Risk in Offspring, Study Finds


New research shows that antidepressant pharmacotherapy does not appear to pose a risk for cardiac defects in infants born to women taking the medicines during the first trimester of pregnancy—including those that are contraindicated for pregnant women.

A research team led by Krista Huybrechts, Ph.D., of Harvard Medical School conducted a large-scale study with nearly 950,000 pregnant women from 2000 to 2007 to compare the potential risk of congenital cardiac birth defects in offspring of mothers exposed to antidepressants during the first trimester of pregnancy with those who were not taking the drugs.

Study findings, published in the New England Journal of Medicine, showed no significant difference between infants in terms of congenital cardiac defect born to women who took antidepressants during the first trimester and those who did not. In addition, the study found no association between cardiac abnormalities in offspring and maternal exposure to paroxetine or sertraline, drugs classified by the Food and Drug Administration as pregnancy category C and D for potential risks for ventricular defects in the fetus. The study was funded by the Agency for Healthcare Research and Quality and the National Institutes of Health.

“This is very reassuring news,” stated Nada Stotland, M.D., a professor of psychiatry at Rush University and expert in OB-GYN psychiatry, during an interview with Psychiatric News. "Nevertheless, psychotherapy is the optimal first choice for treatment for mild to moderate depression during pregnancy; there are no negative side effects, and the patient can also benefit from the support and insight intrinsic to psychotherapy." Stotland, a former APA president, emphasized that more-serious episodes of depression warrant a trial of antidepressant medication, because "untreated depression poses risk for mother, fetus, and newborn."


(Image: michaeljung/shutterstock.com)

Thursday, June 26, 2014

Use of Antipsychotics Concurrent With Other Psychotropic Meds Has Increased in Medicaid-Insured Youth, Study Finds


Use of second-generation antipsychotics (SGAs) concurrently with other psychotropic medications in children in the Medicaid program has increased over the last few years, according to a report published online in the Journal of American Academy of Child and Adolescent Psychiatry.

Researchers at Children’s Hospital of Philadelphia used data from the Medicaid program to estimate the probability and duration of concurrent SGA use with different psychotropic medication classes over time and to examine concurrent SGAs in relation to clinical and demographic characteristics. Their analysis showed that while SGA use overall increased by 22%, about 85% of such use occurred concurrently with use of other psychotropic medications. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. The concurrent SGA use occurred for long durations (69%-89% of annual medication days).

"We knew that antipsychotic use was increasing among youth, but were surprised to learn just how often a child with ADHD or depression receives an antipsychotic as part of their treatment, and when they do, it is for sustained periods of time," said senior author David Rubin, M.D., co-director of the Policy Lab at Children's Hospital of Philadelphia. “In all likelihood, the use of the antipsychotics illustrates the great challenge clinicians are having when responding to disruptive and challenging behaviors in youth that don't neatly fit common diagnostic categories. In a society that often doesn't offer other services to respond to these behaviors, we should not be surprised how quickly the use of antipsychotics has grown.”

For more information on antipsychotic use in children and adolescents, see the Psychiatric News article, "Increase in Off-Label Antipsychotic Use Seen in Canadian Youth." A comprehensive review of psychotropic medication use in this age group can be found in American Psychiatric Publishing's Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition.

(Image: Luis Rego/shutterstock.com)

Wednesday, June 25, 2014

Study Finds Minimal Benefit for Oxytocin in Patients With Early Psychosis


What appears to be the first randomized controlled trial of oxytocin nasal spray for patients with early psychosis found no benefit over placebo with regard to social functioning—although a follow-up analysis looking at dosing suggests that increased use of oxytocin nasal spray was associated with reductions in negative symptoms. The findings appear in a study published online in Schizophrenia Bulletin.

Oxytocin is a hormone that has been associated with empathy and other factors critical to social functioning. Some preliminary studies have suggested that oxytocin might benefit patients with psychosis, especially with regard to the cognitive and social deficits experienced by schizophrenia patients.

Researchers at the Brain and Mind Institute at Australia's University of Sydney conducted a double-blind, randomized, placebo-controlled trial in which 52 individuals aged 16 to 35 diagnosed with an early psychosis schizophrenia-spectrum illness received oxytocin or placebo nasal spray twice-daily for six weeks, combined with group social cognition training. Assessments were conducted at baseline, post-treatment, and three-month follow-up. Primary outcomes were scores on standardized tests measuring social cognition, social functioning, and negative symptoms. Secondary outcomes included self-report and behavioral assessments of social cognition, symptom severity, and social functioning. The data analysis showed that on all primary and secondary outcomes, there was no benefit of oxytocin nasal spray treatment compared with placebo. However, additional exploratory analysis looking at dosing suggested that increased use of nasal spray was associated with reductions in negative symptoms.

“Although the results suggest no benefit of oxytocin treatment, results also highlight an urgent need to consider nasal spray delivery and dose-related variables for future clinical trials," the researchers said.

Psychiatrist Stephen Marder, M.D., of the Semel Institute for Neuroscience at UCLA, has conducted research using oxytocin to study its effects on empathy. Commenting on the Schizophrenia Bulletin study, Marder said that though the findings are disappointing, the results are important for clarifying when and how oxytocin might be useful. “All of the subjects in the trial received social cognition training,” he said. “It's possible that this was very effective, and oxytocin could add little to it.” He added that it could be that oxytocin loses some of its effectiveness when it is administered chronically, as in this study. “As the authors indicate, more work should be done to clarify the best dose of oxytocin and when it should be administered."

To read more about research on this topic, see the Psychiatric News article, "Social Cognition in Schizophrenia May Improve With Oxytocin."


(Image: hddigital/shutterstock.com)

Tuesday, June 24, 2014

CBT Following Fluoxetine May Reduce Depression Relapse Risk in Youth, Study Shows


Following a course of fluoxetine with cognitive-behavioral therapy (CBT) appears to be effective in reducing the risk of relapse in young people with major depression, according to a report online in AJP in Advance titled “Sequential Treatment With Fluoxetine and Relapse-Prevention CBT to Improve Outcomes in Pediatric Depression.”

Researchers at the University of Texas Southwestern Medical Center and Children’s Medical Center of Dallas randomly assigned youth aged 8 to 17 with major depression who responded well to an initial six weeks of fluoxetine treatment to either continued monotherapy with fluoxetine or continued medication management combined with CBT for six months. Primary outcome measures were time to remission (with remission defined as a score of 28 or less on the Children’s Depression Rating Scale–Revised [CDRS-R]) and rate of relapse (with relapse defined as either a CDRS-R score of 40 or more with a history of two weeks of symptom worsening, or clinical deterioration).

During the 30-week continuation treatment period, time to remission did not differ significantly between treatment groups, but the medication management plus CBT group had a significantly lower risk of relapse than the medication management only group. The estimated probability of relapse by week 30 was 9% with medication management plus CBT and 26.5% with medication management only.

“To our knowledge, this is the first randomized controlled trial of a sequential treatment strategy to prevent relapse in youths with major depressive disorder,” the researchers said. “The results demonstrate that, as in adults, sequencing treatments can reduce risk of relapse and lengthen time to relapse in depressed youths.”

For more information on the use of CBT in youth with depression, see the Psychiatric News article, “CBT Program Helps Some Teens Lower Their Depression Risk.”

(image: hikrcn/shutterstock)



Monday, June 23, 2014

IOM Faults Pentagon, VA for Lack of Data to Assess Effectiveness of PTSD Care


In a just-published two-year study, the Institute of Medicine (IOM) has concluded that despite enormous investments of time, money, and effort in programs to treat posttraumatic stress disorder (PTSD), neither the Department of Defense (DoD) nor the Department of Veterans Affairs (VA) "knows with certainty whether those programs and services are actually successful in reducing the prevalence of PTSD in service members or veterans and in improving their lives."

The 300-page report points out that between 7% and 20% of U.S. service members and veterans of the Iraq and Afghanistan wars may have PTSD and that it can "pervade all aspects of a service member's or veteran's life...," yet neither department collects much treatment outcome data, and what few data exist "suggest that there are only modest improvements in PTSD symptoms after treatment in these programs." To remedy this situation, the IOM committee urges the agencies to develop "an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for service members, veterans, and their families, including female veterans and minority group members."

Committee members emphasized as well that the number of mental health care providers "has not kept pace with the growing demand for PTSD services," and the two agencies have "no formal procedures for evaluating those providers" who have been hired in the last few years or for tracking the care they deliver.

APA President Paul Summergrad, M.D., said, "The IOM's report and recommendations are helpful as our nation contemplates comprehensive reforms to the VA. The IOM Committee found that DoD and VA "should have available an adequate workforce of mental health care providers," especially to meet the demand for PTSD treatment, which is why APA is strongly advocating for the passage of the Ensuring Veterans' Resiliency Act. We also agree that it's crucial to have accurate data and mechanisms in place to evaluate which programs are most effective in relieving PTSD symptoms."

To read about the IOM committee's initial report on PTSD programs in the DoD and VA, see the Psychiatric News article, "Military, VA Can Do Better in PTSD Response, Experts Say."

(image: John Gomez/shutterstock)

Depression Linked to Higher Risk for Cardiovascular Events In Younger Women, Study Finds


A new study published in the Journal of the American Heart Association investigates whether depression can be a "hidden" risk factor to explain why younger women with depression suffer at a disproportionately higher rate from adverse cardiac events compared with age-matched men.

Researchers from the departments of cardiology and epidemiology at Emory University School of Medicine conducted a study to assess whether depression in women aged 55 and younger is associated with higher risk for coronary artery disease and adverse outcomes compared with age-matched males and older women with depression. The study included more than 3,200 patients with depression, assessed by the Patient Health Questionnaire (PHQ)-9, and with known or suspected coronary artery disease. Participants were required to undergo coronary angiography and three years of follow-up.

The results showed that each 1-point increment in symptoms of depression was associated with a 7% increased risk for coronary artery disease in women aged 55 and younger, but not aged-matched male and older female counterparts with depression. Young women with moderate to severe depression were twice as likely to suffer a heart attack, die of heart disease, or require an artery-opening procedure during the follow-up compared with males and older women.

Viola Vaccarino, M.D., Ph.D., senior author of the study and chair of epidemiology and a professor cardiology at Emory, said, "Although the risks and benefits of routine screening for depression are still unclear, our study suggests that young women may benefit for special consideration...unfortunately this age group has largely been understudied..." In March, the American Heart Association issued a scientific statement—endorsed by APA—recommending that depression be formally considered as a risk factor, like diabetes and hypertension, for coronary artery disease. “Our data are in accordance with this recommendation, but suggest that young and middle-aged women may be especially vulnerable to depression as a risk factor," Vaccarino concluded.

To read more about depression as a heart-disease risk factor, see the Psychiatric News articles, "Depression Should Be Listed as Heart Disease Risk, Says AHA Panel," and "Building a Bridge Between Cardiology, Psychiatry."

(Image: Sebastian Kaulitzki/shutterstock.com)


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