Mixed Depression May Be More Common Than Previously Thought

AJPMixed states are characterized by concurrent manic and depressive symptoms. The concept of a “with mixed features” specifier for major depressive episodes was introduced in DSM-5 and defined by the presence of at least three nonoverlapping opposite-pole symptoms in the context of a syndromal depressive, hypomanic, or manic episode. There has been growing interest in the phenomenology and clinical implications of the opposing mixed state—that is, manic or hypomanic symptoms during a depressive episode. A study published in the American Journal of Psychiatry assessed the prevalence and features of mixed depression among bipolar disorder patients and qualitatively compared a range of diagnostic thresholds for mixed depression.

Visit outcomes of adult outpatients (N=907) with bipolar disorder across 14,310 visits between 1995 and 2002 were analyzed. At each visit, mania and depression symptoms were assessed using the Inventory of Depressive Symptomatology–Clinician-Rated Version (IDS-C) and the Young Mania Rating Scale (YMRS). Patients with an IDS-C score of greater or equal to 15 and a YMRS score between 2 and 12 at the same visit were classified as having mixed depression. The presence of mixed depression was observed in 2,139 visits (14.9% of total) and among 584 patients (64.4% of total). Those classified as having one or more mixed depression visits also had more symptomatic visits and fewer non-depressed visits compared with those with no mixed depression visits.

The authors concluded that among the patient population studied, depressive symptoms were common, and subthreshold hypomania occurred in almost half of all visits with depression. The study revealed that women were more likely than men to experience hypomanic symptoms concurrently with depression across a range of diagnostic criteria for mixed depression. “The presence of mixed depression appears to be a marker of vulnerability to mixed depression features in general and may portend a more symptomatic course of illness over time. The stability of our mixed depression construct across a range of definitions supports the possibility that broader diagnostic criteria for mixed depression may improve sensitivity while preserving clinical meaningfulness.”

Source: American Journal of Psychiatry
Published Online April 15, 2016

 

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No Changes to Maintenance Of Certification for Psychiatry, Neurology

A number of medical boards are in the process of reviewing their maintenance of certification (MOC) requirements and steps.  Jeffrey Lyness, MD, psychiatry director for the American Board of Psychiatry and Neurology (ABPN), professor of psychiatry and neurology, and senior associate dean for academic affairs at the University of Rochester School of Medicine and Dentistry, in New York, presented at the American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting this month and reported that the ABPN is not likely to make any major changes anytime soon to the MOC process. There were some minor changes for 2016 making the requirements for Part IV, the Improvement in Medical Practice module, which is also known as the Performance in Practice (PIP) module, more flexible.

For the PIP this year, ABPN diplomates can choose either a clinical or a feedback module. In 2015, the clinical module was required, and in 2014, diplomates were expected to do both. Psychiatrists can receive clinical module credit for a wide variety of activities, including completing institutional quality improvement (QI) activities, completing professional QI activities, such as participating in registries, and through meaningful participation in the American Board of Medical Specialties’ (ABMS’) Portfolio Project. Completion of the “Feedback module” requirements can be met through patient or peer surveys, for example, institutional peer review and supervisor evaluation.

Part IV is a three-step process that includes initial assessment, identifying areas that need improvement and implementing an improvement process, and then undertaking a reassessment. Another new requirement beginning in 2016 is that psychiatrists who are being certified or recertified must take a patient safety course. The ABPN will be listing approved courses on its website.

Sources:

Lyness JM. Update On Geriatric Psychiatry Maintenance Of Certification Program. Journal of the American Association For Geriatric Psychiatry.2016;24(3) Supl 1. Abstracts from the 2016 AAGP Annual Meeting. Washington, DC. March 17–20, 2016. Session 207.

Ault A. MOC: No Changes for Psychiatry, Neurology Anytime Soon. Medscape Medical News. Website http://www.medscape.com/viewarticle/860742. Published March 22, 2016. Accessed March 22, 2016

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Antipsychotic Use in Parkinson’s Disease Associated With Mortality Risk

JNA new study by researchers at the Perelman School of Medicine at the University of Pennsylvania, the University of Michigan Medical School, and the Philadelphia and Ann Arbor Veterans Affairs (VA) Medical Centers and suggests that antipsychotic drugs may do significantly more harm in a subset of Parkinson’s patients.

An analysis of approximately 15,000 patient records in a VA database found that Parkinson’s patients who began using antipsychotic drugs were more than twice as likely to die during the following six months, compared to a matched set of Parkinson’s patients who did not use such drugs. Over a decade ago the FDA has mandated “black box” warnings on antipsychotic medications, noting that there is an increased risk of death when these drugs are used in dementia patients. In the new study, researchers examined the possibility that antipsychotic drug use is associated with higher mortality not just in Parkinson’s dementia patients, but in all Parkinson’s disease patients. The analysis revealed that in the 180 days after they first took antipsychotic drugs, patients in the first group died in much larger numbers, compared with the matched control patients during the same periods. Overall the Parkinson’s patients who used antipsychotics had 2.35 times the mortality of the non-users.

Antipsychotics have been used to manage psychosis that can accompany Parkinson’s disease. The underlying causes of psychosis in Parkinson’s are not well understood, but are thought be the result of the spread of the neurodegenerative disease process to certain brain areas, as well as from higher doses of Parkinson’s drugs that enhance dopamine function. The researchers recommend that for the present, neurologists and other physicians should prescribe antipsychotics to Parkinson’s patients only after looking for other possible solutions, such as treating any co-morbid medical conditions associated with psychosis, reducing the dosage of dopamine replacement therapies, and simply managing the psychosis without antipsychotics.

Study

Weintraub D, et al. Association of Antipsychotic Use With Mortality Risk in Patients With Parkinson Disease. JAMA Neurol. 2016 Mar 21.[Epub ahead of print] PMID:26999262

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Intranasal Formulation Studied for Seizure Cluster Patients

Increased seizure activity including seizure clusters (SCs) and acute repetitive seizures (ARS) are seizure emergencies that require prompt medical attention. Immediate and effective treatment is needed or these seizures may progress to status epilepticus. Treatment in a hospital setting is generally with intravenous  benzodiazepines; this requires a trained professional to administer an intravenous medication. Since most seizures occur out of a hospital, novel approaches to clinical management are needed.

According to Bancke and colleagues, “the ideal out-of-hospital medication for SC/ARS would be highly effective, have rapid onset (minutes) along with a prolonged duration of action (hours), and be quick and easy to administer, with little or no monitoring required.” Alternate routes of seizure rescue medication administration have been explored and currently, the only FDA approved rescue treatment for patients with intermittent episodes of increased seizure activity that can be administered by non-health care professionals is rectal diazepam gel. Although this has been used successfully in both home settings and in hospitals, “there re some drawbacks regarding rectal dosing” and it can be difficult to administer rectal medication to a convulsing patient; in addition, rectally administered drugs may be socially embarrassing.

A recent study of midazolam, which is a potent anticonvulsant that has been used in Europe for decades, evaluated a new formulation. It has been formulated as a nasal spray and is being evaluated as a potential rescue treatment for seizures in patients who require control of intermittent episodes of increased seizure activity. The study evaluated 3 doses of the midazolam nasal spray against midazolam intravenous (IV) and midazolam IV administered intranasally (Inj-IN). Results showed  that the intranasal (IN) spray absorption was rapid and consistent, and that the IN formulation had 36% greater relative bioavailability than the injectable formulation. Treatment emergent adverse effects were evaluated as mild. While this is a phase I study, it demonstrates a potential treatment approach and offers hope for patients who suffer from seizure clusters and acute repetitive seizures.

A number of pediatric studies have evaluated intranasal midazolam for seizures and found it to be efficacious and reasonably safe for treatment of acute seizures in the pediatric population. Various studies have demonstrated a shorter time to seizure cessation with intranasal midazolam versus rectal diazepam in children in the community, prehospital, and ED settings. Many first responders, including caregivers, prefer intranasal midazolam and believe that it is less invasive for patients.

Sources:
Bancke, et al. Epilepsia.2015;56(11):1723-1731. PMID: 26332539.
Humphries, et al. J Pediatr Pharmacol Ther. 2013 Apr;18(2):79-87. PMID: 23798902
Thakker, et al. J Neurol. 2013;260(2):470-474. PMID:22983456

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Non-invasive Vagus Nerve Stimulation For Depression

BPsyA new study published in the current issue of Biological Psychiatry describes successful reduction of depressive symptoms in patients using a novel non-invasive method of vagus nerve stimulation (VNS).
Traditional vagus nerve stimulation (VNS) is a neurostimulation technique that has been used to alleviate treatment-resistant symptoms of depression. However, it was also costly and requires neurosurgery to implant the vagal nerve stimulators.

In this new study, researchers from the China Academy of Chinese Medical Sciences in collaboration with Harvard Medical School investigated a new, modified form of VNS called transcutaneous VNS (tVNS), which instead stimulates the vagus nerve through electrodes clipped onto the ear. Compared to patients who received sham VNS, the patients who received real VNS (N=34) showed significant improvement of their depressive symptoms as measured by the Hamilton Depression Rating Scale.

The safe and low-cost characteristics of tVNS have the potential to significantly expand the clinical application of VNS.

Source: Biological Psychiatry

 

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Task Force Calls for Depression Screening During and After Pregnancy

This week the US Preventive Services Task Force (USPSTF) updated their recommendations on screening for depression in adults. Included in the recommendations is the screening of women for depression during pregnancy and after giving birth. This is the first time the Task Force has recommended screening for maternal mental illness.

The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women. It also reviewed the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations. The task force added that  “Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations.”

The USPSTF also describes the benefits of early detection and intervention and treatment. They found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes (ie, reduction or remission of depression symptoms) in adults, including pregnant and postpartum women. It also supports treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.

The USPSTF also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression.

Sources

NY Times
JAMA
USPSTF

 

Posted in Antidepressant medication, Cognitive Behavior Therapy, Depression, Guideline, Mental health, Mood, Post-partum, Practice guideline, Pregnancy, Screening in Primary Care, Treatment, Wellness | Comments Off on Task Force Calls for Depression Screening During and After Pregnancy

Antipsychotic Discontinuation in Recovered First-Episode Psychosis Results in Relapse

jcp-logoA study published in the Journal of Clinical Psychiatry evaluated the risk of symptom recurrence over 3 years after antipsychotic discontinuation in a sample of functionally recovered first-episode nonaffective psychosis (FEP) patients with schizophrenia spectrum disorder.

When to discontinue antipsychotic medication in patients who have fully recovered from their initial episode of psychosis has been discussed and debated over the years. A prospective, open-label, nonrandomized study evaluated patients from an FEP intervention program at a university hospital setting. Forty-six individuals agreed to discontinue medication while 22 chose to be the control group and remain on antipsychotics. Criteria for participation in the study was: (1) a minimum of 18 months on antipsychotic treatment, (2) clinical remission for at least 12 months, (3) functional recovery for at least 6 months, and (4) stabilization at the lowest effective doses for at least 3 months. Forty-six individuals who were willing to discontinue medication were included in the discontinuation group (target group). The rates of relapse over the 3-year period were 67.4% in the discontinuation group and 31.8% in the maintenance group. The mean time to relapse was 209 (median = 122) days and 608 (median = 607) days, respectively

According to the researchers, a comparison of the two groups demonstrated that rate of symptom recurrence in functionally recovered FEP patients following the self-elected discontinuation of treatment was very high. The relapsed individuals demonstrated significant differences (P < .05) in the Assessment of Negative Symptoms scale, the Clinical Global Impressions scale, and the Disability Assessment Schedule from those who did not relapse.

Source: Journal of Clinical Psychiatry

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In Memorium: Robert Spitzer, MD

Dr. Robert Spitzer – a psychiatrist who played a leading role in establishing the Diagnostic and Statistical Manual of Mental Disorders, or the DSM as the agreed-upon standard to describe mental disorders, died Friday December 25, 2015.  Spitzer died of heart problems, said his wife, Columbia University Professor Emerita Janet Williams. Dr. Spitzer’s work on several editions of the DSM, defined all of the major disorders “so all in the profession could agree on what they were seeing,” said Williams, who worked with him on DSM which became a best-selling book.

Dr. Allen Frances, a professor emeritus of psychiatry at Duke University and editor of a later edition of the DSM manual, said that Spitzer “was by far the most influential psychiatrist of his time.”

Source: NY Times

 

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Forget Everything You Know About Diets and Healthy Eating

CellScience now has an explanation for why many of us try out the latest diet only to find that it is not working. A study published in the journal Cell this week, has demonstrated that different people’s bodies respond to eating the same meal very differently – which means that a diet that may work wonders for one person may not have the same impact on another. A key component used in creating balanced diet plans like Atkins, Zone or South Beach called the glycemic index, developed decades ago as a measure of how certain foods impact blood sugar level, was assumed to be a fixed number. But it’s not. It turns out that it varies widely depending on the individual.

The researchers studied 800 volunteers and collected data through health questionnaires, body measurements, blood tests, glucose monitoring and stool samples. They also had the participants input lifestyle and food intake information into a mobile app that ended up collecting information on a total of 46,898 meals. They found that not only does age and body mass index impact blood glucose level after meals but that different individuals showed vastly different response to the same food even though their own responses remained the same day to day.

The Beginnings of Personalized Dieting and Nutrition

The researchers said these findings show that tailoring meal plans to individuals’ biology may be the future of dieting and that the study yielded many surprises for individuals. For example, a middle-aged woman in the study tried and failed many diets. Tests revealed that her blood sugar levels spiked after eating tomatoes – indicating it is a poor diet choice for her since blood sugar has been associated with cardiovascular problems, obesity and diabetes – but since she didn’t know this, she was eating them as part of her healthy diet plans several times a week.

The authors collected extensive phenotypic data from these individuals, which were then used to train a machine-learning algorithm that could accurately predict glycemic response to various meals. This study is an important proof-of-principle for the utility of tailoring nutritional and/or pharmaceutical interventions to each individual. Precise predictions of glycemic response could represent a powerful tool to optimize dosing of insulin (or dietary interventions) in type 1 or even type 2 diabetics to avoid hypoglycemic episodes and more.  According to the lead author, the work “really enlightened us on how inaccurate we all were about one of the most basic concepts of our existence, which is how we eat and how we integrate nutrition into our daily life.”

Source: Cell

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Diabetes Screening Inadequate in Mentally Ill

JAMA-IMNew research shows that despite long-standing recommendations that severely mentally ill patients who take antipsychotics undergo annual screening for diabetes and other metabolic disorders, only 30% receive such screening. A recent research letter in JAMA Internal Medicine described a retrospective cohort study that analyzed diabetes screening prevalence and predictors of screening among adults in the California public mental health care system with severe mental illness taking antipsychotic medications.

The study cohort included adults with a diagnosis of severe mental illness who received a prescription for an antipsychotic medication at least once during each of the study periods. Of 50,915 patients in the study, only 15,315 (30.1%) received diabetes-specific screening. A total of 15,832 (31.1%) received no form of glucose screening at all during the year-long period. The rates for those who received no glucose screening were similar regardless of age (38.4% for patients aged 18 – 27 years; 31.9% for patients aged 28 – 47 years; 26.9% for those aged 48 – 67 years; and 40.9% for those aged 68 years and older). The study noted that contact with primary care improved diabetes screening rates. Patients with severe mental illnesses who had at least one primary care visit in addition to receiving mental health services were more than twice as likely to be screened than those who did not have a primary care visit (35.6% vs 19.8%).

An editorial that accompanied the new study, Mitchell M Katz, MD pointed out that “To improve care for persons with serious mental illness, it will be necessary to break down the silos that separate the mental health and physical health care systems. Integrated care (care provided by a team of physical and mental health clinicians)—or at least colocated care (care provided by physical and mental health clinicians in the same place)—offers the promise of improving the physical health of individuals with mental illness, as well as the mental health of those seeking physical health services.

Mangurian  C, Newcomer  JW, Vittinghoff  E,  et al.  Diabetes screening among underserved adults with severe mental illness who take antipsychotic medications [published online November 9, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.6098.

Katz, MH. Improving the Health of Persons With Serious Mental Illness. JAMA Intern Med. Published online November 09, 2015. doi:10.1001/jamainternmed.2015.6159

Posted in Antipsychotic medication, Bipolar Disorder, Cardiovascular, Cardiovascular Risk Factors, Diabetes, Mental health, Metabolic screening, Schizophrenia | Comments Off on Diabetes Screening Inadequate in Mentally Ill