Updated Information from Literature
Don’t Shut Down Conversations When Youth Present With ‘Trending’ Disorders, Psychiatrist Says
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Youth increasingly rely on social media to diagnose themselves with a variety of psychiatric illnesses—a trend that has been met with more than a few raised eyebrows.
In a short Article, Rettew described how he works with youth with so-called “trending presentations” and cautions against the dangers of oversimplifying such cases.
• Ask patients direct questions about whether they have a specific diagnosis in mind, as well as the research that led them to this conclusion: “[I]t is common for my new patients to get a little sheepish when disclosing the source of their investigations, as most commonly the ideas come from social media platforms such as YouTube or TikTok rather than the medical textbooks that used to make medical students wonder about being stricken with lots of exotic ailments,” he described.
• Reject the tendency to dismiss or deny the patient’s narrative “because it does not fit our current scientific or political perspective”: “Science has shown us repeatedly that virtually everything when it comes to mental functioning—from common personality traits to psychopathology to gender typical behavior—comes from a complicated mash-up of mutually interacting genetic and environmental factors. These environmental contributors include things such as peers and media influences, and their presence in the mix should not immediately disqualify someone’s history as undeserving.”
• The more complicated a clinical situation appears, the more important it is to stick to the basics: Establish good rapport with the patient, be thorough, validate while maintaining some skepticism, and give yourself time to conceptualize, he said. “[I]n so doing, we may find that those supposed trending presentations are an accurate description of symptoms that have been long experienced and suppressed by the individual until they are living in an environment supportive enough for their expression. … Or maybe we find out that, indeed, someone really has been heavily influenced by what they have heard from a peer or seen on a social media video as part of developmentally appropriate needs to feel connected socially and developmentally appropriate introspection at this age about their identity,” he wrote.
FDA Approves First Oral Medication for Postpartum Depression
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The U.S. Food and Drug Administration (FDA) on Friday approved Zurzuvae (zuranolone), the first oral medication for the treatment of postpartum depression in adults. Zuranolone acts on similar receptors in the brain as the intravenous medication brexanolone, which was the first postpartum depression medication to receive FDA approval in 2019. Zuranolone and brexanolone are both manufactured by Sage Therapeutics.
Clinical trial data show the pill works quickly, beginning to ease depression in as little as three days, significantly faster than general antidepressants, which can take two weeks or longer to have an effect.
The efficacy of Zurzuvae was demonstrated in two randomized, double-blind, placebo-controlled trials—196 women aged 18 to 45 with severe postpartum depression were assigned to take either zuranolone (50 mg) or placebo pills daily for 14 days. Those in the zuranolone group experienced significantly greater improvements in their depressive symptoms than those taking placebo pills, and the improvements were maintained one month after the last zuranolone dose. Similar outcomes were reported in the other trial, where women with postpartum depression also received another formulation of zuranaolone (equivalent to 40 mg of Zurzuvae) or placebo for 14 days.
The recommended dose for Zurzuvae is 50 mg daily for 14 days. The medication is to be taken in the evening with fat-containing food.
See the article:
Deligiannidis KM,Meltzer-Brody, Maximos B,et al. Zuranolone for the Treatment of Postpartum Depression. Am J Psychiatry 2023 https://doi.org/10.1176/appi.ajp.20220785
Study Supports Repetitive TMS for Patients With Treatment-Resistant Depression
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About 1 in 4 people with treatment-resistant depression may achieve remission with repetitive transcranial magnetic stimulation (rTMS), according to data collected from patients at five hospitals in France. In their study, Bouaziz and colleagues showed that patients with more severe symptoms at baseline experienced greater improvements following rTMS on average.
The study encompasses a large variety of stimulation settings and comorbidities, reflecting usual clinical practice. Thus, this study is intended to guide psychiatrists in real-life practice, as a complement to [randomized, controlled trials] with strict inclusion criteria.
The researchers collected data from 435 adults who were treated with rTMS at one of five French University Hospitals between January 2015 and December 2020. The patients had a diagnosis of either unipolar or bipolar depression and had not responded to at least two trials of antidepressants. Many of these patients had psychiatric or other medical comorbidities; the only patients excluded from the study were those who had metallic implants, had nonstabilized epilepsy, and/or were pregnant. The rTMS protocols at the hospitals varied; the number of sessions ranged from 10 to 28 and the total delivered pulses per session ranged from 360 to 2,000.
They compared patients’ Montgomery–Åsberg Depression Rating Scale (MADRS) scores at baseline with those following the completion of rTMS. Overall, MADRS scores decreased by about 9.5 points, which represented a 33% reduction from baseline levels. In addition, 22.8% of the patients achieved remission (defined as a MADRS score of 10 or less).
Bouaziz and colleagues next looked at factors that might influence a patient’s response to rTMS. They found that patients with more severe baseline depression had greater MADRS improvements following rTMS on average, whereas patients with milder depression were more likely to achieve remission. Patients who did not have psychiatric comorbidities and those who were not taking lithium showed greater symptom improvement than those who did meet these criteria; however, neither the presence of comorbidities nor use of lithium impacted remission rate.
See the article:
Bouaziz N, Laidi C, Bulteau S, Berjamin C, et al.Real world transcranial magnetic stimulation for major depression: A multisite, naturalistic, retrospective study-.Journal of Affective Dis 2023;326:26-35. https://doi.org/10.1016/j.jad.2023.01.070.
Telepsychiatry Creates Opportunities To Increase Access To Treatment, Flexibility, Convenience Of Routine Care And The Potential Of Increased Privacy
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Blanco and colleagues assert in a viewpoint that Telepsychiatry creates opportunities to increase access to treatment, flexibility, convenience of routine care and the potential of increased privacy. The authors outline some of the choices that will have to be made as telepsychiatry continues to expand and will have far-reaching implications for multiple stakeholders including, among others, regulators, payers, clinicians, health care systems, and patients.
See the article:
Blanco C, Wall MM, Olfson M. Implications of Telepsychiatry for Cost, Quality, and Equity of Mental Health Care. JAMA Psychiatry. Published online October 19, 2022. doi:10.1001/jamapsychiatry.2022.3330
Concept of 'Preaddiction' Could Lead to Early Intervention for Possible Substance Use Disorder
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About 20 years ago, diabetes care changed when an organized effort was made to identify patients at risk of diabetes earlier and connect them with treatment. A similar strategy could be used within the substance use disorder (SUD) field by using the term “preaddiction,” advised by McLellan et al in a viewpoint article.
“Addiction is the most severe form of a full spectrum of substance use disorders,” the authors wrote. “It has been the almost exclusive focus of U.S. clinical and policy efforts. However, serious addiction only results after years of unhealthy substance misuse that could be identified and managed much earlier.”
The transition from using a substance to developing a substance use disorder is usually slow and variable, the authors wrote. “[T]he DSM-5 uses 11 equally weighted symptoms of impaired control to define SUDs along a three-stage severity continuum,” they continued. Severe SUDs, commonly referred to as addiction, are defined by six or more symptoms and found in only 4% to 5% of adults, while mild to moderate SUDs are defined by two to five symptoms and found in about 13% of adults. “However, treatment efforts and public health policies have focused almost exclusively on those with serious, usually chronic addictions, virtually ignoring the much larger population with early-stage SUDs,” the authors wrote.
When faced with a similar problem, the American Diabetes Association suggested the term prediabetes in 2001, defined by elevated scores on two laboratory tests (impaired glucose tolerance and impaired fasting glucose). Advertising campaigns that followed to raise public awareness and partnerships with insurers led to the creation of new medications, testing, and interventions. If a similar approach were taken in the SUD field using the term preaddiction, McLellan, Koob, and Volkow wrote, it would require a similarly integrated effort in three areas, including the following:
• Establish measures to define and detect preaddiction: DSM-5 diagnoses are reliable and could be implemented in clinical settings to define preaddiction.
• Identify effective interventions: Screening, brief interventions, referrals to treatment, and a computerized version of cognitive-behavioral therapy could potentially be used as preaddiction interventions. However, the authors also pointed out the need for a broader range of medication treatments and social support.
• Advocate and educate: Few in the public or even in medical practice know how to recognize or what to do when an individual begins to transition to an SUD, and procedures for screening and tracking early-stage SUDs must be taught in medical or nursing schools and properly reimbursed.
The authors acknowledged that some may be concerned that the term preaddiction could intensify stigma, yet they contend that it is exactly the right term to use for two reasons. First, preaddiction refers to the disease, not the individual. “Second, the term addiction is well understood by clinicians and patients as a serious condition to be avoided,” the authors wrote. “Thus, preaddiction has inherent motivational properties that convey the need for clinical action and patient change—just as prediabetes and precancerous currently do.”
See the article:
McLellan AT, Koob GF, Volkow ND. Preaddiction—A Missing Concept for Treating Substance Use Disorders. JAMA Psychiatry. Published online July 06, 2022. doi:10.1001/jamapsychiatry.2022.1652
Most Males Who Die by Suicide Have No Known Mental Health Conditions
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About 20 years ago, diabetes care changed when an organized effort was made to identify patients at risk of diabetes earlier and connect them with treatment. A similar strategy could be used within the substance use disorder (SUD) field by using the term “preaddiction,” advised by McLellan et al in a viewpoint article.
“Addiction is the most severe form of a full spectrum of substance use disorders,” the authors wrote. “It has been the almost exclusive focus of U.S. clinical and policy efforts. However, serious addiction only results after years of unhealthy substance misuse that could be identified and managed much earlier.”
The transition from using a substance to developing a substance use disorder is usually slow and variable, the authors wrote. “[T]he DSM-5 uses 11 equally weighted symptoms of impaired control to define SUDs along a three-stage severity continuum,” they continued. Severe SUDs, commonly referred to as addiction, are defined by six or more symptoms and found in only 4% to 5% of adults, while mild to moderate SUDs are defined by two to five symptoms and found in about 13% of adults. “However, treatment efforts and public health policies have focused almost exclusively on those with serious, usually chronic addictions, virtually ignoring the much larger population with early-stage SUDs,” the authors wrote.
When faced with a similar problem, the American Diabetes Association suggested the term prediabetes in 2001, defined by elevated scores on two laboratory tests (impaired glucose tolerance and impaired fasting glucose). Advertising campaigns that followed to raise public awareness and partnerships with insurers led to the creation of new medications, testing, and interventions. If a similar approach were taken in the SUD field using the term preaddiction, McLellan, Koob, and Volkow wrote, it would require a similarly integrated effort in three areas, including the following:
• Establish measures to define and detect preaddiction: DSM-5 diagnoses are reliable and could be implemented in clinical settings to define preaddiction.
• Identify effective interventions: Screening, brief interventions, referrals to treatment, and a computerized version of cognitive-behavioral therapy could potentially be used as preaddiction interventions. However, the authors also pointed out the need for a broader range of medication treatments and social support.
• Advocate and educate: Few in the public or even in medical practice know how to recognize or what to do when an individual begins to transition to an SUD, and procedures for screening and tracking early-stage SUDs must be taught in medical or nursing schools and properly reimbursed.
The authors acknowledged that some may be concerned that the term preaddiction could intensify stigma, yet they contend that it is exactly the right term to use for two reasons. First, preaddiction refers to the disease, not the individual. “Second, the term addiction is well understood by clinicians and patients as a serious condition to be avoided,” the authors wrote. “Thus, preaddiction has inherent motivational properties that convey the need for clinical action and patient change—just as prediabetes and precancerous currently do.”
See the article:
McLellan AT, Koob GF, Volkow ND. Preaddiction—A Missing Concept for Treating Substance Use Disorders. JAMA Psychiatry. Published online July 06, 2022. doi:10.1001/jamapsychiatry.2022.1652
Caplyta (lumateperone) Approved for Bipolar Depression in Adults
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The U.S. Food and Drug Administration (FDA) has approved the antipsychotic Caplyta (lumateperone) for the treatment of bipolar depression in adults, either as a monotherapy or an adjunct therapy with lithium or valproate. Caplyta, marketed by Intra-Cellular Therapies Inc., is already approved for the treatment of schizophrenia in adults.
The FDA approval was based on positive findings from two six-week, phase 3 trials. The first trial evaluated the effects of 42 mg/day lumateperone monotherapy versus placebo in 381 adults aged 18 to 75 with bipolar I or II depression. The second trial evaluated 28 mg/day or 42/mg day lumateperone versus placebo in 529 adults with bipolar I or II depression who were also taking lithium or valproate.
In both studies, participants taking 42 mg/day lumateperone showed statistically stronger improvements in their depression symptoms after six weeks compared with those taking placebo. In the monotherapy study, Montgomery-Åsberg Depression Rating scale (MADRS) scores dropped by an average of 16.7 points after six weeks in the lumateperone group compared with 12.1 points in the placebo group. In the adjunct therapy study, MADRS scores dropped by an average of 16.9 points after six weeks in the lumateperone group compared with 14.5 points in the placebo group. The data suggested that lumateperone was effective at treating both bipolar I and bipolar II depression.
Lumateperone also demonstrated a favorable safety profile in both studies. The most common side effects were sleepiness, dizziness, nausea, and dry mouth. Lumateperone was not associated with any significant issues of weight gain, cardiometabolic problems, or extrapyramidal symptoms.
The efficacy and favorable safety and tolerability profile make Caplyta an important treatment option for the millions of patients living with bipolar I or II depression and represents a major development for these patients.
For related information, see the article:
Calabrese JR, Durgam S, Satlin A, Vanover KE, Davis RE, Chen R, Kozauer SG, Mates S, Sachs GS. Efficacy and Safety of Lumateperone for Major Depressive Episodes Associated With Bipolar Bipolar II Disorder or I: A Phase 3 Randomized Placebo-Controlled Trial. Am J Psychiatry. 2021 Dec; 178(12):1098-1106. doi: 10.1176/appi.ajp.2021.20091339.
Ostacher MJ.Slowly Working Toward More Treatments for Depression in Bipolar II Disorder. Am J Psychiatry. 2021 Dec; 178(12): 1075- 1076. https://doi.org/10.1176/appi.ajp.2021.21101028
Childhood Trauma Linked to First-Episode Psychosis
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A history of childhood trauma, including abuse and neglect, is common among patients who experience first-episode psychosis, a recent study suggests.
Vila-Badia and colleagues in Spain examined data from 100 hospitalized patients with first-episode psychosis and 94 volunteers with no history of first-episode psychosis in the PROFEP study. This longitudinal study explores the factors and variables that may influence the development and evolution of patients with first-episode psychosis. All patients were assessed via the Childhood Traumatic Questionnaire, the Positive and Negative Syndrome Scale, the Personal and Social Performance Scale, the Suicide Risk Scale of Plutchik, and the Perceived Stress Scale.
Roughly 61% of patients with first-episode psychosis reported having experienced childhood trauma compared with roughly 17% of people who did not have first-episode psychosis.
The most frequent childhood trauma was emotional abuse: 33% of patients with first-episode psychosis had experienced emotional abuse as children, compared with 10% of people without first-episode psychosis. Among patients with first-episode psychosis, 22% reported physical neglect, 20% reported emotional neglect, and 13% reported physical abuse, compared with 1%, 4%, and 2%, respectively, of people without first-episode psychosis. Patients with first-episode psychosis had fewer years of education, more cannabis use, more perceived stress, and a higher risk of suicide compared with people without first-episode psychosis.
The results highlight possible causal links between childhood trauma and subsequent onset of psychosis. However, causal effects should be tested in longitudinal research.
See the article:
Vila-Badia R, Cacho ND, Butiosa A, Arumi CR, Santjusto ME et al. Prevalence and types of childhood trauma in first episode psychosis patients. Relation with clinical onset variables. J Psychiatr Res 2021
https://doi.org/10.1016/j.jpsychires.2021.12.033
For related information, see the Psychiatric Services article
“Associations Between Childhood and Adolescence Adversity and Risk for Arrest Among Patients With First-Episode Psychosis.”
Depressive Symptoms, Clinically Significant Depression Frequent More Than 12 Weeks After SARS-CoV-2 Infection, Systematic Review Suggests
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A recent systemic review finds that depressive symptoms and clinically significant depression were frequent more than 12 weeks after SARS-CoV-2 infection. researchers concluded after reviewing “six uncontrolled observational studies and two prospective cohort studies published between Jan. 1, 2020, and June 5, 2021, that examined reverse transcriptase polymerase chain reaction…-confirmed COVID-19 in conjunction with depressive symptoms and clinical depression.
See the article
Renaud-Charest O, Lui LMW, Eskanser S, Cebon F, Ho R, Di Vincenzo JD et al. Onset and frequency of depression in post-COVID-19 syndrome: A systematic review. J Psychiatric Res 2021; 144: 129-137. https://doi.org/10.1016/j.jpsychires.2021.09.054
Lumateperone Found to Be Effective in Treating Bipolar Depression
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Patients with bipolar disorder who are experiencing a major depressive episode may benefit from taking the antipsychotic lumateperone. In the phase 3 trial of a study conducted by Calabrese and colleagues, revealed that adults taking lumateperone daily reported significantly greater improvements in their depressive symptoms and overall functioning after six weeks than those taking placebo. Lumateperone was also well tolerated, and participants experienced minimal changes in weight or other metabolic parameters.
Approved antipsychotics for bipolar depression are associated with a range of undesirable side effects, including cardiometabolic disturbances, motor impairments, and hyperprolactinemia.Thus, a new treatment option that is effective for depressive episodes in both bipolar I and bipolar II disorders and has a more benign and favorable safety profile could improve patient outcomes, with lower morbidity and a higher quality of life.The authors added that effective medications for treating depressive episodes associated with bipolar II disorder are particularly needed, as only quetiapine is approved as a monotherapy for treating these symptoms.
In this multinational trial, the investigators randomized 381 adults with bipolar I or II disorder who were experiencing a major depressive episode to receive 42 mg lumateperone or placebo daily for six weeks. Safety and efficacy assessments were conducted weekly during the six-week treatment period, as well as during a follow-up two weeks after each participant’s last dose of medication. The main outcomes of interest were the changes in participants’ Montgomery-Åsberg Depression Rating Scale (MADRS) and Clinical Global Impressions Scale–Bipolar Version severity (CGI-BP-S) scores.
After six weeks, average MADRS scores were 4.6 points lower among participants taking lumateperone compared with those taking placebo; 51.1% of adults taking lumateperone responded to the treatment (defined as a drop in MADRS scores from baseline of at least 50%) compared with 36.7% of adults in the placebo group. Statistical differences in symptom improvement between the two groups were evident by the end of the first week. CGI-BP-S scores were also significantly lower among adults taking lumateperone compared with placebo after six weeks.
The rate of side effects in participants taking lumateperone was similar to that of the placebo groups; drowsiness and nausea were the only common side effects more prominent in the lumateperone group. Only 1% of participants in either treatment group reported clinically significant weight gain (≥7% increase from start of study), and no participants exhibited any significant changes in glucose, insulin, triglyceride, or insulin levels. Lumateperone use was also not associated with movement-related extrapyramidal symptoms, outside of one participant who developed mild dyskinesia after six weeks.
See the article
Calabrese JR, Durgam S, Satlin A, Vanover KE, Davis RE et al. Associated With Bipolar I or Bipolar II Disorder: A Phase 3 Randomized Placebo-Controlled Trial.Am J Psychaitry Advance 2021. https://doi.org/10.1176/appi.ajp.2021.20091339
Zuranolone Appears To Improve Symptoms Of Depression For Women With Postpartum Depression, Small Study Indicates
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A randomized, outpatient trial involving women aged 18 to 45 years, no more than six months postpartum, with postpartum depression and a baseline HAMD-17 score of 26 or higher. Participants were then randomized to either placebo or zuranolone [a neuroactive steroid (NAS) GABAA receptor (GABAAR)–positive allosteric modulator (PAM)] administered orally each evening for two weeks (76 and 77 participants, respectively). From day 3 through day 45, the researchers observed sustained differences in HAMD-17 scores that favoured zuranolon and noted sustained differences at day 15 that favored zuranolone in HAMD-17 response on the basis of HAMD-17 score remission, as well as change from baseline for Montgomery-Åsberg Depression Rating Scale score and Hamilton Rating Scale for Anxiety score. Investigators concluded that for women with postpartum depression, zuranolone improves symptoms of depression.
The pathophysiology of postpartum depression (PPD)
The pathophysiology of PPD is likely multifactorial, with evidence supporting a role for disruption of perinatal γ-aminobutyric acid (GABA) signaling, the major inhibitory signaling pathway of the central nervous system. One potential factor affecting GABAergic signaling and PPD development are dramatic perinatal changes in circulating levels of allopregnanolone, a neuroactive steroid (NAS) GABAA receptor (GABAAR)–positive allosteric modulator (PAM).In brain regions associated with emotion and self-perception, neural network connectivity, supported by GABAergic signaling, is positively correlated with plasma allopregnanolone concentrations in individuals with PPD vs healthy postpartum female individuals.The role of GABAergic signaling is further supported by animal model studies demonstrating PPD-like behaviors in mice lacking the extrasynaptic GABAAR δ subunit or potassium/chloride cotransporter KCC2, and these PPD models also functionally link GABA with the hypothalamic-pituitary axis, a stress pathway implicated in PPD.Administration of a preclinical NAS GABAAR PAM that targets both synaptic and extrasynaptic receptors (SAGE-516; Sage Therapeutics, Inc) in late pregnancy reduced PPD-like behaviors in these mouse models, supporting the development of NAS GABAAR PAMs in PPD treatment.
Clinical research in the treatment of PPD supports a role for NAS GABAAR PAMs. Brexanolone injection, a NAS GABAAR PAM, demonstrated reductions in depressive symptoms in 3 double-blind, randomized, placebo-controlled trials and was approved by the US Food and Drug Administration for treatment of adults with PPD.Zuranolone (SAGE-217; Sage Therapeutics, Inc) is an investigational NAS GABAAR PAM with a similar mechanism of action and a pharmacokinetic profile suitable for once-daily oral dosing.NAS GABAAR PAMs have pharmacological profiles and binding sites distinct from benzodiazepines,with the ability to modulate the activity of both synaptic and extrasynaptic GABAARs.Therefore, we performed a phase 3, double-blind, randomized, placebo-controlled clinical trial comparing the efficacy and safety of zuranolone vs placebo in the outpatient treatment of adult women with PPD.
See the article
Deligiannidis KM, Meltzer-Brody S, Gunduz-Bruce H, et al. Effect of Zuranolone vs Placebo in Postpartum Depression: A Randomized Clinical Trial. JAMA Psychiatry. 2021;78(9):951–959. doi:10.1001/jamapsychiatry.2021.1559.
Certain Psychotherapies Provide Effective, Long-Term Treatment For Depression, Results Find
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The investigators conducted network and random-effects pairwise meta-analyses on 331 randomized trials with 34,285 patients and found greater efficacies for all assessed therapies than care-as-usual and waiting list control conditions. Cognitive behavioral, behavioral activation, problem-solving, ‘third wave therapy,’ interpersonal psychotherapy, psychodynamic, and life-review therapy” may treat depression “more effectively and acceptably, with several” of these psychotherapies having significant long-term effects after 1 year and problem-solving therapy was found to have a somewhat higher long-term efficacy than some other therapies. No consistent differences in acceptability were found.
Researchers concluded that the most important types of psychotherapy are efficacious and acceptable in the acute treatment of adult depression, with few significant differences between them. Patient preference and availability of each treatment type may play a larger role in the choice between types of psychotherapy, although it is possible that a more detailed characterization of patients with a diagnosis of depression may lead to a more precise matching between individual patients and individual psychotherapies.
See the article
Cuijpers P, Quero S, Noma H, Ciharova M, Miguel C, et al. Psychotherapies for depression: a network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry 2021;20(2): 283-293.https://doi.org/10.1002/wps.20860
Nine in Ten Children With ADHD May Experience Symptoms Into Young Adulthood
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A study suggests up to 90% of children who have attention-deficit/hyperactivity disorder (ADHD) may continue to experience residual symptoms of the disorder into young adulthood even though many have periods of remission along the way.
The study findings emphasize that childhood-onset ADHD is a chronic but waxing and waning disorder with periods of full remission that are more often temporary than sustained. Health professionals] should expect recurrence of clinically elevated ADHD symptoms and impairments in most patients who experience remission; continued periodic screening for recurrent symptoms and impairments should therefore be standard practice after successful treatment.
Sibley and colleagues examined data from 558 participants with ADHD who had participated in the Multimodal Treatment Study of ADHD (MTA) and had at least one follow-up assessment over a 16-year period after initial assessment in the MTA. Follow-up assessments were offered to participants and parents at 2, 3, 6, 8, 10, 12, 14, and 16 years after baseline, and participants completed an average of 6.2 of the eight possible follow-up assessments. The average age of the participants who completed the follow-up assessments two years after baseline was 10.44 years, and the average age of participants who completed the assessments 16 years after baseline was 25.12 years.
Overall, 31.4% of the participants experienced full remission of their symptoms at a minimum of one time point. Among those, 59.4% then went on to have either a full or partial recurrence of ADHD after their initial period of full remission. Only 9.1% of participants experienced a full recovery from ADHD by the end of the follow-up period. In addition, 10.8% of participants consistently had symptoms of ADHD throughout the study, 15.6% experienced partial remission that was maintained through the study endpoint, and 63.8% had a pattern of fluctuating ADHD.
The results suggest that over 90% of individuals with childhood ADHD will continue to struggle with residual, although sometimes fluctuating, symptoms and impairments through at least young adulthood,” the researchers wrote. The researchers noted that these results run counter to that of prior research that suggested that ADHD remits by adulthood in 50% of cases. The prior research considered ADHD symptoms at only a single point in time, however. The MTA’s longitudinal perspective highlights that full remission at a single time point should not be conflated with recovery from ADHD.
See the article
Sibley MH, Arnold LE, Swanson JM, Hechtman LT, Kennedy TM, Owens E, Molina BSG, et al. Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry Advance 2021.https://doi.org/10.1176/appi.ajp.2021.21010032.
For more related information
Sibley MH, Rohde LA, Swanson JM, Hechtman LT, Molina BSJ,. Mitchell JT, Arnold LE, Caye A, Kennedy TM, Roy A, Stehli A. Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. Am J Psychiatry 2018; 175(2):140-149.doi: 10.1176/appi.ajp.2017.17030298. Epub 2017 Oct 20.
Study Identifies Two Distinct Pathways By Which Adolescents Develop Self-Harming Behaviors
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Researchers identified 2 distinct pathways to self-harm: a “psychopathology” pathway, associated with early and persistent emotional difficulties and bullying; and an “adolescent risky behavior” pathway, whereby risk taking and external challenges emerge later into adolescence and are associated with self-harm.
A cohort study on 1,580 participants (73% female) who had reported engaging in self-harm at age 14. Investigators used computer modelling to identify any social or behavioral similarities in this group compared with peers who did not self-harm. By doing so, the researchers identified two distinct pathways by which adolescents develop self-harming behaviors: the first is associated with years of emotional difficulties and bullying: the second is associated with more willingness to take risks and experiencing less security with peers and family during adolescence.
See the article:
Uh S, Dalmaijer ES, Siugzdaite R, Ford TJ, Astle DE. Two pathways to self-harm in adolescence J Am Acad Child Adolesc Psychiatry 2021; ePub(ePub): ePub. DOI:https://doi.org/10.1016/j.jaac.2021.03.010
For more information:
Visits at www.drmsimullick.com
Continued Use Of ECT Appears Warranted For Reducing Suicide Risk Among Patients With Severe Depression, Study Indicates
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A registry-based cohort study concluded that the continued use of electroconvulsive therapy [ECT] appeared warranted for reducing suicide risk among patients with severe depression investigators concluded after analyzing data from Swedish national registers of 28,557 patients (ECT group mean age, 55.9 years; non-ECT group, 45.2 years; 55.5% women) who received inpatient care between Jan. 1, 2012, and Oct. 31, 2018, for moderate depression, severe depression or severe depression with psychosis.
For more details, see the article
Gaynes BN. Benefits of Electroconvulsive Therapy for Patients With Major Depressive Disorder. JAMA Netw Open. 2021;4(7):e2116674. doi:10.1001/jamanetworkopen.2021.16674
Benefits of ECT May Outweigh Risks for Patients Hospitalized for Depression
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Electroconvulsive therapy (ECT) does not appear to significantly increase the risk of serious medical events in adults who are hospitalized for depression, according to a retrospective cohort study.. Additionally, the study found that ECT may reduce the risk of suicide in these patients.
Kaster and colleagues compared more than 10,000 hospitalization records for adults with depression who received treatment at psychiatric inpatient facilities in Ontario, Canada, for more than three days between April 1, 2007, and February 28, 2017. The researchers examined the number of serious medical events (defined as hospitalization or death) experienced by patients who received ECT during their hospitalization compared with those who did not receive ECT. Specifically, the researchers were interested in serious medical events that occurred within 30 days of the first exposure to ECT or the corresponding index date (for those patients who did not receive ECT).
Patients in the ECT group received a mean number of eight ECT sessions. Of the 5,008 patients in the ECT group, 105 had a serious medical event within 30 days (an incidence of 0.25 per person-year); of the 5,008 patients who did not receive ECT, 135 had a serious medical event within 30 days (an incidence of 0.33 per person-year). The number of nonsuicide deaths was low in both groups, with 11 in the ECT group and 12 in the group that did not receive ECT. Similarly, deaths by suicide were rare in both groups, but significantly lower in the ECT group, the authors noted.
Despite substantial evidence that ECT can help patients with treatment-resistant depression, ECT remains underused, due in part to patients’ concerns over potential side effects of the treatment, for patients to make fully informed decisions regarding electroconvulsive therapy, studies need to assess risk of serious medical events among those with depression who receive electroconvulsive therapy compared with those who receive standard care.
They concluded that among individuals hospitalized with depression, we found no evidence for a clinically significant increased risk for serious medical events with exposure to electroconvulsive therapy, and the risk of suicide was found to be significantly reduced, suggesting the benefits of electroconvulsive therapy for depression outcomes might outweigh its risks in this population.
See the article
Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study. Kaster TS, Vigod SN,Gomes T, Dutradhar R, Wijeysundera DN, Blumberger DM.Lanset Psychiatry2021;8(8): 686-695/12 :2021DOI:https://doi.org/10.1016/S2215-0366(21)00168-1.
For related information
Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners. Wilkinson ST, Kitay NM,Harper A, Rhee TG, Sint K, Ghosh A, Lopez MO, Saenz S,Jack Tsai J. Psychiatr Services 2921, https://doi.org/10.1176/appi.ps.202000387.
Dementia at Younger Ages More Prevalent Than Previously Estimated, Meta-Analysis Suggests
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The development of dementia in people between the ages of 30 and 64 years (known as young-onset dementia) is more common than previously estimated. according to a report published Monday in JAMA Neurology. The new report estimates young-onset dementia affects some 3.9 million people globally.
The authors wrote that although this is higher than previously thought, it is probably an underestimation owing to lack of high-quality data and, more data are needed from low-income countries as well as studies that include younger age ranges.
Hendriks and colleagues searched the literature for population-based studies on the prevalence of young-onset dementia published between January 1, 1990, and March 31, 2020. A total of 74 studies with more than 2.7 million patients were included in an analysis that looked at the prevalence of dementia in adults grouped by five-year age blocks beginning at age 30 through age 64. (The authors noted that most of the studies included in the analysis were conducted in Europe and in older groups in Asia, North America, and Oceania.) Specific diagnoses analyzed included Alzheimer’s disease, frontotemporal dementia, and vascular dementia.
They found an overall global age-standardized prevalence of 119.0 per 100,000 population in the age range of 30 to 64 years, corresponding to 3.9 million people aged 30 to 64 years living with young-onset dementia in the world. The majority of cases occurred when people were between the ages of 45 and 64 years; the prevalence of dementia in people aged 30 to 34 years was found to be extremely rare at about 1.1 per 100,000 but rose to 77.4 per 100,000 among people aged 60 to 64 years.
The most common diagnosis was Alzheimer’s disease, followed by vascular dementia and frontotemporal dementia. However, in the lower age ranges, until 50 years of age, vascular dementia prevalence was the highest, followed by frontotemporal dementia and Alzheimer’s.
Knopman in his editorial wrote “most dementia care is geared for older patients, and as a consequence, services are rarely available to address the needs of someone diagnosed with dementia in their 50s who has dependent children at home and a spouse who must continue working. Understanding the prevalence and incidence of [young-onset dementia] is a first step in addressing this challenge and rationally derived estimate of dementia prevalence across the population aged 30 to 64 years provides a basis for initiating more efforts to improve methods for timely diagnosis and to address the unique needs of [these] patients.”
For details, see the articles:
Hendriks S, Peetoom K, Bakker C, et al. Global Prevalence of Young-Onset Dementia: A Systematic Review and Meta-analysis. JAMA Neurol. Published online July 19, 2021. doi:10.1001/jamaneurol.2021.2161
Knopman DS. Young-Onset Dementia—New Insights for an Underappreciated Problem. JAMA Neurol. Published online July 19, 2021. doi:10.1001/jamaneurol.2021.1760.
ADHD May Develop in Children Following Severe TBI
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Children who experience a severe traumatic brain injury (TBI) appear to be at greater risk of developing attention-deficit/hyperactivity disorder (ADHD) than children who experience less severe injuries, reports a meta-analysis published today in JAMA Pediatrics. Mild or moderate TBI was not associated with any subsequent risk of ADHD.
The researchers compiled data from 24 studies that assessed the prevalence of ADHD before and after a TBI in children. The studies included 12,374 children aged 4 to 18 who experienced TBI of various severities and 43,491 controls with no TBI history. Sixteen percent of the children who experienced TBI of any severity had preexisting ADHD and were excluded from most post-injury analyses. TBI severity was measured with the Glascow Coma Scale (scores of 13-15 for mild, 9-12 for moderate, and 3-8 for severe TBI). The authors assessed the risk of post-injury ADHD in both the short (1 year or less) and long (>1 year) term.
They found that children who had had a severe TBI and no ADHD prior to their injury were more likely to be diagnosed with ADHD both in the short and long term compared with children without TBI, including children who had experienced other injuries (like broken limbs). Overall, 18.8% of children who had a severe TBI were diagnosed with ADHD within one year, compared with 4.9% of children with a mild TBI and 10.3% of children with moderate TBI; 35.5% of children with severe TBI had ADHD more than a year after their injury.
When confronted with claims that a mild TBI causes persistent, severe ADHD symptoms, clinicians should carefully review how the child was functioning before the TBI before concluding that the child developed ADHD as a result of a TBI. There may be psychosocial and medical issues that antedated the TBI that need to be addressed to adequately treat a child’s ADHD symptoms.
Given the clinical significance of ADHD in pediatric practices and parental concerns about the serious effects of mild TBI/concussion stimulated by media reports, information about the risk for ADHD following TBI may be useful in managing children with TBI and counseling their parents- they concluded.
See that article:
Asarnow RF, Newman N, Weiss RE, Su E. Association of Attention-Deficit/Hyperactivity Disorder Diagnoses With Pediatric Traumatic Brain Injury: A Meta-analysis. JAMA Pediatr. Published online July 12, 2021. doi:10.1001/jamapediatrics.2021.2033.