User login
Depressed, acutely ill elders benefit from short-term CBT
Short-term cognitive-behavioral therapy is an effective intervention for geriatric patients with comorbid acute illness and depression, judging from the findings of a trial of 155 patients.
“The results presented here confirm the interaction of depression with cognitive and functional performance in this vulnerable study population,” wrote Jana Hummel, MD. “However, the extent of the effect on almost all levels of health was unexpected.”
CBT previously had not been used as a treatment for older patients with acute physical illness and comorbid depression, according to Dr. Hummel and her associates (JAMDA. 2017;18:341-9).
The authors recruited patients aged 82 years, plus or minus 6 years, from a 170-bed hospital that served as the Center for Geriatric Medicine at the University of Heidelberg, Germany. Patients who had been admitted to the hospital had a Hospital Anxiety and Depression Scale (HADS) score of greater than 7. Those with dementia or a life expectancy of less than 1 year were excluded from the study, reported Dr. Hummel of the Geriatric and Gerontopsychotherapeutic Practice in Mannheim, Germany, and her associates.
After the patients were discharged, the clinicians began the active intervention. The investigators randomized 56 people into the CBT intervention, a 15-session, manualized program designed for elderly patients who were based at home. The program included several group sessions held at the hospital’s day clinic and two individual sessions conducted by psychotherapists with expertise in gerontology.
The control group was made up of 99 people. Patients in both groups received antidepressants and other medication, the authors reported in the Journal of the American Medical Directors Association.
Four months after discharge, the patients’ severity of depression as measured by HADS scores was significantly lower among the patients in the psychotherapy group than in the usual care group (1.56 plus or minus 1.4, compared with 3.13 plus or minus 1; P less than .001). Likewise, patients in the psychotherapy group also scored lower on the Hamilton Rating Scale for Depression than did those in the control group (10.57 plus or minus 6.4, compared with 21.47 plus or minus 6.9; P less than .001).
In order for CBT to be effective for this population, arrangements might need to be made to transport patients to intervention sites, according to Dr. Hummel and her associates. Alternatively, the treatment could be administered in nursing homes. Ultimately, the authors said, “the interventions have to be tailored to the individual needs, severity of depression, and health situation.”
One limitation of the study is that the cognitive function of some elderly patients could prevent them from benefiting from CBT. However, Dr. Hummel and her associates said they are optimistic about such interventions for other geriatric patients.
“CBT provides psychological benefit to older patients with depressive symptoms, and it also can reverse some of the functional and cognitive decline associated with depression, they wrote. “It may prove to be an important tool in the treatment of depression in old age and multimorbidity.”
The study was funded with grants from the Robert Bosch Foundation and the Dietmar Hopp Foundation. Dr, Hummel and her associates declared no conflicts of interest.
[email protected]
On Twitter @ginalhenderson
Short-term cognitive-behavioral therapy is an effective intervention for geriatric patients with comorbid acute illness and depression, judging from the findings of a trial of 155 patients.
“The results presented here confirm the interaction of depression with cognitive and functional performance in this vulnerable study population,” wrote Jana Hummel, MD. “However, the extent of the effect on almost all levels of health was unexpected.”
CBT previously had not been used as a treatment for older patients with acute physical illness and comorbid depression, according to Dr. Hummel and her associates (JAMDA. 2017;18:341-9).
The authors recruited patients aged 82 years, plus or minus 6 years, from a 170-bed hospital that served as the Center for Geriatric Medicine at the University of Heidelberg, Germany. Patients who had been admitted to the hospital had a Hospital Anxiety and Depression Scale (HADS) score of greater than 7. Those with dementia or a life expectancy of less than 1 year were excluded from the study, reported Dr. Hummel of the Geriatric and Gerontopsychotherapeutic Practice in Mannheim, Germany, and her associates.
After the patients were discharged, the clinicians began the active intervention. The investigators randomized 56 people into the CBT intervention, a 15-session, manualized program designed for elderly patients who were based at home. The program included several group sessions held at the hospital’s day clinic and two individual sessions conducted by psychotherapists with expertise in gerontology.
The control group was made up of 99 people. Patients in both groups received antidepressants and other medication, the authors reported in the Journal of the American Medical Directors Association.
Four months after discharge, the patients’ severity of depression as measured by HADS scores was significantly lower among the patients in the psychotherapy group than in the usual care group (1.56 plus or minus 1.4, compared with 3.13 plus or minus 1; P less than .001). Likewise, patients in the psychotherapy group also scored lower on the Hamilton Rating Scale for Depression than did those in the control group (10.57 plus or minus 6.4, compared with 21.47 plus or minus 6.9; P less than .001).
In order for CBT to be effective for this population, arrangements might need to be made to transport patients to intervention sites, according to Dr. Hummel and her associates. Alternatively, the treatment could be administered in nursing homes. Ultimately, the authors said, “the interventions have to be tailored to the individual needs, severity of depression, and health situation.”
One limitation of the study is that the cognitive function of some elderly patients could prevent them from benefiting from CBT. However, Dr. Hummel and her associates said they are optimistic about such interventions for other geriatric patients.
“CBT provides psychological benefit to older patients with depressive symptoms, and it also can reverse some of the functional and cognitive decline associated with depression, they wrote. “It may prove to be an important tool in the treatment of depression in old age and multimorbidity.”
The study was funded with grants from the Robert Bosch Foundation and the Dietmar Hopp Foundation. Dr, Hummel and her associates declared no conflicts of interest.
[email protected]
On Twitter @ginalhenderson
Short-term cognitive-behavioral therapy is an effective intervention for geriatric patients with comorbid acute illness and depression, judging from the findings of a trial of 155 patients.
“The results presented here confirm the interaction of depression with cognitive and functional performance in this vulnerable study population,” wrote Jana Hummel, MD. “However, the extent of the effect on almost all levels of health was unexpected.”
CBT previously had not been used as a treatment for older patients with acute physical illness and comorbid depression, according to Dr. Hummel and her associates (JAMDA. 2017;18:341-9).
The authors recruited patients aged 82 years, plus or minus 6 years, from a 170-bed hospital that served as the Center for Geriatric Medicine at the University of Heidelberg, Germany. Patients who had been admitted to the hospital had a Hospital Anxiety and Depression Scale (HADS) score of greater than 7. Those with dementia or a life expectancy of less than 1 year were excluded from the study, reported Dr. Hummel of the Geriatric and Gerontopsychotherapeutic Practice in Mannheim, Germany, and her associates.
After the patients were discharged, the clinicians began the active intervention. The investigators randomized 56 people into the CBT intervention, a 15-session, manualized program designed for elderly patients who were based at home. The program included several group sessions held at the hospital’s day clinic and two individual sessions conducted by psychotherapists with expertise in gerontology.
The control group was made up of 99 people. Patients in both groups received antidepressants and other medication, the authors reported in the Journal of the American Medical Directors Association.
Four months after discharge, the patients’ severity of depression as measured by HADS scores was significantly lower among the patients in the psychotherapy group than in the usual care group (1.56 plus or minus 1.4, compared with 3.13 plus or minus 1; P less than .001). Likewise, patients in the psychotherapy group also scored lower on the Hamilton Rating Scale for Depression than did those in the control group (10.57 plus or minus 6.4, compared with 21.47 plus or minus 6.9; P less than .001).
In order for CBT to be effective for this population, arrangements might need to be made to transport patients to intervention sites, according to Dr. Hummel and her associates. Alternatively, the treatment could be administered in nursing homes. Ultimately, the authors said, “the interventions have to be tailored to the individual needs, severity of depression, and health situation.”
One limitation of the study is that the cognitive function of some elderly patients could prevent them from benefiting from CBT. However, Dr. Hummel and her associates said they are optimistic about such interventions for other geriatric patients.
“CBT provides psychological benefit to older patients with depressive symptoms, and it also can reverse some of the functional and cognitive decline associated with depression, they wrote. “It may prove to be an important tool in the treatment of depression in old age and multimorbidity.”
The study was funded with grants from the Robert Bosch Foundation and the Dietmar Hopp Foundation. Dr, Hummel and her associates declared no conflicts of interest.
[email protected]
On Twitter @ginalhenderson
FROM JAMDA
APA Presidential Symposium will focus on trials in geriatric psychiatry
Designing clinical trials within a psychiatric practice is a challenging endeavor, regardless of the population. But, setting up trials for older adults can involve unique ethical and economic considerations.
On Saturday, May 20, a panel of four experts will explore these issues in an Invited Presidential Symposium at this year’s annual meeting of the American Psychiatric Association in San Diego. The symposium, which will be held that morning from 8 to 11 a.m., will feature Mary Sano, PhD, of the Mount Sinai School of Medicine, New York; Joan A. Mackell, PhD, of JM Neuroscience, New York; Olga Brawman-Mintzer, MD, of the Medical University of South Carolina, Charleston; and Maria I. Lapid, MD, of the Mayo Clinic, Rochester, Minn. Dr. Sano will chair the symposium, and Dr. Brawman-Mintzer will be the cochair.
The discussion will examine some of the basics of clinical trial design for geriatric psychiatry for several disorders, including dementia and depression, and for numerous conditions, including agitation and behavioral disturbances. It will also explore other key issues, such as the regulatory knowledge needed to conduct clinical trials, the role of the institutional review board in protecting human subjects, and whether the protocol works and will pay the bills.
It will take place on the upper level of the San Diego Convention Center (session ID: 8012). To look up other sessions, check out the APA’s search function.
Designing clinical trials within a psychiatric practice is a challenging endeavor, regardless of the population. But, setting up trials for older adults can involve unique ethical and economic considerations.
On Saturday, May 20, a panel of four experts will explore these issues in an Invited Presidential Symposium at this year’s annual meeting of the American Psychiatric Association in San Diego. The symposium, which will be held that morning from 8 to 11 a.m., will feature Mary Sano, PhD, of the Mount Sinai School of Medicine, New York; Joan A. Mackell, PhD, of JM Neuroscience, New York; Olga Brawman-Mintzer, MD, of the Medical University of South Carolina, Charleston; and Maria I. Lapid, MD, of the Mayo Clinic, Rochester, Minn. Dr. Sano will chair the symposium, and Dr. Brawman-Mintzer will be the cochair.
The discussion will examine some of the basics of clinical trial design for geriatric psychiatry for several disorders, including dementia and depression, and for numerous conditions, including agitation and behavioral disturbances. It will also explore other key issues, such as the regulatory knowledge needed to conduct clinical trials, the role of the institutional review board in protecting human subjects, and whether the protocol works and will pay the bills.
It will take place on the upper level of the San Diego Convention Center (session ID: 8012). To look up other sessions, check out the APA’s search function.
Designing clinical trials within a psychiatric practice is a challenging endeavor, regardless of the population. But, setting up trials for older adults can involve unique ethical and economic considerations.
On Saturday, May 20, a panel of four experts will explore these issues in an Invited Presidential Symposium at this year’s annual meeting of the American Psychiatric Association in San Diego. The symposium, which will be held that morning from 8 to 11 a.m., will feature Mary Sano, PhD, of the Mount Sinai School of Medicine, New York; Joan A. Mackell, PhD, of JM Neuroscience, New York; Olga Brawman-Mintzer, MD, of the Medical University of South Carolina, Charleston; and Maria I. Lapid, MD, of the Mayo Clinic, Rochester, Minn. Dr. Sano will chair the symposium, and Dr. Brawman-Mintzer will be the cochair.
The discussion will examine some of the basics of clinical trial design for geriatric psychiatry for several disorders, including dementia and depression, and for numerous conditions, including agitation and behavioral disturbances. It will also explore other key issues, such as the regulatory knowledge needed to conduct clinical trials, the role of the institutional review board in protecting human subjects, and whether the protocol works and will pay the bills.
It will take place on the upper level of the San Diego Convention Center (session ID: 8012). To look up other sessions, check out the APA’s search function.
FDA approves Ingrezza for tardive dyskinesia in adults
The Food and Drug Administration has approved valbenazine capsules for the treatment of tardive dyskinesia in adults.
The approval, announced April 11, came after a 6-week, placebo-controlled trial of 234 participants that compared valbenazine to placebo. At the end of the trial, those who took valbenazine experienced improvement in the severity of involuntary movements, compared with those who received placebo. As a vesicular monoamine transporter type 2 inhibitor, valbenazine works by regulating the amount of dopamine that is released into nerve cells by blocking a protein in the brain. The drug, the first to receive approval for tardive dyskinesia in adults, will be marketed as Ingrezza by Neurocrine Biosciences. Valbenazine is reportedly being studied as a treatment for Tourette syndrome in children and adolescents.
In a statement, Mitchell Mathis, MD, director of the FDA’s division of psychiatry products in the Center for Drug Evaluation and Research, praised the approval as “an important advance for patients suffering with tardive dyskinesia.”
Characterized by uncontrolled movement of the face and body, tardive dyskinesia is a side effect in up to 8% of patients taking typical and atypical antipsychotics. The movement disorder also can cause other debilitating problems, including difficulty with chewing, speaking, and swallowing. Some data show that in about 87% of cases, the condition is irreversible even 3 years after the inciting agent has been discontinued (Parkinsonism Relat Disord. 2016. 32;124-6).
“Tardive dyskinesia can be disabling and can further stigmatize patients with mental illness,” Dr. Mathis said in the statement.
The side effects of valbenazine include sleepiness and QT prolongation. The agency said the patients taking the drug should not drive, operate heavy machinery, or engage in other potentially dangerous activities. Likewise, the drug should be avoided in patients with congenital long QT syndrome or in those with abnormal heartbeats associated with a prolonged QT interval, the agency said.
[email protected]
On Twitter @ginalhenderson
The Food and Drug Administration has approved valbenazine capsules for the treatment of tardive dyskinesia in adults.
The approval, announced April 11, came after a 6-week, placebo-controlled trial of 234 participants that compared valbenazine to placebo. At the end of the trial, those who took valbenazine experienced improvement in the severity of involuntary movements, compared with those who received placebo. As a vesicular monoamine transporter type 2 inhibitor, valbenazine works by regulating the amount of dopamine that is released into nerve cells by blocking a protein in the brain. The drug, the first to receive approval for tardive dyskinesia in adults, will be marketed as Ingrezza by Neurocrine Biosciences. Valbenazine is reportedly being studied as a treatment for Tourette syndrome in children and adolescents.
In a statement, Mitchell Mathis, MD, director of the FDA’s division of psychiatry products in the Center for Drug Evaluation and Research, praised the approval as “an important advance for patients suffering with tardive dyskinesia.”
Characterized by uncontrolled movement of the face and body, tardive dyskinesia is a side effect in up to 8% of patients taking typical and atypical antipsychotics. The movement disorder also can cause other debilitating problems, including difficulty with chewing, speaking, and swallowing. Some data show that in about 87% of cases, the condition is irreversible even 3 years after the inciting agent has been discontinued (Parkinsonism Relat Disord. 2016. 32;124-6).
“Tardive dyskinesia can be disabling and can further stigmatize patients with mental illness,” Dr. Mathis said in the statement.
The side effects of valbenazine include sleepiness and QT prolongation. The agency said the patients taking the drug should not drive, operate heavy machinery, or engage in other potentially dangerous activities. Likewise, the drug should be avoided in patients with congenital long QT syndrome or in those with abnormal heartbeats associated with a prolonged QT interval, the agency said.
[email protected]
On Twitter @ginalhenderson
The Food and Drug Administration has approved valbenazine capsules for the treatment of tardive dyskinesia in adults.
The approval, announced April 11, came after a 6-week, placebo-controlled trial of 234 participants that compared valbenazine to placebo. At the end of the trial, those who took valbenazine experienced improvement in the severity of involuntary movements, compared with those who received placebo. As a vesicular monoamine transporter type 2 inhibitor, valbenazine works by regulating the amount of dopamine that is released into nerve cells by blocking a protein in the brain. The drug, the first to receive approval for tardive dyskinesia in adults, will be marketed as Ingrezza by Neurocrine Biosciences. Valbenazine is reportedly being studied as a treatment for Tourette syndrome in children and adolescents.
In a statement, Mitchell Mathis, MD, director of the FDA’s division of psychiatry products in the Center for Drug Evaluation and Research, praised the approval as “an important advance for patients suffering with tardive dyskinesia.”
Characterized by uncontrolled movement of the face and body, tardive dyskinesia is a side effect in up to 8% of patients taking typical and atypical antipsychotics. The movement disorder also can cause other debilitating problems, including difficulty with chewing, speaking, and swallowing. Some data show that in about 87% of cases, the condition is irreversible even 3 years after the inciting agent has been discontinued (Parkinsonism Relat Disord. 2016. 32;124-6).
“Tardive dyskinesia can be disabling and can further stigmatize patients with mental illness,” Dr. Mathis said in the statement.
The side effects of valbenazine include sleepiness and QT prolongation. The agency said the patients taking the drug should not drive, operate heavy machinery, or engage in other potentially dangerous activities. Likewise, the drug should be avoided in patients with congenital long QT syndrome or in those with abnormal heartbeats associated with a prolonged QT interval, the agency said.
[email protected]
On Twitter @ginalhenderson
Lifetime headache, suicide attempts may be linked in older patients
, a study of 1,965 community-dwelling participants aged 65 years and older suggests.
The results hold “even after adjusting for various confounding variables such as depression,” reported Raffaella Calati, PhD, of Inserm U1061 – Hôpital La Colombière in Montpellier, France, and her associates.
The participants were screened at a neurology hospital. A special questionnaire was developed to assess nonmigrainous and migraine headache. In addition, the participants were examined using the Mini-International Neuropsychiatry Interview, which can be used to identify suicidal ideation, suicide attempts, and Axis I psychiatric disorders.
The association between lifetime suicidal attempts and headache proved significant (odds ratio, 1.92; 95% confidence interval, 1.17-3.15). Of the 17% of people who reported migraine, 29% of them reported lifetime suicide attempts, and, of the 10% of people who reported nonmigrainous headaches, 17% reported lifetime suicide attempts. Subjects who reported lifetime suicide attempts shared several characteristics (Eur Psychiatry. 2017;41:132-9).
“The main finding in this cohort of elderly subjects from the general population was the association between lifetime [suicide attempts] and lifetime headache,” Dr. Calati and her associates wrote. “Interestingly, the association remained significant when controlling for other variables such as gender, living alone, tobacco and alcohol consumption, and depressive/manic, hypomanic, and anxiety disorders.”
The findings could lead to early detection of patients at risk of suicide attempts and help guide the choice of treatment, they said. “In headache subjects the use of drugs associated with a suicidal risk warning, such as antiepileptic drugs (used in headache), should be carefully monitored with closer follow-ups evaluating suicidal risk.”
[email protected]
On Twitter @ginalhenderson
, a study of 1,965 community-dwelling participants aged 65 years and older suggests.
The results hold “even after adjusting for various confounding variables such as depression,” reported Raffaella Calati, PhD, of Inserm U1061 – Hôpital La Colombière in Montpellier, France, and her associates.
The participants were screened at a neurology hospital. A special questionnaire was developed to assess nonmigrainous and migraine headache. In addition, the participants were examined using the Mini-International Neuropsychiatry Interview, which can be used to identify suicidal ideation, suicide attempts, and Axis I psychiatric disorders.
The association between lifetime suicidal attempts and headache proved significant (odds ratio, 1.92; 95% confidence interval, 1.17-3.15). Of the 17% of people who reported migraine, 29% of them reported lifetime suicide attempts, and, of the 10% of people who reported nonmigrainous headaches, 17% reported lifetime suicide attempts. Subjects who reported lifetime suicide attempts shared several characteristics (Eur Psychiatry. 2017;41:132-9).
“The main finding in this cohort of elderly subjects from the general population was the association between lifetime [suicide attempts] and lifetime headache,” Dr. Calati and her associates wrote. “Interestingly, the association remained significant when controlling for other variables such as gender, living alone, tobacco and alcohol consumption, and depressive/manic, hypomanic, and anxiety disorders.”
The findings could lead to early detection of patients at risk of suicide attempts and help guide the choice of treatment, they said. “In headache subjects the use of drugs associated with a suicidal risk warning, such as antiepileptic drugs (used in headache), should be carefully monitored with closer follow-ups evaluating suicidal risk.”
[email protected]
On Twitter @ginalhenderson
, a study of 1,965 community-dwelling participants aged 65 years and older suggests.
The results hold “even after adjusting for various confounding variables such as depression,” reported Raffaella Calati, PhD, of Inserm U1061 – Hôpital La Colombière in Montpellier, France, and her associates.
The participants were screened at a neurology hospital. A special questionnaire was developed to assess nonmigrainous and migraine headache. In addition, the participants were examined using the Mini-International Neuropsychiatry Interview, which can be used to identify suicidal ideation, suicide attempts, and Axis I psychiatric disorders.
The association between lifetime suicidal attempts and headache proved significant (odds ratio, 1.92; 95% confidence interval, 1.17-3.15). Of the 17% of people who reported migraine, 29% of them reported lifetime suicide attempts, and, of the 10% of people who reported nonmigrainous headaches, 17% reported lifetime suicide attempts. Subjects who reported lifetime suicide attempts shared several characteristics (Eur Psychiatry. 2017;41:132-9).
“The main finding in this cohort of elderly subjects from the general population was the association between lifetime [suicide attempts] and lifetime headache,” Dr. Calati and her associates wrote. “Interestingly, the association remained significant when controlling for other variables such as gender, living alone, tobacco and alcohol consumption, and depressive/manic, hypomanic, and anxiety disorders.”
The findings could lead to early detection of patients at risk of suicide attempts and help guide the choice of treatment, they said. “In headache subjects the use of drugs associated with a suicidal risk warning, such as antiepileptic drugs (used in headache), should be carefully monitored with closer follow-ups evaluating suicidal risk.”
[email protected]
On Twitter @ginalhenderson
FROM EUROPEAN PSYCHIATRY
Young patients with first-episode psychosis face far higher mortality risk
Young people in the United States experiencing first-episode psychosis face a mortality risk that is 24 times greater than that of their peers in the general population, a new study shows.
“The hugely elevated mortality observed here underscores that young people experiencing psychosis warrant intensive clinical attention,” wrote Michael Schoenbaum, PhD, senior adviser for mental health services, epidemiology, and economics at the National Institute of Mental Health, and his associates. “In the general population, only individuals over 70 years of age have all-cause 12-month mortality approaching the rates we observed among young psychosis patients here.”
The researchers analyzed data on about 5,000 people aged 16-30 with commercial health insurance coverage who had a new ICD-9 diagnosis of schizophrenia, brief psychotic disorder, or psychotic disorder not otherwise specified, and followed them for 12 months. They limited the sample to people who had continuous insurance coverage over a period of 12 months or greater before their first observed diagnosis of psychosis – which they called the “index diagnosis.”
For the entire psychosis cohort, the 12-month mortality was 2.0% (1,968 per 100,000 people), compared with less than 0.1% in the general population (89 per 100,000). The researchers further found mortality “an order of magnitude higher in those with incident psychosis after age 25, compared with those with an incident diagnosis between ages 16 and 20” (Schizophr Bull. 2017 Apr 7. doi: 10.1093/schbul/sbx009).
Information on the cause of death was not available, but the researchers were able to look at the diagnoses that the decedents had received 12 months before their index psychosis diagnosis. Fifteen of the decedents had been diagnosed with cancer, nine with renal disease (end-stage), and one with cystic fibrosis. When those patients were removed from the mortality cohort, the 12-month mortality stood at 1.5%, a rate they said was 18 times higher than mortality in the general population.
“These findings show the importance of tracking mortality in individuals with mental illness,” Dr. Schoenbaum said in a statement. “Health systems do this in other areas of medicine, such as cancer and cardiology, but not for mental illness. Of course, we also need to learn how these young people are losing their lives.”
The study might not be generalizable because the cohort studied had access to continuous access to health insurance coverage “before and after the index psychosis diagnosis.” Also, the size of the cohort was relatively small. Nevertheless, they said, the findings are consistent with other studies showing that care for those with early psychosis falls short.
“Taken together, these findings provide a strong rationale for initiatives to improve early identification and integrated treatment for psychotic disorders in U.S. treatment settings,” Dr. Schoenbaum and his associates wrote.
The Commonwealth Fund provided support for the study. The researchers reported having no conflicts of interest, and said the views expressed in the study are their own and do not necessarily reflect those of the National Institute of Mental Health, or any other organizations or entities.
[email protected]
On Twitter @ginalhenderson
Young people in the United States experiencing first-episode psychosis face a mortality risk that is 24 times greater than that of their peers in the general population, a new study shows.
“The hugely elevated mortality observed here underscores that young people experiencing psychosis warrant intensive clinical attention,” wrote Michael Schoenbaum, PhD, senior adviser for mental health services, epidemiology, and economics at the National Institute of Mental Health, and his associates. “In the general population, only individuals over 70 years of age have all-cause 12-month mortality approaching the rates we observed among young psychosis patients here.”
The researchers analyzed data on about 5,000 people aged 16-30 with commercial health insurance coverage who had a new ICD-9 diagnosis of schizophrenia, brief psychotic disorder, or psychotic disorder not otherwise specified, and followed them for 12 months. They limited the sample to people who had continuous insurance coverage over a period of 12 months or greater before their first observed diagnosis of psychosis – which they called the “index diagnosis.”
For the entire psychosis cohort, the 12-month mortality was 2.0% (1,968 per 100,000 people), compared with less than 0.1% in the general population (89 per 100,000). The researchers further found mortality “an order of magnitude higher in those with incident psychosis after age 25, compared with those with an incident diagnosis between ages 16 and 20” (Schizophr Bull. 2017 Apr 7. doi: 10.1093/schbul/sbx009).
Information on the cause of death was not available, but the researchers were able to look at the diagnoses that the decedents had received 12 months before their index psychosis diagnosis. Fifteen of the decedents had been diagnosed with cancer, nine with renal disease (end-stage), and one with cystic fibrosis. When those patients were removed from the mortality cohort, the 12-month mortality stood at 1.5%, a rate they said was 18 times higher than mortality in the general population.
“These findings show the importance of tracking mortality in individuals with mental illness,” Dr. Schoenbaum said in a statement. “Health systems do this in other areas of medicine, such as cancer and cardiology, but not for mental illness. Of course, we also need to learn how these young people are losing their lives.”
The study might not be generalizable because the cohort studied had access to continuous access to health insurance coverage “before and after the index psychosis diagnosis.” Also, the size of the cohort was relatively small. Nevertheless, they said, the findings are consistent with other studies showing that care for those with early psychosis falls short.
“Taken together, these findings provide a strong rationale for initiatives to improve early identification and integrated treatment for psychotic disorders in U.S. treatment settings,” Dr. Schoenbaum and his associates wrote.
The Commonwealth Fund provided support for the study. The researchers reported having no conflicts of interest, and said the views expressed in the study are their own and do not necessarily reflect those of the National Institute of Mental Health, or any other organizations or entities.
[email protected]
On Twitter @ginalhenderson
Young people in the United States experiencing first-episode psychosis face a mortality risk that is 24 times greater than that of their peers in the general population, a new study shows.
“The hugely elevated mortality observed here underscores that young people experiencing psychosis warrant intensive clinical attention,” wrote Michael Schoenbaum, PhD, senior adviser for mental health services, epidemiology, and economics at the National Institute of Mental Health, and his associates. “In the general population, only individuals over 70 years of age have all-cause 12-month mortality approaching the rates we observed among young psychosis patients here.”
The researchers analyzed data on about 5,000 people aged 16-30 with commercial health insurance coverage who had a new ICD-9 diagnosis of schizophrenia, brief psychotic disorder, or psychotic disorder not otherwise specified, and followed them for 12 months. They limited the sample to people who had continuous insurance coverage over a period of 12 months or greater before their first observed diagnosis of psychosis – which they called the “index diagnosis.”
For the entire psychosis cohort, the 12-month mortality was 2.0% (1,968 per 100,000 people), compared with less than 0.1% in the general population (89 per 100,000). The researchers further found mortality “an order of magnitude higher in those with incident psychosis after age 25, compared with those with an incident diagnosis between ages 16 and 20” (Schizophr Bull. 2017 Apr 7. doi: 10.1093/schbul/sbx009).
Information on the cause of death was not available, but the researchers were able to look at the diagnoses that the decedents had received 12 months before their index psychosis diagnosis. Fifteen of the decedents had been diagnosed with cancer, nine with renal disease (end-stage), and one with cystic fibrosis. When those patients were removed from the mortality cohort, the 12-month mortality stood at 1.5%, a rate they said was 18 times higher than mortality in the general population.
“These findings show the importance of tracking mortality in individuals with mental illness,” Dr. Schoenbaum said in a statement. “Health systems do this in other areas of medicine, such as cancer and cardiology, but not for mental illness. Of course, we also need to learn how these young people are losing their lives.”
The study might not be generalizable because the cohort studied had access to continuous access to health insurance coverage “before and after the index psychosis diagnosis.” Also, the size of the cohort was relatively small. Nevertheless, they said, the findings are consistent with other studies showing that care for those with early psychosis falls short.
“Taken together, these findings provide a strong rationale for initiatives to improve early identification and integrated treatment for psychotic disorders in U.S. treatment settings,” Dr. Schoenbaum and his associates wrote.
The Commonwealth Fund provided support for the study. The researchers reported having no conflicts of interest, and said the views expressed in the study are their own and do not necessarily reflect those of the National Institute of Mental Health, or any other organizations or entities.
[email protected]
On Twitter @ginalhenderson
FROM SCHIZOPHRENIA BULLETIN
Childhood adversities tied to depressive symptoms in older homeless adults
Childhood adversities, which are known contributors to psychiatric morbidity in adults, continue to be disruptive later in life, a cross-sectional study of 350 older homeless adults shows.
“Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations,” wrote Chuan-Mei Lee, MD, and her associates (Am J Geriatr Psychiatry. 2017 Feb;25[2]:107-17).
At the start of the study, Dr. Lee and her associates recruited 350 adults who met the participation criteria from several places frequented by homeless individuals in Oakland, Calif., including shelters and encampments.
The median age of the participants was 58.1 years, 77.1% were men, and 79.7% were African American. All of the participants were English speakers and were homeless as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act (Psychiatr Ser. 2009;60[4]:465-72). Many of the participants (43.4%) had experienced their first homeless episode at age 50 years or later, reported Dr. Lee of the department of psychiatry at the University of California, San Francisco, and her associates.
The older homeless adults were accessed clinically and asked whether a health care provider had ever told them that they had any of several conditions, including hypertension, coronary artery disease, diabetes, stroke, cancer, and HIV/AIDS. The investigators used the Modified Mini-Mental State examination to assess the participants’ cognitive statuses.
The participants were asked about seven categories of adverse events that they might have experienced before age 18. Specifically, they were asked if they had experienced physical neglect, verbal abuse, physical abuse, sexual abuse, the death of either parent, incarceration of a parent for 1 month or more, or placement in the child welfare system. Each person received a childhood adversity score ranging from 0 to 7.
“Because of the low prevalence of scores of 5 or greater, we grouped study participants with four or more childhood adversities together,” Dr. Lee and her associates wrote.
Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD). A CESD score equal to or greater than 22 was used to define moderate to severe depressive symptoms.
Participants who completed the enrollment procedures received a $5 gift card, and those who completed the enrollment interview received a $20 gift card.
Of the 350 total participants, 251 reported a history of childhood adversity, and 99 reported no such history. Verbal abuse was the most commonly reported childhood adversity (49.3%), followed by physical abuse (33.3%) and parental death (21.4%).
Overall, the investigators found that more than one-third of the participants (38.3%) received CESD scores high enough to place them in the moderate to severe depressive symptoms category. Furthermore, they found a dose-response relationship between the number of adverse experiences and higher odds of moderate to severe depressive symptoms.
Participants with “exposure to one childhood adversity had a twofold increase in odds of reporting moderate to severe depressive symptoms (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7), whereas those with exposure to four or more childhood adversities had a sixfold increase (AOR, 6.0; 95% CI, 2.4-15.4), compared with those with no adverse events,” the investigators noted.
Similar dose-response relationships were found between the number of adverse childhood events and the number of lifetime suicide attempts.
Dr. Lee and her associates said their findings have implications for clinical practice. The Substance Abuse and Mental Health Services Administration recommends that clinicians screen all patients for physical and sexual trauma but not for parental loss, they said.
“Our findings suggest that mental health and primary care providers should consider screening older homeless adults for all childhood adversities,” they wrote. “This may enhance suicide risk assessment by identifying those with multiple adversities, who are at highest risk.”
The investigators cited several limitations. For example, estimates of childhood adversity might have been underreported. Also, the study’s cross-sectional design made it difficult to establish causation between childhood adversity and psychiatric morbidity.
Nevertheless, “psychiatrists working with low-income, older populations should screen for homelessness,” they wrote. “The high prevalence of psychiatric morbidity in this medically complex population presents challenges to the mental health workforce [amid] a shortage of geriatric psychiatrists.”
Dr. Lee reported no conflicts of interest. The principal investigator, Margot Kushel, MD, reported serving on the leadership board of EveryOne Home, a group that seeks to bring an end to homelessness in Alameda County, Calif. The National Institute on Aging, the National Institute of Mental Health, and SAMHSA provided funding support.
[email protected]
On Twitter @ginalhenderson
Childhood adversities, which are known contributors to psychiatric morbidity in adults, continue to be disruptive later in life, a cross-sectional study of 350 older homeless adults shows.
“Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations,” wrote Chuan-Mei Lee, MD, and her associates (Am J Geriatr Psychiatry. 2017 Feb;25[2]:107-17).
At the start of the study, Dr. Lee and her associates recruited 350 adults who met the participation criteria from several places frequented by homeless individuals in Oakland, Calif., including shelters and encampments.
The median age of the participants was 58.1 years, 77.1% were men, and 79.7% were African American. All of the participants were English speakers and were homeless as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act (Psychiatr Ser. 2009;60[4]:465-72). Many of the participants (43.4%) had experienced their first homeless episode at age 50 years or later, reported Dr. Lee of the department of psychiatry at the University of California, San Francisco, and her associates.
The older homeless adults were accessed clinically and asked whether a health care provider had ever told them that they had any of several conditions, including hypertension, coronary artery disease, diabetes, stroke, cancer, and HIV/AIDS. The investigators used the Modified Mini-Mental State examination to assess the participants’ cognitive statuses.
The participants were asked about seven categories of adverse events that they might have experienced before age 18. Specifically, they were asked if they had experienced physical neglect, verbal abuse, physical abuse, sexual abuse, the death of either parent, incarceration of a parent for 1 month or more, or placement in the child welfare system. Each person received a childhood adversity score ranging from 0 to 7.
“Because of the low prevalence of scores of 5 or greater, we grouped study participants with four or more childhood adversities together,” Dr. Lee and her associates wrote.
Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD). A CESD score equal to or greater than 22 was used to define moderate to severe depressive symptoms.
Participants who completed the enrollment procedures received a $5 gift card, and those who completed the enrollment interview received a $20 gift card.
Of the 350 total participants, 251 reported a history of childhood adversity, and 99 reported no such history. Verbal abuse was the most commonly reported childhood adversity (49.3%), followed by physical abuse (33.3%) and parental death (21.4%).
Overall, the investigators found that more than one-third of the participants (38.3%) received CESD scores high enough to place them in the moderate to severe depressive symptoms category. Furthermore, they found a dose-response relationship between the number of adverse experiences and higher odds of moderate to severe depressive symptoms.
Participants with “exposure to one childhood adversity had a twofold increase in odds of reporting moderate to severe depressive symptoms (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7), whereas those with exposure to four or more childhood adversities had a sixfold increase (AOR, 6.0; 95% CI, 2.4-15.4), compared with those with no adverse events,” the investigators noted.
Similar dose-response relationships were found between the number of adverse childhood events and the number of lifetime suicide attempts.
Dr. Lee and her associates said their findings have implications for clinical practice. The Substance Abuse and Mental Health Services Administration recommends that clinicians screen all patients for physical and sexual trauma but not for parental loss, they said.
“Our findings suggest that mental health and primary care providers should consider screening older homeless adults for all childhood adversities,” they wrote. “This may enhance suicide risk assessment by identifying those with multiple adversities, who are at highest risk.”
The investigators cited several limitations. For example, estimates of childhood adversity might have been underreported. Also, the study’s cross-sectional design made it difficult to establish causation between childhood adversity and psychiatric morbidity.
Nevertheless, “psychiatrists working with low-income, older populations should screen for homelessness,” they wrote. “The high prevalence of psychiatric morbidity in this medically complex population presents challenges to the mental health workforce [amid] a shortage of geriatric psychiatrists.”
Dr. Lee reported no conflicts of interest. The principal investigator, Margot Kushel, MD, reported serving on the leadership board of EveryOne Home, a group that seeks to bring an end to homelessness in Alameda County, Calif. The National Institute on Aging, the National Institute of Mental Health, and SAMHSA provided funding support.
[email protected]
On Twitter @ginalhenderson
Childhood adversities, which are known contributors to psychiatric morbidity in adults, continue to be disruptive later in life, a cross-sectional study of 350 older homeless adults shows.
“Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations,” wrote Chuan-Mei Lee, MD, and her associates (Am J Geriatr Psychiatry. 2017 Feb;25[2]:107-17).
At the start of the study, Dr. Lee and her associates recruited 350 adults who met the participation criteria from several places frequented by homeless individuals in Oakland, Calif., including shelters and encampments.
The median age of the participants was 58.1 years, 77.1% were men, and 79.7% were African American. All of the participants were English speakers and were homeless as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act (Psychiatr Ser. 2009;60[4]:465-72). Many of the participants (43.4%) had experienced their first homeless episode at age 50 years or later, reported Dr. Lee of the department of psychiatry at the University of California, San Francisco, and her associates.
The older homeless adults were accessed clinically and asked whether a health care provider had ever told them that they had any of several conditions, including hypertension, coronary artery disease, diabetes, stroke, cancer, and HIV/AIDS. The investigators used the Modified Mini-Mental State examination to assess the participants’ cognitive statuses.
The participants were asked about seven categories of adverse events that they might have experienced before age 18. Specifically, they were asked if they had experienced physical neglect, verbal abuse, physical abuse, sexual abuse, the death of either parent, incarceration of a parent for 1 month or more, or placement in the child welfare system. Each person received a childhood adversity score ranging from 0 to 7.
“Because of the low prevalence of scores of 5 or greater, we grouped study participants with four or more childhood adversities together,” Dr. Lee and her associates wrote.
Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD). A CESD score equal to or greater than 22 was used to define moderate to severe depressive symptoms.
Participants who completed the enrollment procedures received a $5 gift card, and those who completed the enrollment interview received a $20 gift card.
Of the 350 total participants, 251 reported a history of childhood adversity, and 99 reported no such history. Verbal abuse was the most commonly reported childhood adversity (49.3%), followed by physical abuse (33.3%) and parental death (21.4%).
Overall, the investigators found that more than one-third of the participants (38.3%) received CESD scores high enough to place them in the moderate to severe depressive symptoms category. Furthermore, they found a dose-response relationship between the number of adverse experiences and higher odds of moderate to severe depressive symptoms.
Participants with “exposure to one childhood adversity had a twofold increase in odds of reporting moderate to severe depressive symptoms (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7), whereas those with exposure to four or more childhood adversities had a sixfold increase (AOR, 6.0; 95% CI, 2.4-15.4), compared with those with no adverse events,” the investigators noted.
Similar dose-response relationships were found between the number of adverse childhood events and the number of lifetime suicide attempts.
Dr. Lee and her associates said their findings have implications for clinical practice. The Substance Abuse and Mental Health Services Administration recommends that clinicians screen all patients for physical and sexual trauma but not for parental loss, they said.
“Our findings suggest that mental health and primary care providers should consider screening older homeless adults for all childhood adversities,” they wrote. “This may enhance suicide risk assessment by identifying those with multiple adversities, who are at highest risk.”
The investigators cited several limitations. For example, estimates of childhood adversity might have been underreported. Also, the study’s cross-sectional design made it difficult to establish causation between childhood adversity and psychiatric morbidity.
Nevertheless, “psychiatrists working with low-income, older populations should screen for homelessness,” they wrote. “The high prevalence of psychiatric morbidity in this medically complex population presents challenges to the mental health workforce [amid] a shortage of geriatric psychiatrists.”
Dr. Lee reported no conflicts of interest. The principal investigator, Margot Kushel, MD, reported serving on the leadership board of EveryOne Home, a group that seeks to bring an end to homelessness in Alameda County, Calif. The National Institute on Aging, the National Institute of Mental Health, and SAMHSA provided funding support.
[email protected]
On Twitter @ginalhenderson
FROM THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY
Unhealthy eating habits might precede depressive symptoms
Unhealthy eating behaviors could be a risk factor for the development of depressive symptoms, new research suggests.
“This prospective study is the first to reveal the combined relationship between unhealthy eating and the incidence of depressive symptoms,” wrote Cong Huang, PhD, and his coauthors. “In contrast to previous studies, in which the focus of research has been on the impact of depressive symptoms on eating habits, we considered depressive symptoms to be a consequence of these unhealthy behaviors. Taken together, these findings reveal the possibility of a vicious cycle between unhealthy eating habits and mental health problems,” wrote Dr. Huang of Tohoku University in Sendai, Japan.
Dr. Huang and coauthors recruited 376 Japanese adults aged 24-38 over a 2-year period. Three hundred of the participants were men, and none had depressive symptoms at baseline (J Epidemiol. 2017;27[1]:42-7).
The participants were asked to answer three questions aimed at assessing their eating habits. Eating behaviors that were deemed unhealthy included skipping breakfast at least three times per week, eating dinner within 2 hours of going to bed, and eating snacks after dinner more than three times per week. Meanwhile, the participants’ depressive symptoms were measured at baseline and follow-up using the Japanese version of the Zung Self-Rating Depression Scale.
The investigators found that skipping breakfast appeared tied to a higher prevalence of depressive symptoms (P = .026). They also found a prospective relationship between eating snacks after dinner and depressive symptoms (relative risk, 1.77; 95% confidence interval, 1.00-3.14). Interestingly, the relationship between snacking after dinner and depressive symptoms “was limited to those who had [the] habit of having dinner shortly before bedtime (P for the interaction = .044),” they wrote.
In light of these findings, improving eating habits could have an impact on depressive disorders, Dr. Huang and coauthors said. Read the full study here.
[email protected]
On Twitter @ginalhenderson
Unhealthy eating behaviors could be a risk factor for the development of depressive symptoms, new research suggests.
“This prospective study is the first to reveal the combined relationship between unhealthy eating and the incidence of depressive symptoms,” wrote Cong Huang, PhD, and his coauthors. “In contrast to previous studies, in which the focus of research has been on the impact of depressive symptoms on eating habits, we considered depressive symptoms to be a consequence of these unhealthy behaviors. Taken together, these findings reveal the possibility of a vicious cycle between unhealthy eating habits and mental health problems,” wrote Dr. Huang of Tohoku University in Sendai, Japan.
Dr. Huang and coauthors recruited 376 Japanese adults aged 24-38 over a 2-year period. Three hundred of the participants were men, and none had depressive symptoms at baseline (J Epidemiol. 2017;27[1]:42-7).
The participants were asked to answer three questions aimed at assessing their eating habits. Eating behaviors that were deemed unhealthy included skipping breakfast at least three times per week, eating dinner within 2 hours of going to bed, and eating snacks after dinner more than three times per week. Meanwhile, the participants’ depressive symptoms were measured at baseline and follow-up using the Japanese version of the Zung Self-Rating Depression Scale.
The investigators found that skipping breakfast appeared tied to a higher prevalence of depressive symptoms (P = .026). They also found a prospective relationship between eating snacks after dinner and depressive symptoms (relative risk, 1.77; 95% confidence interval, 1.00-3.14). Interestingly, the relationship between snacking after dinner and depressive symptoms “was limited to those who had [the] habit of having dinner shortly before bedtime (P for the interaction = .044),” they wrote.
In light of these findings, improving eating habits could have an impact on depressive disorders, Dr. Huang and coauthors said. Read the full study here.
[email protected]
On Twitter @ginalhenderson
Unhealthy eating behaviors could be a risk factor for the development of depressive symptoms, new research suggests.
“This prospective study is the first to reveal the combined relationship between unhealthy eating and the incidence of depressive symptoms,” wrote Cong Huang, PhD, and his coauthors. “In contrast to previous studies, in which the focus of research has been on the impact of depressive symptoms on eating habits, we considered depressive symptoms to be a consequence of these unhealthy behaviors. Taken together, these findings reveal the possibility of a vicious cycle between unhealthy eating habits and mental health problems,” wrote Dr. Huang of Tohoku University in Sendai, Japan.
Dr. Huang and coauthors recruited 376 Japanese adults aged 24-38 over a 2-year period. Three hundred of the participants were men, and none had depressive symptoms at baseline (J Epidemiol. 2017;27[1]:42-7).
The participants were asked to answer three questions aimed at assessing their eating habits. Eating behaviors that were deemed unhealthy included skipping breakfast at least three times per week, eating dinner within 2 hours of going to bed, and eating snacks after dinner more than three times per week. Meanwhile, the participants’ depressive symptoms were measured at baseline and follow-up using the Japanese version of the Zung Self-Rating Depression Scale.
The investigators found that skipping breakfast appeared tied to a higher prevalence of depressive symptoms (P = .026). They also found a prospective relationship between eating snacks after dinner and depressive symptoms (relative risk, 1.77; 95% confidence interval, 1.00-3.14). Interestingly, the relationship between snacking after dinner and depressive symptoms “was limited to those who had [the] habit of having dinner shortly before bedtime (P for the interaction = .044),” they wrote.
In light of these findings, improving eating habits could have an impact on depressive disorders, Dr. Huang and coauthors said. Read the full study here.
[email protected]
On Twitter @ginalhenderson
ECT tied to better responses in late-onset depression in older patients
Older patients with late-onset treatment-resistant depression and psychotic symptoms appear to get better results from electroconvulsive therapy than those with early-onset depression and fewer psychotic symptoms, a longitudinal study of 110 patients suggests.
“Our results indicate that [electroconvulsive therapy] is very effective even in pharmacotherapy-resistant [late-life depression] with vascular burden,” wrote Annemiek Dols, MD, PhD, Filip Bouckaert, MD, and associates.
The investigators recruited severely depressed patients who were receiving electroconvulsive therapy (ECT) from psychiatric hospitals in Amsterdam and Leuven, Belgium, as part of the Mood Disorders in Elderly Treated with Electroconvulsive Therapy (MODECT) study between January 2011 and December 2013.
They defined early-onset depression as a first depressive episode experienced by patients before age 55 years. Late-onset depression was defined as a first depressive episode that occurred at age 55 and older, reported Dr. Dols of the department of old age psychiatry at GGZ inGeest in Amsterdam and Dr. Bouckaert of the department of radiology and nuclear medicine at VU University Medical Center, also in Amsterdam.
The average age of the 110 patients was 73 years, and 72 were women. Patients with diagnoses of bipolar and schizoaffective disorder were excluded, as were patients with a history of neurologic illnesses such as Parkinson’s disease, stroke, or dementia.
Dr. Dols, Dr. Bouckaert, and associates measured the patients’ cognition using several instruments, including the 30-point Mini-Mental State Examination (MMSE) before, during, and after 1 week of a course of ECT. A response was defined as an improvement of 50% or more in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline during an ECT course. Remission was defined as a MADRS score below 10 points after ECT (Am J Geriatr Psychiatry. 2017 Feb;25[2]:178-89).
Mean MMSE scores climbed from 24.5 before ECT to 27.25 for the early-onset depression patients, compared with 24.04 to 25.39 for the late-onset depression patients. Overall, the investigators reported, patients with late-onset depression had a response rate of 86.9%, compared with a response rate of 67.3% for those with early-onset depression after receiving a similar number of ECT sessions.
However, the higher response rates in late-onset depression could not be explained by “clinical or structural brain characteristics,” the investigators noted. “The number of responders with [late-onset depression] was probably too low (n = 8) to find statistically significant associations.”
To read more about the study, click here.
[email protected]
On Twitter @ginalhenderson
Older patients with late-onset treatment-resistant depression and psychotic symptoms appear to get better results from electroconvulsive therapy than those with early-onset depression and fewer psychotic symptoms, a longitudinal study of 110 patients suggests.
“Our results indicate that [electroconvulsive therapy] is very effective even in pharmacotherapy-resistant [late-life depression] with vascular burden,” wrote Annemiek Dols, MD, PhD, Filip Bouckaert, MD, and associates.
The investigators recruited severely depressed patients who were receiving electroconvulsive therapy (ECT) from psychiatric hospitals in Amsterdam and Leuven, Belgium, as part of the Mood Disorders in Elderly Treated with Electroconvulsive Therapy (MODECT) study between January 2011 and December 2013.
They defined early-onset depression as a first depressive episode experienced by patients before age 55 years. Late-onset depression was defined as a first depressive episode that occurred at age 55 and older, reported Dr. Dols of the department of old age psychiatry at GGZ inGeest in Amsterdam and Dr. Bouckaert of the department of radiology and nuclear medicine at VU University Medical Center, also in Amsterdam.
The average age of the 110 patients was 73 years, and 72 were women. Patients with diagnoses of bipolar and schizoaffective disorder were excluded, as were patients with a history of neurologic illnesses such as Parkinson’s disease, stroke, or dementia.
Dr. Dols, Dr. Bouckaert, and associates measured the patients’ cognition using several instruments, including the 30-point Mini-Mental State Examination (MMSE) before, during, and after 1 week of a course of ECT. A response was defined as an improvement of 50% or more in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline during an ECT course. Remission was defined as a MADRS score below 10 points after ECT (Am J Geriatr Psychiatry. 2017 Feb;25[2]:178-89).
Mean MMSE scores climbed from 24.5 before ECT to 27.25 for the early-onset depression patients, compared with 24.04 to 25.39 for the late-onset depression patients. Overall, the investigators reported, patients with late-onset depression had a response rate of 86.9%, compared with a response rate of 67.3% for those with early-onset depression after receiving a similar number of ECT sessions.
However, the higher response rates in late-onset depression could not be explained by “clinical or structural brain characteristics,” the investigators noted. “The number of responders with [late-onset depression] was probably too low (n = 8) to find statistically significant associations.”
To read more about the study, click here.
[email protected]
On Twitter @ginalhenderson
Older patients with late-onset treatment-resistant depression and psychotic symptoms appear to get better results from electroconvulsive therapy than those with early-onset depression and fewer psychotic symptoms, a longitudinal study of 110 patients suggests.
“Our results indicate that [electroconvulsive therapy] is very effective even in pharmacotherapy-resistant [late-life depression] with vascular burden,” wrote Annemiek Dols, MD, PhD, Filip Bouckaert, MD, and associates.
The investigators recruited severely depressed patients who were receiving electroconvulsive therapy (ECT) from psychiatric hospitals in Amsterdam and Leuven, Belgium, as part of the Mood Disorders in Elderly Treated with Electroconvulsive Therapy (MODECT) study between January 2011 and December 2013.
They defined early-onset depression as a first depressive episode experienced by patients before age 55 years. Late-onset depression was defined as a first depressive episode that occurred at age 55 and older, reported Dr. Dols of the department of old age psychiatry at GGZ inGeest in Amsterdam and Dr. Bouckaert of the department of radiology and nuclear medicine at VU University Medical Center, also in Amsterdam.
The average age of the 110 patients was 73 years, and 72 were women. Patients with diagnoses of bipolar and schizoaffective disorder were excluded, as were patients with a history of neurologic illnesses such as Parkinson’s disease, stroke, or dementia.
Dr. Dols, Dr. Bouckaert, and associates measured the patients’ cognition using several instruments, including the 30-point Mini-Mental State Examination (MMSE) before, during, and after 1 week of a course of ECT. A response was defined as an improvement of 50% or more in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline during an ECT course. Remission was defined as a MADRS score below 10 points after ECT (Am J Geriatr Psychiatry. 2017 Feb;25[2]:178-89).
Mean MMSE scores climbed from 24.5 before ECT to 27.25 for the early-onset depression patients, compared with 24.04 to 25.39 for the late-onset depression patients. Overall, the investigators reported, patients with late-onset depression had a response rate of 86.9%, compared with a response rate of 67.3% for those with early-onset depression after receiving a similar number of ECT sessions.
However, the higher response rates in late-onset depression could not be explained by “clinical or structural brain characteristics,” the investigators noted. “The number of responders with [late-onset depression] was probably too low (n = 8) to find statistically significant associations.”
To read more about the study, click here.
[email protected]
On Twitter @ginalhenderson
FROM THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY
‘Anxiety sensitivity’ tied to psychodermatologic disorders
Adult patients who experience stress in the form of “anxiety sensitivity” are more likely to develop psychodermatological conditions than those that are not psychodermatological, a cross-sectional study of 115 participants shows.
“The results suggest that [anxiety sensitivity] interventions combined with dermatology treatments may be beneficial for psychodermatological patients,” wrote Laura J. Dixon, PhD, of the University of Mississippi Medical Center, Jackson, and her associates. “There is strong evidence that cognitive-behavioral therapy significantly reduces [anxiety sensitivity] through strategies such as psychoeducation, interoceptive exposure, and cognitive therapy.”
Dr. Dixon and her associates recruited 123 dermatologic patients aged 18-83 years over 30 weeks through three outpatient university dermatology clinics in Central Mississippi. Sixty-five percent of the participants were white, 33% were black, 1% were Asian, and 1% were Native American; 65% were female. Most of the patients were married and living with their spouses. The final sample of participants comprised 63 psychodermatological patients and 52 nonpsychodermatological patients (Psychosomatics. 2016;57:498-504).
The investigators assessed general anxiety symptoms using the 7-item depression, anxiety, and stress subscale (DASS-A) from the 21-item version of the questionnaire (DASS-21). Anxiety sensitivity – which refers to the “extent of beliefs that anxiety symptoms or arousal can have harmful consequences” (Turk Psikiyatri Derg. 2011 Fall;22[3]:187-93) – was measured using the Anxiety Sensitivity Index–3 (ASI-3, an 18-item self-report instrument that assesses physical manifestations of anxiety, such as blushing and fast heart beating.
Psychodermatological conditions were classified as disorders that might be rooted in or made worse by psychological, behavioral, or stress-related factors. Conditions in this category include acne, alopecia, atopic dermatitis, eczema, hidradenitis, prurigo, psoriasis, and rosacea. Dermatologic conditions not tied to psychological factors and classified as biologically based include brittle fingernails, cysts, keloids, rashes, skin cancer, skin lesions, spider veins, and warts, reported Dr. Dixon.
No significant differences were observed on the DASS-A scores between the two groups.
The mean scores of psychodermatological patients on the ASI-3 were significantly higher than the scores of patients with nonpsychodermatological conditions (21.1 vs. 13.7; P = .013). In fact, Dr. Dixon and her associates found that “each 1-unit increment in the ASI-3 social subscale score was associated with a 12.7% increased odds of patients having a psychodermatological condition.”
“Taken together, these results are supported by existing theoretical models of psychodermatological disorders that highlight the importance of stress among patients with certain dermatological conditions,” the researchers wrote.
One of the authors, dermatologist Robert T. Brodell, disclosed receiving honoraria from Allergan, Galderma Laboratories, and PharmaDerm; he also disclosed receiving consultant fees and performing clinical trials for other pharmaceutical companies. Neither Dr. Dixon nor any of the other authors declared relevant financial disclosures.
[email protected]
On Twitter @ginalhenderson
Adult patients who experience stress in the form of “anxiety sensitivity” are more likely to develop psychodermatological conditions than those that are not psychodermatological, a cross-sectional study of 115 participants shows.
“The results suggest that [anxiety sensitivity] interventions combined with dermatology treatments may be beneficial for psychodermatological patients,” wrote Laura J. Dixon, PhD, of the University of Mississippi Medical Center, Jackson, and her associates. “There is strong evidence that cognitive-behavioral therapy significantly reduces [anxiety sensitivity] through strategies such as psychoeducation, interoceptive exposure, and cognitive therapy.”
Dr. Dixon and her associates recruited 123 dermatologic patients aged 18-83 years over 30 weeks through three outpatient university dermatology clinics in Central Mississippi. Sixty-five percent of the participants were white, 33% were black, 1% were Asian, and 1% were Native American; 65% were female. Most of the patients were married and living with their spouses. The final sample of participants comprised 63 psychodermatological patients and 52 nonpsychodermatological patients (Psychosomatics. 2016;57:498-504).
The investigators assessed general anxiety symptoms using the 7-item depression, anxiety, and stress subscale (DASS-A) from the 21-item version of the questionnaire (DASS-21). Anxiety sensitivity – which refers to the “extent of beliefs that anxiety symptoms or arousal can have harmful consequences” (Turk Psikiyatri Derg. 2011 Fall;22[3]:187-93) – was measured using the Anxiety Sensitivity Index–3 (ASI-3, an 18-item self-report instrument that assesses physical manifestations of anxiety, such as blushing and fast heart beating.
Psychodermatological conditions were classified as disorders that might be rooted in or made worse by psychological, behavioral, or stress-related factors. Conditions in this category include acne, alopecia, atopic dermatitis, eczema, hidradenitis, prurigo, psoriasis, and rosacea. Dermatologic conditions not tied to psychological factors and classified as biologically based include brittle fingernails, cysts, keloids, rashes, skin cancer, skin lesions, spider veins, and warts, reported Dr. Dixon.
No significant differences were observed on the DASS-A scores between the two groups.
The mean scores of psychodermatological patients on the ASI-3 were significantly higher than the scores of patients with nonpsychodermatological conditions (21.1 vs. 13.7; P = .013). In fact, Dr. Dixon and her associates found that “each 1-unit increment in the ASI-3 social subscale score was associated with a 12.7% increased odds of patients having a psychodermatological condition.”
“Taken together, these results are supported by existing theoretical models of psychodermatological disorders that highlight the importance of stress among patients with certain dermatological conditions,” the researchers wrote.
One of the authors, dermatologist Robert T. Brodell, disclosed receiving honoraria from Allergan, Galderma Laboratories, and PharmaDerm; he also disclosed receiving consultant fees and performing clinical trials for other pharmaceutical companies. Neither Dr. Dixon nor any of the other authors declared relevant financial disclosures.
[email protected]
On Twitter @ginalhenderson
Adult patients who experience stress in the form of “anxiety sensitivity” are more likely to develop psychodermatological conditions than those that are not psychodermatological, a cross-sectional study of 115 participants shows.
“The results suggest that [anxiety sensitivity] interventions combined with dermatology treatments may be beneficial for psychodermatological patients,” wrote Laura J. Dixon, PhD, of the University of Mississippi Medical Center, Jackson, and her associates. “There is strong evidence that cognitive-behavioral therapy significantly reduces [anxiety sensitivity] through strategies such as psychoeducation, interoceptive exposure, and cognitive therapy.”
Dr. Dixon and her associates recruited 123 dermatologic patients aged 18-83 years over 30 weeks through three outpatient university dermatology clinics in Central Mississippi. Sixty-five percent of the participants were white, 33% were black, 1% were Asian, and 1% were Native American; 65% were female. Most of the patients were married and living with their spouses. The final sample of participants comprised 63 psychodermatological patients and 52 nonpsychodermatological patients (Psychosomatics. 2016;57:498-504).
The investigators assessed general anxiety symptoms using the 7-item depression, anxiety, and stress subscale (DASS-A) from the 21-item version of the questionnaire (DASS-21). Anxiety sensitivity – which refers to the “extent of beliefs that anxiety symptoms or arousal can have harmful consequences” (Turk Psikiyatri Derg. 2011 Fall;22[3]:187-93) – was measured using the Anxiety Sensitivity Index–3 (ASI-3, an 18-item self-report instrument that assesses physical manifestations of anxiety, such as blushing and fast heart beating.
Psychodermatological conditions were classified as disorders that might be rooted in or made worse by psychological, behavioral, or stress-related factors. Conditions in this category include acne, alopecia, atopic dermatitis, eczema, hidradenitis, prurigo, psoriasis, and rosacea. Dermatologic conditions not tied to psychological factors and classified as biologically based include brittle fingernails, cysts, keloids, rashes, skin cancer, skin lesions, spider veins, and warts, reported Dr. Dixon.
No significant differences were observed on the DASS-A scores between the two groups.
The mean scores of psychodermatological patients on the ASI-3 were significantly higher than the scores of patients with nonpsychodermatological conditions (21.1 vs. 13.7; P = .013). In fact, Dr. Dixon and her associates found that “each 1-unit increment in the ASI-3 social subscale score was associated with a 12.7% increased odds of patients having a psychodermatological condition.”
“Taken together, these results are supported by existing theoretical models of psychodermatological disorders that highlight the importance of stress among patients with certain dermatological conditions,” the researchers wrote.
One of the authors, dermatologist Robert T. Brodell, disclosed receiving honoraria from Allergan, Galderma Laboratories, and PharmaDerm; he also disclosed receiving consultant fees and performing clinical trials for other pharmaceutical companies. Neither Dr. Dixon nor any of the other authors declared relevant financial disclosures.
[email protected]
On Twitter @ginalhenderson
Ask service members and veterans about sexual health
SILVER SPRING, MD. – Tending to the psychiatric and physical needs of military servicemen, servicewomen, and veterans must include attention to their sexual functioning, according to Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.
“Think of sexual activity as an activity of daily living,” Dr. Ritchie said at the Trauma Treatment from the Trenches meeting at the Forest Glen Annex in Silver Spring, Md., organized by Sawsan Ghurani, MD, a psychiatrist and Navy captain, and sponsored by the Walter Reed National Military Medical Center in Bethesda, Md.
Despite the deployment of 2.7 million service members over more than 15 years of war in the United States, research on the sexual health of this population has been scant, Dr. Ritchie said. Research has been similarly limited in the civilian population, except for the work that has been done among civilians on the impact of spinal cord injuries on sexual dysfunction, she said (J Spinal Cord Med. 2016 Aug 31:1-12).
Clinicians who work with service members and veterans find that wives complain about the impact of medical interventions on their partners, said Dr. Ritchie, a former Army psychiatry consultant and current chief of Community-Based Outpatient Clinics at the Washington (D.C.) Veterans Affairs Medical Center. “As part of the discussion on sexual health, I remind them that sexual activity is broader than penetration.”
Another issue to be aware of among service members is anger. “Often our patients are angry, and often that anger comes out to us as therapists,” she said. “We need to tell our colleagues about this and get them to expect it.”
Treating post-traumatic stress disorder can be a tricky proposition because of the sexual side effects caused by selective serotonin reuptake inhibitors, Dr. Ritchie said. She prefers bupropion because it is not linked to sexual side effects. Mood stabilizers cause weight gain, as do antipsychotics. Meanwhile, drug holidays lead to problems with adherence, she said. To mitigate side effects, Dr. Ritchie advised “trying one thing at a time and adding trazodone in low doses for sleep.” However, trazodone has been linked to priapism (Gen Hosp Psychiatry. 2015 Jan-Feb;37[1]:40-5), and so must be used with care.
Another treatment for PTSD that is showing promise is stellate ganglion block, which has proven effective for treating hot flashes in postmenopausal women and in addressing estrogen depletion tied to breast cancer treatment in small numbers of patients (Med Hypotheses. 2009 Jun;72[6]:657-61).
“Studies have found a reduction in PTSD symptoms as well as pain,” Dr. Ritchie said. “I’m pushing the VA to do more research in this area.”
In effort to treat sexual dysfunction, Dr. Ritchie said her family practice colleagues prescribe a lot of Viagra and other phosphodiesterase inhibitors. She speculated that flibanserin, a selective agonist for 5-HT1A and an antagonist for 5-HT2A receptors approved in 2015 by the Food and Drug Administration for premenopausal women with hypoactive sexual desire disorder, “will start making its way into the general population,” said Dr. Ritchie, whose comments about using phosphodiesterase inhibitors pertain to VA patients.
Many service members who participated in Operation Iraqi Freedom and Operation Enduring Freedom were aged 18-25 years. Partly because the Department of Defense (DOD) and the VA work with very young families, clinicians are tasked with teaching them about their needs as couples, including the need to discuss intimacy and sexual health. For political reasons, Dr. Ritchie said, in vitro fertilization is not covered by the VA, even though injuries from bomb blasts can make it impossible for couples to conceive naturally.
Toxic and infectious substances faced by troops that are not commonly found in the United States, such as chemicals, pesticides, and motor oils, also need to be acknowledged and addressed by clinicians. “We don’t do a good job about what a veteran thinks about what exposure does to their reproductive systems,” Dr. Ritchie said.
In an interview, Dr. Ghurani said that she came up with the title of the meeting to illustrate the extent to which providers treat PTSD in the military every day. Conference speakers examined the latest treatments on sexual trauma, and the state of the art therapy and research taking place at Walter Reed.
At the meeting, she discussed the distinction between military sexual trauma (MST) and sexual trauma within the civilian population. Research shows that veterans who screen positive for MST “are more likely to have a history of a suicide attempt documented in their VA medical record” (Psychiatry Res. 2016;244:257-65).
A 2008 study found that women are far more likely to screen positive for MST than men. Specifically, the study found that 25% of women and 1.3% of men who are screened for MST within the Veterans Health Administration screen positive (Trauma Violence Abuse. 2008 Oct;9[4]250-69).
Walter Reed’s Interpersonal Recovery Program at the Psychiatry Continuity Service is the only intensive outpatient program within the DOD that provides ongoing treatment for active duty service members with PTSD from a sexual trauma, Dr. Ghurani said.
Earlier during the meeting, Capt. (Ret.) William P. Nash, MD, director of psychological health at the Marine Corps and a 30-year veteran of the Navy, discussed moral injury, and contrasted it with PTSD and other sequelae of psychological trauma. He also described his work on the Moral Injury Events Scale as a tool for recognizing potentially morally injurious events in clinical and research settings.
Dr. Ritchie is the editor of “Intimacy Post-Injury: Combat Trauma and Sexual Health,” (New York: Oxford University Press, 2016). Dr. Ghurani contributed to a chapter in “Intimacy Post Injury,” and Dr. Nash has written extensively about PTSD, particularly among deployed Marines.
[email protected]
On Twitter @ginalhenderson
SILVER SPRING, MD. – Tending to the psychiatric and physical needs of military servicemen, servicewomen, and veterans must include attention to their sexual functioning, according to Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.
“Think of sexual activity as an activity of daily living,” Dr. Ritchie said at the Trauma Treatment from the Trenches meeting at the Forest Glen Annex in Silver Spring, Md., organized by Sawsan Ghurani, MD, a psychiatrist and Navy captain, and sponsored by the Walter Reed National Military Medical Center in Bethesda, Md.
Despite the deployment of 2.7 million service members over more than 15 years of war in the United States, research on the sexual health of this population has been scant, Dr. Ritchie said. Research has been similarly limited in the civilian population, except for the work that has been done among civilians on the impact of spinal cord injuries on sexual dysfunction, she said (J Spinal Cord Med. 2016 Aug 31:1-12).
Clinicians who work with service members and veterans find that wives complain about the impact of medical interventions on their partners, said Dr. Ritchie, a former Army psychiatry consultant and current chief of Community-Based Outpatient Clinics at the Washington (D.C.) Veterans Affairs Medical Center. “As part of the discussion on sexual health, I remind them that sexual activity is broader than penetration.”
Another issue to be aware of among service members is anger. “Often our patients are angry, and often that anger comes out to us as therapists,” she said. “We need to tell our colleagues about this and get them to expect it.”
Treating post-traumatic stress disorder can be a tricky proposition because of the sexual side effects caused by selective serotonin reuptake inhibitors, Dr. Ritchie said. She prefers bupropion because it is not linked to sexual side effects. Mood stabilizers cause weight gain, as do antipsychotics. Meanwhile, drug holidays lead to problems with adherence, she said. To mitigate side effects, Dr. Ritchie advised “trying one thing at a time and adding trazodone in low doses for sleep.” However, trazodone has been linked to priapism (Gen Hosp Psychiatry. 2015 Jan-Feb;37[1]:40-5), and so must be used with care.
Another treatment for PTSD that is showing promise is stellate ganglion block, which has proven effective for treating hot flashes in postmenopausal women and in addressing estrogen depletion tied to breast cancer treatment in small numbers of patients (Med Hypotheses. 2009 Jun;72[6]:657-61).
“Studies have found a reduction in PTSD symptoms as well as pain,” Dr. Ritchie said. “I’m pushing the VA to do more research in this area.”
In effort to treat sexual dysfunction, Dr. Ritchie said her family practice colleagues prescribe a lot of Viagra and other phosphodiesterase inhibitors. She speculated that flibanserin, a selective agonist for 5-HT1A and an antagonist for 5-HT2A receptors approved in 2015 by the Food and Drug Administration for premenopausal women with hypoactive sexual desire disorder, “will start making its way into the general population,” said Dr. Ritchie, whose comments about using phosphodiesterase inhibitors pertain to VA patients.
Many service members who participated in Operation Iraqi Freedom and Operation Enduring Freedom were aged 18-25 years. Partly because the Department of Defense (DOD) and the VA work with very young families, clinicians are tasked with teaching them about their needs as couples, including the need to discuss intimacy and sexual health. For political reasons, Dr. Ritchie said, in vitro fertilization is not covered by the VA, even though injuries from bomb blasts can make it impossible for couples to conceive naturally.
Toxic and infectious substances faced by troops that are not commonly found in the United States, such as chemicals, pesticides, and motor oils, also need to be acknowledged and addressed by clinicians. “We don’t do a good job about what a veteran thinks about what exposure does to their reproductive systems,” Dr. Ritchie said.
In an interview, Dr. Ghurani said that she came up with the title of the meeting to illustrate the extent to which providers treat PTSD in the military every day. Conference speakers examined the latest treatments on sexual trauma, and the state of the art therapy and research taking place at Walter Reed.
At the meeting, she discussed the distinction between military sexual trauma (MST) and sexual trauma within the civilian population. Research shows that veterans who screen positive for MST “are more likely to have a history of a suicide attempt documented in their VA medical record” (Psychiatry Res. 2016;244:257-65).
A 2008 study found that women are far more likely to screen positive for MST than men. Specifically, the study found that 25% of women and 1.3% of men who are screened for MST within the Veterans Health Administration screen positive (Trauma Violence Abuse. 2008 Oct;9[4]250-69).
Walter Reed’s Interpersonal Recovery Program at the Psychiatry Continuity Service is the only intensive outpatient program within the DOD that provides ongoing treatment for active duty service members with PTSD from a sexual trauma, Dr. Ghurani said.
Earlier during the meeting, Capt. (Ret.) William P. Nash, MD, director of psychological health at the Marine Corps and a 30-year veteran of the Navy, discussed moral injury, and contrasted it with PTSD and other sequelae of psychological trauma. He also described his work on the Moral Injury Events Scale as a tool for recognizing potentially morally injurious events in clinical and research settings.
Dr. Ritchie is the editor of “Intimacy Post-Injury: Combat Trauma and Sexual Health,” (New York: Oxford University Press, 2016). Dr. Ghurani contributed to a chapter in “Intimacy Post Injury,” and Dr. Nash has written extensively about PTSD, particularly among deployed Marines.
[email protected]
On Twitter @ginalhenderson
SILVER SPRING, MD. – Tending to the psychiatric and physical needs of military servicemen, servicewomen, and veterans must include attention to their sexual functioning, according to Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.
“Think of sexual activity as an activity of daily living,” Dr. Ritchie said at the Trauma Treatment from the Trenches meeting at the Forest Glen Annex in Silver Spring, Md., organized by Sawsan Ghurani, MD, a psychiatrist and Navy captain, and sponsored by the Walter Reed National Military Medical Center in Bethesda, Md.
Despite the deployment of 2.7 million service members over more than 15 years of war in the United States, research on the sexual health of this population has been scant, Dr. Ritchie said. Research has been similarly limited in the civilian population, except for the work that has been done among civilians on the impact of spinal cord injuries on sexual dysfunction, she said (J Spinal Cord Med. 2016 Aug 31:1-12).
Clinicians who work with service members and veterans find that wives complain about the impact of medical interventions on their partners, said Dr. Ritchie, a former Army psychiatry consultant and current chief of Community-Based Outpatient Clinics at the Washington (D.C.) Veterans Affairs Medical Center. “As part of the discussion on sexual health, I remind them that sexual activity is broader than penetration.”
Another issue to be aware of among service members is anger. “Often our patients are angry, and often that anger comes out to us as therapists,” she said. “We need to tell our colleagues about this and get them to expect it.”
Treating post-traumatic stress disorder can be a tricky proposition because of the sexual side effects caused by selective serotonin reuptake inhibitors, Dr. Ritchie said. She prefers bupropion because it is not linked to sexual side effects. Mood stabilizers cause weight gain, as do antipsychotics. Meanwhile, drug holidays lead to problems with adherence, she said. To mitigate side effects, Dr. Ritchie advised “trying one thing at a time and adding trazodone in low doses for sleep.” However, trazodone has been linked to priapism (Gen Hosp Psychiatry. 2015 Jan-Feb;37[1]:40-5), and so must be used with care.
Another treatment for PTSD that is showing promise is stellate ganglion block, which has proven effective for treating hot flashes in postmenopausal women and in addressing estrogen depletion tied to breast cancer treatment in small numbers of patients (Med Hypotheses. 2009 Jun;72[6]:657-61).
“Studies have found a reduction in PTSD symptoms as well as pain,” Dr. Ritchie said. “I’m pushing the VA to do more research in this area.”
In effort to treat sexual dysfunction, Dr. Ritchie said her family practice colleagues prescribe a lot of Viagra and other phosphodiesterase inhibitors. She speculated that flibanserin, a selective agonist for 5-HT1A and an antagonist for 5-HT2A receptors approved in 2015 by the Food and Drug Administration for premenopausal women with hypoactive sexual desire disorder, “will start making its way into the general population,” said Dr. Ritchie, whose comments about using phosphodiesterase inhibitors pertain to VA patients.
Many service members who participated in Operation Iraqi Freedom and Operation Enduring Freedom were aged 18-25 years. Partly because the Department of Defense (DOD) and the VA work with very young families, clinicians are tasked with teaching them about their needs as couples, including the need to discuss intimacy and sexual health. For political reasons, Dr. Ritchie said, in vitro fertilization is not covered by the VA, even though injuries from bomb blasts can make it impossible for couples to conceive naturally.
Toxic and infectious substances faced by troops that are not commonly found in the United States, such as chemicals, pesticides, and motor oils, also need to be acknowledged and addressed by clinicians. “We don’t do a good job about what a veteran thinks about what exposure does to their reproductive systems,” Dr. Ritchie said.
In an interview, Dr. Ghurani said that she came up with the title of the meeting to illustrate the extent to which providers treat PTSD in the military every day. Conference speakers examined the latest treatments on sexual trauma, and the state of the art therapy and research taking place at Walter Reed.
At the meeting, she discussed the distinction between military sexual trauma (MST) and sexual trauma within the civilian population. Research shows that veterans who screen positive for MST “are more likely to have a history of a suicide attempt documented in their VA medical record” (Psychiatry Res. 2016;244:257-65).
A 2008 study found that women are far more likely to screen positive for MST than men. Specifically, the study found that 25% of women and 1.3% of men who are screened for MST within the Veterans Health Administration screen positive (Trauma Violence Abuse. 2008 Oct;9[4]250-69).
Walter Reed’s Interpersonal Recovery Program at the Psychiatry Continuity Service is the only intensive outpatient program within the DOD that provides ongoing treatment for active duty service members with PTSD from a sexual trauma, Dr. Ghurani said.
Earlier during the meeting, Capt. (Ret.) William P. Nash, MD, director of psychological health at the Marine Corps and a 30-year veteran of the Navy, discussed moral injury, and contrasted it with PTSD and other sequelae of psychological trauma. He also described his work on the Moral Injury Events Scale as a tool for recognizing potentially morally injurious events in clinical and research settings.
Dr. Ritchie is the editor of “Intimacy Post-Injury: Combat Trauma and Sexual Health,” (New York: Oxford University Press, 2016). Dr. Ghurani contributed to a chapter in “Intimacy Post Injury,” and Dr. Nash has written extensively about PTSD, particularly among deployed Marines.
[email protected]
On Twitter @ginalhenderson
FROM TRAUMA TREATMENT FROM THE TRENCHES