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This Week in Psychiatry — 7/11/11

Drug-Related Suicide Attempts Treated in the ED on the Rise in Men

The Drug Abuse Warning Network recently released a report detailing the increase in emergency department (ED) visits by men owing to drug-related suicide attempts. They found that drug-related suicide attempts accounted for 77,971 ED visits in men 21–34 years of age in 2009—an increase of 54.6% since 2005. ED visits associated with pain relievers increased by 60.2%, antidepressants by 155.2%, and anxiety or insomnia medications by 93.4%. Suicide attempt-related ED visits due to narcotic pain relievers increased from 2,380 in 2005 to 4,270 in 2009 in men between 24–49 years of age, and increased from 882 visits in 2005 to 2,589 visits in 2009 in men >50 years of age.

When Antidepressant Combinations Square Off Against Monotherapy

Several antidepressant combinations did not outperform SSRI monotherapy in 665 outpatients with chronic/recurrent MDD. Researchers measured response and remission rates (defined by a score of <8 and <6 on 2 consecutive QIDSSR16) for the following combinations: escitalopram and placebo (12-week remission rate 38.8%); sustained-released bupropion and escitalopram (38.9%); extended-release venlafaxine and mirtazapine (37.7%). Remission rates and response rates did not differ significantly at 7-month follow-up; the venlafaxine and mirtazapine combination also carried a higher number of adverse events (5.7) than the escitalopram and placebo combination (4.7). This study was published in The American Journal of Psychiatry.

Prevalence of Adolescent Eating Disorders: Cross-Sectional Results

A population-based cross-sectional study, published in the Archives of General Psychiatry, evaluated the prevalence and correlates of eating disorders in US adolescents. Over 10,000 adolescents from 13–18 years of age were assessed in person. Lifetime prevalence estimates were 0.3% for anorexia nervosa, 0.9% for bulimia nervosa, and 1.6% for binge eating disorder. A majority of respondents received some treatment, but only a minority of treatment-seekers received treatment specifically for an eating disorder. Significant psychiatric comorbidity and suicidality were also reported in this population.

“This Week in Psychiatry” is written Christopher Naccari and Lonnie Stoltzfoos


This Week in Psychiatry — 6/28/11

Are Rates of Common Mental Disorders Really Rising?

According to three adult morbidity surveys, administered in 1993, 2000, and 2007 (8,670, 6,977, and 6,815 respondents, respectively), the prevalence of Revised Clinical Interview Schedule (CIS-R) psychiatric disorders remained stable over the 15-year survey period. The rate of common mental disorders in women was reported at 18.1%, 18.5%, and 18.9% at the respective follow-up periods, although sleep disorders in women increased from 28.4% in 1993 to 36.7% in 2007. In 2000, the men’s prevalence rate peaked at 12.6%, up from 10.9% in 2000, before settling at 11.8% in 2007. These findings were published in The British Journal of Psychiatry.

 Self-Perception A Key Factor in Social Anxiety Severity

Research from two studies published in Behaviour Research and Therapy looked to examine how the interpersonal lives of patients with social anxiety disorder (SAD) affects their SAD. The first study compared SAD patients without MDD (n=42) to controls (n=47). The second study compared patients with SAD and MDD (n=45) to patients with other anxiety disorders and MDD (n=31). The results of these studies indicated that SAD patients perceived themselves as having a low social rank, being inferior, behaving submissively, and perceiving themselves to have low intimacy and closeness among their peers, friendships, and romantic relationships. Both studies found that SAD was associated with these perceptions above and beyond the symptomatic as well as the syndrome-level effect of depression’

In Young People With Frequent ER Visits, Some Past Mental Struggles

The authors of a study in Psychiatric Services assessed the status of mental health care for youths with repeat psychiatric emergency department (ED) visits. Over an 8-year period, a child psychiatrist completed the Pediatric Psychiatry Emergency Evaluation Form for 338 youths who made a repeat ED visit within 6 months of their initial visit. Fifty percent of youths presented with behavior problems at both visits. Sixty-five percent of youths reported ongoing outpatient psychiatric care at both visits. Youths who reported outpatient mental health care at initial visit were 5 times more likely to report such care during their repeat visit.

“This Week in Psychiatry” is written Christopher Naccari and Lonnie Stoltzfoos

This Week in Psychiatry — 6/13/11

Vilazodone: Safe and Effective for MDD

In the latest Journal of Clinical Psychiatry, researchers evaluated the safety and efficacy of vilazodone in adults with MDD. The 481 patients in this 8-week study received either vilazodone 40 mg/day or placebo. At endpoint, patients receiving vilazodone had a significantly greater improvement in their MADRS scores, as well as significantly higher MADRS response rates, compared to patients receiving placebo (44% vs. 30%, P=.002). However, MADRS remission rates for both populations were similar (27.3% vs. 20.3%, P=.066). The vilazodone patients also had greater improvements in HAM-D17, HAM-D21, HARS, and CGI-I scores. The researchers therefore believe that vilazodone is both safe and effective in adults with MDD.

An “Integrative” Recovery Style May Predict Remission in Psychosis 

A Dutch study, published in the Journal of Nervous & Mental Disease, explored the concept of recovery style and whether it is tied to 1-year outcomes in patients with psychotic disorders. The researchers evaluated recovery style (“sealing over” versus “integrating”), insight, and symptoms in 103 patients with a psychotic disorder. Follow-up assessments occurred at 6 and 12 months. Higher levels of an integrative recovery style were associated with a 1.84-fold improved odds of remission, but insight and therapeutic alliance were not. The only baseline criterion associated with 1-year outcome was presence of positive symptoms, which is independent of recovery style.

Good Outcomes or Old Habits: What Motivates Compulsions in OCD?

What lies between the OCD patient’s compulsions and simultaneous recognition of the pathological nature of said compulsions? The authors of a paper in The American Journal of Psychiatry compared 21 OCD patients to 30 healthy controls in tasks designed to assess goal-directed behavior versus control of habitual behaviors. After exposure to structured stimuli with the objective of winning rewarding outcomes, subjects completed questionnaires to give feedback on the test’s link between stimuli and reward. OCD patients were able to express appropriate responses to the stimuli during feedback, but their conception of its embedded outcomes and rewards was poor, compared to controls. Also, OCD patients were more likely to respond habitually to stimuli, rather than responding in a goal- and outcomedirected manner.

This Week in Psychiatry” is written Christopher Naccari and Lonnie Stoltzfoos


The APA Debates Removing the Term “Asperger’s” From the DSM-5

Although Asperger’s syndrome was first described in 1944, it was not included in the Diagnostic and Statistical Manual of Mental Disorders until the publication of the Fourth Edition, in 1994. Earlier this year, the American Psychiatric Association (APA) announced that they are considering deleting the term “Asperger’s” from the forthcoming Fifth Edition of the DSM, scheduled to be published in 2013. Instead of using Asperger’s syndrome when diagnosing a patient, the APA’s Neurodevelopmental Disorders Workgroup recommends changing the diagnosis to an “autism spectrum disorder.” They feel that this change in diagnosis will have a positive impact on each patient’s individual special skills and needs.

The Neurodevelopment Disorders Workgroup believes that combining autism, pervasive developmental disorder (PDD), and Asperger’s into a single spectrum better reflects the pathology and symptoms; that the separation of autism spectrum disorder from typical development is reliable and valid, while separation of disorders within the spectrum is variable and inconsistent; and individuals with autism, PDD-not otherwise specified, or Asperger’s disorder are frequently diagnosed by severity, rather than unique, separate criteria defining the three diagnoses.

Many physicians feel that changing this diagnosis in this manner will have a negative impact on patients with Asperger’s. Mainly, these patients will lose their identities and be lumped in with patients with other disorders on the autism spectrum.

If you’d like to weigh in on this topic, the APA has asked for public comments via — Christopher Naccari

Secondhand Smoke Significantly Impacts nAChRs in Smokers and Non-Smokers

Secondhand smoke has been found to be the most dangerous aspect of sharing a space, regardless of size, with a smoker, as it can be more toxic than the smoke being inhaled by the smoker. Arthur L. Brody, MD, and colleagues, measured the effects of secondhand smoke on brain α4ß2* nicotinic acetylcholine receptor (nAChR) occupancy via positron emission tomography (PET) scanning and radiotracers. Brody and colleagues compared 11 smokers (smoking a mean of 15.2 cigarettes/day for an average of 13 years) and 13 non-smokers (subjects with >2 years without a cigarette or no history of nicotine dependence). At baseline, the patients documented their smoking history using the Smoker’s Profile Form, and were evaluated with the Fagerström Test for Nicotine Dependence, the Hamilton Depression Rating Scale, and Hamilton Anxiety Rating Scale. A Micro Smokerlyzer was used to assess and verify smoking status (carbon monoxide level 8 ppm for active smokers and 4 ppm for nonsmokers).

At 6 PM two nights before their PET scans, the smokers were required to abstain from smoking, ensuring that nicotine in their systems from cigarettes would not compete with the secondhand smoke breathed during the study. The day before the PET scans, a brief clinical interview was conducted and a carbon monoxide measurement taken. Exhaling a carbon monoxide level of <8 PPM confirmed smoking abstinence. On the day of the PET scan, the patients received a bolus plus continuous infusion of 2-FA, the bolus being equal to the amount infused over 500 minutes. Three hours after the PET scans, subjects sat in the passenger seat of a car next to a smoker in the driver’s seat. Each “driver” smoker smoked a mean of 3.7 cigarettes in order to keep the car’s carbon monoxide level >7 ppm. The secondhand smoke “passengers” were then re-scanned for an hour, and were then allowed to smoke during a 10-minute break. Smoking saturated the α4ß2* nAChRs, allowing the researchers to obtain a measure of non-displaceable radioactivity and determine which radiotracers could then be displaced from the brain.

The researchers administered the Secondhand Smoke Rating Scale, which analyzes the most common symptoms of exposure to secondhand smoke (chest tightness, coughing, eye irritation, heart palpitations, nasal congestion, nose irritation, and runny nose), before and after each subject was exposed to secondhand smoke.

Brody and colleagues found that moderate secondhand smoke exposure caused a mean 19% occupancy of α4ß2* nAChRs in smokers and 18% for non-smokers. The receptor occupancy values for the thalamus, brainstem, and cerebellum were P=.02, P=.01, and P=.01, respectively, for smokers, and P=.002, P=.008, and P=.001, respectively, for non-smokers. Non-smokers were found to have a more significant increase (1.2 to 3.9) in symptom ratings compared to smokers (2.8 to 3.4) on the Secondhand Smoker Rating Scale. The smokers had a 23% increase in craving with secondhand smoke exposure.

Overall, Brody and colleagues found that nicotine inhaled from secondhand smoke crosses the blood brain barrier which results in α4ß2* nAChRs occupancy in non-smokers.

Funding for this research was provided by grant 16RT-0098from the Tobacco-Related Disease Research Program awarded to Dr. Brody, grant R01 DA20872 from the National Institute on Drug Abuseawarded to Dr. Brody, a Veterans Affairs Type I Merit Review Award awarded to Dr. Brody, grant DABT63-00-C-1003 from the Office of National Drug Control Policy awarded to Dr. London, and endowments from the Richard Metzner Chair in Clinical Neuropharmacology awarded to Dr. Brody, the Thomas P. and Katherine K. Pike Chair in Addiction Studies awarded to Dr. London, and the Marjorie Greene Family Trust awarded to Dr. London.

The full paper can be found at —Christopher Naccari

This Week in Psychiatry — 5/30/11

Adjunctive Aripiprazole Effective in Geriatric MDD Patients

The International Journal of Geriatric Psychiatry recently published a study reviewing the effi- cacy of adjunctive aripiprazole, compared to standard antidepressant therapy, for MDD in younger (18–49 years of age) and older (50–67 years of age) patients. By endpoint, the older patients receiving aripiprazole had a greater improve- ment in MADRS total score versus placebo. These improvements were similar to those seen in the younger group. The older patients receiving aripiprazole also had a 32.5% remis- sion rate, compared to 17.1% of patients receiving placebo. The younger patients had a 26.9% remission rate, compared to 16.4% of placebo patients.

Characteristics of Sexual Dysfunction in First-Episode Schizophrenia

A report from the European First Episode Schizophrenia Trial examined characteristics of sexual dysfunction in first-episode schizophrenia. Higher Positive and Negative Syndrome Scale (PANSS) scores and higher prolactin levels were associated with erectile dysfunction and ejaculatory problems in men; more PANSS negative symptoms and older age were also associated with decreased libido. In women, higher prolactin levels were associated with amenorrhea, and PANSS negative symptoms also predicted decreased libido in women. Higher prolactin levels in men and women were significantly more prevalent in patients receiving amisulpride, an atypical antipsychotic not approved for use in the US. The authors concluded that sexual dysfunction in schizophrenia seems to result from both medication side effects and the inherent nature of schizophrenia.

Reducing Inpatient Rates of Restraint and Seclusion

Multiple behavioral interventions can decrease the frequency of seclusion and restraint in inpatient psychiatric settings, reports a recent study in Psychiatric Services. Five inpatient units in a large US hospital were randomized to implement intervention com- ponents in a varying order, including changes to the unit’s rules and language, additional trauma care training for staff, changes to the physical environment, and more patient involvement in care. There was a postintervention reduction of 82.3% in patient seclusion or restraint days over 3.5 years, which the authors attributed to changes in the physical environment.

“This Week in Psychiatry” is written Christopher Naccari and Lonnie Stoltzfoos

This Week in Psychiatry — 5/9/11

Psychosis and Substance Abuse are Possible Risk Factors for Osteoporosis

Psychosis and substance abuse are possible risk factors for osteoporosis, yet the frequency of screening and disease risk as relatively unknown. Research published in Osteoporois International studied 18,593 women between 50—64 years of age. Of these women, 6.7% had osteoporosis. Women diagnosed with both substance use disorder and psychosis were found to have a higher prevalence of osteoporosis (OR=6.4 CI=1.51-27.6, P=.012). This interaction was also more prevalent in the patients between 55–64 years of age compared to those between 50–54 years of age

Psychiatric Disorder Risks and Paternal Age 

A Dutch population study, published in Schizophrenia Research, analyzed 14,231 patients and 56,924 matched controls for an association between paternal age and risk of psychiatric disorders, such as autism spectrum disorders, major depression, bipolar disorder, and schizophrenia. Using logistic regression, the authors found that older fathers (>40 years of age) have a 3.3 times increased odds of having a child with autism spectrum disorders compared to fathers <20 years of age. Schizophrenia was associated with fathers aged >35 years (OR=1.27, 95% CI: 1.05-1.53), major depression was associated with younger and older fathers, and there was no association between paternal age and bipolar disorder

Secondhand Smoke Exposure: Effects on Nicotine Receptor Occupancy in Smokers and Nonsmokers

Researchers used PET scanning and radiotracers to determine the effects of secondhand smoke on brain α4ß2* nicotinic acetylcholine receptor occupancy. The study, published in the Archives of General Psychiatry, included 24 young adults (11 moderately dependent cigarette smokers, 13 nonsmokers) who underwent PET scanning during 1 hour of moderate exposure or no exposure, respectively, to secondhand smoke in an environment resembling an automobile’s front passenger seat. Secondhand smoke exposure caused a mean 19% occupancy of α4ß2* nAChRs occupancy. Smokers had a 23% increase in craving with secondhand smoke exposure, as well.

“This Week in Psychiatry” is written Christopher Naccari and Lonnie Stoltzfoos

US FDA Approves Lamotrigine XR Tablets for the Treatment of Partial Seizures

The United States Food and Drug Administration approved lamotrigine extended-release tablets (Lamictal XR, GlaxoSmthiKline) for the treatment of partial seizures in patients greater than or equal to 13 years of age who are already receiving one anti-eplieptic medication.

Approval was based on results from the LAM30055 study, an international, multicenter, historical control study of 226 patients greater than or equal to 13 years of age. These patients were already receiving one anti-eplieptic, and lamotrigine XR was then added to each patient’s regimen. From there, the original anti-epileptic was gradually withdrawn while lamotrigine XR became monotherapy.

The most common adverse events (those occurring in greater than or equal to 5% of patients) found in either treatment group were dizziness, headache, insomnia, nasopharyngitis, nausea, rash, and somnolence.

For more information on lamotrigine, please consult the medication’s full prescribing information ( —Christopher Naccari

This Week in Psychiatry — 5/2/11

Updated: Alzheimer’s Diagnostic Guidelines

The Alzheimer’s Association and the National Institute on Aging have combined their efforts to create new guidelines for the diagnosis of Alzheimer’s disease. The proposed guidelines, which are open for peer commentary and discussion, focus on 3 main areas: (1) distinguishing between mild cognitive impairment due to aging or as an early symptom of Alzheimer’s; (2) establishing biomarkers indicating a “preclinical” stage of Alzheimer’s, with research possibilities involving brain imaging and cerebrospinal fluid proteins; (3) and eventually implementing biomarker benchmarks for all clinical stages of Alzheimer’s. The research and guidelines are discussed further in 4 papers found at the following link:

Poor Are Likelier to Experience Mood Disorders than Middle Class

A prospective longitudinal study, published in the Archives of General Psychiatry, surveyed a US population (n=34,653 adults, ≥20 years of age) on income levels and prevalence of mental disorders. Subjects with a yearly household income of <$20,000 had a greater risk of mood disorder incidence between baseline and year 3 compared to subjects with a yearly household income of ≥$70,000. A decrease in income from baseline to year 3 was also associated with greater risk for mood disorders (adjusted OR, 1.30; 99% CI). Presence of mental disorders at baseline, however, did not affect income levels at year 3.

Although Rare, Comorbid Epilepsy A Long-Term Concern in Autism

Although epilepsy is one of autism’s less frequent comorbidities, it is still a cause for concern for physicians. After interviewing 150 adults with autism, research published in The British Journal of Psychiatry found that 22% had epilepsy with the onset of seizures at 10 years of age. Of these patients 50% had weekly seizures and 90% received 1–2 anticonvulsants. They were mostly female, had intellectual disability, and poorer verbal skills. Physicians should be aware of the putative risk factors of epilepsy in autism patients during childhood in order to develop a proper long-term treatment regimen.

“This Week in Psychiatry” is written Christopher Naccari and Lonnie Stoltzfoos

This Week in Psychiatry — 4/18/11

Short Sleeves on Physicians Have MRSA, Too

To prevent the spread of bacterial contamination, recent guidelines in the UK have banned long-sleeved physicians’ white coats, instituting instead daily laundered short-sleeved uniforms. A new study, however, published in the Journal of Hospital Medicine, found no statistical difference in the amount of methicillin-resistant Staphylococcus aureus present on long and short sleeves (or the wrists of physicians wearing short sleeves) after 8 hours. In fact, after 3 hours of wear short sleeves already contained 50% of the MRSA found at the 8-hour time point.

Food and Brain Reward Activation: Does That Savor of Addiction?

A new Archives of General Psychiatry report suggests that “food addiction” may have a neurobiological profile similar to other addictive behaviors. Researchers used fMRI to evaluate reward activation in 48 young women (ranging from normal weight to obese) during anticipation and receipt of a chocolate milkshake. Any food addiction spectrum score was associated with greater reward response during anticipation of food. A high food addiction score was associated with greater reward response during anticipation of food, but less activation in the lateral orbitofrontal cortex after receipt of food. This trajectory of higher anticipation until gratification is achieved compares with the reward trajectory in substance dependence, write the authors

Antenatal Depression, Race Risk Factors

Black and Asian women are more likely to experience antenatal depression compared to non-Hispanic White women, according to a recent study in General Hospital Psychiatry. Using data collected over 6 years (n=1,997), the researchers used logistic regression analyses to evaluate sociodemographic—among other—characteristics in the context of antenatal depression, as verified by the Patient Health Questionnaire. Just over 5% of the women in the study reported antenatal depression. The increased risk of such in Black and Asian women maintained its significance after controlling for multiple factors.

“This Week in Psychiatry” is written Lonnie Stoltzfoos