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This Week in Psychiatry — 4/4/11

Does Bupropion Aid Smoking Cessation in Acute Coronary Syndrome Patients?

The authors of an Archives of Internal Medicine study evaluated the safety and efficacy of proven smoking cessation aid, bupropion, in patients with acute coronary syndrome. Their 8-week, double-blind, randomized study (n=151) compared bupropion with nurse-administered support for smoking cessation to placebo. Primary outcome measures for efficacy and safety were smoking prevalence at 1-year post hospitalization and intervention, and 1-year adverse events, respectively. Smoking abstinence rates for bupropion and placebo were 45% vs 44% at 3 months, respectively; 37% vs 42% at 6 months; and 31% vs 33% at 1 year. There was therefore no significant therapeutic effect in this population. Dizziness was the most commonly reported safety event when compared to placebo.

Another Copy Number Variation Linked to Schizophrenia

A group of genomics researchers recently published a study in Nature in which they identified a genetic mutation they believe is linked to a higher risk of schizophrenia. According to the researchers, some copy number variations implicated previously in the context of schizophrenia risk play a very limited role as such. A genome-wide scan of a large group of rare copy number variations revealed a significant association between pathogenesis of schizophrenia and duplications near the vasoactive intestinal peptide receptor 2 gene (VIPR2).

Electronic Tracking Systems Lead to Fewer Medication Errors

A single-site study, published in the Journal of Psychiatric Practice, evaluated the potential of an electronic tracking system to reduce medication errors. The researchers reviewed 65,466 patient days and 617,524 billed doses over 5-years at a psychiatric unit. A web-based medication error reporting system and a separate but linked prescribing system were implemented. There were 27.89 medication errors per 1,000 patients in year 1, decreasing to 5.50 per 1,000 patients in year 3 and to 3.43 per 1,000 in year 5. Achievement of successively fewer prescription mistakes in the years following implementation of these systems was achieved by continuing user training, according to the authors.

“This Week in Psychiatry” is written Lonnie Stoltzfoos


Implementation of Electronic Tracking Systems Leads to Fewer Medication Errors

Medication errors are a common occurrence across all fields of medicine. They can be caused by illegible handwriting on prescriptions, medical personnel fatigue, pharmacy dispensing errors that provide the patient with the wrong medication or the wrong dose, and administration mistakes. These medication errors can cause severe adverse events that can lead to hospitalization or death. Of note, although the majority of psychotropics are rarely deadly on their own, their interactions with non-psychotropics, ie, insulin or blood thinners, can be lethal.

Geetha Jayaram, MD, MBA, and colleagues reviewed 65,466 patient days and 617,524 billed doses over a 5-year period at the 88-bed psychiatric unit of Johns Hopkins Hospital in Baltimore. In the first year of the study (2003), they found 27.89 medication errors per 1,000 patients. They implemented the Patient Safety Net (PSN), a web-based medication error reporting system, and the Provider Order Entry (POE) program, a prescribing system that allows prescriptions to be entered directly by medical personnel with the licensure and privileges to do so. Mistakes are reported in the PSN, allowing the physicians to follow up with corrective action when an error occurs. The PSN also categorizes unsafe conditions and near-miss events.

Jayaram and colleagues educated and trained the Johns Hopkins staff on how to use the PSN and the POE in relation to one another. By implementing these programs, the researchers as well as the staff were able to have support for medication dosage selection, medication allergy alerts, drug interactions, and patient identifiers and monitoring. They also conducted chart reviews in an effort to provide a truer estimate in error reduction and provided feedback as the errors occurred.

By using the PSN and POE, the medication error rate decreased to 5.50 per 1,000 patients in 2005 and to 3.43 per 1,000 in 2007. Jayaram and colleagues believe that the use of computerized proctors will allow for less medications errors and there will be a reduction in pharmacist clarification. (J Psychiatr Pract. 2011;17(2):81-88.) —Christopher Naccari

This Week in Psychiatry – 3/7/11

Maternal History of Alzheimer’s Disease Could Determine Risk

The authors of a recent Neurology study examined whether cognitively healthy patients with a family history of Alzheimer’s disease would have less gray matter volume (GMV) and if those differences in GMV reflect family history. Subjects included 67 cognitively intact patients >60 years of age with 1 first-degree maternal relative with an onset of dementia between 60–80 years of age. Sixteen patients had a paternal history of Alzheimer’s disease, 8 had no paternal history, and 43 had no parental history at all. Subjects with a maternal history of Alzheimer’s disease had lower GMV in those brain regions most vulnerable to Alzheimer’s disease—the prefrontal cortices (Brodmann area 45, 46, and 47) and the precuneus. Subjects in the paternal history group did not have any GMV decreases.

Metacognitive Training for Cognitive Symptoms in Schizophrenia

Previous studies have validated the association of a jumping-to-conclusions bias with schizophrenia. A Behaviour Research and Therapy study assessed the effect of metacognitive training (MCT)—a group treatment—for jumping to conclusions and other schizophrenia- related cognitive biases. Subjects with subacute or remitted schizophrenia were randomized to MCT or treatment as usual. Delusion distress, and memory and social skills were significantly reduced in the MCT group compared to treatment as usual, and the incidence of jumping to conclusions decreased in the MCT group.

Patients Weigh In On Quality of PCP Care for Anxiety Disorders

Quality pharmacologic or psychosocial care for anxiety disorders is not common in primary care settings, according to a Journal of Clinical Psychiatry study. A sample of 1,004 patients with an anxiety disorder was surveyed. Of the initial sample, 576 patients (57.4%) had received an indicated anxiolytic during the previous 6 months. As for psychosocial treatment, only 213 patients (21.2%) received strong counseling, defined as including ≥3 elements of CBT, and 81 patients (8.1%) received both quality pharmacotherapy and psychotherapy. Receiving quality psychosocial treatment was the only positive predictor of patient satisfaction for anxiety disorder treatment in this survey.

This Week in Psychiatry is written by Lonnie Stoltzfoos

Maternal History of Alzheimer’s Disease Could Determine Increased Risk

Family history is an important factor when assessing a patients’ risk for future illnesses. Recent research into Alzheimer’s disease has focused on brain imaging via positron emission tomography scans, functional magnetic resonance imaging, and magnetic resonance imaging (MRI) to determine overall reductions in brain regions vulnerable to Alzheimer’s disease. Robyn A. Honea, DPhil, and colleagues from the University of Kansas School of Medicine went a different route. Not only did they analyze brain scans, they also reviewed patients’ family history of Alzheimer’s disease in order to determine if cognitively healthy patients with a family history of Alzheimer’s disease would have less gray matter volume (GMV) and the differences in GMV decreases based on family history.

Honea and colleagues studied 67 cognitively intact patients greater than or equal to 60 years of age for 2 years who had 1 first-degree relative with an onset of dementia between 60–80 years of age. Sixteen patients had a maternal history of Alzheimer’s disease, 8 had a paternal history, and 43 had neither. Throughout the study, patients were given the Mini-Mental State Examination to determine their cognition levels, and structural MRIs were used to review total gray matter, white matter, and intracranial volume.

Honea and colleagues found that those patients with a maternal history of Alzheimer’s disease had lower GMV in those brain regions most vulnerable to Alzheimer’s disease. Specifically, the prefrontal cortices (Brodmann area 45, 46, and 47) and the precuneus. The patients in the paternal history group did not have any GMV decreases. Interestingly, the researchers did not find significant changes in the GMV in the hippocampus, the region of the brain most commonly associated with volumetric changes due to Alzheimer’s disease.

The researchers have stated that they will need to conduct a longitudinal examination of these patients in order to determine if these GMV decreases predispose the maternal history patients to more atrophy in those brain regions vulnerable to Alzheimer’s disease. Future studies will need to examine whether maternal history also influences disease severity, rate of cognitive decline, and/or age of onset.

The full article can be found at:

Funding for this research was provided by grants from the National Institutes of Aging, the National Institute on Neurological Disorders and Stroke, and the Hoglund Brain Imaging Center. (Neurology. 2011:74(2):113-120.) —Christopher Naccari

This Week in Psychiatry – 2/28/2011

Family Support for Depression Linked to Recovery

Strong family support predicts sooner recovery from depressive symptoms, a new study in the Journal of Clinical Psychology reports. Data were collected from 373 subjects with depression at baseline, with follow-ups at years 1, 4, 10, and 23. Stronger family support was associated with a quicker path to recovery and lower depressive symptoms at baseline and follow-up for all participants. Family support also predicted a quicker path to recovery. Women in the study, however, were more likely to show faster and more marked improvement when receiving strong family support.

Experimental Compound for Cognitive Impairment in Schizophrenia: RCT Results

The authors of a recent double-blind, randomized, placebo-controlled trial in Biological Psychiatry tested an experimental compound that was previously reported to show some efficacy for cognitive impairment in schizophrenia. Sixty subjects with schizophrenia were randomized to receive 3 mg BID or 8 mg BID of the γ-aminobutyric acid (GABA)A α2/α3 partial agonist (n=39), known as MK-0777, or placebo (n=21). There were no significant differences between active and placebo groups in this trial, according to the primary outcome measure, the MATRICS Consensus Cognitive Battery score. In fact, it was suggested that members of the placebo group performed better on visual memory and problem solving than subjects who received either dose of the active compound.

Older Adults With Insomnia May Benefit from Brief Behavioral Treatment

Chronic insomnia can exact a heavy toll from older adults, considering both quality of life and adverse events from pharmacologic treatment. An Archives of Internal Medicine study compared brief behavioral treatment for insomnia (BBTI) with an information control. Subjects included 79 adults with a mean age of 72 years, with a majority (70%) being female. BBTI consisted of 2 sessions and 2 phone calls of individually tailored instructions; the information control only provided printed educational material. Self-reported improvements at 4 weeks were significantly greater for BBTI than for controls, verified by actigraphy but not polysomnography. BBTI improvements were sustained at 6 months.

This Week is Psychiatry is written by Lonnie Stoltzfoos.

This Week in Psychiatry – 2/7/11

Antidepressants, But No Lifetime Mental Disorder

A study from The Journal of Clinical Psychiatry used a large mental health epidemiology survey (N=20,013) to examine the use of antidepressants in the absence of a lifetime psychiatric disorder. Respondents with or without a 1-year or lifetime mental disorder who were taking an antidepressant were asked to indicate why they needed the medication. Of the respondents who had taken an antidepressant in the past year (n=1,441), 26.3% did not meet lifetime criteria, of whom 89% cited at least one indicator of need. The most common 3 indicators were depressive symptoms, anxiety symptoms, and poor sleep. Respondents receiving antidepressants without lifetime criteria were more likely to be older, white, and female, and to receive their prescriptions from family physicians.

Trajectory of MDD with Subthreshold Hypomania

Does subthreshold hypomania in MDD patients predict onset of new mania? Participants in the NIMH Collaborative Depression Study with an MDD diagnosis at intake (n=550) were followed prospectively for a mean of 17.5 years. Monitoring intervals tracked their course of illness and identified any hypomania or mania. Hypomania or mania was identified in 19.6% of the sample, of which 12.2% and 7.5% received a revised diagnosis for bipolar II and bipolar I disorder, respectively. Age at onset, psychotic symptoms, and number of subthreshold hypomania symptoms predicted development of bipolar disorder. This study appeared in The American Journal of Psychiatry.

Bright Light Therapy: Effects on Older Adults with MDD

Bright light therapy may improve circadian rhythm disturbances in older people with nonseasonal MDD. Published in the Archives of General Psychiatry, a double-blind, randomized, placebo-controlled trial tested 3 weeks of 1-hour early morning bright light therapy in 89 patients (aged >60 years) with MDD. Outcome measures included Hamilton Scale Depression scores, and levels of sleep, cortisol, and melatonin. Depression scores improved after bright light therapy, sleep efficiency increased, and evening levels of melatonin rose more steeply, and 24-hour cortisol levels decreased, compared to placebo.



“This Week in Psychiatry” is written by Lonnie Stoltzfoos

Study of Retired Football Players Reveals Higher Rates of Painkiller Misuse

Playing football takes a heavy toll on one’s body. Most players start playing football in their early teens and retire in their late-20s to early-30s. Post-retirement, their bodies then have to deal with 20 years of physical abuse, serious injuries, and numerous diagnosed and mis-diagnosed concussions. This causes long-lasting physical pain as well as an increased potential for brain disorders. Linda B. Cottler, PhD, and colleagues recently studied how retired NFL players are currently dealing with the pain that lingers from their playing careers.

Cottler and colleagues conducted a 20-minute phone survey of 644 former NFL players who retired between 1979 and 2006. The retired players had an average age of 48 years and played in the NFL for an average of 7.6 seasons. The study breaks the players down into position played and total number of injuries they suffered during their careers. Forty-seven percent of the players had an average of >3 serious injuries and 55% reported that their careers were ended due to injury.

The players were asked about their overall current health as well as level of pain, history of injuries and concussions, and their use of prescription pain pills, both during and after their career. When rating their pain, 75% of the players stated they had severe pain and ~70% reported mild-to-severe physical impairment. Only 26% of the general population suffers from some level of pain.

Of these retired players, 7% are currently taking opioids, which is over 4 times the rate that the general population is taking them. Over 50% of the retired players were using opioids when they played football, and >71% of those players admitted to misusing opioids when they were taking them. Misuse was defined as using the medication for a different reason than it was prescribed and taking a medication that was prescribed to someone else. Another 15% of retired players who acknowledged misusing the medication admitted to misusing it within the past 30 days of the study. Pain, along with undiagnosed concussions, were the main reasons given by the players for their misuse of these medications. Of the players who were using the medications as prescribed, 5% admitted to misusing their prescription within the past 30 days of the study. Fifteen percent of the players that misused opioids as players continued misusing them within the past 30 days of the study.

Finally, 37% of the players reported having physician prescriptions for their opioids while the remaining 63% where given medication from someone other than a physician. These sources included teammates, coaches, trainers, family members, dealer, or off the Internet. The players also noted that all they had to do to get the medication was ask, no prescription was needed during the season.

Alcoholism was the most present comorbidity in these patients, Cottler and colleagues also found that 31% of the players had >15 drinks in the past week and 27% had >20 drinks in the past week. The risk for overdose and death is greatly increased when a patient drinks alcohol on top of their opioid use.

Cottler and colleagues believe that former NFL players need to be better monitored to ensure that they are properly taking their prescribed medications.

Funding for this research was provided by a grant from ESPN and additional funding from the National Institute on Drug Abuse and the National Institutes of Health. (Drug and Alcohol Dependence. 2011;113(3):ePub Ahead of Print). —Christopher Naccari

Relevant Link

This Week in Psychiatry – 1/31/11

Full Recovery from BDD Often Likely, Study Finds

A recent report in The Journal of Nervous and Mental Disease addressed the course of illnessof body dysmorphic disorder (BDD). Of 514 subjects in the Harvard/Brown Anxiety Research Project, 17 (3.3%) had current BDD and 22 (4.3%) had lifetime BDD at study outset. Over the 8-year study period, the probability of full recovery from BDD, and probability of recurrence once remitted, was 0.76 and 0.14, respectively.

Can Fluoxetine Improve Recovery For Some Types of Stroke-Induced Paralysis?

Fluoxetine may improve physiological recovery following ischemic stroke, according to a Lancet Neurology report. The double-blind randomized controlled trial included patients with ischemic stroke with hemiplegia or hemiparesis, and a Fugl-Meyer motor scale (FMMS) score of ≤55. Subjects were prescribed fluoxetine 20 mg/day for 3 months 5–10 days following stroke (treatment group, n=57; placebo group, n=56). All subjects received physiotherapy. The treatment group demonstrated significantly greater improvement in the primary outcome measure, FMMS score at 90 days (34 points [95% CI, 29.7–38.4]), compared to placebo (24.3 points [19.9–28.7]; P=.003). The authors suggest that manipulating brain plasticity may account for the treatment group’s improvement

“This Week in Psychiatry” is written by Lonnie Stoltzfoos

US FDA Approves Vilazodone for MDD

The United States Food and Drug Administration approved vilazodone (Viibryd, Trovis Pharmaceuticals) for the treatment of major depressive disorder (MDD). The recommended starting dose is 10 mg QD for the first 7 days. The dosage can then be titrated to a maximum of 40 mg QD.

Approval was based on two, 8-week randomized, double-blind, placebo-controlled trials in 869 adults (436 received vilazodone; 433 received placebo) between 18–70 years of age meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Revised criteria for MDD. In both studies, the Montgomery-Asberg Depression Rating Scale was used to assess all of the patients’ depressive symptoms. By study endpoint, vilazodone was found to be superior to placebo in terms of improving the patients’ depressive symptoms.

The most common adverse events (those occurring in greater than or equal to 5% of patients) were diarrhea, nausea, vomiting, and insomnia.

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

This Week in Psychiatry — 1/24/11

Cognitive Function, Awareness, and Illness Insight in Schizophrenia

Schizophrenia Bulletin published a study in which the authors examined awareness and insight in schizophrenia in 31 patients with mostly chronic schizophrenia. The authors assessed the independence or overlap of multiple domains of function and how those dimensions relate to neuropsychological function, clinical, demographic, and mood variables. Insight into cognitive deficits was greater than insight into symptoms. Self-certainty and self-reflexivity were more highly indicative of cognitive insight than neuropsychological factors.

Early Menarche Associated with Greater Depression in Young Girls

A recent study from the British Journal of Psychiatry found a correlation between early onset of menstruation in girls and higher depression symptoms throughout adolescence. Using data from a longitudinal parent and child study, the researchers took into account age at onset of menstruation and depressive symptoms at ages 10.5, 13, and 14 years in 2,184 girls. Girls with an early onset of menstruation (<11.5 years of age) had higher levels of depression at ages 13 (P=.007) and 14 (P<.001) years compared to girls with a normal onset of menstruation, at age 13.5 years. These findings could support selective early intervention for depressive symptoms, the authors say.

Comparative Opioid Safety Findings

Opioids are commonly used to control non-malignant pain in adults. An Archives of Internal Medicine study evaluated the comparative safety of these drugs in 6,275 subjects over nearly 10 years. Cancer, hospice care, and nursing care patients were excluded. Cardiovascular events at 30 days were similar among the 5 opioid groups, but codeine had the highest rate of cardiovascular events after 180 days of use. Propoxyphene and tramadol had a lower risk of fracture compared to hydrocodone. Compared to hydrocodone, oxycodone and codeine had higher all-cause mortality rates after 30 days. Gastrointestinal events did not vary across all 5 opioid groups.

“This Week in Psychiatry” is written by Lonnie Stoltzfoos