Thursday, December 31, 2009

Atypical Antipsychotics Increase Cardiometabolic Risk in Children

A study of the adverse effects of 4 second-generation antipsychotics in children and adolescents documented substantial weight gain during 11 weeks of treatment with each agent, with the increased abdominal fat that has been associated with development of metabolic syndrome in adults. Metabolic abnormalities emerged with 3 of the 4 agents, differing in type and severity with the agent and, in some cases, with the dose.

In this analysis from the Second-Generation Antipsychotic Treatment Indications, Effectiveness and Tolerability in Youth (SATIETY) study, 10% to 36% of 272 patients between 4 and 19 years of age (mean, 13.9 years) who had not previously received antipsychotic medication became overweight or obese. There was minimal weight change in a comparison group of patients who had refused the agent, or who discontinued it within 4 weeks.1

Christoph Correll, MD, Zucker Hillside Hospital, Glen Oaks, NY, and colleagues conducted this observational cohort study as the largest to date of adverse experiences with second-generation antipsychotics in antipsychotic treatment–naive children. The researchers noted that there has been increasing use of these agents in younger patients for psychotic and bipolar disorders as well as nonpsychotic disorders, despite little available age-specific data on adverse reactions.


Wednesday, December 30, 2009

Cognitive-Behavioral Therapy for Childhood Anxiety and Depression

For both depression and anxiety disorders in youths, there is increasing evidence of clinical benefit from cognitive-behavioral therapy (CBT).

Anxiety disorders

Both SSRIs and CBT individually have been shown to be effective in the treatment of children with anxiety disorders. A recent large randomized controlled trial examined the combined efficacy of these treatments in 488 children and adolescents (aged 7 to 17 years) who had anxiety disorder (separation anxiety disorder, social phobia, or generalized anxiety disorder).1

Patients were randomized to receive sertraline, CBT, sertraline and CBT, or placebo for 12 weeks. Combination treatment was significantly superior to either sertraline or CBT alone. Response rates were 81% for combination treatment, 60% for CBT, 55% for sertraline, and 24% for placebo. The effect size for combination treatment was 0.86 compared with 0.45 for sertraline and 0.31 for CBT. The investigators concluded that children and adolescents who receive combination treatment for anxiety disorders can consistently expect a significant reduction in anxiety severity.

Is CBT effective for young children with anxiety disorders? Typically, anxiety studies include children older than 8 years. Recently, Freeman and colleagues2 compared the efficacy of family-based CBT with family-based relaxation treatment for children aged 5 to 8 years who have ob-sessive-compulsive disorder (OCD). The 12-session CBT treatment was tailored to younger children to address their developmental stage. CBT had a moderate treatment effect (0.53). Half of the children who received CBT obtained clinical remission compared with 20% in the relaxation treatment group. The authors recommended family-based CBT as an important component when addressing early childhood–onset OCD.


Tuesday, December 29, 2009

Mental health isn't the issue - stigma is

Mark Dayton at his campaign headquarters in downtown Minneapolis.

Many politicians have overcome admissions of addiction or depression, thanks to better understanding of the manageable diseases. Can Dayton, too?

There was a time when the public admission of mental illness could derail a candidate's political career.

That could still happen to Mark Dayton, the Democratic candidate for governor who went public this week with his history of depression. But if so, experts say, it's the stigma -- not the disease itself -- that would sabotage his run for office.

Today, more than a decade into Prozac Nation, there is no reason why someone being treated for mild to moderate depression shouldn't hold a job with enormous responsibility, doctors say. Abraham Lincoln and Winston Churchill both suffered from depression, they say, and that was long before Prozac and even more effective medications that are available now.

READ MOE @ Minneapolis Star Tribune

Monday, December 28, 2009

Schizophrenia Mouse Model Should Improve Understanding and Treatment of the Disorder

Scientists have created what appears to be a schizophrenic mouse by reducing the inhibition of brain cells involved in complex reasoning and decisions about appropriate social behavior.

Findings by Medical College of Georgia scientists, published Dec. 28 in the Proceedings of the National Academy of Sciences, elucidate the critical balance between excitation and inhibition of these cells that appears to go awry in schizophrenia. They also provide the first animal model for studying the disabling psychiatric disorder that affects about 1 percent of the population.

"We believe the mouse, which exhibits some of the same aberrant behavior as patients with this disorder, will help identify better therapies," said Dr. Lin Mei, a developmental neurobiologist who directs MCG's Institute of Molecular Medicine and Genetics. "We are doing testing to see if antipsychotic drugs already on the market are effective in treating the mouse."

MCG scientists made the mouse by deleting a candidate gene for schizophrenia, ErbB4, from interneurons, which are brain cells that help shower larger decision-making neurons, called pyramidal cells, with inhibition.


Friday, December 25, 2009

A happy Christmas – alone Before we universally condemn loneliness we should ensure we understand its roots, and that sometimes solitude can be sweet

The meaning of Christmas, and its supposed power to bring friends and family together, is again in evidence this year. Jonathan Freedland admirably called for an end to loneliness, and urged social policy to address it – a sentiment echoed by a Guardian leader.

I do not wish to detract from the importance of addressing chronic loneliness, particularly in the elderly. Many people end up alone, not just over the festive season, but for significantly longer periods, for want of company, and not of their own volition. It is easy to pity them (which is just offensive) and say that we must do more as a society to help them. What is significantly harder is to understand the nature of, and the causes behind, loneliness in various sections of society, and ask whether and where society should act.

Recently, we have begun to regard loneliness, and not just in the elderly, as a purely social problem. In fact, there can be plenty of individual factors that underlie feelings of loneliness – from bereavement to serious medical illnesses. Therefore, trying to address it through political policy without adequate consultation is a cause for concern. After all, do we know that loneliness is largely a social problem? If so, is it just in the elderly or even among younger generations? What engenders it? Apart from a few intuitive ideas invoking the alienation triggered by online worlds, our obsession with communicating via screens, and the intrusiveness of corporate chains, we frankly do not know.


Thursday, December 24, 2009

Stress speeds mental decline in impaired elders

Chronic stress can speed up memory decline in older people who already have some impairment in their mental function, a new study in the American Journal of Psychiatry shows.

But being stressed doesn't appear to affect memory in older people without such impairment, Dr. Guerry M. Peavy of the University of California San Diego and colleagues found.

Research suggests a "strong relationship" between increased stress and memory loss, the researchers note, but few investigators have looked at stress and memory over time. Chronic stress may affect memory by causing prolonged release of so-called "stress hormones," such as cortisol, resulting in damage to the brain.

To investigate, the researchers followed 52 people 65 to 97 years old for up to three years. Twenty-five had no loss of mental function at the beginning of the study, while the remaining 27 showed evidence of mild mental impairment.

To measure stress, the researchers asked study participants about whether they had experienced stressful life events in the previous year or six months, such as being hospitalized or having a death in the family. A person was considered to have "high stress" if they reported at least one such event in a given period.


Monday, December 21, 2009

Antidepressants cut risk of hospital readmission for suicidal youth

Suicidal adolescents who were prescribed an antidepressant medication during inpatient psychiatric hospital treatment were 85 percent less likely than others to be readmitted within a month after discharge, a new study found.

The results provide additional evidence that antidepressants may play a key role in helping improve the mental health of suicidal youth, said Cynthia Fontanella, co-author of the study and assistant professor of social work at Ohio State University.

The findings are especially important now, because antidepressant use dropped in 2003 after the Food and Drug Administration issued a black box warning that some antidepressants may increase the risk of suicidal behavior for pediatric patients. A black-box warning is the most serious type of warning in prescription drug labeling.

"We found that antidepressant treatment had a protective effect on readmission," Fontanella said. "Although the findings are preliminary, our results should be reassuring to child psychiatrists who may have been concerned about prescribing antidepressants since the FDA warning."

But another key finding from the study showed that hospitalized youth who were prescribed three or more medications from different drug classes for mental health issues had a 3-fold increased risk of being readmitted within a month of discharge.


Sunday, December 20, 2009

Not All Drugs Are the Same After All

LET me start by saying I’m a fan of generic drugs. They save Americans billions of dollars each year and give us access to wonderful drugs at affordable prices. I’ve recommended generics in this column many times and use them myself when possible.

But there is a gnawing concern among some doctors and researchers that certain prescription generic drugs may not work as well as their brand-name counterparts. The problem is not pervasive, but it’s something consumers should be aware of — especially now that more insurers insist that patients take generic medications when they are available.

Let me also prepare the groundwork for what I hope will be full and frank reader comments, by acknowledging that this issue is controversial.

Joe Graedon, who has been writing about pharmaceuticals for three decades and runs a consumer advocacy Web site, the People’s Pharmacy (, was 100 percent behind generics for many years.

“We were the country’s leading generic enthusiasts,” he told me recently. But over the last eight or nine years, Mr. Graedon began hearing about “misadventures” from people who read his syndicated newspaper column, also called The People’s Pharmacy.


This blog resumes its posts as of Sunday, December 20, 2009 after a 2 week hiatus

Sunday, December 6, 2009

SSRIs May Prolong Seizure Duration but Shorten Post-Seizure Depression in Patients With Epilepsy: Presented at AES

Use of selective serotonin reuptake inhibitors (SSRIs) appears to be associated with longer seizures in patients with epilepsy, confounding basic science results suggesting SSRIs reduce the frequency of epileptic seizures in animal models, according to a study presented here at the American Epilepsy Society (AES) 63rd Annual Meeting.

"What we found was not necessarily a causal relationship, but an association, between SSRI use and longer seizures," study presenter Eugen Trinka, MD, MSc, Innsbruck Medical University, Innsbruck, Austria. "Based on our study, we cannot conclude that SSRIs prolong seizures." However, "doctors should use caution in using SSRIs in patients with epilepsy," Dr. Trinka added during his poster presentation held on December 5.

The study found that epilepsy seizures in those on SSRIs lasted a median 132 seconds, compared with 85 seconds in those not using SSRIs.


Saturday, December 5, 2009

US FDA Approves SEROQUEL XR(R) For Add-On Treatment Of Major Depressive Disorder

AstraZeneca (NYSE: AZN) announced that the US Food and Drug Administration (FDA) has approved once-daily SEROQUEL XR® (quetiapine fumarate) Extended Release Tablets as adjunctive (add-on) treatment to antidepressants in adults with Major Depressive Disorder (MDD). SEROQUEL XR is the only medication in its class approved by the FDA to treat both major depressive disorder as adjunctive therapy and acute depressive episodes associated with bipolar disorder as monotherapy.(1)(2)

MDD affects approximately 14.2 million American adults in a given year, and today it is often treated with antidepressants(3). Selective serotonin reuptake inhibitors, or SSRIs, are among the most commonly prescribed class of antidepressant medications for depression; however, in many cases patients fail to respond adequately to treatment(4). Results from a National Institute of Mental Health study, STAR*D, showed that approximately 63% of patients did not achieve remission with the SSRI citalopram when used as a first-line treatment(4). Additionally, this study reported that overall approximately one-third of patients with MDD failed to achieve study defined remission(4). This approval for SEROQUEL XR provides physicians with a new adjunctive treatment option for patients with MDD who have an inadequate response to their current antidepressant.


Friday, December 4, 2009

Why Psychiatry May Sometimes Need “Fuzzy” Diagnoses

“Well, while I’m here, I’ll do the work—and what’s the work? To ease the pain of living . . .”
—Allen Ginsberg

"Many words . . . don't have a strict meaning. But this is not a defect. To think it is would be like saying that the light of my reading lamp is no real light at all, because it has no sharp boundary."
—Ludwig Wittgenstein, The Blue and Brown Books

As a general proposition, most scientists and physicians prefer sharpness to fuzziness, at least when it comes to defining terms. I generally share this view, as regards psychiatric diagnosis, but only up to a point. That point is defined by the well-being of my patient—and sometimes this may call for a “fuzzy” diagnosis.

To understand why this is so, consider the following thought experiment. Imagine that we have a set of psychiatric signs and symptoms, designated as A through F. Suppose that if we select “A,B,C,D,E” as constituting our identified “Syndrome X,” we can correlate it with a specific pathophysiology and even with a specific genetic anomaly. Sounds terrific, right? And all so very “scientific”! But suppose that the syndrome, so defined, corresponds poorly to our patients’ subjective experience of distress; and furthermore, that the “ABCDE” syndrome does not lend itself well to any effective treatment.

Now imagine we start with the same A through F signs and symptoms, but we decide to group them as either “A,B,C,D,E” or as “B,C,D,E, F.” We are, in other words, making our definition of Syndrome X “fuzzier.” We now find that Syndrome X no longer corresponds as well to a particular pathophysiology or genetic defect, but that it better captures our patients’ subjective experience, and also lends itself to an effective treatment. In short, the fuzzier syndrome allows us to reduce our patients’ degree of suffering and incapacity to a greater extent than did the “sharp” ABCDE category. Which syndrome is more “real”—the “sharp” or the “fuzzy” one? Which is more pragmatically useful? And which syndrome leads us to more humane medical care, consistent with our ethical responsibilities as physicians?


Thursday, December 3, 2009

New Safety Concern Related to Antipsychotic Treatment

Overall, antipsychotic medications are reasonably effective, and fairly well tolerated treatments for mood and psychotic disorders. However, treatment with a number of antipsychotic medications is associated with weight gain, and for some, hyperglycemia and hyperlipidemia. In the current issue of Biological Psychiatry, published by Elsevier, researchers discuss this cluster of metabolic side effects and how it may contribute to the risk for diabetes, hypertension, and other medical disorders associated with heart disease. This is of particular concern because there is a higher cardiovascular mortality among the severely mentally ill compared to the general population.

Researchers already know that differences exist between antipsychotics in their effect on clinical measures associated with cardiovascular risk, namely weight, lipids and glucose. Systemic inflammation has recently emerged as an important marker of cardiovascular risk, but the effects of antipsychotics on inflammatory markers in the blood have not been extensively studied until now.


Wednesday, December 2, 2009

The Doctors Were Real, the Patients Undercover

It had all the markings of a television detective show. Posing as patients, three undercover observers got themselves admitted as patients to a locked psychiatric ward to investigate conditions on the inside.

Each undercover patient had rehearsed an extensive back story, and the supposed family members who visited them were professional actors. A remote team monitored the project via hidden cameras and microphones from a command center in a nearby hotel.

The project, which took place this spring in De Gelderse Roos, a psychiatric complex about 40 miles from Amsterdam, was not a sting operation. The staff was told there would be mystery shoppers, of a sort, in the facility over a couple of months.

“We didn’t go in there like cowboys,” said Menko Soeters, a partner at Clearfields, a consulting firm that developed the project with De Gelderse Roos. “But we did use an unorthodox instrument for psychiatric care.”

Surrounded by manicured greenery, the closed-off ward of the complex, known as De Riethorst, recalls a suburban dental clinic, and its sunny gymnasium and carpeted hallways do little to suggest that it houses up to a dozen acute psychiatric patients, many of whom are there involuntarily.

And that is why the undercover participants were all experienced psychiatric nurses. “You couldn’t have done it otherwise,” said Edo De Vries, the director of De Gelderse Roos, which released the results of the project last summer.


Tuesday, December 1, 2009

Antidepressants can be helpful but risky

Feelings of unhappiness, decreased energy, insomnia and irritability are all symptoms of depression. And antidepressants can help relieve depression.

But for some people, these drugs may also have dangerous or troubling side effects -- drowsiness, feelings of panic, nervousness, sexual problems, thoughts of suicide or weight gain -- and should be taken only by people who really need them. So it's alarming that a new study shows antidepressant use has nearly doubled in the United States since the mid-1990s.

In the study, published in the August issue of Archives of General Psychiatry, researchers analyzed data from a national survey of antidepressant use conducted in 1996 and again in 2005. The survey included people age 6 and older.

Between 1996 and 2005, the rate of those reporting that they had used antidepressants in the past year jumped from 5.8 percent to 10.1 percent. This translates to an increase from about 13.3 million people to 27 million. The change was more dramatic among whites than African Americans or Hispanics.