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Chronic pain patients swapping opioids for medical cannabis
new research shows.
“That patients report substituting cannabis for pain medicines so much really underscores the need for research on the benefits and risks of using cannabis for chronic pain,” lead author Mark C. Bicket, MD, PhD, assistant professor, department of anesthesiology, and director, Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, said in an interview.
However, he added, the question is whether they’re turning to cannabis and away from other pain treatments. “What’s not clear and one of the gaps that we wanted to address in the study was if medical cannabis use is changing the use of other treatments for chronic pain,” said Dr. Bicket.
The study was published online in JAMA Network Open.
Decreased opioid use
The survey included a representative sample of 1724 American adults aged 18 years or older with chronic noncancer pain living in areas with a medical cannabis program.
Respondents were asked about their use of three categories of pain treatments. This included medical cannabis; pharmacologic treatments including prescription opioids, nonopioid analgesics, and over-the-counter analgesics; and common nonpharmacologic treatments such as physical therapy, meditation, and cognitive-behavioral therapy (CBT).
Just over 96% of respondents completed the full survey. About 57% of the sample was female and the mean age of the study sample was 52.3 years.
Among study participants, 31% (95% CI, 28.2% - 34.1%) reported having ever used cannabis to manage pain; 25.9% (95% confidence interval, 23.2%-28.8%) reported use in the past 12 months, and 23.2% (95% CI, 20.6%-26%) reported use in the past 30 days.
“This translates into a large number of individuals who are using cannabis in an intended medical way” to treat chronic condition such as low back pain, migraine, and fibromyalgia, said Dr. Bicket.
More than half of survey respondents reported their medical cannabis use led to a decrease in prescription opioid use, prescription nonopioid use and use of over-the-counter medications.
Dr. Bicket noted “almost no one” said medical cannabis use led to higher use of these drugs.
As for nonpharmacologic treatments, 38.7% reported their use of cannabis led to decreased use of physical therapy, 19.1% to lower use of meditation, and 26% to less CBT. At the same time, 5.9%, 23.7% and 17.1%, respectively, reported it led to increased use of physical therapy, meditation, and CBT.
Medical cannabis is regulated at a state level. On a federal level, it’s considered a Schedule I substance, which means it’s deemed not to have a therapeutic use, although some groups are trying to change that categorization, said Dr. Bicket.
As a result, cannabis products “are quite variable” in terms of how they’re used (smoked, eaten etc.) and in their composition, including percentage of cannabidiol and tetrahydrocannabinol.
“We really don’t have a good sense of the relative risks and benefits that could come from cannabis as a treatment for chronic pain,” said Dr. Bicket. “As a physician, it’s difficult to have discussions with patients because I’m not able to understand the products they’re using based on this regulatory environment we have.”
He added clinicians “are operating in an area of uncertainty right now.”
What’s needed is research to determine how safe and effective medical cannabis is for chronic pain, he said.
Pain a leading indication
Commenting on the findings, Jason W. Busse, PhD, professor, department of anesthesia, and associate director, Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ont., said the study reinforces results of some prior research.
“It gives us current information certainly highlighting the high rate of use of medical cannabis among individuals with chronic pain once it becomes legally available.”
In addition, this high rate of use “means we desperately need information about the benefits and harms” of medical marijuana, he said.
Dr. Busse noted the survey didn’t provide information on the types of cannabis being used or the mode of administration. Oil drops and sprays cause less pulmonary harm than smoked versions, he said. It’s also not clear from the survey if participants are taking formulations with high levels of tetrahydrocannabinol that are associated with greater risk of harm.
He noted cannabis may interact with prescription drugs to make them less effective or, in some cases, to augment their adverse effects.
Dr. Busse pointed out some patients could be using fewer opioids because providers are under “enormous pressure” to reduce prescriptions of these drugs in the wake of spikes in opioid overdoses and deaths.
Chronic pain is “absolutely the leading indication” for medical marijuana, said Dr. Busse. U.S. reimbursement data suggest up to 65% of individuals get cannabis to treat a listed indication for chronic pain.
He said he hopes this new study will increase interest in funding new trials “so we can have better evidence to guide practice to help patients make decisions.”
The study received support from the National Institute on Drug Abuse. Dr. Bicket reported receiving personal fees from Axial Healthcare as well as grants from the National Institutes of Health, the Centers for Disease Control and Prevention, Michigan Department of Health and Human Services, Arnold Foundation, and the Patient-Centered Outcomes Research Institute outside the submitted work. Dr. Busse reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research shows.
“That patients report substituting cannabis for pain medicines so much really underscores the need for research on the benefits and risks of using cannabis for chronic pain,” lead author Mark C. Bicket, MD, PhD, assistant professor, department of anesthesiology, and director, Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, said in an interview.
However, he added, the question is whether they’re turning to cannabis and away from other pain treatments. “What’s not clear and one of the gaps that we wanted to address in the study was if medical cannabis use is changing the use of other treatments for chronic pain,” said Dr. Bicket.
The study was published online in JAMA Network Open.
Decreased opioid use
The survey included a representative sample of 1724 American adults aged 18 years or older with chronic noncancer pain living in areas with a medical cannabis program.
Respondents were asked about their use of three categories of pain treatments. This included medical cannabis; pharmacologic treatments including prescription opioids, nonopioid analgesics, and over-the-counter analgesics; and common nonpharmacologic treatments such as physical therapy, meditation, and cognitive-behavioral therapy (CBT).
Just over 96% of respondents completed the full survey. About 57% of the sample was female and the mean age of the study sample was 52.3 years.
Among study participants, 31% (95% CI, 28.2% - 34.1%) reported having ever used cannabis to manage pain; 25.9% (95% confidence interval, 23.2%-28.8%) reported use in the past 12 months, and 23.2% (95% CI, 20.6%-26%) reported use in the past 30 days.
“This translates into a large number of individuals who are using cannabis in an intended medical way” to treat chronic condition such as low back pain, migraine, and fibromyalgia, said Dr. Bicket.
More than half of survey respondents reported their medical cannabis use led to a decrease in prescription opioid use, prescription nonopioid use and use of over-the-counter medications.
Dr. Bicket noted “almost no one” said medical cannabis use led to higher use of these drugs.
As for nonpharmacologic treatments, 38.7% reported their use of cannabis led to decreased use of physical therapy, 19.1% to lower use of meditation, and 26% to less CBT. At the same time, 5.9%, 23.7% and 17.1%, respectively, reported it led to increased use of physical therapy, meditation, and CBT.
Medical cannabis is regulated at a state level. On a federal level, it’s considered a Schedule I substance, which means it’s deemed not to have a therapeutic use, although some groups are trying to change that categorization, said Dr. Bicket.
As a result, cannabis products “are quite variable” in terms of how they’re used (smoked, eaten etc.) and in their composition, including percentage of cannabidiol and tetrahydrocannabinol.
“We really don’t have a good sense of the relative risks and benefits that could come from cannabis as a treatment for chronic pain,” said Dr. Bicket. “As a physician, it’s difficult to have discussions with patients because I’m not able to understand the products they’re using based on this regulatory environment we have.”
He added clinicians “are operating in an area of uncertainty right now.”
What’s needed is research to determine how safe and effective medical cannabis is for chronic pain, he said.
Pain a leading indication
Commenting on the findings, Jason W. Busse, PhD, professor, department of anesthesia, and associate director, Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ont., said the study reinforces results of some prior research.
“It gives us current information certainly highlighting the high rate of use of medical cannabis among individuals with chronic pain once it becomes legally available.”
In addition, this high rate of use “means we desperately need information about the benefits and harms” of medical marijuana, he said.
Dr. Busse noted the survey didn’t provide information on the types of cannabis being used or the mode of administration. Oil drops and sprays cause less pulmonary harm than smoked versions, he said. It’s also not clear from the survey if participants are taking formulations with high levels of tetrahydrocannabinol that are associated with greater risk of harm.
He noted cannabis may interact with prescription drugs to make them less effective or, in some cases, to augment their adverse effects.
Dr. Busse pointed out some patients could be using fewer opioids because providers are under “enormous pressure” to reduce prescriptions of these drugs in the wake of spikes in opioid overdoses and deaths.
Chronic pain is “absolutely the leading indication” for medical marijuana, said Dr. Busse. U.S. reimbursement data suggest up to 65% of individuals get cannabis to treat a listed indication for chronic pain.
He said he hopes this new study will increase interest in funding new trials “so we can have better evidence to guide practice to help patients make decisions.”
The study received support from the National Institute on Drug Abuse. Dr. Bicket reported receiving personal fees from Axial Healthcare as well as grants from the National Institutes of Health, the Centers for Disease Control and Prevention, Michigan Department of Health and Human Services, Arnold Foundation, and the Patient-Centered Outcomes Research Institute outside the submitted work. Dr. Busse reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research shows.
“That patients report substituting cannabis for pain medicines so much really underscores the need for research on the benefits and risks of using cannabis for chronic pain,” lead author Mark C. Bicket, MD, PhD, assistant professor, department of anesthesiology, and director, Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, said in an interview.
However, he added, the question is whether they’re turning to cannabis and away from other pain treatments. “What’s not clear and one of the gaps that we wanted to address in the study was if medical cannabis use is changing the use of other treatments for chronic pain,” said Dr. Bicket.
The study was published online in JAMA Network Open.
Decreased opioid use
The survey included a representative sample of 1724 American adults aged 18 years or older with chronic noncancer pain living in areas with a medical cannabis program.
Respondents were asked about their use of three categories of pain treatments. This included medical cannabis; pharmacologic treatments including prescription opioids, nonopioid analgesics, and over-the-counter analgesics; and common nonpharmacologic treatments such as physical therapy, meditation, and cognitive-behavioral therapy (CBT).
Just over 96% of respondents completed the full survey. About 57% of the sample was female and the mean age of the study sample was 52.3 years.
Among study participants, 31% (95% CI, 28.2% - 34.1%) reported having ever used cannabis to manage pain; 25.9% (95% confidence interval, 23.2%-28.8%) reported use in the past 12 months, and 23.2% (95% CI, 20.6%-26%) reported use in the past 30 days.
“This translates into a large number of individuals who are using cannabis in an intended medical way” to treat chronic condition such as low back pain, migraine, and fibromyalgia, said Dr. Bicket.
More than half of survey respondents reported their medical cannabis use led to a decrease in prescription opioid use, prescription nonopioid use and use of over-the-counter medications.
Dr. Bicket noted “almost no one” said medical cannabis use led to higher use of these drugs.
As for nonpharmacologic treatments, 38.7% reported their use of cannabis led to decreased use of physical therapy, 19.1% to lower use of meditation, and 26% to less CBT. At the same time, 5.9%, 23.7% and 17.1%, respectively, reported it led to increased use of physical therapy, meditation, and CBT.
Medical cannabis is regulated at a state level. On a federal level, it’s considered a Schedule I substance, which means it’s deemed not to have a therapeutic use, although some groups are trying to change that categorization, said Dr. Bicket.
As a result, cannabis products “are quite variable” in terms of how they’re used (smoked, eaten etc.) and in their composition, including percentage of cannabidiol and tetrahydrocannabinol.
“We really don’t have a good sense of the relative risks and benefits that could come from cannabis as a treatment for chronic pain,” said Dr. Bicket. “As a physician, it’s difficult to have discussions with patients because I’m not able to understand the products they’re using based on this regulatory environment we have.”
He added clinicians “are operating in an area of uncertainty right now.”
What’s needed is research to determine how safe and effective medical cannabis is for chronic pain, he said.
Pain a leading indication
Commenting on the findings, Jason W. Busse, PhD, professor, department of anesthesia, and associate director, Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ont., said the study reinforces results of some prior research.
“It gives us current information certainly highlighting the high rate of use of medical cannabis among individuals with chronic pain once it becomes legally available.”
In addition, this high rate of use “means we desperately need information about the benefits and harms” of medical marijuana, he said.
Dr. Busse noted the survey didn’t provide information on the types of cannabis being used or the mode of administration. Oil drops and sprays cause less pulmonary harm than smoked versions, he said. It’s also not clear from the survey if participants are taking formulations with high levels of tetrahydrocannabinol that are associated with greater risk of harm.
He noted cannabis may interact with prescription drugs to make them less effective or, in some cases, to augment their adverse effects.
Dr. Busse pointed out some patients could be using fewer opioids because providers are under “enormous pressure” to reduce prescriptions of these drugs in the wake of spikes in opioid overdoses and deaths.
Chronic pain is “absolutely the leading indication” for medical marijuana, said Dr. Busse. U.S. reimbursement data suggest up to 65% of individuals get cannabis to treat a listed indication for chronic pain.
He said he hopes this new study will increase interest in funding new trials “so we can have better evidence to guide practice to help patients make decisions.”
The study received support from the National Institute on Drug Abuse. Dr. Bicket reported receiving personal fees from Axial Healthcare as well as grants from the National Institutes of Health, the Centers for Disease Control and Prevention, Michigan Department of Health and Human Services, Arnold Foundation, and the Patient-Centered Outcomes Research Institute outside the submitted work. Dr. Busse reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
More evidence suicidal thoughts, behaviors are genetically based
“It’s really important for us to continue to study the genetic risk factors for suicidal behaviors so we can really understand the biology and develop better treatments,” study investigator Allison E. Ashley-Koch, PhD, professor in the department of medicine at Duke University Medical Center, Durham, N.C., told this news organization.
The findings were published online in JAMA Psychiatry).
SITB heritability
Suicide is a leading cause of death, particularly among individuals aged 15-29 years. Whereas the global rate of suicide has decreased by 36% in the past 20 years, the rate in the United States has increased by 35%, with the greatest rise in military veterans.
Twin studies suggest heritability for SITB is between 30% and 55%, but the molecular genetic basis of SITB remains elusive.
To address this research gap, investigators conducted a study of 633,778 U.S. military veterans from the Million Veteran Program (MVP) cohort. Of these, 71% had European ancestry, 19% had African ancestry, 8% were Hispanic, and 1% were Asian. Just under 10% of the sample was female.
Study participants donated a blood sample and agreed to have their genetic information linked with their electronic health record data.
From diagnostic codes and other sources, researchers identified 121,211 individuals with SITB. They classified participants with no documented lifetime history of suicidal ideation, suicide attempt, or suicide death as controls.
Rates of SITB differed significantly by ancestry – 25% in those with African or Hispanic ancestry, 21% in those with Asian ancestry, and 16.8% in those with European ancestry. Rates also differed by age and sex; those with SITB were younger and more likely to be female.
In addition to age and sex, covariates included “genetic principal components,” which Dr. Ashley-Koch said accounts for combining data of individuals with different ethnic/racial backgrounds.
Through meta-analysis, the investigators identified seven genome-wide, significant cross-ancestry risk loci.
To evaluate whether the findings could be replicated, researchers used the International Suicide Genetics Consortium (ISGC), a primarily civilian international consortium of roughly 550,000 individuals of mostly European ancestry.
The analysis showed the top replicated cross-ancestry risk locus was rs6557168, an intronic single-nucleotide variant (SNV) in the ESR1 gene that encodes an estrogen receptor. Previous work identified ESR1 as a causal genetic driver gene for development of posttraumatic stress disorder and depression, both of which are risk factors for SITB among veterans.
The second-strongest replicated cross-ancestry locus was rs12808482, an intronic variant in the DRD2 gene, which encodes the D2 dopamine-receptor subtype. The authors noted DRD2 is highly expressed in brain tissue and has been associated with numerous psychiatric phenotypes.
Research suggests DRD2 is associated with other risk factors for SITB, such as schizophrenia, mood disorders, and attention-deficit/hyperactivity disorder, but DRD2 could also contribute to suicide risk directly. The authors noted it is highly expressed in the prefrontal cortex, nucleus accumbens, substantia nigra, and hippocampus.
Outstanding candidate gene
The study revealed a cross-ancestry GWS association for rs10671545, a variant in DCC, which is “also an outstanding candidate gene,” the investigators write.
They note it is expressed in brain tissue, is involved in synaptic plasticity, axon guidance, and circadian entrainment, and has been associated with multiple psychiatric phenotypes.
Researchers also found what they called “intriguing” cross-ancestry GWS associations for the TRAF3 gene, which regulates type-1 interferon production. Many patients receiving interferon therapy develop major depressive disorder and suicidal ideation.
TRAF3 is also associated with antisocial behavior, substance use, and ADHD. Lithium – a standard treatment for bipolar disorder that reduces suicide risk – modulates the expression of TRAF3.
Dr. Ashley-Koch noted the replication of these loci (ESR1, DRD2, TRAF3, and DCC) was in a population of mostly White civilians. “This suggests to us that at least some of the risk for suicidal thoughts and behaviors does cross ancestry and also crosses military and civilian populations.”
It was “exciting” that all four genes the study focused on had previously been implicated in other psychiatric disorders, said Dr. Ashley-Koch. “What gave us a little more confidence, above and beyond the replication, was that these genes are somehow important for psychiatric disorders, and not any psychiatric disorders, but the ones that are also associated with a high risk of suicide behavior, such as depression, PTSD, schizophrenia, and ADHD.”
The findings will not have an immediate impact on clinical practice, said Dr. Ashley-Koch.
“We need to take the next step, which is to try to understand how these genetic factors may impact risk and what else is happening biologically to increase that risk. Then once we do that, hopefully we can develop some new treatments,” she added.
‘Valuable and noble’ research
Commenting on the study, Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, said this kind of genetic research is “valuable and noble.”
Researchers have long been interested in risk factors for suicide among military personnel and veterans, said Dr. Ritchie. Evidence to date suggests being a young male is a risk factor as is feeling excluded or not fitting into the unit, and drug or alcohol addiction.
Dr. Ritchie noted other psychiatric disorders, including schizophrenia, depression, and bipolar disorder, are at least partially inherited.
She noted the study’s findings should not be used to discriminate against those who might have the identified genetic loci without clearer evidence of their impact.
“If we were able to identify these genes, would we start screening everybody who joins the military to see if they have these genes, and how would that impact the ability to recruit or retain personnel?”
She agreed additional work is needed to determine if and how carrying these genes might impact clinical care.
In addition, she pointed out that behavior is influenced not only by genetic load but also by environment. “This study may show the impact of the genetic load a little bit more clearly; right now, we tend to look at environmental factors.”
The study was supported by an award from the Clinical Science Research and Development (CSR&D) service of the Veterans Health Administration’s Office of Research and Development. The work was also supported in part by the joint U.S. Department of Veterans Affairs and U.S. Department of Energy MVP CHAMPION program.
Dr. Ashley-Koch reported grants from Veterans Administration during the conduct of the study. Several other coauthors report relationships with industry, nonprofit organizations, and government agencies. The full list can be found with the original article. Dr. Ritchie reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“It’s really important for us to continue to study the genetic risk factors for suicidal behaviors so we can really understand the biology and develop better treatments,” study investigator Allison E. Ashley-Koch, PhD, professor in the department of medicine at Duke University Medical Center, Durham, N.C., told this news organization.
The findings were published online in JAMA Psychiatry).
SITB heritability
Suicide is a leading cause of death, particularly among individuals aged 15-29 years. Whereas the global rate of suicide has decreased by 36% in the past 20 years, the rate in the United States has increased by 35%, with the greatest rise in military veterans.
Twin studies suggest heritability for SITB is between 30% and 55%, but the molecular genetic basis of SITB remains elusive.
To address this research gap, investigators conducted a study of 633,778 U.S. military veterans from the Million Veteran Program (MVP) cohort. Of these, 71% had European ancestry, 19% had African ancestry, 8% were Hispanic, and 1% were Asian. Just under 10% of the sample was female.
Study participants donated a blood sample and agreed to have their genetic information linked with their electronic health record data.
From diagnostic codes and other sources, researchers identified 121,211 individuals with SITB. They classified participants with no documented lifetime history of suicidal ideation, suicide attempt, or suicide death as controls.
Rates of SITB differed significantly by ancestry – 25% in those with African or Hispanic ancestry, 21% in those with Asian ancestry, and 16.8% in those with European ancestry. Rates also differed by age and sex; those with SITB were younger and more likely to be female.
In addition to age and sex, covariates included “genetic principal components,” which Dr. Ashley-Koch said accounts for combining data of individuals with different ethnic/racial backgrounds.
Through meta-analysis, the investigators identified seven genome-wide, significant cross-ancestry risk loci.
To evaluate whether the findings could be replicated, researchers used the International Suicide Genetics Consortium (ISGC), a primarily civilian international consortium of roughly 550,000 individuals of mostly European ancestry.
The analysis showed the top replicated cross-ancestry risk locus was rs6557168, an intronic single-nucleotide variant (SNV) in the ESR1 gene that encodes an estrogen receptor. Previous work identified ESR1 as a causal genetic driver gene for development of posttraumatic stress disorder and depression, both of which are risk factors for SITB among veterans.
The second-strongest replicated cross-ancestry locus was rs12808482, an intronic variant in the DRD2 gene, which encodes the D2 dopamine-receptor subtype. The authors noted DRD2 is highly expressed in brain tissue and has been associated with numerous psychiatric phenotypes.
Research suggests DRD2 is associated with other risk factors for SITB, such as schizophrenia, mood disorders, and attention-deficit/hyperactivity disorder, but DRD2 could also contribute to suicide risk directly. The authors noted it is highly expressed in the prefrontal cortex, nucleus accumbens, substantia nigra, and hippocampus.
Outstanding candidate gene
The study revealed a cross-ancestry GWS association for rs10671545, a variant in DCC, which is “also an outstanding candidate gene,” the investigators write.
They note it is expressed in brain tissue, is involved in synaptic plasticity, axon guidance, and circadian entrainment, and has been associated with multiple psychiatric phenotypes.
Researchers also found what they called “intriguing” cross-ancestry GWS associations for the TRAF3 gene, which regulates type-1 interferon production. Many patients receiving interferon therapy develop major depressive disorder and suicidal ideation.
TRAF3 is also associated with antisocial behavior, substance use, and ADHD. Lithium – a standard treatment for bipolar disorder that reduces suicide risk – modulates the expression of TRAF3.
Dr. Ashley-Koch noted the replication of these loci (ESR1, DRD2, TRAF3, and DCC) was in a population of mostly White civilians. “This suggests to us that at least some of the risk for suicidal thoughts and behaviors does cross ancestry and also crosses military and civilian populations.”
It was “exciting” that all four genes the study focused on had previously been implicated in other psychiatric disorders, said Dr. Ashley-Koch. “What gave us a little more confidence, above and beyond the replication, was that these genes are somehow important for psychiatric disorders, and not any psychiatric disorders, but the ones that are also associated with a high risk of suicide behavior, such as depression, PTSD, schizophrenia, and ADHD.”
The findings will not have an immediate impact on clinical practice, said Dr. Ashley-Koch.
“We need to take the next step, which is to try to understand how these genetic factors may impact risk and what else is happening biologically to increase that risk. Then once we do that, hopefully we can develop some new treatments,” she added.
‘Valuable and noble’ research
Commenting on the study, Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, said this kind of genetic research is “valuable and noble.”
Researchers have long been interested in risk factors for suicide among military personnel and veterans, said Dr. Ritchie. Evidence to date suggests being a young male is a risk factor as is feeling excluded or not fitting into the unit, and drug or alcohol addiction.
Dr. Ritchie noted other psychiatric disorders, including schizophrenia, depression, and bipolar disorder, are at least partially inherited.
She noted the study’s findings should not be used to discriminate against those who might have the identified genetic loci without clearer evidence of their impact.
“If we were able to identify these genes, would we start screening everybody who joins the military to see if they have these genes, and how would that impact the ability to recruit or retain personnel?”
She agreed additional work is needed to determine if and how carrying these genes might impact clinical care.
In addition, she pointed out that behavior is influenced not only by genetic load but also by environment. “This study may show the impact of the genetic load a little bit more clearly; right now, we tend to look at environmental factors.”
The study was supported by an award from the Clinical Science Research and Development (CSR&D) service of the Veterans Health Administration’s Office of Research and Development. The work was also supported in part by the joint U.S. Department of Veterans Affairs and U.S. Department of Energy MVP CHAMPION program.
Dr. Ashley-Koch reported grants from Veterans Administration during the conduct of the study. Several other coauthors report relationships with industry, nonprofit organizations, and government agencies. The full list can be found with the original article. Dr. Ritchie reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“It’s really important for us to continue to study the genetic risk factors for suicidal behaviors so we can really understand the biology and develop better treatments,” study investigator Allison E. Ashley-Koch, PhD, professor in the department of medicine at Duke University Medical Center, Durham, N.C., told this news organization.
The findings were published online in JAMA Psychiatry).
SITB heritability
Suicide is a leading cause of death, particularly among individuals aged 15-29 years. Whereas the global rate of suicide has decreased by 36% in the past 20 years, the rate in the United States has increased by 35%, with the greatest rise in military veterans.
Twin studies suggest heritability for SITB is between 30% and 55%, but the molecular genetic basis of SITB remains elusive.
To address this research gap, investigators conducted a study of 633,778 U.S. military veterans from the Million Veteran Program (MVP) cohort. Of these, 71% had European ancestry, 19% had African ancestry, 8% were Hispanic, and 1% were Asian. Just under 10% of the sample was female.
Study participants donated a blood sample and agreed to have their genetic information linked with their electronic health record data.
From diagnostic codes and other sources, researchers identified 121,211 individuals with SITB. They classified participants with no documented lifetime history of suicidal ideation, suicide attempt, or suicide death as controls.
Rates of SITB differed significantly by ancestry – 25% in those with African or Hispanic ancestry, 21% in those with Asian ancestry, and 16.8% in those with European ancestry. Rates also differed by age and sex; those with SITB were younger and more likely to be female.
In addition to age and sex, covariates included “genetic principal components,” which Dr. Ashley-Koch said accounts for combining data of individuals with different ethnic/racial backgrounds.
Through meta-analysis, the investigators identified seven genome-wide, significant cross-ancestry risk loci.
To evaluate whether the findings could be replicated, researchers used the International Suicide Genetics Consortium (ISGC), a primarily civilian international consortium of roughly 550,000 individuals of mostly European ancestry.
The analysis showed the top replicated cross-ancestry risk locus was rs6557168, an intronic single-nucleotide variant (SNV) in the ESR1 gene that encodes an estrogen receptor. Previous work identified ESR1 as a causal genetic driver gene for development of posttraumatic stress disorder and depression, both of which are risk factors for SITB among veterans.
The second-strongest replicated cross-ancestry locus was rs12808482, an intronic variant in the DRD2 gene, which encodes the D2 dopamine-receptor subtype. The authors noted DRD2 is highly expressed in brain tissue and has been associated with numerous psychiatric phenotypes.
Research suggests DRD2 is associated with other risk factors for SITB, such as schizophrenia, mood disorders, and attention-deficit/hyperactivity disorder, but DRD2 could also contribute to suicide risk directly. The authors noted it is highly expressed in the prefrontal cortex, nucleus accumbens, substantia nigra, and hippocampus.
Outstanding candidate gene
The study revealed a cross-ancestry GWS association for rs10671545, a variant in DCC, which is “also an outstanding candidate gene,” the investigators write.
They note it is expressed in brain tissue, is involved in synaptic plasticity, axon guidance, and circadian entrainment, and has been associated with multiple psychiatric phenotypes.
Researchers also found what they called “intriguing” cross-ancestry GWS associations for the TRAF3 gene, which regulates type-1 interferon production. Many patients receiving interferon therapy develop major depressive disorder and suicidal ideation.
TRAF3 is also associated with antisocial behavior, substance use, and ADHD. Lithium – a standard treatment for bipolar disorder that reduces suicide risk – modulates the expression of TRAF3.
Dr. Ashley-Koch noted the replication of these loci (ESR1, DRD2, TRAF3, and DCC) was in a population of mostly White civilians. “This suggests to us that at least some of the risk for suicidal thoughts and behaviors does cross ancestry and also crosses military and civilian populations.”
It was “exciting” that all four genes the study focused on had previously been implicated in other psychiatric disorders, said Dr. Ashley-Koch. “What gave us a little more confidence, above and beyond the replication, was that these genes are somehow important for psychiatric disorders, and not any psychiatric disorders, but the ones that are also associated with a high risk of suicide behavior, such as depression, PTSD, schizophrenia, and ADHD.”
The findings will not have an immediate impact on clinical practice, said Dr. Ashley-Koch.
“We need to take the next step, which is to try to understand how these genetic factors may impact risk and what else is happening biologically to increase that risk. Then once we do that, hopefully we can develop some new treatments,” she added.
‘Valuable and noble’ research
Commenting on the study, Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, said this kind of genetic research is “valuable and noble.”
Researchers have long been interested in risk factors for suicide among military personnel and veterans, said Dr. Ritchie. Evidence to date suggests being a young male is a risk factor as is feeling excluded or not fitting into the unit, and drug or alcohol addiction.
Dr. Ritchie noted other psychiatric disorders, including schizophrenia, depression, and bipolar disorder, are at least partially inherited.
She noted the study’s findings should not be used to discriminate against those who might have the identified genetic loci without clearer evidence of their impact.
“If we were able to identify these genes, would we start screening everybody who joins the military to see if they have these genes, and how would that impact the ability to recruit or retain personnel?”
She agreed additional work is needed to determine if and how carrying these genes might impact clinical care.
In addition, she pointed out that behavior is influenced not only by genetic load but also by environment. “This study may show the impact of the genetic load a little bit more clearly; right now, we tend to look at environmental factors.”
The study was supported by an award from the Clinical Science Research and Development (CSR&D) service of the Veterans Health Administration’s Office of Research and Development. The work was also supported in part by the joint U.S. Department of Veterans Affairs and U.S. Department of Energy MVP CHAMPION program.
Dr. Ashley-Koch reported grants from Veterans Administration during the conduct of the study. Several other coauthors report relationships with industry, nonprofit organizations, and government agencies. The full list can be found with the original article. Dr. Ritchie reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA PSYCHIATRY
Improving sleep boosts cognition in refractory temporal lobe epilepsy
NASHVILLE, TENN. – Targeting relevant sleep problems for patients with refractory temporal lobe epilepsy (TLE) improves cognition, results of a new, double-blind, randomized controlled trial suggest.
Study findings show significant improvement in REM sleep and language scores for patients with TLE who took the cholinesterase inhibitor donepezil and better slow-wave sleep and memory scores for those who took the sleep aid zolpidem.
, study investigator Garima Shukla, MBBS, MD, DM, professor, division of neurology, department of medicine, Queens University, Kingston, Ont., told this news organization.
Daytime sleepiness could be a red flag in these patients, although it could mean they just have treatable sleep apnea, said Dr. Shukla. “But if they have very poor slow-wave sleep, we could try increasing its percentage by prescribing zolpidem.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Sleep, cognitive disturbances common
Sleep disturbances and cognitive disturbances are common among patients with TLE. Executive function is affected in almost all patients with refractory epilepsy, and it’s “super common” that TLE patients have memory disturbances, said Dr. Shukla.
The study included 108 patients with refractory TLE who were awaiting surgery. The patients, who had no severe comorbidities, were randomly assigned to three groups; the final number in each group was 36.
Patients in group 1 received donepezil 10 mg in the morning and a placebo at night. (Donepezil is used to treat memory loss associated with Alzheimer’s disease.)
Those in group 2 received a placebo in the morning and zolpidem 6.25 mg at night. Group 3 patients received a placebo in the morning and again at night.
The mean age of the patients was 25.4, 27.1, and 27.6 years, and the percentage of men was 63.8%, 72.2%, and 63.8% in groups 1, 2, and 3, respectively.
In all groups, patients had been experiencing about three seizures per month. The median number of antiseizure medications was two in group 1 and three in both groups 2 and 3.
Researchers evaluated sleep using the Pittsburgh Sleep Quality Index, the Epsworth Sleepiness Scale, and video polysomnography and electroencephalography.
To assess executive function, they used the Trail A & B, Stroop, and forward and backward Digit Span tests. For memory, they used the Weschler Memory Scale, and for language, the Western Aphasia Battery. They conducted follow-up evaluations at 6 months.
The results showed significant improvement in the percentage of rapid eye movement (REM) sleep in group 1 (from 14.81 at baseline to 18.21 at 6 months). In this group, the number of patients whose REM sleep percentage was less than 15 dropped significantly from 29 (of 36) to 10.
In group 2, sleep-onset latency significantly improved, and the percentage of N3 (slow-wave) sleep stage increased significantly from 25.27 to 28.74.
Regarding cognitive outcomes, backward Digit Span was significantly improved for patients in group 1. In this group, there was also a significant reduction in the time taken for Stroop A test, and there was significant improvement in language.
In group 2, there was a significant improvement in verbal and visual memory scores. There were no significant changes in group 3.
The increase in REM sleep percentage in group 1 strongly correlated with increased language and executive function scores. Similarly, in group 2, the increase in N3 sleep percentage strongly correlated with an increase in verbal memory scores.
On the basis of these observations, giving a small dose of zolpidem to a patient with “acceptable” REM sleep but very little slow-wave sleep may boost the patient’s non-REM sleep, said Dr. Shukla. “By improving non-REM sleep percentage, we will possibly help memory consolidation.”
Dr. Shukla sees this study as “a stepping-stone” to larger, multicenter trials testing “the effect of zolpidem through its impact on improving non-REM sleep percentage consolidation and its impact on memory.”
This idea veers somewhat from the traditional idea that REM sleep plays a greater role in memory consolidation, she said. “We actually found it correlates very well with language, which we have also seen in some of our anecdotal case reports.”
Patients whose language scores are very poor are “the population I would pick to target REM sleep through donepezil,” said Dr. Shukla.
‘Encouraging’ findings
Commenting for this news organization, Daniel Goldenholz, MD, PhD, assistant professor, Harvard Beth Israel Deaconess Medical Center, Boston, praised the study design.
“It allows for comparison between different treatments, as well as a placebo control group,” said Dr. Goldenholz, who added, “There appears to be good follow-up” as well.
The fact that medication may provide some cognitive benefit for patients with TLE is “very encouraging,” he said.
He noted many patients with TLE complain of memory or language problems. “So, this is a major concern.”
However, he cautioned about side effects. “Putting all temporal lobe epilepsy patients who say that they have memory problems or language problems on these medications could have some serious consequences.”
The study was funded by a Department of Health Research grant from the government of India. Dr. Goldenholz is on the advisory board for epilepsy AI, Eyzs, and Magic Leap.
A version of this article first appeared on Medscape.com.
NASHVILLE, TENN. – Targeting relevant sleep problems for patients with refractory temporal lobe epilepsy (TLE) improves cognition, results of a new, double-blind, randomized controlled trial suggest.
Study findings show significant improvement in REM sleep and language scores for patients with TLE who took the cholinesterase inhibitor donepezil and better slow-wave sleep and memory scores for those who took the sleep aid zolpidem.
, study investigator Garima Shukla, MBBS, MD, DM, professor, division of neurology, department of medicine, Queens University, Kingston, Ont., told this news organization.
Daytime sleepiness could be a red flag in these patients, although it could mean they just have treatable sleep apnea, said Dr. Shukla. “But if they have very poor slow-wave sleep, we could try increasing its percentage by prescribing zolpidem.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Sleep, cognitive disturbances common
Sleep disturbances and cognitive disturbances are common among patients with TLE. Executive function is affected in almost all patients with refractory epilepsy, and it’s “super common” that TLE patients have memory disturbances, said Dr. Shukla.
The study included 108 patients with refractory TLE who were awaiting surgery. The patients, who had no severe comorbidities, were randomly assigned to three groups; the final number in each group was 36.
Patients in group 1 received donepezil 10 mg in the morning and a placebo at night. (Donepezil is used to treat memory loss associated with Alzheimer’s disease.)
Those in group 2 received a placebo in the morning and zolpidem 6.25 mg at night. Group 3 patients received a placebo in the morning and again at night.
The mean age of the patients was 25.4, 27.1, and 27.6 years, and the percentage of men was 63.8%, 72.2%, and 63.8% in groups 1, 2, and 3, respectively.
In all groups, patients had been experiencing about three seizures per month. The median number of antiseizure medications was two in group 1 and three in both groups 2 and 3.
Researchers evaluated sleep using the Pittsburgh Sleep Quality Index, the Epsworth Sleepiness Scale, and video polysomnography and electroencephalography.
To assess executive function, they used the Trail A & B, Stroop, and forward and backward Digit Span tests. For memory, they used the Weschler Memory Scale, and for language, the Western Aphasia Battery. They conducted follow-up evaluations at 6 months.
The results showed significant improvement in the percentage of rapid eye movement (REM) sleep in group 1 (from 14.81 at baseline to 18.21 at 6 months). In this group, the number of patients whose REM sleep percentage was less than 15 dropped significantly from 29 (of 36) to 10.
In group 2, sleep-onset latency significantly improved, and the percentage of N3 (slow-wave) sleep stage increased significantly from 25.27 to 28.74.
Regarding cognitive outcomes, backward Digit Span was significantly improved for patients in group 1. In this group, there was also a significant reduction in the time taken for Stroop A test, and there was significant improvement in language.
In group 2, there was a significant improvement in verbal and visual memory scores. There were no significant changes in group 3.
The increase in REM sleep percentage in group 1 strongly correlated with increased language and executive function scores. Similarly, in group 2, the increase in N3 sleep percentage strongly correlated with an increase in verbal memory scores.
On the basis of these observations, giving a small dose of zolpidem to a patient with “acceptable” REM sleep but very little slow-wave sleep may boost the patient’s non-REM sleep, said Dr. Shukla. “By improving non-REM sleep percentage, we will possibly help memory consolidation.”
Dr. Shukla sees this study as “a stepping-stone” to larger, multicenter trials testing “the effect of zolpidem through its impact on improving non-REM sleep percentage consolidation and its impact on memory.”
This idea veers somewhat from the traditional idea that REM sleep plays a greater role in memory consolidation, she said. “We actually found it correlates very well with language, which we have also seen in some of our anecdotal case reports.”
Patients whose language scores are very poor are “the population I would pick to target REM sleep through donepezil,” said Dr. Shukla.
‘Encouraging’ findings
Commenting for this news organization, Daniel Goldenholz, MD, PhD, assistant professor, Harvard Beth Israel Deaconess Medical Center, Boston, praised the study design.
“It allows for comparison between different treatments, as well as a placebo control group,” said Dr. Goldenholz, who added, “There appears to be good follow-up” as well.
The fact that medication may provide some cognitive benefit for patients with TLE is “very encouraging,” he said.
He noted many patients with TLE complain of memory or language problems. “So, this is a major concern.”
However, he cautioned about side effects. “Putting all temporal lobe epilepsy patients who say that they have memory problems or language problems on these medications could have some serious consequences.”
The study was funded by a Department of Health Research grant from the government of India. Dr. Goldenholz is on the advisory board for epilepsy AI, Eyzs, and Magic Leap.
A version of this article first appeared on Medscape.com.
NASHVILLE, TENN. – Targeting relevant sleep problems for patients with refractory temporal lobe epilepsy (TLE) improves cognition, results of a new, double-blind, randomized controlled trial suggest.
Study findings show significant improvement in REM sleep and language scores for patients with TLE who took the cholinesterase inhibitor donepezil and better slow-wave sleep and memory scores for those who took the sleep aid zolpidem.
, study investigator Garima Shukla, MBBS, MD, DM, professor, division of neurology, department of medicine, Queens University, Kingston, Ont., told this news organization.
Daytime sleepiness could be a red flag in these patients, although it could mean they just have treatable sleep apnea, said Dr. Shukla. “But if they have very poor slow-wave sleep, we could try increasing its percentage by prescribing zolpidem.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Sleep, cognitive disturbances common
Sleep disturbances and cognitive disturbances are common among patients with TLE. Executive function is affected in almost all patients with refractory epilepsy, and it’s “super common” that TLE patients have memory disturbances, said Dr. Shukla.
The study included 108 patients with refractory TLE who were awaiting surgery. The patients, who had no severe comorbidities, were randomly assigned to three groups; the final number in each group was 36.
Patients in group 1 received donepezil 10 mg in the morning and a placebo at night. (Donepezil is used to treat memory loss associated with Alzheimer’s disease.)
Those in group 2 received a placebo in the morning and zolpidem 6.25 mg at night. Group 3 patients received a placebo in the morning and again at night.
The mean age of the patients was 25.4, 27.1, and 27.6 years, and the percentage of men was 63.8%, 72.2%, and 63.8% in groups 1, 2, and 3, respectively.
In all groups, patients had been experiencing about three seizures per month. The median number of antiseizure medications was two in group 1 and three in both groups 2 and 3.
Researchers evaluated sleep using the Pittsburgh Sleep Quality Index, the Epsworth Sleepiness Scale, and video polysomnography and electroencephalography.
To assess executive function, they used the Trail A & B, Stroop, and forward and backward Digit Span tests. For memory, they used the Weschler Memory Scale, and for language, the Western Aphasia Battery. They conducted follow-up evaluations at 6 months.
The results showed significant improvement in the percentage of rapid eye movement (REM) sleep in group 1 (from 14.81 at baseline to 18.21 at 6 months). In this group, the number of patients whose REM sleep percentage was less than 15 dropped significantly from 29 (of 36) to 10.
In group 2, sleep-onset latency significantly improved, and the percentage of N3 (slow-wave) sleep stage increased significantly from 25.27 to 28.74.
Regarding cognitive outcomes, backward Digit Span was significantly improved for patients in group 1. In this group, there was also a significant reduction in the time taken for Stroop A test, and there was significant improvement in language.
In group 2, there was a significant improvement in verbal and visual memory scores. There were no significant changes in group 3.
The increase in REM sleep percentage in group 1 strongly correlated with increased language and executive function scores. Similarly, in group 2, the increase in N3 sleep percentage strongly correlated with an increase in verbal memory scores.
On the basis of these observations, giving a small dose of zolpidem to a patient with “acceptable” REM sleep but very little slow-wave sleep may boost the patient’s non-REM sleep, said Dr. Shukla. “By improving non-REM sleep percentage, we will possibly help memory consolidation.”
Dr. Shukla sees this study as “a stepping-stone” to larger, multicenter trials testing “the effect of zolpidem through its impact on improving non-REM sleep percentage consolidation and its impact on memory.”
This idea veers somewhat from the traditional idea that REM sleep plays a greater role in memory consolidation, she said. “We actually found it correlates very well with language, which we have also seen in some of our anecdotal case reports.”
Patients whose language scores are very poor are “the population I would pick to target REM sleep through donepezil,” said Dr. Shukla.
‘Encouraging’ findings
Commenting for this news organization, Daniel Goldenholz, MD, PhD, assistant professor, Harvard Beth Israel Deaconess Medical Center, Boston, praised the study design.
“It allows for comparison between different treatments, as well as a placebo control group,” said Dr. Goldenholz, who added, “There appears to be good follow-up” as well.
The fact that medication may provide some cognitive benefit for patients with TLE is “very encouraging,” he said.
He noted many patients with TLE complain of memory or language problems. “So, this is a major concern.”
However, he cautioned about side effects. “Putting all temporal lobe epilepsy patients who say that they have memory problems or language problems on these medications could have some serious consequences.”
The study was funded by a Department of Health Research grant from the government of India. Dr. Goldenholz is on the advisory board for epilepsy AI, Eyzs, and Magic Leap.
A version of this article first appeared on Medscape.com.
AT AES 2022
‘Striking’ rate of mental health comorbidities in epilepsy
NASHVILLE, TENN. – , new research reveals.
“We hope these results inspire epileptologists and neurologists to both recognize and screen for suicide ideation and behaviors in their adolescent patients,” said study investigator Hadley Greenwood, a third-year medical student at New York University.
The new data should also encourage providers “to become more comfortable” providing support to patients, “be that by increasing their familiarity with prescribing different antidepressants or by being well versed in how to connect patients to resources within their community,” said Mr. Greenwood.
The findings were presented here at the annual meeting of the American Epilepsy Society.
Little research
Previous studies have reported on the prevalence of suicidality as well as depression and anxiety among adults with epilepsy. “We wanted to look at adolescents because there’s much less in the literature out there about psychiatric comorbidity, and specifically suicidality, in this population,” said Mr. Greenwood.
Researchers used data from the Human Epilepsy Project, a study that collected data from 34 sites in the United States, Canada, Europe, and Australia from 2012 to 2017.
From a cohort of more than 400 participants, researchers identified 67 patients aged 11-17 years who were enrolled within 4 months of starting treatment for focal epilepsy.
Participants completed the Columbia–Suicide Severity Rating Scale (C-SSRS) at enrollment and at follow-ups over 36 months. The C-SSRS measures suicidal ideation and severity, said Mr. Greenwood.
“It’s scaled from passive suicide ideation, such as thoughts of ‘I wish I were dead’ without active intent, all the way up to active suicidal ideation with a plan and intent.”
Researchers were able to distinguish individuals with passive suicide ideation from those with more serious intentions, said Mr. Greenwood. They used medical records to evaluate the prevalence of suicidal ideation and behavior.
The investigators found that more than one in five (20.9%) teens endorsed any lifetime suicide ideation. This, said Mr. Greenwood, is “roughly equivalent” to the prevalence reported earlier in the adult cohort of the Human Epilepsy Project (21.6%).
‘Striking’ rate
The fact that one in five adolescents had any lifetime suicide ideation is “definitely a striking number,” said Mr. Greenwood.
Researchers found that 15% of patients experienced active suicide ideation, 7.5% exhibited preparatory or suicidal behaviors, and 3% had made a prior suicide attempt.
All of these percentages increased at 3 years: Thirty-one percent for suicide ideation; 25% for active suicide behavior, 15% for preparatory or suicide behaviors, and 5% for prior suicide attempt.
The fact that nearly one in three adolescents endorsed suicide ideation at 3 years is another “striking” finding, said Mr. Greenwood.
Of the 53 adolescents who had never had suicide ideation at the time of enrollment, 7 endorsed new-onset suicide ideation in the follow-up period. Five of 14 who had had suicide ideation at some point prior to enrollment continued to endorse it.
“The value of the study is identifying the prevalence and identifying the significant number of adolescents with epilepsy who are endorsing either suicide ideation or suicidal behaviors,” said Mr. Greenwood.
The researchers found that among younger teens (aged 11–14 years) rates of suicide ideation were higher than among their older counterparts (aged 15–17 years).
The study does not shed light on the biological connection between epilepsy and suicidality, but Mr. Greenwood noted that prior research has suggested a bidirectional relationship.
“Depression and other psychiatric comorbidities might exist prior to epileptic activity and actually predispose to epileptic activity.”
Mr. Greenwood noted that suicide ideation has “spiked” recently across the general population, and so it’s difficult to compare the prevalence in her study with “today’s prevalence.”
However, other research generally shows that the suicide ideation rate in the general adolescent population is much lower than in teens with epilepsy.
Unique aspects of the current study are that it reports suicide ideation and behaviors at around the time of an epilepsy diagnosis and documents how suicidality progresses or resolves over time, said Mr. Greenwood.
Underdiagnosed, undertreated
Commenting on the research, Elizabeth Donner, MD, director of the comprehensive epilepsy program, Hospital for Sick Children, and associate professor, department of pediatrics, University of Toronto, said a “key point” from the study is that the suicidality rate among teens with epilepsy exceeds that of children not living with epilepsy.
“We are significantly underdiagnosing and undertreating the mental health comorbidities in epilepsy,” said Dr. Donner. “Epilepsy is a brain disease and so are mental health disorders, so it shouldn’t come as any surprise that they coexist in individuals with epilepsy.”
The new results contribute to what is already known about the significant mortality rates among persons with epilepsy, said Dr. Donner. She referred to a 2018 study that showed that people with epilepsy were 3.5 times more likely to die by suicide.
Other research has shown that people with epilepsy are 10 times more likely to die by drowning, mostly in the bathtub, said Dr. Donner.
“You would think that we’re educating these people about risks related to their epilepsy, but either the messages don’t get through, or they don’t know how to keep themselves safe,” she said.
“This needs to be seen in a bigger picture, and the bigger picture is we need to recognize comorbid mental health issues; we need to address them once recognized; and then we need to counsel and support people to live safely with their epilepsy.
The study received funding from the Epilepsy Study Consortium, Finding a Cure for Epilepsy and Seizures (FACES) and other related foundations, UCB, Pfizer, Eisai, Lundbeck, and Sunovion. Mr. Greenwood and Dr. Donner report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
NASHVILLE, TENN. – , new research reveals.
“We hope these results inspire epileptologists and neurologists to both recognize and screen for suicide ideation and behaviors in their adolescent patients,” said study investigator Hadley Greenwood, a third-year medical student at New York University.
The new data should also encourage providers “to become more comfortable” providing support to patients, “be that by increasing their familiarity with prescribing different antidepressants or by being well versed in how to connect patients to resources within their community,” said Mr. Greenwood.
The findings were presented here at the annual meeting of the American Epilepsy Society.
Little research
Previous studies have reported on the prevalence of suicidality as well as depression and anxiety among adults with epilepsy. “We wanted to look at adolescents because there’s much less in the literature out there about psychiatric comorbidity, and specifically suicidality, in this population,” said Mr. Greenwood.
Researchers used data from the Human Epilepsy Project, a study that collected data from 34 sites in the United States, Canada, Europe, and Australia from 2012 to 2017.
From a cohort of more than 400 participants, researchers identified 67 patients aged 11-17 years who were enrolled within 4 months of starting treatment for focal epilepsy.
Participants completed the Columbia–Suicide Severity Rating Scale (C-SSRS) at enrollment and at follow-ups over 36 months. The C-SSRS measures suicidal ideation and severity, said Mr. Greenwood.
“It’s scaled from passive suicide ideation, such as thoughts of ‘I wish I were dead’ without active intent, all the way up to active suicidal ideation with a plan and intent.”
Researchers were able to distinguish individuals with passive suicide ideation from those with more serious intentions, said Mr. Greenwood. They used medical records to evaluate the prevalence of suicidal ideation and behavior.
The investigators found that more than one in five (20.9%) teens endorsed any lifetime suicide ideation. This, said Mr. Greenwood, is “roughly equivalent” to the prevalence reported earlier in the adult cohort of the Human Epilepsy Project (21.6%).
‘Striking’ rate
The fact that one in five adolescents had any lifetime suicide ideation is “definitely a striking number,” said Mr. Greenwood.
Researchers found that 15% of patients experienced active suicide ideation, 7.5% exhibited preparatory or suicidal behaviors, and 3% had made a prior suicide attempt.
All of these percentages increased at 3 years: Thirty-one percent for suicide ideation; 25% for active suicide behavior, 15% for preparatory or suicide behaviors, and 5% for prior suicide attempt.
The fact that nearly one in three adolescents endorsed suicide ideation at 3 years is another “striking” finding, said Mr. Greenwood.
Of the 53 adolescents who had never had suicide ideation at the time of enrollment, 7 endorsed new-onset suicide ideation in the follow-up period. Five of 14 who had had suicide ideation at some point prior to enrollment continued to endorse it.
“The value of the study is identifying the prevalence and identifying the significant number of adolescents with epilepsy who are endorsing either suicide ideation or suicidal behaviors,” said Mr. Greenwood.
The researchers found that among younger teens (aged 11–14 years) rates of suicide ideation were higher than among their older counterparts (aged 15–17 years).
The study does not shed light on the biological connection between epilepsy and suicidality, but Mr. Greenwood noted that prior research has suggested a bidirectional relationship.
“Depression and other psychiatric comorbidities might exist prior to epileptic activity and actually predispose to epileptic activity.”
Mr. Greenwood noted that suicide ideation has “spiked” recently across the general population, and so it’s difficult to compare the prevalence in her study with “today’s prevalence.”
However, other research generally shows that the suicide ideation rate in the general adolescent population is much lower than in teens with epilepsy.
Unique aspects of the current study are that it reports suicide ideation and behaviors at around the time of an epilepsy diagnosis and documents how suicidality progresses or resolves over time, said Mr. Greenwood.
Underdiagnosed, undertreated
Commenting on the research, Elizabeth Donner, MD, director of the comprehensive epilepsy program, Hospital for Sick Children, and associate professor, department of pediatrics, University of Toronto, said a “key point” from the study is that the suicidality rate among teens with epilepsy exceeds that of children not living with epilepsy.
“We are significantly underdiagnosing and undertreating the mental health comorbidities in epilepsy,” said Dr. Donner. “Epilepsy is a brain disease and so are mental health disorders, so it shouldn’t come as any surprise that they coexist in individuals with epilepsy.”
The new results contribute to what is already known about the significant mortality rates among persons with epilepsy, said Dr. Donner. She referred to a 2018 study that showed that people with epilepsy were 3.5 times more likely to die by suicide.
Other research has shown that people with epilepsy are 10 times more likely to die by drowning, mostly in the bathtub, said Dr. Donner.
“You would think that we’re educating these people about risks related to their epilepsy, but either the messages don’t get through, or they don’t know how to keep themselves safe,” she said.
“This needs to be seen in a bigger picture, and the bigger picture is we need to recognize comorbid mental health issues; we need to address them once recognized; and then we need to counsel and support people to live safely with their epilepsy.
The study received funding from the Epilepsy Study Consortium, Finding a Cure for Epilepsy and Seizures (FACES) and other related foundations, UCB, Pfizer, Eisai, Lundbeck, and Sunovion. Mr. Greenwood and Dr. Donner report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
NASHVILLE, TENN. – , new research reveals.
“We hope these results inspire epileptologists and neurologists to both recognize and screen for suicide ideation and behaviors in their adolescent patients,” said study investigator Hadley Greenwood, a third-year medical student at New York University.
The new data should also encourage providers “to become more comfortable” providing support to patients, “be that by increasing their familiarity with prescribing different antidepressants or by being well versed in how to connect patients to resources within their community,” said Mr. Greenwood.
The findings were presented here at the annual meeting of the American Epilepsy Society.
Little research
Previous studies have reported on the prevalence of suicidality as well as depression and anxiety among adults with epilepsy. “We wanted to look at adolescents because there’s much less in the literature out there about psychiatric comorbidity, and specifically suicidality, in this population,” said Mr. Greenwood.
Researchers used data from the Human Epilepsy Project, a study that collected data from 34 sites in the United States, Canada, Europe, and Australia from 2012 to 2017.
From a cohort of more than 400 participants, researchers identified 67 patients aged 11-17 years who were enrolled within 4 months of starting treatment for focal epilepsy.
Participants completed the Columbia–Suicide Severity Rating Scale (C-SSRS) at enrollment and at follow-ups over 36 months. The C-SSRS measures suicidal ideation and severity, said Mr. Greenwood.
“It’s scaled from passive suicide ideation, such as thoughts of ‘I wish I were dead’ without active intent, all the way up to active suicidal ideation with a plan and intent.”
Researchers were able to distinguish individuals with passive suicide ideation from those with more serious intentions, said Mr. Greenwood. They used medical records to evaluate the prevalence of suicidal ideation and behavior.
The investigators found that more than one in five (20.9%) teens endorsed any lifetime suicide ideation. This, said Mr. Greenwood, is “roughly equivalent” to the prevalence reported earlier in the adult cohort of the Human Epilepsy Project (21.6%).
‘Striking’ rate
The fact that one in five adolescents had any lifetime suicide ideation is “definitely a striking number,” said Mr. Greenwood.
Researchers found that 15% of patients experienced active suicide ideation, 7.5% exhibited preparatory or suicidal behaviors, and 3% had made a prior suicide attempt.
All of these percentages increased at 3 years: Thirty-one percent for suicide ideation; 25% for active suicide behavior, 15% for preparatory or suicide behaviors, and 5% for prior suicide attempt.
The fact that nearly one in three adolescents endorsed suicide ideation at 3 years is another “striking” finding, said Mr. Greenwood.
Of the 53 adolescents who had never had suicide ideation at the time of enrollment, 7 endorsed new-onset suicide ideation in the follow-up period. Five of 14 who had had suicide ideation at some point prior to enrollment continued to endorse it.
“The value of the study is identifying the prevalence and identifying the significant number of adolescents with epilepsy who are endorsing either suicide ideation or suicidal behaviors,” said Mr. Greenwood.
The researchers found that among younger teens (aged 11–14 years) rates of suicide ideation were higher than among their older counterparts (aged 15–17 years).
The study does not shed light on the biological connection between epilepsy and suicidality, but Mr. Greenwood noted that prior research has suggested a bidirectional relationship.
“Depression and other psychiatric comorbidities might exist prior to epileptic activity and actually predispose to epileptic activity.”
Mr. Greenwood noted that suicide ideation has “spiked” recently across the general population, and so it’s difficult to compare the prevalence in her study with “today’s prevalence.”
However, other research generally shows that the suicide ideation rate in the general adolescent population is much lower than in teens with epilepsy.
Unique aspects of the current study are that it reports suicide ideation and behaviors at around the time of an epilepsy diagnosis and documents how suicidality progresses or resolves over time, said Mr. Greenwood.
Underdiagnosed, undertreated
Commenting on the research, Elizabeth Donner, MD, director of the comprehensive epilepsy program, Hospital for Sick Children, and associate professor, department of pediatrics, University of Toronto, said a “key point” from the study is that the suicidality rate among teens with epilepsy exceeds that of children not living with epilepsy.
“We are significantly underdiagnosing and undertreating the mental health comorbidities in epilepsy,” said Dr. Donner. “Epilepsy is a brain disease and so are mental health disorders, so it shouldn’t come as any surprise that they coexist in individuals with epilepsy.”
The new results contribute to what is already known about the significant mortality rates among persons with epilepsy, said Dr. Donner. She referred to a 2018 study that showed that people with epilepsy were 3.5 times more likely to die by suicide.
Other research has shown that people with epilepsy are 10 times more likely to die by drowning, mostly in the bathtub, said Dr. Donner.
“You would think that we’re educating these people about risks related to their epilepsy, but either the messages don’t get through, or they don’t know how to keep themselves safe,” she said.
“This needs to be seen in a bigger picture, and the bigger picture is we need to recognize comorbid mental health issues; we need to address them once recognized; and then we need to counsel and support people to live safely with their epilepsy.
The study received funding from the Epilepsy Study Consortium, Finding a Cure for Epilepsy and Seizures (FACES) and other related foundations, UCB, Pfizer, Eisai, Lundbeck, and Sunovion. Mr. Greenwood and Dr. Donner report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT AES 2022
Significant racial disparities persist in status epilepticus
NASHVILLE, Tenn. – Investigators found that among Black patients with status epilepticus, the hospitalization rate was twice that of their White counterparts. Other findings reveal age and income disparities.
“The results suggest that racial minorities, those with a lower income, and the elderly are an appropriate target to improve health outcomes and reduce health inequality,” said Gabriela Tantillo Sepúlveda, MD, assistant professor of neurology, Baylor College of Medicine, Houston.
The findings were presented at the annual meeting of the American Epilepsy Society.
An examination of outcomes
Status epilepticus is associated with high rates of morbidity and mortality. Disparities in epilepsy care have previously been described, but little attention has been paid to the contribution of disparities to status epilepticus care and associated outcomes.
Researchers used 2010-2019 data from the Nationwide Inpatient Sample, a database covering a cross-section of hospitalizations in 48 states and the District of Columbia. From relevant diagnostic codes, they calculated status epilepticus prevalence as the rate per 10,000 hospitalizations and stratified this by demographics.
Over the study period, investigators identified 486,861 status epilepticus hospitalizations, most (71.3%) at urban teaching hospitals.
Status epilepticus prevalence was highest for non-Hispanic Black patients, at 27.3, followed by non-Hispanic others, at 16.1, Hispanic patients, at 15.8, and non-Hispanic-White patients, at 13.7 (P < .01).
The finding that Black patients had double the rate as White patients was “definitely surprising,” said Dr. Tantillo Sepúlveda.
Research over the past 20 years revealed similar disparities related to status epilepticus, “so it’s upsetting that these disparities have persisted. Unfortunately, we still have a lot of work to do to reduce health inequalities,” she said.
The investigators found that the prevalence of status epilepticus was higher in the lowest-income quartile, compared with the highest (18.7 vs. 14; P < .01).
Need for physician advocacy
Unlike previous studies, this research assessed various interventions in different age groups and showed that the likelihood of intubation, tracheostomy, gastrostomy, and in-hospital mortality increased with age.
For example, compared with the reference group (patients aged 18-39 years), the odds of intubation were 1.22 (95% confidence interval, 1.16-1.27) for those aged 40-59 years and 1.48 (95% CI, 1.42-1.54) for those aged 60-79. Those aged 80 and older were most likely to be intubated, at an odds ratio of 1.5 (95% CI, 1.43-1.58).
Elderly patients were most likely to undergo tracheostomy (OR, 2.0; 95% CI, 1.75-2.27), gastrostomy (OR, 3.37; 95% CI, 2.97-3.83), and to experience in-hospital mortality (OR, 6.51; 95% CI, 5.95-7.13), compared with the youngest patients.
These intervention rates also varied by racial/ethnic groups. Minority populations, particularly Black people, had higher odds of tracheostomy and gastrostomy, compared with non-Hispanic White persons.
The odds of undergoing electroencephalography monitoring progressively rose as income level increased (OR, 1.47; 95% CI, 1.34-1.62) for the highest income quartile versus the lowest quartile. The odds of undergoing EEG monitoring were also higher at urban teaching hospitals than at rural hospitals.
Tackling these disparities in this patient population include increasing resources, personnel, and health education aimed at minorities, low-income patients, and the elderly, said Dr. Tantillo Sepúlveda. She added that more research is needed “to determine the most effective ways of accomplishing this goal.”
The medical community can help reduce disparities, said Dr. Tantillo Sepúlveda, by working to improve health literacy, to reduce stigma associated with seizures, and to increase awareness of seizure risk factors.
They can also work to expand access to outpatient neurology clinics, epilepsy monitoring units, and epilepsy surgery. “Ethnic and racial minorities are less likely to receive epilepsy surgery for temporal lobe epilepsy, which has been shown to improve quality of life and reduce seizure burden,” Dr. Tantillo Sepúlveda noted.
Across-the-board problem
Commenting on the research, Daniel Lowenstein, MD, professor of neurology, University of California, San Francisco, said the findings aren’t at all surprising. “It’s yet another piece of evidence on what has now become a rather voluminous literature that documents the very significant disparities that exist in our health care system,” said Dr. Lowenstein. “There’s just a huge literature on ‘name your disease and you’ll see the disparities.’ ”
Disparities exist, for example, in diagnosing breast cancer and prostate cancer, in the treatment of stroke and in related outcomes, and there is a well-documented “big disparity” in the approach to pain control among patients presenting at the emergency department, said Dr. Lowenstein.
However, he doesn’t know how disparities in epilepsy and specifically in status epilepticus, compared with disparities regarding other diseases and disorders. He noted that in the case of epilepsy, the situation is likely exacerbated by the stigma associated with that disease.
Dr. Lowenstein agreed that clinicians should play a role in reversing disparities. “We as physicians have a responsibility to be a voice for change in our health care system.”
The study was supported by the Center of Excellence for health equity, training, and research at the Baylor College of Medicine. Dr. Tantillo Sepúlveda and Dr. Lowenstein report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
NASHVILLE, Tenn. – Investigators found that among Black patients with status epilepticus, the hospitalization rate was twice that of their White counterparts. Other findings reveal age and income disparities.
“The results suggest that racial minorities, those with a lower income, and the elderly are an appropriate target to improve health outcomes and reduce health inequality,” said Gabriela Tantillo Sepúlveda, MD, assistant professor of neurology, Baylor College of Medicine, Houston.
The findings were presented at the annual meeting of the American Epilepsy Society.
An examination of outcomes
Status epilepticus is associated with high rates of morbidity and mortality. Disparities in epilepsy care have previously been described, but little attention has been paid to the contribution of disparities to status epilepticus care and associated outcomes.
Researchers used 2010-2019 data from the Nationwide Inpatient Sample, a database covering a cross-section of hospitalizations in 48 states and the District of Columbia. From relevant diagnostic codes, they calculated status epilepticus prevalence as the rate per 10,000 hospitalizations and stratified this by demographics.
Over the study period, investigators identified 486,861 status epilepticus hospitalizations, most (71.3%) at urban teaching hospitals.
Status epilepticus prevalence was highest for non-Hispanic Black patients, at 27.3, followed by non-Hispanic others, at 16.1, Hispanic patients, at 15.8, and non-Hispanic-White patients, at 13.7 (P < .01).
The finding that Black patients had double the rate as White patients was “definitely surprising,” said Dr. Tantillo Sepúlveda.
Research over the past 20 years revealed similar disparities related to status epilepticus, “so it’s upsetting that these disparities have persisted. Unfortunately, we still have a lot of work to do to reduce health inequalities,” she said.
The investigators found that the prevalence of status epilepticus was higher in the lowest-income quartile, compared with the highest (18.7 vs. 14; P < .01).
Need for physician advocacy
Unlike previous studies, this research assessed various interventions in different age groups and showed that the likelihood of intubation, tracheostomy, gastrostomy, and in-hospital mortality increased with age.
For example, compared with the reference group (patients aged 18-39 years), the odds of intubation were 1.22 (95% confidence interval, 1.16-1.27) for those aged 40-59 years and 1.48 (95% CI, 1.42-1.54) for those aged 60-79. Those aged 80 and older were most likely to be intubated, at an odds ratio of 1.5 (95% CI, 1.43-1.58).
Elderly patients were most likely to undergo tracheostomy (OR, 2.0; 95% CI, 1.75-2.27), gastrostomy (OR, 3.37; 95% CI, 2.97-3.83), and to experience in-hospital mortality (OR, 6.51; 95% CI, 5.95-7.13), compared with the youngest patients.
These intervention rates also varied by racial/ethnic groups. Minority populations, particularly Black people, had higher odds of tracheostomy and gastrostomy, compared with non-Hispanic White persons.
The odds of undergoing electroencephalography monitoring progressively rose as income level increased (OR, 1.47; 95% CI, 1.34-1.62) for the highest income quartile versus the lowest quartile. The odds of undergoing EEG monitoring were also higher at urban teaching hospitals than at rural hospitals.
Tackling these disparities in this patient population include increasing resources, personnel, and health education aimed at minorities, low-income patients, and the elderly, said Dr. Tantillo Sepúlveda. She added that more research is needed “to determine the most effective ways of accomplishing this goal.”
The medical community can help reduce disparities, said Dr. Tantillo Sepúlveda, by working to improve health literacy, to reduce stigma associated with seizures, and to increase awareness of seizure risk factors.
They can also work to expand access to outpatient neurology clinics, epilepsy monitoring units, and epilepsy surgery. “Ethnic and racial minorities are less likely to receive epilepsy surgery for temporal lobe epilepsy, which has been shown to improve quality of life and reduce seizure burden,” Dr. Tantillo Sepúlveda noted.
Across-the-board problem
Commenting on the research, Daniel Lowenstein, MD, professor of neurology, University of California, San Francisco, said the findings aren’t at all surprising. “It’s yet another piece of evidence on what has now become a rather voluminous literature that documents the very significant disparities that exist in our health care system,” said Dr. Lowenstein. “There’s just a huge literature on ‘name your disease and you’ll see the disparities.’ ”
Disparities exist, for example, in diagnosing breast cancer and prostate cancer, in the treatment of stroke and in related outcomes, and there is a well-documented “big disparity” in the approach to pain control among patients presenting at the emergency department, said Dr. Lowenstein.
However, he doesn’t know how disparities in epilepsy and specifically in status epilepticus, compared with disparities regarding other diseases and disorders. He noted that in the case of epilepsy, the situation is likely exacerbated by the stigma associated with that disease.
Dr. Lowenstein agreed that clinicians should play a role in reversing disparities. “We as physicians have a responsibility to be a voice for change in our health care system.”
The study was supported by the Center of Excellence for health equity, training, and research at the Baylor College of Medicine. Dr. Tantillo Sepúlveda and Dr. Lowenstein report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
NASHVILLE, Tenn. – Investigators found that among Black patients with status epilepticus, the hospitalization rate was twice that of their White counterparts. Other findings reveal age and income disparities.
“The results suggest that racial minorities, those with a lower income, and the elderly are an appropriate target to improve health outcomes and reduce health inequality,” said Gabriela Tantillo Sepúlveda, MD, assistant professor of neurology, Baylor College of Medicine, Houston.
The findings were presented at the annual meeting of the American Epilepsy Society.
An examination of outcomes
Status epilepticus is associated with high rates of morbidity and mortality. Disparities in epilepsy care have previously been described, but little attention has been paid to the contribution of disparities to status epilepticus care and associated outcomes.
Researchers used 2010-2019 data from the Nationwide Inpatient Sample, a database covering a cross-section of hospitalizations in 48 states and the District of Columbia. From relevant diagnostic codes, they calculated status epilepticus prevalence as the rate per 10,000 hospitalizations and stratified this by demographics.
Over the study period, investigators identified 486,861 status epilepticus hospitalizations, most (71.3%) at urban teaching hospitals.
Status epilepticus prevalence was highest for non-Hispanic Black patients, at 27.3, followed by non-Hispanic others, at 16.1, Hispanic patients, at 15.8, and non-Hispanic-White patients, at 13.7 (P < .01).
The finding that Black patients had double the rate as White patients was “definitely surprising,” said Dr. Tantillo Sepúlveda.
Research over the past 20 years revealed similar disparities related to status epilepticus, “so it’s upsetting that these disparities have persisted. Unfortunately, we still have a lot of work to do to reduce health inequalities,” she said.
The investigators found that the prevalence of status epilepticus was higher in the lowest-income quartile, compared with the highest (18.7 vs. 14; P < .01).
Need for physician advocacy
Unlike previous studies, this research assessed various interventions in different age groups and showed that the likelihood of intubation, tracheostomy, gastrostomy, and in-hospital mortality increased with age.
For example, compared with the reference group (patients aged 18-39 years), the odds of intubation were 1.22 (95% confidence interval, 1.16-1.27) for those aged 40-59 years and 1.48 (95% CI, 1.42-1.54) for those aged 60-79. Those aged 80 and older were most likely to be intubated, at an odds ratio of 1.5 (95% CI, 1.43-1.58).
Elderly patients were most likely to undergo tracheostomy (OR, 2.0; 95% CI, 1.75-2.27), gastrostomy (OR, 3.37; 95% CI, 2.97-3.83), and to experience in-hospital mortality (OR, 6.51; 95% CI, 5.95-7.13), compared with the youngest patients.
These intervention rates also varied by racial/ethnic groups. Minority populations, particularly Black people, had higher odds of tracheostomy and gastrostomy, compared with non-Hispanic White persons.
The odds of undergoing electroencephalography monitoring progressively rose as income level increased (OR, 1.47; 95% CI, 1.34-1.62) for the highest income quartile versus the lowest quartile. The odds of undergoing EEG monitoring were also higher at urban teaching hospitals than at rural hospitals.
Tackling these disparities in this patient population include increasing resources, personnel, and health education aimed at minorities, low-income patients, and the elderly, said Dr. Tantillo Sepúlveda. She added that more research is needed “to determine the most effective ways of accomplishing this goal.”
The medical community can help reduce disparities, said Dr. Tantillo Sepúlveda, by working to improve health literacy, to reduce stigma associated with seizures, and to increase awareness of seizure risk factors.
They can also work to expand access to outpatient neurology clinics, epilepsy monitoring units, and epilepsy surgery. “Ethnic and racial minorities are less likely to receive epilepsy surgery for temporal lobe epilepsy, which has been shown to improve quality of life and reduce seizure burden,” Dr. Tantillo Sepúlveda noted.
Across-the-board problem
Commenting on the research, Daniel Lowenstein, MD, professor of neurology, University of California, San Francisco, said the findings aren’t at all surprising. “It’s yet another piece of evidence on what has now become a rather voluminous literature that documents the very significant disparities that exist in our health care system,” said Dr. Lowenstein. “There’s just a huge literature on ‘name your disease and you’ll see the disparities.’ ”
Disparities exist, for example, in diagnosing breast cancer and prostate cancer, in the treatment of stroke and in related outcomes, and there is a well-documented “big disparity” in the approach to pain control among patients presenting at the emergency department, said Dr. Lowenstein.
However, he doesn’t know how disparities in epilepsy and specifically in status epilepticus, compared with disparities regarding other diseases and disorders. He noted that in the case of epilepsy, the situation is likely exacerbated by the stigma associated with that disease.
Dr. Lowenstein agreed that clinicians should play a role in reversing disparities. “We as physicians have a responsibility to be a voice for change in our health care system.”
The study was supported by the Center of Excellence for health equity, training, and research at the Baylor College of Medicine. Dr. Tantillo Sepúlveda and Dr. Lowenstein report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT AES 2022
More evidence in utero exposure to antiseizure meds safe for children’s cognition
NASHVILLE, TENN. – There is no negative impact of in utero exposure to antiseizure medications on children’s creativity, new research shows.
The results of this study, along with other research, suggest the risk for cognitive problems “is fairly low” overall for children of women with epilepsy taking lamotrigine or levetiracetam, study investigator, Kimford J. Meador, MD, professor, department of neurology & neurological sciences, Stanford (Calif.) University School of Medicine, told this news organization.
“This is another encouraging piece that’s showing these new drugs are safe with regard to cognition.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Capturing creativity
Fetal exposure to antiseizure medications can produce adverse neurodevelopmental effects. These are typically assessed using measures such as general intelligence, verbal/nonverbal abilities, or additional educational needs.
However, these measures don’t capture creativity, which “is related to intelligence but not completely,” said Dr. Meador. “I have seen wonderful examples of creativity in people who have a lot of cognitive impairment.”
He referred to one of his patients with epilepsy who is “spectacularly good” at painting with watercolors, even though she has significant cognitive impairment.
The new analysis is part of the MONEAD study, a prospective, observational multicenter study examining pregnancy outcomes for both mother and child. It included pregnant women who were enrolled at under 20 weeks’ gestational age.
The women with epilepsy in the study were primarily on monotherapy (73%), and of these, 82% were on lamotrigine or levetiracetam. About 22% were on polytherapy, of which 42% were on dual therapy with lamotrigine and levetiracetam.
Fluency, originality
Researchers assessed the children of these women at age 4½ years using the Torrance Test of Creative Thinking-Figural (TTCT-F). This is a standardized assessment of creative thinking with index scores measuring such things as fluency, originality, abstractness, and elaboration.
Dr. Meador noted the research team used a shorter version of the test battery “so as to not wear out the families and kids.”
During the test, children were given lines of different shapes and asked to draw a picture using these lines. Dr. Meador pointed out the drawings ranged from quite basic to more intricate.
One child cleverly turned a few squiggly lines into a car. “I can look at this and say this kid’s going to do very well,” said Dr. Meador.
Investigators compared scores between 241 children of women with epilepsy (WWE) and 65 children of healthy women (HW). They adjusted for the mother’s IQ, education level, age at enrollment, gestation age at enrollment, post-birth average anxiety score, and the child’s ethnicity and sex.
Investigators found the mean TTCT-F scores did not differ significantly between the two groups: adjusted least squares mean of 89.5 (95% confidence interval, 86.7-92.3) for children of WWE, compared with adjusted least square mean of 92.0 (95% CI, 86.4-97.6) for children of HW.
Balancing act
The researchers haven’t looked at a dose effect in this current study, but Dr. Meador said it’s always “a balancing act” between giving enough of the drug to keep mothers from seizing, which affect both the mother and fetus, and giving as low a dose as possible to protect the fetus.
In addition, as medication levels change during pregnancy, he said he recommends that drug levels are monitored monthly so that medication can be adjusted as necessary.
Looking at what factors might predict creativity scores, researchers found children did less well creatively if their mother didn’t have a college degree (estimate –9.5; 95% CI, –17.9 to –1.2; P = .025).
“It looks like being in a home where the mother has had more education is going to have an impact on the kid’s thinking and creativity,” said Dr. Meador.
These new findings are consistent with a lack of differences in other cognitive abilities that Dr. Meador and his team found when the children were younger.
“At age 3, we did not find an overall difference in cognitive and verbal abilities and intelligence between the children of mothers with epilepsy and those of healthy women,” he said.
The researchers aim to assess cognitive and behavioral outcomes in these children when they are 6 years old.
Helpful information
Commenting on the findings, Stéphane Auvin, MD, PhD, chair of the department of pediatric neurology at the University of Paris, who co-moderated a platform session featuring the research, said the study “is an interesting measure of the impact of being exposed to antiseizure medications.”
Creativity is “complex,” he said. “It’s not only cognition; it could be things like behavior and impulsivity.”
The new information is “very helpful.” Focusing on something broader than just IQ “gives you a better picture of what’s going on.”
The study received funding from NIH, NINDS, and NICH. Dr. Meador has received grants from NIH/NINDS, NIH/NICHD, Veterans Administration, and Eisai. He has been a consultant for Epilepsy Consortium, Novartis, Supernus, Upsher Smith Labs, and UCB Pharma. Dr. Auvin reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
NASHVILLE, TENN. – There is no negative impact of in utero exposure to antiseizure medications on children’s creativity, new research shows.
The results of this study, along with other research, suggest the risk for cognitive problems “is fairly low” overall for children of women with epilepsy taking lamotrigine or levetiracetam, study investigator, Kimford J. Meador, MD, professor, department of neurology & neurological sciences, Stanford (Calif.) University School of Medicine, told this news organization.
“This is another encouraging piece that’s showing these new drugs are safe with regard to cognition.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Capturing creativity
Fetal exposure to antiseizure medications can produce adverse neurodevelopmental effects. These are typically assessed using measures such as general intelligence, verbal/nonverbal abilities, or additional educational needs.
However, these measures don’t capture creativity, which “is related to intelligence but not completely,” said Dr. Meador. “I have seen wonderful examples of creativity in people who have a lot of cognitive impairment.”
He referred to one of his patients with epilepsy who is “spectacularly good” at painting with watercolors, even though she has significant cognitive impairment.
The new analysis is part of the MONEAD study, a prospective, observational multicenter study examining pregnancy outcomes for both mother and child. It included pregnant women who were enrolled at under 20 weeks’ gestational age.
The women with epilepsy in the study were primarily on monotherapy (73%), and of these, 82% were on lamotrigine or levetiracetam. About 22% were on polytherapy, of which 42% were on dual therapy with lamotrigine and levetiracetam.
Fluency, originality
Researchers assessed the children of these women at age 4½ years using the Torrance Test of Creative Thinking-Figural (TTCT-F). This is a standardized assessment of creative thinking with index scores measuring such things as fluency, originality, abstractness, and elaboration.
Dr. Meador noted the research team used a shorter version of the test battery “so as to not wear out the families and kids.”
During the test, children were given lines of different shapes and asked to draw a picture using these lines. Dr. Meador pointed out the drawings ranged from quite basic to more intricate.
One child cleverly turned a few squiggly lines into a car. “I can look at this and say this kid’s going to do very well,” said Dr. Meador.
Investigators compared scores between 241 children of women with epilepsy (WWE) and 65 children of healthy women (HW). They adjusted for the mother’s IQ, education level, age at enrollment, gestation age at enrollment, post-birth average anxiety score, and the child’s ethnicity and sex.
Investigators found the mean TTCT-F scores did not differ significantly between the two groups: adjusted least squares mean of 89.5 (95% confidence interval, 86.7-92.3) for children of WWE, compared with adjusted least square mean of 92.0 (95% CI, 86.4-97.6) for children of HW.
Balancing act
The researchers haven’t looked at a dose effect in this current study, but Dr. Meador said it’s always “a balancing act” between giving enough of the drug to keep mothers from seizing, which affect both the mother and fetus, and giving as low a dose as possible to protect the fetus.
In addition, as medication levels change during pregnancy, he said he recommends that drug levels are monitored monthly so that medication can be adjusted as necessary.
Looking at what factors might predict creativity scores, researchers found children did less well creatively if their mother didn’t have a college degree (estimate –9.5; 95% CI, –17.9 to –1.2; P = .025).
“It looks like being in a home where the mother has had more education is going to have an impact on the kid’s thinking and creativity,” said Dr. Meador.
These new findings are consistent with a lack of differences in other cognitive abilities that Dr. Meador and his team found when the children were younger.
“At age 3, we did not find an overall difference in cognitive and verbal abilities and intelligence between the children of mothers with epilepsy and those of healthy women,” he said.
The researchers aim to assess cognitive and behavioral outcomes in these children when they are 6 years old.
Helpful information
Commenting on the findings, Stéphane Auvin, MD, PhD, chair of the department of pediatric neurology at the University of Paris, who co-moderated a platform session featuring the research, said the study “is an interesting measure of the impact of being exposed to antiseizure medications.”
Creativity is “complex,” he said. “It’s not only cognition; it could be things like behavior and impulsivity.”
The new information is “very helpful.” Focusing on something broader than just IQ “gives you a better picture of what’s going on.”
The study received funding from NIH, NINDS, and NICH. Dr. Meador has received grants from NIH/NINDS, NIH/NICHD, Veterans Administration, and Eisai. He has been a consultant for Epilepsy Consortium, Novartis, Supernus, Upsher Smith Labs, and UCB Pharma. Dr. Auvin reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
NASHVILLE, TENN. – There is no negative impact of in utero exposure to antiseizure medications on children’s creativity, new research shows.
The results of this study, along with other research, suggest the risk for cognitive problems “is fairly low” overall for children of women with epilepsy taking lamotrigine or levetiracetam, study investigator, Kimford J. Meador, MD, professor, department of neurology & neurological sciences, Stanford (Calif.) University School of Medicine, told this news organization.
“This is another encouraging piece that’s showing these new drugs are safe with regard to cognition.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Capturing creativity
Fetal exposure to antiseizure medications can produce adverse neurodevelopmental effects. These are typically assessed using measures such as general intelligence, verbal/nonverbal abilities, or additional educational needs.
However, these measures don’t capture creativity, which “is related to intelligence but not completely,” said Dr. Meador. “I have seen wonderful examples of creativity in people who have a lot of cognitive impairment.”
He referred to one of his patients with epilepsy who is “spectacularly good” at painting with watercolors, even though she has significant cognitive impairment.
The new analysis is part of the MONEAD study, a prospective, observational multicenter study examining pregnancy outcomes for both mother and child. It included pregnant women who were enrolled at under 20 weeks’ gestational age.
The women with epilepsy in the study were primarily on monotherapy (73%), and of these, 82% were on lamotrigine or levetiracetam. About 22% were on polytherapy, of which 42% were on dual therapy with lamotrigine and levetiracetam.
Fluency, originality
Researchers assessed the children of these women at age 4½ years using the Torrance Test of Creative Thinking-Figural (TTCT-F). This is a standardized assessment of creative thinking with index scores measuring such things as fluency, originality, abstractness, and elaboration.
Dr. Meador noted the research team used a shorter version of the test battery “so as to not wear out the families and kids.”
During the test, children were given lines of different shapes and asked to draw a picture using these lines. Dr. Meador pointed out the drawings ranged from quite basic to more intricate.
One child cleverly turned a few squiggly lines into a car. “I can look at this and say this kid’s going to do very well,” said Dr. Meador.
Investigators compared scores between 241 children of women with epilepsy (WWE) and 65 children of healthy women (HW). They adjusted for the mother’s IQ, education level, age at enrollment, gestation age at enrollment, post-birth average anxiety score, and the child’s ethnicity and sex.
Investigators found the mean TTCT-F scores did not differ significantly between the two groups: adjusted least squares mean of 89.5 (95% confidence interval, 86.7-92.3) for children of WWE, compared with adjusted least square mean of 92.0 (95% CI, 86.4-97.6) for children of HW.
Balancing act
The researchers haven’t looked at a dose effect in this current study, but Dr. Meador said it’s always “a balancing act” between giving enough of the drug to keep mothers from seizing, which affect both the mother and fetus, and giving as low a dose as possible to protect the fetus.
In addition, as medication levels change during pregnancy, he said he recommends that drug levels are monitored monthly so that medication can be adjusted as necessary.
Looking at what factors might predict creativity scores, researchers found children did less well creatively if their mother didn’t have a college degree (estimate –9.5; 95% CI, –17.9 to –1.2; P = .025).
“It looks like being in a home where the mother has had more education is going to have an impact on the kid’s thinking and creativity,” said Dr. Meador.
These new findings are consistent with a lack of differences in other cognitive abilities that Dr. Meador and his team found when the children were younger.
“At age 3, we did not find an overall difference in cognitive and verbal abilities and intelligence between the children of mothers with epilepsy and those of healthy women,” he said.
The researchers aim to assess cognitive and behavioral outcomes in these children when they are 6 years old.
Helpful information
Commenting on the findings, Stéphane Auvin, MD, PhD, chair of the department of pediatric neurology at the University of Paris, who co-moderated a platform session featuring the research, said the study “is an interesting measure of the impact of being exposed to antiseizure medications.”
Creativity is “complex,” he said. “It’s not only cognition; it could be things like behavior and impulsivity.”
The new information is “very helpful.” Focusing on something broader than just IQ “gives you a better picture of what’s going on.”
The study received funding from NIH, NINDS, and NICH. Dr. Meador has received grants from NIH/NINDS, NIH/NICHD, Veterans Administration, and Eisai. He has been a consultant for Epilepsy Consortium, Novartis, Supernus, Upsher Smith Labs, and UCB Pharma. Dr. Auvin reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM AES 2022
Recommending exercise for migraine: Just do it
with high-intensity aerobics coming in second, and both beating top-line migraine medications topiramate and amitriptyline, new research suggests.
The new results should encourage clinicians to recommend patients with migraine engage in strength-training exercise whenever possible, study investigator Yohannes W. Woldeamanuel, MD, a physician-scientist and instructor, department of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.
“Exercise is something patients can do all their lives and use it to prevent migraine attacks instead of taking daily medications or repetitive injections that have several adverse effects.”
The findings were published online in the Journal of Headache and Pain.
Head-to-head comparison
Several clinical trials have shown exercise is effective for migraine management, but to date, there have been no head-to-head comparisons of strength training and aerobic exercise, said Dr. Woldeamanuel.
This new study used a systematic review with network meta-analysis (NMA), which compares multiple interventions and ranks the efficacy of each one.
After a literature search, researchers included 21 clinical trials with an exercise regimen arm and a comparison control arm. All study data reported monthly frequency of migraine at baseline and at the end of the intervention.
The total combined sample size was 1,195 patients with migraine, who were a mean age of 35.5 years, with a female-to-male ratio of 6.7:1. All studies used International Classification of Headache Disorders (ICHD) criteria for migraine diagnosis.
The NMA provided 27 pairwise comparisons and 8 indirect comparisons. The pairwise comparisons provided direct evidence between the different interventions.
Researchers combined strength training, including weightlifting, with resistance training. Both modalities target muscles, while aerobic exercise targets cardiovascular health.
The average number of weeks was 9.3, 9.3, and 10.7, and the average number of hours per session for strength/resistance training, high-intensity aerobic exercise, and moderate-intensity aerobic exercise interventions was 50, 56, and 45.3, respectively.
The analysis showed all exercise interventions were more effective than the placebo groups in reducing the frequency of migraine. In terms of ranking, strength training came out on top, with a mean difference in monthly migraine days of −3.55 (95% confidence interval, −6.15 to −0.95) between the active and placebo groups.
Next was high-intensity aerobic exercise (−3.13; 95% CI, −5.28 to −0.97) and moderate-intensity aerobic exercise (−2.18; 95% CI, −3.25 to −1.11), followed by topiramate, placebo, and then amitriptyline.
Strength/resistance training was superior possibly because it targets muscle strengthening, particularly major muscles in the neck and shoulder area, which can be a source of the pain trigger, said Dr. Woldeamanuel. He added neck pain is highly comorbid with migraine.
Interestingly, patients doing exercises that focus on unaffected muscles – for example, squats – still get the benefits of less migraine burden, said Dr. Woldeamanuel.
Training recommendations
Strength training also increases or preserves lean muscle mass, which is associated with reduced migraine frequency. Research shows preservation of lean body mass combats central sensitization in various pain syndromes, said Dr. Woldeamanuel.
The superior effects of high- versus moderate-intensity aerobic exercise may be due to recruitment of endogenous molecules involved in exercise-mediated hypoalgesia (pain reduction).
The most common pathways are the opioid and endocannabinoid systems, although other systems are also likely involved, said Dr. Woldeamanuel. He noted migraine has been linked to a deficiency of both opioidergic and endocannabinoidergic signaling.
Dr. Woldeamanuel commented on the difficulty of comparing exercise interventions for patients with chronic versus episodic migraine, as many studies include both.
However, the two studies with moderate-intensity aerobic exercise exclusively involving patients with chronic migraine showed large effect sizes (Cohen’s d) of 0.80 and 1.10 in reducing monthly headache frequency.
Based on these new results and their own experience, the researchers recommend strength training start with 50% of repetition maximum (RM) with 2-3 sets of 12-15 repetitions three times a week along with 10 minutes of warm-up, stretching, and cool-down, totaling 45-60 minutes per session. Weight/resistance load can then be increased weekly by 5% of RM if the patient is capable of successfully completing three sets.
They also recommend including active recovery days (low-intensity exercise) between training days. All major muscles, including neck, shoulder, and upper limb muscles, should be trained in a rotation.
For high-intensity aerobic exercise, the authors recommend starting with interval training at 55% VO2max (maximum respiratory capacity), or 50% HRmax (maximal heart rate) for 45-60 minutes per session, including 10 minutes of warm-up and cool-down, three times per week. The intensity can then be increased by 5%-10% each week to reach a maximum target of 80%-90% by week 12.
It is best for patients to start with a trainer for guidance and supervision, but once they master the routines, they can do the exercises independently, said Dr. Woldeamanuel.
Managing flare-ups
Headache flare-ups are normal during exercise, which may be caused by “boom and bust cycles” – exercising excessively when feeling good then completely stopping when feeling bad, said Dr. Woldeamanuel. He noted these flare-ups don’t mean “there’s something wrong with the brain or there’s some injury to muscles.”
The best way to manage such flare-ups is to use a pacing strategy that involves “not going overboard on good days and avoiding excessive rest on bad days,” the investigators note.
Dr. Woldeamanuel noted exercise is a lifestyle-based intervention; it not only helps reduce migraine attacks but also helps control other known comorbidities such as obesity and hypertension.
In a comment, Elizabeth Loder, MD, vice-chair, academic affairs, department of neurology, Brigham and Women’s Hospital, and professor of neurology, Harvard Medical School, both in Boston, said, “It’s useful to collect and summarize all of these studies, and to focus on helping patients and doctors understand the possible value of different kinds of exercise.”
The review was “well done,” said Dr. Loder, adding the researchers “have looked carefully at the quality of included studies.”
The study received support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. Dr. Woldeamanuel has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
with high-intensity aerobics coming in second, and both beating top-line migraine medications topiramate and amitriptyline, new research suggests.
The new results should encourage clinicians to recommend patients with migraine engage in strength-training exercise whenever possible, study investigator Yohannes W. Woldeamanuel, MD, a physician-scientist and instructor, department of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.
“Exercise is something patients can do all their lives and use it to prevent migraine attacks instead of taking daily medications or repetitive injections that have several adverse effects.”
The findings were published online in the Journal of Headache and Pain.
Head-to-head comparison
Several clinical trials have shown exercise is effective for migraine management, but to date, there have been no head-to-head comparisons of strength training and aerobic exercise, said Dr. Woldeamanuel.
This new study used a systematic review with network meta-analysis (NMA), which compares multiple interventions and ranks the efficacy of each one.
After a literature search, researchers included 21 clinical trials with an exercise regimen arm and a comparison control arm. All study data reported monthly frequency of migraine at baseline and at the end of the intervention.
The total combined sample size was 1,195 patients with migraine, who were a mean age of 35.5 years, with a female-to-male ratio of 6.7:1. All studies used International Classification of Headache Disorders (ICHD) criteria for migraine diagnosis.
The NMA provided 27 pairwise comparisons and 8 indirect comparisons. The pairwise comparisons provided direct evidence between the different interventions.
Researchers combined strength training, including weightlifting, with resistance training. Both modalities target muscles, while aerobic exercise targets cardiovascular health.
The average number of weeks was 9.3, 9.3, and 10.7, and the average number of hours per session for strength/resistance training, high-intensity aerobic exercise, and moderate-intensity aerobic exercise interventions was 50, 56, and 45.3, respectively.
The analysis showed all exercise interventions were more effective than the placebo groups in reducing the frequency of migraine. In terms of ranking, strength training came out on top, with a mean difference in monthly migraine days of −3.55 (95% confidence interval, −6.15 to −0.95) between the active and placebo groups.
Next was high-intensity aerobic exercise (−3.13; 95% CI, −5.28 to −0.97) and moderate-intensity aerobic exercise (−2.18; 95% CI, −3.25 to −1.11), followed by topiramate, placebo, and then amitriptyline.
Strength/resistance training was superior possibly because it targets muscle strengthening, particularly major muscles in the neck and shoulder area, which can be a source of the pain trigger, said Dr. Woldeamanuel. He added neck pain is highly comorbid with migraine.
Interestingly, patients doing exercises that focus on unaffected muscles – for example, squats – still get the benefits of less migraine burden, said Dr. Woldeamanuel.
Training recommendations
Strength training also increases or preserves lean muscle mass, which is associated with reduced migraine frequency. Research shows preservation of lean body mass combats central sensitization in various pain syndromes, said Dr. Woldeamanuel.
The superior effects of high- versus moderate-intensity aerobic exercise may be due to recruitment of endogenous molecules involved in exercise-mediated hypoalgesia (pain reduction).
The most common pathways are the opioid and endocannabinoid systems, although other systems are also likely involved, said Dr. Woldeamanuel. He noted migraine has been linked to a deficiency of both opioidergic and endocannabinoidergic signaling.
Dr. Woldeamanuel commented on the difficulty of comparing exercise interventions for patients with chronic versus episodic migraine, as many studies include both.
However, the two studies with moderate-intensity aerobic exercise exclusively involving patients with chronic migraine showed large effect sizes (Cohen’s d) of 0.80 and 1.10 in reducing monthly headache frequency.
Based on these new results and their own experience, the researchers recommend strength training start with 50% of repetition maximum (RM) with 2-3 sets of 12-15 repetitions three times a week along with 10 minutes of warm-up, stretching, and cool-down, totaling 45-60 minutes per session. Weight/resistance load can then be increased weekly by 5% of RM if the patient is capable of successfully completing three sets.
They also recommend including active recovery days (low-intensity exercise) between training days. All major muscles, including neck, shoulder, and upper limb muscles, should be trained in a rotation.
For high-intensity aerobic exercise, the authors recommend starting with interval training at 55% VO2max (maximum respiratory capacity), or 50% HRmax (maximal heart rate) for 45-60 minutes per session, including 10 minutes of warm-up and cool-down, three times per week. The intensity can then be increased by 5%-10% each week to reach a maximum target of 80%-90% by week 12.
It is best for patients to start with a trainer for guidance and supervision, but once they master the routines, they can do the exercises independently, said Dr. Woldeamanuel.
Managing flare-ups
Headache flare-ups are normal during exercise, which may be caused by “boom and bust cycles” – exercising excessively when feeling good then completely stopping when feeling bad, said Dr. Woldeamanuel. He noted these flare-ups don’t mean “there’s something wrong with the brain or there’s some injury to muscles.”
The best way to manage such flare-ups is to use a pacing strategy that involves “not going overboard on good days and avoiding excessive rest on bad days,” the investigators note.
Dr. Woldeamanuel noted exercise is a lifestyle-based intervention; it not only helps reduce migraine attacks but also helps control other known comorbidities such as obesity and hypertension.
In a comment, Elizabeth Loder, MD, vice-chair, academic affairs, department of neurology, Brigham and Women’s Hospital, and professor of neurology, Harvard Medical School, both in Boston, said, “It’s useful to collect and summarize all of these studies, and to focus on helping patients and doctors understand the possible value of different kinds of exercise.”
The review was “well done,” said Dr. Loder, adding the researchers “have looked carefully at the quality of included studies.”
The study received support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. Dr. Woldeamanuel has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
with high-intensity aerobics coming in second, and both beating top-line migraine medications topiramate and amitriptyline, new research suggests.
The new results should encourage clinicians to recommend patients with migraine engage in strength-training exercise whenever possible, study investigator Yohannes W. Woldeamanuel, MD, a physician-scientist and instructor, department of neurology and neurological sciences, Stanford (Calif.) University, told this news organization.
“Exercise is something patients can do all their lives and use it to prevent migraine attacks instead of taking daily medications or repetitive injections that have several adverse effects.”
The findings were published online in the Journal of Headache and Pain.
Head-to-head comparison
Several clinical trials have shown exercise is effective for migraine management, but to date, there have been no head-to-head comparisons of strength training and aerobic exercise, said Dr. Woldeamanuel.
This new study used a systematic review with network meta-analysis (NMA), which compares multiple interventions and ranks the efficacy of each one.
After a literature search, researchers included 21 clinical trials with an exercise regimen arm and a comparison control arm. All study data reported monthly frequency of migraine at baseline and at the end of the intervention.
The total combined sample size was 1,195 patients with migraine, who were a mean age of 35.5 years, with a female-to-male ratio of 6.7:1. All studies used International Classification of Headache Disorders (ICHD) criteria for migraine diagnosis.
The NMA provided 27 pairwise comparisons and 8 indirect comparisons. The pairwise comparisons provided direct evidence between the different interventions.
Researchers combined strength training, including weightlifting, with resistance training. Both modalities target muscles, while aerobic exercise targets cardiovascular health.
The average number of weeks was 9.3, 9.3, and 10.7, and the average number of hours per session for strength/resistance training, high-intensity aerobic exercise, and moderate-intensity aerobic exercise interventions was 50, 56, and 45.3, respectively.
The analysis showed all exercise interventions were more effective than the placebo groups in reducing the frequency of migraine. In terms of ranking, strength training came out on top, with a mean difference in monthly migraine days of −3.55 (95% confidence interval, −6.15 to −0.95) between the active and placebo groups.
Next was high-intensity aerobic exercise (−3.13; 95% CI, −5.28 to −0.97) and moderate-intensity aerobic exercise (−2.18; 95% CI, −3.25 to −1.11), followed by topiramate, placebo, and then amitriptyline.
Strength/resistance training was superior possibly because it targets muscle strengthening, particularly major muscles in the neck and shoulder area, which can be a source of the pain trigger, said Dr. Woldeamanuel. He added neck pain is highly comorbid with migraine.
Interestingly, patients doing exercises that focus on unaffected muscles – for example, squats – still get the benefits of less migraine burden, said Dr. Woldeamanuel.
Training recommendations
Strength training also increases or preserves lean muscle mass, which is associated with reduced migraine frequency. Research shows preservation of lean body mass combats central sensitization in various pain syndromes, said Dr. Woldeamanuel.
The superior effects of high- versus moderate-intensity aerobic exercise may be due to recruitment of endogenous molecules involved in exercise-mediated hypoalgesia (pain reduction).
The most common pathways are the opioid and endocannabinoid systems, although other systems are also likely involved, said Dr. Woldeamanuel. He noted migraine has been linked to a deficiency of both opioidergic and endocannabinoidergic signaling.
Dr. Woldeamanuel commented on the difficulty of comparing exercise interventions for patients with chronic versus episodic migraine, as many studies include both.
However, the two studies with moderate-intensity aerobic exercise exclusively involving patients with chronic migraine showed large effect sizes (Cohen’s d) of 0.80 and 1.10 in reducing monthly headache frequency.
Based on these new results and their own experience, the researchers recommend strength training start with 50% of repetition maximum (RM) with 2-3 sets of 12-15 repetitions three times a week along with 10 minutes of warm-up, stretching, and cool-down, totaling 45-60 minutes per session. Weight/resistance load can then be increased weekly by 5% of RM if the patient is capable of successfully completing three sets.
They also recommend including active recovery days (low-intensity exercise) between training days. All major muscles, including neck, shoulder, and upper limb muscles, should be trained in a rotation.
For high-intensity aerobic exercise, the authors recommend starting with interval training at 55% VO2max (maximum respiratory capacity), or 50% HRmax (maximal heart rate) for 45-60 minutes per session, including 10 minutes of warm-up and cool-down, three times per week. The intensity can then be increased by 5%-10% each week to reach a maximum target of 80%-90% by week 12.
It is best for patients to start with a trainer for guidance and supervision, but once they master the routines, they can do the exercises independently, said Dr. Woldeamanuel.
Managing flare-ups
Headache flare-ups are normal during exercise, which may be caused by “boom and bust cycles” – exercising excessively when feeling good then completely stopping when feeling bad, said Dr. Woldeamanuel. He noted these flare-ups don’t mean “there’s something wrong with the brain or there’s some injury to muscles.”
The best way to manage such flare-ups is to use a pacing strategy that involves “not going overboard on good days and avoiding excessive rest on bad days,” the investigators note.
Dr. Woldeamanuel noted exercise is a lifestyle-based intervention; it not only helps reduce migraine attacks but also helps control other known comorbidities such as obesity and hypertension.
In a comment, Elizabeth Loder, MD, vice-chair, academic affairs, department of neurology, Brigham and Women’s Hospital, and professor of neurology, Harvard Medical School, both in Boston, said, “It’s useful to collect and summarize all of these studies, and to focus on helping patients and doctors understand the possible value of different kinds of exercise.”
The review was “well done,” said Dr. Loder, adding the researchers “have looked carefully at the quality of included studies.”
The study received support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. Dr. Woldeamanuel has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JOURNAL OF HEADACHE AND PAIN
Meditation equal to first-line medication for anxiety
“I would encourage clinicians to list meditation training as one possible treatment option for patients who are diagnosed with anxiety disorders. Doctors should feel comfortable recommending in-person, group-based meditation classes,” study investigator Elizabeth A. Hoge, MD, director, Anxiety Disorders Research Program, Georgetown University Medical Center, Washington, told this news organization.
The findings were published online in JAMA Psychiatry.
Screening recommended
Anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and agoraphobia, are the most common type of mental disorder, affecting an estimated 301 million people worldwide. Owing to their high prevalence, the United States Preventive Services Task Force recommends screening for anxiety disorders.
Effective treatments for anxiety disorders include medications and cognitive-behavioral therapy. However, not all patients have access to these interventions, respond to them, or are comfortable seeking care in a psychiatric setting.
Mindfulness meditation, which has risen in popularity in recent years, may help people experiencing intrusive, anxious thoughts. “By practicing mindfulness meditation, people learn not to be overwhelmed by those thoughts,” said Dr. Hoge.
The study included 276 adult patients with an anxiety disorder, mostly generalized anxiety or social anxiety. The mean age of the study population was 33 years; 75% were women, 59% were White, 15% were Black, and 20% were Asian.
Researchers randomly assigned 136 patients to receive MBSR and 140 to receive the selective serotonin reuptake inhibitor escitalopram, a first-line medication for treating anxiety disorders.
The MBSR intervention included a weekly 2.5-hour class and a day-long weekend class. Participants also completed daily 45-minute guided meditation sessions at home. They learned mindfulness meditation exercises, including breath awareness, body scanning, and mindful movement.
Those in the escitalopram group initially received 10 mg of the oral drug daily. The dose was increased to 20 mg daily at week 2 if well tolerated.
The primary outcome was the score on the Clinical Global Impression of Severity (CGI-S) scale for anxiety, assessed by clinicians blinded to treatment allocation. This instrument measures overall symptom severity on a scale from 1 (not at all ill) to 7 (most extremely ill) and can be used to assess different types of anxiety disorders, said Dr. Hoge.
Among the 208 participants who completed the study, the baseline mean CGI-S score was 4.44 for MBSR and 4.51 for escitalopram. At week 8, on the CGI-S scale, the MBSR group’s score improved by a mean of 1.35 points, and the escitalopram group’s score improved by 1.43 points (difference of –0.07; 95% CI, –0.38 to 0.23; P = .65).
The lower end of the confidence interval (–0.38) was smaller than the prespecified noninferiority margin of –0.495, indicating noninferiority of MBSR, compared with escitalopram.
Remarkable results
“What was remarkable was that the medication worked great, like it always does, but the meditation also worked great; we saw about a 30% drop in symptoms for both groups,” said Dr. Hoge. “That helps us know that meditation, and in particular mindfulness meditation, could be useful as a first-line treatment for patients with anxiety disorders.”
The patient-reported outcome of the Overall Anxiety Severity and Impairment Scale also showed no significant group differences. “It’s important to have the self-reports, because that gives us two ways to look at the information,” said Dr. Hoge.
Anecdotally, participants noted that the meditation helped with their personal relationships and with being “kinder to themselves,” said Dr. Hoge. “In meditation, there’s an implicit teaching to be accepting and nonjudgmental towards your own thoughts, and that teaches people to be more self-compassionate.”
Just over 78% of patients in the escitalopram group had at least one treatment-related adverse event (AE), which included sleep disturbances, nausea, fatigue, and headache, compared with 15.4% in the MBSR group.
The most common AE in the meditation group was anxiety, which is “counterintuitive” but represents “a momentary anxiety,” said Dr. Hoge. “People who are meditating have feelings come up that maybe they didn’t pay attention to before. This gives them an opportunity to process through those emotions.”
Fatigue was the next most common AE for meditators, which “makes sense,” since they’re putting away their phones and not being stimulated, said Dr. Hoge.
MBSR was delivered in person, which limits extrapolation to mindfulness apps or programs delivered over the internet. Dr. Hoge believes apps would likely be less effective because they don’t have the face-to-face component, instructors available for consultation, or fellow participants contributing group support.
But online classes might work if “the exact same class,” including all its components, is moved online, she said.
MBSR is available in all major U.S. cities, doesn’t require finding a therapist, and is available outside a mental health environment – for example, at yoga centers and some places of employment. Anyone can learn MBSR, although it takes time and commitment, said Dr. Hoge.
A time-tested intervention
Commenting on the study, psychiatrist Gregory Scott Brown, MD, affiliate faculty, University of Texas Dell Medical School, and author of “The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression and Revitalizing Your Life,” said the results aren’t surprising inasmuch as mindfulness, including spirituality, breath work, and meditation, is a “time-tested and evidence-based” intervention.
“I’m encouraged by the fact studies like this are now being conducted and there’s more evidence that supports these mindfulness-based interventions, so they can start to make their way into standard-of-care treatments.” he said.
He noted that mindfulness can produce “long-term, sustainable improvements” and that the 45-minute daily home exercise included in the study “is not a huge time commitment when you talk about benefits you can potentially glean from incorporating that time.”
Because most study participants were women and “men are anxious too,” Dr. Brown said he would like to see the study replicated “with a more diverse pool of participants.”
The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Hoge and Dr. Brown have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“I would encourage clinicians to list meditation training as one possible treatment option for patients who are diagnosed with anxiety disorders. Doctors should feel comfortable recommending in-person, group-based meditation classes,” study investigator Elizabeth A. Hoge, MD, director, Anxiety Disorders Research Program, Georgetown University Medical Center, Washington, told this news organization.
The findings were published online in JAMA Psychiatry.
Screening recommended
Anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and agoraphobia, are the most common type of mental disorder, affecting an estimated 301 million people worldwide. Owing to their high prevalence, the United States Preventive Services Task Force recommends screening for anxiety disorders.
Effective treatments for anxiety disorders include medications and cognitive-behavioral therapy. However, not all patients have access to these interventions, respond to them, or are comfortable seeking care in a psychiatric setting.
Mindfulness meditation, which has risen in popularity in recent years, may help people experiencing intrusive, anxious thoughts. “By practicing mindfulness meditation, people learn not to be overwhelmed by those thoughts,” said Dr. Hoge.
The study included 276 adult patients with an anxiety disorder, mostly generalized anxiety or social anxiety. The mean age of the study population was 33 years; 75% were women, 59% were White, 15% were Black, and 20% were Asian.
Researchers randomly assigned 136 patients to receive MBSR and 140 to receive the selective serotonin reuptake inhibitor escitalopram, a first-line medication for treating anxiety disorders.
The MBSR intervention included a weekly 2.5-hour class and a day-long weekend class. Participants also completed daily 45-minute guided meditation sessions at home. They learned mindfulness meditation exercises, including breath awareness, body scanning, and mindful movement.
Those in the escitalopram group initially received 10 mg of the oral drug daily. The dose was increased to 20 mg daily at week 2 if well tolerated.
The primary outcome was the score on the Clinical Global Impression of Severity (CGI-S) scale for anxiety, assessed by clinicians blinded to treatment allocation. This instrument measures overall symptom severity on a scale from 1 (not at all ill) to 7 (most extremely ill) and can be used to assess different types of anxiety disorders, said Dr. Hoge.
Among the 208 participants who completed the study, the baseline mean CGI-S score was 4.44 for MBSR and 4.51 for escitalopram. At week 8, on the CGI-S scale, the MBSR group’s score improved by a mean of 1.35 points, and the escitalopram group’s score improved by 1.43 points (difference of –0.07; 95% CI, –0.38 to 0.23; P = .65).
The lower end of the confidence interval (–0.38) was smaller than the prespecified noninferiority margin of –0.495, indicating noninferiority of MBSR, compared with escitalopram.
Remarkable results
“What was remarkable was that the medication worked great, like it always does, but the meditation also worked great; we saw about a 30% drop in symptoms for both groups,” said Dr. Hoge. “That helps us know that meditation, and in particular mindfulness meditation, could be useful as a first-line treatment for patients with anxiety disorders.”
The patient-reported outcome of the Overall Anxiety Severity and Impairment Scale also showed no significant group differences. “It’s important to have the self-reports, because that gives us two ways to look at the information,” said Dr. Hoge.
Anecdotally, participants noted that the meditation helped with their personal relationships and with being “kinder to themselves,” said Dr. Hoge. “In meditation, there’s an implicit teaching to be accepting and nonjudgmental towards your own thoughts, and that teaches people to be more self-compassionate.”
Just over 78% of patients in the escitalopram group had at least one treatment-related adverse event (AE), which included sleep disturbances, nausea, fatigue, and headache, compared with 15.4% in the MBSR group.
The most common AE in the meditation group was anxiety, which is “counterintuitive” but represents “a momentary anxiety,” said Dr. Hoge. “People who are meditating have feelings come up that maybe they didn’t pay attention to before. This gives them an opportunity to process through those emotions.”
Fatigue was the next most common AE for meditators, which “makes sense,” since they’re putting away their phones and not being stimulated, said Dr. Hoge.
MBSR was delivered in person, which limits extrapolation to mindfulness apps or programs delivered over the internet. Dr. Hoge believes apps would likely be less effective because they don’t have the face-to-face component, instructors available for consultation, or fellow participants contributing group support.
But online classes might work if “the exact same class,” including all its components, is moved online, she said.
MBSR is available in all major U.S. cities, doesn’t require finding a therapist, and is available outside a mental health environment – for example, at yoga centers and some places of employment. Anyone can learn MBSR, although it takes time and commitment, said Dr. Hoge.
A time-tested intervention
Commenting on the study, psychiatrist Gregory Scott Brown, MD, affiliate faculty, University of Texas Dell Medical School, and author of “The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression and Revitalizing Your Life,” said the results aren’t surprising inasmuch as mindfulness, including spirituality, breath work, and meditation, is a “time-tested and evidence-based” intervention.
“I’m encouraged by the fact studies like this are now being conducted and there’s more evidence that supports these mindfulness-based interventions, so they can start to make their way into standard-of-care treatments.” he said.
He noted that mindfulness can produce “long-term, sustainable improvements” and that the 45-minute daily home exercise included in the study “is not a huge time commitment when you talk about benefits you can potentially glean from incorporating that time.”
Because most study participants were women and “men are anxious too,” Dr. Brown said he would like to see the study replicated “with a more diverse pool of participants.”
The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Hoge and Dr. Brown have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“I would encourage clinicians to list meditation training as one possible treatment option for patients who are diagnosed with anxiety disorders. Doctors should feel comfortable recommending in-person, group-based meditation classes,” study investigator Elizabeth A. Hoge, MD, director, Anxiety Disorders Research Program, Georgetown University Medical Center, Washington, told this news organization.
The findings were published online in JAMA Psychiatry.
Screening recommended
Anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and agoraphobia, are the most common type of mental disorder, affecting an estimated 301 million people worldwide. Owing to their high prevalence, the United States Preventive Services Task Force recommends screening for anxiety disorders.
Effective treatments for anxiety disorders include medications and cognitive-behavioral therapy. However, not all patients have access to these interventions, respond to them, or are comfortable seeking care in a psychiatric setting.
Mindfulness meditation, which has risen in popularity in recent years, may help people experiencing intrusive, anxious thoughts. “By practicing mindfulness meditation, people learn not to be overwhelmed by those thoughts,” said Dr. Hoge.
The study included 276 adult patients with an anxiety disorder, mostly generalized anxiety or social anxiety. The mean age of the study population was 33 years; 75% were women, 59% were White, 15% were Black, and 20% were Asian.
Researchers randomly assigned 136 patients to receive MBSR and 140 to receive the selective serotonin reuptake inhibitor escitalopram, a first-line medication for treating anxiety disorders.
The MBSR intervention included a weekly 2.5-hour class and a day-long weekend class. Participants also completed daily 45-minute guided meditation sessions at home. They learned mindfulness meditation exercises, including breath awareness, body scanning, and mindful movement.
Those in the escitalopram group initially received 10 mg of the oral drug daily. The dose was increased to 20 mg daily at week 2 if well tolerated.
The primary outcome was the score on the Clinical Global Impression of Severity (CGI-S) scale for anxiety, assessed by clinicians blinded to treatment allocation. This instrument measures overall symptom severity on a scale from 1 (not at all ill) to 7 (most extremely ill) and can be used to assess different types of anxiety disorders, said Dr. Hoge.
Among the 208 participants who completed the study, the baseline mean CGI-S score was 4.44 for MBSR and 4.51 for escitalopram. At week 8, on the CGI-S scale, the MBSR group’s score improved by a mean of 1.35 points, and the escitalopram group’s score improved by 1.43 points (difference of –0.07; 95% CI, –0.38 to 0.23; P = .65).
The lower end of the confidence interval (–0.38) was smaller than the prespecified noninferiority margin of –0.495, indicating noninferiority of MBSR, compared with escitalopram.
Remarkable results
“What was remarkable was that the medication worked great, like it always does, but the meditation also worked great; we saw about a 30% drop in symptoms for both groups,” said Dr. Hoge. “That helps us know that meditation, and in particular mindfulness meditation, could be useful as a first-line treatment for patients with anxiety disorders.”
The patient-reported outcome of the Overall Anxiety Severity and Impairment Scale also showed no significant group differences. “It’s important to have the self-reports, because that gives us two ways to look at the information,” said Dr. Hoge.
Anecdotally, participants noted that the meditation helped with their personal relationships and with being “kinder to themselves,” said Dr. Hoge. “In meditation, there’s an implicit teaching to be accepting and nonjudgmental towards your own thoughts, and that teaches people to be more self-compassionate.”
Just over 78% of patients in the escitalopram group had at least one treatment-related adverse event (AE), which included sleep disturbances, nausea, fatigue, and headache, compared with 15.4% in the MBSR group.
The most common AE in the meditation group was anxiety, which is “counterintuitive” but represents “a momentary anxiety,” said Dr. Hoge. “People who are meditating have feelings come up that maybe they didn’t pay attention to before. This gives them an opportunity to process through those emotions.”
Fatigue was the next most common AE for meditators, which “makes sense,” since they’re putting away their phones and not being stimulated, said Dr. Hoge.
MBSR was delivered in person, which limits extrapolation to mindfulness apps or programs delivered over the internet. Dr. Hoge believes apps would likely be less effective because they don’t have the face-to-face component, instructors available for consultation, or fellow participants contributing group support.
But online classes might work if “the exact same class,” including all its components, is moved online, she said.
MBSR is available in all major U.S. cities, doesn’t require finding a therapist, and is available outside a mental health environment – for example, at yoga centers and some places of employment. Anyone can learn MBSR, although it takes time and commitment, said Dr. Hoge.
A time-tested intervention
Commenting on the study, psychiatrist Gregory Scott Brown, MD, affiliate faculty, University of Texas Dell Medical School, and author of “The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression and Revitalizing Your Life,” said the results aren’t surprising inasmuch as mindfulness, including spirituality, breath work, and meditation, is a “time-tested and evidence-based” intervention.
“I’m encouraged by the fact studies like this are now being conducted and there’s more evidence that supports these mindfulness-based interventions, so they can start to make their way into standard-of-care treatments.” he said.
He noted that mindfulness can produce “long-term, sustainable improvements” and that the 45-minute daily home exercise included in the study “is not a huge time commitment when you talk about benefits you can potentially glean from incorporating that time.”
Because most study participants were women and “men are anxious too,” Dr. Brown said he would like to see the study replicated “with a more diverse pool of participants.”
The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Hoge and Dr. Brown have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA PSYCHIATRY
‘Disturbing’ lack of follow-up care after psychiatric crises
There is a concerning lack of follow-up care for young people who experience a mental health crisis, new research suggests.
The follow-up rate was less than 30% for those who had visited an ED.
The strongest predictor of follow-up was having received both primary and mental health care during the 6 months prior to using the acute service.
“For people discharging folks after a psychiatric crisis, whether it be in a hospital or emergency room setting, connecting them with their outpatient provider to ensure the transfer of care and continuity of care is vitally important to reduce risks for this population,” coinvestigator Brian Skehan, MD, PhD, assistant professor and psychiatrist, University of Massachusetts, Worcester, said during a press briefing.
If these discharged patients do not have a provider, “make sure they get one,” Lisa Dixon, MD, editor-in-chief of Psychiatric Services, added during the same briefing. “That’s the gift of life potentially for these young people.”
The findings were published online in Psychiatric Services.
Alarming trends
The alarming suicide trends among youths were exacerbated by the COVID-19 pandemic, Dr. Skehan noted.
He cited a 2021 study that showed more than 44% of high school students experienced persistent sadness or hopelessness over the previous year, 1 in 5 seriously considered suicide, and almost 1 in 10 actually attempted suicide.
“When we look at the number of young adults and adolescents struggling with behavioral health issues, the data trend is disturbing nationwide,” Dr. Skehan said.
The current study included participants aged 12-27 years who had private insurance. Many youth in this age category are experiencing significant changes, such as moving from high school to college and from pediatric providers to adult providers – and some “get lost in this transition,” said Dr. Skehan.
He noted many inpatient psychiatric units are not geared to young adults. “They may miss out on some aspects of inpatient care because it’s not geared to their developmental stage,” he said.
Assessing U.S. patient data in the IBM MarketScan commercial database (2013-2018), the researchers created two study samples: 95,153 inpatients and 108,576 patients who used the ED. All had an acute event stemming from a mental health condition.
The investigators explored the role of “established” outpatient care, defined as having had at least one visit with a provider of primary or mental health care in the 6 months prior to the acute psychiatric event.
Covariates included age at time of service (aged 12-17 years or 18-27 years), gender, health care plan type, psychiatric diagnosis, whether the acute event was self-harm or suicide related, and medical complexity.
Low follow-up rates
In the inpatient group, the average age was 18.9 years, the most common length of hospital stay was 4-6 days, and 1.5% left against medical advice. The most common primary diagnosis was major depression (53.7%), followed by bipolar disorder (22.3%). The least common disorders were PTSD, comorbid eating disorders, and disruptive disorders.
About one-third of participants had used both primary and mental health care during the 6 months before hospitalization, whereas 22.8% had no established outpatient care. Established care was most common among those with comorbid eating disorders and least common among those with psychotic disorders.
Results showed 42.7% of the hospitalized patients received follow up within 7 days and 67.4% received follow up within 30 days.
The strongest predictor of mental health follow-up care was established outpatient care. Compared with those who had no such care, those who had received both primary care and mental health care before the acute event had the highest odds of receiving follow-up (within 7 days, adjusted odds ratio, 2.81; 95% confidence interval, 2.68-2.94).
Older age and leaving against medical advice were associated with decreased likelihood of follow-up. Female sex, hospitalizations related to self-harm or suicidality, and longer length of stay were associated with increased likelihood of mental health follow-up care.
Compared with those hospitalized for major depression, those hospitalized for schizophrenia, bipolar disorder, PTSD, disruptive disorders, or comorbid substance use disorder were less likely to receive mental health follow-up. For example, only 23.7% of youth with comorbid substance use discharged from the hospital had follow-up within 7 days.
Similar patterns were observed for 30-day follow-up care.
‘Accessible and appealing’ options needed
In the ED-visit group, the average age was 19.5 years (58% female). Most (70.4%) had no chronic health conditions other than a psychiatric disorder. The primary diagnoses were anxiety disorders or phobias (44.1%) and major depression (23%).
One in four visits included a code for self-harm, suicidal ideation, or suicide attempt. And almost one third lacked established outpatient care before the ED visit.
Results showed 28.6% of the ED group received mental health care follow-up within 7 days and 46.4% received it within 30 days.
Again, the strongest predictor of mental health follow-up was prior outpatient care. For example, compared with participants with no established outpatient care, those with both primary care and mental health care were the most likely to receive follow-up within 7 days (aOR, 4.06; 95% CI, 3.72-4.42).
These numbers “are far from the goal of making sure everybody is getting follow-up care within 7 days of an acute psychiatric event,” Dr. Skehan said.
He stressed the need for “accessible and appealing options for youth.” These could include telehealth services, improved communication among health care providers in the ED, and reducing barriers to access follow-up care.
“This probably highlights the need to have more case management and referral services, and maybe make sure patients have a follow-up appointment before they leave the emergency room,” said Dr. Skehan. “This doesn’t necessarily guarantee they’ll get there but hopefully it makes it more likely they will have that access should they need it.”
The study was funded by grants from the National Institute of General Medical Sciences and the National Center for Advancing Translational Sciences, from the National Institutes of Health. The investigators reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
There is a concerning lack of follow-up care for young people who experience a mental health crisis, new research suggests.
The follow-up rate was less than 30% for those who had visited an ED.
The strongest predictor of follow-up was having received both primary and mental health care during the 6 months prior to using the acute service.
“For people discharging folks after a psychiatric crisis, whether it be in a hospital or emergency room setting, connecting them with their outpatient provider to ensure the transfer of care and continuity of care is vitally important to reduce risks for this population,” coinvestigator Brian Skehan, MD, PhD, assistant professor and psychiatrist, University of Massachusetts, Worcester, said during a press briefing.
If these discharged patients do not have a provider, “make sure they get one,” Lisa Dixon, MD, editor-in-chief of Psychiatric Services, added during the same briefing. “That’s the gift of life potentially for these young people.”
The findings were published online in Psychiatric Services.
Alarming trends
The alarming suicide trends among youths were exacerbated by the COVID-19 pandemic, Dr. Skehan noted.
He cited a 2021 study that showed more than 44% of high school students experienced persistent sadness or hopelessness over the previous year, 1 in 5 seriously considered suicide, and almost 1 in 10 actually attempted suicide.
“When we look at the number of young adults and adolescents struggling with behavioral health issues, the data trend is disturbing nationwide,” Dr. Skehan said.
The current study included participants aged 12-27 years who had private insurance. Many youth in this age category are experiencing significant changes, such as moving from high school to college and from pediatric providers to adult providers – and some “get lost in this transition,” said Dr. Skehan.
He noted many inpatient psychiatric units are not geared to young adults. “They may miss out on some aspects of inpatient care because it’s not geared to their developmental stage,” he said.
Assessing U.S. patient data in the IBM MarketScan commercial database (2013-2018), the researchers created two study samples: 95,153 inpatients and 108,576 patients who used the ED. All had an acute event stemming from a mental health condition.
The investigators explored the role of “established” outpatient care, defined as having had at least one visit with a provider of primary or mental health care in the 6 months prior to the acute psychiatric event.
Covariates included age at time of service (aged 12-17 years or 18-27 years), gender, health care plan type, psychiatric diagnosis, whether the acute event was self-harm or suicide related, and medical complexity.
Low follow-up rates
In the inpatient group, the average age was 18.9 years, the most common length of hospital stay was 4-6 days, and 1.5% left against medical advice. The most common primary diagnosis was major depression (53.7%), followed by bipolar disorder (22.3%). The least common disorders were PTSD, comorbid eating disorders, and disruptive disorders.
About one-third of participants had used both primary and mental health care during the 6 months before hospitalization, whereas 22.8% had no established outpatient care. Established care was most common among those with comorbid eating disorders and least common among those with psychotic disorders.
Results showed 42.7% of the hospitalized patients received follow up within 7 days and 67.4% received follow up within 30 days.
The strongest predictor of mental health follow-up care was established outpatient care. Compared with those who had no such care, those who had received both primary care and mental health care before the acute event had the highest odds of receiving follow-up (within 7 days, adjusted odds ratio, 2.81; 95% confidence interval, 2.68-2.94).
Older age and leaving against medical advice were associated with decreased likelihood of follow-up. Female sex, hospitalizations related to self-harm or suicidality, and longer length of stay were associated with increased likelihood of mental health follow-up care.
Compared with those hospitalized for major depression, those hospitalized for schizophrenia, bipolar disorder, PTSD, disruptive disorders, or comorbid substance use disorder were less likely to receive mental health follow-up. For example, only 23.7% of youth with comorbid substance use discharged from the hospital had follow-up within 7 days.
Similar patterns were observed for 30-day follow-up care.
‘Accessible and appealing’ options needed
In the ED-visit group, the average age was 19.5 years (58% female). Most (70.4%) had no chronic health conditions other than a psychiatric disorder. The primary diagnoses were anxiety disorders or phobias (44.1%) and major depression (23%).
One in four visits included a code for self-harm, suicidal ideation, or suicide attempt. And almost one third lacked established outpatient care before the ED visit.
Results showed 28.6% of the ED group received mental health care follow-up within 7 days and 46.4% received it within 30 days.
Again, the strongest predictor of mental health follow-up was prior outpatient care. For example, compared with participants with no established outpatient care, those with both primary care and mental health care were the most likely to receive follow-up within 7 days (aOR, 4.06; 95% CI, 3.72-4.42).
These numbers “are far from the goal of making sure everybody is getting follow-up care within 7 days of an acute psychiatric event,” Dr. Skehan said.
He stressed the need for “accessible and appealing options for youth.” These could include telehealth services, improved communication among health care providers in the ED, and reducing barriers to access follow-up care.
“This probably highlights the need to have more case management and referral services, and maybe make sure patients have a follow-up appointment before they leave the emergency room,” said Dr. Skehan. “This doesn’t necessarily guarantee they’ll get there but hopefully it makes it more likely they will have that access should they need it.”
The study was funded by grants from the National Institute of General Medical Sciences and the National Center for Advancing Translational Sciences, from the National Institutes of Health. The investigators reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
There is a concerning lack of follow-up care for young people who experience a mental health crisis, new research suggests.
The follow-up rate was less than 30% for those who had visited an ED.
The strongest predictor of follow-up was having received both primary and mental health care during the 6 months prior to using the acute service.
“For people discharging folks after a psychiatric crisis, whether it be in a hospital or emergency room setting, connecting them with their outpatient provider to ensure the transfer of care and continuity of care is vitally important to reduce risks for this population,” coinvestigator Brian Skehan, MD, PhD, assistant professor and psychiatrist, University of Massachusetts, Worcester, said during a press briefing.
If these discharged patients do not have a provider, “make sure they get one,” Lisa Dixon, MD, editor-in-chief of Psychiatric Services, added during the same briefing. “That’s the gift of life potentially for these young people.”
The findings were published online in Psychiatric Services.
Alarming trends
The alarming suicide trends among youths were exacerbated by the COVID-19 pandemic, Dr. Skehan noted.
He cited a 2021 study that showed more than 44% of high school students experienced persistent sadness or hopelessness over the previous year, 1 in 5 seriously considered suicide, and almost 1 in 10 actually attempted suicide.
“When we look at the number of young adults and adolescents struggling with behavioral health issues, the data trend is disturbing nationwide,” Dr. Skehan said.
The current study included participants aged 12-27 years who had private insurance. Many youth in this age category are experiencing significant changes, such as moving from high school to college and from pediatric providers to adult providers – and some “get lost in this transition,” said Dr. Skehan.
He noted many inpatient psychiatric units are not geared to young adults. “They may miss out on some aspects of inpatient care because it’s not geared to their developmental stage,” he said.
Assessing U.S. patient data in the IBM MarketScan commercial database (2013-2018), the researchers created two study samples: 95,153 inpatients and 108,576 patients who used the ED. All had an acute event stemming from a mental health condition.
The investigators explored the role of “established” outpatient care, defined as having had at least one visit with a provider of primary or mental health care in the 6 months prior to the acute psychiatric event.
Covariates included age at time of service (aged 12-17 years or 18-27 years), gender, health care plan type, psychiatric diagnosis, whether the acute event was self-harm or suicide related, and medical complexity.
Low follow-up rates
In the inpatient group, the average age was 18.9 years, the most common length of hospital stay was 4-6 days, and 1.5% left against medical advice. The most common primary diagnosis was major depression (53.7%), followed by bipolar disorder (22.3%). The least common disorders were PTSD, comorbid eating disorders, and disruptive disorders.
About one-third of participants had used both primary and mental health care during the 6 months before hospitalization, whereas 22.8% had no established outpatient care. Established care was most common among those with comorbid eating disorders and least common among those with psychotic disorders.
Results showed 42.7% of the hospitalized patients received follow up within 7 days and 67.4% received follow up within 30 days.
The strongest predictor of mental health follow-up care was established outpatient care. Compared with those who had no such care, those who had received both primary care and mental health care before the acute event had the highest odds of receiving follow-up (within 7 days, adjusted odds ratio, 2.81; 95% confidence interval, 2.68-2.94).
Older age and leaving against medical advice were associated with decreased likelihood of follow-up. Female sex, hospitalizations related to self-harm or suicidality, and longer length of stay were associated with increased likelihood of mental health follow-up care.
Compared with those hospitalized for major depression, those hospitalized for schizophrenia, bipolar disorder, PTSD, disruptive disorders, or comorbid substance use disorder were less likely to receive mental health follow-up. For example, only 23.7% of youth with comorbid substance use discharged from the hospital had follow-up within 7 days.
Similar patterns were observed for 30-day follow-up care.
‘Accessible and appealing’ options needed
In the ED-visit group, the average age was 19.5 years (58% female). Most (70.4%) had no chronic health conditions other than a psychiatric disorder. The primary diagnoses were anxiety disorders or phobias (44.1%) and major depression (23%).
One in four visits included a code for self-harm, suicidal ideation, or suicide attempt. And almost one third lacked established outpatient care before the ED visit.
Results showed 28.6% of the ED group received mental health care follow-up within 7 days and 46.4% received it within 30 days.
Again, the strongest predictor of mental health follow-up was prior outpatient care. For example, compared with participants with no established outpatient care, those with both primary care and mental health care were the most likely to receive follow-up within 7 days (aOR, 4.06; 95% CI, 3.72-4.42).
These numbers “are far from the goal of making sure everybody is getting follow-up care within 7 days of an acute psychiatric event,” Dr. Skehan said.
He stressed the need for “accessible and appealing options for youth.” These could include telehealth services, improved communication among health care providers in the ED, and reducing barriers to access follow-up care.
“This probably highlights the need to have more case management and referral services, and maybe make sure patients have a follow-up appointment before they leave the emergency room,” said Dr. Skehan. “This doesn’t necessarily guarantee they’ll get there but hopefully it makes it more likely they will have that access should they need it.”
The study was funded by grants from the National Institute of General Medical Sciences and the National Center for Advancing Translational Sciences, from the National Institutes of Health. The investigators reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM PSYCHIATRIC SERVICES
Poor visual acuity linked to depression, changes in brain structure
After multiple adjustments, analysis of data from more than 114,000 participants in the UK Biobank Study showed that visual impairment was linked to a 19% higher risk for depression.
In addition, imaging results showed a significant link between deteriorating brain structures and depression in those with poor visual acuity.
“Our findings highlight the value of visual health in association with mental health,” Xiayin Zhang, PhD, Guangdong Eye Institute, department of ophthalmology, Guangdong Provincial People’s Hospital, Guangzhou, China, and colleagues write.
“Screening of vision at an early stage should be embedded in the middle-aged and older population to stratify the vulnerable population at risk for depression,” the investigators add.
The findings were published online in JAMA Network Open.
UK biobank analyses
The analysis included 114,583 participants (54.5% women; mean age, 56.8 years) from the UK Biobank who completed standardized questionnaires and underwent ocular examinations.
To test distance visual acuity, all were asked to read letters on lines from the top to the bottom of a chart while wearing prescribed optical correction. Visual impairment was defined as visual acuity worse than 0.3 logarithm of the minimum angle of resolution (LogMAR) units.
Depressive symptoms were self-reported using the two-item Patient Health Questionnaire (PHQ-2), in which a score of 3 or more indicates depression. As well, a medical practitioner conducted an assessment of depression at baseline.
Among the participants, 87.2% had no visual impairment or depression and acted as the healthy control group. In addition, 3.2% showed visual impairment, 10% reported a diagnosis of depression, and 0.4% had both.
Researchers adjusted for age, sex, race, ethnicity, education, smoking, alcohol consumption, physical activity, family history of severe depression, obesity, hypertension, diabetes, hyperlipidemia, and deprivation on the Townsend index.
Among those with visual impairment, 12.4% had depression, compared with 9.9% without visual impairment.
Structure deterioration
After adjusting for potential confounders, visual impairment was associated with a 19% higher risk for depression (odds ratio, 1.19; 95% confidence interval, 1.05-1.34; P = .003). In addition, 1-line–worse visual acuity was associated with 5% higher odds of depression (OR, 1.05; 95% CI, 1.04-1.07; P < .001).
The association between visual acuity and depression was found in both younger (39-58 years) and older (59-72 years) groups, as well as in both men and women.
The researchers also explored the association between depressive symptoms and brain structure using MRI scans from a subset of 7,844 individuals (51% women; 2% with visual impairment).
Results showed linear associations between PHQ-2 scores and the left volume of gray matter in the supracalcarine cortex (coefficient, 7.61; 95% CI, 3.9-11.3; adjusted P = .006).
The investigators note that the supracalcarine cortex is spatially connected to the primary visual cortex, suggesting the visual cortex may be involved in the pathogenesis of depression.
PHQ-2 scores were also associated with mean isotropic volume fraction (ISOVF) in the right fornix (cres) and/or stria terminalis (coefficient, .003; 95% CI, 0.001-0.004; adjusted P = .01).
The links “could be moderated by visual acuity, whereby increased PHQ score was associated with higher ISOVF levels only among those with poorer visual acuity (P = .02 for interaction),” the investigators report.
These results “suggest that poorer visual acuity was associated with greater depressive symptoms and may have contributed to the related deterioration of the fornix and stria terminalis,” they add.
They note that previous studies have supported the hypothesis that the fornix and stria terminalis are involved in the pathophysiology of other brain-related conditions, including schizophrenia, bipolar disorder, and autism spectrum disorder.
However, the investigators did not have information on how long the participants had experienced visual impairment, so they couldn’t investigate whether results were affected by time. Additional study limitations cited were that depression may affect vision and that a large proportion of the participants (89.3%) were White.
Study ‘adds nuance’
Commenting on the study, Ipsit V. Vahia, MD, of the department of psychiatry at Harvard Medical School, Boston, and associate chief of geriatric psychiatry at McLean Hospital, Belmont, Mass., said the study “adds nuance to our understanding” of the well-established relationship between vision deficits and depression.
“It indicates that even mild visual deficits may be associated with depression,” said Dr. Vahia, who was not involved with the research.
The investigators validated this association by showing that visual acuity was also associated with neuroimaging markers of depression, he added.
Although the study was not designed to demonstrate causal relationships between mood and vision and its findings do not confirm that correcting visual acuity deficits will resolve depressive symptoms, “the large study sample and high quality of data should give clinicians confidence in the study’s findings,” Dr. Vahia said.
“Correcting visual acuity deficits can be considered standard care for older adults worldwide, and this study suggests that providing this standard care could also benefit mental health,” he concluded.
The study was supported by the National Natural Science Foundation of China, the China Postdoctoral Science Foundation, the Outstanding Young Talent Trainee Program of Guangdong Provincial People’s Hospital, the Guangdong Provincial People’s Hospital Scientific Research Funds for Leading Medical Talents and Distinguished Young Scholars in Guangdong Province, the Talent Introduction Fund of Guangdong Provincial People’s Hospital, the Science and Technology Program of Guangzhou, China, the Project of Special Research on Cardiovascular Diseases, the Research Foundation of Medical Science and Technology of Guangdong Province, the University of Melbourne at Research Accelerator Program, and the CERA (Centre for Eye Research Australia) Foundation and Victorian State Government for the Centre for Eye Research Australia. The investigators and Dr. Vahia have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
After multiple adjustments, analysis of data from more than 114,000 participants in the UK Biobank Study showed that visual impairment was linked to a 19% higher risk for depression.
In addition, imaging results showed a significant link between deteriorating brain structures and depression in those with poor visual acuity.
“Our findings highlight the value of visual health in association with mental health,” Xiayin Zhang, PhD, Guangdong Eye Institute, department of ophthalmology, Guangdong Provincial People’s Hospital, Guangzhou, China, and colleagues write.
“Screening of vision at an early stage should be embedded in the middle-aged and older population to stratify the vulnerable population at risk for depression,” the investigators add.
The findings were published online in JAMA Network Open.
UK biobank analyses
The analysis included 114,583 participants (54.5% women; mean age, 56.8 years) from the UK Biobank who completed standardized questionnaires and underwent ocular examinations.
To test distance visual acuity, all were asked to read letters on lines from the top to the bottom of a chart while wearing prescribed optical correction. Visual impairment was defined as visual acuity worse than 0.3 logarithm of the minimum angle of resolution (LogMAR) units.
Depressive symptoms were self-reported using the two-item Patient Health Questionnaire (PHQ-2), in which a score of 3 or more indicates depression. As well, a medical practitioner conducted an assessment of depression at baseline.
Among the participants, 87.2% had no visual impairment or depression and acted as the healthy control group. In addition, 3.2% showed visual impairment, 10% reported a diagnosis of depression, and 0.4% had both.
Researchers adjusted for age, sex, race, ethnicity, education, smoking, alcohol consumption, physical activity, family history of severe depression, obesity, hypertension, diabetes, hyperlipidemia, and deprivation on the Townsend index.
Among those with visual impairment, 12.4% had depression, compared with 9.9% without visual impairment.
Structure deterioration
After adjusting for potential confounders, visual impairment was associated with a 19% higher risk for depression (odds ratio, 1.19; 95% confidence interval, 1.05-1.34; P = .003). In addition, 1-line–worse visual acuity was associated with 5% higher odds of depression (OR, 1.05; 95% CI, 1.04-1.07; P < .001).
The association between visual acuity and depression was found in both younger (39-58 years) and older (59-72 years) groups, as well as in both men and women.
The researchers also explored the association between depressive symptoms and brain structure using MRI scans from a subset of 7,844 individuals (51% women; 2% with visual impairment).
Results showed linear associations between PHQ-2 scores and the left volume of gray matter in the supracalcarine cortex (coefficient, 7.61; 95% CI, 3.9-11.3; adjusted P = .006).
The investigators note that the supracalcarine cortex is spatially connected to the primary visual cortex, suggesting the visual cortex may be involved in the pathogenesis of depression.
PHQ-2 scores were also associated with mean isotropic volume fraction (ISOVF) in the right fornix (cres) and/or stria terminalis (coefficient, .003; 95% CI, 0.001-0.004; adjusted P = .01).
The links “could be moderated by visual acuity, whereby increased PHQ score was associated with higher ISOVF levels only among those with poorer visual acuity (P = .02 for interaction),” the investigators report.
These results “suggest that poorer visual acuity was associated with greater depressive symptoms and may have contributed to the related deterioration of the fornix and stria terminalis,” they add.
They note that previous studies have supported the hypothesis that the fornix and stria terminalis are involved in the pathophysiology of other brain-related conditions, including schizophrenia, bipolar disorder, and autism spectrum disorder.
However, the investigators did not have information on how long the participants had experienced visual impairment, so they couldn’t investigate whether results were affected by time. Additional study limitations cited were that depression may affect vision and that a large proportion of the participants (89.3%) were White.
Study ‘adds nuance’
Commenting on the study, Ipsit V. Vahia, MD, of the department of psychiatry at Harvard Medical School, Boston, and associate chief of geriatric psychiatry at McLean Hospital, Belmont, Mass., said the study “adds nuance to our understanding” of the well-established relationship between vision deficits and depression.
“It indicates that even mild visual deficits may be associated with depression,” said Dr. Vahia, who was not involved with the research.
The investigators validated this association by showing that visual acuity was also associated with neuroimaging markers of depression, he added.
Although the study was not designed to demonstrate causal relationships between mood and vision and its findings do not confirm that correcting visual acuity deficits will resolve depressive symptoms, “the large study sample and high quality of data should give clinicians confidence in the study’s findings,” Dr. Vahia said.
“Correcting visual acuity deficits can be considered standard care for older adults worldwide, and this study suggests that providing this standard care could also benefit mental health,” he concluded.
The study was supported by the National Natural Science Foundation of China, the China Postdoctoral Science Foundation, the Outstanding Young Talent Trainee Program of Guangdong Provincial People’s Hospital, the Guangdong Provincial People’s Hospital Scientific Research Funds for Leading Medical Talents and Distinguished Young Scholars in Guangdong Province, the Talent Introduction Fund of Guangdong Provincial People’s Hospital, the Science and Technology Program of Guangzhou, China, the Project of Special Research on Cardiovascular Diseases, the Research Foundation of Medical Science and Technology of Guangdong Province, the University of Melbourne at Research Accelerator Program, and the CERA (Centre for Eye Research Australia) Foundation and Victorian State Government for the Centre for Eye Research Australia. The investigators and Dr. Vahia have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
After multiple adjustments, analysis of data from more than 114,000 participants in the UK Biobank Study showed that visual impairment was linked to a 19% higher risk for depression.
In addition, imaging results showed a significant link between deteriorating brain structures and depression in those with poor visual acuity.
“Our findings highlight the value of visual health in association with mental health,” Xiayin Zhang, PhD, Guangdong Eye Institute, department of ophthalmology, Guangdong Provincial People’s Hospital, Guangzhou, China, and colleagues write.
“Screening of vision at an early stage should be embedded in the middle-aged and older population to stratify the vulnerable population at risk for depression,” the investigators add.
The findings were published online in JAMA Network Open.
UK biobank analyses
The analysis included 114,583 participants (54.5% women; mean age, 56.8 years) from the UK Biobank who completed standardized questionnaires and underwent ocular examinations.
To test distance visual acuity, all were asked to read letters on lines from the top to the bottom of a chart while wearing prescribed optical correction. Visual impairment was defined as visual acuity worse than 0.3 logarithm of the minimum angle of resolution (LogMAR) units.
Depressive symptoms were self-reported using the two-item Patient Health Questionnaire (PHQ-2), in which a score of 3 or more indicates depression. As well, a medical practitioner conducted an assessment of depression at baseline.
Among the participants, 87.2% had no visual impairment or depression and acted as the healthy control group. In addition, 3.2% showed visual impairment, 10% reported a diagnosis of depression, and 0.4% had both.
Researchers adjusted for age, sex, race, ethnicity, education, smoking, alcohol consumption, physical activity, family history of severe depression, obesity, hypertension, diabetes, hyperlipidemia, and deprivation on the Townsend index.
Among those with visual impairment, 12.4% had depression, compared with 9.9% without visual impairment.
Structure deterioration
After adjusting for potential confounders, visual impairment was associated with a 19% higher risk for depression (odds ratio, 1.19; 95% confidence interval, 1.05-1.34; P = .003). In addition, 1-line–worse visual acuity was associated with 5% higher odds of depression (OR, 1.05; 95% CI, 1.04-1.07; P < .001).
The association between visual acuity and depression was found in both younger (39-58 years) and older (59-72 years) groups, as well as in both men and women.
The researchers also explored the association between depressive symptoms and brain structure using MRI scans from a subset of 7,844 individuals (51% women; 2% with visual impairment).
Results showed linear associations between PHQ-2 scores and the left volume of gray matter in the supracalcarine cortex (coefficient, 7.61; 95% CI, 3.9-11.3; adjusted P = .006).
The investigators note that the supracalcarine cortex is spatially connected to the primary visual cortex, suggesting the visual cortex may be involved in the pathogenesis of depression.
PHQ-2 scores were also associated with mean isotropic volume fraction (ISOVF) in the right fornix (cres) and/or stria terminalis (coefficient, .003; 95% CI, 0.001-0.004; adjusted P = .01).
The links “could be moderated by visual acuity, whereby increased PHQ score was associated with higher ISOVF levels only among those with poorer visual acuity (P = .02 for interaction),” the investigators report.
These results “suggest that poorer visual acuity was associated with greater depressive symptoms and may have contributed to the related deterioration of the fornix and stria terminalis,” they add.
They note that previous studies have supported the hypothesis that the fornix and stria terminalis are involved in the pathophysiology of other brain-related conditions, including schizophrenia, bipolar disorder, and autism spectrum disorder.
However, the investigators did not have information on how long the participants had experienced visual impairment, so they couldn’t investigate whether results were affected by time. Additional study limitations cited were that depression may affect vision and that a large proportion of the participants (89.3%) were White.
Study ‘adds nuance’
Commenting on the study, Ipsit V. Vahia, MD, of the department of psychiatry at Harvard Medical School, Boston, and associate chief of geriatric psychiatry at McLean Hospital, Belmont, Mass., said the study “adds nuance to our understanding” of the well-established relationship between vision deficits and depression.
“It indicates that even mild visual deficits may be associated with depression,” said Dr. Vahia, who was not involved with the research.
The investigators validated this association by showing that visual acuity was also associated with neuroimaging markers of depression, he added.
Although the study was not designed to demonstrate causal relationships between mood and vision and its findings do not confirm that correcting visual acuity deficits will resolve depressive symptoms, “the large study sample and high quality of data should give clinicians confidence in the study’s findings,” Dr. Vahia said.
“Correcting visual acuity deficits can be considered standard care for older adults worldwide, and this study suggests that providing this standard care could also benefit mental health,” he concluded.
The study was supported by the National Natural Science Foundation of China, the China Postdoctoral Science Foundation, the Outstanding Young Talent Trainee Program of Guangdong Provincial People’s Hospital, the Guangdong Provincial People’s Hospital Scientific Research Funds for Leading Medical Talents and Distinguished Young Scholars in Guangdong Province, the Talent Introduction Fund of Guangdong Provincial People’s Hospital, the Science and Technology Program of Guangzhou, China, the Project of Special Research on Cardiovascular Diseases, the Research Foundation of Medical Science and Technology of Guangdong Province, the University of Melbourne at Research Accelerator Program, and the CERA (Centre for Eye Research Australia) Foundation and Victorian State Government for the Centre for Eye Research Australia. The investigators and Dr. Vahia have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN