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Opioid agonist therapy guards against self-harm, suicide
FROM THE LANCET PSYCHIATRY
Cessation of opioid agonist therapy (OAT) significantly increases the risk of self-harm and death by suicide in the first month after stopping the treatment in new findings that highlight the need for “advanced safety planning” during this critical time.
Investigators found that 4 weeks after stopping OAT, the risk of death by suicide was almost five times higher and the risk of hospital admission for self-harm was almost three times higher during this period, compared with the 4 weeks after initiation of OAT to treatment end.
These results highlight the importance of a “transition” period when stopping OAT and highlight the need for better supports for patients coming off this treatment, study investigator Prianka Padmanathan, MD, PhD candidate, Population Health Sciences, University of Bristol (England), told this news organization.
She noted the study supports previous findings that OAT “has an important role” in suicide prevention.
“Suicide and self-harm risk is greatly increased during treatment cessation, and advanced safety planning and additional psychosocial support during this time may be required,” Dr. Padmanathan said.
The findings were published online Dec. 15 in The Lancet Psychiatry.
Suicide, self-harm risk
Previous research shows an increased risk for overdose deaths and death in general during the first few weeks of starting and stopping treatment for opioid dependence.
“We wanted to see if the risk of dying by suicide was also elevated during these times,” said Dr. Padmanathan. As suicides are relatively rare, the researchers also looked at self-harm, “which is an important risk factor for suicide.”
, particularly buprenorphine or methadone.
“We tried to exclude people prescribed these drugs for pain and focused specifically on their prescription for opioid dependence,” Dr. Padmanathan said.
They estimated rates and adjusted risk ratios of hospital admissions for nonfatal self-harm and completed suicide during treatment initiation, maintenance, and cessation.
The study included 8,070 patients (69.3% men; mean baseline age, 33.3 years) who received OAT at least once from January 1998 through November 2018. The median treatment time was 84 days. Most of the participants lived in the most deprived neighborhoods and were White.
There were 807 hospital admissions for self-harm (1.99 per 100 person-years) and 46 suicides (0.11 per 100 person-years).
The investigators examined age, sex, socioeconomic status, number of previous OAT treatment episodes, previous self-harm, previous mental illness, and major chronic illness scores as potential confounders.
Need for psychosocial care
Results showed the risk for self-harm was significantly increased while off OAT (aRR, 1.5; 95% confidence interval, 1.21-1.88).
The overall age- and sex-standardized mortality ratio for suicide was 7.5 times higher (95% CI, 5.5-10) in the study cohort, compared with the general population in England between 1998 and 2017.
There was insufficient evidence to show the risk for suicide was higher off, versus on, treatment, but this may be because suicides are relatively rare, Dr. Padmanathan noted.
“The sample may have been too small to enable a difference to be detected. In contrast, self-harm is more common, so there was power to detect a difference there,” she said.
Risk for self-harm was more than double in the first 4 weeks after stopping OAT versus stable periods on treatment (aRR, 2.60; 95% CI, 1.83-3.7). Risk for suicide more than quadrupled during this period (aRR, 4.68; 95% CI, 1.63-13.42).
These new results suggest additional interventions may be in order, Dr. Padmanathan noted.
“We already knew that extra care – for example, providing naloxone when coming off OAT – was important to prevent overdoses. But this study suggests providing psychosocial care and other extra care may also be important to prevent suicides,” she said.
There was no statistical evidence of difference between buprenorphine and methadone in terms of self-harm and suicide risks. However, this may be because the sample was not large enough to detect a difference, said Dr. Padmanathan.
Although there are currently no guidelines to indicate an ideal OAT period, previous study results have suggested extending treatment to 2 years may be beneficial, perhaps reducing self-harm and, therefore, suicides, she noted.
“We think most of these adverse outcomes likely occur during short treatment episodes with an unplanned ending. Extending OAT sufficiently to enable a planned ending might help to reduce these risks,” she added.
‘A window of vulnerability’
Authors of an accompanying editorial note the study “adds weight” to the evidence that OAT is a “lifesaving” treatment.
“It’s critical to recognize that transitions in and out of care are vulnerable periods” when it comes to suicide, the coauthor of the editorial, Paul S. Nestadt, MD, department of psychiatry and behavioral sciences, Johns Hopkins University, Baltimore, told this news organization.
Official suicide statistics may not reflect the entire story, as many deaths that occur because of overdose after treatment cessation are not counted as suicides, he said. “It can be difficult for medical examiners to determine if an overdose was intentional or not,” Dr. Nestadt added.
After treatment has been established, physicians “would be wise to delay treatment cessation” until the patient is in a stable condition and can be closely followed by mental health professionals, the editorialists note.
“We must consider the month following OAT cessation to be a window of vulnerability, not just for relapse but also for suicide,” they write.
The finding that patients prescribed OAT have such a high rate of suicide, compared with the general population, is “troubling” and “highlights the importance of interventions which address both opioid use and suicide risk,” they add.
The editorialists point out the median treatment period of 84 days is less than what is generally recommended, raising the question of whether longer treatment might lower suicide risk after treatment discontinuation.
They also emphasized the need for further study to test potential suicide prevention interventions in the period after treatment cessation.
Dr. Nestadt added the new findings are “quite generalizable outside of the U.K.” and referred to similar studies carried out in Australia and elsewhere.
The study was funded by the Medical Research Council. Dr. Padmanathan was a coapplicant on an a grant awarded to University of Bristol by Bristol and Weston Hospital Charity focusing on suicide prevention for patients presenting to the emergency department with self-harm and harmful substance use. Dr. Nestadt has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE LANCET PSYCHIATRY
Cessation of opioid agonist therapy (OAT) significantly increases the risk of self-harm and death by suicide in the first month after stopping the treatment in new findings that highlight the need for “advanced safety planning” during this critical time.
Investigators found that 4 weeks after stopping OAT, the risk of death by suicide was almost five times higher and the risk of hospital admission for self-harm was almost three times higher during this period, compared with the 4 weeks after initiation of OAT to treatment end.
These results highlight the importance of a “transition” period when stopping OAT and highlight the need for better supports for patients coming off this treatment, study investigator Prianka Padmanathan, MD, PhD candidate, Population Health Sciences, University of Bristol (England), told this news organization.
She noted the study supports previous findings that OAT “has an important role” in suicide prevention.
“Suicide and self-harm risk is greatly increased during treatment cessation, and advanced safety planning and additional psychosocial support during this time may be required,” Dr. Padmanathan said.
The findings were published online Dec. 15 in The Lancet Psychiatry.
Suicide, self-harm risk
Previous research shows an increased risk for overdose deaths and death in general during the first few weeks of starting and stopping treatment for opioid dependence.
“We wanted to see if the risk of dying by suicide was also elevated during these times,” said Dr. Padmanathan. As suicides are relatively rare, the researchers also looked at self-harm, “which is an important risk factor for suicide.”
, particularly buprenorphine or methadone.
“We tried to exclude people prescribed these drugs for pain and focused specifically on their prescription for opioid dependence,” Dr. Padmanathan said.
They estimated rates and adjusted risk ratios of hospital admissions for nonfatal self-harm and completed suicide during treatment initiation, maintenance, and cessation.
The study included 8,070 patients (69.3% men; mean baseline age, 33.3 years) who received OAT at least once from January 1998 through November 2018. The median treatment time was 84 days. Most of the participants lived in the most deprived neighborhoods and were White.
There were 807 hospital admissions for self-harm (1.99 per 100 person-years) and 46 suicides (0.11 per 100 person-years).
The investigators examined age, sex, socioeconomic status, number of previous OAT treatment episodes, previous self-harm, previous mental illness, and major chronic illness scores as potential confounders.
Need for psychosocial care
Results showed the risk for self-harm was significantly increased while off OAT (aRR, 1.5; 95% confidence interval, 1.21-1.88).
The overall age- and sex-standardized mortality ratio for suicide was 7.5 times higher (95% CI, 5.5-10) in the study cohort, compared with the general population in England between 1998 and 2017.
There was insufficient evidence to show the risk for suicide was higher off, versus on, treatment, but this may be because suicides are relatively rare, Dr. Padmanathan noted.
“The sample may have been too small to enable a difference to be detected. In contrast, self-harm is more common, so there was power to detect a difference there,” she said.
Risk for self-harm was more than double in the first 4 weeks after stopping OAT versus stable periods on treatment (aRR, 2.60; 95% CI, 1.83-3.7). Risk for suicide more than quadrupled during this period (aRR, 4.68; 95% CI, 1.63-13.42).
These new results suggest additional interventions may be in order, Dr. Padmanathan noted.
“We already knew that extra care – for example, providing naloxone when coming off OAT – was important to prevent overdoses. But this study suggests providing psychosocial care and other extra care may also be important to prevent suicides,” she said.
There was no statistical evidence of difference between buprenorphine and methadone in terms of self-harm and suicide risks. However, this may be because the sample was not large enough to detect a difference, said Dr. Padmanathan.
Although there are currently no guidelines to indicate an ideal OAT period, previous study results have suggested extending treatment to 2 years may be beneficial, perhaps reducing self-harm and, therefore, suicides, she noted.
“We think most of these adverse outcomes likely occur during short treatment episodes with an unplanned ending. Extending OAT sufficiently to enable a planned ending might help to reduce these risks,” she added.
‘A window of vulnerability’
Authors of an accompanying editorial note the study “adds weight” to the evidence that OAT is a “lifesaving” treatment.
“It’s critical to recognize that transitions in and out of care are vulnerable periods” when it comes to suicide, the coauthor of the editorial, Paul S. Nestadt, MD, department of psychiatry and behavioral sciences, Johns Hopkins University, Baltimore, told this news organization.
Official suicide statistics may not reflect the entire story, as many deaths that occur because of overdose after treatment cessation are not counted as suicides, he said. “It can be difficult for medical examiners to determine if an overdose was intentional or not,” Dr. Nestadt added.
After treatment has been established, physicians “would be wise to delay treatment cessation” until the patient is in a stable condition and can be closely followed by mental health professionals, the editorialists note.
“We must consider the month following OAT cessation to be a window of vulnerability, not just for relapse but also for suicide,” they write.
The finding that patients prescribed OAT have such a high rate of suicide, compared with the general population, is “troubling” and “highlights the importance of interventions which address both opioid use and suicide risk,” they add.
The editorialists point out the median treatment period of 84 days is less than what is generally recommended, raising the question of whether longer treatment might lower suicide risk after treatment discontinuation.
They also emphasized the need for further study to test potential suicide prevention interventions in the period after treatment cessation.
Dr. Nestadt added the new findings are “quite generalizable outside of the U.K.” and referred to similar studies carried out in Australia and elsewhere.
The study was funded by the Medical Research Council. Dr. Padmanathan was a coapplicant on an a grant awarded to University of Bristol by Bristol and Weston Hospital Charity focusing on suicide prevention for patients presenting to the emergency department with self-harm and harmful substance use. Dr. Nestadt has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE LANCET PSYCHIATRY
Cessation of opioid agonist therapy (OAT) significantly increases the risk of self-harm and death by suicide in the first month after stopping the treatment in new findings that highlight the need for “advanced safety planning” during this critical time.
Investigators found that 4 weeks after stopping OAT, the risk of death by suicide was almost five times higher and the risk of hospital admission for self-harm was almost three times higher during this period, compared with the 4 weeks after initiation of OAT to treatment end.
These results highlight the importance of a “transition” period when stopping OAT and highlight the need for better supports for patients coming off this treatment, study investigator Prianka Padmanathan, MD, PhD candidate, Population Health Sciences, University of Bristol (England), told this news organization.
She noted the study supports previous findings that OAT “has an important role” in suicide prevention.
“Suicide and self-harm risk is greatly increased during treatment cessation, and advanced safety planning and additional psychosocial support during this time may be required,” Dr. Padmanathan said.
The findings were published online Dec. 15 in The Lancet Psychiatry.
Suicide, self-harm risk
Previous research shows an increased risk for overdose deaths and death in general during the first few weeks of starting and stopping treatment for opioid dependence.
“We wanted to see if the risk of dying by suicide was also elevated during these times,” said Dr. Padmanathan. As suicides are relatively rare, the researchers also looked at self-harm, “which is an important risk factor for suicide.”
, particularly buprenorphine or methadone.
“We tried to exclude people prescribed these drugs for pain and focused specifically on their prescription for opioid dependence,” Dr. Padmanathan said.
They estimated rates and adjusted risk ratios of hospital admissions for nonfatal self-harm and completed suicide during treatment initiation, maintenance, and cessation.
The study included 8,070 patients (69.3% men; mean baseline age, 33.3 years) who received OAT at least once from January 1998 through November 2018. The median treatment time was 84 days. Most of the participants lived in the most deprived neighborhoods and were White.
There were 807 hospital admissions for self-harm (1.99 per 100 person-years) and 46 suicides (0.11 per 100 person-years).
The investigators examined age, sex, socioeconomic status, number of previous OAT treatment episodes, previous self-harm, previous mental illness, and major chronic illness scores as potential confounders.
Need for psychosocial care
Results showed the risk for self-harm was significantly increased while off OAT (aRR, 1.5; 95% confidence interval, 1.21-1.88).
The overall age- and sex-standardized mortality ratio for suicide was 7.5 times higher (95% CI, 5.5-10) in the study cohort, compared with the general population in England between 1998 and 2017.
There was insufficient evidence to show the risk for suicide was higher off, versus on, treatment, but this may be because suicides are relatively rare, Dr. Padmanathan noted.
“The sample may have been too small to enable a difference to be detected. In contrast, self-harm is more common, so there was power to detect a difference there,” she said.
Risk for self-harm was more than double in the first 4 weeks after stopping OAT versus stable periods on treatment (aRR, 2.60; 95% CI, 1.83-3.7). Risk for suicide more than quadrupled during this period (aRR, 4.68; 95% CI, 1.63-13.42).
These new results suggest additional interventions may be in order, Dr. Padmanathan noted.
“We already knew that extra care – for example, providing naloxone when coming off OAT – was important to prevent overdoses. But this study suggests providing psychosocial care and other extra care may also be important to prevent suicides,” she said.
There was no statistical evidence of difference between buprenorphine and methadone in terms of self-harm and suicide risks. However, this may be because the sample was not large enough to detect a difference, said Dr. Padmanathan.
Although there are currently no guidelines to indicate an ideal OAT period, previous study results have suggested extending treatment to 2 years may be beneficial, perhaps reducing self-harm and, therefore, suicides, she noted.
“We think most of these adverse outcomes likely occur during short treatment episodes with an unplanned ending. Extending OAT sufficiently to enable a planned ending might help to reduce these risks,” she added.
‘A window of vulnerability’
Authors of an accompanying editorial note the study “adds weight” to the evidence that OAT is a “lifesaving” treatment.
“It’s critical to recognize that transitions in and out of care are vulnerable periods” when it comes to suicide, the coauthor of the editorial, Paul S. Nestadt, MD, department of psychiatry and behavioral sciences, Johns Hopkins University, Baltimore, told this news organization.
Official suicide statistics may not reflect the entire story, as many deaths that occur because of overdose after treatment cessation are not counted as suicides, he said. “It can be difficult for medical examiners to determine if an overdose was intentional or not,” Dr. Nestadt added.
After treatment has been established, physicians “would be wise to delay treatment cessation” until the patient is in a stable condition and can be closely followed by mental health professionals, the editorialists note.
“We must consider the month following OAT cessation to be a window of vulnerability, not just for relapse but also for suicide,” they write.
The finding that patients prescribed OAT have such a high rate of suicide, compared with the general population, is “troubling” and “highlights the importance of interventions which address both opioid use and suicide risk,” they add.
The editorialists point out the median treatment period of 84 days is less than what is generally recommended, raising the question of whether longer treatment might lower suicide risk after treatment discontinuation.
They also emphasized the need for further study to test potential suicide prevention interventions in the period after treatment cessation.
Dr. Nestadt added the new findings are “quite generalizable outside of the U.K.” and referred to similar studies carried out in Australia and elsewhere.
The study was funded by the Medical Research Council. Dr. Padmanathan was a coapplicant on an a grant awarded to University of Bristol by Bristol and Weston Hospital Charity focusing on suicide prevention for patients presenting to the emergency department with self-harm and harmful substance use. Dr. Nestadt has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Transcranial magnetic stimulation shows promise for alcohol addiction
Deep, repetitive transcranial magnetic stimulation (TMS) is safe and effective in decreasing symptoms of alcohol addiction and brain reactivity, new research suggests.
In a randomized, double-blind, sham-controlled trial, participants who received TMS targeting the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC) for 3 weeks showed significantly reduced heavy drinking days, compared with a group who received a sham treatment.
and showed less functional connectivity on MRI in areas of the brain that can trigger craving and relapse.
Clinicians should “keep their eyes open” in the wake of this phase 2 trial, cocorresponding author Markus Heilig, MD, PhD, professor of psychiatry and director at the Center for Social and Affective Neuroscience, department of biomedical and clinical sciences, Linköping (Sweden) University, said in an interview.
“If and when this replicates in the equivalent of a phase 3 study, we will actually have a completely novel treatment available for this difficult to treat and very impactful disease,” Dr. Heilig said.
The findings were published online Dec. 5, 2021, in Biological Psychiatry.
Proof of concept
In the proof-of-concept trial, researchers enrolled and randomly assigned 51 treatment-seeking adults with moderate to severe alcohol dependence to receive active or sham treatment. Before treatment, participants completed “craving induction,” which included holding and smelling but not consuming an alcoholic beverage.
Dr. Heilig noted that, before stimulating the brain, “you want to make it as malleable as possible;” and brain networks tend to be more malleable when they are active.
During the 3-week treatment phase, active or sham stimulations were delivered in five 30-minute sessions per week. During the sessions, all participants wore a helmet with a deep TMS coil produced by BrainsWay.
In the active-stimulation group, each session included 100 trains of 30 pulses at 10 Hz (3 seconds) with 15-second intervals, for a total of 3,000 pulses. The sham stimulation produced the same acoustic artifact and generated skin sensations mimicking those of the active stimulation, but it did not involve a magnetic field.
Participants, operators, and raters were blinded to the type of coil used.
Five participants relapsed during the first 3 weeks of treatment and were excluded from the analysis. The mean age of those completing treatment (n = 23 in each group) was 43 years, and two-thirds were men.
The gender makeup of the study reflects “what a real treatment-seeking group looks like,” Dr. Heilig said.
During the 12-week follow-up phase, five additional participants dropped out.
‘Pretty robust’ treatment effect
The primary outcome was reduction in percentage of heavy drinking days (pHDD), defined as consuming at least five drinks of 12 grams of alcohol per day for men and at least four such drinks for women.
Initially, pHDD dropped in both groups, which is something generally seen in alcohol studies, said Dr. Heilig. “The moment people decide to participate in a study, everybody drops their consumption, [which] biases a study like this against picking up an effect.”
However, heavy drinking days increased during follow-up in the sham group but remained low in the active-treatment group. The mean pHDD was significantly lower in the active versus sham groups (2.9% vs. 10.6%, P = .037).
“So despite the bias, a treatment effect does emerge,” and was “pretty robust,” Dr. Heilig said.
This was supported by a significant group difference in weekly alcohol consumption and a trend-level difference in percentage of alcohol-positive urine samples.
A secondary outcome was change in alcohol craving, assessed with the Penn Alcohol Craving Scale; PACS scores decreased in both groups during treatment but was more steeply reduced in the active group. During follow-up, craving levels increased to a lesser extent in the active group.
MRI scans showed reduced connectivity from the mPFC to the subgenual ACC, an area involved in negative emotions that can trigger craving and relapse, said Dr. Heilig. There was also reduced connectivity between the dorsal ACC and caudate, a circuit involved in the reward system.
In treatment trials, researchers look for a biomarker of target engagement. However, “to date, there has been no study using TMS that has actually demonstrated the intervention had a measurable effect on brain activity. So to me, this is a biomarker; it did something to the brain,” Dr. Heilig said.
Delving deeper into the brain
The results underline the importance of stimulating deeper parts of the brain, cocorresponding author Abraham Zangen, PhD, head of the Brain Stimulation and Behavior Lab and chair of the psychobiology brain program, Ben Gurion University, Be’er Sheva, Israel, said in an interview.
Early TMS studies, which involved superficial brain stimulation, reduced cigarette consumption but was not associated with quitting, Dr. Zangen said. “It was only when we targeted deeper parts of the prefrontal cortex that we were able to induce smoking cessation.”
It was this research that led to approval by the Food and Drug Administration of deep TMS for smoking cessation.
This same deep-brain approach was used in the current study. “So the emphasis on the technology that allows penetration into deeper parts of the brain and targeting the relevant pathological circuitry of addiction is a key complement of the success of this study,” Dr. Zangen said.
Results also showed no serious adverse events. Only a few participants reported transient headaches, which all resolved spontaneously; and frequency did not differ between groups.
Dr. Heilig now hopes to carry out a multisite phase 3 study of the intervention and would suggest it involve 4 (instead of 3) weeks of initial treatment and then a weekly booster session. “There are biological reasons to believe that might be more efficient, although we don’t have the data,” he said.
On the other hand, he noted, the longer the trial, the more difficult it might be to recruit patients.
Clinically significant?
Commenting on the study, Derek Blevins, MD, assistant professor of clinical psychiatry at Columbia University and research psychiatrist, division on substance use disorders, New York State Psychiatric Institute, both in New York, called the research “really exciting.”
To date, most TMS studies have been relatively small and looked at a target such as craving. Although these studies did show some effect, the clinical significance of that effect was unclear, said Dr. Blevins, who was not involved with the current research.
“I think this new study actually demonstrated a clinically significant effect of a noninvasive treatment for a disease that’s very difficult to treat,” he said.
A potential limitation of the study, however, was it required abstinence, Dr. Blevins noted. It would be “really helpful” to understand how TMS might aid individuals such as those who relapsed during the study, “because they’re the more treatment-refractory individuals we see in clinical practice.”
If a multicenter trial is launched, Dr. Blevins said he would also like it to include an ethnically and racially diverse population.
The study was supported by grants from the European Union’s Horizon 2020 research and innovation program and the Swedish Research Council. Dr. Heilig reported having received consulting fees, research support, or other compensation from Indivior, Camurus, BrainsWay, Aelis Farma, and Janssen Pharmaceuticals. Dr. Zangen is an inventor of deep TMS coils and has financial interest in BrainsWay, which produces and markets these coils. Dr. Blevins reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Deep, repetitive transcranial magnetic stimulation (TMS) is safe and effective in decreasing symptoms of alcohol addiction and brain reactivity, new research suggests.
In a randomized, double-blind, sham-controlled trial, participants who received TMS targeting the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC) for 3 weeks showed significantly reduced heavy drinking days, compared with a group who received a sham treatment.
and showed less functional connectivity on MRI in areas of the brain that can trigger craving and relapse.
Clinicians should “keep their eyes open” in the wake of this phase 2 trial, cocorresponding author Markus Heilig, MD, PhD, professor of psychiatry and director at the Center for Social and Affective Neuroscience, department of biomedical and clinical sciences, Linköping (Sweden) University, said in an interview.
“If and when this replicates in the equivalent of a phase 3 study, we will actually have a completely novel treatment available for this difficult to treat and very impactful disease,” Dr. Heilig said.
The findings were published online Dec. 5, 2021, in Biological Psychiatry.
Proof of concept
In the proof-of-concept trial, researchers enrolled and randomly assigned 51 treatment-seeking adults with moderate to severe alcohol dependence to receive active or sham treatment. Before treatment, participants completed “craving induction,” which included holding and smelling but not consuming an alcoholic beverage.
Dr. Heilig noted that, before stimulating the brain, “you want to make it as malleable as possible;” and brain networks tend to be more malleable when they are active.
During the 3-week treatment phase, active or sham stimulations were delivered in five 30-minute sessions per week. During the sessions, all participants wore a helmet with a deep TMS coil produced by BrainsWay.
In the active-stimulation group, each session included 100 trains of 30 pulses at 10 Hz (3 seconds) with 15-second intervals, for a total of 3,000 pulses. The sham stimulation produced the same acoustic artifact and generated skin sensations mimicking those of the active stimulation, but it did not involve a magnetic field.
Participants, operators, and raters were blinded to the type of coil used.
Five participants relapsed during the first 3 weeks of treatment and were excluded from the analysis. The mean age of those completing treatment (n = 23 in each group) was 43 years, and two-thirds were men.
The gender makeup of the study reflects “what a real treatment-seeking group looks like,” Dr. Heilig said.
During the 12-week follow-up phase, five additional participants dropped out.
‘Pretty robust’ treatment effect
The primary outcome was reduction in percentage of heavy drinking days (pHDD), defined as consuming at least five drinks of 12 grams of alcohol per day for men and at least four such drinks for women.
Initially, pHDD dropped in both groups, which is something generally seen in alcohol studies, said Dr. Heilig. “The moment people decide to participate in a study, everybody drops their consumption, [which] biases a study like this against picking up an effect.”
However, heavy drinking days increased during follow-up in the sham group but remained low in the active-treatment group. The mean pHDD was significantly lower in the active versus sham groups (2.9% vs. 10.6%, P = .037).
“So despite the bias, a treatment effect does emerge,” and was “pretty robust,” Dr. Heilig said.
This was supported by a significant group difference in weekly alcohol consumption and a trend-level difference in percentage of alcohol-positive urine samples.
A secondary outcome was change in alcohol craving, assessed with the Penn Alcohol Craving Scale; PACS scores decreased in both groups during treatment but was more steeply reduced in the active group. During follow-up, craving levels increased to a lesser extent in the active group.
MRI scans showed reduced connectivity from the mPFC to the subgenual ACC, an area involved in negative emotions that can trigger craving and relapse, said Dr. Heilig. There was also reduced connectivity between the dorsal ACC and caudate, a circuit involved in the reward system.
In treatment trials, researchers look for a biomarker of target engagement. However, “to date, there has been no study using TMS that has actually demonstrated the intervention had a measurable effect on brain activity. So to me, this is a biomarker; it did something to the brain,” Dr. Heilig said.
Delving deeper into the brain
The results underline the importance of stimulating deeper parts of the brain, cocorresponding author Abraham Zangen, PhD, head of the Brain Stimulation and Behavior Lab and chair of the psychobiology brain program, Ben Gurion University, Be’er Sheva, Israel, said in an interview.
Early TMS studies, which involved superficial brain stimulation, reduced cigarette consumption but was not associated with quitting, Dr. Zangen said. “It was only when we targeted deeper parts of the prefrontal cortex that we were able to induce smoking cessation.”
It was this research that led to approval by the Food and Drug Administration of deep TMS for smoking cessation.
This same deep-brain approach was used in the current study. “So the emphasis on the technology that allows penetration into deeper parts of the brain and targeting the relevant pathological circuitry of addiction is a key complement of the success of this study,” Dr. Zangen said.
Results also showed no serious adverse events. Only a few participants reported transient headaches, which all resolved spontaneously; and frequency did not differ between groups.
Dr. Heilig now hopes to carry out a multisite phase 3 study of the intervention and would suggest it involve 4 (instead of 3) weeks of initial treatment and then a weekly booster session. “There are biological reasons to believe that might be more efficient, although we don’t have the data,” he said.
On the other hand, he noted, the longer the trial, the more difficult it might be to recruit patients.
Clinically significant?
Commenting on the study, Derek Blevins, MD, assistant professor of clinical psychiatry at Columbia University and research psychiatrist, division on substance use disorders, New York State Psychiatric Institute, both in New York, called the research “really exciting.”
To date, most TMS studies have been relatively small and looked at a target such as craving. Although these studies did show some effect, the clinical significance of that effect was unclear, said Dr. Blevins, who was not involved with the current research.
“I think this new study actually demonstrated a clinically significant effect of a noninvasive treatment for a disease that’s very difficult to treat,” he said.
A potential limitation of the study, however, was it required abstinence, Dr. Blevins noted. It would be “really helpful” to understand how TMS might aid individuals such as those who relapsed during the study, “because they’re the more treatment-refractory individuals we see in clinical practice.”
If a multicenter trial is launched, Dr. Blevins said he would also like it to include an ethnically and racially diverse population.
The study was supported by grants from the European Union’s Horizon 2020 research and innovation program and the Swedish Research Council. Dr. Heilig reported having received consulting fees, research support, or other compensation from Indivior, Camurus, BrainsWay, Aelis Farma, and Janssen Pharmaceuticals. Dr. Zangen is an inventor of deep TMS coils and has financial interest in BrainsWay, which produces and markets these coils. Dr. Blevins reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Deep, repetitive transcranial magnetic stimulation (TMS) is safe and effective in decreasing symptoms of alcohol addiction and brain reactivity, new research suggests.
In a randomized, double-blind, sham-controlled trial, participants who received TMS targeting the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC) for 3 weeks showed significantly reduced heavy drinking days, compared with a group who received a sham treatment.
and showed less functional connectivity on MRI in areas of the brain that can trigger craving and relapse.
Clinicians should “keep their eyes open” in the wake of this phase 2 trial, cocorresponding author Markus Heilig, MD, PhD, professor of psychiatry and director at the Center for Social and Affective Neuroscience, department of biomedical and clinical sciences, Linköping (Sweden) University, said in an interview.
“If and when this replicates in the equivalent of a phase 3 study, we will actually have a completely novel treatment available for this difficult to treat and very impactful disease,” Dr. Heilig said.
The findings were published online Dec. 5, 2021, in Biological Psychiatry.
Proof of concept
In the proof-of-concept trial, researchers enrolled and randomly assigned 51 treatment-seeking adults with moderate to severe alcohol dependence to receive active or sham treatment. Before treatment, participants completed “craving induction,” which included holding and smelling but not consuming an alcoholic beverage.
Dr. Heilig noted that, before stimulating the brain, “you want to make it as malleable as possible;” and brain networks tend to be more malleable when they are active.
During the 3-week treatment phase, active or sham stimulations were delivered in five 30-minute sessions per week. During the sessions, all participants wore a helmet with a deep TMS coil produced by BrainsWay.
In the active-stimulation group, each session included 100 trains of 30 pulses at 10 Hz (3 seconds) with 15-second intervals, for a total of 3,000 pulses. The sham stimulation produced the same acoustic artifact and generated skin sensations mimicking those of the active stimulation, but it did not involve a magnetic field.
Participants, operators, and raters were blinded to the type of coil used.
Five participants relapsed during the first 3 weeks of treatment and were excluded from the analysis. The mean age of those completing treatment (n = 23 in each group) was 43 years, and two-thirds were men.
The gender makeup of the study reflects “what a real treatment-seeking group looks like,” Dr. Heilig said.
During the 12-week follow-up phase, five additional participants dropped out.
‘Pretty robust’ treatment effect
The primary outcome was reduction in percentage of heavy drinking days (pHDD), defined as consuming at least five drinks of 12 grams of alcohol per day for men and at least four such drinks for women.
Initially, pHDD dropped in both groups, which is something generally seen in alcohol studies, said Dr. Heilig. “The moment people decide to participate in a study, everybody drops their consumption, [which] biases a study like this against picking up an effect.”
However, heavy drinking days increased during follow-up in the sham group but remained low in the active-treatment group. The mean pHDD was significantly lower in the active versus sham groups (2.9% vs. 10.6%, P = .037).
“So despite the bias, a treatment effect does emerge,” and was “pretty robust,” Dr. Heilig said.
This was supported by a significant group difference in weekly alcohol consumption and a trend-level difference in percentage of alcohol-positive urine samples.
A secondary outcome was change in alcohol craving, assessed with the Penn Alcohol Craving Scale; PACS scores decreased in both groups during treatment but was more steeply reduced in the active group. During follow-up, craving levels increased to a lesser extent in the active group.
MRI scans showed reduced connectivity from the mPFC to the subgenual ACC, an area involved in negative emotions that can trigger craving and relapse, said Dr. Heilig. There was also reduced connectivity between the dorsal ACC and caudate, a circuit involved in the reward system.
In treatment trials, researchers look for a biomarker of target engagement. However, “to date, there has been no study using TMS that has actually demonstrated the intervention had a measurable effect on brain activity. So to me, this is a biomarker; it did something to the brain,” Dr. Heilig said.
Delving deeper into the brain
The results underline the importance of stimulating deeper parts of the brain, cocorresponding author Abraham Zangen, PhD, head of the Brain Stimulation and Behavior Lab and chair of the psychobiology brain program, Ben Gurion University, Be’er Sheva, Israel, said in an interview.
Early TMS studies, which involved superficial brain stimulation, reduced cigarette consumption but was not associated with quitting, Dr. Zangen said. “It was only when we targeted deeper parts of the prefrontal cortex that we were able to induce smoking cessation.”
It was this research that led to approval by the Food and Drug Administration of deep TMS for smoking cessation.
This same deep-brain approach was used in the current study. “So the emphasis on the technology that allows penetration into deeper parts of the brain and targeting the relevant pathological circuitry of addiction is a key complement of the success of this study,” Dr. Zangen said.
Results also showed no serious adverse events. Only a few participants reported transient headaches, which all resolved spontaneously; and frequency did not differ between groups.
Dr. Heilig now hopes to carry out a multisite phase 3 study of the intervention and would suggest it involve 4 (instead of 3) weeks of initial treatment and then a weekly booster session. “There are biological reasons to believe that might be more efficient, although we don’t have the data,” he said.
On the other hand, he noted, the longer the trial, the more difficult it might be to recruit patients.
Clinically significant?
Commenting on the study, Derek Blevins, MD, assistant professor of clinical psychiatry at Columbia University and research psychiatrist, division on substance use disorders, New York State Psychiatric Institute, both in New York, called the research “really exciting.”
To date, most TMS studies have been relatively small and looked at a target such as craving. Although these studies did show some effect, the clinical significance of that effect was unclear, said Dr. Blevins, who was not involved with the current research.
“I think this new study actually demonstrated a clinically significant effect of a noninvasive treatment for a disease that’s very difficult to treat,” he said.
A potential limitation of the study, however, was it required abstinence, Dr. Blevins noted. It would be “really helpful” to understand how TMS might aid individuals such as those who relapsed during the study, “because they’re the more treatment-refractory individuals we see in clinical practice.”
If a multicenter trial is launched, Dr. Blevins said he would also like it to include an ethnically and racially diverse population.
The study was supported by grants from the European Union’s Horizon 2020 research and innovation program and the Swedish Research Council. Dr. Heilig reported having received consulting fees, research support, or other compensation from Indivior, Camurus, BrainsWay, Aelis Farma, and Janssen Pharmaceuticals. Dr. Zangen is an inventor of deep TMS coils and has financial interest in BrainsWay, which produces and markets these coils. Dr. Blevins reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM BIOLOGICAL PSYCHIATRY
Many clinicians feel ill-prepared for drug overdose deaths
new research suggests.
However, results from a survey study also showed that colleagues were an important source of support in the wake of this type of event.
“A patient overdose death can change clinical decision-making for providers experiencing high levels of stress related to the overdose death,” noted the investigators, led by Amy Yule, MD, director of adolescent addiction psychiatry, Boston Medical Center, and assistant professor of psychiatry at Boston University Medical Center.
The findings were presented by Dr. Yule at the annual meeting of the American Academy of Addiction Psychiatry.
All-time high
As reported by this news organization, there has recently been a record number of drug overdose deaths. And these deaths affect families, communities, and often providers, Dr. Yule told meeting attendees.
Previous research has looked at the impact of drug overdose deaths and the opioid epidemic on first responders and community health workers in the field of overdose prevention.
“But there’s less in the literature to my knowledge that describes the experience of providers and clinicians who are working in more formalized medical settings,” said Dr. Yule.
In December 2020, researchers sent an email to members of the Providers Clinical Support System (PCSS) inviting them to complete an anonymous survey. The PCSS program was created in response to the opioid overdose epidemic to train primary care clinicians in the prevention and treatment of opioid use disorders.
A total of 12,204 members received the email, 1,064 opened the survey link, and 523 completed the survey.
Participants were mostly White and female, with an average age of 52 years. Respondents had been practicing for an average of about 16 years.
The largest responder group was physicians (47%), followed by counselors (29%), nurse practitioners (17%), and nurses (7%).
Among physician respondents, 41% reported having received additional formal training in addiction.
Only 24% of the respondents indicated they received training in “postvention,” which refers to interventions after a suicide to support the bereaved. Such interventions “could be helpful in potentially preparing them for a drug overdose death in their practice,” said Dr. Yule.
Categories of preparedness
The survey inquired about three categories of preparedness: coping with a drug overdose death, providing support to a colleague, and talking with families who have lost a member to a drug overdose.
Overall, 59% said they felt somewhat or fairly well prepared for the first two categories and 55% for the third category.
“I think it’s notable that there is a higher percentage of people who felt not at all prepared to talk with family members (20.5%), compared to those who felt not at all prepared to cope with a drug overdose death (13.8%) or prepared to support a colleague (12%),” Dr. Yule said.
More than half of respondents (55%) indicated a drug overdose death had occurred in their own practice.
The survey also looked at frequency of consultations with colleagues, critical incident debriefing sessions, and interactions with a patient’s family.
Almost half (48%) of the sample said they consulted with a colleague after most patient overdose deaths. Only 24% said they had a critical incidence debriefing session after most of these events, and 20% said they interacted with the patient’s family.
Asked what resources they found helpful for coping with a recent patient drug overdose death, respondents flagged their colleagues and meetings with families.
The survey also examined provider trauma after a patient drug overdose death, using the Impact of Event Scale–R. “If the score is above a certain cutoff level, there is potential concern” for PTSD, Dr. Yule said.
Among the 141 respondents who had a patient drug overdose death in their practice during the previous year, 121 completed this trauma scale. Of these, 18% had “a very elevated” score, Dr. Yule reported.
Sources of support
Commenting on the survey study, Larissa Mooney, MD, associate professor and director of the addiction psychiatry division in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, said it is not surprising that many providers do not feel adequately prepared to cope with an overdose death, or how to support a colleague after such an event.
“This is not routinely covered in training, and patient overdose may occur without warning signs,” said Dr. Mooney, who was not involved with the research.
However, these new findings suggest a range of potential sources of support for providers after a patient overdose death that may be helpful, “including colleagues, friends, therapy, supervision, and meeting with the patient’s family,” she said.
The study received funding from the PCSS. Dr. Yule disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests.
However, results from a survey study also showed that colleagues were an important source of support in the wake of this type of event.
“A patient overdose death can change clinical decision-making for providers experiencing high levels of stress related to the overdose death,” noted the investigators, led by Amy Yule, MD, director of adolescent addiction psychiatry, Boston Medical Center, and assistant professor of psychiatry at Boston University Medical Center.
The findings were presented by Dr. Yule at the annual meeting of the American Academy of Addiction Psychiatry.
All-time high
As reported by this news organization, there has recently been a record number of drug overdose deaths. And these deaths affect families, communities, and often providers, Dr. Yule told meeting attendees.
Previous research has looked at the impact of drug overdose deaths and the opioid epidemic on first responders and community health workers in the field of overdose prevention.
“But there’s less in the literature to my knowledge that describes the experience of providers and clinicians who are working in more formalized medical settings,” said Dr. Yule.
In December 2020, researchers sent an email to members of the Providers Clinical Support System (PCSS) inviting them to complete an anonymous survey. The PCSS program was created in response to the opioid overdose epidemic to train primary care clinicians in the prevention and treatment of opioid use disorders.
A total of 12,204 members received the email, 1,064 opened the survey link, and 523 completed the survey.
Participants were mostly White and female, with an average age of 52 years. Respondents had been practicing for an average of about 16 years.
The largest responder group was physicians (47%), followed by counselors (29%), nurse practitioners (17%), and nurses (7%).
Among physician respondents, 41% reported having received additional formal training in addiction.
Only 24% of the respondents indicated they received training in “postvention,” which refers to interventions after a suicide to support the bereaved. Such interventions “could be helpful in potentially preparing them for a drug overdose death in their practice,” said Dr. Yule.
Categories of preparedness
The survey inquired about three categories of preparedness: coping with a drug overdose death, providing support to a colleague, and talking with families who have lost a member to a drug overdose.
Overall, 59% said they felt somewhat or fairly well prepared for the first two categories and 55% for the third category.
“I think it’s notable that there is a higher percentage of people who felt not at all prepared to talk with family members (20.5%), compared to those who felt not at all prepared to cope with a drug overdose death (13.8%) or prepared to support a colleague (12%),” Dr. Yule said.
More than half of respondents (55%) indicated a drug overdose death had occurred in their own practice.
The survey also looked at frequency of consultations with colleagues, critical incident debriefing sessions, and interactions with a patient’s family.
Almost half (48%) of the sample said they consulted with a colleague after most patient overdose deaths. Only 24% said they had a critical incidence debriefing session after most of these events, and 20% said they interacted with the patient’s family.
Asked what resources they found helpful for coping with a recent patient drug overdose death, respondents flagged their colleagues and meetings with families.
The survey also examined provider trauma after a patient drug overdose death, using the Impact of Event Scale–R. “If the score is above a certain cutoff level, there is potential concern” for PTSD, Dr. Yule said.
Among the 141 respondents who had a patient drug overdose death in their practice during the previous year, 121 completed this trauma scale. Of these, 18% had “a very elevated” score, Dr. Yule reported.
Sources of support
Commenting on the survey study, Larissa Mooney, MD, associate professor and director of the addiction psychiatry division in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, said it is not surprising that many providers do not feel adequately prepared to cope with an overdose death, or how to support a colleague after such an event.
“This is not routinely covered in training, and patient overdose may occur without warning signs,” said Dr. Mooney, who was not involved with the research.
However, these new findings suggest a range of potential sources of support for providers after a patient overdose death that may be helpful, “including colleagues, friends, therapy, supervision, and meeting with the patient’s family,” she said.
The study received funding from the PCSS. Dr. Yule disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests.
However, results from a survey study also showed that colleagues were an important source of support in the wake of this type of event.
“A patient overdose death can change clinical decision-making for providers experiencing high levels of stress related to the overdose death,” noted the investigators, led by Amy Yule, MD, director of adolescent addiction psychiatry, Boston Medical Center, and assistant professor of psychiatry at Boston University Medical Center.
The findings were presented by Dr. Yule at the annual meeting of the American Academy of Addiction Psychiatry.
All-time high
As reported by this news organization, there has recently been a record number of drug overdose deaths. And these deaths affect families, communities, and often providers, Dr. Yule told meeting attendees.
Previous research has looked at the impact of drug overdose deaths and the opioid epidemic on first responders and community health workers in the field of overdose prevention.
“But there’s less in the literature to my knowledge that describes the experience of providers and clinicians who are working in more formalized medical settings,” said Dr. Yule.
In December 2020, researchers sent an email to members of the Providers Clinical Support System (PCSS) inviting them to complete an anonymous survey. The PCSS program was created in response to the opioid overdose epidemic to train primary care clinicians in the prevention and treatment of opioid use disorders.
A total of 12,204 members received the email, 1,064 opened the survey link, and 523 completed the survey.
Participants were mostly White and female, with an average age of 52 years. Respondents had been practicing for an average of about 16 years.
The largest responder group was physicians (47%), followed by counselors (29%), nurse practitioners (17%), and nurses (7%).
Among physician respondents, 41% reported having received additional formal training in addiction.
Only 24% of the respondents indicated they received training in “postvention,” which refers to interventions after a suicide to support the bereaved. Such interventions “could be helpful in potentially preparing them for a drug overdose death in their practice,” said Dr. Yule.
Categories of preparedness
The survey inquired about three categories of preparedness: coping with a drug overdose death, providing support to a colleague, and talking with families who have lost a member to a drug overdose.
Overall, 59% said they felt somewhat or fairly well prepared for the first two categories and 55% for the third category.
“I think it’s notable that there is a higher percentage of people who felt not at all prepared to talk with family members (20.5%), compared to those who felt not at all prepared to cope with a drug overdose death (13.8%) or prepared to support a colleague (12%),” Dr. Yule said.
More than half of respondents (55%) indicated a drug overdose death had occurred in their own practice.
The survey also looked at frequency of consultations with colleagues, critical incident debriefing sessions, and interactions with a patient’s family.
Almost half (48%) of the sample said they consulted with a colleague after most patient overdose deaths. Only 24% said they had a critical incidence debriefing session after most of these events, and 20% said they interacted with the patient’s family.
Asked what resources they found helpful for coping with a recent patient drug overdose death, respondents flagged their colleagues and meetings with families.
The survey also examined provider trauma after a patient drug overdose death, using the Impact of Event Scale–R. “If the score is above a certain cutoff level, there is potential concern” for PTSD, Dr. Yule said.
Among the 141 respondents who had a patient drug overdose death in their practice during the previous year, 121 completed this trauma scale. Of these, 18% had “a very elevated” score, Dr. Yule reported.
Sources of support
Commenting on the survey study, Larissa Mooney, MD, associate professor and director of the addiction psychiatry division in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, said it is not surprising that many providers do not feel adequately prepared to cope with an overdose death, or how to support a colleague after such an event.
“This is not routinely covered in training, and patient overdose may occur without warning signs,” said Dr. Mooney, who was not involved with the research.
However, these new findings suggest a range of potential sources of support for providers after a patient overdose death that may be helpful, “including colleagues, friends, therapy, supervision, and meeting with the patient’s family,” she said.
The study received funding from the PCSS. Dr. Yule disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM AAAP 2021
Most addiction specialists support legalized therapeutic psychedelics
The majority of addiction specialists, including psychiatrists, believe psychedelics are promising for the treatment of substance use disorders (SUDs) and psychiatric illnesses and, with some caveats, support legalization of the substances for these indications, results of a new survey show.
This strong positive attitude is “a surprise” given previous wariness of addiction specialists regarding legalization of marijuana, noted study investigator Amanda Kim, MD, JD, of Brigham and Women’s Hospital and Harvard Medical School, Boston.
“We had hypothesized that addiction specialists would express more skepticism about psychedelics compared to nonaddiction specialists,” Dr. Kim said.
Instead, addiction experts who participated in the survey were very much in favor of psychedelics being legalized for therapeutic use, but only in a controlled setting.
The findings were presented at the annual meeting of the American Academy of Addiction Psychiatry.
Growing interest
In recent years, there has been increased interest in the scientific community and among the general public in the therapeutic potential of psychedelics, said Dr. Kim. Previous research has shown growing positivity about psychedelics and support for their legalization among psychiatrists, she added.
Psychedelics have been decriminalized and/or legalized in several jurisdictions. The Food and Drug Administration has granted breakthrough therapy designation for 3,4-methylenedioxymethamphetamine (MDMA) in the treatment of posttraumatic stress disorder (PTSD) and has granted the same designation to psilocybin in the treatment of major depressive disorder.
“Despite psychedelics increasingly entering the mainstream, we are unaware of any studies specifically assessing the current attitudes of physicians specializing in addictions regarding psychedelics,” Dr. Kim said.
For the study, investigators identified prospective survey participants from the AAAP directory. They also reached out to program directors of addiction medicine and addiction psychiatry fellowships.
In the anonymous online survey, respondents were asked to rate their level of agreement with 30 statements.
The analysis included 145 respondents (59% men; mean age, 46.2 years). Psychiatrists made up about two-thirds of the sample. The remainder specialized in internal and family medicine.
Most respondents had some clinical exposure to psychedelics.
Positive attitudes, concerns
Overall, participants expressed very positive attitudes regarding the therapeutic use of psychedelics. About 64% strongly agreed or agreed psychedelics show promise in treating SUDs, and 82% agreed they show promise in treating psychiatric disorders.
However, more than one-third of respondents (37.9%) expressed concern about the addictive potential of psychedelics. This is more than in previous research polling psychiatrists, possibly because the study’s “broad” definition of psychedelics included “nonclassic, nonserotonergic hallucinogens,” such as ketamine and MDMA, Dr. Kim noted.
Because ketamine and MDMA are both lumped into the hallucinogen category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), “and both are known to have addictive potential, this may have obscured participant responses,” she added.
Some 28% of participants expressed concern about psychedelic use increasing the risk for subsequent psychiatric disorders and long-term cognitive impairment.
Almost three-quarters (74.5%) believe the therapeutic use of psychedelics should be legalized. However, most wanted legal therapeutic psychedelics to be highly regulated and administered only in controlled settings with specially trained providers.
Almost half of the sample believed therapeutic psychedelics should be legal in a variety of different contexts and by non-Western providers, in accordance with indigenous and/or spiritual traditions.
One surprising finding was that most respondents believed patients would be keen on using psychedelics to treat SUDs, said Dr. Kim.
“This may reflect evolving attitudes of both providers and patients about psychedelics, and it will be interesting to further study attitudes of patients toward the use of psychedelics to treat SUD in the future,” she added.
Attitudes toward psychedelics were generally similar for psychiatrists and nonpsychiatrists; but psychiatrists expressed greater comfort in discussing them with patients and were more likely to have observed complications of psychedelics use in their practice.
Dr. Kim said the study’s limitations included the small sample size and possible selection bias, as those with more favorable views of psychedelics may have been more likely to respond.
The study was supported by the Source Research Foundation.
A version of this article first appeared on Medscape.com.
The majority of addiction specialists, including psychiatrists, believe psychedelics are promising for the treatment of substance use disorders (SUDs) and psychiatric illnesses and, with some caveats, support legalization of the substances for these indications, results of a new survey show.
This strong positive attitude is “a surprise” given previous wariness of addiction specialists regarding legalization of marijuana, noted study investigator Amanda Kim, MD, JD, of Brigham and Women’s Hospital and Harvard Medical School, Boston.
“We had hypothesized that addiction specialists would express more skepticism about psychedelics compared to nonaddiction specialists,” Dr. Kim said.
Instead, addiction experts who participated in the survey were very much in favor of psychedelics being legalized for therapeutic use, but only in a controlled setting.
The findings were presented at the annual meeting of the American Academy of Addiction Psychiatry.
Growing interest
In recent years, there has been increased interest in the scientific community and among the general public in the therapeutic potential of psychedelics, said Dr. Kim. Previous research has shown growing positivity about psychedelics and support for their legalization among psychiatrists, she added.
Psychedelics have been decriminalized and/or legalized in several jurisdictions. The Food and Drug Administration has granted breakthrough therapy designation for 3,4-methylenedioxymethamphetamine (MDMA) in the treatment of posttraumatic stress disorder (PTSD) and has granted the same designation to psilocybin in the treatment of major depressive disorder.
“Despite psychedelics increasingly entering the mainstream, we are unaware of any studies specifically assessing the current attitudes of physicians specializing in addictions regarding psychedelics,” Dr. Kim said.
For the study, investigators identified prospective survey participants from the AAAP directory. They also reached out to program directors of addiction medicine and addiction psychiatry fellowships.
In the anonymous online survey, respondents were asked to rate their level of agreement with 30 statements.
The analysis included 145 respondents (59% men; mean age, 46.2 years). Psychiatrists made up about two-thirds of the sample. The remainder specialized in internal and family medicine.
Most respondents had some clinical exposure to psychedelics.
Positive attitudes, concerns
Overall, participants expressed very positive attitudes regarding the therapeutic use of psychedelics. About 64% strongly agreed or agreed psychedelics show promise in treating SUDs, and 82% agreed they show promise in treating psychiatric disorders.
However, more than one-third of respondents (37.9%) expressed concern about the addictive potential of psychedelics. This is more than in previous research polling psychiatrists, possibly because the study’s “broad” definition of psychedelics included “nonclassic, nonserotonergic hallucinogens,” such as ketamine and MDMA, Dr. Kim noted.
Because ketamine and MDMA are both lumped into the hallucinogen category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), “and both are known to have addictive potential, this may have obscured participant responses,” she added.
Some 28% of participants expressed concern about psychedelic use increasing the risk for subsequent psychiatric disorders and long-term cognitive impairment.
Almost three-quarters (74.5%) believe the therapeutic use of psychedelics should be legalized. However, most wanted legal therapeutic psychedelics to be highly regulated and administered only in controlled settings with specially trained providers.
Almost half of the sample believed therapeutic psychedelics should be legal in a variety of different contexts and by non-Western providers, in accordance with indigenous and/or spiritual traditions.
One surprising finding was that most respondents believed patients would be keen on using psychedelics to treat SUDs, said Dr. Kim.
“This may reflect evolving attitudes of both providers and patients about psychedelics, and it will be interesting to further study attitudes of patients toward the use of psychedelics to treat SUD in the future,” she added.
Attitudes toward psychedelics were generally similar for psychiatrists and nonpsychiatrists; but psychiatrists expressed greater comfort in discussing them with patients and were more likely to have observed complications of psychedelics use in their practice.
Dr. Kim said the study’s limitations included the small sample size and possible selection bias, as those with more favorable views of psychedelics may have been more likely to respond.
The study was supported by the Source Research Foundation.
A version of this article first appeared on Medscape.com.
The majority of addiction specialists, including psychiatrists, believe psychedelics are promising for the treatment of substance use disorders (SUDs) and psychiatric illnesses and, with some caveats, support legalization of the substances for these indications, results of a new survey show.
This strong positive attitude is “a surprise” given previous wariness of addiction specialists regarding legalization of marijuana, noted study investigator Amanda Kim, MD, JD, of Brigham and Women’s Hospital and Harvard Medical School, Boston.
“We had hypothesized that addiction specialists would express more skepticism about psychedelics compared to nonaddiction specialists,” Dr. Kim said.
Instead, addiction experts who participated in the survey were very much in favor of psychedelics being legalized for therapeutic use, but only in a controlled setting.
The findings were presented at the annual meeting of the American Academy of Addiction Psychiatry.
Growing interest
In recent years, there has been increased interest in the scientific community and among the general public in the therapeutic potential of psychedelics, said Dr. Kim. Previous research has shown growing positivity about psychedelics and support for their legalization among psychiatrists, she added.
Psychedelics have been decriminalized and/or legalized in several jurisdictions. The Food and Drug Administration has granted breakthrough therapy designation for 3,4-methylenedioxymethamphetamine (MDMA) in the treatment of posttraumatic stress disorder (PTSD) and has granted the same designation to psilocybin in the treatment of major depressive disorder.
“Despite psychedelics increasingly entering the mainstream, we are unaware of any studies specifically assessing the current attitudes of physicians specializing in addictions regarding psychedelics,” Dr. Kim said.
For the study, investigators identified prospective survey participants from the AAAP directory. They also reached out to program directors of addiction medicine and addiction psychiatry fellowships.
In the anonymous online survey, respondents were asked to rate their level of agreement with 30 statements.
The analysis included 145 respondents (59% men; mean age, 46.2 years). Psychiatrists made up about two-thirds of the sample. The remainder specialized in internal and family medicine.
Most respondents had some clinical exposure to psychedelics.
Positive attitudes, concerns
Overall, participants expressed very positive attitudes regarding the therapeutic use of psychedelics. About 64% strongly agreed or agreed psychedelics show promise in treating SUDs, and 82% agreed they show promise in treating psychiatric disorders.
However, more than one-third of respondents (37.9%) expressed concern about the addictive potential of psychedelics. This is more than in previous research polling psychiatrists, possibly because the study’s “broad” definition of psychedelics included “nonclassic, nonserotonergic hallucinogens,” such as ketamine and MDMA, Dr. Kim noted.
Because ketamine and MDMA are both lumped into the hallucinogen category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), “and both are known to have addictive potential, this may have obscured participant responses,” she added.
Some 28% of participants expressed concern about psychedelic use increasing the risk for subsequent psychiatric disorders and long-term cognitive impairment.
Almost three-quarters (74.5%) believe the therapeutic use of psychedelics should be legalized. However, most wanted legal therapeutic psychedelics to be highly regulated and administered only in controlled settings with specially trained providers.
Almost half of the sample believed therapeutic psychedelics should be legal in a variety of different contexts and by non-Western providers, in accordance with indigenous and/or spiritual traditions.
One surprising finding was that most respondents believed patients would be keen on using psychedelics to treat SUDs, said Dr. Kim.
“This may reflect evolving attitudes of both providers and patients about psychedelics, and it will be interesting to further study attitudes of patients toward the use of psychedelics to treat SUD in the future,” she added.
Attitudes toward psychedelics were generally similar for psychiatrists and nonpsychiatrists; but psychiatrists expressed greater comfort in discussing them with patients and were more likely to have observed complications of psychedelics use in their practice.
Dr. Kim said the study’s limitations included the small sample size and possible selection bias, as those with more favorable views of psychedelics may have been more likely to respond.
The study was supported by the Source Research Foundation.
A version of this article first appeared on Medscape.com.
FROM AAAP 2021
Is prescribing stimulants OK for comorbid opioid use disorder, ADHD?
A growing number of patients with opioid use disorder (OUD) have a diagnosis of comorbid attention-deficit/hyperactivity disorder (ADHD), raising issues about whether it’s appropriate to prescribe stimulants in this patient population.
One new study showed that from 2007-2017, there was a threefold increase in OUD and comorbid ADHD and that a significant number of these patients received prescription stimulants.
“This is the beginning stages of looking at whether or not there are risks of prescribing stimulants to patients who are on medications for opioid use disorder,” investigator Tae Woo (Ted) Park, MD, assistant professor, department of psychiatry, University of Pittsburgh School of Medicine, told this news organization.
“More and more people are being identified with ADHD, and we need to do more research on the best way to manage this patient group,” Dr. Park added.
The findings were presented at the annual meeting of the American Academy of Addiction Psychiatry.
Biological connection?
Dr. Park is not convinced there is “an actual biological connection” between ADHD and OUD, noting that there are many reasons why patients with ADHD may be more prone to developing such a disorder.
Perhaps they did not get an ADHD diagnosis as a child, “which led to impairment in their ability to be successful at school and then in a job,” which in turn predisposed them to having a substance use disorder, said Dr. Park.
From previous research and his own clinical experience, ADHD can significantly affect quality of life and “cause increased impairment” in patients with a substance use disorder, he added.
Interestingly, there’s evidence suggesting patients treated for ADHD early in life are less likely to develop a substance use disorder later on, he said.
The “gold standard” treatment for ADHD is a prescription stimulant, which carries its own addiction risks. “So the issue is about whether or not to prescribe risky medications and how to weigh the risks and benefits,” said Dr. Park.
From a private health insurance database, researchers examined records for patients aged 18-64 years who were receiving medication for OUD, including buprenorphine, methadone, or naltrexone, from 2007-2017.
In the study sample, about 17,000 individuals were receiving stimulants, and 156,000 were not receiving these drugs. The largest percentage of participants in both groups was in the age-18-to-25 category.
About 35% of those receiving stimulants had ADHD, and about the same percentage had a mood disorder diagnosis.
Percentage of co-occurring ADHD and OUD increased from more than 4% in 2007 to more than 14% in 2017. The prevalence of stimulant use plus medication for OUD also increased during that time.
The increase in ADHD diagnoses may reflect growing identification of the condition, Dr. Park noted. As the opioid problem became more apparent and additional treatments made available, “there were more health care contacts, more assessments, and more diagnoses, including of ADHD,” he said.
Risks versus benefits
Stimulants may also be risky in patients with OUD. Results from another study presented at the AAAP meeting showed these drugs were associated with an increased chance of poisoning in patients receiving buprenorphine.
However, Dr. Park is skeptical the combination of stimulants and buprenorphine “leads to a biological risk of overdose.” He used a hypothetical scenario where other factors play into the connection: A patient gets a prescription stimulant, becomes addicted, then starts using street or illicit stimulants, which leads to a relapse on opioids, and then to an overdose.
Dr. Park noted that the same study that found an increased poisoning risk in stimulant users also found that patients tend to stay on buprenorphine treatment, providing protection against overdose.
“So there are risks and benefits of prescribing these medications, and it becomes tricky to know whether to prescribe them or not,” he said.
While stimulants are by far the best treatment for ADHD, atomoxetine (Strattera), a nonstimulant medication with antidepressant effects is another option, Dr. Park said.
He added that a limitation of his study was that very few individuals in the database received methadone.
A version of this article first appeared on Medscape.com.
A growing number of patients with opioid use disorder (OUD) have a diagnosis of comorbid attention-deficit/hyperactivity disorder (ADHD), raising issues about whether it’s appropriate to prescribe stimulants in this patient population.
One new study showed that from 2007-2017, there was a threefold increase in OUD and comorbid ADHD and that a significant number of these patients received prescription stimulants.
“This is the beginning stages of looking at whether or not there are risks of prescribing stimulants to patients who are on medications for opioid use disorder,” investigator Tae Woo (Ted) Park, MD, assistant professor, department of psychiatry, University of Pittsburgh School of Medicine, told this news organization.
“More and more people are being identified with ADHD, and we need to do more research on the best way to manage this patient group,” Dr. Park added.
The findings were presented at the annual meeting of the American Academy of Addiction Psychiatry.
Biological connection?
Dr. Park is not convinced there is “an actual biological connection” between ADHD and OUD, noting that there are many reasons why patients with ADHD may be more prone to developing such a disorder.
Perhaps they did not get an ADHD diagnosis as a child, “which led to impairment in their ability to be successful at school and then in a job,” which in turn predisposed them to having a substance use disorder, said Dr. Park.
From previous research and his own clinical experience, ADHD can significantly affect quality of life and “cause increased impairment” in patients with a substance use disorder, he added.
Interestingly, there’s evidence suggesting patients treated for ADHD early in life are less likely to develop a substance use disorder later on, he said.
The “gold standard” treatment for ADHD is a prescription stimulant, which carries its own addiction risks. “So the issue is about whether or not to prescribe risky medications and how to weigh the risks and benefits,” said Dr. Park.
From a private health insurance database, researchers examined records for patients aged 18-64 years who were receiving medication for OUD, including buprenorphine, methadone, or naltrexone, from 2007-2017.
In the study sample, about 17,000 individuals were receiving stimulants, and 156,000 were not receiving these drugs. The largest percentage of participants in both groups was in the age-18-to-25 category.
About 35% of those receiving stimulants had ADHD, and about the same percentage had a mood disorder diagnosis.
Percentage of co-occurring ADHD and OUD increased from more than 4% in 2007 to more than 14% in 2017. The prevalence of stimulant use plus medication for OUD also increased during that time.
The increase in ADHD diagnoses may reflect growing identification of the condition, Dr. Park noted. As the opioid problem became more apparent and additional treatments made available, “there were more health care contacts, more assessments, and more diagnoses, including of ADHD,” he said.
Risks versus benefits
Stimulants may also be risky in patients with OUD. Results from another study presented at the AAAP meeting showed these drugs were associated with an increased chance of poisoning in patients receiving buprenorphine.
However, Dr. Park is skeptical the combination of stimulants and buprenorphine “leads to a biological risk of overdose.” He used a hypothetical scenario where other factors play into the connection: A patient gets a prescription stimulant, becomes addicted, then starts using street or illicit stimulants, which leads to a relapse on opioids, and then to an overdose.
Dr. Park noted that the same study that found an increased poisoning risk in stimulant users also found that patients tend to stay on buprenorphine treatment, providing protection against overdose.
“So there are risks and benefits of prescribing these medications, and it becomes tricky to know whether to prescribe them or not,” he said.
While stimulants are by far the best treatment for ADHD, atomoxetine (Strattera), a nonstimulant medication with antidepressant effects is another option, Dr. Park said.
He added that a limitation of his study was that very few individuals in the database received methadone.
A version of this article first appeared on Medscape.com.
A growing number of patients with opioid use disorder (OUD) have a diagnosis of comorbid attention-deficit/hyperactivity disorder (ADHD), raising issues about whether it’s appropriate to prescribe stimulants in this patient population.
One new study showed that from 2007-2017, there was a threefold increase in OUD and comorbid ADHD and that a significant number of these patients received prescription stimulants.
“This is the beginning stages of looking at whether or not there are risks of prescribing stimulants to patients who are on medications for opioid use disorder,” investigator Tae Woo (Ted) Park, MD, assistant professor, department of psychiatry, University of Pittsburgh School of Medicine, told this news organization.
“More and more people are being identified with ADHD, and we need to do more research on the best way to manage this patient group,” Dr. Park added.
The findings were presented at the annual meeting of the American Academy of Addiction Psychiatry.
Biological connection?
Dr. Park is not convinced there is “an actual biological connection” between ADHD and OUD, noting that there are many reasons why patients with ADHD may be more prone to developing such a disorder.
Perhaps they did not get an ADHD diagnosis as a child, “which led to impairment in their ability to be successful at school and then in a job,” which in turn predisposed them to having a substance use disorder, said Dr. Park.
From previous research and his own clinical experience, ADHD can significantly affect quality of life and “cause increased impairment” in patients with a substance use disorder, he added.
Interestingly, there’s evidence suggesting patients treated for ADHD early in life are less likely to develop a substance use disorder later on, he said.
The “gold standard” treatment for ADHD is a prescription stimulant, which carries its own addiction risks. “So the issue is about whether or not to prescribe risky medications and how to weigh the risks and benefits,” said Dr. Park.
From a private health insurance database, researchers examined records for patients aged 18-64 years who were receiving medication for OUD, including buprenorphine, methadone, or naltrexone, from 2007-2017.
In the study sample, about 17,000 individuals were receiving stimulants, and 156,000 were not receiving these drugs. The largest percentage of participants in both groups was in the age-18-to-25 category.
About 35% of those receiving stimulants had ADHD, and about the same percentage had a mood disorder diagnosis.
Percentage of co-occurring ADHD and OUD increased from more than 4% in 2007 to more than 14% in 2017. The prevalence of stimulant use plus medication for OUD also increased during that time.
The increase in ADHD diagnoses may reflect growing identification of the condition, Dr. Park noted. As the opioid problem became more apparent and additional treatments made available, “there were more health care contacts, more assessments, and more diagnoses, including of ADHD,” he said.
Risks versus benefits
Stimulants may also be risky in patients with OUD. Results from another study presented at the AAAP meeting showed these drugs were associated with an increased chance of poisoning in patients receiving buprenorphine.
However, Dr. Park is skeptical the combination of stimulants and buprenorphine “leads to a biological risk of overdose.” He used a hypothetical scenario where other factors play into the connection: A patient gets a prescription stimulant, becomes addicted, then starts using street or illicit stimulants, which leads to a relapse on opioids, and then to an overdose.
Dr. Park noted that the same study that found an increased poisoning risk in stimulant users also found that patients tend to stay on buprenorphine treatment, providing protection against overdose.
“So there are risks and benefits of prescribing these medications, and it becomes tricky to know whether to prescribe them or not,” he said.
While stimulants are by far the best treatment for ADHD, atomoxetine (Strattera), a nonstimulant medication with antidepressant effects is another option, Dr. Park said.
He added that a limitation of his study was that very few individuals in the database received methadone.
A version of this article first appeared on Medscape.com.
FROM AAAP 2021
New insights into psychogenic seizures in teens
, results of a small study suggest.
The school experience of teens with PNES is overwhelmingly negative, study investigator Andrea Tanner, PhD, a postdoctoral fellow at Indiana University School of Nursing, Indianapolis.
She hopes this research will spur a collaborative effort between students, schools, families, and health care providers “to develop an effective plan to help these adolescents cope, to manage this condition, and hopefully reach seizure freedom.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Anxiety, perfectionism
Although psychogenic seizures resemble epileptic seizures, they have a psychological basis and, unlike epilepsy, are not caused by abnormal electrical brain activity.
While the school experience has previously been identified as a source of predisposing, precipitating, and perpetuating factors for PNES, little is known about the school experience of adolescents with the disorder and the role it may play in PNES management, the investigators noted.
During her 20 years as a school nurse, Dr. Tanner saw firsthand how school staff struggled with responding appropriately to teens with PNES. “They wanted to call 911 every time; they wanted to respond as if it [were] an epileptic seizure.”
For the study, she interviewed 10 teens with PNES, aged 12 to 19 years, whom she found mostly through Facebook support groups but also through flyers. All participants had undergone video EEG and been diagnosed with PNES.
From the interviews, Dr. Tanner and colleagues conducted a qualitative content analysis and uncovered “overarching” themes.
A main theme was stress, some of which focused on bullying by peers or harassment by school personnel, much of which was related to accusations of the children “faking” seizures to get attention, said Dr. Tanner.
Some teens reported being banned from school events, such as field trips, out of concern they would be a “distraction,” which led to feelings of isolation and exclusion, said Dr. Tanner.
Research points to a growing incidence of PNES among adolescents. This may be because it is now better recognized, or it may stem from the unique stressors today’s teens face, said Dr. Tanner.
Adolescents discussed the pressures they feel to be the best at everything. “They wanted to be good in athletics; they wanted to be good in academics; they wanted to get into a good college,” said Dr. Tanner.
Some study participants had undergone psychotherapy, including cognitive-behavioral therapy, and others had investigated mindfulness-based therapy. However, not all were receiving treatment. For some, such care was inaccessible, while others had tried a mental health care intervention but had abandoned it.
Although all the study participants were female, Dr. Tanner has interviewed males outside this study and found their experiences are similar.
Her next research step is to try to quantify the findings. “I would like to begin to look at what would be the appropriate outcomes if I were to do an intervention to improve the school experience.”
Her message for doctors is to see school nurses as a “partner” or “liaison” who “can bridge the world of health care and education.”
Important, novel research
Commenting on the research, Barbara Dworetzky, MD, Chief, Epilepsy, Brigham and Women’s Hospital, and professor of neurology, Harvard Medical School, said it’s “important and novel.”
The study focuses on the main factors – or themes – that lead to increased stress, such as bullying, isolation, and “not being believed,” that are likely triggers for PNES, said Dr. Dworetzky.
The study is also important because it focuses on factors that help make the girls “feel supported and protected” – for example, having staff “take the episodes seriously,” she said.
The study’s qualitative measures “are a valid way of understanding these girls and giving them a voice,” said Dr. Dworetzky. She added the study provides “practical information” that could help target treatments to improve outcomes in this group.
A limitation of the study was that the very small cohort of teenage girls was selected only through families in Facebook support groups or flyers to school nurses, said Dr. Dworetzky.
“There are likely many other groups who don’t even have families trying to help them. Larger cohorts without this type of bias may be next steps.”
A version of this article first appeared on Medscape.com.
, results of a small study suggest.
The school experience of teens with PNES is overwhelmingly negative, study investigator Andrea Tanner, PhD, a postdoctoral fellow at Indiana University School of Nursing, Indianapolis.
She hopes this research will spur a collaborative effort between students, schools, families, and health care providers “to develop an effective plan to help these adolescents cope, to manage this condition, and hopefully reach seizure freedom.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Anxiety, perfectionism
Although psychogenic seizures resemble epileptic seizures, they have a psychological basis and, unlike epilepsy, are not caused by abnormal electrical brain activity.
While the school experience has previously been identified as a source of predisposing, precipitating, and perpetuating factors for PNES, little is known about the school experience of adolescents with the disorder and the role it may play in PNES management, the investigators noted.
During her 20 years as a school nurse, Dr. Tanner saw firsthand how school staff struggled with responding appropriately to teens with PNES. “They wanted to call 911 every time; they wanted to respond as if it [were] an epileptic seizure.”
For the study, she interviewed 10 teens with PNES, aged 12 to 19 years, whom she found mostly through Facebook support groups but also through flyers. All participants had undergone video EEG and been diagnosed with PNES.
From the interviews, Dr. Tanner and colleagues conducted a qualitative content analysis and uncovered “overarching” themes.
A main theme was stress, some of which focused on bullying by peers or harassment by school personnel, much of which was related to accusations of the children “faking” seizures to get attention, said Dr. Tanner.
Some teens reported being banned from school events, such as field trips, out of concern they would be a “distraction,” which led to feelings of isolation and exclusion, said Dr. Tanner.
Research points to a growing incidence of PNES among adolescents. This may be because it is now better recognized, or it may stem from the unique stressors today’s teens face, said Dr. Tanner.
Adolescents discussed the pressures they feel to be the best at everything. “They wanted to be good in athletics; they wanted to be good in academics; they wanted to get into a good college,” said Dr. Tanner.
Some study participants had undergone psychotherapy, including cognitive-behavioral therapy, and others had investigated mindfulness-based therapy. However, not all were receiving treatment. For some, such care was inaccessible, while others had tried a mental health care intervention but had abandoned it.
Although all the study participants were female, Dr. Tanner has interviewed males outside this study and found their experiences are similar.
Her next research step is to try to quantify the findings. “I would like to begin to look at what would be the appropriate outcomes if I were to do an intervention to improve the school experience.”
Her message for doctors is to see school nurses as a “partner” or “liaison” who “can bridge the world of health care and education.”
Important, novel research
Commenting on the research, Barbara Dworetzky, MD, Chief, Epilepsy, Brigham and Women’s Hospital, and professor of neurology, Harvard Medical School, said it’s “important and novel.”
The study focuses on the main factors – or themes – that lead to increased stress, such as bullying, isolation, and “not being believed,” that are likely triggers for PNES, said Dr. Dworetzky.
The study is also important because it focuses on factors that help make the girls “feel supported and protected” – for example, having staff “take the episodes seriously,” she said.
The study’s qualitative measures “are a valid way of understanding these girls and giving them a voice,” said Dr. Dworetzky. She added the study provides “practical information” that could help target treatments to improve outcomes in this group.
A limitation of the study was that the very small cohort of teenage girls was selected only through families in Facebook support groups or flyers to school nurses, said Dr. Dworetzky.
“There are likely many other groups who don’t even have families trying to help them. Larger cohorts without this type of bias may be next steps.”
A version of this article first appeared on Medscape.com.
, results of a small study suggest.
The school experience of teens with PNES is overwhelmingly negative, study investigator Andrea Tanner, PhD, a postdoctoral fellow at Indiana University School of Nursing, Indianapolis.
She hopes this research will spur a collaborative effort between students, schools, families, and health care providers “to develop an effective plan to help these adolescents cope, to manage this condition, and hopefully reach seizure freedom.”
The findings were presented at the annual meeting of the American Epilepsy Society.
Anxiety, perfectionism
Although psychogenic seizures resemble epileptic seizures, they have a psychological basis and, unlike epilepsy, are not caused by abnormal electrical brain activity.
While the school experience has previously been identified as a source of predisposing, precipitating, and perpetuating factors for PNES, little is known about the school experience of adolescents with the disorder and the role it may play in PNES management, the investigators noted.
During her 20 years as a school nurse, Dr. Tanner saw firsthand how school staff struggled with responding appropriately to teens with PNES. “They wanted to call 911 every time; they wanted to respond as if it [were] an epileptic seizure.”
For the study, she interviewed 10 teens with PNES, aged 12 to 19 years, whom she found mostly through Facebook support groups but also through flyers. All participants had undergone video EEG and been diagnosed with PNES.
From the interviews, Dr. Tanner and colleagues conducted a qualitative content analysis and uncovered “overarching” themes.
A main theme was stress, some of which focused on bullying by peers or harassment by school personnel, much of which was related to accusations of the children “faking” seizures to get attention, said Dr. Tanner.
Some teens reported being banned from school events, such as field trips, out of concern they would be a “distraction,” which led to feelings of isolation and exclusion, said Dr. Tanner.
Research points to a growing incidence of PNES among adolescents. This may be because it is now better recognized, or it may stem from the unique stressors today’s teens face, said Dr. Tanner.
Adolescents discussed the pressures they feel to be the best at everything. “They wanted to be good in athletics; they wanted to be good in academics; they wanted to get into a good college,” said Dr. Tanner.
Some study participants had undergone psychotherapy, including cognitive-behavioral therapy, and others had investigated mindfulness-based therapy. However, not all were receiving treatment. For some, such care was inaccessible, while others had tried a mental health care intervention but had abandoned it.
Although all the study participants were female, Dr. Tanner has interviewed males outside this study and found their experiences are similar.
Her next research step is to try to quantify the findings. “I would like to begin to look at what would be the appropriate outcomes if I were to do an intervention to improve the school experience.”
Her message for doctors is to see school nurses as a “partner” or “liaison” who “can bridge the world of health care and education.”
Important, novel research
Commenting on the research, Barbara Dworetzky, MD, Chief, Epilepsy, Brigham and Women’s Hospital, and professor of neurology, Harvard Medical School, said it’s “important and novel.”
The study focuses on the main factors – or themes – that lead to increased stress, such as bullying, isolation, and “not being believed,” that are likely triggers for PNES, said Dr. Dworetzky.
The study is also important because it focuses on factors that help make the girls “feel supported and protected” – for example, having staff “take the episodes seriously,” she said.
The study’s qualitative measures “are a valid way of understanding these girls and giving them a voice,” said Dr. Dworetzky. She added the study provides “practical information” that could help target treatments to improve outcomes in this group.
A limitation of the study was that the very small cohort of teenage girls was selected only through families in Facebook support groups or flyers to school nurses, said Dr. Dworetzky.
“There are likely many other groups who don’t even have families trying to help them. Larger cohorts without this type of bias may be next steps.”
A version of this article first appeared on Medscape.com.
From AES 2021
‘Alarming’ rate of abuse in pregnant women with epilepsy
, new research shows.
Study investigator Naveed Chaudhry, MD, a recent epilepsy fellow and assistant professor of neurology, University of Colorado School of Medicine, described the finding as “alarming” and called for more support for this patient population.
Investigators found that women with epilepsy are also more likely to report other stressors, including divorce, illness, lost pay, and partner discord, while expecting.
“As epilepsy physicians, it’s important that we ask the right questions and dive a little bit deeper with these patients, even if it’s uncomfortable and not something we’re used to,” said Dr. Chaudhry.
The findings were presented at the annual meeting of the American Epilepsy Society.
Cause for concern
Women with epilepsy may be under stress for a variety of social and economic reasons. In some women, stress can trigger seizures, and during pregnancy, this can lead to complications such as preterm labor and low birth weight.
For the study, researchers tapped into the Center for Disease Control and Prevention Pregnancy Risk Assessment and Monitoring System (PRAMS). This database includes information from surveys asking women across the U.S. about their pregnancy and postpartum period.
Thirteen states collected data on stresses in women with and without epilepsy. Respondents were asked about 14 economic and other worries in the year prior to their baby’s birth, including the pregnancy period.
The analysis included 64,951 women, 1,140 of whom had epilepsy, who were included in surveys from 2012-2020. There were no significant demographic differences between those with and those without the disorder.
After adjusting for maternal age, race, ethnicity, marital status, education, and socioeconomic status, the study found that women with epilepsy experienced an average of 2.41 of the stressors compared with 1.72 for women without epilepsy.
Women with epilepsy were more likely to have experienced family illness, divorce, homelessness, partner job loss, reduced work or pay, increased arguments, having a partner in jail, drug use, and the death of someone close to them.
The results showed that unmarried and younger women as well as those with lower incomes were particularly prone to experience stress during pregnancy.
It’s not clear why women with epilepsy report more stressors. “Looking at the literature, no one has really looked at the exact reason for this, but we postulate it could be a lack of supports and support systems,” said Dr. Chaudhry.
Women were asked about physical, sexual, and emotional abuse. Results showed that substantially more women with epilepsy than those without the disorder reported such abuse during pregnancy – 10.6% versus 4.1%. The adjusted odds ratio for women with epilepsy reporting abuse was 2.78 (95% CI, 2.07-3.74).
“That raises our concern and needs to be looked at in more detail,” said Dr. Chaudhry.
It is unclear whether some women might have had psychogenic non-epileptic seizures (PNES), which are linked to a higher rate of abuse, said Dr. Chaudhry. “But the prevalence of PNES in the general population is quite low, so we don’t think it’s contributing to a large extent to this finding.”
The findings highlight the importance of addressing stress in women with epilepsy during pregnancy, he said. “We need to have good support services and we need to counsel women to optimize good outcomes.”
This applies to all women of childbearing age. “We suspect abuse and stressors are going to be going on throughout that period,” said Dr. Chaudhry. “It’s important to ask about it and have appropriate support staff and social work and people available to help when an issue is identified.”
Stress a common seizure trigger
Commenting on the research, Kimford Meador, MD, professor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, noted the study was well conducted and had a large sample size.
The findings are important, as stress is a common trigger for seizures in people with epilepsy and is associated with mood and anxiety, which can affect quality of life, said Dr. Meador.
Results of his analysis from the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, also presented at this year’s AES meeting, showed that women with epilepsy had more depressive symptoms during the postpartum period and more anxiety symptoms during pregnancy and postpartum in comparison with those without epilepsy.
Dr. Meador’s group also recently conducted a study that was published in JAMA Neurology, showing that in women with epilepsy during the postpartum period, anxiety is associated with lower cognitive ability in their children at age 2 years.
“All these findings highlight the importance of assessing and managing stress, anxiety, and mood in women with epilepsy,” said Dr. Meador. “Interventions could impact seizures and quality of life in pregnant women with epilepsy and long-term outcomes in their children.”
A version of this article first appeared on Medscape.com.
, new research shows.
Study investigator Naveed Chaudhry, MD, a recent epilepsy fellow and assistant professor of neurology, University of Colorado School of Medicine, described the finding as “alarming” and called for more support for this patient population.
Investigators found that women with epilepsy are also more likely to report other stressors, including divorce, illness, lost pay, and partner discord, while expecting.
“As epilepsy physicians, it’s important that we ask the right questions and dive a little bit deeper with these patients, even if it’s uncomfortable and not something we’re used to,” said Dr. Chaudhry.
The findings were presented at the annual meeting of the American Epilepsy Society.
Cause for concern
Women with epilepsy may be under stress for a variety of social and economic reasons. In some women, stress can trigger seizures, and during pregnancy, this can lead to complications such as preterm labor and low birth weight.
For the study, researchers tapped into the Center for Disease Control and Prevention Pregnancy Risk Assessment and Monitoring System (PRAMS). This database includes information from surveys asking women across the U.S. about their pregnancy and postpartum period.
Thirteen states collected data on stresses in women with and without epilepsy. Respondents were asked about 14 economic and other worries in the year prior to their baby’s birth, including the pregnancy period.
The analysis included 64,951 women, 1,140 of whom had epilepsy, who were included in surveys from 2012-2020. There were no significant demographic differences between those with and those without the disorder.
After adjusting for maternal age, race, ethnicity, marital status, education, and socioeconomic status, the study found that women with epilepsy experienced an average of 2.41 of the stressors compared with 1.72 for women without epilepsy.
Women with epilepsy were more likely to have experienced family illness, divorce, homelessness, partner job loss, reduced work or pay, increased arguments, having a partner in jail, drug use, and the death of someone close to them.
The results showed that unmarried and younger women as well as those with lower incomes were particularly prone to experience stress during pregnancy.
It’s not clear why women with epilepsy report more stressors. “Looking at the literature, no one has really looked at the exact reason for this, but we postulate it could be a lack of supports and support systems,” said Dr. Chaudhry.
Women were asked about physical, sexual, and emotional abuse. Results showed that substantially more women with epilepsy than those without the disorder reported such abuse during pregnancy – 10.6% versus 4.1%. The adjusted odds ratio for women with epilepsy reporting abuse was 2.78 (95% CI, 2.07-3.74).
“That raises our concern and needs to be looked at in more detail,” said Dr. Chaudhry.
It is unclear whether some women might have had psychogenic non-epileptic seizures (PNES), which are linked to a higher rate of abuse, said Dr. Chaudhry. “But the prevalence of PNES in the general population is quite low, so we don’t think it’s contributing to a large extent to this finding.”
The findings highlight the importance of addressing stress in women with epilepsy during pregnancy, he said. “We need to have good support services and we need to counsel women to optimize good outcomes.”
This applies to all women of childbearing age. “We suspect abuse and stressors are going to be going on throughout that period,” said Dr. Chaudhry. “It’s important to ask about it and have appropriate support staff and social work and people available to help when an issue is identified.”
Stress a common seizure trigger
Commenting on the research, Kimford Meador, MD, professor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, noted the study was well conducted and had a large sample size.
The findings are important, as stress is a common trigger for seizures in people with epilepsy and is associated with mood and anxiety, which can affect quality of life, said Dr. Meador.
Results of his analysis from the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, also presented at this year’s AES meeting, showed that women with epilepsy had more depressive symptoms during the postpartum period and more anxiety symptoms during pregnancy and postpartum in comparison with those without epilepsy.
Dr. Meador’s group also recently conducted a study that was published in JAMA Neurology, showing that in women with epilepsy during the postpartum period, anxiety is associated with lower cognitive ability in their children at age 2 years.
“All these findings highlight the importance of assessing and managing stress, anxiety, and mood in women with epilepsy,” said Dr. Meador. “Interventions could impact seizures and quality of life in pregnant women with epilepsy and long-term outcomes in their children.”
A version of this article first appeared on Medscape.com.
, new research shows.
Study investigator Naveed Chaudhry, MD, a recent epilepsy fellow and assistant professor of neurology, University of Colorado School of Medicine, described the finding as “alarming” and called for more support for this patient population.
Investigators found that women with epilepsy are also more likely to report other stressors, including divorce, illness, lost pay, and partner discord, while expecting.
“As epilepsy physicians, it’s important that we ask the right questions and dive a little bit deeper with these patients, even if it’s uncomfortable and not something we’re used to,” said Dr. Chaudhry.
The findings were presented at the annual meeting of the American Epilepsy Society.
Cause for concern
Women with epilepsy may be under stress for a variety of social and economic reasons. In some women, stress can trigger seizures, and during pregnancy, this can lead to complications such as preterm labor and low birth weight.
For the study, researchers tapped into the Center for Disease Control and Prevention Pregnancy Risk Assessment and Monitoring System (PRAMS). This database includes information from surveys asking women across the U.S. about their pregnancy and postpartum period.
Thirteen states collected data on stresses in women with and without epilepsy. Respondents were asked about 14 economic and other worries in the year prior to their baby’s birth, including the pregnancy period.
The analysis included 64,951 women, 1,140 of whom had epilepsy, who were included in surveys from 2012-2020. There were no significant demographic differences between those with and those without the disorder.
After adjusting for maternal age, race, ethnicity, marital status, education, and socioeconomic status, the study found that women with epilepsy experienced an average of 2.41 of the stressors compared with 1.72 for women without epilepsy.
Women with epilepsy were more likely to have experienced family illness, divorce, homelessness, partner job loss, reduced work or pay, increased arguments, having a partner in jail, drug use, and the death of someone close to them.
The results showed that unmarried and younger women as well as those with lower incomes were particularly prone to experience stress during pregnancy.
It’s not clear why women with epilepsy report more stressors. “Looking at the literature, no one has really looked at the exact reason for this, but we postulate it could be a lack of supports and support systems,” said Dr. Chaudhry.
Women were asked about physical, sexual, and emotional abuse. Results showed that substantially more women with epilepsy than those without the disorder reported such abuse during pregnancy – 10.6% versus 4.1%. The adjusted odds ratio for women with epilepsy reporting abuse was 2.78 (95% CI, 2.07-3.74).
“That raises our concern and needs to be looked at in more detail,” said Dr. Chaudhry.
It is unclear whether some women might have had psychogenic non-epileptic seizures (PNES), which are linked to a higher rate of abuse, said Dr. Chaudhry. “But the prevalence of PNES in the general population is quite low, so we don’t think it’s contributing to a large extent to this finding.”
The findings highlight the importance of addressing stress in women with epilepsy during pregnancy, he said. “We need to have good support services and we need to counsel women to optimize good outcomes.”
This applies to all women of childbearing age. “We suspect abuse and stressors are going to be going on throughout that period,” said Dr. Chaudhry. “It’s important to ask about it and have appropriate support staff and social work and people available to help when an issue is identified.”
Stress a common seizure trigger
Commenting on the research, Kimford Meador, MD, professor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, noted the study was well conducted and had a large sample size.
The findings are important, as stress is a common trigger for seizures in people with epilepsy and is associated with mood and anxiety, which can affect quality of life, said Dr. Meador.
Results of his analysis from the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, also presented at this year’s AES meeting, showed that women with epilepsy had more depressive symptoms during the postpartum period and more anxiety symptoms during pregnancy and postpartum in comparison with those without epilepsy.
Dr. Meador’s group also recently conducted a study that was published in JAMA Neurology, showing that in women with epilepsy during the postpartum period, anxiety is associated with lower cognitive ability in their children at age 2 years.
“All these findings highlight the importance of assessing and managing stress, anxiety, and mood in women with epilepsy,” said Dr. Meador. “Interventions could impact seizures and quality of life in pregnant women with epilepsy and long-term outcomes in their children.”
A version of this article first appeared on Medscape.com.
From AES 2021
Optimal epilepsy care extends well beyond managing seizures
, new research shows. Investigators also found racial and ethnic disparities in comorbidity prevalence.
“Our study identified that people with epilepsy have complex health care needs that extend well beyond their epilepsy,” said co-investigator Wyatt P. Bensken, a PhD candidate in the Department of Population and Quantitative Health Sciences at Case Western Reserve University, Cleveland.
The findings were presented at the annual meeting of the American Epilepsy Society.
A vulnerable population
Researchers identified individuals with epilepsy using Medicaid claims from 2010 to 2014. Mr. Bensken noted that the approximately one-third of patients with epilepsy covered by Medicaid represent “the most vulnerable” population with the disorder because they may not be working and often have other disabilities.
Based on an algorithm that puts diagnostic codes into clinically meaningful categories, the investigators focused on 190 conditions.
“A strength of the study was that we were able to cast such a broad net” to capture conditions, Mr. Bensken said.
Anxiety and mood disorders were originally in separate categories but were grouped together “after recognizing that those who had one pretty much had the other,” he added.
The researchers used a machine learning technique known as association rule mining (ARM) to uncover frequently occurring conditions and combinations of conditions. This same statistical technique is used by companies such as Amazon to determine future purchases based on articles people have bought.
Among 81,963 patients with epilepsy, the most common conditions were anxiety and mood disorders (46.5%). These were followed by hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache including migraine (29.5%). Urinary tract infections (UTIs) were experienced by 22.8% of the sample.
The rate of anxiety and mood disorders was not unexpected, “but I was surprised to see hypertension so high on the list,” said Mr. Bensken. He noted there is also increasing evidence pointing to a cardiovascular-epilepsy connection.
What should neurologists do?
The study also highlights the relatively high rate of back problems, which are not usually considered a comorbidity in patients with epilepsy, Mr. Bensken said. “Back problems likely greatly impact a patient’s quality of life, and seeing them so high on the list makes me wonder if neurologists or epileptologists or primary care doctors are even asking about back pain and how that might impact the ability to function day to day,” he added.
How do these rates compare with the general population? From other studies, the estimated prevalence for anxiety and mood disorders is 20%-30%, compared with almost 50% of the current sample, said Mr. Bensken.
In addition, the rate of hypertension in the study’s epilepsy population was about 7% higher than the general population, and the rate of UTIs was about 12% higher, he reported.
When examining combinations of conditions, anxiety and mood disorders continued to have an “outsized” prevalence, appearing in nearly every combination, the investigators noted.
Almost a quarter (24.7%) of participants had back problems plus anxiety and a mood disorder, and about 15% had headaches and back problems as well as anxiety and a mood disorder.
“That’s a non-negligible amount of the population that have not just one or two things going on but three and four,” said Mr. Bensken.
These new results underscore how complex these patients can be and the need to integrate medical care among different specialties, he noted.
“We don’t believe it’s the neurologist’s job to also manage the hypertension, but being aware of how prevalent hypertension may be and working with the primary care doctor, or at least checking in with the patient and asking if they’re managing their hypertension, is a real priority,” he said.
Researchers also used the ARM system to identify racial disparities, “which have been largely understudied in the epilepsy context,” said Mr. Bensken.
American Indians and Alaskan Natives had a substantially higher prevalence of developmental disabilities, while Black participants had a higher prevalence of hypertension.
One of the study’s themes was that disparities were not uniform, Mr. Bensken noted. “It wasn’t that in every condition the prevalence was lowest for White individuals and highest for everybody else,” he said.
These results point to the need for a larger study to examine the cultural context of these subgroups and such things as structural racism that might drive disparities, he added.
When researchers examined combinations of comorbidities in individuals in the top quartile of hospitalizations and emergency department visits, they found high users had a much higher disease burden, with 75.8% having anxiety or a mood disorder.
The study highlights that patients with epilepsy on Medicaid are “a high priority population,” said Mr. Bensken.
‘Drift down hypothesis’
Commenting on the findings, Fred A. Lado, MD, PhD, director of epilepsy at Northwell Health Eastern and Central Regions, said the increased incidence of comorbidities in patients of low socioeconomic status was not surprising.
“The interesting data here is that we see an even higher incidence among people with epilepsy,” said Dr. Lado, who was not involved with the research.
The study shows how epilepsy exacerbates the effects of low socioeconomic status, he added.
“One of the determinants of socioeconomic status in this case may well be the fact they have seizures and have a limited ability to work and are often more dependent on state assistance and disability support,” Dr. Lado said.
He also referred to the “drift down hypothesis” of chronic disease. “If you have epilepsy and are born into a middle-class family, chances are you will be on disability and can’t work, so you probably have a lower socioeconomic status than your family did as you grew up.”
Dr. Lado noted how “extremely common” mood disorders are in this population and that certain pain syndromes “tracked with those mood disorders.”
“We know mood disorders are more prevalent in people with epilepsy, and now we see that pain-related problems – headache and back pain – are more prevalent in people with epilepsy,” he said.
The data showing “downstream effects of the mood disorders,” from epilepsy to mood disorders to pain disorders, was “very interesting,” Dr. Lado said.
The study was funded by the Centers for Disease Control and Prevention and the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Mr. Bensken has reported receiving research support for this work from the NIH.
A version of this article first appeared on Medscape.com.
, new research shows. Investigators also found racial and ethnic disparities in comorbidity prevalence.
“Our study identified that people with epilepsy have complex health care needs that extend well beyond their epilepsy,” said co-investigator Wyatt P. Bensken, a PhD candidate in the Department of Population and Quantitative Health Sciences at Case Western Reserve University, Cleveland.
The findings were presented at the annual meeting of the American Epilepsy Society.
A vulnerable population
Researchers identified individuals with epilepsy using Medicaid claims from 2010 to 2014. Mr. Bensken noted that the approximately one-third of patients with epilepsy covered by Medicaid represent “the most vulnerable” population with the disorder because they may not be working and often have other disabilities.
Based on an algorithm that puts diagnostic codes into clinically meaningful categories, the investigators focused on 190 conditions.
“A strength of the study was that we were able to cast such a broad net” to capture conditions, Mr. Bensken said.
Anxiety and mood disorders were originally in separate categories but were grouped together “after recognizing that those who had one pretty much had the other,” he added.
The researchers used a machine learning technique known as association rule mining (ARM) to uncover frequently occurring conditions and combinations of conditions. This same statistical technique is used by companies such as Amazon to determine future purchases based on articles people have bought.
Among 81,963 patients with epilepsy, the most common conditions were anxiety and mood disorders (46.5%). These were followed by hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache including migraine (29.5%). Urinary tract infections (UTIs) were experienced by 22.8% of the sample.
The rate of anxiety and mood disorders was not unexpected, “but I was surprised to see hypertension so high on the list,” said Mr. Bensken. He noted there is also increasing evidence pointing to a cardiovascular-epilepsy connection.
What should neurologists do?
The study also highlights the relatively high rate of back problems, which are not usually considered a comorbidity in patients with epilepsy, Mr. Bensken said. “Back problems likely greatly impact a patient’s quality of life, and seeing them so high on the list makes me wonder if neurologists or epileptologists or primary care doctors are even asking about back pain and how that might impact the ability to function day to day,” he added.
How do these rates compare with the general population? From other studies, the estimated prevalence for anxiety and mood disorders is 20%-30%, compared with almost 50% of the current sample, said Mr. Bensken.
In addition, the rate of hypertension in the study’s epilepsy population was about 7% higher than the general population, and the rate of UTIs was about 12% higher, he reported.
When examining combinations of conditions, anxiety and mood disorders continued to have an “outsized” prevalence, appearing in nearly every combination, the investigators noted.
Almost a quarter (24.7%) of participants had back problems plus anxiety and a mood disorder, and about 15% had headaches and back problems as well as anxiety and a mood disorder.
“That’s a non-negligible amount of the population that have not just one or two things going on but three and four,” said Mr. Bensken.
These new results underscore how complex these patients can be and the need to integrate medical care among different specialties, he noted.
“We don’t believe it’s the neurologist’s job to also manage the hypertension, but being aware of how prevalent hypertension may be and working with the primary care doctor, or at least checking in with the patient and asking if they’re managing their hypertension, is a real priority,” he said.
Researchers also used the ARM system to identify racial disparities, “which have been largely understudied in the epilepsy context,” said Mr. Bensken.
American Indians and Alaskan Natives had a substantially higher prevalence of developmental disabilities, while Black participants had a higher prevalence of hypertension.
One of the study’s themes was that disparities were not uniform, Mr. Bensken noted. “It wasn’t that in every condition the prevalence was lowest for White individuals and highest for everybody else,” he said.
These results point to the need for a larger study to examine the cultural context of these subgroups and such things as structural racism that might drive disparities, he added.
When researchers examined combinations of comorbidities in individuals in the top quartile of hospitalizations and emergency department visits, they found high users had a much higher disease burden, with 75.8% having anxiety or a mood disorder.
The study highlights that patients with epilepsy on Medicaid are “a high priority population,” said Mr. Bensken.
‘Drift down hypothesis’
Commenting on the findings, Fred A. Lado, MD, PhD, director of epilepsy at Northwell Health Eastern and Central Regions, said the increased incidence of comorbidities in patients of low socioeconomic status was not surprising.
“The interesting data here is that we see an even higher incidence among people with epilepsy,” said Dr. Lado, who was not involved with the research.
The study shows how epilepsy exacerbates the effects of low socioeconomic status, he added.
“One of the determinants of socioeconomic status in this case may well be the fact they have seizures and have a limited ability to work and are often more dependent on state assistance and disability support,” Dr. Lado said.
He also referred to the “drift down hypothesis” of chronic disease. “If you have epilepsy and are born into a middle-class family, chances are you will be on disability and can’t work, so you probably have a lower socioeconomic status than your family did as you grew up.”
Dr. Lado noted how “extremely common” mood disorders are in this population and that certain pain syndromes “tracked with those mood disorders.”
“We know mood disorders are more prevalent in people with epilepsy, and now we see that pain-related problems – headache and back pain – are more prevalent in people with epilepsy,” he said.
The data showing “downstream effects of the mood disorders,” from epilepsy to mood disorders to pain disorders, was “very interesting,” Dr. Lado said.
The study was funded by the Centers for Disease Control and Prevention and the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Mr. Bensken has reported receiving research support for this work from the NIH.
A version of this article first appeared on Medscape.com.
, new research shows. Investigators also found racial and ethnic disparities in comorbidity prevalence.
“Our study identified that people with epilepsy have complex health care needs that extend well beyond their epilepsy,” said co-investigator Wyatt P. Bensken, a PhD candidate in the Department of Population and Quantitative Health Sciences at Case Western Reserve University, Cleveland.
The findings were presented at the annual meeting of the American Epilepsy Society.
A vulnerable population
Researchers identified individuals with epilepsy using Medicaid claims from 2010 to 2014. Mr. Bensken noted that the approximately one-third of patients with epilepsy covered by Medicaid represent “the most vulnerable” population with the disorder because they may not be working and often have other disabilities.
Based on an algorithm that puts diagnostic codes into clinically meaningful categories, the investigators focused on 190 conditions.
“A strength of the study was that we were able to cast such a broad net” to capture conditions, Mr. Bensken said.
Anxiety and mood disorders were originally in separate categories but were grouped together “after recognizing that those who had one pretty much had the other,” he added.
The researchers used a machine learning technique known as association rule mining (ARM) to uncover frequently occurring conditions and combinations of conditions. This same statistical technique is used by companies such as Amazon to determine future purchases based on articles people have bought.
Among 81,963 patients with epilepsy, the most common conditions were anxiety and mood disorders (46.5%). These were followed by hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache including migraine (29.5%). Urinary tract infections (UTIs) were experienced by 22.8% of the sample.
The rate of anxiety and mood disorders was not unexpected, “but I was surprised to see hypertension so high on the list,” said Mr. Bensken. He noted there is also increasing evidence pointing to a cardiovascular-epilepsy connection.
What should neurologists do?
The study also highlights the relatively high rate of back problems, which are not usually considered a comorbidity in patients with epilepsy, Mr. Bensken said. “Back problems likely greatly impact a patient’s quality of life, and seeing them so high on the list makes me wonder if neurologists or epileptologists or primary care doctors are even asking about back pain and how that might impact the ability to function day to day,” he added.
How do these rates compare with the general population? From other studies, the estimated prevalence for anxiety and mood disorders is 20%-30%, compared with almost 50% of the current sample, said Mr. Bensken.
In addition, the rate of hypertension in the study’s epilepsy population was about 7% higher than the general population, and the rate of UTIs was about 12% higher, he reported.
When examining combinations of conditions, anxiety and mood disorders continued to have an “outsized” prevalence, appearing in nearly every combination, the investigators noted.
Almost a quarter (24.7%) of participants had back problems plus anxiety and a mood disorder, and about 15% had headaches and back problems as well as anxiety and a mood disorder.
“That’s a non-negligible amount of the population that have not just one or two things going on but three and four,” said Mr. Bensken.
These new results underscore how complex these patients can be and the need to integrate medical care among different specialties, he noted.
“We don’t believe it’s the neurologist’s job to also manage the hypertension, but being aware of how prevalent hypertension may be and working with the primary care doctor, or at least checking in with the patient and asking if they’re managing their hypertension, is a real priority,” he said.
Researchers also used the ARM system to identify racial disparities, “which have been largely understudied in the epilepsy context,” said Mr. Bensken.
American Indians and Alaskan Natives had a substantially higher prevalence of developmental disabilities, while Black participants had a higher prevalence of hypertension.
One of the study’s themes was that disparities were not uniform, Mr. Bensken noted. “It wasn’t that in every condition the prevalence was lowest for White individuals and highest for everybody else,” he said.
These results point to the need for a larger study to examine the cultural context of these subgroups and such things as structural racism that might drive disparities, he added.
When researchers examined combinations of comorbidities in individuals in the top quartile of hospitalizations and emergency department visits, they found high users had a much higher disease burden, with 75.8% having anxiety or a mood disorder.
The study highlights that patients with epilepsy on Medicaid are “a high priority population,” said Mr. Bensken.
‘Drift down hypothesis’
Commenting on the findings, Fred A. Lado, MD, PhD, director of epilepsy at Northwell Health Eastern and Central Regions, said the increased incidence of comorbidities in patients of low socioeconomic status was not surprising.
“The interesting data here is that we see an even higher incidence among people with epilepsy,” said Dr. Lado, who was not involved with the research.
The study shows how epilepsy exacerbates the effects of low socioeconomic status, he added.
“One of the determinants of socioeconomic status in this case may well be the fact they have seizures and have a limited ability to work and are often more dependent on state assistance and disability support,” Dr. Lado said.
He also referred to the “drift down hypothesis” of chronic disease. “If you have epilepsy and are born into a middle-class family, chances are you will be on disability and can’t work, so you probably have a lower socioeconomic status than your family did as you grew up.”
Dr. Lado noted how “extremely common” mood disorders are in this population and that certain pain syndromes “tracked with those mood disorders.”
“We know mood disorders are more prevalent in people with epilepsy, and now we see that pain-related problems – headache and back pain – are more prevalent in people with epilepsy,” he said.
The data showing “downstream effects of the mood disorders,” from epilepsy to mood disorders to pain disorders, was “very interesting,” Dr. Lado said.
The study was funded by the Centers for Disease Control and Prevention and the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Mr. Bensken has reported receiving research support for this work from the NIH.
A version of this article first appeared on Medscape.com.
From AES 2021
Boom in sports betting spurs new guidance on gambling disorder
Amid growing concerns about the impact of increased legalized online sports gambling, the American Psychiatric Association has issued an updated guide on gambling disorder.
The guide provides expert guidance based on current research and provides information on the etiology, psychopathology, neurobiology, and treatment of the disorder.
“For doctors who might think of gambling as either innocuous behavior or simply equivalent to, say, an alcohol problem, this guide not only shows the complexity and seriousness of gambling disorder but also evidence-based treatments that may help people actually get better,” the guide’s coeditor, Jon E. Grant, MD, MPH, JD, professor of psychiatry at the University of Chicago, said in an interview.
Online sports betting is booming. “It has really taken off” in recent years and is now a multibillion dollar industry worldwide, Dr. Grant added.
A recent CBS News report highlights a record volume of legally placed online sports bets during the first week of this year’s NFL season. All told, 26 states now have legalized sports betting.
said Dr. Grant. “They realized they could stay home, stay safe, and still gamble, so there was an uptick in that movement.”
However, the popularity of online gambling is also a sign of the times. “A whole generation of young adults have been raised on the Internet. A lot of companies realize this is not a market that would ever go to a land-based casino, so they essentially took their product to the young people,” said Dr. Grant.
Gambling meets technology
In addition to football, online gamblers can bet on other sports, including horse racing, or participate in “fantasy” sports where users assemble virtual teams of stand-ins for real professional players. There are also online casinos where users can play such things as blackjack and roulette.
The new guide devotes a chapter to online gambling and the complex interplay between gambling and technology. It highlights the growth of interactive platforms, the role of new player experiences and reward structures, and the integration into other online activities, such as social media.
Other chapters explore the interface between gambling and the legal system and differences in gender and between age groups.
There is also information on advances in treatments. Although there are no Food and Drug Administration–approved drugs for gambling disorder, new evidence supports the use of certain agents for this disorder, said Dr. Grant.
These include naltrexone, which has long been used for alcohol and drug addiction, and over-the-counter N-acetylcysteine (NAC), an amino acid that affects the reward system in the brain and has been used for cocaine and marijuana addiction.
Research also suggests that brief-format cognitive-behavioral therapy may be effective for gambling disorder, said Dr. Grant.
An estimated 1% of the population has such a disorder, which involves repeated, problem gambling with sufferers struggling to control their gambling behavior. Gambling disorder is associated with decreased self-esteem, comorbid substance abuse disorders, financial and legal difficulties, relationship and family stress, and suicidality.
Early intervention is key
Most gamblers don’t have a diagnosable disorder and can participate in the pastime without any long-term harm. However, some will show signs of problem gambling, Dr. Grant noted.
“We believe that’s where interventions may have an even bigger impact,” said Dr. Grant. “We want to get people early on in the illness.” He added that gambling “runs along a continuum” from simply dabbling to serious addiction.
Whereas previous versions of the DSM put gambling in an impulse control category, the latest version – DSM-5 – recognizes gambling as an addiction alongside substances.
“That shows greater awareness of the biological connection to substance addiction,” said Dr. Grant. “It’s important for clinicians who are screening substance use disorder folks to make sure they include gambling in that screening.”
The guide includes information on available screening and assessment instruments for diagnosing gambling disorder and for monitoring symptom changes.
Many clinicians may be unaware of the personal and social consequences of gambling disorder and its implications for public health. The new guide provides a detailed look at the effects of gambling on society and families, as well as on individual health and well-being.
A version of this article first appeared on Medscape.com.
Amid growing concerns about the impact of increased legalized online sports gambling, the American Psychiatric Association has issued an updated guide on gambling disorder.
The guide provides expert guidance based on current research and provides information on the etiology, psychopathology, neurobiology, and treatment of the disorder.
“For doctors who might think of gambling as either innocuous behavior or simply equivalent to, say, an alcohol problem, this guide not only shows the complexity and seriousness of gambling disorder but also evidence-based treatments that may help people actually get better,” the guide’s coeditor, Jon E. Grant, MD, MPH, JD, professor of psychiatry at the University of Chicago, said in an interview.
Online sports betting is booming. “It has really taken off” in recent years and is now a multibillion dollar industry worldwide, Dr. Grant added.
A recent CBS News report highlights a record volume of legally placed online sports bets during the first week of this year’s NFL season. All told, 26 states now have legalized sports betting.
said Dr. Grant. “They realized they could stay home, stay safe, and still gamble, so there was an uptick in that movement.”
However, the popularity of online gambling is also a sign of the times. “A whole generation of young adults have been raised on the Internet. A lot of companies realize this is not a market that would ever go to a land-based casino, so they essentially took their product to the young people,” said Dr. Grant.
Gambling meets technology
In addition to football, online gamblers can bet on other sports, including horse racing, or participate in “fantasy” sports where users assemble virtual teams of stand-ins for real professional players. There are also online casinos where users can play such things as blackjack and roulette.
The new guide devotes a chapter to online gambling and the complex interplay between gambling and technology. It highlights the growth of interactive platforms, the role of new player experiences and reward structures, and the integration into other online activities, such as social media.
Other chapters explore the interface between gambling and the legal system and differences in gender and between age groups.
There is also information on advances in treatments. Although there are no Food and Drug Administration–approved drugs for gambling disorder, new evidence supports the use of certain agents for this disorder, said Dr. Grant.
These include naltrexone, which has long been used for alcohol and drug addiction, and over-the-counter N-acetylcysteine (NAC), an amino acid that affects the reward system in the brain and has been used for cocaine and marijuana addiction.
Research also suggests that brief-format cognitive-behavioral therapy may be effective for gambling disorder, said Dr. Grant.
An estimated 1% of the population has such a disorder, which involves repeated, problem gambling with sufferers struggling to control their gambling behavior. Gambling disorder is associated with decreased self-esteem, comorbid substance abuse disorders, financial and legal difficulties, relationship and family stress, and suicidality.
Early intervention is key
Most gamblers don’t have a diagnosable disorder and can participate in the pastime without any long-term harm. However, some will show signs of problem gambling, Dr. Grant noted.
“We believe that’s where interventions may have an even bigger impact,” said Dr. Grant. “We want to get people early on in the illness.” He added that gambling “runs along a continuum” from simply dabbling to serious addiction.
Whereas previous versions of the DSM put gambling in an impulse control category, the latest version – DSM-5 – recognizes gambling as an addiction alongside substances.
“That shows greater awareness of the biological connection to substance addiction,” said Dr. Grant. “It’s important for clinicians who are screening substance use disorder folks to make sure they include gambling in that screening.”
The guide includes information on available screening and assessment instruments for diagnosing gambling disorder and for monitoring symptom changes.
Many clinicians may be unaware of the personal and social consequences of gambling disorder and its implications for public health. The new guide provides a detailed look at the effects of gambling on society and families, as well as on individual health and well-being.
A version of this article first appeared on Medscape.com.
Amid growing concerns about the impact of increased legalized online sports gambling, the American Psychiatric Association has issued an updated guide on gambling disorder.
The guide provides expert guidance based on current research and provides information on the etiology, psychopathology, neurobiology, and treatment of the disorder.
“For doctors who might think of gambling as either innocuous behavior or simply equivalent to, say, an alcohol problem, this guide not only shows the complexity and seriousness of gambling disorder but also evidence-based treatments that may help people actually get better,” the guide’s coeditor, Jon E. Grant, MD, MPH, JD, professor of psychiatry at the University of Chicago, said in an interview.
Online sports betting is booming. “It has really taken off” in recent years and is now a multibillion dollar industry worldwide, Dr. Grant added.
A recent CBS News report highlights a record volume of legally placed online sports bets during the first week of this year’s NFL season. All told, 26 states now have legalized sports betting.
said Dr. Grant. “They realized they could stay home, stay safe, and still gamble, so there was an uptick in that movement.”
However, the popularity of online gambling is also a sign of the times. “A whole generation of young adults have been raised on the Internet. A lot of companies realize this is not a market that would ever go to a land-based casino, so they essentially took their product to the young people,” said Dr. Grant.
Gambling meets technology
In addition to football, online gamblers can bet on other sports, including horse racing, or participate in “fantasy” sports where users assemble virtual teams of stand-ins for real professional players. There are also online casinos where users can play such things as blackjack and roulette.
The new guide devotes a chapter to online gambling and the complex interplay between gambling and technology. It highlights the growth of interactive platforms, the role of new player experiences and reward structures, and the integration into other online activities, such as social media.
Other chapters explore the interface between gambling and the legal system and differences in gender and between age groups.
There is also information on advances in treatments. Although there are no Food and Drug Administration–approved drugs for gambling disorder, new evidence supports the use of certain agents for this disorder, said Dr. Grant.
These include naltrexone, which has long been used for alcohol and drug addiction, and over-the-counter N-acetylcysteine (NAC), an amino acid that affects the reward system in the brain and has been used for cocaine and marijuana addiction.
Research also suggests that brief-format cognitive-behavioral therapy may be effective for gambling disorder, said Dr. Grant.
An estimated 1% of the population has such a disorder, which involves repeated, problem gambling with sufferers struggling to control their gambling behavior. Gambling disorder is associated with decreased self-esteem, comorbid substance abuse disorders, financial and legal difficulties, relationship and family stress, and suicidality.
Early intervention is key
Most gamblers don’t have a diagnosable disorder and can participate in the pastime without any long-term harm. However, some will show signs of problem gambling, Dr. Grant noted.
“We believe that’s where interventions may have an even bigger impact,” said Dr. Grant. “We want to get people early on in the illness.” He added that gambling “runs along a continuum” from simply dabbling to serious addiction.
Whereas previous versions of the DSM put gambling in an impulse control category, the latest version – DSM-5 – recognizes gambling as an addiction alongside substances.
“That shows greater awareness of the biological connection to substance addiction,” said Dr. Grant. “It’s important for clinicians who are screening substance use disorder folks to make sure they include gambling in that screening.”
The guide includes information on available screening and assessment instruments for diagnosing gambling disorder and for monitoring symptom changes.
Many clinicians may be unaware of the personal and social consequences of gambling disorder and its implications for public health. The new guide provides a detailed look at the effects of gambling on society and families, as well as on individual health and well-being.
A version of this article first appeared on Medscape.com.
CBT prevents depression in up to 50% of patients with insomnia
Cognitive-behavioral therapy (CBT) is linked to a significantly reduced risk of depression in patients with insomnia, new research shows.
Insomnia affects over 50% of older adults, and insomnia contributes to a twofold greater risk for major depression, investigators noted.
“We show that by treating insomnia with a simple behavioral approach called Cognitive Behavioral Therapy for Insomnia, or CBT-I, you can reduce the likelihood of developing depression by over 50%,” lead author Michael R. Irwin, MD, Cousins Distinguished Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, said in an interview.
The study is unique in that the treatment “is not just reducing depression, it’s preventing depression,” Dr. Irwin added.
The findings were published online Nov. 24 in JAMA Psychiatry.
Primary outcome met
within the previous 12 months.
All were randomly assigned to receive either CBT-I or Sleep Education Therapy (SET).
CBT-I is a first-line treatment for insomnia that includes five components: cognitive therapy targeting dysfunctional thoughts about sleep, stimulus control, sleep restriction, sleep hygiene, and relaxation.
SET provides information on behavioral and environmental factors contributing to poor sleep. While sleep education provides tips on improving sleep, CBT-I helps patients implement those changes and behaviors, Dr. Irwin noted.
Both interventions were delivered by trained personnel in weekly 120-minute group sessions for 2 months, consistent with the format and duration of most CBT-I trials.
The primary outcome was time to incident or recurrent major depressive disorder as diagnosed by the Structured Clinical Interview of the DSM-5 every 6 months during 36 months of follow-up. A monthly Patient Health Questionnaire 9 (PHQ-9) was used to screen for depressive symptoms.
Results showed depression occurred in 12.2% of the CBT-I group versus 25.9% of the SET group. The hazard ratio (HR) for depression in the CBT-I group compared with the SET group was 0.51 (95% confidence interval, 0.29-0.88; P = .02). The number needed to treat to prevent incident or recurrent depression was 7.3.
After adjustment for factors affecting depression risk such as sex, educational level, income, comorbidity, and history of depression, the HR for depression in the CBT-I group versus the SET group was 0.45 (95% CI, 0.23-0.86; P = .02).
Treatment with CBT-I yielded an annual 4.1% incidence of depression, which is similar to the population rate and half the rate in SET, which was 8.6%.
‘Remission is key’
The secondary outcome was sustained remission of insomnia disorder. The investigators found a greater proportion of the CBT-I group than the SET group achieved remission after treatment (50.7% vs. 37.7%; 95% CI, 0.10-0.93; P = .02).
“Remission is really key to the benefits that we’re seeing,” said Dr. Irwin.
Inflammation may explain why insomnia raises the risk for depression, he noted. “We know sleep disturbance can lead to inflammation and we also know inflammation can produce depression,” Dr. Irwin said.
It is also possible insomnia leads to an impaired pleasure or reward system, which is linked to depression, he added.
The authors noted that because insomnia is associated with suicidal ideation and dementia, CBT-I may reduce risk for suicide or cognitive decline.
While 8-week CBT-I treatments are readily available, “unfortunately, most clinicians will prescribe medications,” said Dr. Irwin. He noted that in older adults, drugs are linked to adverse events such as falls and cognitive problems.
These new results “really argue that psychology and psychiatry need to be fully integrated into what we call collaborative care models,” Dr. Irwin said.
There were no adverse events during treatment, and none of the serious events that occurred during follow-up were attributed to the trial.
Convincing argument?
Commenting on the findings for this news organization, Philip R. Muskin, MD, professor of psychiatry at Columbia University Irving Medical Center, New York, said the study was “nicely written” and the authors put forward “a very convincing argument” for CBT-I to prevent depression.
“It’s eye opening in that it’s a robust study; it’s carefully done; subjects were followed for a long period of time, and it’s an accessible treatment,” said Dr. Muskin, who was not involved with the research.
The study also shows “it’s possible to intervene in something we know is a risk factor in elderly people,” he added. “We think of older people as being less malleable to these kinds of things, but they’re not. They clearly participated, and there wasn’t a huge dropout rate.”
Dr. Muskin noted that less than half of the older participants were married or had a partner. He would have liked more information on this status because being widowed or divorced, as well as when this life change occurred, could affect vulnerability to depression.
The authors of an accompanying editorial called the study “seminal,” and noted that insomnia treatment possibly preventing depressive disorders is a “major finding.”
Proving this preventive strategy is effective in older adults will be important because “insomnia and depression are highly prevalent in this population and the uptake of both preventive and treatment services is low,” wrote Pim Cuijpers, PhD, department of clinical, neuro, and developmental psychology, Amsterdam Public Health Research Institute, and Charles F. Reynolds III, MD, department of psychiatry, University of Pittsburgh.
If the reduced rates of depression observed in the study could be generalized to the total population with insomnia, “the incidence of major depression could be reduced considerably,” they wrote.
“Can we prevent depression through interventions aimed at procrastination in college students, interventions aimed at perfectionism in perinatal women, stress management training for employees, social skills training in adolescents?” they asked.
This approach to preventing depressive disorders “offers all kinds of new opportunities to develop and test indirect interventions” for problems that are significantly associated with the onset of depression, the editorialists wrote.
The study was funded by a grant from the National Institute on Aging to the University of California, which partially supported the authors’ salaries. Dr. Irwin, Dr. Muskin, and Dr. Cuijpers have reported no relevant financial relationships. Dr. Reynolds reported being coinventor of the Pittsburgh Sleep Quality Index, for which he receives royalties.
A version of this article first appeared on Medscape.com.
Cognitive-behavioral therapy (CBT) is linked to a significantly reduced risk of depression in patients with insomnia, new research shows.
Insomnia affects over 50% of older adults, and insomnia contributes to a twofold greater risk for major depression, investigators noted.
“We show that by treating insomnia with a simple behavioral approach called Cognitive Behavioral Therapy for Insomnia, or CBT-I, you can reduce the likelihood of developing depression by over 50%,” lead author Michael R. Irwin, MD, Cousins Distinguished Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, said in an interview.
The study is unique in that the treatment “is not just reducing depression, it’s preventing depression,” Dr. Irwin added.
The findings were published online Nov. 24 in JAMA Psychiatry.
Primary outcome met
within the previous 12 months.
All were randomly assigned to receive either CBT-I or Sleep Education Therapy (SET).
CBT-I is a first-line treatment for insomnia that includes five components: cognitive therapy targeting dysfunctional thoughts about sleep, stimulus control, sleep restriction, sleep hygiene, and relaxation.
SET provides information on behavioral and environmental factors contributing to poor sleep. While sleep education provides tips on improving sleep, CBT-I helps patients implement those changes and behaviors, Dr. Irwin noted.
Both interventions were delivered by trained personnel in weekly 120-minute group sessions for 2 months, consistent with the format and duration of most CBT-I trials.
The primary outcome was time to incident or recurrent major depressive disorder as diagnosed by the Structured Clinical Interview of the DSM-5 every 6 months during 36 months of follow-up. A monthly Patient Health Questionnaire 9 (PHQ-9) was used to screen for depressive symptoms.
Results showed depression occurred in 12.2% of the CBT-I group versus 25.9% of the SET group. The hazard ratio (HR) for depression in the CBT-I group compared with the SET group was 0.51 (95% confidence interval, 0.29-0.88; P = .02). The number needed to treat to prevent incident or recurrent depression was 7.3.
After adjustment for factors affecting depression risk such as sex, educational level, income, comorbidity, and history of depression, the HR for depression in the CBT-I group versus the SET group was 0.45 (95% CI, 0.23-0.86; P = .02).
Treatment with CBT-I yielded an annual 4.1% incidence of depression, which is similar to the population rate and half the rate in SET, which was 8.6%.
‘Remission is key’
The secondary outcome was sustained remission of insomnia disorder. The investigators found a greater proportion of the CBT-I group than the SET group achieved remission after treatment (50.7% vs. 37.7%; 95% CI, 0.10-0.93; P = .02).
“Remission is really key to the benefits that we’re seeing,” said Dr. Irwin.
Inflammation may explain why insomnia raises the risk for depression, he noted. “We know sleep disturbance can lead to inflammation and we also know inflammation can produce depression,” Dr. Irwin said.
It is also possible insomnia leads to an impaired pleasure or reward system, which is linked to depression, he added.
The authors noted that because insomnia is associated with suicidal ideation and dementia, CBT-I may reduce risk for suicide or cognitive decline.
While 8-week CBT-I treatments are readily available, “unfortunately, most clinicians will prescribe medications,” said Dr. Irwin. He noted that in older adults, drugs are linked to adverse events such as falls and cognitive problems.
These new results “really argue that psychology and psychiatry need to be fully integrated into what we call collaborative care models,” Dr. Irwin said.
There were no adverse events during treatment, and none of the serious events that occurred during follow-up were attributed to the trial.
Convincing argument?
Commenting on the findings for this news organization, Philip R. Muskin, MD, professor of psychiatry at Columbia University Irving Medical Center, New York, said the study was “nicely written” and the authors put forward “a very convincing argument” for CBT-I to prevent depression.
“It’s eye opening in that it’s a robust study; it’s carefully done; subjects were followed for a long period of time, and it’s an accessible treatment,” said Dr. Muskin, who was not involved with the research.
The study also shows “it’s possible to intervene in something we know is a risk factor in elderly people,” he added. “We think of older people as being less malleable to these kinds of things, but they’re not. They clearly participated, and there wasn’t a huge dropout rate.”
Dr. Muskin noted that less than half of the older participants were married or had a partner. He would have liked more information on this status because being widowed or divorced, as well as when this life change occurred, could affect vulnerability to depression.
The authors of an accompanying editorial called the study “seminal,” and noted that insomnia treatment possibly preventing depressive disorders is a “major finding.”
Proving this preventive strategy is effective in older adults will be important because “insomnia and depression are highly prevalent in this population and the uptake of both preventive and treatment services is low,” wrote Pim Cuijpers, PhD, department of clinical, neuro, and developmental psychology, Amsterdam Public Health Research Institute, and Charles F. Reynolds III, MD, department of psychiatry, University of Pittsburgh.
If the reduced rates of depression observed in the study could be generalized to the total population with insomnia, “the incidence of major depression could be reduced considerably,” they wrote.
“Can we prevent depression through interventions aimed at procrastination in college students, interventions aimed at perfectionism in perinatal women, stress management training for employees, social skills training in adolescents?” they asked.
This approach to preventing depressive disorders “offers all kinds of new opportunities to develop and test indirect interventions” for problems that are significantly associated with the onset of depression, the editorialists wrote.
The study was funded by a grant from the National Institute on Aging to the University of California, which partially supported the authors’ salaries. Dr. Irwin, Dr. Muskin, and Dr. Cuijpers have reported no relevant financial relationships. Dr. Reynolds reported being coinventor of the Pittsburgh Sleep Quality Index, for which he receives royalties.
A version of this article first appeared on Medscape.com.
Cognitive-behavioral therapy (CBT) is linked to a significantly reduced risk of depression in patients with insomnia, new research shows.
Insomnia affects over 50% of older adults, and insomnia contributes to a twofold greater risk for major depression, investigators noted.
“We show that by treating insomnia with a simple behavioral approach called Cognitive Behavioral Therapy for Insomnia, or CBT-I, you can reduce the likelihood of developing depression by over 50%,” lead author Michael R. Irwin, MD, Cousins Distinguished Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, said in an interview.
The study is unique in that the treatment “is not just reducing depression, it’s preventing depression,” Dr. Irwin added.
The findings were published online Nov. 24 in JAMA Psychiatry.
Primary outcome met
within the previous 12 months.
All were randomly assigned to receive either CBT-I or Sleep Education Therapy (SET).
CBT-I is a first-line treatment for insomnia that includes five components: cognitive therapy targeting dysfunctional thoughts about sleep, stimulus control, sleep restriction, sleep hygiene, and relaxation.
SET provides information on behavioral and environmental factors contributing to poor sleep. While sleep education provides tips on improving sleep, CBT-I helps patients implement those changes and behaviors, Dr. Irwin noted.
Both interventions were delivered by trained personnel in weekly 120-minute group sessions for 2 months, consistent with the format and duration of most CBT-I trials.
The primary outcome was time to incident or recurrent major depressive disorder as diagnosed by the Structured Clinical Interview of the DSM-5 every 6 months during 36 months of follow-up. A monthly Patient Health Questionnaire 9 (PHQ-9) was used to screen for depressive symptoms.
Results showed depression occurred in 12.2% of the CBT-I group versus 25.9% of the SET group. The hazard ratio (HR) for depression in the CBT-I group compared with the SET group was 0.51 (95% confidence interval, 0.29-0.88; P = .02). The number needed to treat to prevent incident or recurrent depression was 7.3.
After adjustment for factors affecting depression risk such as sex, educational level, income, comorbidity, and history of depression, the HR for depression in the CBT-I group versus the SET group was 0.45 (95% CI, 0.23-0.86; P = .02).
Treatment with CBT-I yielded an annual 4.1% incidence of depression, which is similar to the population rate and half the rate in SET, which was 8.6%.
‘Remission is key’
The secondary outcome was sustained remission of insomnia disorder. The investigators found a greater proportion of the CBT-I group than the SET group achieved remission after treatment (50.7% vs. 37.7%; 95% CI, 0.10-0.93; P = .02).
“Remission is really key to the benefits that we’re seeing,” said Dr. Irwin.
Inflammation may explain why insomnia raises the risk for depression, he noted. “We know sleep disturbance can lead to inflammation and we also know inflammation can produce depression,” Dr. Irwin said.
It is also possible insomnia leads to an impaired pleasure or reward system, which is linked to depression, he added.
The authors noted that because insomnia is associated with suicidal ideation and dementia, CBT-I may reduce risk for suicide or cognitive decline.
While 8-week CBT-I treatments are readily available, “unfortunately, most clinicians will prescribe medications,” said Dr. Irwin. He noted that in older adults, drugs are linked to adverse events such as falls and cognitive problems.
These new results “really argue that psychology and psychiatry need to be fully integrated into what we call collaborative care models,” Dr. Irwin said.
There were no adverse events during treatment, and none of the serious events that occurred during follow-up were attributed to the trial.
Convincing argument?
Commenting on the findings for this news organization, Philip R. Muskin, MD, professor of psychiatry at Columbia University Irving Medical Center, New York, said the study was “nicely written” and the authors put forward “a very convincing argument” for CBT-I to prevent depression.
“It’s eye opening in that it’s a robust study; it’s carefully done; subjects were followed for a long period of time, and it’s an accessible treatment,” said Dr. Muskin, who was not involved with the research.
The study also shows “it’s possible to intervene in something we know is a risk factor in elderly people,” he added. “We think of older people as being less malleable to these kinds of things, but they’re not. They clearly participated, and there wasn’t a huge dropout rate.”
Dr. Muskin noted that less than half of the older participants were married or had a partner. He would have liked more information on this status because being widowed or divorced, as well as when this life change occurred, could affect vulnerability to depression.
The authors of an accompanying editorial called the study “seminal,” and noted that insomnia treatment possibly preventing depressive disorders is a “major finding.”
Proving this preventive strategy is effective in older adults will be important because “insomnia and depression are highly prevalent in this population and the uptake of both preventive and treatment services is low,” wrote Pim Cuijpers, PhD, department of clinical, neuro, and developmental psychology, Amsterdam Public Health Research Institute, and Charles F. Reynolds III, MD, department of psychiatry, University of Pittsburgh.
If the reduced rates of depression observed in the study could be generalized to the total population with insomnia, “the incidence of major depression could be reduced considerably,” they wrote.
“Can we prevent depression through interventions aimed at procrastination in college students, interventions aimed at perfectionism in perinatal women, stress management training for employees, social skills training in adolescents?” they asked.
This approach to preventing depressive disorders “offers all kinds of new opportunities to develop and test indirect interventions” for problems that are significantly associated with the onset of depression, the editorialists wrote.
The study was funded by a grant from the National Institute on Aging to the University of California, which partially supported the authors’ salaries. Dr. Irwin, Dr. Muskin, and Dr. Cuijpers have reported no relevant financial relationships. Dr. Reynolds reported being coinventor of the Pittsburgh Sleep Quality Index, for which he receives royalties.
A version of this article first appeared on Medscape.com.
FROM JAMA PSYCHIATRY