Psychiatry News

Risperidone: Better Mania Control in Kids, but at a Price
Twice as many children and adolescents with bipolar I mania responded to first-line treatment with risperidone than with lithium or divalproex, data from a randomized trial showed. Risperidone treatment led to a response rate of 68.5% as compared with 35.6% for lithium and 24.0% with divalproex.  However, the improved response rate came at a cost of significantly more metabolic disturbances in the risperidone group, investigators reported online in Archives of General Psychiatry.

A Look at Updated ADHD Guidelines
For the first time in 10 years, the American Academy of Pediatrics (AAP) has issued an updated set of guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD).[1] The update was recently released at the AAP's 2011National Conference & Exhibition and includes a number of important revisions. The following slideshow summarizes the key components and action statements included in the new recommendations.

Treating Prodromal Symptoms of Psychosis
What are the pros and cons of treating subtreshold high-risk psychotic symptoms? Does early intervention help or hinder patient outcomes? Can conversion to psychosis be delayed or prevented? Dr Hurford reviews some of the latest study findings on the pharmacological treatment of prodromal psychosis.

Treatment of Suicide Attempters With Bipolar Disorder
Bipolar disorder is associated with high risk for suicidal acts. Observational studies suggest a protective effect of lithium against suicidal behavior. However, testing this effect in randomized clinical trials is logistically and ethically challenging. The authors tested the hypothesis that lithium offers bipolar patients with a history of suicide attempt greater protection against suicidal behavior compared to valproate. Patients with bipolar disorder and past suicide attempts (N=98) were randomly assigned to treatment with lithium or valproate, plus adjunctive medications as indicated, in a double-blind 2.5-year trial.   Despite the high frequency of suicide events during the study, this randomized controlled trial detected no difference between lithium and valproate in time to suicide attempt or suicide event in a sample of suicide attempters with bipolar disorder. However, smaller clinically significant differences between the two drugs were not ruled out.

Lithium carbonate no help in amyotrophic lateral sclerosis
The authors of this article used a historical placebo control design to determine whether lithium carbonate slows progression of amyotrophic lateral sclerosis (ALS). A phase II trial was conducted at 10 sites in the Western ALS Study Group using similar dosages (300–450 mg/day), target blood levels (0.3–0.8 mEq/L), outcome measures, and trial duration (13 months) as the positive trial. Overall it was shown that the lack of therapeutic benefit and safety concerns, taken together with similar results from 2 other recent trials, weighs against the use of lithium carbonate in patients with ALS. The absence of drift over time and the availability of a large database of patients for selecting a matched historical control group suggest that use of historical controls may result in more efficient phase II trials for screening putative ALS therapeutic agents.

High-Dose Citalopram Tied to Heart Risks
The antidepressant citalopram should not be used at doses greater than 40 mg per day because such doses can lead to prolongation of the QT interval, the Food and Drug Administration announced Aug. 24 in a drug safety communication. Further, the drug should not be prescribed to patients with congenital long QT syndrome, and extra precautions should be taken for patients with other underlying heart conditions, the agency said. Studies do not show a benefit in the treatment of depression at doses of the selective serotonin reuptake inhibitor higher than 40 mg/day. Previously, the citalopram (Celexa) label stated that some patients might require a dose of 60 mg/day.

J&J, Lilly drugs found among best for manic episodes
Antipsychotics are far more effective than mood stabilizers in tackling acute manic episodes, researchers found, and Eli Lilly's Zyprexa, Johnson & Johnson's Risperdal and generic haloperidol outperform the rest. In a study published in the Lancet medical journal on Wednesday, researchers from Britain and Italy ranked antipsychotic drugs according to their effectiveness and said that since current treatment guidelines don't differentiate between the drugs, their findings could offer useful guidance for doctors. Cipriani's team analyzed the results from 68 randomized controlled trials involving more than 16,000 participants from January 1980 to November 2010 to compare the most common drugs used to treat acute mania in adults. They found that haloperidol, Zyprexa and Risperdal were the most effective antimanic drugs and said they "should be considered as among the best of the available options for the treatment of manic episodes."

Panic Attacks Don't Come Out of the Blue Afterall
 Panic attacks do not come "out of the blue" but are preceded by physiological changes similar to those that precede seizures, stroke, and even manic episodes, a new study suggests. "There is reason to believe that waves of physiological instability occur for a substantial period of time before the attack is reported by patients," Alicia E. Meuret, PhD, an assistant professor from the Department of Psychology, Southern Methodist University, in Dallas, Texas, who led the study, told Medscape Medical News. The finding may have relevance for other medical disorders where symptoms seemingly happen "out of the blue," such as seizures, strokes, and even manic episodes, the researchers note. There is speculation that panic attacks are triggered by marked changes in physiology, in particular breathing, Dr. Meuret explained. However, until now, very little is known on the physiological functioning of those with panic attacks outside the laboratory.

Antidepressant Use During Pregnancy May Increase Childhood Autism Spectrum Disorders
The prevalence of autism spectrum disorders (ASDs) has increased over recent years. Use of antidepressant medications during pregnancy also shows a secular increase in recent decades, prompting concerns that prenatal exposure may contribute to increased risk of ASD. This article sought to systematically evaluate whether prenatal exposure to antidepressant medications is associated with increased risk of ASD. Although the number of children exposed prenatally to selective serotonin reuptake inhibitors in this population was low, results suggest that exposure, especially during the first trimester, may modestly increase the risk of ASD. The potential risk associated with exposure must be balanced with the risk to the mother or fetus of untreated mental health disorders. Further studies are needed to replicate and extend these findings.

A Nationwide Cohort Study of Oral and Depot Antipsychotics After First Hospitalization for Schizophrenia
Data on the effectiveness of antipsychotics in the early phase of schizophrenia are limited. The authors examined the risk of rehospitalization and drug discontinuation in a nationwidecohort of 2,588 consecutive patients hospitalized for the first time with a diagnosis of schizophrenia between 2000 and 2007 in Finland. The authors linked national databases of hospitalization, mortality, and antipsychotic prescriptions and computed hazard ratios, adjusting for the effects of sociodemographic and clinical variables, the temporal sequence of the antipsychotics used, and the choice of the initial antipsychotic for each patient. In Finland, only a minority of patients adhere to their initial antipsychotic during the first 60 days after discharge from their first hospitalization for schizophrenia. Use of depot antipsychotics was associated with a significantly lower risk of rehospitalization than use of oral formulations of the same compounds. Among oral antipsychotics, clozapine and olanzapine were associated with more favorable outcomes. Use of any antipsychotic was associated with lower mortality.

Seasonality patterns in postpartum depression
The authors investigated the possible association between postpartum depressive symptoms and season of delivery. During 1 year, delivering women in the Uppsala University Hospital were asked to participate in the study by filling out 3 postpartum questionnaires containing the Edinburgh Postnatal Depression scale and questions assessing life style, medical history, breastfeeding, and social support. Overall it was found that women delivering during the last quartile of the year had a significantly higher risk for depressive symptoms 6 weeks and 6 months postpartum and would thus benefit from a closer support and follow-up after delivery.

Association Between Bipolar Spectrum Features and Treatment Outcomes in Outpatients With Major Depressive Disorder
It has been suggested that patients with major depressive disorder (MDD) who display pretreatment features suggestive of bipolar disorder or bipolar spectrum features might have poorer treatment outcomes. The authors sought to assess the association between bipolar spectrum features and antidepressant treatment outcome in MDD. Of the 4041 subjects who entered the study, 1198 (30.0%) endorsed at least 1 item on the psychosis scale and 1524 (38.1%) described at least 1 recent maniclike/hypomaniclike symptom. Irritability and psychoticlike symptoms at entry were significantly associated with poorer outcomes across up to 4 treatment levels, as were shorter episodes and some neurovegetative symptoms of depression. However, other indicators of bipolar diathesis including recent maniclike symptoms and family history of bipolar disorder as well as summary measures of bipolar spectrum features were not associated with treatment resistance. Self-reported psychoticlike symptoms were common in a community sample of outpatients with MDD and strongly associated with poorer outcomes. Overall, the data do not support the hypothesis that unrecognized bipolar spectrum illness contributes substantially to antidepressant treatment resistance.

Can Lithium Help Prevent Suicide?
Evidence suggests that lithium can reduce depression severity, aggressiveness, and impulsivity. Does lithium’s protective effect against suicidal behaviors make it a new treatment choice? Many studies consistently support the impression that risks of suicide and of life-threatening attempts are far lower during treatment with lithium (and even with a placebo) than without treatment. The apparent effectiveness of lithium treatment in suicide prevention may be associated with reduction of risk or severity of recurrences of depression or dysphoric-agitated, mixed manic-depressive states, and with reduced impulsivity and aggressiveness in those with mood disorders.18 The antiaggressive effects of lithium have been observed in various populations and settings, including elderly residents in nursing homes; mentally disabled persons; children and adolescents who have hyperactive, hostile, and aggressive behavior; and hyperaggressive prisoners.

Understanding and Overcoming the Myths of Suicide
Myths about suicide abound in the therapeutic setting. They often inhibit the ability of clinicians (and families) to assess the severity and magnitude of a patient’s suicide risk. This special report discusses some of those myths.

Antidepressants in Bipolar Depression: A New Meta-Analysis for an Old Controversy
Critics have noted that meta-analysis, when misused, resembles statistical alchemy, taking the dross of individually negative studies to produce the gold of a positive pooled result.2 This happened with an influential 2004 publication on antidepressants in acute bipolar depression, and it is being slightly rectified with a recently published update of that study.3,4 In both cases, reasonable judgments cannot be made unless we understand how to use, and abuse, meta-analysis.

Increased Mortality Risk in Women With Depression and Diabetes Mellitus
Depression and diabetes mellitus have been associated with an increased risk of all-cause and cardiovascular disease (CVD) mortality. However, data evaluating the joint effects of these 2 conditions on mortality are sparse. This articled evaluated the individual and joint effects of depression and diabetes on all-cause and CVD mortality rate. Overall it was found that depression and diabetes are associated with a significantly increased risk of all-cause and CVD mortality rate. The coexistence of these conditions identifies women atparticularly high risk.

Study Examines Early Indicators Of Criminal Lifestyle
Conduct disorders in preteens are predictive of eventual teenage serious violent and delinquent behavior, according to a new study from the Universite de Montreal. The findings, published in this month's issue of Journal of Child Psychology and Psychiatry, have implications for concerned parents.  Preteens who steal, destroy property, fight and bully are six times as likely to sell illicit drugs, nine times as likely to join a gang, 11 times as likely to carry a weapon and eight times as likely to be arrested as a future teenager, according to principle author, Éric Lacourse, a researcher at the Groupe de recherche sur l'inadaptation psychosociale chez l'enfant (GRIP) at the Université de Montréal. 

Estimated intelligence quotient in anorexia nervosa: a systematic review and meta-analysis of the literature
It has been hypothesised that people with anorexia nervosa have a higher intelligence quotient (IQ) level than the general population. The purpose of this review was to systematically appraise the research into reported IQ levels in people with anorexia nervosa.  This review established that people with anorexia nervosa score 10.8 units and 5.9 units above the average intelligence quotient of the normative population on the National Adult Reading Test and Wechsler Intelligence Scales, respectively. An association was found between Body Mass Index and intelligence quotient, as measured by the National Adult Reading Test. More studies including other eating disorder categories and recovered people are needed to explore important questions regarding the role of the intelligence quotient in treatment response.

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