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In-utero exposure to prescription stimulants is not associated with an increased risk for neurodevelopmental disorders in children. Exposure to amphetamine/dextroamphetamine and methylphenidate in utero is not meaningfully associated with an increased risk for childhood neurodevelopmental disorders (NDDs), according to study results published in JAMA Psychiatry. These findings may help inform treatment for pregnant individuals who depend on prescription stimulants for daily functioning. Stimulant medications cross the placenta and can increase the concentrations of norepinephrine and dopamine, which are known to play an important role in fetal neurodevelopment. However, it is unclear whether amphetamine treatment for pregnant individuals poses a risk for childhood NDDs. Therefore, researchers performed a cohort study using national Medicaid data from 2000 to 2018 and MarketScan data from 2003 to 2020. The researchers identified pregnant individuals who filled prescriptions for amphetamine/dextroamphetamine and methylphenidate in the second half of pregnancy (week 19 to delivery) to assess the association between stimulant use for attention-deficit/hyperactivity disorder (ADHD) during pregnancy and neurodevelopmental outcomes. Children from these pregnancies were monitored from birth until their continuous enrollment ended, they developed a NDD, the study period ended, or they died (whichever came first). The primary outcome of any NDD was defined as a composite of autism spectrum disorder (ASD), ADHD, specific learning disorders, developmental speech or language disorder, developmental coordination disorder, intellectual disability, and behavioral disorder. The analyses included 4,317,502 pregnancies from both the Medicaid and MarketScan cohorts, and pregnant individuals had a mean age of 25.2 (SD, 6.0) and 31.6 (SD, 4.6) years at enrollment, respectively. During the second half of pregnancy, 7065 individuals were exposed to amphetamine/dextroamphetamine and 1123 were exposed to methylphenidate. Upon controlling for confounding variables, exposure to amphetamine/dextroamphetamine was not found to be significantly correlated with neurodevelopmental outcomes. The hazard ratios (HRs) were 0.80 (95% CI, 0.56-1.14) for ASD, 1.07 (95% CI, 0.89-1.28) for ADHD, and 0.91 (95% CI, 0.81-1.02) for any NDD. In the subset of patients with maternal ADHD diagnoses, risk elevation for these outcomes was not evident in either crude or adjusted analyses. Relative to individuals who ceased amphetamine use before pregnancy, the researchers observed no significant associations between amphetamines and ADHD and any NDD, while the adjusted HR for ASD was 1.35 (95% CI, 0.84-2.15) for early exposure and 1.81 (95% CI, 1.04-3.12) for late exposure. Overall, there were no meaningful associations between amphetamine exposure and ADHD and composite NDDs. When examining pregnancies exposed to methylphenidate, initial estimates indicated a 2- to 3-fold increase in ASD, ADHD, and composite NDDs. However, these estimates were greatly reduced after adjusting for confounding factors. The adjusted HRs for exposure during late pregnancy were 1.06 (95% CI, 0.62-1.81) for ASD, 1.43 (95% CI, 1.12-1.82) for ADHD, and 1.15 (95% CI, 0.97-1.36) for NDD overall. The associations were even weaker in analyses that included only mothers with ADHD and those who discontinued methylphenidate use before pregnancy. Study authors concluded, “Given the recent rise in use of stimulant medications for ADHD in adults and during pregnancy, these results are reassuring for patients who depend on these medications throughout pregnancy for control of debilitating ADHD symptoms that interfere with daily functioning.” These study findings may be limited by potential outcome misclassification and substantial attrition due to insurance disenrollment. Additionally, as prescription stimulants for ADHD can be used as needed, evidence of dispensing may not accurately indicate consumption. This article originally appeared on Psychiatry Advisor

A higher risk was seen with increasing somatic symptoms during early to mid adolescence. HealthDay News — Persistent withdrawn symptoms and increasing somatic symptoms during early to mid adolescence are associated with an increased risk for suicidal thoughts in mid adolescence, according to a study published online Jan. 25 in JAMA Network Open. Akito Uno, M.D., from the University of Tokyo, and colleagues assessed which categories and trajectories of psychopathological and behavioral symptoms are associated with suicidal thoughts in adolescence. The analysis included data from three waves of the Tokyo Teen Cohort study (2,780 adolescents) conducted at ages 10, 12, and 16 years from October 2012 to September 2021. The researchers found that 8.2 percent of participants had suicidal thoughts. When adjusting for each symptom trajectory and confounders, adolescents with persistent high withdrawn symptoms (odds ratio, 1.88) and increasing somatic symptoms (odds ratio, 1.97) had a significantly higher risk for suicidal thoughts versus adolescents without these symptoms. For the risk for suicidal thoughts, there was no interaction between these symptom trajectories. “A wide range of people involved in adolescent health should pay attention to the suicidal risk associated with these symptoms and consider the possibility of providing psychosocial support, particularly when the symptoms persist or increase in the longitudinal follow-up,” the authors write. This article originally appeared on Psychiatry Advisor

Single exercise sessions of 30 minutes or less led to small, but significant, improvements in ADHD core symptoms and executive function among adolescents. A single session of exercise had small effect-size improvements in core symptoms and executive function among adolescents with attention-deficit/hyperactivity disorder (ADHD), according to results from a systematic review and meta-analysis published in the Journal of Attention Disorders. In particular, high-intensity interval training, single exercise sessions of 30 minutes or less, and cycling exercises were most effective for symptom improvement. While medications for ADHD are effective in improving attention, hyperactivity, and executive function in ADHD, these therapies can have adverse side effects and recent drug-shortages have left many patients without an effective treatment option. To investigate the utility of exercise interventions for ADHD symptoms, investigators conducted a systematic review and meta-analysis of publication databases from inception through July 2023 for randomized controlled trials (RCTs) or crossover RCTs that included adolescents with ADHD who underwent a single session of exercise intervention (aerobic, resistance, or aerobic + resistance) for ADHD symptom management. The investigators included a total of 13 studies with a pooled sample size of 437 participants, who were primarily boys/men (71.6%) with a mean age range of 10 to 24 years. Core symptoms of ADHD (inattention and impulsivity) were primarily assessed with Conner’s Continuous Performance Test and the Barkley Adult ADHD Rating Scale-Modified, while executive function was evaluated with the Stroop Test and Flanker Task. All single exercise sessions were open chain (eg, swimming, cycling, running), were moderate to vigorous in intensity, and ranged from 10 to 40 minutes in duration. Control groups mainly watched videos. The investigators found that single-session exercise had small effect-size improvements in core symptoms of hyperactivity and attention (standardized mean difference [SMD], 0.35; 95% CI, 0.08-0.63; P =.01) and executive function (SMD, 0.28; 95% CI, 0.13-0.43; P =.00) among adolescents with ADHD. When stratified by age, the investigators observed small effect-size improvements in core symptoms and executive function among participants aged 10 to 13 years (standardized mean difference [SMD], 0.30; 95% CI, 0.12-0.48; P =.00) and 18 to 24 years (SMD, 0.42; 95% CI, 0.12-0.72; P =.01). However, single-session exercise did not significantly improve ADHD symptoms among participants 14 to 17 years of age (SMD, 0.16; 95% CI, -0.08 to 0.40; P =.65). When stratified by exercise type, high-intensity interval training was more effective in improving core symptoms and executive function (SMD, 0.44; 95% CI, 0.08-0.80; P =.02) relative to moderate-intensity continuous training (SMD, 0.27; 95% CI, 0.13-0.41; P =.00). Additionally, exercise sessions under 30 minutes were more effective (SMD, 0.35; 95% CI, 0.19-0.51; P =.00) than sessions of 30 minutes or more (SMD, 0.22; 95% CI, 0.00-0.44; P =.05), and cycling led to greater symptom improvements (SMD, 0.40; 95% CI, 0.17-0.63; P =.00) than running (SMD, 0.11; 95% CI, -0.04 to 0.27; P =.91). The investigators concluded, “This study supports the role of exercise in improving core symptoms and executive functioning in adolescent ADHD and provides additional evidence-based treatment options for a large number of adolescent patients with ADHD who are not amenable to medication.” These findings may be limited by the small number of relevant studies and heterogeneity in the reliability and sensitivity of assessment standards. Note: This article originally appeared on Psychiatry Advisor

Iloperidone, a second-generation antipsychotic used to treat schizophrenia, appears to be safe and effective in the treatment of bipolar mania, new research suggested. Results of the phase 3 randomized double-blind placebo-controlled trial show patients with bipolar mania who received iloperidone had significantly greater change from baseline to 4 weeks on the Young Mania Rating Scale (YMRS) compared with placebo, an improvement detected as early as 14 days from the initial dose. The incidence of akathisia and extrapyramidal symptoms (EPS) was low in the treatment group, and the medication was well-tolerated. "This study provides evidence that iloperidone improves the symptoms of bipolar mania in adults and can be a useful treatment option for people with bipolar disorder," the investigators, led by Rosarelis Torres, PhD, of Vanda Pharmaceuticals Inc., and colleagues wrote. The study was published online on January 15 in the Journal of Clinical Psychiatry. Early Improvement Iloperidone was first approved by the US Food and Drug Administration in 2009 for treatment of schizophrenia. The current study included 414 participants (mean age, 43 years; 56% male) across 17 US and international sites. Patients with psychotic features received a fixed daily dose of 24 mg of iloperidone (n = 206) or placebo (n = 208). Participants completed a screening period of up to 7 days before randomization, followed by a 1-day baseline evaluation period and a 28-day treatment phase. The primary efficacy endpoint was change from baseline to week 4 on the YMRS (vs placebo), while secondary efficacy endpoints included change from baseline on the Clinical Global Impressions-Severity and Clinical Global Impression of Change scales (CGI-S and CGI-C, respectively). Compared with placebo, iloperidone was associated with significant improvement of mania symptoms at week 4, with a mean reduction on the YMRS scale of −4.0 (P = .000008), and significant decreases on the CGI-S (mean, −0.4; P = .0005) and CGI-C scales (mean, −0.5; P = .0002). Statistically significant differences between iloperidone and placebo were observed as early as day 14 and continued through days 21 and 28. Post hoc analyses found no difference in efficacy even when patients who had received benzodiazepines were excluded, regardless of the presence or absence of psychotic features at baseline. Favorable Akathisia Profile As for safety, 68% of patients in the iloperidone group experienced at least one adverse event, compared with 49% of patients in the placebo group. Patients in the treatment group had a higher rate of withdrawal from the study than those in the placebo group (32.9% vs 27.1%), and more patients in the iloperidone group experienced treatment-emergent adverse events (TEAEs) leading to study drug discontinuation (8.7% vs 5.3%). However, no TEAEs associated with discontinuation occurred in more than two patients in either group, and none of the participants experienced any AE leading to death. The most common adverse events (AEs) were tachycardia (18%), dizziness (11%), dry mouth (9%), increased alanine aminotransferase (7%), nasal congestion (6%), weight gain (6%), and somnolence (5%). Five serious AEs were reported in four participants in the treatment group and one in the placebo group. Two were identified as related to the study medication. These included sedation and spontaneous penile erection. Changes from baseline in clinical laboratory parameters were not largely different between the groups, but there were post-randomization changes in QT interval in three iloperidone patients. The incidence of orthostatic response was also higher for iloperidone vs placebo. Although "much improved compared to early antipsychotics, SGAs can still cause considerable adverse motor side effects," the authors wrote. "However, among all SGAs, iloperidone's akathisia profile is favorable." Antipsychotic-induced akathisia has been reported more frequently in patients with bipolar disorder than in those with schizophrenia treated with the same medication, investigators noted. One study limitation is the fact that long-term efficacy in the prevention of manic or depressive episodes was not assessed. Potential Second-Line Treatment Commenting on the study for Medscape Medical News, Richard Louis Price, MD, assistant professor of psychiatry, at Weill Cornell Medical College, New York City, said the findings suggest iloperidone may be "modestly effective" for patients with bipolar 1 mania or mixed episodes. "It's helpful to have new treatment options, especially for patients who have difficulty tolerating other agents," said Price, who was not involved with the study. Also commenting on the research for Medscape Medical News, Roger S. McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, Toronto, Ontario, Canada, noted iloperidone's "interesting antipsychotic pharmacodynamic," highlighting the drug's high-binding affinity for serotonin 5HT2A and dopamine D2 and D3 receptors, as well as the noradrenergic α1 receptors. The drug's profile "suggests benefit in manic features and agitation, perhaps with a lower propensity to EPS, which is especially important in persons at higher risk, like persons living with bipolar disorder," McIntyre said. McIntyre, who was not involved with the study, added iloperidone could be a second-line therapy because of its tolerability profile, provided the study results can be replicated. "When considering alternatives with similar efficacy, absence of titration (or simple titration) minimal to no weight gain, no orthostatic hypotension, and no potential concerns with QT, those alternatives would have to be considered first-line, assuming that the study results are replicated," he said. Note: This article originally appeared on Medscape

TOPLINE: In 2022, approximately 13% of mental health specialists switched to practicing exclusively via telemedicine, with rates highest among psychiatric nurse practitioners and clinicians working in densely populated areas, and with females more likely than males to switch, new research revealed. METHODOLOGY: Researchers used health insurance claims from OptumLabs Data Warehouse for commercial insurance and Medicare Advantage enrollees for the years 2019 and 2022 after the start of the pandemic. They identified mental health specialists (psychiatrists, psychologists, social workers, and psychiatric mental health nurse practitioners [PMHNPs]) who had at least 30 visits and five patients in both years and conducted less than 25% of visits virtually in 2019. The study investigated the likelihood of providing "telemedicine-only" care in 2022, defined as conducting more than 95% of visits virtually. For each clinician, the study captured specialty, sex, region, age range of patient population, proportion of patients with severe mental illness, and median house value and population where most of their patients resided. TAKEAWAY: Among 51,309 mental health specialists included in the analysis, 13.0% provided telemedicine-only care in 2022. The adjusted rate was highest among PMHNPs (18.7%; 95% CI, 17.1%-20.3%) and lowest among psychiatrists (9.1%; 95% CI, 8.6%-9.7%). Characteristics associated with a greater likelihood of switching to telemedicine only included being female (adjusted rate, 14.0% vs 11.1% for males; P < .001), working in counties in the top (vs lowest) quartile of housing value (16.6% vs 8.8%; P < .001), and having the highest (vs lowest) population density (16.0% vs 8.8%; P < .001). Clinicians with a pediatric focus and those with an older adult focus (6.7%; 95% CI, 6.0%-7.5% and 6.5%; 95% CI, 5.6%-7.4%, respectively) were significantly less likely than general clinicians (14.1%; 95% CI, 13.8%-14.4%; P < .001) to have a telemedicine-only practice. IN PRACTICE: It's unclear how telemedicine-only clinicians will navigate Medicare and Medicaid changes, taking effect in 2025, that will require patients to get an annual in-person visit to continue receiving telemedicine visits for mental illness, the researchers wrote. They add that in-person requirements for visits and prescribing may "cause care interruptions, particularly for conditions such as opioid use disorder." LIMITATIONS: As the analysis included only clinicians treating patients with commercial insurance or Medicare Advantage, results may not be generalizable. Researchers were unable to determine where clinicians physically practiced. Given the shortage of mental health clinicians, future research should explore whether a virtual-only model affects clinician burnout or workforce retention. DISCLOSURES: The study was supported by the National Institute of Mental Health. Hailu reported no relevant conflicts of interest. The disclosures of the other investigators can be found in the paper.

TOPLINE: Prescriptions for Schedule II (C-II) stimulants and nonstimulant attention-deficit/hyperactivity disorder (ADHD) medications significantly increased in the United States during the COVID-19 pandemic, particularly in young adults and females, results of a cross-sectional study showed. METHODOLOGY: Using the National Prescription Audit commercial database, which captures more than 94% of US outpatient prescription drug activity, researchers examined US trends in prescriptions dispensed before (April 2018-March 2020) and during (April 2020-March 2022) the COVID-19 pandemic. Researcher analyzed monthly incident prescriptions for oral formulations of drugs in five classes (antidepressants, benzodiazepines, C-II stimulants, nonstimulant ADHD drugs, and buprenorphine products labeled as medications for opioid use disorder [MOUD]), dispensed to a patient with no prescriptions within the same drug class in the prior 12 months. For each drug class, investigators ranked the three highest-volume prescriber specialties and identified the top two drugs dispensed. TAKEAWAY: After an initial drop in dispensing across all drugs examined, including significant decreases for ADHD drugs and buprenorphine MOUD, prescriptions increased during the pandemic for C-II stimulants (14%) and nonstimulant ADHD drugs (32%), most notably among adults aged 20-39 years (30% and 81%, respectively) and women (25% and 59%, respectively). Among specialties, the largest increases were for prescriptions written by nurse practitioners across all drug classes, ranging from 7% for benzodiazepines to 78% for buprenorphine MOUD. Trends in prescriptions dispensed for antidepressants and benzodiazepines did not significantly change as was the case for buprenorphine MOUD, possibly because telemedicine prescribing flexibilities allowed clinicians to continue to diagnose and start treatment for OUD, the authors wrote. In the C-II stimulant class, amphetamine-dextroamphetamine increased more than methylphenidate, whereas among nonstimulant ADHD medications, there was an increase for atomoxetine but not for guanfacine extended release. IN PRACTICE: Increases in ADHD medication prescriptions during the pandemic "underscore the need for robust policies to address unmet needs while balancing public health concerns" wrote the authors, adding that future research "should prioritize clinical ADHD guideline development" to define treatment appropriateness. LIMITATIONS: Prescriptions dispensed outside the defined timeframe (during the previous year) may have been misclassified as an incident. The study could not determine causal relationships between drug utilization patterns and effects of the pandemic. Dispensed prescription data may not reflect demand or medical need during periods of drug shortage. The data did not contain information on race. Note: This article originally appeared on Medscape

Schizophrenia is far-reaching, affecting individuals, families, and society. Schizophrenia has been called “the worst disease affecting mankind” (1). It is a complex neuropsychiatric disorder, with multiple clinical features. These include cognitive impairment and deficits, mood symptoms, and psychiatric symptoms (hallucinations and delusions). It is also arguably the diagnosis that carries the greatest degree of stigma. For many years, schizophrenia was untreatable, until the discovery of antipsychotic medications in the 1950s. These first-generation antipsychotic medications offered hope, but many people were left with either a lack of efficacy or intolerable side effects. Today, thanks to the newer second-generation antipsychotic medications, and clozapine for treatment-resistance, the odds for recovery from schizophrenia are possible for many. The absence of insight is one of the most serious symptoms that prevents an individual with schizophrenia from receiving treatment. A lack of insight is called anosognosia. It is common in schizophrenia and other serious mental illness. It is more than denial, it is a firm and false belief that the affected individual is not sick and does not need medical treatment. Many people with schizophrenia develop delusions and believe things a mentally healthy person would find absurd. In the movie, A Beautiful Mind, while struggling with schizophrenia, Nobel Prize-winning mathematician John Nash believes that a microchip has been inserted in his body by the FBI because he is on a special mission. When a person begins their journey on a downward spiral into schizophrenia, especially untreated schizophrenia, the following are some consequences: Individuals become tortured with delusions and hallucinations Symptoms of schizophrenia can undermine a person’s life and can take away what matters most, such as a college education, pursuing a career, establishing relationships, buying a house, and raising a family. A person with schizophrenia often neglects personal hygiene and becomes malodorous. Many live in fear of the hallucinations raging inside their minds and feel detached from reality. Despite this, many will never seek out treatment until they are involuntarily hospitalized, which state laws allow. Psychiatric hospitalizations, which can often be avoided with early intervention, can be very costly ($1500 to $3000 a day depending on the location. Families are fractured Families of individuals struggling with schizophrenia often wonder what they did wrong, though schizophrenia is a genetic disorder, and no one is at fault. Parents may feel burdened by the many hours of care they have to provide, traveling to doctors’ appointments, researching how to best help their loved one, and having long and frustrating conversations to try and convince him or her they need treatment. Some parents who refuse to allow a delusional, violent, and unpredictable son or daughter to live in their home are struck by guilt, wondering if they did the right thing. Hundreds of billions of dollars annually in cost to society Schizophrenia incurs high direct and indirect costs to society that are expensive. Multiple hospitalizations, a lifetime of regular outpatient visits, legal costs (arrests, court hearings, re-incarceration due to a relapse) and lifetime disability (payments for room and board) add up to a huge cost. But, notably, if a person is identified earlier, they will have a better outcome. Full adherence to antipsychotic medication can prevent relapse (similar to full adherence to insulin in people with diabetes), and many who stick to their treatment plan may regain healthy minds return to their baseline, and contribute to society. Homelessness and substance use Untreated schizophrenia may lead to self-medicating with illicit substances, which can cause recurrence of psychosis and sabotage recovery. It is a daunting task to care for persons with schizophrenia who are addicted to substances. Many will become homeless, with cognition too impaired to hold even a simple job. People with schizophrenia are vastly overrepresented in the homeless community (2). The legal and prison systems When deinstitutionalization began in the '60s, funding and programs for those with developmental disabilities such as autism and Down’s Syndrome were made available. However, people with schizophrenia were not adequately covered by health insurance, often ending up on the streets, or in jail for crimes stemming from abnormal behavior triggered by the illness. Today, people with schizophrenia are also vastly overrepresented in jails and prisons (3). The pharmaceutical industry Hundreds of millions of dollars have been spent to search for a cure for schizophrenia, or at least better medication options with greater efficacy and fewer side effects than first-generation antipsychotics. Clozapine was approved by the FDA in 1989 and remains the antipsychotic drug with the highest efficacy after several decades, although it can have several safety and tolerability issues. Research continues with the hope that future medications will not only address the psychotic symptoms of schizophrenia, such as hallucinations and delusions, but also cognitive deficits (in memory, attention, or decision-making) and negative symptoms such as apathy, lack of motivation, inability to socialize, anhedonia, and blunted facial expression. Though a few medications are in the pipeline, their efficacy will not be known until the controlled clinical trials are completed and examined by the FDA for possible approval (4,5). The effects of suicide There is a very high suicide rate in people with schizophrenia. The rate of suicide in persons with schizophrenia is 4 to 13 percent (6). Studies report up to 10,000 percent higher death rates from suicide in young people with schizophrenia compared with the same age group in the general population (7). This is tragic for young people just starting their lives and is difficult to prevent. There is hope that the recent initiation of the 988 crisis hotline will offer more people struggling with suicide much-needed support (8). There is hope Despite the devastating impacts of schizophrenia, there is hope. Today, many people with ongoing treatment for schizophrenia (usually by committing to taking antipsychotic medication for life) reclaim their lives, work, attend college, and enjoy meaningful relationships again. Persons affected by schizophrenia can achieve remission by avoiding any further psychotic relapses after the initial hospitalization with uninterrupted adherence made possible through long-acting injectable antipsychotics (with no need for pills) that can be given once every one to six months. Unfortunately, the vast majority of persons with schizophrenia who improve significantly during their first hospitalization are discharged on pills, which they often do not take regularly, leading to multiple relapses that can destroy more brain cells and render the person disabled. Prompt and efficacious treatment with 100 percent adherence to antipsychotic medications can heal people with schizophrenia, enable them to return to their baseline functioning (like school or work) and bring families back together again. This will also avoid rehospitalization, re-incarceration, suicide, homelessness, and exorbitant costs to society. Recovery from schizophrenia is a win-win for patients, their families, and society. Note: This article originally appeared on Psychology Today

TOPLINE: Legalization of recreational and medical cannabis is not associated with a reduction in opioid prescriptions or overall opioid overdose mortality, a new study suggested. However, investigators did find that recreational cannabis laws may be tied to a potential reduction in synthetic opioid deaths. METHODOLOGY: Investigators analyzed state-level data from the US Centers for Disease Control and Prevention and other databases (2006-2020) on the number of opioid prescriptions (per 100,000 persons). Prescription opioids included buprenorphine (except products to treat opioid use disorder), codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, and tramadol. Researchers used regression analyses to account for poverty rates and real gross domestic product and a generalized difference-in-differences method that accounted for staggered implementation of cannabis laws. TAKEAWAY: During the full study period, 13 states legalized recreational cannabis and 23 legalized medical cannabis. No statistically significant association was found between recreational cannabis laws and opioid prescriptions (3.08 fewer prescriptions per 100 persons; P = .17) or overall opioid overdose mortality (3.05 fewer deaths per 100,000; P = .24). The changes in outcomes associated with medical cannabis laws were larger in magnitude than those for recreational cannabis laws but also not statistically significant (3.54 additional prescriptions per 100 persons; P = .17 and 3.09 additional deaths per 100,000; P = .07). A potential reduction was found in synthetic opioid deaths associated specifically with states that had recreational cannabis laws (4.9 fewer deaths per 100,000; P = .04), but there were no differences in overdose deaths with other opioids. IN PRACTICE: "These results contrast with recent studies that suggested that recreational and medical cannabis legalization are associated with reductions in opioid prescriptions and medical cannabis legalization is associated with an increase in opioid mortality," the authors wrote. Note: This article originally appeared on Medscape

Sleep dysfunction affects symptom severity and communication among children with ASD or ADHD. Sleep problems mediated the relationship between symptom severity and communication difficulties among children with attention-deficit/hyperactivity disorder (ADHD) or with autism spectrum disorder (ASD), according to findings published in Autism Research. These results highlight the need to develop sleep interventions for these populations. Sleep problems are commonly reported among children with ADHD and ASD. However, it remains unclear how this disturbed sleep could potentially contribute to or exacerbate ADHD and ASD symptoms. Investigators from the Universitat de València in Spain hypothesized that children with ADHD and ASD would have more sleep problems than typically developing children and that these sleep problems and associated symptom severity would be associated with reduced communication skills among cases. The investigators recruited children (N=122) aged 7 to 12 years with ADHD (n=43) or ASD (n=47) from specialized psychoeducational care centers and matched (by age and intelligence quotient [IQ]) the cases with children who were developing typically (n=32). All study participants were assessed for sleep problems using the Sleep Disturbance Scale for Children (SDSC), for communication skills using the Children’s Communication Checklist second edition (CCC-2), and for symptom severity using a diagnostic interview for ADHD or the Autism Diagnostic Interview-Revised (ADI-R) instrument. The ADHD, ASD, and control groups comprised 90.7%, 89.3%, and 65.6% boys (P =.006); were 9.29, 9.37, and 8.75 years of age, on average; and their IQ was 98.94, 98.37, and 100.4, respectively. In a multivariate analysis, a significant main effect of group was observed for SDSC scores (F[12,214], 4.76; P <.001), in which there were significant group differences for all SDSC dimensions. In a post-hoc analysis, the ADHD and ASD groups differed significantly from the controls on all SDSC dimensions, except for sleep breathing disorders and sleep hyperhidrosis. Out of a total of 45 pairwise comparisons assessing the correlations between sleep problems, communication skills, and symptom severity, 37 significant correlations were observed among children with ADHD and 25 correlations were observed among children with ASD. Among children with ADHD and ASD, total sleep problem scores correlated (all P £.05) with structural communication (r, ADHD: 0.61; ASD: 0.33), pragmatic communication (r, ADHD: 0.55; ASD: 0.47), and symptoms severity (r, ADHD: 0.42; ASD: 0.32). In the multiple regression analyses, sleep problems and symptoms severity explained 44% of the variance in structural language and 35% of the variance in pragmatic language among children with ADHD. For children with ASD, sleep problems and symptoms severity explained 22% of the variance in structural communication dysfunction and 49% of the variance in pragmatic communication dysfunction. In the final models, for both groups, symptom severity, sleep problems, and communication skills were all significantly related with indirect effects of symptom severity on communication skills mediated through sleep problems. Study authors concluded, “The results of the mediation analysis indicate that in both groups, sleep problems mediate the relationship between symptoms and communication skills, so sleep difficulties have an indirect and partial effect on the communication challenges that these children experience.” Study limitations include the small sample size, imbalance in participant gender, and lack of participation of children with intellectual disabilities. This article originally appeared on Psychiatric Advisor

“Weight” a minute! Researchers investigated the impact of body mass index on the clinical features of bipolar disorder in the STEP-BD study. CASE VIGNETTE “Mr Lee” is a 32-year-old male with a history of bipolar I disorder, with depression during his most recent episode. The onset of his mood disorder was at age 21 years. He failed previous trials of valproic acid and aripiprazole. He has a history of 2 suicide attempts by overdose on medications. He was also previously treated with a course of electroconvulsive therapy (ECT). He has been taking lithium 900 mg daily for the past 5 years. During this time, he has not had any episodes of mania, but he does have chronic mild depressive symptoms. He has a history of comorbid obesity and type 2 diabetes, but he does not have hypertension or hyperlipidemia. His current body mass index (BMI) is 38. At an outpatient visit, Mr Lee expresses a desire to try to exercise by walking while his son plays at a local park. He asks about the potential mental health benefits of exercise. As his psychiatrist, how would you respond? Bipolar disorder is associated with a 2- to 3-fold increased risk of premature mortality, with an average reduced lifespan of 9 to 17 years.1 Obesity rates in the United States are increasing,2 and individuals with mood disorders, including bipolar disorder, are at increased risk.3,4 Suicide mortality in the United States is also increasing,5 although evidence for an association between obesity and suicidal behavior is inconsistent. There is also evidence that increased low-grade inflammation, associated with higher BMI, may be associated with a more severe course of illness in patients with bipolar disorder. The Current Study Kadriu and colleagues8 aimed to assess whether higher BMI affected disease course and severity, symptom severity, and disease burden (medical and psychiatric comorbidity) in patients with bipolar disorder from the 7-year, longitudinal Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. Participants met DSM-IV criteria for bipolar disorder, cyclothymia, or schizoaffective disorder, bipolar type. Psychiatric comorbidities, including anxiety disorders, substance use disorders, eating disorders, and attention-deficit/hyperactivity disorder were also permitted. Participants were treated in a naturalistic setting. Study investigators included 2790 outpatients with data on height and weight. Data were also available on current mood, medical and psychiatric comorbidities, medication use, adverse effects, substance use, stressors, care utilization, history of ECT, history of suicide attempt, bipolarity index, the Montgomery-Åsberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). Participants were grouped into 7 categories by BMI: underweight (<18.5), thin (18.5-20), normal (20 to 25), overweight (25 to 30), class I obesity (30 to 35), class II obesity (35 to 40), and class III obesity (>40). The investigators used a network-based approach (Watts-Strogatz) to assess the influence of BMI on comorbidities. Relationships between BMI and psychosocial variables were assessed with logistic regression. The association between BMI and mood symptoms was assessed with linear regression. The mean participant age was 40 years, and 54% of participants were female. The average BMI was 28.4 ± 6.4 (median 27.2). Sex was significantly different across BMI categories (females were more likely to be underweight, and males were more likely to be obese.) Overweight and obese patients had a significantly higher bipolarity index. History of previous ECT treatment was also significantly different across BMI categories (lowest prevalence in the BMI <20 groups). There was a significant relationship between higher BMI and history of suicide attempt, with the highest prevalence in individuals with class III obesity. There was evidence of a bimodal distribution for BMI and the number of hospitalizations during the study, although the findings did not reach statistical significance. There was no significant difference in depressive episodes across BMI categories. However, manic episodes, bipolar II disorder diagnosis, panic disorder, social phobia, and posttraumatic stress disorder all differed significantly by BMI groups. Graph theory demonstrated a robust linear increase in comorbidities with increasing BMI. Trajectory clustering analysis indicated that higher BMIs were associated with worsening trajectory of core depressive symptoms. Study Conclusions In the STEP-BD study, the investigators found that BMI was associated with greater symptom severity, a greater number of psychiatric and medical comorbidities, a history of ECT, and a worsening trajectory of core depressive symptoms. The investigators noted factors such as obesity, hypothalamic pituitary adrenal (HPA) axis activation, and inflammation as potential mechanisms underlying these associations. Study strengths included the large sample size, real-world data, long-term continuity of care, and rigorous statistical analyses. Study limitations included the use cross-sectional data (which delimits inferences about causality), the exploratory nature of some of the analyses, the inability to account for fluctuations in weight over the course of the study, that all study sites were in the United States, that BMI cannot delineate subcutaneous versus visceral adiposity, and the absence of data on waist circumference or waist-to-hip ratio. The Bottom Line The study findings suggest that higher BMI adversely affects disease course and severity in individuals with bipolar disorder. Therefore, this measure is germane to the clinical care of this patient population. Note: This article originally appeared on Psychiatric Times

Increased hazard ratios were seen for all-cause mortality and mortality due to natural and unnatural causes. HealthDay News — Individuals with obsessive compulsive disorder (OCD) have an increased risk for all-cause mortality, according to a study published online Jan. 17 in The BMJ. Lorena Fernández de la Cruz, Ph.D., from the Karolinska Institute in Stockholm, and colleagues conducted a population-based matched cohort and sibling cohort study to estimate the risk for all-cause and cause-specific mortality in people with OCD. The population-based cohort included 61,378 people with OCD and 613,780 unaffected people matched on sex, birth year, and county of residence; the sibling cohort included 34,085 people with OCD and 47,874 unaffected full siblings. The cohorts were followed for a median of 8.1 years. During the study period, 4,787 people with OCD and 30,619 unaffected people died (crude mortality rates, 8.1 and 5.1 per 1,000 person-years, respectively). The researchers found that people with OCD had an increased risk for all-cause mortality and mortality due to natural causes and unnatural causes (hazard ratios, 1.82, 1.31, and 3.30, respectively) in hazard models adjusted for birth year, sex, county, migrant status, and sociodemographic variables. In the OCD cohort, higher natural causes of death included those due to endocrine, nutritional, and metabolic diseases; mental and behavioral disorders; and diseases of the nervous, circulatory, respiratory, digestive, and genitourinary systems; conversely, the risk for death due to neoplasms was lower. Of unnatural causes, the highest hazard ratio was seen for suicide followed by accidents. “Better surveillance, prevention, and early intervention strategies should be implemented to reduce the risk of fatal outcomes in people with OCD,” the authors write. Several authors disclosed ties to the pharmaceutical, publishing, and medical technology industries. This article originally appeared on Psychiatry Advisor

Does psychiatry’s future lean towards online practice? Telepsychiatry is a form of telemedicine that uses telephone or video conferencing tools to provide psychiatric services. As with in-person psychiatric treatment, telepsychiatry providers can evaluate and diagnose, provide therapy, and prescribe medication. On the one hand, I fully agree with Dr Varas that something is lost when we are not meeting in the same room with our patients. As I stated in my article, however, I think that telepsychiatry will increasingly be the way of the future, especially with younger generations of patients and therapists, along with continued advances in technology. Dr. Reddy believes that telepsych allows patients that are in remote areas of the country of state the access to quality doctors. People feel more comfortable taking about sensitive issues in their own environment. It eliminates the white coat syndrome. The no show rate is dramatically improved as it is much more flexible than commuting at least 30 minutes to 1 hour for an appointment, then seeing the doctor then being stuck in traffic. In this fast paced word, we don't have much time. The advantage of telepsych is we don't have to do a physical examination on patients, which is unlike many other fields who are transitioning into telehealth. I see patients from 7 hours away which would have been impossible with the benefits of telepsychiatry. I can see patients all over Missouri and Kansas City which is a major advantage as they are often burned out by their local providers and want a clean state. Now a days it's common to psychiatrists to practice in multiple states to reach more patients. I hope to expand with more Midwest states in the near especially with the patient population i see which is highly vulnerable. Dr Vilash Reddy is the owner of One Life Psychiatry. As a child/adult/addiction psychiatrist, he has a holistic approach mental health, through the use of medication, therapy, and alternative remedies.  His main focus he believes is vitally important is to educate and empower patients that are struggling with mental illness. He places a strong emphasis on understanding the patient way before prescribing random medicines which why he often the 2nd, 3rd, etc opinion.