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Issue 60, Apr 2017
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Smartphone addiction? There’s an app for that!

Lin YH, Lin PH, Chiang CL, et al. Incorporation of Mobile Application (App) Measures Into the Diagnosis of Smartphone Addiction. J Clin Psychiatry. 2017 Jan 31. [Epub ahead of print] PubMed PMID: 28146615.


Smartphone usage has become highly prevalent. 

We clinically encounter persons whose smartphone usage seems to show features similar to other addictive behavior. However, “smartphone addiction” is not an official diagnosis in DSM-5 or ICD-10.

We currently rely on the users to tell us about the extent and frequency of their smartphone usage. But users probably significantly underestimate how much they use their phones. 

This study used an app to record the extent of smartphone usage by the person. It evaluated whether incorporating such data could assist in diagnosing smartphone addiction. 


A new app was developed and used to record smartphone usage by 79 college students who were considered to be at high risk of smartphone addiction.

The app recorded the time from screen on to screen off, with each such episode being considered one period of usage. Both the mean duration of these periods of use and the number of periods per day were considered. 

The students were evaluated by one of three experienced psychiatrists and a diagnosis of “smartphone addiction” was made: 

1. Using only a clinical diagnostic interview by a psychiatrist, OR

2. Using a clinical diagnostic interview by a psychiatrist plus data from the app.

The results of the study were then used to suggest how data from the app could be used in developing diagnostic criteria for smartphone addiction. 


About one-third of the participants were diagnosed as having a smartphone addiction. 

Both the frequency and duration of daily smartphone use significantly predicted the final diagnosis of smartphone addiction. 

Prediction of the diagnosis was further improved by combining the duration of use per day, frequency of use per day, and how the frequency of use per day was trending over one month of follow up.

Seven diagnostic criteria were identified that predicted a diagnosis of smartphone addiction (made using the combination of app data and clinical diagnostic interview). 

The criteria were both clinical (e.g., recurrent failure to resist the impulse to use the smartphone) and app-based (e.g., excessively frequent smartphone use: > 68.4 periods per day). 

Together, these diagnostic criteria correctly predicted the diagnosis of smartphone addiction in 92% cases. 


ombining the data from the app with a clinical diagnostic interview improved the diagnosis of smartphone addiction. 

Importantly, data from the app functioned well as a screen for predicting a final diagnosis of smartphone addiction. 

Clinical Commentary

Addiction can present in many ways and across a broad spectrum of behaviors. 

It has become clear that the technologies like the internet and smartphones can be incredibly addictive for those who are vulnerable to such addiction. 

If all smartphones used an app that automatically monitored the user for excessive use that was potentially problematic, this could make early identification of problematic use much easier. Many such apps are available for both iOS and Android. 

Smartphone usage frequency, duration, and trends could be used as the first step—a screening tool—that could trigger an evaluation for a possibly significant problem. 

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When to screen for borderline personality disorder

Zimmerman M, Chelminski I, Dalrymple K, et al. Principal diagnoses in psychiatric outpatients with borderline personality disorder: Implications for screening recommendations. Ann Clin Psychiatry. 2017 Feb;29(1):54-60. PubMed PMID: 28207916.


When is it most important for clinicians to screen patients for borderline personality disorder? 

Borderline personality disorder usually presents with comorbid disorders. Patients often present for treatment complaining of the comorbid problem rather than symptoms of the borderline personality disorder.

The DSM convention is that the principal diagnosis is the disorder that the patient indicated was the main reason for seeking treatment.

This study evaluated the prevalence of borderline personality disorder in persons being treated in an outpatient mental health clinic and determined which principal diagnoses were more likely to be associated with an additional diagnosis of borderline personality disorder.


About 3600 persons being treated in an outpatient psychiatric clinic were evaluated using a semi-structured diagnostic interview for DSM-IV borderline personality disorder.

The patients in this study were predominantly white and female, and had health insurance. 


Of these 3600 patients, the detailed evaluation found that in 11% of patients on the diagnostic criteria for borderline personality disorder were met--either as the principal diagnosis or as an additional diagnosis. 

In 21% of the persons with borderline personality disorder, the chief complaint was related to one of the clinical features of the personality disorder. Therefore, the principal diagnosis was borderline personality disorder. 

In the rest of the patients, a different disorder was the principal diagnosis and the borderline personality disorder was an additional diagnosis. 

Patients for whom the principal diagnosis was either bipolar I or bipolar II disorder were the most likely to have borderline personality disorder as an additional diagnosis—in as many as 34% and 27% of patients, respectively. 

Patients for whom the principal diagnosis was adjustment disorder, dysthymic disorder, or generalized anxiety disorder were statistically significantly less likely to have an additional diagnosis of borderline personality disorder than persons with other principal diagnoses.

To my surprise, in this group of patients, those with a principal diagnosis of alcohol or drug abuse/dependence were not more likely to have an additional diagnosis of borderline personality disorder.


The majority of psychiatric outpatients with borderline personality disorder seek treatment for a mood or anxiety disorder rather than for the borderline personality disorder, per se. 

Therefore, it is important that patients presenting for treatment be specifically screened for possible presence of comorbid borderline personality disorder. 

Clinical Commentary

Borderline personality disorder is a common and disabling condition that is known to be underdiagnosed and, therefore, inadequately treated.  

Failure to identify that the person presenting with a mood disorder or anxiety disorder has comorbid or “underlying” borderline personality disorder would be a significant error and is likely to lead to suboptimal treatment overall.

As the authors point out, it may not be practical to screen every single person for possible borderline personality disorder. They recommend that clinicians should screen for borderline personality disorder in patients who present to a general psychiatric outpatient practice with a principal diagnosis of major depressive disorder, bipolar disorder, PTSD, or panic disorder with agoraphobia. These are disorders with which there is a 10% or greater prevalence of comorbidity. 

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Computerized cognitive training for mild cognitive impairment or dementia?

Hill NT, Mowszowski L, Naismith SL, et al. Computerized Cognitive Training in Older Adults With Mild Cognitive Impairment or Dementia: A Systematic Review and Meta-Analysis. Am J Psychiatry. 2016 Nov 14:appiajp201616030360. [Epub ahead of print] PubMed PMID: 27838936.   


Computerized cognitive training consists of guided drill-and-practice on standardized tasks. The tasks that the person is asked to do are designed to require specific cognitive processes. 

Typically, in computerized cognitive testing, there is only practice; memory strategies or problem-solving strategies are not explicitly taught. This is a difference between computerized cognitive training and other approaches to cognitive remediation.

Previous meta-analyses have suggested that computerized cognitive training is efficacious for improving cognition in healthy older adults and in persons with Parkinson’s disease or major depression. 

However, we don’t know whether this computerized cognitive training is helpful for persons with either mild cognitive impairment (largely equivalent to Mild Neurocognitive Disorder in DSM-5) or dementia (largely equivalent to Major Neurocognitive Disorder in DSM-5).


Multiple databases were searched to identify randomized controlled trials of computerized cognitive training in older adults with mild cognitive impairment or dementia. 

Data from these clinical trials were combined using meta-analysis.


Seventeen randomized controlled clinical trials of computerized cognitive training in persons with mild cognitive impairment were found. 

These trials showed a moderate benefit on cognition overall (Hedges' g=0.35). 

Small to moderate benefits of computerized cognitive training were found for global cognition (g=0.38), verbal memory (g=0.42), non-verbal learning (g=0.5), working memory (g=0.74), and attention (g=0.44).

Statistically significant improvements were also found in psychosocial functioning and in depressive symptoms. 

However, there were other areas in which statistically significant benefits were not found in persons with mild cognitive impairment: nonverbal memory, executive function, processing speed, visuospatial skills, language, and instrumental activities of daily living. 

What about in persons with dementia? Eleven clinical trials of computerized cognitive training in persons with dementia were found. 

A small but statistically significant benefit of computerized cognitive training for overall cognition (Hedge’s g =0.26) and a moderate effect for visuospatial skills (g=0.54) was found. However, this benefit was found mainly in the studies that used either virtual reality or the Nintendo Wii. 


Computerized cognitive training is efficacious in persons with mild cognitive impairment. 

However, computerized cognitive training shows limited benefit in persons with dementia.

Clinical Commentary

Even a modest benefit from computerized cognitive training could have major implications due to the large number of persons with mild cognitive impairment.  

The effect size for the benefit of computerized cognitive training on global cognition in mild cognitive impairment was 0.38. To put that in context, the effect size of the benefit of medications for Alzheimer’s disease was 0.23 (Ströhle et al., 2015), of memantine for cognitive function in persons with Alzheimer’s disease was 0.27 (Matsunaga et al., 2015), and of the combination of cholinesterase inhibitors and memantine for moderate to severe Alzheimer’s disease was also 0.27 (Schmidt et al., 2015).

While computerized cognitive training was helpful for mild cognitive impairment, cholinesterase inhibitors do not seem to be effective for this condition (Tricco et al., 2013; Russ and Morling, 2012). 

Mild cognitive impairment is, to some extent, a precursor to dementia. Further research will have to show whether or not computerized cognitive training in persons with mild cognitive impairment has a role in delaying the clinical manifestations of dementia. 

In dementia, the benefit of computerized cognitive training was weak. Perhaps computerized cognitive training needs to be implemented at an earlier stage in cognitive decline?  

Some newer technologies like virtual reality and the Nintendo Wii may turn out to have special roles in persons with neurocognitive disorders, including those with dementia. 

Further research is needed to understand why computerized cognitive training did not help processing speed, which was surprising. Also why it did not help executive dysfunction, which is an important predictor of functional decline. 

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Is premature ejaculation related to depression?

Xia Y, Li J, Shan G, Qian H, et al. Relationship between premature ejaculation and depression: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2016 Aug;95(35):e4620. PubMed PMID: 27583879; PubMed Central PMCID: PMC5008563.


Premature ejaculation is the most prevalent of the different types of male sexual dysfunctions. 

Previous data has suggested the premature ejaculation may be related to depression but the data have been unclear. 

This study aimed to combine all available data on this topic. 


A literature search was conducted to identify observational studies on the risk of premature ejaculation in adult males with a history of depression. 

The data from these studies were then pooled and a meta-analysis was conducted. 


Eight studies that included a total of about 18,000 participants were included in the meta-analysis. 

Three studies were from Europe, four from Asia, and one from Australia. 

A history of depression was associated with a statistically significantly increased risk of premature ejaculation (odds ratio 1.6). 

This association was unchanged when subgroups were analyzed based on factors like the mean age of the participants, geographical region, etc.. 


A history of depression is associated with an increased risk of premature ejaculation irrespective of other variables. 

Clinical Commentary

The most important question, of course, is whether the depression leads to premature ejaculation or premature ejaculation leads to depression. It is likely that the relationship is bidirectional. That is, depression may make premature ejaculation more likely and persons with premature ejaculation may be more likely to become depressed. 

Clinicians should make sure to elicit a sexual history in persons with a history of depression in order to identify sexual dysfunction, including premature ejaculation. 

Further studies are needed to assess which treatments may be particularly appropriate for persons with a history of depression who also have premature ejaculation. 

Could it be that antidepressants like paroxetine that are associated with higher rates of sexual dysfunction, including delayed ejaculation, may paradoxically be particularly useful in this subgroup of patients? 

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Proton pump inhibitors and increased risk of dementia?

Batchelor R, Gilmartin JF, Kemp W, et al. Dementia, cognitive impairment and proton pump inhibitor therapy - a systematic review. J Gastroenterol Hepatol. 2017 Jan 27. [Epub ahead of print] PubMed PMID: 28128476.


It has been suggested that persons who take a proton pump inhibitor may be at increased risk of dementia or acute cognitive impairment.

What are potential mechanisms through which this may happen? Proton pump inhibitors increase deposition of amyloid protein in mouse brains. They have also been linked with development of vitamin B12 deficiency. 

What about potential mechanisms for acute cognitive impairment? Acute cognitive impairment associated with use of proton pump inhibitors has been reported to be associated with hypomagnesaemia or hyponatremia. 

This study aimed to combine data from previous publications to assess whether proton pump inhibitors are associated with dementia or with acute cognitive impairment. 


A systematic search of multiple databases was done to identify relevant publications. 

Published reports of the association between use of proton pump inhibitors and a diagnosis of either dementia or acute cognitive impairment were identified. 


Eleven relevant publications were identified. It is important to note that this review included various types of studies and even included case reports. 

Four publications (two cohort studies, one case-control study and one cross-sectional study) provided data on the potential relationship between the use of proton pump inhibitors and dementia.

Three of these four publications found that there was an association between the two. 

Seven publications (one randomized controlled trial, two cohort studies, one case series and three case reports) provided data on the potential relationship between the use of proton pump inhibitors and acute cognitive impairment. These included four cases of hypomagnesemia-associated delirium or confusion and one case of hyponatremic delirium. 

A majority of these seven publications found that there was an association between use of a proton pump inhibitor and acute cognitive impairment. 


All the publications used in this review had methodological problems and potential biases.  Therefore, it remains unclear whether and to what extent there is an association betwen use of proton pump inhibitors and either dementia or acute cognitive impairment. 

Clinical Commentary

Use of proton pump inhibitors like esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix), dexlansoprazole (Dexilant), etc. is extremely common. 

Thus, the implications of the potential association of the use of proton pump inhibitors and dementia and/or acute cognitive impairment could be quite significant. 

Further research is needed so that patients can be either reassured or warned as the case may turn out to be. 

In the meanwhile, it is probably wise to not assume that proton pump inhibitors are devoid of potentially serious adverse effects. It may be best to avoid unnecessary, especially long-term, use.  

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Rajnish Mago, MD
Medical Editor, GME Research Review

GME Research Review is a monthly newsletter edited by Rajnish Mago, MD, who is author of "The Latest Antidepressants" and "Side Effects of Psychiatric Medications: Prevention, Assessment, and Management." Dr. Mago selects, summarizes, and provides a clinical commentary on the latest published research in psychiatry. 

We are always carefully evaluating which research papers to discuss in GME Research Review. Have come across a research paper published in the last 6 months that you thought is clinically relevant? Do you want me to analyze it for you and for the benefit of others? Please email Dr. Mago the citation at [email protected].

To contact GME, email us at [email protected]

GME does not provide medical advice. The website and articles are intended for informational purposes only. They are not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the GME Website. If you think you may have a medical emergency, immediately call your doctor or dial 911.

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