Issue 89, Sep 2019
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Screen time and depression: Relationship?

Boers E. et al. JAMA Pediatr. 2019; Jul 15. doi: 10.1001/jamapediatrics.2019.1759. [Epub ahead of print]

PMID:31305878

Background

Growing up as an adolescent these days in the era of social media demands screen time. Additionally, video games add to this problem. In the past, increases in screen time have been found to be associated with depressive symptoms, but longitudinal studies are lacking.

Methods

This 4-year study included data from a randomized clinical trial that originally assessed the efficacy of a personality-targeted drug and alcohol prevention group. The sample group consisted of 3826 adolescents who had entered the seventh grade in 31 schools in the Greater Montreal Area from September 2012 to September 2018. The outcome studied was the symptoms of depression, which was measured using the Brief Symptoms Inventory. The independent variables included social media, television, video gaming, and computer use.

To test the Displacement Hypothesis (all screen time negatively affects mental well-being because it displaces time participating in healthier activities), the Upward Social Comparison Hypothesis (the effect of screen time on mental health depends on the nature of the content), and the Reinforcing spirals hypothesis (screen time effects are mediated through content). Additionally, exercise and self-esteem were assessed as part of the study.  

Results

Social media and computer use were associated with increased depression. Excessive TV use is associated with depression.  This study did not find an association of video games with increased depression. There was no relationship to exercise. Low levels of self-esteem were associated with more severe symptoms of depression.  

Conclusions

Time-varying associations between social media, television, and depression were found, which appeared to be more explained by upward social comparison and reinforcing spirals hypotheses than by the displacement hypothesis. Both screen time modes should be taken into account when developing preventive measures and when advising patients.

Clinical Commentary

There is clear evidence developing against screen time. It can get to be an addiction using the reward pathway, just like other addictions. This study fractionated screen time into social media, computer, TV, and video games, which was the first of its kind and a longitudinal one (over four years). Such studies are hard to do.

  • It was a surprise to me as a clinician that video games were not associated with depression. This is possibly because the gamer is not alone, and it is a social activity. They may play together while being physically together or with an online friend. Hence there does not appear to be isolation.
  • Social media by virtue of depictions of ideal images results in low self-esteem, isolation, and depression. In addition, depressed individuals consume more depressive content by reinforcement, which perpetuates depression.
  • This study suggests that all screen time may not predispose to depression, but certain social media and TV content could reinforce consumption of more depressive content.
  • In summary, adolescent screen time needs to be monitored and limited, especially in those with mood disorders and low self-esteem. The content especially needs monitoring on a regular basis.
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Prenatal cannabis use: Effects on maternal, perinatal, and neonatal outcomes

Corsi DJ et al. JAMA. 2019 Jun 18; 332 (2):145-152. Doi: 10.1001/jama.2019.8734. [Epub ahead of print]

PMID: 31211826

Background

In the United States and Canada there has been increasing approval of medical and recreational use of cannabis. Cannabis was approved for recreational use all over Canada in October 2018. Even before approval, cannabis use during pregnancy was rising. The aim of this study was to assess the associations between self-reported prenatal cannabis use and adverse maternal and perinatal outcomes.

Methods

This was a large Canadian population-based retrospective cohort study (N=661,617) covering live births and stillbirths among women aged 15 years and older between April 2012 and December 2017. Self-reported cannabis exposure in pregnancy was ascertained through routine perinatal care. The primary outcome was preterm birth before 37 weeks’ gestation. Ten secondary outcomes were examined, including small for gestational age, placental abruption, transfer to neonatal intensive care, and 5-minute Apgar score.

Results

The mean gestational age was 39.3 weeks, and 51% of infants were male. During this time frame, the average maternal age was 30.4 years, and 1.4% reported using cannabis.  The crude preterm birth rate at less than 37 weeks of gestation was 6.1% in those not using cannabis and 12% in those using cannabis. Cannabis exposure was associated with a risk difference (RD) of 2.98% and a relative risk (RR) 1.41 for preterm birth. Compared with no reported use, cannabis exposure was associated with significantly greater frequency of small for gestational age, placental abruption, and transfer to neonatal ICU.

Conclusions

Cannabis exposure in Ontario, Canada, was significantly associated with an increased risk of preterm birth. 

Clinical Commentary

This population-based Canadian study conducted before all of Canada going recreational revealed higher preterm birth and other complications such as small for gestational age in women with prenatal exposure to cannabis. These findings have important implications. I chose this article despite the fact that it does not address psychiatric illness because the use of cannabis is high in those with mental illness, and these questions do arise in our practice.

  • This study answers the questions “doc can I smoke pot as I am pregnant” or a similar question for a female attempting to get pregnant.  These figures would change significantly in the next ten years as recreational cannabis is now legal in Canada.
  • All other complications of exposure to cannabis/marijuana in the general population would apply. Perhaps an increase in children born with decreased grey matter volume who have in utero cannabis exposure resulting in impairment in neuropsychological testing.
  • Marijuana today is “not your parents’ marijuana.” This has become an industry, and the marijuana is more concentrated and can be laced with other substances. This fact is often forgotten.
  • Limitations: This study is retrospective and does not have a matched control group.
  • In summary, this study clearly indicates that marijuana use during pregnancy is associated with complications such as increased preterm birth and other complications. The answer to using cannabis in pregnancy is a “No.”
  • Cannabis (marijuana) has no randomized clinical trials to support its use in mental illness treatment. It does, however, have adverse effects.
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Physical activity as a protective factor for anxiety: The data

Schuch FB et al. Depress Anxiety. 2019; June 17. doi: 1002/da.22915 [E pub ahead of print]

PMID 31209958

Background

Anxiety is a common complaint amongst patients with psychiatric disorders as well as a disorder by itself. The prevalence of anxiety is 11% worldwide. Patients with anxiety are tougher to treat. We all have patients in our practice who are on benzodiazepines, other medications such as buspirone and atypical antipsychotics, and still having anxiety. There is often uncertainty in these individuals. There is an unmet need to look for other treatments, including lifestyle changes, to help with anxiety. This study examined the relationship between physical activity (PA) and incident anxiety.

Methods

This study was a meta-analysis of prospective cohort studies. Databases were searched from inception to October 10th, 2018 for prospective studies (at least one year of follow -up) that calculated the odds ratio (OR) of incident anxiety in people with high PA against people with low PA. Study quality was assessed using the Newcastle-Ottawa Scale (NOS).    

Results

Across 14 cohorts of 13 prospective studies (N=75,831, median males = 50.1%), participants were followed for a total of 357,424 person-years. Individuals with high PA were at reduced odds of developing anxiety. High PA was noted to be protective against the emergence of agoraphobia and posttraumatic stress disorder. The populations that these results were found in were from Asia and Europe. The protective effects were evident for both children and adults.  

Conclusions

There is evidence to support that self-reported PA can confer protection against the emergence of anxiety regardless of demographic factors. High physical activity levels protect from agoraphobia and posttraumatic stress disorder.

Clinical Commentary

This study was very enlightening regarding the protective effects of physical activity against agoraphobia and posttraumatic stress disorder. Anxiety disorders are associated with a 39% and 146% increase in mortality from natural causes and unnatural causes, respectively. This meta-analysis includes studies from multiple continents, including Europe (8 studies), Asia (1 study), North America (3 studies), Oceania (2 studies).

  • The positive studies were only from Asia and Europe, suggesting attitude and lifestyle differences which need to be investigated further. Another reason is a culturally diverse sample.
  • The data suggests that by adding lifestyle measures such as increased PA, we may be able to reduce the medication burden in patients with PTSD and Agoraphobia. Traditionally these patients are on benzodiazepines with limited response and may also be self-medicating with illicit drugs and alcohol.
  • From the biological perspective, increased PA increases brain derived neurotrophic factor (BDNF) and can reduce interleukin 6. This is the possible mechanism for the protective effects of PA.
  • It is important to note that an increased PA was not protective against generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, and specific phobias. Hence that data is focused on protective effects on Agoraphobia and PTSD where we clinicians may try this approach.
  •  In summary, we know there are multiple benefits to increasing physical activity in our patients who are prone to metabolic issues.  Specifically, we can focus on patients suffering from PTSD. Increase PA is complementary to medications and does not have any side-effects, or associated costs.
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Does electroconvulsive therapy (ECT) cause brain damage?

Gbyl K et al. Acta Psychiatr Scand. 2018 Sep; 138 (3):180-195. Doi: 10.1111/acps.12884 Epub 2018 Apr 29.

PMID:29707778

Background

ECT is a highly effective treatment for severe major depression. There has been a controversy that ECT causes brain damage. The purpose of this study was to gather evidence on ECT’s effects on hippocampal volume.

Methods

A systematic literature review of longitudinal studies of depressed patients treated with ECT was conducted. The studies included had magnetic resonance imaging (MRI) data, and a meta-analysis of ECT’s effect on hippocampal volume was conducted.  

Results

Thirty-two studies were included in this meta-analysis. This included 467 patients and 285 controls. The MRI studies did not find any evidence of ECT-related brain damage. The MRI volumetric studies found ECT-induced volume increases in certain brain areas, most consistently in the hippocampus. The diffusion tensor imaging studies (DTI) suggest that ECT induces integrity of white matter pathways in frontal and temporal lobes. The result of correlations between volume increases and treatment efficacy were inconsistent.

Conclusions

The MRI studies do not support the hypothesis that ECT causes brain damage. On the contrary, the treatment induces volume increases in fronto-limbic areas. There is a need for future studies to explore the relationship between volume increases and treatment effect and cognitive side-effects.

Clinical Commentary
  • There are multiple studies using MRI and CT scans which do not support the issue of brain damage resulting from ECT.
  • The primary advantage of ECT is rapid efficacy. Often, a course of 10-12 acute treatments is followed by maintenance ECT whose frequency is determined by the psychiatrist and patient together. ECT is highly effective for psychotic depression as well as associated conditions like failure to thrive.
  • The STAR* D study did not include ECT. It could be placed in the algorithm at the level three of STAR*D.
  • ECT is a highly efficacious treatment for TRD (treatment-resistant depression). Its efficacy is rapid, and the major side-effect is memory loss. For most patients, it is not problematic. Bilateral ECT is more effective, but the memory loss is greater too.  The Montreal Cognitive Assessment test (MOCA) is used to assess cognition in ECT patients. ECT should be made available to more patients to reduce morbidity from depression.
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Opioid overdose: Associated with opioid prescriptions to family members.

Khan NF. et al. JAMA Internal Medicine 2019; June 24. doi:10.1001/jamainternmed.2019.1064 [Pub ahead of print]

PMID 31233088

Background

The misuse of prescription opioids is a huge public health problem. This leads to overdose which can be fatal. Several approaches are being tried to contain this epidemic. This includes medication-assisted treatment (MAT), easy access to naloxone, public education, physicians to check medication registries for other controlled medications, and limiting access. Patients can still get opioids from prescriptions received by family members. This study was designed to determine if prescription opioids to family members was associated with overdose for individuals who themselves did not have access to an opioid prescription.

Methods

This 1:4 matched case-control study was completed using health care utilization data from 2004 through 2015 from a large commercial insurance company in the US. The primary outcome in this study was an opioid overdose resulting in an emergency department visit or hospitalization. Individuals who experienced overdose were identified by their first opioid overdose after the baseline period and matched to control participants by time in the database, calendar time, age, sex, and number of individuals in the family unit. Both groups were restricted to individuals with no prior opioid dispensing of their own.

Results

In the absence of opioid prescriptions to either the individual or family members, the baseline overdose rate was 3.80 events per 100,000 person-years. The odds ratio with any prior dispensing of opioids to family members was 4.08 in children age 0-6, 4.38 in children age 7 to 12 years, 3.38 in adolescents age 13 to 18 years, 1.78 in young adults age 19 to 34 years, 2.28 in adults age 35 to 59 years, and 1.80 in adults 60 years and older.

A dose-response association was found between the amount of opioids dispensed to family members and the odds of individual overdose. Amounts >0-<50 morphine milligram equivalents (MMEs) per day was associated with 2.71 times the odds of overdose, 7.80 when dispensed 50-89 MMEs per day and 15.08 when dispensed ≥90 MMEs per day.

Conclusions

In this study, opioid prescriptions to family members was associated with overdose among individuals who did not receive opioid prescriptions. Interventions may focus on expanding access to opioid antagonists, locking prescription opioids in the home, and providing greater patient education to limit fatal overdose among family members.

Clinical Commentary

This study highlights very important issues for us clinicians. The increased risk of overdose (OD) in patients not prescribed opioid prescription medicine whose family member has been prescribed these agents. Secondly, the greater the dosage prescribed, the greater the risk of OD. It seems logical, but I did not think about it until seeing the study. It’s all about access. The rate increase is about 3 fold in this population and present across all age groups, which is startling.

  • In my opinion, education is a key issue in the physician’s hands, including us in psychiatry. We should be watchful and ask mentally ill patients if they know of family members getting these drugs. The patient being prescribed the opioid needs education too (most important) that the prescription could be used by a family member in an OD or be abused. They should keep prescriptions secured.
  • Patients being prescribed opioid drugs have an elevated risk of mood disorders and that may also be an issue with family members. Opioid drugs that can be accessed via a family member can be then used for OD.
  • The four-fold increase in the OD in the 0-6 age group is quite remarkable and suggests the need to keep these medications securely.
  • In Summary: The goal is to reduce access and provide treatment. Use of naloxone as well as tightening of prescriptions has for the first time resulted in a downward trend in opioid OD related deaths. Education in this area may be an additional strategy to tighten access. When we check the registry for controlled medications, we should specifically mention to patients to keep the medications securely for this reason.
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Sanjay Gupta, MD
Clinical Professor of Psychiatry, SUNY Buffalo

GME Research Review is a monthly newsletter edited by Sanjay Gupta, MD, Clinical Professor of Psychiatry, SUNY Buffalo. Dr. Gupta 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. Gupta the citation at [email protected]