Issue 85, May 2019
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Bariatric surgery: Long-term effects on depression and anxiety.

Gill H et al. J Affect Disord. 2019 Mar 1; 246:886-894. doi: 10.1016/j.jad.2018.12.113. Epub 2018 Dec 28. PMID: 30795495

Background

There is a bidirectional relationship between obesity and mood and anxiety disorders. Bariatric surgery has become a popular procedure for patients with morbid obesity. This is the first study that has investigated the long-term effects of bariatric surgery on mood and anxiety disorders.

Methods

A systematic search of databases such as Psych INFO, Google Scholar, and PubMed was conducted to retrieve prospective studies published from inception to 14th June 2018.  This study evaluated long-term outcome (>24 months) changes in the severity of depression and anxiety symptoms in bariatric surgery patients (BMI >35kg/m2).

Results

This study reviewed over 2000 articles of which 14 prospective studies were included. 13 studies reported significant reductions in depressive symptom severity 2-3 years after bariatric surgery. There was also an overall reduction in the severity of anxiety symptoms at >24 month follow up. Pre-operative depression and anxiety scores did not predict outcomes of post-operative BMI.  Post-surgery weight loss was not predictive of changes in anxiety symptoms.

Conclusions

The data suggests that bariatric surgery is associated with long-term reduction of anxiety and depressive symptoms. Metabolic treatments may be a therapeutic intervention for mood disorders. 

Clinical Commentary

Psychiatrists should consider bariatric surgery for their morbidly obese patients especially those with comorbid anxiety and depression. It should not be the only treatment though as more studies are needed.  

  • The treatment needs to have a multi-pronged approach. This needs to include lifestyle measures such as cutting soda and substituting with water, reduction of helping size, focus on fruits and vegetables, chicken and fish, and exercise such as walking 30 mins a day.  
  • A number of patients also have an overeating disorder, and if these issues are not addressed weight gain will recur.
  • Patients and providers need to understand that bariatric surgery is not a magic bullet for one’s problems but a mode to jumpstart the weight loss journey for the patient. Issues related to self-esteem and relationships need to be worked on, and weight loss may not change that. Patients should stick to diet, exercise, and lifestyle changes. Patients should be careful not to swap addictions (substitute of food for alcohol or other addictions).
  • In summary weight loss surgery has been shown in this study to help reduce anxiety and depression, however we need to keep the results in perspective as there are other psychological issues that need to be attended to. 
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Mortality in schizophrenia: implication of treatment oral vs long acting injectables (LAIs) vs no treatment

Taipale H et al. Schizophrenia Res. 2017 Dec 20. pii: S0920-9964(17)30762-4. doi:10.1016/j.schres.2017.12.010. [Epub ahead of print]  PMID:29273734

Background

Patients with schizophrenia have a 15-20-year shorter life expectancy compared with the general population. There is a controversy if antipsychotics contribute to mortality. Additionally, there are questions of differences in mortality between agents as well as routes of administration. This Scandinavian study aims to address this very issue.

Methods

This large study linked prospectively gathered nationwide register-based data during 2006-2013 to study all-cause mortality among all patients aged 16-64 years with (N=29,823 in total; N=4603 in the incident cohort) schizophrenia in Sweden (N=29,823 in total; N=4603 in the incident cohort). The main outcome measure was all-cause mortality.

Results

During the follow up time frame 8.4% of patients died. The adjusted risk of death was 56% lower during use of any antipsychotic compared with no use of antipsychotic. The lowest risk of death was observed with second generation LAIs. Oral aripiprazole and commonly used LAIs were observed to have the lowest mortality. Paliperidone once a month, oral aripiprazole, and risperidone LAI were associated with the least mortality. Overall, LAIs were associated with 33% lower mortality compared with oral agents.

Conclusions

In patients with schizophrenia, LAI use is associated with lower mortality compared with oral agents. The lowest mortality was associated with second generation LAIs and oral aripiprazole.

Clinical Commentary

Sudden death in patients with schizophrenia is known to occur as well as a shortened lifespan. This large study suggests that antipsychotic treatment of patients with schizophrenia lowers mortality significantly.

  • This study highlights the importance of treating patients with schizophrenia using antipsychotics.
  • This study also suggests lower mortality as another major reason to use second generation LAIs (30% lower risk of death). Most often LAIs are used for noncompliance/ drug abuse in schizophrenia.
  • Clinicians should adopt using LAIs for another important reason as they significantly lower mortality. If using an oral agent aripiprazole should be tried first as it has the least mortality amongst oral antipsychotics.
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Strategy post suicide attempt: Comparison of three different strategies (Priority appointment, enhanced contact intervention, and psychotherapeutic program).

Martinez-Ales G. et al. J Clin Psychiatry. 2019 Feb 26;80 (2) pii1812416. doi:10.4088/JCP.18m12416.  PMID:30817098

Background

Psychiatric patients often have suicide attempts and survive for various reasons such as it being a cry for help, receiving competent and modern emergency care, and having watchful relatives.  It is often unclear as to which strategy performed post suicide attempt has the better outcome. This study investigated the comparative effectiveness of three common strategies which include a priority appointment with a psychiatrist, enhanced contact intervention, and a psychotherapeutic program.  

Methods

This observational Spanish study was conducted in Madrid between 2013 to 2017 and included a sample of 1,492 suicide attempters.  Relapse was defined as return to the ER after a new attempt within a 1-year follow up. The statistical analysis included Kaplan-Meier survival functions by intervention and Cox hazard regression models. In addition, age, sex, history of suicide attempts, history of psychiatric disorders, main ICD-10 psychiatric diagnostic groups, medical comorbidities, and family support were reviewed.

Results

In this study, 133 subjects (8.9%) relapsed. Individual psychotherapy and enhanced contact were more effective than a single priority appointment at reducing a subsequent relapse suicide attempt. There was a 40% lower relapse risk. The results were unaffected by sex and age.

Conclusions

The patients exposed to enhanced contact intervention and individual psychotherapy post suicide attempts had a lower relapse risk compared to a single priority appointment group.

Clinical Commentary

Suicidal behaviors are a growing and critical public health issue in the United States. Death by suicide is an outcome all clinicians would like to prevent. Mental health clinicians care for multiple suicidal patients on a daily basis. Suicide risk assessment is an important aspect of every mental health visit or discharge from a psychiatric unit. There is often a feeling that seeing a psychiatrist post suicide attempt on a priority basis is an important, often the only thought of intervention.

  • Patients discharged from the inpatient unit are high risk especially within the first 30 days.
  • It is important to rethink the strategy post suicide attempt as a priority psychiatric visit is often already set up.
  • It may be important to consider weekly 30-minute psychotherapy sessions with focus on stress reduction and problem solving. Problem solving therapy (PST) may have a unique role as solving problems reduces tension, anxiety, and insomnia. The patient does begin to see light at the end of the tunnel.
  • Enhanced contact which includes multiple short contacts with the patient post attempts provides support as well as helps boost morale, which improves outcome. This also detects early a decline in psychiatric condition as well as the appearance of new symptoms.
  • Setting up a priority psychiatric appointment should not be the sole intervention, but should be combined with enhanced contact and frequent psychotherapy visits.  This would lower the risk of relapse.
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Pharmacotherapy of pediatric anxiety disorders: Data based efficacy and tolerability.

Dobson ET et al. J Clin Psychiatry 2019 Jan 29;80(1). Pii:17r12064. doi:10.4088/JCP.17r12064.  PMID 30753760

Background

Anxiety disorders are common in children and adolescents. Although the guidelines suggest selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) as first line treatment agents, clinicians especially pediatricians (often on the frontlines) use drugs they feel most comfortable/have experience with. This study included randomized controlled trials (RCT) in a meta-analysis to assess efficacy and tolerability issues.

Methods

This study included RCTs of pharmacotherapy in the treatment of pediatric patients for generalized, social, and/ or separation anxiety disorders. Data extracted was related to demographics, symptom severity, global improvement, discontinuation, and suicidality. A network meta-analysis was performed comparing the efficacy and tolerability of medications and medication classes.

Results

22 RCTs were identified which revealed that SSRIs were the only drug class effective in reducing anxiety compared to placebo. The SSRIs had greater efficacy compared to SNRIs and 5-HT1A agonists. Adverse events were greater with SSRIs than SNRIs. Treatment emergent suicidality did not differ by class but by medication. Sertraline had the least treatment emergent suicidality. Paroxetine treated patients had significantly greater treatment emergent suicidality. Benzodiazepines may be associated with significant tolerability concerns in children, including suicidality compared with those not on benzodiazepines.

Conclusions

The SSRIs had superior efficacy compared to SNRIs and other agents but also had the greatest discontinuation due to adverse events. For the clinician it appeared that sertraline should be the drug of first choice amongst the SSRIs. Determining whether efficacy and tolerability differences represent true differences (or reflect differences in trial design) requires additional head to head medication trials. These should include medications that have been used successfully to treat anxiety in adults but have not been evaluated in youth. 

Clinical Commentary

The results of this study were consistent with the guidelines of the American Academy of Child and Adolescent Psychiatry recommending SSRIs as the first line agents for treatment of anxiety disorders.

  • Sertraline would be a preferred agent and paroxetine would be the least preferred agent.  
  • The finding that suicidality is significantly greater in those on benzodiazepines like clonazepam along with tolerability issues in the pediatric population is important. Benzodiazepines do not have a boxed warning compared to other medications used in children. This needs reevaluation and mention of differential risk should be considered
  • Bottom line: Sertraline in the agent of choice in children and adolescents based on efficacy, tolerability, and suicide risk. Benzodiazepines should be avoided.
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Psychiatric illness and crime in the US population: Where do the data point?

Moore KE et al. J Clin Psychiatry. 2019 Feb 12; 80(2). pii:18m12172. doi: 10. 4088/JCP.18m12317.  PMID 30758921

Background

Currently there is limited knowledge of the interaction between psychiatric disorders and criminal behavior. We often hear that jails have become defacto psychiatric hospitals. This study investigated the relationship between DSM-5 psychiatric disorders, comorbid substance abuse, multi morbidity (number of disorders) with criminal behavior and justice involvement among non-institutionalized US adults.

Methods

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; 2012-2013; N=36,309). Logistic regressions were used to examine the association of specific disorders (e.g. mood, anxiety, eating, posttraumatic stress, substance use), comorbid substance use and mental health disorders, multimorbidity with lifetime criminal behavior, incarceration experience, and past-12-month general, alcohol-related, and drug-related legal problems. 

Results

28.5 % of the participants reported a history of criminal behavior, 11.4% reported a history of incarceration, 1.8% reported current legal problems, 0.8% reported current alcohol-related legal problems, and 2.7% reported current drug-related legal problems.  The presence of any disorder was associated with 4-5 times the risk of crime outcomes. Drug use disorders were associated with the highest risk of lifetime crime and incarceration. Having multiple diagnoses, and comorbid substance abuse carried additional risk. Controlling for antisocial personality disorder did not change the findings.

Conclusions

Community adults with substance use disorders, comorbid substance use and mental health disorders, and those with multiple disorders are at a high risk for crime and justice involvement. This study underscores the need for screening and treating addictions in the community.

Clinical Commentary

This study highlights the fact that having mental illness, substance abuse, and the combination of the two increases the interaction with the legal system. In addition, as the total number of diagnoses increase there is increased legal involvement. Antisocial personality disorder is not the only source of legal involvement. We should be open to mental illness and substance abuse as high-risk factors leading to legal complications.

  • The screening in my opinion should be bidirectional.  Psychiatric patients should be screened for substance abuse, especially those with multiple comorbidities. The substance abuse should be addressed early and definitively. On the other hand, those with legal offenses should also be screened for mental illness and treated appropriately.
  • I would recommend the CAGE for screening for both alcohol and substance abuse. It is easy to use and can be done quickly.
  • Patients picked up for DWI should be screened for psychiatric illnesses such as mood and anxiety disorders.
  • The disease model approach should be used avoiding pejorative terms such as addict /addiction to keep patients in treatment.
  • The inpatient psychiatric unit is an excellent place to start as the patients are a captive audience and also receptive.
  •  Long acting injections (LAIs) should be used whenever indicated as psychiatric medication noncompliance often results in relapse of substance abuse.
  • In summary there needs to be a closer working partnership between the mental health and the legal system to improve outcomes for patients.
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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]