Prevalence and correlates of antipsychotic polypharmacy in children and adolescents receiving antipsychotic treatment*

Antipsychotic polypharmacy (APP), which is common in adults with psychotic disorders, is of unproven efficacy and raises safety concerns. Although youth are increasingly prescribed antipsychotics, little is known about APP in this population. We performed a systematic PubMed search (last update 26 January 2013) of studies reporting the prevalence of APP in antipsychotic-treated youth. Summary statistics and statistical tests were calculated at the study level and not weighted by sample size. Fifteen studies (n=58041, range 68-23183) reported on APP in youth [mean age=13.4 +/- 1.7 yr, 67.1 +/- 10.2% male, 77.9 +/- 27.4% treated with second-generation antipsychotics (SGAs)]. Data collected in these studies covered 1993-2008. The most common diagnoses were attention-deficit hyperactivity disorder (ADHD; 39.9 +/- 23.5%) and conduct disorder/oppositional defiant disorder (CD/ODD; 33.6 +/- 24.8). In studies including predominantly children (mean age=yr, N=5), the most common diagnosis were ADHD (50.6 +/- 25.4%) and CD/ODD (39.5 +/- 27.5%); while in studies with predominantly adolescents (mean age=13yr, N=7) the most common diagnoses were schizophrenia-spectrum disorders (28.6 +/- 23.8%), anxiety disorders (26.9 +/- 14.9%) and bipolar-spectrum disorders (26.6 +/- 7.0%), followed closely by CD/ODD (25.8 +/- 17.7). The prevalence of APP among antipsychotic-treated youth was 9.6 +/- 7.2% (5.9 +/- 4.5% in child studies, 12.0 +/- 7.9% in adolescent studies, p=0.15). Higher prevalence of APP was correlated with a bipolar disorder or schizophrenia diagnosis (p=0.019) and APP involving SGA+SGA combinations (p=0.0027). No correlation was found with APP definition [1d (N=10) vs. \u3e30-90d (N=5), p=0.88]. Despite lacking safety and efficacy data, APP in youth is not uncommon, even in samples predominantly consisting of non-psychotic patients. The duration, clinical motivations and effectiveness of this practice require further study

Balancing the Risks and Benefits of Benzodiazepines

In September 2020, the US Food and Drug Administration (FDA) announced an anticipated update to the boxed warning on all benzodiazepines to explicitly “address the serious risks of abuse, addiction, physical dependence, and withdrawal reactions” among this class of medications.1 The current boxed warning for benzodiazepines (eg, alprazolam, lorazepam, clonazepam, diazepam) highlights only the risks of coadministration of opioids and benzodiazepines. Benzodiazepines are prescribed for multiple indications, most notably generalized anxiety disorder, panic, social phobia, insomnia, and seizure prophylaxis and rescue

Identification of medically actionable secondary findings in the 1000 genomes

The American College of Medical Genetics and Genomics (ACMG) recommends that clinical sequencing laboratories return secondary findings in 56 genes associated with medically actionable conditions. Our goal was to apply a systematic, stringent approach consistent with clinical standards to estimate the prevalence of pathogenic variants associated with such conditions using a diverse sequencing reference sample. Candidate variants in the 56 ACMG genes were selected from Phase 1 of the 1000 Genomes dataset, which contains sequencing information on 1,092 unrelated individuals from across the world. These variants were filtered using the Human Gene Mutation Database (HGMD) Professional version and defined parameters, appraised through literature review, and examined by a clinical laboratory specialist and expert physician. Over 70,000 genetic variants were extracted from the 56 genes, and filtering identified 237 variants annotated as disease causing by HGMD Professional. Literature review and expert evaluation determined that 7 of these variants were pathogenic or likely pathogenic. Furthermore, 5 additional truncating variants not listed as disease causing in HGMD Professional were identified as likely pathogenic. These 12 secondary findings are associated with diseases that could inform medical follow-up, including cancer predisposition syndromes, cardiac conditions, and familial hypercholesterolemia. The majority of the identified medically actionable findings were in individuals from the European (5/379) and Americas (4/181) ancestry groups, with fewer findings in Asian (2/286) and African (1/246) ancestry groups. Our results suggest that medically relevant secondary findings can be identified in approximately 1% (12/1092) of individuals in a diverse reference sample. As clinical sequencing laboratories continue to implement the ACMG recommendations, our results highlight that at least a small number of potentially important secondary findings can be selected for return. Our results also confirm that understudied populations will not reap proportionate benefits of genomic medicine, highlighting the need for continued research efforts on genetic diseases in these populations

Psychological Management In Routine Family Practice

Background: Little is known about the provision of psychological management in routine primary care. This study examines patient demographic and clinical characteristics which predict who receives psychological management at three university affiliated family medicine practices. Methods: Primary care patients (N=937) completed a mental health screening form immediately prior to their medical visit. Results were withheld from their physicians (N=7). Following the visit, the physicians were asked to classify the range of psychological interventions they used to manage their patients’ emotional problems during the visit. A structured psychiatric diagnostic interview was subsequently administered to a subgroup of the patients (N=288). Results: At least one psychological intervention was provided to nearly a quarter (24.1%) of the patients. The interventions included listening to the patient’s emotional problems (22.4%), providing advice (19.0%), discussing the patient’s mental disorder diagnosis (11.4%), and providing individual counseling (8.4%) or family counseling (0.6%). Two thirds (66.7%) of the patients who reported that their emotional health was poor received at least one of these psychological interventions. In a multivariate model, the likelihood of receiving a psychological intervention was increased for patients who were separated or divorced; between 45 and 59 years of age; had less than a college education; received disability payments; reported poor emotional health; or had a positive SDDS-PC screen for panic disorder, major depressive disorder, or obsessive-compulsive disorder. Conclusion: Primary care physicians may be far more extensively involved in providing psychological interventions than is commonly assumed. Individual determinants of who receives psychological interventions included measures of clinical need and predisposing sociodemographic characteristics

Pain, cannabis use, and physical and mental health indicators among veterans and nonveterans: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III

AbstractChronic pain is associated with mental and physical health difficulties and is prevalent among veterans. Cannabis has been put forth as a treatment for chronic pain, and changes in laws, attitudes, and use patterns have occurred over the past 2 decades. Differences in prevalence of nonmedical cannabis use and cannabis use disorder (CUD) were examined across 2 groups: veterans or nonveterans and those reporting or not reporting recent pain. Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013; n = 36,309) were analyzed using logistic regression. Prevalence differences (PDs) for 3 cannabis outcomes (1) past-year nonmedical cannabis use, (2) frequent (≥3 times a week) nonmedical use, and (3) DSM-5 CUD were estimated for those reporting recent moderate to severe pain (veterans or nonveterans) and veterans reporting or not reporting recent pain. Difference in differences was calculated to investigate PDs on outcomes associated with residence in a state with medical cannabis laws (MCLs). Associations between physical and mental health and cannabis variables were tested. The results indicated that the prevalence of recent pain was greater among veterans (PD = 7.25%, 95% confidence interval (CI) [4.90-9.60]). Among veterans, the prevalence of frequent cannabis use was greater among those with pain (PD = 1.92%, 98% CI [0.21-3.63]), and among veterans residing in a state with MCLs, the prevalence of CUD was greater among those reporting recent pain (PD = 3.88%, 98% CI [0.36-7.39]). Findings failed to support the hypothesis that cannabis use improves mental or physical health for veterans with pain. Providers treating veterans with pain in MCL states should monitor such patients closely for CUD

Development And Validation Of The Sdds-pc Screen For Multiple Mental Disorders In Primary Care

Objective: To develop, validate, and cross-validate a patient-completeds creen for multiplemental disorders in primary care. Design: Comparison of a patient self-report screen with an independent diagnostic assessment by mental health professionals using the Structured Clinical Interview for DSM-III-R diagnoses as criterion standard. Setting: Three Rhode Island family practices and a South Carolina family medicine residency. Subjects: In the initial validation study, 937 patients in Rhode Island were screened; 388 were interviewed. In the cross-validation study, 775 patients were screened in Rhode Island and South Carolina, and 257 were interviewed. Screen Items: Sixty-two questions pertaining to nine mental disorders and suicidal ideation. Results: A 16-item screen remained after analys is of item and scale performance. Sensitivity, specificity, and positive predictive value, respectively, were calculated for the following scales: alcohol abuse or dependence (62%, 98%, and 54%), generalized anxiety disorder (90%, 54%, and 5%), major depression (90%, 77%, and 40%), obsessive-compulsive disorder (65%, 73%, and 5%), panic disorder (78%, 80%, and 21%), and suicidal ideation (43%, 91%, and 51%). Replicationin a new sampleshowed attenuated but acceptable operating characteristics for cross-validation. Conclusions: The Symptom-Driven Diagnostic System for Primary Care screen assesses multiple mental disorders that are common to primary care. It serves as a sensitive, valid, and patient-friendly first step in a new approach to recognizing and managing mental disorders in primary care. Finally, it aids the primary care clinician in selecting an appropriate diagnostic interview module for the disease for which the patient screened positive

The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review

Background Nonadherence to mental health treatment incurs clinical and economic burdens. The clinician-patient alliance, negotiated through clinical interaction, presents a critical intervention point. Recent medical reviews of communication and adherence behaviour exclude studies with psychiatric samples. The following examines the impact of clinician-patient alliance and communication on adherence in mental health, identifying the specific mechanisms that mobilise patient engagement. Methods In December 2010, a systematic search was conducted in Pubmed, PsychInfo, Web of Science, Cochrane Library, Embase and Cinahl and yielded 6672 titles. A secondary hand search was performed in relevant journals, grey literature and reference. Results 23 studies met the inclusion criteria for the review. The methodological quality overall was moderate. 17 studies reported positive associations with adherence, only four of which employed intervention designs. 10 studies examined the association between clinician-patient alliance and adherence. Subjective ratings of clinical communication styles and messages were assessed in 12 studies. 1 study examined the association between objectively rated communication and adherence. Meta-analysis was not possible due to heterogeneity of methods. Findings were presented as a narrative synthesis. Conclusions Clinician-patient alliance and communication are associated with more favourable patient adherence. Further research of observer rated communication would better facilitate the application of findings in clinical practice. Establishing agreement on the tasks of treatment, utilising collaborative styles of communication and discussion of treatment specifics may be important for clinicians in promoting cooperation with regimens. These findings align with those in health communication. However, the benefits of shared decision making for adherence in mental health are less conclusive than in general medicine

Has Behavioral Science Tumbled Through the Biological Looking Glass? Will Brief, Evidence-Based Training Return It From the Rabbit Hole?

Time constraints and professional demands leave practicing professionals unlikely to enroll in extended training such as a semester-long graduate course. Thus, the three-hour continuing education format has become a standard for those in practice. One may ask what sorts of training strategies optimize that format. To explore that, a three hour training program for seventy-six practicing mental health professionals, most of whom self-identified as psychologists, was devised. It made use of primarily antecedent techniques that have been shown to bring about changed perceptions on a number of topics. Content focused on two areas of importance to behavior analysts, the culture’s increasing acceptance of the biological causation model of disorders such as attentiondeficit hyperactivity disorder (ADHD), unipolar depression, anxiety disorders, and schizophrenia, and the field’s increasing reliance on medications, often to the exclusion of behavioral methods. Pre-post assessment showed that participants had changed their thinking regarding the two content areas. The authors caution that participants’ changed opinions may serve as setting events to changes in practice, but those changes are verbal. One must not assume changes in practice techniques will automatically occur

Evaluation of a Fotonovela to Increase Depression Knowledge and Reduce Stigma Among Hispanic Adults

Fotonovelas—small booklets that portray a dramatic story using photographs and captions— represent a powerful health education tool for low-literacy and ethnic minority audiences. This study evaluated the effectiveness of a depression fotonovela in increasing depression knowledge, decreasing stigma, increasing self-efficacy to recognize depression, and increasing intentions to seek treatment, relative to a text pamphlet. Hispanic adults attending a community adult school (N = 157, 47.5 % female, mean age = 35.8 years, 84 % immigrants, 63 % with less than high school education) were randomly assigned to read the fotonovela or a low-literacy text pamphlet about depression. They completed surveys before reading the material, immediately after reading the material, and 1 month later. The fotonovela and text pamphlet both produced significant improvements in depression knowledge and self-efficacy to identify depression, but the fotonovela produced significantly larger reductions in antidepressant stigma and mental health care stigma. The fotonovela also was more likely to be passed on to family or friends after the study, potentially increasing its reach throughout the community. Results indicate that fotonovelas can be useful for improving health literacy among underserved populations, which could reduce health disparities