HealthDay News — In a policy statement issued by the American Academy of Pediatrics (AAP) and published online August 16 in Pediatrics, recommendations are presented for improving emergency care for pediatric mental and behavioral health (MBH).

Mohsen Saidinejad, MD, from the David Geffen School of Medicine at UCLA in Los Angeles, and colleagues highlighted strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

In an accompanying technical report, the authors note there has been an increase in MBH visits of children and youth to emergency departments in the US, with reasons for these visits ranging from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite this increase, the health care system does not have the capacity to screen, diagnose, and manage these patients.

The authors recommend developing emergency department facility transfer protocols involving emergency medical services for children, including appropriate referrals to psychiatric crisis units, which could provide short-term stabilization and referrals. Development of telehealth emergency psychiatric medical control is recommended to identify and divert low-acuity patients to facilities equipped to manage MBH conditions. In addition, the AAP recommends that existing mental health mobile crisis teams be activated to be able to respond as necessary, and resources should be provided for prehospital personnel in acute management of MBH emergencies. Emergency department staff should be provided with resources related to recognition and provision of initial care to children and youth with potentially increased risks for MBH concerns. Expansion of telehealth consultation should be explored, especially in resource-limited areas or during disease outbreaks. The AAP also recommends advocating for community-based behavioral services that use a culturally sensitive, patient-centered approach to identify and manage concerns before development of an emergency condition. An increase in MBH research funding is necessary to screen and identify those at risk and connect with the appropriate resources.

“A dedicated multipronged, multidisciplinary approach will be necessary to provide patient-centered, trauma-informed services to improve the care of children and youth with MBH emergencies,” the authors write.

Policy Statement

Technical Report

The Food and Drug Administration (FDA) has approved Abilify Asimtufii^® (aripiprazole extended-release injectable suspension) for the treatment of schizophrenia in adults and as maintenance monotherapy treatment of bipolar I disorder in adults.

Abilify Asimtufii, an atypical antipsychotic, is intended for dosing every 2 months via intramuscular injection in the gluteal muscle. The approval was based on safety and efficacy data from Abilify Maintena (once monthly dosing) trials, as well as findings from an open-label, multiple-dose, parallel-arm phase 1/2 study (ClinicalTrials.gov Identifier: NCT04030143) that included  266 adults with schizophrenia or bipolar I disorder.

Study participants were randomly assigned to receive either Abilify Asimtufii 960mg (n=132) administered every 56 days (total of 4 injections) or Abilify Maintena 400mg (n=134) administered every 28 days (total of 8 injections). Results showed that treatment with Abilify Asimtufii met the primary endpoint demonstrating similar aripiprazole plasma concentrations and comparable efficacy to Abilify Maintena.

Treatment with the every 2-month injectable was found to be safe and well tolerated; no new safety concerns were reported with multiple administrations. The most common adverse reactions reported were increased weight, akathisia, injection site pain, and sedation.

Each dose of Abilify Asimtufii is provided in a single-chamber, prefilled syringe, and is administered by a health care provider. The product is available in 720mg/2.4mL and 960mg/3.2mL dosage strengths.

Pauline Gerard, from the University of Colorado School of Medicine in Aurora, and colleagues conducted a retrospective cohort study to examine the relationship between cardiomyopathy and duration of stimulant medication use in adults diagnosed with ADHD aged 20 to 40 years. The window of analysis was limited to 30 years after ADHD diagnosis.

A total of 12,759 pairs of patients categorized by the presence or absence of stimulant medication prescription with a decade-long record were matched. The researchers found that the prevalence of cardiomyopathy was 0.36 and 0.31% in the one-year stimulant and nonstimulant groups, respectively. This prevalence increased to 0.72 and 0.53% in the 10-year stimulant and nonstimulant groups, respectively. The one-year stimulant group had higher odds of cardiomyopathy (odds ratio, 1.17), which increased at 8 years (odds ratio, 1.57), then decreased slightly at 10 years (odds ratio, 1.37).

“The longer you leave patients on these medications, the more likely they are to develop cardiomyopathy, but the risk of that is very low,” Gerard said in a statement.

Press Release

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The American College of Physicians (ACP) has issued updated guidelines for the treatment of major depressive disorder (MDD). The recommendations include both nonpharmacologic and pharmacologic interventions for adults in the acute phase of MDD based on a systematic review of available evidence.

For initial treatment of moderate to severe MDD, ACP recommends monotherapy with either cognitive behavioral therapy (CBT) or a second generation antidepressant (eg, selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], bupropion, mirtazapine, nefazodone, trazodone, vilazodone, vortioxetine). If an antidepressant is initiated, the guidelines suggest starting treatment with a low dose to reduce the chances of side effects and improve adherence. A combination of CBT and second generation antidepressant as initial treatment was also suggested as an alternative treatment option.

For patients with moderate to severe MDD who do not respond to initial treatment with an adequate dose of a second generation antidepressant, the clinical guidelines committee (CGC) recommends switching to or adding CBT or switching to a different second generation antidepressant or adding a second pharmacological agent (eg, mirtazapine, bupropion, buspirone).

For patients with mild MDD, monotherapy with CBT is suggested for initial treatment. If access or cost of CBT is a concern, or if the patient has a history of moderate to severe MDD, a second generation antidepressant may be considered for initial treatment, according to the CGC.

When making treatment decisions, the guidelines stress the importance of informed decision making, taking into account patient preferences, the potential benefits and harms of treatment, comorbidities, concomitant medications, and cost.

Additional clinical considerations are available in the full guideline.

References

1. American College of Physicians recommends cognitive behavioral therapy or second-generation antidepressants for adults with major depressive disorder. News release. January 23, 2023. https://www.eurekalert.org/news-releases/976964.
2. Qaseem A, Owens DK, et al. Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: A living clinical guideline from the American College of Physicians. Published online January 24, 2023. Annals of Internal Medicine. doi.org/10.7326/M22-2056

Heidi Taipale, PhD, from the Karolinska Institutet in Stockholm, and colleagues examined the association between use of specific ADHD medications and hospitalization outcomes and work disability in a nationwide register-based cohort study involving adolescents and adults with ADHD during 2006 to 2021. The study cohort included 221,714 persons with ADHD.

The most commonly used ADHD medication was methylphenidate, followed by lisdexamphetamine (68.5 and 35.2%). The researchers found that amphetamine, lisdexamphetamine, ADHD drug polytherapy, dexamphetamine, and methylphenidate were associated with a reduced risk for psychiatric hospitalizations (adjusted hazard ratios, 0.74, 0.80, 0.85, 0.88, and 0.93, respectively). There were no associations seen for modafinil, atomoxetine, clonidine, or guanfacine. Use of dexamphetamine, lisdexamphetamine, and methylphenidate was associated with a reduced risk for suicidal behavior (adjusted hazard ratios, 0.69, 0.76, and 0.92, respectively). Amphetamine, lisdexamphetamine, polytherapy, dexamphetamine, methylphenidate, and atomoxetine were associated with a reduced risk for nonpsychiatric hospitalization. Regarding work disability, the results were only significant for use of atomoxetine (adjusted hazard ratio, 0.89), especially for those aged 16 to 29 years (adjusted hazard ratio, 0.82).

“Considering the high prevalence of psychiatric comorbidity in persons with ADHD, these results suggest that ADHD medication use can reduce morbidity in adolescents and adults with ADHD,” the authors write.

Several authors disclosed ties to the pharmaceutical industry.

Abstract/Full Text

Shebani Sethi, MD, from Stanford Medicine in California, and colleagues investigated the effects of a four-month ketogenic diet on individuals with schizophrenia or bipolar disorder with existing metabolic abnormalities. The analysis included 23 participants in a single arm.

The researchers found improvements in metabolic health, with no participants meeting metabolic syndrome criteria by study conclusion. There were significant reductions in weight (12%), body mass index (12%), waist circumference (13%), and visceral adipose tissue (36%) among adherent individuals. There were also improvements in biomarkers, including a 27% decrease in homeostatic model assessment for insulin resistance and a 25% drop in triglyceride levels. Participants with schizophrenia showed a 32% reduction in Brief Psychiatric Rating Scale scores. Additionally, overall Clinical Global Impression (CGI) severity improved by an average of 31% and the proportion of participants who started with elevated symptomatology improved at least 1 point on the CGI (79%). Participants reported increased life satisfaction (17%) and enhanced sleep quality (19%).

“The ketogenic diet has been proven to be effective for treatment-resistant epileptic seizures by reducing the excitability of neurons in the brain,” Sethi said in a statement. “We thought it would be worth exploring this treatment in psychiatric conditions.”

Abstract/Full Text

Maarten G. Poirot, from University of Amsterdam, and colleagues assessed whether a multimodal machine learning approach could predict early sertraline response in patients with major depressive disorder. The analysis included 229 adult outpatients with unmedicated recurrent or chronic major depressive disorder who underwent magnetic resonance neuroimaging and had clinical data collected before and 1 week after treatment.

The researchers found that internal cross-validation performance was significantly better than chance in predicting response to sertraline (balanced accuracy [bAcc], 68%; area under the receiver operating characteristic curve [AUROC], 0.73). Using external cross-validation on data from placebo nonresponders (bAcc, 62%; AUROC, 0.66) and placebo nonresponders who were switched to sertraline (bAcc, 65%; AUROC, 0.68) resulted in differences that suggest specificity for sertraline treatment vs placebo treatment.

“This is important news for patients. Normally, it takes 6 to 8 weeks before it is known whether an antidepressant will work,” coauthor Liesbeth Reneman, MD, PhD, also from University of Amsterdam, said in a statement. “With this method, we can already prevent two-thirds of the number of ‘erroneous’ prescriptions of sertraline and thus offer better quality of care for the patient. Because the drug also has side effects.”

Several authors disclosed ties to the pharmaceutical or medical technology industries.

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HealthDay News — Augmentation of existing antidepressants with aripiprazole improves well-being among older adults with treatment-resistant depression, according to a study published online March 3 in the New England Journal of Medicine.

Eric J. Lenze, MD, from the Washington University School of Medicine in St. Louis, and colleagues conducted a two-step trial involving adults aged 60 years or older with treatment-resistant depression. A total of 619 patients were enrolled in step 1 and randomly assigned to augmentation of existing antidepressant medication with aripiprazole, augmentation with bupropion, or a switch from existing antidepressant medication to bupropion (211, 206, and 202 patients, respectively). Those who did not benefit from or were ineligible for step 1 were randomly assigned to augmentation with lithium or a switch to nortriptyline in step 2 (127 and 121 patients, respectively).

The researchers found that in step 1, the well-being scores improved by 4.83, 4.33, and 2.04 points, respectively, in the aripiprazole-augmentation, bupropion-augmentation, and switch-to-bupropion groups, with a significant difference seen between the aripiprazole-augmentation group and the switch-to-bupropion group. Remission occurred in 28.9, 28.2, and 19.3% of patients, respectively. The highest rate of falls was seen with bupropion augmentation. In step 2, well-being scores improved by 3.17 and 2.18 points, respectively, with lithium augmentation and switch to nortriptyline. Remission occurred in 18.9 and 21.5%, respectively, and the rate of falls was similar between the groups.

“Given the high prevalence of depression and the extent of nonresponses to first-line therapies, treatment resistance is a great clinical concern and has poor outcomes,” write the authors of an accompanying editorial. “The findings from this trial should help clinicians and older adult patients make informed decisions regarding the next steps, in the absence of a response to conventional pharmacologic approaches.”

Several authors disclosed financial ties to the biopharmaceutical industry.

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Editorial (subscription or payment may be required)

HealthDay News — Americans will continue to be able to get free preventive health care services, at least for now.

The US Court of Appeals for the Fifth Circuit in New Orleans temporarily blocked a lower court decision on Monday, pausing a ruling that challenged an Affordable Care Act (ACA) provision that all health plans cover certain care, The New York Times reported.

The earlier ruling in March, by Judge Reed O’Connor of the Federal District Court for the Northern District of Texas, would have immediately eliminated access to a long list of free preventive services mandated under the ACA since 2010. This was one of the most popular provisions of the ACA and includes depression screening for teens and drugs that prevent HIV transmission for about 150 million Americans enrolled in private employer-sponsored health insurance or through the ACA marketplaces, The Times noted.

O’Connor maintained that the US Preventive Services Task Force, which recommends the list of services, was not appointed by Congress. He ruled that the group did not have the constitutional authority to make a decision about health care services. The USPSTF is an independent group of experts that makes evidence-based recommendations on effective ways to prevent disease and prolong life.

This is not O’Connor’s only ruling on ACA provisions. He ruled in 2018 that the ACA was unconstitutional, a ruling that was later overturned by the US Supreme Court. O’Connor also ruled last September that the ACA mandate requiring coverage of an HIV prevention pill violated a company’s religious freedom, according to the news report.

Americans will keep this free preventive health care while the case works its way through the appeals process. It could end up in the Supreme Court.

The New York Times Article

HealthDay News — Adolescent girls are experiencing increasing levels of sexual violence and persistent levels of sadness or hopelessness, according to a report published online February 13 by the US Centers for Disease Control and Prevention.

Authors from the CDC reviewed the most recent surveillance data and 10-year trends relating to health behaviors and experiences among high school students in the US. These include sexual behaviors, substance use, suicidal thoughts and behaviors, and experiences such as violence and poor mental health.

According to the report, several areas of adolescent health and well-being are continuing to improve overall, including risky sexual behavior and substance use. However, other indicators of health and well-being, including experiences of violence, mental health, and suicidal thoughts and behaviors, have worsened significantly. Female students seem to be faring more poorly than male students, with almost 20% of girls experiencing sexual violence by anyone during the past year; almost 60% experiencing persistent feelings of sadness or hopelessness during the past year; and almost 25% making a suicide plan. Disparities are also seen among students who identify as lesbian, gay, bisexual, questioning, or another nonheterosexual identity, with increased use or misuse of all substances, increased likelihood of experiencing violence, and almost 70% experiencing persistent feelings of sadness or hopelessness.

“These data make it clear that young people in the US are collectively experiencing a level of distress that calls on us to act,” the authors write. “Although the primary goal of schools is academic learning, they also play a critical role in shaping mental, physical, and social growth.”

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