Psychotropic Medications Are Prescribed Appropriately Among U.S. Teens, National Study Finds

Prescribed psychotropic medications are not being misused or overused among U.S. youth, according to a study using nationally representative data sponsored by NIMH. The study was published December 3, 2012, online ahead of print in the Archives of Pediatric and Adolescent Medicine. Background Psychotropic medications affect the brain chemicals associated with mood and behavior. Some studies and media reports have raised concerns about their use among youth. However, much of the concern stems from information found in anecdotal reports, small clinical samples, or insurance databases rather than on representative samples of U.S. youth with clinical assessments of emotional and behavioral disorders. Studies from regional community samples have found widely varying rates, which can lead to skewed perceptions. For example, different studies have found a wide range of stimulant medication use for attention deficit hyperactivity disorder (ADHD)—from 7 percent to 72 percent—likely due to methodological and regional differences. As a result, it has been difficult to get a clear, accurate understanding of medication use among youth. Kathleen Merikangas, Ph.D., of NIMH and colleagues collected information on specific medication use in the National Comorbidity Study-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey from 2004 of more than 10,000 teens ages 13 to 18.The teens were asked questions that helped to ascertain information about mental disorders and service use. A previous report published in October 2010 using data from the NCS-A indicated that about 20 percent of U.S. youth are affected by some type of mental disorder during their lifetime serious enough to affect their functioning. In this most recent analysis, the researchers examined patterns of prescribed medication use among youth who met criteria for a wide range of mental disorders. Psychotropic medications that were examined include antipsychotics, antidepressants, and stimulants Professional Counselor Continuing Education Results of the Study Among those youth who met criteria for any mental disorder, 14.2 percent reported that they had been treated with a psychotropic medication. Teens with ADHD had the highest rates of prescribed medication use at 31 percent, while 19.7 percent of those with a mood disorder like depression or bipolar disorder were taking psychotropic medication. Among those with eating disorders, about 19 percent were taking a psychotropic medication, and 11.6 percent of those with anxiety disorders reported taking medication. Very few youth reported use of antipsychotic medications. They were most frequently used by youth with severe bipolar disorder (1.7 percent) or a neurodevelopmental disorder such as autism (2.0 percent). Approximately 2.5 percent of teens without a diagnosed mental disorder were prescribed a psychotropic medication. Among these youth, 78 percent reported having a previous mental or neurodevelopmental disorder and associated psychological distress or impairment. Significance The data suggest that most adolescent youth who are taking psychotropic medications have serious behavioral, cognitive or emotional disturbances. The findings also showed that youth being treated by a mental health professional were more likely to be receiving appropriate medication as opposed to those being treated within general medicine or other settings. However, more research is needed on medication use among children younger than age 13. Reference Merikangas K, He J, Rapoport J, Vitiello B, Olfson M. Medication use in US Youth with Mental Disorders. Archives of Pediatric and Adolescent Medicine. Online ahead of print Dec 3, 2012.

Switching Off a Specific Brain Region Can Alter Ingrained Habits in Rats

Ingrained habits in rats can be quickly broken—and reestablished—by targeting and switching off a specific site in the brain’s prefrontal cortex using a technique known as optogenetics, according to an NIMH-funded study published November 13, 2012, in the Proceedings of the National Academy of Sciences (PNAS). Background Studies have established that the prefrontal region of the brain is associated with habit formation and expression. It is also linked to emotion regulation and to regions in the brain that are associated with behavioral flexibility, which counteracts habit. Kyle Smith Ph.D., Ann Graybiel Ph.D., of the Massachusetts Institute of Technology, and colleagues, trained rats to run a T-shaped maze. At the decision point, the rats were cued to turn to either one side, where chocolate milk awaited them as a reward, or to the other side, where the reward was sugar water. Eventually, running the maze and responding to each cue correctly became a habit, and the rats continued to do so even after the rewards were removed. The researchers then returned the rewards but paired the chocolate milk with exposure to lithium chloride, which causes nausea. Once the rats realized the milk made them ill, they declined to drink it. However, they continued to run the maze and turn toward the chocolate milk side of the maze when cued, indicating that running in that direction when prompted had become a nearly automatic behavior. Results of the Study To determine whether the habit could be broken, the researchers then applied a technique known as optogenetics—in which a laser light is delivered to brain cells through optical fibers—to see if they could manipulate a specific region of the rats’ prefrontal cortex known as the infralimbic (IL) cortex. When the laser was turned on and the IL cortex was disrupted, the rats nearly instantaneously stopped running habitually toward the chocolate milk reward. Instead, they appeared to act more thoughtfully, running toward the other side, where the untainted sugar water awaited. Once the rats were broken of the habit of running automatically to the chocolate milk side, they began to develop a habit of always running to the other side, even when they were cued to run toward the chocolate milk, and even after the untainted chocolate milk was returned. But when the IL region was again disrupted optogenetically, the rats returned to their original habit of running to the chocolate milk side when cued to do so. Significance Control of a small part of the prefrontal cortex can change whether or not habits are expressed. An old habit can be blocked abruptly, and a new habit can override it. But if the new habit is then blocked, the old habit returns, thus lending credence to the notion that old habits die hard Social Worker Continuing Education In addition, the fact that habitual behavior can be altered if IL activity is disturbed suggests that the circuitry in this region of the brain is coordinating on some level with other brain regions that directly access circuits involved in behavioral flexibility, as well as addictive behaviors. What’s Next Although the optogenetic technique is too invasive to use in humans, it does have implications for potentially disrupting destructive habits. Targeting this specific region of the brain could lead to better ways of controlling addiction disorders or mental disorders in which habitual behaviors are out of balance, such as obsessive compulsive disorder. Reference Smith K, Virkud A, Deisseroth K, Graybiel A. Reversible online control of habitual behavior by optogenetic perturbation of media prefrontal cortex. PNAS. Nov 13, 2012. 109(46):18932-18937.

Study: Use of antipsychotic drugs improves life expectancy for individuals with schizophrenia

Results of a Johns Hopkins study suggest that individuals with schizophrenia are significantly more likely to live longer if they take their antipsychotic drugs on schedule, avoid extremely high doses and also regularly see a mental health professional. Psychiatrists have long known that people with schizophrenia who stick to a drug regimen have fewer of the debilitating delusions and hallucinations that are hallmarks of this illness. But there have been concerns about whether some of the known side effects of the medications — increased risk of cardiovascular disease and diabetes, for example — carry higher mortality risks, the researchers say. "We know that antipsychotic medications reduce symptoms, and our study shows that staying on reasonable, recommended doses is associated with longer life," says Bernadette A. Cullen, M.B., B.Ch., B.A.O., MRCPsych, an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine, and leader of the study published in Schizophrenia Bulletin. "The same is true for going to see a psychiatrist or therapist," she says, noting that regular visits to a mental health professional are one way to monitor and encourage drug-use compliance, but also in and of themselves increased survival in this vulnerable population. Cullen and her colleagues analyzed data collected between 1994 through 2004 on 2,132 adult Maryland Medicaid beneficiaries with schizophrenia. The researchers reviewed how much medication the patients took, how regularly they took it and how often they visited a mental health professional. The goal of the study was to review how adherence to the 2009 pharmacological Schizophrenia Patient Outcomes Research Team (PORT) guidelines was associated with mortality in this population. Comparing data from year to year, the researchers found that among those patients who had 90 percent or better compliance with their medication schedules, the risk of death was 25 percent lower compared to those who were less than 10 percent compliant. Over the decade-long study period, taking medication did not increase the risk of death and there was a trend towards reducing the mortality rate. In addition, the researchers found that each additional visit per year to a mental health professional was linked to a 5 percent reduction in risk of death overall LSW Continuing Education Cullen's study did not rule out all links between increased mortality and antipsychotic drugs. For example, her team found that people who took high doses of first-generation antipsychotic medication daily (1500 mg or greater chlorpromazine equivalents) were 88 percent more likely to die. She says mortality rates possibly increased in this group because first-generation antipsychotics have been associated with cardiac disease risks, and among those who died while taking the larger doses, 53 percent died of cardiovascular disease. "These drugs work very well, but there is clearly a point of diminishing returns," she says. "You rarely need to be on extremely high doses." Among those whose information was reviewed, the most common cause of death was cardiovascular disease (28 percent); unintended harm, including suicide, was responsible for 8 percent. "If people are taking their medications, they usually have fewer symptoms and are able to be more organized in other areas of their lives," says Cullen, director of community psychiatry at The Johns Hopkins Hospital. "We believe they are then more likely to make appointments with their primary care doctors, to stay on top of other illnesses they may have and to regularly take diabetes, blood pressure or cholesterol medication that they may require to stay healthy. We also believe that they are more likely to be socially engaged and have a healthier lifestyle." "If your illness is under control, you can do a lot more," she adds. Cullen says the study clearly lays out the value of mental health providers to individuals with schizophrenia. Those who saw therapists or psychiatrists were more likely to survive, regardless of whether the individual also took his or her antipsychotic medication on a regular basis, she says. This finding is crucial, she says, given that Maryland Medicaid officials are considering capping the number of mental health visits allowed each year, something the data now suggest is potentially detrimental to survival. Cullen notes that adherence to a medication regimen and moderate first-generation antipsychotic dosing are both part of the 2009 PORT recommendations designed to guide treatment. ### The study was supported by a grant from the National Institutes of Health's National Institute of Mental Health (R01MH074070). Other Johns Hopkins researchers involved in the study include Emma E. McGinty, M.S.; Yiyi Zhang, Ph.D.; Susan dos Reis, Ph.D.; Donald M. Steinwachs, Ph.D.; Eliseo Guallar, M.D., Dr.PH.; and Gail L. Daumit, M.D., M.H.S. For more information: http://www.hopkinsmedicine.org/psychiatry/specialty_areas/community_psych/

Autism early intervention found to normalize brain activity in children as young as 18 months

An intensive early intervention therapy that is effective for improving cognition and language skills among very young children with autism also normalizes their brain activity, decreases their autism symptoms and improves their social skills, a nationwide study has found. The researchers said the study is the first to demonstrate that an autism early intervention program can normalize brain activity. "We know that infant brains are quite malleable and previously demonstrated that this therapy capitalizes on the potential of learning that an infant brain has in order to limit autism's deleterious effects," said study author Sally Rogers, professor of psychiatry and behavioral sciences and a researcher with the UC Davis MIND Institute. "The findings on improved behavioral outcomes and the ability to normalize brain activity associated with social activities signify that there is tremendous potential for the brains of children with autism to develop and grow more normally," Rogers said. Published online today in the Journal of the American Academy of Child & Adolescent Psychiatry, the randomized, case-controlled, multi-centered study titled "Early behavioral intervention is associated with normalized brain activity in young children with autism," found that the children who received the intervention exhibited greater brain activation when viewing faces rather than objects, a response that was typical of the normal children in the study, and the opposite of the children with autism who received other intervention counselor ceus The U.S. Centers for Disease Control and Prevention estimates that 1 in 88 children born today will be diagnosed with autism spectrum disorder. Hallmarks of the neurodevelopmental condition include persistent deficits in social communication and relatedness, and repetitive or restrictive patterns of interest that appear in early childhood and impair everyday functioning. Named the Early Start Denver Model (ESDM), the intervention method was developed by Rogers and Geraldine Dawson, chief science officer of the research and advocacy organization Autism Speaks. The therapy fuses a play-based, developmental, relationship-based approach and the teaching methods of applied behavioral analysis. "This may be the first demonstration that a behavioral intervention for autism is associated with changes in brain function as well as positive changes in behavior," said Thomas R. Insel, director of the National Institute of Mental Health, which funded the study. "By studying changes in the neural response to faces, Dawson and her colleagues have identified a new target and a potential biomarker that can guide treatment development." For the present study, the researchers recruited 48 diverse male and female children diagnosed with autism between 18 and 30 months in Sacramento, Calif., and in Seattle, as well as typically developing case controls. The ratio of male-to-female participants was more than 3-to-1. Autism is five times more common among boys than girls. Approximately half of the children with autism were randomly assigned to receive the ESDM intervention for over two years. The participants received ESDM therapy for 20 hours each week, and their parents also were trained to deliver the treatment, a core feature of the intervention. The other participants with autism received similar amounts of various community-based interventions as well as evaluations, referrals, resource manuals and other reading materials. At the study's conclusion, the participants' brain activity was assessed using electroencephalograms (EEGs) that measured brain activation while viewing social stimuli -- faces -- and non-social stimuli -- toys. Earlier studies have found that typical infants and young children show increased brain activity when viewing social stimuli rather than objects, while children with autism show the opposite pattern. Twice as many of the children who received the ESDM intervention showed greater brain activation when viewing faces rather than when viewing objects -- a demonstration of normalized brain activity. Eleven of the 15 children who received the ESDM intervention, 73 percent, showed more brain activation when viewing faces than toys. Similarly, 12 of the 17 typically developing children, or 71 percent, showed the same pattern. But the majority -- 64 percent -- of the recipients of the community intervention showed the opposite, "autistic" pattern, i.e., greater response to toys than faces. Only 5 percent showed the brain activation of typical children. Further, the children receiving ESDM who had greater brain activity while viewing faces also had fewer social-pragmatic problems and improved social communication, including the ability to initiate interactions, make eye contact and imitate others, said MIND Institute researcher Rogers. Use of the ESDM intervention has been shown to improve cognition, language and daily living skills. A study published in 2009 found that ESDM recipients showed more than three times as much gain in IQ and language than the recipients of community interventions. "This is the first case-controlled study of an intensive early intervention that demonstrates both improvement of social skills and normalized brain activity resulting from intensive early intervention therapy," said Dawson, the study's lead author and professor of psychiatry at the University of North Carolina, Chapel Hill. "Given that the American Academy of Pediatrics recommends that all 18- and 24-month-old children be screened for autism, it is vital that we have effective therapies available for young children as soon as they are diagnosed." "For the first time," Dawson continued, "parents and practitioners have evidence that early intervention can alter the course of brain and behavioral development in young children. It is crucial that all children with autism have access to early intervention which can promote the most positive long-term outcomes." Rogers, Dawson and Laurie J. Vismara, also a researcher with the MIND Institute, have authored two books on the intervention. One for professionals is titled "Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement" and one for parents titled "An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate, and Learn." The ESDM intervention is available in Sacramento through the MIND Institute clinic and in a number of locations throughout the U.S. and other nations. Training in delivering the ESDM method is provided through the MIND Institute and the University of Washington. ### Other study authors include Emily J.H. Jones, Kaitlin Venema, Rachel Lowy, Susan Faja, Dana Kamara, Michale Murias, Jessica Greenson, Jamie Winter, Milani Smith and Sara J. Webb, all of the University of Washington, and Kristen Merkle of Vanderbilt University. The study was funded by a grant from the National Institute of Mental Health and by a postdoctoral fellowship to Jones from Autism Speaks. Autism Speaks is the world's leading autism science and advocacy organization. It is dedicated to funding research into the causes, prevention, treatments and a cure for autism; increasing awareness of autism spectrum disorders; and advocating for the needs of individuals with autism and their families. At the UC Davis MIND Institute, world-renowned scientists engage in collaborative, interdisciplinary research to find the causes of and develop treatments and cures for autism, attention-deficit/hyperactivity disorder (ADHD), fragile X syndrome, 22q11.2 deletion syndrome, Down syndrome and other neurodevelopmental disorders. For more information, visit mindinstitute.ucdavis.edu

WSU researchers find the missing link between mental health disorders and chronic diseases in Iraq war refugees

October 15, 2012Subjects who fled Iraq after Gulf War were 43 times more likely to suffer from obstructive sleep apneaDETROIT – Wayne State University School of Medicine researchers may have discovered why people exposed to war are at increased risk to develop chronic problems like heart disease years later. And the culprit that links the two is surprising.Beginning in the mid-2000s, WSU researchers interviewed a random sample of 145 American immigrants who left Iraq before the 1991 Gulf War, and 205 who fled Iraq after the Gulf War began. All were residing in metropolitan Detroit at the time of the study. Study subjects were asked about socio-demographics, pre-migration trauma, how they rated their current health, physician-diagnosed and physician-treated obstructive sleep apnea, somatic disorders and psychosomatic disorders. Those who left Iraq after the war began and suffered from mental disorders such as post-traumatic stress disorder (PTSD) and depression, and self-rated their physical health as worse than their actual health, were 43 times more likely than pre-Gulf War immigrants to report obstructive sleep apnea (30.2 percent versus 0.7 percent) and later develop major chronic health issues such as cardiovascular disease.“I was surprised, but we had a specific theory we wanted to test. Changes in the stress system would contribute to sleep apnea. What happens? Maybe it’s the stress that leads to this fractured sleep,” said Bengt Arnetz, M.D., Ph.D., M.P.H., School of Medicine professor of occupational and environmental health, deputy director of the Institute of Environmental Health Sciences at Wayne State, and the study’s principal investigator and first author. “No one had explored this possible link before, although basic research suggests it as plausible.”The results are featured in the October 2012 issue of Psychosomatic Medicine, the peer-reviewed journal of the American Psychosomatic Society.According to the article, “Obstructive Sleep Apnea, Post-traumatic Stress Disorder, and Health in Immigrants,” obstructive sleep apnea occurs when the muscles supporting the soft palate at the back of the throat relax, but less is known about the reasons behind this neuromuscular malfunctioning.“It’s a known fact that the more exposure to violence you have, the more likely you are to report PTSD and depression, and the worse your self-rated health is, the more likely your actual health will suffer in five to 10 years,” Arnetz said.Hikmet Jamil, M.D., Ph.D., professor of occupational and environmental health in WSU’s School of Medicine, and Thomas Templin, Ph.D., research professor in WSU’s College of Nursing, also contributed to the article.The obstructive sleep apnea and chronic disase link has been observed among many trauma-exposed populations, including refugees, Arnetz said.“Iraqis were exposed to harsh conditions during the entirety of Saddam Hussein’s more than 20 years of reign. However, trauma and environmental exposures increased measurably and dramatically after the initiation of the 1991 Gulf War,” the article states.The study can now be used as a model for other populations, including U.S. soldiers returning home from battle.The multidisciplinary study brought together mental health research, sleep research and chronic disease research, Arnetz said.He and Jamil were partially supported by the National Institute of Mental Health of the National Institutes of Health (award number R01MH085793).To further test their ideas, the researchers plan to apply for funding from the National Institutes of Health to collaborate with Safwan Badr, M.D., professor and chief of the School of Medicine’s Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, and Thomas Roth, Ph.D., director of the Henry Ford Sleep Disorders and Research Center.###Wayne State University is one of the nation’s pre-eminent public research universities in an urban setting. Through its multidisciplinary approach to research and education, and its ongoing collaboration with government, industry and other institutions, the university seeks to enhance economic growth and improve the quality of life in the city of Detroit, state of Michigan and throughout the world. For more information about research at Wayne State University, visit http://www.research.wayne.edu.Founded in 1868, the Wayne State University School of Medicine is the largest single-campus medical school in the nation, with more than 1,000 medical students. In addition to undergraduate medical education, the school offers master’s degree, Ph.D. and M.D.-Ph.D. programs in 14 areas of basic science to about 400 students annually Professional Counselor Continuing Education

School-wide interventions improve student behavior

An analysis of a school behavior strategy—known as School-Wide Positive Behavioral Interventions and Supports (SWPBIS)—found that these types of programs significantly reduced children's aggressive behaviors and office discipline referrals, as well as improved problems with concentration and emotional regulation. The study, conducted by researchers from the Johns Hopkins Bloomberg School of Public Health, is the first randomized control trial to examine the impact of SWPBIS programs over multiple school years. The results were published October 15 in the journal Pediatrics as an eFirst publication.SWPBIS is a prevention strategy that aims to alter student behavior by setting universal, positively stated expectations for student behavior that are implemented across the entire school. Policies and decisions related to student behaviors are based on data analysis. SWPBIS programs are used in more than 16,000 schools in the U.S."These findings are very exciting, given the wide use of SWPBIS across the country. These results are among the first to document significant impacts of the program on children's problem behaviors, as well as positive behaviors, across multiple years as a result of SWPBIS," said Catherine P. Bradshaw, PhD, MEd, lead author of the study and associate professor in the Bloomberg School's Department of Mental Health.The randomized trial included a representative sample of 12,344 elementary school children from 37 schools. Approximately half of the students received free or reduced-priced meals, and nearly 13 percent received special education services. The researchers analyzed teachers' ratings of students' behavior and concentration problems, social-emotional functioning, pro-social behavior, office discipline referrals, and suspension over 4 school years.Overall, the study found significant improvement in children's behavior problems, concentration problems, social-emotional functioning, and pro-social behavior in schools using SWPBIS. Children in SWPBIS schools also were 33 percent less likely to receive an office discipline referral than those in the comparison schools. The effects tended to be strongest among children who were first exposed to SWPBIS in kindergarten."A unique feature of the model is the overall structure that is formed in schools to support sustainable services for students across a range of behavioral needs LCSW Continuing Education Using this framework, school staff can identify students at greatest need of services and efficiently target programs and resources to them," said Bradshaw.###The author of "Effects of School-Wide Positive Behavioral Interventions and Supports on Child Behavior Problems" include Catherine Bradshaw, PhD, MEd; Tracy E. Waasdorp, PhD, MEd; and Philip J. Leaf, PhD.

Many Teens Considering Suicide Do Not Receive Specialized Mental Health Care

HomeScience NewsScience News from 2012Science Update • October 12, 2012

Many Teens Considering Suicide Do Not Receive Specialized Mental Health Care

Source: iStockPhotoMost adolescents who are considering suicide or who have attempted suicide do not receive specialized mental health services, according to an analysis published online August 15, 2012, in Psychiatric Services, a journal of the American Psychiatric Association.

Background

National survey data from the Centers for Disease Control and Prevention (CDC) notes that approximately 14 percent of high school students seriously consider suicide each year, 11 percent have a suicide plan, and 6 percent attempt suicide. Other research has suggested that less than half of teens who attempt suicide received mental health services in the year prior to their attempt.Kathleen Merikangas, Ph.D., of NIMH and colleagues analyzed data from the National Comorbidity Survey-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey of more than 10,000 teens ages 13 to 18. They asked teens whether they had any suicidal thoughts, plans, or actions (ideation) over a one-year period prior to the survey. They also completed a structured diagnostic interview regarding the full range of mental disorders including mood, anxiety, eating and anxiety disorders and whether they had received treatment for emotional or behavioral problems in the past 12 months. Respondents were asked to differentiate between receiving care from a mental health specialist such as a social worker, psychiatrist or other mental health professional, and receiving care from a general service provider, such as a primary care physician.

Results of the study

The survey revealed that, within the past year, 3.6 percent of adolescents had suicidal thoughts, but did not make a specific plan or suicide attempt. In addition, 0.6 percent reported having a plan, and 1.9 percent reported having made a suicide attempt within the past year.Suicidal behavior among youth was not only associated with major depression, but also with a range of other mental health problems including eating, anxiety, substance use and behavior disorders, as well as physical health problems. Between 50 and 75 percent of those teens who reported having suicidal ideation had recent contact with a service provider. However, most only had three or fewer visits, suggesting that treatment tends to be terminated prematurely. Moreover, most teens with suicidal ideation did not receive specialized mental health care.

Significance

The results of this study suggest that depression and other mood disorders are not the only pathways to suicide. They also highlight the importance of integrating risk assessment for suicide into routine physical and mental health care for teens. Even if adolescents are in treatment, they should continue to be monitored for suicidal ideation and behaviors, the researchers concluded.

Reference

Husky M, Olfson M, He J, Nock M, Swanson S, Merikangas K. Twelve-month suicidal symptoms and use of services among adolescents: results from the National Comorbidity Survey. Psychiatric Services in Advance, Aug 15, 2012. 

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