June, 2016 - Western State Hospital Internship Program

June 06 2016

Article Review: Comparative Efficacy And Tolerability Of Antidepressants For Major Depressive Disorder in Children and Adolescents: A Network Meta-Analysis

Major Depressive Disorder (MDD) is one of the most common mental disorders in children and adolescents. The researchers noted estimates suggesting it affects about 3 percent of children aged 6 to 12, and 6 percent of teens aged 13 to 18. Whether to use pharmacological interventions in this population and which drug should be preferred are still matters of controversy. The use of antidepressants among U.S. and U.K. children and teenagers up to age 19 has continued to increase. Antidepressant use among children and teens rose from 1.3 to 1.6 percent between 2005 and 2012, according to a separate study published in The Lancet. The U.S National Institutes of Health estimates that some 2.8 million children (or about 11 percent) between the ages of 12 and 17 have suffered from at least one episode of depression.

Depressive symptoms in children and adolescents are rather undifferentiated. You notice more irritability, aggressive behavior and problems at school. Consequences of depressive episodes in children and adolescents are dramatic because they include impairments in their social functioning, but also an increased risk of suicidal ideation and attempts. According to a study conducted by researchers from McGill University in Montreal, and published in the Journal of the American Medical Association (JAMA), nearly half of people taking depressants are not suffering from depression at all. After researchers analyzed a decade of antidepressant prescription records, they concluded that only 55 percent were given for depression, while the remaining 45 percent was written for conditions such as anxiety, sleeping problems, pain, panic disorders and Attention Deficit Hyperactivity Disorder (ADHD).

For this study, researchers of the University of Oxford conducted a systematic meta-analysis of both published and unpublished randomized control trials on the use of antidepressants for the treatment of major depression in children and young adults up to May 31, 2015. They examined trials on fourteen different antidepressants: amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine. They aimed to compare and rank antidepressants and placebo for MDD in young people. The study also used the Cochrane risk of bias measures to account for the quality of the included studies. The bias analysis was essential to their conclusions as 88 percent of all of the trials were found to have a risk for bias and 65 percent of all of the trials were funded by drug companies.

They found 34 trials eligible, including 5,260 participants ages 9 to 18. Researchers discovered, for efficacy, only fluoxetine was statistically significantly more effective than placebo. In terms of tolerability, fluoxetine was also better than duloxetine and imipramine. Children taking venlafaxine actually showed an increased risk of suicidal thoughts and attempts. Nortriptyline was less effective than seven other antidepressants and the placebo. Imipramine, venlafaxine and duloxetine were the least tolerable, with many patients discontinuing them.

When considering the risk–benefit profile of antidepressants in the acute treatment of MDD, these drugs do not seem to offer a clear advantage for children and adolescents. Fluoxetine is probably the best option to consider when a pharmacological treatment is indicated. The lack of individual-level data from trials makes it difficult to get accurate estimates of just how these drugs affect patients, and how many become suicidal. The authors warn that this doesn’t paint a full picture, since a lack of reliable data did not allow them to fully assess the risk of suicidality for all drugs. That’s partly because 65 percent of the trials they reviewed were funded by pharmaceutical companies. So those reports could have overestimated how well their drugs worked and minimized the side effects.

The authors suggest that parents and medical professionals monitor children and adolescents taking antidepressants closely, regardless of the drug chosen. The brains in children and teens are not yet developed, so it’s important to lead with caution when prescribing medication.

Reference:
Cipriani, A., Zhou, X., Giovane, C.D.; Hetrick, S.E.; Qin, B., Whittington, C.,…Coghill, D. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. The Lancet. DOI: http://dx.doi.org/10.1016/S0140-6736(16)30385-3

Jonathan Torres, M.S.
WKPIC Doctoral Intern

June 06 2016

Friday Factoids Catch-Up: Binge-Eating Disorder

We have all heard or used the phrase “binge eating” or “binging.” It is a phrase that gets thrown around often, especially during the Thanksgiving and Christmas holiday seasons. Most of us use it to describe eating more than normal portions at a meal or continuing to take a few more bites because it tastes so good! However, true binge eating can be a psychological disorder.

Binge-Eating Disorder (BED) is a new diagnosis added to the category of Feeding and Eating Disorders found in the DSM-5. It is the most common eating disorder in the United States. The number of those suffering from BED outnumbers individuals experiencing anorexia and bulimia combined by more than three times. Current estimates suggest that 3.5% of women and 2% of men suffer from this disorder. While the estimated number of people experiencing BED might not initially seem large, when calculated it comes out to be 2.8 million American adults. That puts it into perspective.

So what exactly is BED? It is considered to be, “Eating in response to something other than physical hunger in an attempt to numb unwanted or uncomfortable emotions that goes beyond emotional eating or compulsive overeating,” (Binge-Eating Disorder, 2016). During these binge episodes, individuals have uncontrollable and unstoppable urges to eat. They will even eat to the point of discomfort and/or actual pain. Additionally, during an episode, a BED sufferer may consume several thousand calories which can be very unhealthy. Afterwards, they often feel shameful and guilty. Many desperately try to hide their binge eating from others.

The DSM-5 lists the following official criteria for a BED diagnosis:

A. Recurrent episodes of binge eating characterized by both 1.) Eating in a discrete period of time an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances 2.) a sense of lack of control over eating during the episode

B. The episodes are associated with three or more of the following 1.) Eating much faster than usual 2.) Eating to the point of discomfort or pain 3.) Eating large amounts of food even though you are not physically hungry 4.) Eating alone due to embarrassment resulting from the large amount of food consumed 5.) Feeling guilty, shameful and/or disgusted after the episode.

C. Increased stress due to binge eating

D. Experiencing binge eating episodes at least once a week for three months

E. Binge eating is not followed by unsuitable, compensatory actions (such as bulimia) and does not occur in concurrence with anorexia or bulimia nervosa.

While approximately 30% of individuals with BED fall within normal weight categories for their height, 70% are considered overweight. Bullying, shaming and stigmas surrounding weight can often trigger more intense and/or more frequent episodes of binge eating as well as additional emotional distress. Some additional, common psychological issues that those who suffer from BED experience are OCD, anxiety, and depression. Common physical health issues also experienced are type 2 diabetes, heart disease, sleep apnea, high blood pressure, and osteoarthritis.

Individuals suffering from the symptoms of BED often feel like they are out of control. Through repetition of binge eating, their brains have actually been altered to respond to food in a very comparable way to that of the brain of a substance user/drug addict. Unfortunately, though, they can’t just stop eating. Therefore, the goal of treatment for BED is a reduction or complete cessation of binging episodes. Treatment teams consisting of an individual’s PCP, psychologist and dietician have proven to be more effective then utilizing one of the services alone. Support groups for individuals suffering from BED as well as additional resources can now be found online.

Works Cited
“Binge-Eating Disorder.” Binge-Eating Disorder. N.p., n.d. Web. 02 June 2016. http://www.niddk.nih.gov/health-information/health-topics/weight-Control/binge_eating/Pages/binge-eating-disorder.aspx

“Binge-eating Disorder.” Overview. N.p., 2016. Web. 03 June 2016. http://www.mayoclinic.org/diseases-conditions/binge-eating-disorder/home/ovc-20182926 – 37k

“Eating Disorders: About More Than Food.” NIMH RSS. N.p., n.d. Web. 03 June 2016. https://www.nimh.nih.gov/health/publications/eating-disorders-new trifold/index.shtml

“Info about Binge-Eating Disorder in Adults.” Binge-Eating Disorder. N.p., n.d. Web. 02 June 2016. http://www.bingeeatingdisorder.com/

Crystal Bray
WKPIC Doctoral Intern

June 06 2016

Friday Factoids Catch-Up: Understanding Naltrexone

Unfortunately, in the world we all live in today, most of us know someone who is suffering from opioid and/or alcohol addiction. That or we are struggling with it in our own lives. Regardless of the initial purpose behind using either substance, finding a true cure for those who have become addicted to these substances has become vital, and even more urgent. Enter Naltrexone.

Naltrexone is a prescription drug that is predominantly used in the management of opioid and alcohol dependence. It is sold under the legal trade names of Revia, Depade, and Vivitrol (a once-monthly, extended-released, injectable formulation). Naltrexone is also being used to help save the lives of individuals who have overdosed on opioids. EMS units, ER’s, and even pharmacies carry it for this exact purpose. It literally reverses the effects of opioids within minutes, but how does it work for addiction?

For opioid addiction, naltrexone acts as a blocking agent. It attaches itself to opioid receptors in the brain. It then prevents the receptors from up-taking any the substance which in turn prevents the pleasurable feelings caused by the opioids. However, it does not prevent good feelings that come from other naturally pleasurable activities. This action makes it very beneficial, along with therapy, to assist with opioid relapse prevention.

For alcohol addiction, scientists and doctors are not certain how Naltrexone works but do know it decreases the cravings for alcohol. It is hypothesized that, as with opioid addiction, it works as a blocking agent and prevents the pleasurable feelings drinking alcohol promotes because it partially prevents the uptake of endorphins associated with euphoric inebriation.

Whether taken for alcohol or opioid addiction, Naltrexone does have serious side effects. These include confusion, auditory and/or visual hallucinations, blurred vision, severe vomiting and/or diarrhea, and liver damage. The less severe and more common side effects are nausea, difficulty falling or staying asleep, increased or decreased energy, drowsiness. muscle or joint pain, rash, vomiting, stomach pain or cramping, mild diarrhea, constipation, loss of appetite, headache, dizziness, anxiety, nervousness, irritability and/or tearfulness.

Any individual interested in obtaining a prescription for Naltrexone would need to consult with their medical doctor and be undergoing outpatient/inpatient therapy for substance abuse treatment.

Work Cited
Naltrexone: MedlinePlus Drug Information. (n.d.). Retrieved May 30, 2016, from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a685041.html

VIVITROL® Official Site | VIVITROL® (Naltrexone for extended-release injectable suspension). (n.d.). Retrieved May 30, 2016, from https://www.vivitrol.com/

Crystal Bray,
WKPIC Doctoral Intern

June 06 2016

Friday Factoid Catch-Up: Yeast Infection Linked to Mental Illness

Candida albicans is a yeast-like fungus naturally found in small amounts in human digestive tracts. Symptoms cause burning, itching, thrush, and genital yeast infections. In its more serious forms, it can enter the bloodstream. Most Candida infections can be treated in their early stages, and clinicians should make it a point to look out for these infections in their patients with mental illness. Decreased sugar intake and other dietary modifications, avoidance of unnecessary antibiotics, and improvement of hygiene can prevent Candida infections.

Johns Hopkins researchers focused on a possible association between Candida susceptibility and mental illness. There has been growing evidence suggesting that Schizophrenia may be related to problems with the immune system. For the study, researchers took blood samples from a group of 808 people between the ages of 18 and 65. This group was composed of 277 controls without a history of mental disorder, 261 individuals with Schizophrenia and 270 people with Bipolar Disorder. The researchers used the blood samples to quantify the amount of immunoglobulin G antibodies to Candida, which indicates a past infection.

The research group found that a history of Candida yeast infections was more common in a group of men with Schizophrenia or Bipolar Disorder than in those without these disorders, and that women with Schizophrenia or Bipolar Disorder who tested positive for Candida performed worse on a standard memory test than women with these mental health disorder who had no evidence of past infection. The researchers caution that their findings and do not establish a cause-and-effect relationship between mental illness and yeast infections. This may support the role of lifestyle, immune system weaknesses and gut-brain connections as contributing factors to the risk of psychiatric disorders and memory impairment.

The study found no connection between the presence of Candida antibodies and mental illness overall in the total group. But when the investigators looked only at men, they found 26 percent of those with Schizophrenia had Candida antibodies, compared to 14 percent of the control males. There was not any difference found in infection rate between women with Schizophrenia (31.3 percent) and controls (29.4 percent). Men with Bipolar Disorder had clear increases in Candida as well, with a 26.4 percent infection rate, compared to only 14 percent in male controls. The researchers found that this association could likely be attributed to homelessness. However, the link between men with Schizophrenia and Candida infection could not be explained by homelessness or other environmental factors. Many people who are homeless are subjected to unpredictable changes in stress, sanitation and diet, which can lead to infections like those caused by Candida. The data provided support to the idea that environmental exposures related to lifestyle and immune system factors may be linked to Schizophrenia and Bipolar Disorder.

To determine whether infection with Candida affected any neurological responses, all participants in the study were assessed with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Form A to measure immediate memory, delayed memory, attention skills, use of language and visual-spatial skills. Results showed that the control group had no measureable differences. However, the researchers noticed that women with Schizophrenia and Bipolar Disorder who had a history of Candida infection had lower scores on immediate and delayed memory than the controls.

The data showed that some factor associated with Candida infection, and possibly the organism itself, plays a role in affecting the memory of women with Schizophrenia and Bipolar Disorder. The researchers are investigating whether pathogens, such as bacteria or viruses, may contribute or trigger certain mental disorders.

Reference:
Yolken, R., Gressitt, K., Stallings, C., Katsafanas, E., Schweinfurth, L., Savage, C.,…Markus, F. (2016). Candida albicans exposures, sex specificity and cognitive deficits in schizophrenia and bipolar disorder. Nature Paper Journals. doi:10.1038/npjschz.2016.18

Jonathan Torres, M.S.
WKPIC Pre-doctoral Intern

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Monthly Archives: June 2016

Article Review: Comparative Efficacy And Tolerability Of Antidepressants For Major Depressive Disorder in Children and Adolescents: A Network Meta-Analysis

Friday Factoids Catch-Up: Binge-Eating Disorder

Friday Factoids Catch-Up: Understanding Naltrexone

Friday Factoid Catch-Up: Yeast Infection Linked to Mental Illness

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