MDedge Psychiatry

The percentage of Americans who have been infected with COVID-19 jumped from 34% in December 2021 to 58% in February 2022, a new study from the Centers for Disease Control and Prevention reveals.

This is the first time the seroprevalence of prior infection is more than 50% in the American population.

“I definitely expected that we were going to see an increase continue ... but I didn’t expect it to increase quite this much. But we follow the data ... and this is what the evidence is showing us,” lead study researcher Kristie E. N. Clarke, MD, said during a CDC media briefing April 26.

Researchers found that presence of antinucleocapsid (anti-N) antibodies from prior infection varied by age. The rate varied from as high as 75% in children and teenagers 17 years and younger to 33% in those 65 and older, for example.  

The study showed that the anti-N antibodies were more common in age groups with the lowest vaccination numbers.

Combined with up-to-date CDC data on deaths, hospitalizations, and cases, the study provides a clearer picture of where we are now and where we might be headed in terms of the pandemic.
 

Vaccination still valuable

The fact that nearly 60% of Americans have antibodies from prior infection is not a reason to think people with a history of COVID-19 should skip vaccination, said CDC director Rochelle P. Walensky, MD.

“I can’t underscore enough that those with detectable antibodies from previous infection, we encourage them to still get vaccinated,” Dr. Walensky said.

“We do know that reinfections happen,” she said, “so that’s important in terms of thinking forward.”

The CDC continues to encourage all Americans to stay up to date with their COVID-19 vaccinations, said Dr. Clarke, colead for the CDC’s COVID-19 Epidemiology and Surveillance Taskforce Seroprevalence Team. “Having infection-induced antibodies does not necessarily mean you are protected against future infections.”

The study, published in the CDC’s Morbidity and Mortality Weekly Report (MMWR), did not evaluate antibody protection from COVID-19 vaccination.

It should also be noted that the study looked at presence or absence of anti-N antibodies, and not whether certain levels were linked to less or more protection.
 

Where are we now?

Dr. Walensky used the media briefing as an opportunity to share current COVID-19 numbers.

“Overall, we can continue to have some mixed trends. Deaths, fortunately, are continuing to trend downward with a 7-day average of about 300 per day, which represents an estimated 18% decline from the prior week,” she said.

Hospital admissions also remain low, at about 1,500 per day. “But we should note that for the second week in a row, they are slowly trending upwards,” Dr. Walensky said. There was an increase of about 9% at press time compared with the prior week.

Cases remain “comparatively low” to even where we were a month ago, at 44,000 per day,” Dr. Walensky said. “Although this too represents an increase of about 25% in the past week.”

Dr. Walensky noted that positive test numbers are not as reliable a metric as they were before the growth in use of rapid home tests. But it’s not the only measure. “We continue to believe that our PCR testing data, especially when we corroborate it with information from our other surveillance systems – like wastewater surveillance and emergency department surveillance – provide us a reliable picture of the trajectory of COVID-19 across our country.”

She recommended that people continue to consult the CDC’s COVID-19 county tracker to monitor local levels of COVID-19.

Dr. Walensky also shared recent findings from genomic sequencing that continue to show the predominance of the Omicron variant. “Essentially a hundred percent of what we’re finding now is Omicron,” she said. In terms of individual variants, the Omicron BA.1 variant is about 3% of circulating virus, the BA.2 variant is about 68%, and BA.2.12.1 makes up about 35%.

“We’re just starting to learn about the impact of BA2.121,” Dr. Walensky said. “It appears it might have a transmission advantage of about 25% over the BA2 subvariant.”

A version of this article first appeared on Medscape.com.

The percentage of Americans who have been infected with COVID-19 jumped from 34% in December 2021 to 58% in February 2022, a new study from the Centers for Disease Control and Prevention reveals.

This is the first time the seroprevalence of prior infection is more than 50% in the American population.

“I definitely expected that we were going to see an increase continue ... but I didn’t expect it to increase quite this much. But we follow the data ... and this is what the evidence is showing us,” lead study researcher Kristie E. N. Clarke, MD, said during a CDC media briefing April 26.

Researchers found that presence of antinucleocapsid (anti-N) antibodies from prior infection varied by age. The rate varied from as high as 75% in children and teenagers 17 years and younger to 33% in those 65 and older, for example.  

The study showed that the anti-N antibodies were more common in age groups with the lowest vaccination numbers.

Combined with up-to-date CDC data on deaths, hospitalizations, and cases, the study provides a clearer picture of where we are now and where we might be headed in terms of the pandemic.
 

Vaccination still valuable

The fact that nearly 60% of Americans have antibodies from prior infection is not a reason to think people with a history of COVID-19 should skip vaccination, said CDC director Rochelle P. Walensky, MD.

“I can’t underscore enough that those with detectable antibodies from previous infection, we encourage them to still get vaccinated,” Dr. Walensky said.

“We do know that reinfections happen,” she said, “so that’s important in terms of thinking forward.”

The CDC continues to encourage all Americans to stay up to date with their COVID-19 vaccinations, said Dr. Clarke, colead for the CDC’s COVID-19 Epidemiology and Surveillance Taskforce Seroprevalence Team. “Having infection-induced antibodies does not necessarily mean you are protected against future infections.”

The study, published in the CDC’s Morbidity and Mortality Weekly Report (MMWR), did not evaluate antibody protection from COVID-19 vaccination.

It should also be noted that the study looked at presence or absence of anti-N antibodies, and not whether certain levels were linked to less or more protection.
 

Where are we now?

Dr. Walensky used the media briefing as an opportunity to share current COVID-19 numbers.

“Overall, we can continue to have some mixed trends. Deaths, fortunately, are continuing to trend downward with a 7-day average of about 300 per day, which represents an estimated 18% decline from the prior week,” she said.

Hospital admissions also remain low, at about 1,500 per day. “But we should note that for the second week in a row, they are slowly trending upwards,” Dr. Walensky said. There was an increase of about 9% at press time compared with the prior week.

Cases remain “comparatively low” to even where we were a month ago, at 44,000 per day,” Dr. Walensky said. “Although this too represents an increase of about 25% in the past week.”

Dr. Walensky noted that positive test numbers are not as reliable a metric as they were before the growth in use of rapid home tests. But it’s not the only measure. “We continue to believe that our PCR testing data, especially when we corroborate it with information from our other surveillance systems – like wastewater surveillance and emergency department surveillance – provide us a reliable picture of the trajectory of COVID-19 across our country.”

She recommended that people continue to consult the CDC’s COVID-19 county tracker to monitor local levels of COVID-19.

Dr. Walensky also shared recent findings from genomic sequencing that continue to show the predominance of the Omicron variant. “Essentially a hundred percent of what we’re finding now is Omicron,” she said. In terms of individual variants, the Omicron BA.1 variant is about 3% of circulating virus, the BA.2 variant is about 68%, and BA.2.12.1 makes up about 35%.

“We’re just starting to learn about the impact of BA2.121,” Dr. Walensky said. “It appears it might have a transmission advantage of about 25% over the BA2 subvariant.”

A version of this article first appeared on Medscape.com.

The percentage of Americans who have been infected with COVID-19 jumped from 34% in December 2021 to 58% in February 2022, a new study from the Centers for Disease Control and Prevention reveals.

This is the first time the seroprevalence of prior infection is more than 50% in the American population.

“I definitely expected that we were going to see an increase continue ... but I didn’t expect it to increase quite this much. But we follow the data ... and this is what the evidence is showing us,” lead study researcher Kristie E. N. Clarke, MD, said during a CDC media briefing April 26.

Researchers found that presence of antinucleocapsid (anti-N) antibodies from prior infection varied by age. The rate varied from as high as 75% in children and teenagers 17 years and younger to 33% in those 65 and older, for example.  

The study showed that the anti-N antibodies were more common in age groups with the lowest vaccination numbers.

Combined with up-to-date CDC data on deaths, hospitalizations, and cases, the study provides a clearer picture of where we are now and where we might be headed in terms of the pandemic.
 

Vaccination still valuable

The fact that nearly 60% of Americans have antibodies from prior infection is not a reason to think people with a history of COVID-19 should skip vaccination, said CDC director Rochelle P. Walensky, MD.

“I can’t underscore enough that those with detectable antibodies from previous infection, we encourage them to still get vaccinated,” Dr. Walensky said.

“We do know that reinfections happen,” she said, “so that’s important in terms of thinking forward.”

The CDC continues to encourage all Americans to stay up to date with their COVID-19 vaccinations, said Dr. Clarke, colead for the CDC’s COVID-19 Epidemiology and Surveillance Taskforce Seroprevalence Team. “Having infection-induced antibodies does not necessarily mean you are protected against future infections.”

The study, published in the CDC’s Morbidity and Mortality Weekly Report (MMWR), did not evaluate antibody protection from COVID-19 vaccination.

It should also be noted that the study looked at presence or absence of anti-N antibodies, and not whether certain levels were linked to less or more protection.
 

Where are we now?

Dr. Walensky used the media briefing as an opportunity to share current COVID-19 numbers.

“Overall, we can continue to have some mixed trends. Deaths, fortunately, are continuing to trend downward with a 7-day average of about 300 per day, which represents an estimated 18% decline from the prior week,” she said.

Hospital admissions also remain low, at about 1,500 per day. “But we should note that for the second week in a row, they are slowly trending upwards,” Dr. Walensky said. There was an increase of about 9% at press time compared with the prior week.

Cases remain “comparatively low” to even where we were a month ago, at 44,000 per day,” Dr. Walensky said. “Although this too represents an increase of about 25% in the past week.”

Dr. Walensky noted that positive test numbers are not as reliable a metric as they were before the growth in use of rapid home tests. But it’s not the only measure. “We continue to believe that our PCR testing data, especially when we corroborate it with information from our other surveillance systems – like wastewater surveillance and emergency department surveillance – provide us a reliable picture of the trajectory of COVID-19 across our country.”

She recommended that people continue to consult the CDC’s COVID-19 county tracker to monitor local levels of COVID-19.

Dr. Walensky also shared recent findings from genomic sequencing that continue to show the predominance of the Omicron variant. “Essentially a hundred percent of what we’re finding now is Omicron,” she said. In terms of individual variants, the Omicron BA.1 variant is about 3% of circulating virus, the BA.2 variant is about 68%, and BA.2.12.1 makes up about 35%.

“We’re just starting to learn about the impact of BA2.121,” Dr. Walensky said. “It appears it might have a transmission advantage of about 25% over the BA2 subvariant.”

A version of this article first appeared on Medscape.com.

A novel virtual reality (VR) intervention significantly reduces agoraphobia in patients with psychosis, new research suggests.

The cognitive-behavioral therapy–based treatment was particularly effective for patients with the highest level of avoidance of everyday situations.

Courtesy University of Oxford

“Virtual reality is an inherently therapeutic medium which could be extremely useful in mental health services,” study investigator Daniel Freeman, PhD, DClinPsy, professor of clinical psychology, University of Oxford (England), told this news organization.  “This intervention is coming; the question really is when.”

The study was published online  in The Lancet Psychiatry.
 

Real-world feel

Immersive VR involves interactive three-dimensional computer-generated environments that produce the sensation of being in the real world.

For patients with psychosis, dealing with the real world can be an anxious experience, particularly if they have verbal or auditory hallucinations.

Some may develop agoraphobia and start to avoid places or situations. A virtual environment allows patients to practice dealing with situations that make them anxious or uncomfortable and to learn to reengage in everyday situations.

The study included 346 patients diagnosed with schizophrenia or a related disorder. The mean age of the patients was 37.2 years (67% were men, 85% were White). Most were single and unemployed. All were receiving treatment for psychosis and had difficulty going out because of anxiety.

The researchers randomly assigned 174 participants to an automated VR cognitive therapy intervention (gameChange) plus usual care and 172 to usual care alone. Trial assessors were blinded to group allocation.

The gameChange intervention was delivered in six sessions that were conducted over a 6-week period. Each session involved 30 minutes of VR.

A session begins when participants enter the virtual therapist’s office. They are met by a coach who guides them through the therapy. They can choose from among six VR social situations. These include a cafe, a general practice waiting room, a pub, a bus, opening the front door of their home onto the street, or entering a small local shop.

Each scenario has five levels of difficulty that are based on the number and proximity of people in the social situation and the degree of social interaction. Users can work their way through these various levels.

The virtual sessions took place in patients’ homes in about 50% of cases; the remainder were conducted in the clinic. A mental health worker was in the room during the therapy.

Between virtual sessions, participants were encouraged to apply what they learned in the real world, for example, by spending time in a pub.

Usual care typically included regular visits from a community mental health worker and occasional outpatient appointments with a psychiatrist.
 

Widely applicable?

The primary outcome was the eight-item Oxford Agoraphobic Avoidance Scale (O-AS) questionnaire. This scale assesses distress and avoidance related to performing increasingly difficult everyday tasks.

The researchers assessed patients at baseline, at the conclusion of the 6-week treatment, and at 26 weeks.

Compared with the group that received usual care alone, the VR therapy group demonstrated a significant reduction in both agoraphobic avoidance (O-AS adjusted mean difference, -0.47; 95% confidence interval [CI], –0.88 to –0.06; Cohen’s d, –0.18; P = .026) and distress (–4.33; 95% CI, –7.78 to –0.87; Cohen’s d, –0.26; P = .014) at 6 weeks.

This translates to being able to do about 1.5 more activities on the O-AS, such as going to a shopping center alone, said Dr. Freeman.

Further analyses showed that VR therapy was especially effective for patients with severe agoraphobia. On average, these patients could complete two more O-AS activities at 26 weeks, said Dr. Freeman.

The authors believe the intervention worked by reducing defense behaviors, such as avoiding eye contact and fearful thoughts.

There was no significant difference in occurrence of adverse events between the study groups. These events, which were mild, transient, and did not affect the outcome, included side effects such as claustrophobia when using headsets.

The intervention would likely work for patients with agoraphobia who do not have psychosis, said Dr. Freeman. “Agoraphobia is often the final common pathway in lots of mental health conditions.”

Automated VR not only addresses the problem of patients being too afraid to leave home for in-person treatment but may also help address the shortage of trained mental health care providers.

The intervention is available at pilot implementation sites in the United Kingdom and a few sites in the United States, he said.
 

‘Cool, interesting’

Commenting on the research, Arash Javanbakht, MD, associate professor (clinical scholar), Wayne State University, Detroit, described the study as “cool and interesting.”

However, he said, the findings were not surprising, because exposure therapy has proved effective in treating phobias. Because of the significant lack of access to exposure therapy providers, “the more mechanized, the more automated therapies that can be easily used, the better,” he said.

He noted the VR therapy did not require a high level of training; the study used peer support staff who sat next to those using the technology.

He also liked the fact that the intervention “focused on things that in reality impair a person’s life,” for example, not being able to go to the grocery store.

However, he wondered why the investigators studied VR for patients with psychosis and agoraphobia and not for those with just agoraphobia.

In addition, he noted that the treatment’s efficacy was partly due to having someone next to the participants offering support, which the control group didn’t have.

Dr. Javanbakht has researched augmented therapy (AR) for delivering exposure therapy. This technology, which mixes virtually created objects with reality and allows users to move around their real environment, is newer and more advanced than VR but is more complicated, he said.

He explained that AR is more appropriate for delivering exposure therapy in certain situations.

“The basis of exposure therapy is ‘extinction learning’ – exposing a person to a fear cue over and over again until the fear response is extinguished,” and extinction learning is “context dependent,” said Dr. Javanbakht.

“VR is good when you need to create the whole context and environment, and AR is good when you need to focus on specific objects or cues in the environment,” for example, spiders or snakes, he said.

The study was funded by the National Institute of Health Research. Dr. Freeman is a founder and a non-executive director of Oxford VR, which will commercialize the therapy. He holds equity in and receives personal payments from Oxford VR; holds a contract for his university team to advise Oxford VR on treatment development; and reports grants from the National Institute for Health Research, the Medical Research Council, and the International Foundation. Dr. Javanbakht has a patent for an AR exposure therapy.

A version of this article first appeared on Medscape.com.

A novel virtual reality (VR) intervention significantly reduces agoraphobia in patients with psychosis, new research suggests.

The cognitive-behavioral therapy–based treatment was particularly effective for patients with the highest level of avoidance of everyday situations.

Courtesy University of Oxford

“Virtual reality is an inherently therapeutic medium which could be extremely useful in mental health services,” study investigator Daniel Freeman, PhD, DClinPsy, professor of clinical psychology, University of Oxford (England), told this news organization.  “This intervention is coming; the question really is when.”

The study was published online  in The Lancet Psychiatry.
 

Real-world feel

Immersive VR involves interactive three-dimensional computer-generated environments that produce the sensation of being in the real world.

For patients with psychosis, dealing with the real world can be an anxious experience, particularly if they have verbal or auditory hallucinations.

Some may develop agoraphobia and start to avoid places or situations. A virtual environment allows patients to practice dealing with situations that make them anxious or uncomfortable and to learn to reengage in everyday situations.

The study included 346 patients diagnosed with schizophrenia or a related disorder. The mean age of the patients was 37.2 years (67% were men, 85% were White). Most were single and unemployed. All were receiving treatment for psychosis and had difficulty going out because of anxiety.

The researchers randomly assigned 174 participants to an automated VR cognitive therapy intervention (gameChange) plus usual care and 172 to usual care alone. Trial assessors were blinded to group allocation.

The gameChange intervention was delivered in six sessions that were conducted over a 6-week period. Each session involved 30 minutes of VR.

A session begins when participants enter the virtual therapist’s office. They are met by a coach who guides them through the therapy. They can choose from among six VR social situations. These include a cafe, a general practice waiting room, a pub, a bus, opening the front door of their home onto the street, or entering a small local shop.

Each scenario has five levels of difficulty that are based on the number and proximity of people in the social situation and the degree of social interaction. Users can work their way through these various levels.

The virtual sessions took place in patients’ homes in about 50% of cases; the remainder were conducted in the clinic. A mental health worker was in the room during the therapy.

Between virtual sessions, participants were encouraged to apply what they learned in the real world, for example, by spending time in a pub.

Usual care typically included regular visits from a community mental health worker and occasional outpatient appointments with a psychiatrist.
 

Widely applicable?

The primary outcome was the eight-item Oxford Agoraphobic Avoidance Scale (O-AS) questionnaire. This scale assesses distress and avoidance related to performing increasingly difficult everyday tasks.

The researchers assessed patients at baseline, at the conclusion of the 6-week treatment, and at 26 weeks.

Compared with the group that received usual care alone, the VR therapy group demonstrated a significant reduction in both agoraphobic avoidance (O-AS adjusted mean difference, -0.47; 95% confidence interval [CI], –0.88 to –0.06; Cohen’s d, –0.18; P = .026) and distress (–4.33; 95% CI, –7.78 to –0.87; Cohen’s d, –0.26; P = .014) at 6 weeks.

This translates to being able to do about 1.5 more activities on the O-AS, such as going to a shopping center alone, said Dr. Freeman.

Further analyses showed that VR therapy was especially effective for patients with severe agoraphobia. On average, these patients could complete two more O-AS activities at 26 weeks, said Dr. Freeman.

The authors believe the intervention worked by reducing defense behaviors, such as avoiding eye contact and fearful thoughts.

There was no significant difference in occurrence of adverse events between the study groups. These events, which were mild, transient, and did not affect the outcome, included side effects such as claustrophobia when using headsets.

The intervention would likely work for patients with agoraphobia who do not have psychosis, said Dr. Freeman. “Agoraphobia is often the final common pathway in lots of mental health conditions.”

Automated VR not only addresses the problem of patients being too afraid to leave home for in-person treatment but may also help address the shortage of trained mental health care providers.

The intervention is available at pilot implementation sites in the United Kingdom and a few sites in the United States, he said.
 

‘Cool, interesting’

Commenting on the research, Arash Javanbakht, MD, associate professor (clinical scholar), Wayne State University, Detroit, described the study as “cool and interesting.”

However, he said, the findings were not surprising, because exposure therapy has proved effective in treating phobias. Because of the significant lack of access to exposure therapy providers, “the more mechanized, the more automated therapies that can be easily used, the better,” he said.

He noted the VR therapy did not require a high level of training; the study used peer support staff who sat next to those using the technology.

He also liked the fact that the intervention “focused on things that in reality impair a person’s life,” for example, not being able to go to the grocery store.

However, he wondered why the investigators studied VR for patients with psychosis and agoraphobia and not for those with just agoraphobia.

In addition, he noted that the treatment’s efficacy was partly due to having someone next to the participants offering support, which the control group didn’t have.

Dr. Javanbakht has researched augmented therapy (AR) for delivering exposure therapy. This technology, which mixes virtually created objects with reality and allows users to move around their real environment, is newer and more advanced than VR but is more complicated, he said.

He explained that AR is more appropriate for delivering exposure therapy in certain situations.

“The basis of exposure therapy is ‘extinction learning’ – exposing a person to a fear cue over and over again until the fear response is extinguished,” and extinction learning is “context dependent,” said Dr. Javanbakht.

“VR is good when you need to create the whole context and environment, and AR is good when you need to focus on specific objects or cues in the environment,” for example, spiders or snakes, he said.

The study was funded by the National Institute of Health Research. Dr. Freeman is a founder and a non-executive director of Oxford VR, which will commercialize the therapy. He holds equity in and receives personal payments from Oxford VR; holds a contract for his university team to advise Oxford VR on treatment development; and reports grants from the National Institute for Health Research, the Medical Research Council, and the International Foundation. Dr. Javanbakht has a patent for an AR exposure therapy.

A version of this article first appeared on Medscape.com.

A novel virtual reality (VR) intervention significantly reduces agoraphobia in patients with psychosis, new research suggests.

The cognitive-behavioral therapy–based treatment was particularly effective for patients with the highest level of avoidance of everyday situations.

Courtesy University of Oxford

“Virtual reality is an inherently therapeutic medium which could be extremely useful in mental health services,” study investigator Daniel Freeman, PhD, DClinPsy, professor of clinical psychology, University of Oxford (England), told this news organization.  “This intervention is coming; the question really is when.”

The study was published online  in The Lancet Psychiatry.
 

Real-world feel

Immersive VR involves interactive three-dimensional computer-generated environments that produce the sensation of being in the real world.

For patients with psychosis, dealing with the real world can be an anxious experience, particularly if they have verbal or auditory hallucinations.

Some may develop agoraphobia and start to avoid places or situations. A virtual environment allows patients to practice dealing with situations that make them anxious or uncomfortable and to learn to reengage in everyday situations.

The study included 346 patients diagnosed with schizophrenia or a related disorder. The mean age of the patients was 37.2 years (67% were men, 85% were White). Most were single and unemployed. All were receiving treatment for psychosis and had difficulty going out because of anxiety.

The researchers randomly assigned 174 participants to an automated VR cognitive therapy intervention (gameChange) plus usual care and 172 to usual care alone. Trial assessors were blinded to group allocation.

The gameChange intervention was delivered in six sessions that were conducted over a 6-week period. Each session involved 30 minutes of VR.

A session begins when participants enter the virtual therapist’s office. They are met by a coach who guides them through the therapy. They can choose from among six VR social situations. These include a cafe, a general practice waiting room, a pub, a bus, opening the front door of their home onto the street, or entering a small local shop.

Each scenario has five levels of difficulty that are based on the number and proximity of people in the social situation and the degree of social interaction. Users can work their way through these various levels.

The virtual sessions took place in patients’ homes in about 50% of cases; the remainder were conducted in the clinic. A mental health worker was in the room during the therapy.

Between virtual sessions, participants were encouraged to apply what they learned in the real world, for example, by spending time in a pub.

Usual care typically included regular visits from a community mental health worker and occasional outpatient appointments with a psychiatrist.
 

Widely applicable?

The primary outcome was the eight-item Oxford Agoraphobic Avoidance Scale (O-AS) questionnaire. This scale assesses distress and avoidance related to performing increasingly difficult everyday tasks.

The researchers assessed patients at baseline, at the conclusion of the 6-week treatment, and at 26 weeks.

Compared with the group that received usual care alone, the VR therapy group demonstrated a significant reduction in both agoraphobic avoidance (O-AS adjusted mean difference, -0.47; 95% confidence interval [CI], –0.88 to –0.06; Cohen’s d, –0.18; P = .026) and distress (–4.33; 95% CI, –7.78 to –0.87; Cohen’s d, –0.26; P = .014) at 6 weeks.

This translates to being able to do about 1.5 more activities on the O-AS, such as going to a shopping center alone, said Dr. Freeman.

Further analyses showed that VR therapy was especially effective for patients with severe agoraphobia. On average, these patients could complete two more O-AS activities at 26 weeks, said Dr. Freeman.

The authors believe the intervention worked by reducing defense behaviors, such as avoiding eye contact and fearful thoughts.

There was no significant difference in occurrence of adverse events between the study groups. These events, which were mild, transient, and did not affect the outcome, included side effects such as claustrophobia when using headsets.

The intervention would likely work for patients with agoraphobia who do not have psychosis, said Dr. Freeman. “Agoraphobia is often the final common pathway in lots of mental health conditions.”

Automated VR not only addresses the problem of patients being too afraid to leave home for in-person treatment but may also help address the shortage of trained mental health care providers.

The intervention is available at pilot implementation sites in the United Kingdom and a few sites in the United States, he said.
 

‘Cool, interesting’

Commenting on the research, Arash Javanbakht, MD, associate professor (clinical scholar), Wayne State University, Detroit, described the study as “cool and interesting.”

However, he said, the findings were not surprising, because exposure therapy has proved effective in treating phobias. Because of the significant lack of access to exposure therapy providers, “the more mechanized, the more automated therapies that can be easily used, the better,” he said.

He noted the VR therapy did not require a high level of training; the study used peer support staff who sat next to those using the technology.

He also liked the fact that the intervention “focused on things that in reality impair a person’s life,” for example, not being able to go to the grocery store.

However, he wondered why the investigators studied VR for patients with psychosis and agoraphobia and not for those with just agoraphobia.

In addition, he noted that the treatment’s efficacy was partly due to having someone next to the participants offering support, which the control group didn’t have.

Dr. Javanbakht has researched augmented therapy (AR) for delivering exposure therapy. This technology, which mixes virtually created objects with reality and allows users to move around their real environment, is newer and more advanced than VR but is more complicated, he said.

He explained that AR is more appropriate for delivering exposure therapy in certain situations.

“The basis of exposure therapy is ‘extinction learning’ – exposing a person to a fear cue over and over again until the fear response is extinguished,” and extinction learning is “context dependent,” said Dr. Javanbakht.

“VR is good when you need to create the whole context and environment, and AR is good when you need to focus on specific objects or cues in the environment,” for example, spiders or snakes, he said.

The study was funded by the National Institute of Health Research. Dr. Freeman is a founder and a non-executive director of Oxford VR, which will commercialize the therapy. He holds equity in and receives personal payments from Oxford VR; holds a contract for his university team to advise Oxford VR on treatment development; and reports grants from the National Institute for Health Research, the Medical Research Council, and the International Foundation. Dr. Javanbakht has a patent for an AR exposure therapy.

A version of this article first appeared on Medscape.com.

Antidepressant use is not associated with significant improvement in health-related quality of life (HRQoL) in patients with depression, new research suggests.

Researchers who conducted the study admit this finding was unexpected, and outside experts say no firm conclusions can be drawn from the research.

“Of course we were surprised by the results,” first author Omar Almohammed, PharmD, PhD, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia, told this news organization.

“We were expecting to see some positive impact with the use of antidepressant medications on the HRQoL measures when we compared these patients to patients that did not use antidepressant medications,” Dr. Almohammed said.

The study was published online  in PLOS ONE.
 

Controversial impact on quality of life

Depression is known to harm HRQoL. Despite evidence that antidepressants improve depressed mood, their effect on patients’ overall well-being and HRQoL remains controversial.

The researchers examined the effect of antidepressants on HRQoL in adults with depression using 11 years of data from the U.S. Medical Expenditures Panel Survey (MEPS), a large longitudinal survey that tracks health service use in the United States. HRQoL was measured using the 12-item Short Form Health Survey (SF-12).

On average, about 17.5 million adults were diagnosed with depression each year during the study period (2005-2016). More than half (57.6%) of these patients were treated with antidepressants.

Patients with depression had an average age of 48.3 years. Women made up more than two-thirds of the total sample (68%), and more women than men received antidepressants (61% vs. 52%).

Compared with no antidepressant use, antidepressant use was associated with some improvement on the mental, but not physical, component of the SF-12, the researchers report.

However, difference-in-differences (D-I-D) univariate analysis showed no significant difference between adults using and not using antidepressants in the SF-12 physical (-0.35 vs. -0.34; P = .9,595) or mental component (1.28 vs. 1.13; P = .6,405).

“The multivariate D-I-D analyses ensured the robustness of these results,” the researchers note.

The change in HRQoL observed in patients using antidepressants was not significantly different from that seen among peers not using these drugs, the researchers report.

“We are not saying that antidepressant medications are not helpful at all; HRQoL is only one of many measures intended to assess health outcomes,” Dr. Almohammed told this news organization.

“Based on our research design and data, we can only say that patients who used antidepressant medications did not experience better change in terms of HRQoL compared to patients who did not use antidepressant medications,” he said.

“These patients may have had some improvement on other clinical outcome measures, but that clinical improvement did not have a significant positive impact on HRQoL,” he noted.

“We still recommend that patients continue using their antidepressant medications, but they may want to ask their doctors to provide them with other nonpharmacologic interventions as this may have additional impact on their HRQoL,” Dr. Almohammed said.

Further research is needed to address a “gap in knowledge” about the impact of nondrug interventions – alone or in combination with antidepressant medications – on patients’ HRQoL, Dr. Almohammed added.
 

Experts weigh in

Several experts weighed in on the study in a statement from the British nonprofit Science Media Center.

Gemma Lewis, PhD, with University College London (UCL), noted that “clinical trials with experimental designs have found that antidepressants improve mental health-related quality of life.”

University College London

Bruce Jancin/MDedge News

A version of this article first appeared on Medscape.com.

Antidepressant use is not associated with significant improvement in health-related quality of life (HRQoL) in patients with depression, new research suggests.

Researchers who conducted the study admit this finding was unexpected, and outside experts say no firm conclusions can be drawn from the research.

“Of course we were surprised by the results,” first author Omar Almohammed, PharmD, PhD, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia, told this news organization.

“We were expecting to see some positive impact with the use of antidepressant medications on the HRQoL measures when we compared these patients to patients that did not use antidepressant medications,” Dr. Almohammed said.

The study was published online  in PLOS ONE.
 

Controversial impact on quality of life

Depression is known to harm HRQoL. Despite evidence that antidepressants improve depressed mood, their effect on patients’ overall well-being and HRQoL remains controversial.

The researchers examined the effect of antidepressants on HRQoL in adults with depression using 11 years of data from the U.S. Medical Expenditures Panel Survey (MEPS), a large longitudinal survey that tracks health service use in the United States. HRQoL was measured using the 12-item Short Form Health Survey (SF-12).

On average, about 17.5 million adults were diagnosed with depression each year during the study period (2005-2016). More than half (57.6%) of these patients were treated with antidepressants.

Patients with depression had an average age of 48.3 years. Women made up more than two-thirds of the total sample (68%), and more women than men received antidepressants (61% vs. 52%).

Compared with no antidepressant use, antidepressant use was associated with some improvement on the mental, but not physical, component of the SF-12, the researchers report.

However, difference-in-differences (D-I-D) univariate analysis showed no significant difference between adults using and not using antidepressants in the SF-12 physical (-0.35 vs. -0.34; P = .9,595) or mental component (1.28 vs. 1.13; P = .6,405).

“The multivariate D-I-D analyses ensured the robustness of these results,” the researchers note.

The change in HRQoL observed in patients using antidepressants was not significantly different from that seen among peers not using these drugs, the researchers report.

“We are not saying that antidepressant medications are not helpful at all; HRQoL is only one of many measures intended to assess health outcomes,” Dr. Almohammed told this news organization.

“Based on our research design and data, we can only say that patients who used antidepressant medications did not experience better change in terms of HRQoL compared to patients who did not use antidepressant medications,” he said.

“These patients may have had some improvement on other clinical outcome measures, but that clinical improvement did not have a significant positive impact on HRQoL,” he noted.

“We still recommend that patients continue using their antidepressant medications, but they may want to ask their doctors to provide them with other nonpharmacologic interventions as this may have additional impact on their HRQoL,” Dr. Almohammed said.

Further research is needed to address a “gap in knowledge” about the impact of nondrug interventions – alone or in combination with antidepressant medications – on patients’ HRQoL, Dr. Almohammed added.
 

Experts weigh in

Several experts weighed in on the study in a statement from the British nonprofit Science Media Center.

Gemma Lewis, PhD, with University College London (UCL), noted that “clinical trials with experimental designs have found that antidepressants improve mental health-related quality of life.”

University College London

Bruce Jancin/MDedge News

A version of this article first appeared on Medscape.com.

Antidepressant use is not associated with significant improvement in health-related quality of life (HRQoL) in patients with depression, new research suggests.

Researchers who conducted the study admit this finding was unexpected, and outside experts say no firm conclusions can be drawn from the research.

“Of course we were surprised by the results,” first author Omar Almohammed, PharmD, PhD, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia, told this news organization.

“We were expecting to see some positive impact with the use of antidepressant medications on the HRQoL measures when we compared these patients to patients that did not use antidepressant medications,” Dr. Almohammed said.

The study was published online  in PLOS ONE.
 

Controversial impact on quality of life

Depression is known to harm HRQoL. Despite evidence that antidepressants improve depressed mood, their effect on patients’ overall well-being and HRQoL remains controversial.

The researchers examined the effect of antidepressants on HRQoL in adults with depression using 11 years of data from the U.S. Medical Expenditures Panel Survey (MEPS), a large longitudinal survey that tracks health service use in the United States. HRQoL was measured using the 12-item Short Form Health Survey (SF-12).

On average, about 17.5 million adults were diagnosed with depression each year during the study period (2005-2016). More than half (57.6%) of these patients were treated with antidepressants.

Patients with depression had an average age of 48.3 years. Women made up more than two-thirds of the total sample (68%), and more women than men received antidepressants (61% vs. 52%).

Compared with no antidepressant use, antidepressant use was associated with some improvement on the mental, but not physical, component of the SF-12, the researchers report.

However, difference-in-differences (D-I-D) univariate analysis showed no significant difference between adults using and not using antidepressants in the SF-12 physical (-0.35 vs. -0.34; P = .9,595) or mental component (1.28 vs. 1.13; P = .6,405).

“The multivariate D-I-D analyses ensured the robustness of these results,” the researchers note.

The change in HRQoL observed in patients using antidepressants was not significantly different from that seen among peers not using these drugs, the researchers report.

“We are not saying that antidepressant medications are not helpful at all; HRQoL is only one of many measures intended to assess health outcomes,” Dr. Almohammed told this news organization.

“Based on our research design and data, we can only say that patients who used antidepressant medications did not experience better change in terms of HRQoL compared to patients who did not use antidepressant medications,” he said.

“These patients may have had some improvement on other clinical outcome measures, but that clinical improvement did not have a significant positive impact on HRQoL,” he noted.

“We still recommend that patients continue using their antidepressant medications, but they may want to ask their doctors to provide them with other nonpharmacologic interventions as this may have additional impact on their HRQoL,” Dr. Almohammed said.

Further research is needed to address a “gap in knowledge” about the impact of nondrug interventions – alone or in combination with antidepressant medications – on patients’ HRQoL, Dr. Almohammed added.
 

Experts weigh in

Several experts weighed in on the study in a statement from the British nonprofit Science Media Center.

Gemma Lewis, PhD, with University College London (UCL), noted that “clinical trials with experimental designs have found that antidepressants improve mental health-related quality of life.”

University College London

Bruce Jancin/MDedge News

A version of this article first appeared on Medscape.com.

This article was originally published in Italian on Univadis .

The arrival of Ukrainian refugees in Western Europe, and especially the arrival of women and children coming from the cities most affected by the attacks, has made local medical services the first point of contact for the diagnosis and care of the psychological effects of war.

Many studies demonstrate the high prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety among refugees. For example, a study from 2019 on refugee mental health offers a disturbing epidemiologic insight: Ten percent of refugees escaping conflict in Nepal showed signs of PTSD, 27.5% suffered from depression, and 22.9% suffered from anxiety. The rate of depression surpasses 90% in all studies carried out on survivors of torture.
 

Official guidelines

Posttraumatic stress is a form of mental disorder that manifests after experiencing highly traumatic events. Defined and studied in the United States, especially in veterans of the Vietnam War, and subsequently reviewed in relation to more recent conflicts, PTSD may appear in people of all ages. It also can occur in family members, witnesses, and aid workers involved in traumatic events. PTSD may come from repeated exposure to episodes of violence and degradation.

Because PTSD is a complex mental disorder derived from multiple factors, both personal and environmental, a diagnosis is never straightforward. It is generally indicated as “a condition of acute stress which manifests after exposure to a traumatic event.”

Among the most common symptoms of war-related trauma, according to experts, are the onset of flashbacks of troublesome memories, intrusive trauma-related thoughts, panic attacks, insomnia and night terrors, and social avoidance. In children, elements of regression can be observed, such as a need to sleep next to their parents.

Research performed directly on different areas of the brain has demonstrated that people affected by PTSD produce abnormal levels of hormones that are involved in responding to stress and fear. The area of the brain responsible for this response is the amygdala, which activates during moments of fear and produces natural pain-relieving molecules. In people with PTSD, the production of these molecules can carry on long after the event is over, causing a change in emotional state. Furthermore, levels of neurotransmitters that reach the hippocampus are also altered, which influences memory and learning capability. These same alterations concerning neurotransmitter levels are the basis for sudden flashbacks.

People with PTSD are subject to a change in blood flow to the brain and structural changes to brain tissue.
 

Social factors

“A factor that worsens the mental condition of Ukrainian refugees is the speed in which they have passed from a normal life, similar to that of many other Western countries, to a state of war, death, and injury,” writes Arash Javanbakht, MD, associate professor of psychiatry at Wayne State University in Detroit, and an expert in PTSD in war refugees.

Courtesy Shantanu Madaboosi

“Furthermore, they are experiencing an awful feeling of injustice, as the democracy and freedom that they have fought so hard to have has been put at risk, and they don’t feel sufficiently supported by their allies.”

As of this writing, the World Health Organization has estimated that there are 3.6 million Ukrainian refugees. This population already has experienced war and its psychological consequences. A study from 2019 assessed the prevalence of PTSD (27%) and depression (21%) among the 1.5 million Ukrainians who had to leave their homes after the first Russian invasion in 2014 and the rebellion of predominantly Russian regions.

Children are particularly at risk of developing PTSD, as seen from studies conducted on Syrian refugees. They have a roughly 70% chance of developing separation anxiety, a condition that many workers and volunteers have experienced firsthand recently. Some children do not accept being separated from their parents even to allow them to go to the bathroom or wash themselves, which also aggravates stress levels among adults. Infant trauma increases the risk of developing physical or mental disorders during adulthood, including depression, chronic pain, heart disorders, and diabetes.

War-related trauma entails transmissible epigenetic alterations, as shown by studies on the transmissibility of trauma on a biological level.
 

Diagnosis and treatment

People with PTSD have difficulty controlling their emotions, resulting in irritability, sudden rage or emotional confusion, depression and anxiety, and insomnia. They also are determined to avoid any actions that remind them of the traumatic event. Another common symptom is a sense of shame, as a result of having survived or not having been able to save others.

Physical symptoms include chest pain, dizziness, gastrointestinal problems, migraine, and a weakened immune system. A diagnosis of PTSD can be made when, in accordance with the National Institute of Mental Health (NIMH), the patient presents with the characteristic symptoms for more than a month after the event that caused the symptoms occurred.

The NIMH highlights that a diagnosis cannot always be made in a systematic way. In many cases, patients with PTSD are treated for the physical symptoms only, without any consideration for the overall picture.

The American Psychiatric Association (APA) has created a detailed list of PTSD symptoms. According to the APA, these symptoms usually appear within 3 months of the trauma, even if stress may appear later. Symptoms are arranged into the following three well-defined categories:

• Intrusive memories. People with PTSD suffer from sudden, vivid memories that are accompanied by painful emotions and a feeling of reliving the trauma. At times, this experience is so strong that the person involved feels as though the traumatic event is repeating itself.
• Avoidance and numbing. The individual seeks to avoid contact with anyone or anything that brings back memories of the trauma. Initially, the person experiences an emotional state of disinterest and detachment, reducing the capacity for emotional interaction and resulting in participation only in simple, routine activities. A lack of emotional processing causes an accumulation of anxiety and tension, which can become a chronic condition, leading to depression. At the same time, people frequently experience a sense of shame.
• Hyperarousal and hypervigilance. People behave as if they are constantly threatened. They react in a sudden, violent way, are unable to concentrate, and have problems with their memory. At times, they use alcohol or other drugs to alleviate pain. People with PTSD may lose control of their lives and therefore be at risk for suicidal behavior.

Why do some people pass unscathed through traumatic situations, whereas others carry the scars forever? There is a correlation with the severity of the trauma, but also with biological and genetic factors, as well as with previous experiences that contribute to increasing an individual’s resilience. Another key element is the rapid and effective treatment of symptoms, which also relates to personal and financial security.

It is not a coincidence that the first guidelines that clinicians follow when treating a traumatized patient aren’t strictly medical. It is necessary to guarantee the financial security of a refugee, but also the security of the few valuable items they have with them (such as keepsakes and pets). Clinicians are advised to facilitate contact with any of the patient’s family members located elsewhere whenever possible. It is appropriate to use relaxation techniques that are compatible with the patient’s cultural approach. Clinicians also check for the most common conditions in the refugee’s population of origin. It is advisable constantly to check for trauma-related symptoms and to listen to the patient’s story. Caregivers should be allowed to stay close to their children and should be provided sufficient information, but not an overwhelming amount.

There isn’t a consensus on how to treat people with PTSD. The possibility that PTSD can be resolved even without specific treatments has not been excluded, if the affected person is cared for and helped within a family and community setting, and if the person’s personal condition allows for this. However, in general, some form of treatment is beneficial before symptoms become chronic.

Pharmacologic and psychological treatment may be implemented. For the latter, the NIMH and the APA suggest that good results can be obtained from cognitive behavioral therapy, where the patient learns to manage his or her anxiety and depression and amend dangerous behaviors, such as the dismissal of his or her own emotions. According to these organizations, group therapy and other forms of psychotherapy have provided good results. The indicated duration of treatment is generally 6-12 weeks, even if this duration strongly depends on the individual’s condition, with subsequent periodic follow-ups. The involvement of the patient’s family and community is important.

The National Center for PTSD in Washington (run by the U.S. Department of Veterans Affairs) has highlighted the importance of a detailed case-by-case assessment to put in place a precise therapy plan. If patients should continue to find themselves in a state of crisis, for example during a war or in cases of domestic violence, working toward removing the cause of stress is first necessary before beginning treatment.

An important aspect is making the victim aware of the disorder. Treatment should therefore begin after the patient and family have been informed about the possibility of PTSD and the way in which it develops. Recognizing the symptoms over the following weeks and working quickly to manage and treat them significantly affects treatment success.

A version of this article first appeared on Medscape.com.

This article was originally published in Italian on Univadis .

The arrival of Ukrainian refugees in Western Europe, and especially the arrival of women and children coming from the cities most affected by the attacks, has made local medical services the first point of contact for the diagnosis and care of the psychological effects of war.

Many studies demonstrate the high prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety among refugees. For example, a study from 2019 on refugee mental health offers a disturbing epidemiologic insight: Ten percent of refugees escaping conflict in Nepal showed signs of PTSD, 27.5% suffered from depression, and 22.9% suffered from anxiety. The rate of depression surpasses 90% in all studies carried out on survivors of torture.
 

Official guidelines

Posttraumatic stress is a form of mental disorder that manifests after experiencing highly traumatic events. Defined and studied in the United States, especially in veterans of the Vietnam War, and subsequently reviewed in relation to more recent conflicts, PTSD may appear in people of all ages. It also can occur in family members, witnesses, and aid workers involved in traumatic events. PTSD may come from repeated exposure to episodes of violence and degradation.

Because PTSD is a complex mental disorder derived from multiple factors, both personal and environmental, a diagnosis is never straightforward. It is generally indicated as “a condition of acute stress which manifests after exposure to a traumatic event.”

Among the most common symptoms of war-related trauma, according to experts, are the onset of flashbacks of troublesome memories, intrusive trauma-related thoughts, panic attacks, insomnia and night terrors, and social avoidance. In children, elements of regression can be observed, such as a need to sleep next to their parents.

Research performed directly on different areas of the brain has demonstrated that people affected by PTSD produce abnormal levels of hormones that are involved in responding to stress and fear. The area of the brain responsible for this response is the amygdala, which activates during moments of fear and produces natural pain-relieving molecules. In people with PTSD, the production of these molecules can carry on long after the event is over, causing a change in emotional state. Furthermore, levels of neurotransmitters that reach the hippocampus are also altered, which influences memory and learning capability. These same alterations concerning neurotransmitter levels are the basis for sudden flashbacks.

People with PTSD are subject to a change in blood flow to the brain and structural changes to brain tissue.
 

Social factors

“A factor that worsens the mental condition of Ukrainian refugees is the speed in which they have passed from a normal life, similar to that of many other Western countries, to a state of war, death, and injury,” writes Arash Javanbakht, MD, associate professor of psychiatry at Wayne State University in Detroit, and an expert in PTSD in war refugees.

Courtesy Shantanu Madaboosi

“Furthermore, they are experiencing an awful feeling of injustice, as the democracy and freedom that they have fought so hard to have has been put at risk, and they don’t feel sufficiently supported by their allies.”

As of this writing, the World Health Organization has estimated that there are 3.6 million Ukrainian refugees. This population already has experienced war and its psychological consequences. A study from 2019 assessed the prevalence of PTSD (27%) and depression (21%) among the 1.5 million Ukrainians who had to leave their homes after the first Russian invasion in 2014 and the rebellion of predominantly Russian regions.

Children are particularly at risk of developing PTSD, as seen from studies conducted on Syrian refugees. They have a roughly 70% chance of developing separation anxiety, a condition that many workers and volunteers have experienced firsthand recently. Some children do not accept being separated from their parents even to allow them to go to the bathroom or wash themselves, which also aggravates stress levels among adults. Infant trauma increases the risk of developing physical or mental disorders during adulthood, including depression, chronic pain, heart disorders, and diabetes.

War-related trauma entails transmissible epigenetic alterations, as shown by studies on the transmissibility of trauma on a biological level.
 

Diagnosis and treatment

People with PTSD have difficulty controlling their emotions, resulting in irritability, sudden rage or emotional confusion, depression and anxiety, and insomnia. They also are determined to avoid any actions that remind them of the traumatic event. Another common symptom is a sense of shame, as a result of having survived or not having been able to save others.

Physical symptoms include chest pain, dizziness, gastrointestinal problems, migraine, and a weakened immune system. A diagnosis of PTSD can be made when, in accordance with the National Institute of Mental Health (NIMH), the patient presents with the characteristic symptoms for more than a month after the event that caused the symptoms occurred.

The NIMH highlights that a diagnosis cannot always be made in a systematic way. In many cases, patients with PTSD are treated for the physical symptoms only, without any consideration for the overall picture.

The American Psychiatric Association (APA) has created a detailed list of PTSD symptoms. According to the APA, these symptoms usually appear within 3 months of the trauma, even if stress may appear later. Symptoms are arranged into the following three well-defined categories:

• Intrusive memories. People with PTSD suffer from sudden, vivid memories that are accompanied by painful emotions and a feeling of reliving the trauma. At times, this experience is so strong that the person involved feels as though the traumatic event is repeating itself.
• Avoidance and numbing. The individual seeks to avoid contact with anyone or anything that brings back memories of the trauma. Initially, the person experiences an emotional state of disinterest and detachment, reducing the capacity for emotional interaction and resulting in participation only in simple, routine activities. A lack of emotional processing causes an accumulation of anxiety and tension, which can become a chronic condition, leading to depression. At the same time, people frequently experience a sense of shame.
• Hyperarousal and hypervigilance. People behave as if they are constantly threatened. They react in a sudden, violent way, are unable to concentrate, and have problems with their memory. At times, they use alcohol or other drugs to alleviate pain. People with PTSD may lose control of their lives and therefore be at risk for suicidal behavior.

Why do some people pass unscathed through traumatic situations, whereas others carry the scars forever? There is a correlation with the severity of the trauma, but also with biological and genetic factors, as well as with previous experiences that contribute to increasing an individual’s resilience. Another key element is the rapid and effective treatment of symptoms, which also relates to personal and financial security.

It is not a coincidence that the first guidelines that clinicians follow when treating a traumatized patient aren’t strictly medical. It is necessary to guarantee the financial security of a refugee, but also the security of the few valuable items they have with them (such as keepsakes and pets). Clinicians are advised to facilitate contact with any of the patient’s family members located elsewhere whenever possible. It is appropriate to use relaxation techniques that are compatible with the patient’s cultural approach. Clinicians also check for the most common conditions in the refugee’s population of origin. It is advisable constantly to check for trauma-related symptoms and to listen to the patient’s story. Caregivers should be allowed to stay close to their children and should be provided sufficient information, but not an overwhelming amount.

There isn’t a consensus on how to treat people with PTSD. The possibility that PTSD can be resolved even without specific treatments has not been excluded, if the affected person is cared for and helped within a family and community setting, and if the person’s personal condition allows for this. However, in general, some form of treatment is beneficial before symptoms become chronic.

Pharmacologic and psychological treatment may be implemented. For the latter, the NIMH and the APA suggest that good results can be obtained from cognitive behavioral therapy, where the patient learns to manage his or her anxiety and depression and amend dangerous behaviors, such as the dismissal of his or her own emotions. According to these organizations, group therapy and other forms of psychotherapy have provided good results. The indicated duration of treatment is generally 6-12 weeks, even if this duration strongly depends on the individual’s condition, with subsequent periodic follow-ups. The involvement of the patient’s family and community is important.

The National Center for PTSD in Washington (run by the U.S. Department of Veterans Affairs) has highlighted the importance of a detailed case-by-case assessment to put in place a precise therapy plan. If patients should continue to find themselves in a state of crisis, for example during a war or in cases of domestic violence, working toward removing the cause of stress is first necessary before beginning treatment.

An important aspect is making the victim aware of the disorder. Treatment should therefore begin after the patient and family have been informed about the possibility of PTSD and the way in which it develops. Recognizing the symptoms over the following weeks and working quickly to manage and treat them significantly affects treatment success.

A version of this article first appeared on Medscape.com.

This article was originally published in Italian on Univadis .

The arrival of Ukrainian refugees in Western Europe, and especially the arrival of women and children coming from the cities most affected by the attacks, has made local medical services the first point of contact for the diagnosis and care of the psychological effects of war.

Many studies demonstrate the high prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety among refugees. For example, a study from 2019 on refugee mental health offers a disturbing epidemiologic insight: Ten percent of refugees escaping conflict in Nepal showed signs of PTSD, 27.5% suffered from depression, and 22.9% suffered from anxiety. The rate of depression surpasses 90% in all studies carried out on survivors of torture.
 

Official guidelines

Posttraumatic stress is a form of mental disorder that manifests after experiencing highly traumatic events. Defined and studied in the United States, especially in veterans of the Vietnam War, and subsequently reviewed in relation to more recent conflicts, PTSD may appear in people of all ages. It also can occur in family members, witnesses, and aid workers involved in traumatic events. PTSD may come from repeated exposure to episodes of violence and degradation.

Because PTSD is a complex mental disorder derived from multiple factors, both personal and environmental, a diagnosis is never straightforward. It is generally indicated as “a condition of acute stress which manifests after exposure to a traumatic event.”

Among the most common symptoms of war-related trauma, according to experts, are the onset of flashbacks of troublesome memories, intrusive trauma-related thoughts, panic attacks, insomnia and night terrors, and social avoidance. In children, elements of regression can be observed, such as a need to sleep next to their parents.

Research performed directly on different areas of the brain has demonstrated that people affected by PTSD produce abnormal levels of hormones that are involved in responding to stress and fear. The area of the brain responsible for this response is the amygdala, which activates during moments of fear and produces natural pain-relieving molecules. In people with PTSD, the production of these molecules can carry on long after the event is over, causing a change in emotional state. Furthermore, levels of neurotransmitters that reach the hippocampus are also altered, which influences memory and learning capability. These same alterations concerning neurotransmitter levels are the basis for sudden flashbacks.

People with PTSD are subject to a change in blood flow to the brain and structural changes to brain tissue.
 

Social factors

“A factor that worsens the mental condition of Ukrainian refugees is the speed in which they have passed from a normal life, similar to that of many other Western countries, to a state of war, death, and injury,” writes Arash Javanbakht, MD, associate professor of psychiatry at Wayne State University in Detroit, and an expert in PTSD in war refugees.

Courtesy Shantanu Madaboosi

“Furthermore, they are experiencing an awful feeling of injustice, as the democracy and freedom that they have fought so hard to have has been put at risk, and they don’t feel sufficiently supported by their allies.”

As of this writing, the World Health Organization has estimated that there are 3.6 million Ukrainian refugees. This population already has experienced war and its psychological consequences. A study from 2019 assessed the prevalence of PTSD (27%) and depression (21%) among the 1.5 million Ukrainians who had to leave their homes after the first Russian invasion in 2014 and the rebellion of predominantly Russian regions.

Children are particularly at risk of developing PTSD, as seen from studies conducted on Syrian refugees. They have a roughly 70% chance of developing separation anxiety, a condition that many workers and volunteers have experienced firsthand recently. Some children do not accept being separated from their parents even to allow them to go to the bathroom or wash themselves, which also aggravates stress levels among adults. Infant trauma increases the risk of developing physical or mental disorders during adulthood, including depression, chronic pain, heart disorders, and diabetes.

War-related trauma entails transmissible epigenetic alterations, as shown by studies on the transmissibility of trauma on a biological level.
 

Diagnosis and treatment

People with PTSD have difficulty controlling their emotions, resulting in irritability, sudden rage or emotional confusion, depression and anxiety, and insomnia. They also are determined to avoid any actions that remind them of the traumatic event. Another common symptom is a sense of shame, as a result of having survived or not having been able to save others.

Physical symptoms include chest pain, dizziness, gastrointestinal problems, migraine, and a weakened immune system. A diagnosis of PTSD can be made when, in accordance with the National Institute of Mental Health (NIMH), the patient presents with the characteristic symptoms for more than a month after the event that caused the symptoms occurred.

The NIMH highlights that a diagnosis cannot always be made in a systematic way. In many cases, patients with PTSD are treated for the physical symptoms only, without any consideration for the overall picture.

The American Psychiatric Association (APA) has created a detailed list of PTSD symptoms. According to the APA, these symptoms usually appear within 3 months of the trauma, even if stress may appear later. Symptoms are arranged into the following three well-defined categories:

• Intrusive memories. People with PTSD suffer from sudden, vivid memories that are accompanied by painful emotions and a feeling of reliving the trauma. At times, this experience is so strong that the person involved feels as though the traumatic event is repeating itself.
• Avoidance and numbing. The individual seeks to avoid contact with anyone or anything that brings back memories of the trauma. Initially, the person experiences an emotional state of disinterest and detachment, reducing the capacity for emotional interaction and resulting in participation only in simple, routine activities. A lack of emotional processing causes an accumulation of anxiety and tension, which can become a chronic condition, leading to depression. At the same time, people frequently experience a sense of shame.
• Hyperarousal and hypervigilance. People behave as if they are constantly threatened. They react in a sudden, violent way, are unable to concentrate, and have problems with their memory. At times, they use alcohol or other drugs to alleviate pain. People with PTSD may lose control of their lives and therefore be at risk for suicidal behavior.

Why do some people pass unscathed through traumatic situations, whereas others carry the scars forever? There is a correlation with the severity of the trauma, but also with biological and genetic factors, as well as with previous experiences that contribute to increasing an individual’s resilience. Another key element is the rapid and effective treatment of symptoms, which also relates to personal and financial security.

It is not a coincidence that the first guidelines that clinicians follow when treating a traumatized patient aren’t strictly medical. It is necessary to guarantee the financial security of a refugee, but also the security of the few valuable items they have with them (such as keepsakes and pets). Clinicians are advised to facilitate contact with any of the patient’s family members located elsewhere whenever possible. It is appropriate to use relaxation techniques that are compatible with the patient’s cultural approach. Clinicians also check for the most common conditions in the refugee’s population of origin. It is advisable constantly to check for trauma-related symptoms and to listen to the patient’s story. Caregivers should be allowed to stay close to their children and should be provided sufficient information, but not an overwhelming amount.

There isn’t a consensus on how to treat people with PTSD. The possibility that PTSD can be resolved even without specific treatments has not been excluded, if the affected person is cared for and helped within a family and community setting, and if the person’s personal condition allows for this. However, in general, some form of treatment is beneficial before symptoms become chronic.

Pharmacologic and psychological treatment may be implemented. For the latter, the NIMH and the APA suggest that good results can be obtained from cognitive behavioral therapy, where the patient learns to manage his or her anxiety and depression and amend dangerous behaviors, such as the dismissal of his or her own emotions. According to these organizations, group therapy and other forms of psychotherapy have provided good results. The indicated duration of treatment is generally 6-12 weeks, even if this duration strongly depends on the individual’s condition, with subsequent periodic follow-ups. The involvement of the patient’s family and community is important.

The National Center for PTSD in Washington (run by the U.S. Department of Veterans Affairs) has highlighted the importance of a detailed case-by-case assessment to put in place a precise therapy plan. If patients should continue to find themselves in a state of crisis, for example during a war or in cases of domestic violence, working toward removing the cause of stress is first necessary before beginning treatment.

An important aspect is making the victim aware of the disorder. Treatment should therefore begin after the patient and family have been informed about the possibility of PTSD and the way in which it develops. Recognizing the symptoms over the following weeks and working quickly to manage and treat them significantly affects treatment success.

A version of this article first appeared on Medscape.com.

One year after hospitalization for COVID-19 only a minority of people feel fully recovered, with being female, obesity, and having had mechanical ventilation in hospital risk factors for not feeling fully recovered.

In the new U.K. study of more than 2,000 patients, presented at this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID 2022), and published in The Lancet Respiratory Medicine, research showed that one in four patients feel fully well again 1 year after hospitalization for COVID-19.

For their study, researchers from the University of Leicester used data from the post-hospitalization COVID-19 (PHOSP-COVID) prospective, longitudinal cohort study, which assessed adults aged 18 years and over who had been hospitalized with COVID-19 across the United Kingdom and subsequently discharged. The researchers assessed the recovery of 2,320 participants discharged from 39 U.K. hospitals between March 7, 2020, and April 18, 2021, who were assessed via patient-reported outcome measures, physical performance, and organ function at 5 months and at 1 year after hospital discharge. Blood samples were taken at the 5-month visit to be analyzed for the presence of various inflammatory proteins.

All participants were assessed at 5 months after discharge and 807 participants (33%) completed both the 5-month and 1-year visits at the time of the analysis. The study is ongoing. The 807 patients were mean age of 59 years, 36% were women, and 28% received invasive mechanical ventilation. The proportion of patients reporting full recovery was similar between 5 months (26%) and 1 year (29%).
 

Female sex and obesity major risk factors for not recovering

Being female, obese, and having had mechanical ventilation in hospital makes someone 32%, 50%, and 58%, respectively, less likely to feel fully recovered 1 year after COVID-19 hospitalization, the authors said.

“We found female sex and obesity were major risk factors for not recovering at one year,” said the researchers, led by Rachael Evans, PhD, Louise V. Wain, and Christopher E. Brightling, PhD, National Institute for Health Research, Leicester Biomedical Research Centre, University of Leicester.

The authors said fatigue, muscle pain, physically slowing down, poor sleep, and breathlessness were most common ongoing long COVID symptoms. They noted how the total number and range of ongoing symptoms at 1 year was “striking,” positively associated with the severity of long COVID, and emphasizes the “multisystem nature of long COVID.”
 

Several inflammatory mediators increased

An earlier publication from this study identified four groups or “clusters” of symptom severity at 5 months, which were confirmed by this new study at 1 year, the authors said. They reported that 20% had very severe physical and mental health impairment, 30% had severe physical and mental health impairment, 11% had moderate physical health impairment with cognitive impairment, and 39% had mild mental and physical health impairment.

They added that having obesity, reduced exercise capacity, a greater number of symptoms, and increased levels of C-reactive protein were associated with the “more severe clusters.” In both the very severe and the moderate with cognitive impairment clusters, levels of interleukin-6 (IL-6) were higher when compared with the mild cluster.

“The limited recovery from 5 months to 1 year after hospitalisation in our study across symptoms, mental health, exercise capacity, organ impairment, and quality-of-life is striking,” the researchers noted.

“In our clusters, female sex and obesity were also associated with more severe ongoing health impairments including reduced exercise performance and health-related quality of life at one year,” and suggested that this potentially highlighted a group that “might need higher intensity interventions such as supervised rehabilitation,” they added.

There are no specific therapeutics for long COVID, the researchers said, noting that “effective interventions are urgently required.” The persistent systemic inflammation identified, particularly in those in the very severe and moderate with cognitive impairment clusters, suggested that these groups “might respond to anti-inflammatory strategies,” the authors wrote.

“We found that a minority of participants felt fully recovered 1 year after hospital discharge, with minimal improvement after a 5-month assessment,” they noted.

They added that the findings suggest the need for complex interventions that target both physical and mental health impairments to alleviate symptoms, and that specific therapeutic approaches to manage posttraumatic stress disorder might also be needed. The authors pointed out how “pharmacological and non-pharmacological interventions are urgently needed,” with a “precision-medicine approach with potential treatable traits of systemic inflammation and obesity.”

They said their study highlighted the “urgent need for health-care services to support the large and rapidly increasing patient population in whom a substantial burden of symptoms exist, including reduced exercise capacity and substantially decreased health-related quality of life one year after hospital discharge.”

They warned that without effective treatments, long COVID could become a “highly prevalent new long-term condition.”

A version of this article first appeared on Medscape UK.

One year after hospitalization for COVID-19 only a minority of people feel fully recovered, with being female, obesity, and having had mechanical ventilation in hospital risk factors for not feeling fully recovered.

In the new U.K. study of more than 2,000 patients, presented at this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID 2022), and published in The Lancet Respiratory Medicine, research showed that one in four patients feel fully well again 1 year after hospitalization for COVID-19.

For their study, researchers from the University of Leicester used data from the post-hospitalization COVID-19 (PHOSP-COVID) prospective, longitudinal cohort study, which assessed adults aged 18 years and over who had been hospitalized with COVID-19 across the United Kingdom and subsequently discharged. The researchers assessed the recovery of 2,320 participants discharged from 39 U.K. hospitals between March 7, 2020, and April 18, 2021, who were assessed via patient-reported outcome measures, physical performance, and organ function at 5 months and at 1 year after hospital discharge. Blood samples were taken at the 5-month visit to be analyzed for the presence of various inflammatory proteins.

All participants were assessed at 5 months after discharge and 807 participants (33%) completed both the 5-month and 1-year visits at the time of the analysis. The study is ongoing. The 807 patients were mean age of 59 years, 36% were women, and 28% received invasive mechanical ventilation. The proportion of patients reporting full recovery was similar between 5 months (26%) and 1 year (29%).
 

Female sex and obesity major risk factors for not recovering

Being female, obese, and having had mechanical ventilation in hospital makes someone 32%, 50%, and 58%, respectively, less likely to feel fully recovered 1 year after COVID-19 hospitalization, the authors said.

“We found female sex and obesity were major risk factors for not recovering at one year,” said the researchers, led by Rachael Evans, PhD, Louise V. Wain, and Christopher E. Brightling, PhD, National Institute for Health Research, Leicester Biomedical Research Centre, University of Leicester.

The authors said fatigue, muscle pain, physically slowing down, poor sleep, and breathlessness were most common ongoing long COVID symptoms. They noted how the total number and range of ongoing symptoms at 1 year was “striking,” positively associated with the severity of long COVID, and emphasizes the “multisystem nature of long COVID.”
 

Several inflammatory mediators increased

An earlier publication from this study identified four groups or “clusters” of symptom severity at 5 months, which were confirmed by this new study at 1 year, the authors said. They reported that 20% had very severe physical and mental health impairment, 30% had severe physical and mental health impairment, 11% had moderate physical health impairment with cognitive impairment, and 39% had mild mental and physical health impairment.

They added that having obesity, reduced exercise capacity, a greater number of symptoms, and increased levels of C-reactive protein were associated with the “more severe clusters.” In both the very severe and the moderate with cognitive impairment clusters, levels of interleukin-6 (IL-6) were higher when compared with the mild cluster.

“The limited recovery from 5 months to 1 year after hospitalisation in our study across symptoms, mental health, exercise capacity, organ impairment, and quality-of-life is striking,” the researchers noted.

“In our clusters, female sex and obesity were also associated with more severe ongoing health impairments including reduced exercise performance and health-related quality of life at one year,” and suggested that this potentially highlighted a group that “might need higher intensity interventions such as supervised rehabilitation,” they added.

There are no specific therapeutics for long COVID, the researchers said, noting that “effective interventions are urgently required.” The persistent systemic inflammation identified, particularly in those in the very severe and moderate with cognitive impairment clusters, suggested that these groups “might respond to anti-inflammatory strategies,” the authors wrote.

“We found that a minority of participants felt fully recovered 1 year after hospital discharge, with minimal improvement after a 5-month assessment,” they noted.

They added that the findings suggest the need for complex interventions that target both physical and mental health impairments to alleviate symptoms, and that specific therapeutic approaches to manage posttraumatic stress disorder might also be needed. The authors pointed out how “pharmacological and non-pharmacological interventions are urgently needed,” with a “precision-medicine approach with potential treatable traits of systemic inflammation and obesity.”

They said their study highlighted the “urgent need for health-care services to support the large and rapidly increasing patient population in whom a substantial burden of symptoms exist, including reduced exercise capacity and substantially decreased health-related quality of life one year after hospital discharge.”

They warned that without effective treatments, long COVID could become a “highly prevalent new long-term condition.”

A version of this article first appeared on Medscape UK.

One year after hospitalization for COVID-19 only a minority of people feel fully recovered, with being female, obesity, and having had mechanical ventilation in hospital risk factors for not feeling fully recovered.

In the new U.K. study of more than 2,000 patients, presented at this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID 2022), and published in The Lancet Respiratory Medicine, research showed that one in four patients feel fully well again 1 year after hospitalization for COVID-19.

For their study, researchers from the University of Leicester used data from the post-hospitalization COVID-19 (PHOSP-COVID) prospective, longitudinal cohort study, which assessed adults aged 18 years and over who had been hospitalized with COVID-19 across the United Kingdom and subsequently discharged. The researchers assessed the recovery of 2,320 participants discharged from 39 U.K. hospitals between March 7, 2020, and April 18, 2021, who were assessed via patient-reported outcome measures, physical performance, and organ function at 5 months and at 1 year after hospital discharge. Blood samples were taken at the 5-month visit to be analyzed for the presence of various inflammatory proteins.

All participants were assessed at 5 months after discharge and 807 participants (33%) completed both the 5-month and 1-year visits at the time of the analysis. The study is ongoing. The 807 patients were mean age of 59 years, 36% were women, and 28% received invasive mechanical ventilation. The proportion of patients reporting full recovery was similar between 5 months (26%) and 1 year (29%).
 

Female sex and obesity major risk factors for not recovering

Being female, obese, and having had mechanical ventilation in hospital makes someone 32%, 50%, and 58%, respectively, less likely to feel fully recovered 1 year after COVID-19 hospitalization, the authors said.

“We found female sex and obesity were major risk factors for not recovering at one year,” said the researchers, led by Rachael Evans, PhD, Louise V. Wain, and Christopher E. Brightling, PhD, National Institute for Health Research, Leicester Biomedical Research Centre, University of Leicester.

The authors said fatigue, muscle pain, physically slowing down, poor sleep, and breathlessness were most common ongoing long COVID symptoms. They noted how the total number and range of ongoing symptoms at 1 year was “striking,” positively associated with the severity of long COVID, and emphasizes the “multisystem nature of long COVID.”
 

Several inflammatory mediators increased

An earlier publication from this study identified four groups or “clusters” of symptom severity at 5 months, which were confirmed by this new study at 1 year, the authors said. They reported that 20% had very severe physical and mental health impairment, 30% had severe physical and mental health impairment, 11% had moderate physical health impairment with cognitive impairment, and 39% had mild mental and physical health impairment.

They added that having obesity, reduced exercise capacity, a greater number of symptoms, and increased levels of C-reactive protein were associated with the “more severe clusters.” In both the very severe and the moderate with cognitive impairment clusters, levels of interleukin-6 (IL-6) were higher when compared with the mild cluster.

“The limited recovery from 5 months to 1 year after hospitalisation in our study across symptoms, mental health, exercise capacity, organ impairment, and quality-of-life is striking,” the researchers noted.

“In our clusters, female sex and obesity were also associated with more severe ongoing health impairments including reduced exercise performance and health-related quality of life at one year,” and suggested that this potentially highlighted a group that “might need higher intensity interventions such as supervised rehabilitation,” they added.

There are no specific therapeutics for long COVID, the researchers said, noting that “effective interventions are urgently required.” The persistent systemic inflammation identified, particularly in those in the very severe and moderate with cognitive impairment clusters, suggested that these groups “might respond to anti-inflammatory strategies,” the authors wrote.

“We found that a minority of participants felt fully recovered 1 year after hospital discharge, with minimal improvement after a 5-month assessment,” they noted.

They added that the findings suggest the need for complex interventions that target both physical and mental health impairments to alleviate symptoms, and that specific therapeutic approaches to manage posttraumatic stress disorder might also be needed. The authors pointed out how “pharmacological and non-pharmacological interventions are urgently needed,” with a “precision-medicine approach with potential treatable traits of systemic inflammation and obesity.”

They said their study highlighted the “urgent need for health-care services to support the large and rapidly increasing patient population in whom a substantial burden of symptoms exist, including reduced exercise capacity and substantially decreased health-related quality of life one year after hospital discharge.”

They warned that without effective treatments, long COVID could become a “highly prevalent new long-term condition.”

A version of this article first appeared on Medscape UK.

Political elections can be hard on the heart, suggests a study that showed a substantial uptick in hospital admissions for acute cardiovascular conditions immediately after the 2020 American presidential election.

The analysis of nearly 6.4 million adults showed that the rate of hospitalization for acute cardiovascular disease (CVD) was 17% higher in the 5 days after the election than in a 5-day period 2 weeks earlier.

The rate of acute myocardial infarction (AMI) was 42% higher, with no significant difference for heart failure or stroke hospital admissions.

“These findings suggest that awareness of the heightened risk of CVD and strategies to mitigate risk during notable political events are needed,” write Matthew T. Mefford, PhD, of Kaiser Permanente Southern California, Pasadena, and colleagues.

The study was published in the April issue of JAMA Network Open.
 

Stress and the heart

In the American Psychological Association Stress in America 2020 survey conducted roughly 3 months before the 2020 presidential election, 77% of adults cited the future of the country as a substantial source of stress, enhanced by the ongoing COVID-19 pandemic, the authors note. More than two-thirds said the election was a substantial source of stress.

Dr. Mefford and colleagues compared CVD hospitalizations at Kaiser Permanente Southern and Northern California hospitals in the 5-day risk window of Nov. 4-8, 2020, with the control window of Oct. 21-25, 2020.

There were 666 CVD hospitalizations (760.47 per 100,000 person-years [PY]) in the risk window, compared with 569 (647.97 per 100,000 PY) in the control window (rate ratio, 1.17; 95% confidence interval, 1.05-1.31).

There were also significantly more hospitalizations for AMI immediately after the election than before (179 vs. 126 AMI hospitalizations; 204.4 vs. 143.5 per 100,000 PY; RR, 1.42; 95% CI, 1.13-1.79).

There was no significant difference between the risk and control periods for hospitalizations because of stroke or heart failure.

The study also suggests higher rates of acute CVD after the election in older adults, men, and White individuals. Political affiliation was not examined in the study.

“Importantly, results were consistent before and after excluding patients with confirmed COVID-19 infection,” the study team notes.

Yet, the potential influence of COVID-19 stressors on increasing CVD risk cannot be ruled out, they say.

However, COVID-19 stressors occurred over a much longer period and are less likely to explain the transient risks observed in the defined risk and control windows that are in close proximity to the 2020 election, the investigators point out.

There is growing evidence that psychological health contributes to CVD.

Previous studies shown a higher risk for acute CVD around population-wide psychosocial or environmental stressors, but less was known about acute CVD risk in relation to political events.

The researchers note future studies evaluating stress-relieving interventions may be important for understanding the intersection of political events, associated stress, and acute CVD risk.

Partial funding for the study was provided by a grant from the W.K. Kellogg Foundation. The authors have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Political elections can be hard on the heart, suggests a study that showed a substantial uptick in hospital admissions for acute cardiovascular conditions immediately after the 2020 American presidential election.

The analysis of nearly 6.4 million adults showed that the rate of hospitalization for acute cardiovascular disease (CVD) was 17% higher in the 5 days after the election than in a 5-day period 2 weeks earlier.

The rate of acute myocardial infarction (AMI) was 42% higher, with no significant difference for heart failure or stroke hospital admissions.

“These findings suggest that awareness of the heightened risk of CVD and strategies to mitigate risk during notable political events are needed,” write Matthew T. Mefford, PhD, of Kaiser Permanente Southern California, Pasadena, and colleagues.

The study was published in the April issue of JAMA Network Open.
 

Stress and the heart

In the American Psychological Association Stress in America 2020 survey conducted roughly 3 months before the 2020 presidential election, 77% of adults cited the future of the country as a substantial source of stress, enhanced by the ongoing COVID-19 pandemic, the authors note. More than two-thirds said the election was a substantial source of stress.

Dr. Mefford and colleagues compared CVD hospitalizations at Kaiser Permanente Southern and Northern California hospitals in the 5-day risk window of Nov. 4-8, 2020, with the control window of Oct. 21-25, 2020.

There were 666 CVD hospitalizations (760.47 per 100,000 person-years [PY]) in the risk window, compared with 569 (647.97 per 100,000 PY) in the control window (rate ratio, 1.17; 95% confidence interval, 1.05-1.31).

There were also significantly more hospitalizations for AMI immediately after the election than before (179 vs. 126 AMI hospitalizations; 204.4 vs. 143.5 per 100,000 PY; RR, 1.42; 95% CI, 1.13-1.79).

There was no significant difference between the risk and control periods for hospitalizations because of stroke or heart failure.

The study also suggests higher rates of acute CVD after the election in older adults, men, and White individuals. Political affiliation was not examined in the study.

“Importantly, results were consistent before and after excluding patients with confirmed COVID-19 infection,” the study team notes.

Yet, the potential influence of COVID-19 stressors on increasing CVD risk cannot be ruled out, they say.

However, COVID-19 stressors occurred over a much longer period and are less likely to explain the transient risks observed in the defined risk and control windows that are in close proximity to the 2020 election, the investigators point out.

There is growing evidence that psychological health contributes to CVD.

Previous studies shown a higher risk for acute CVD around population-wide psychosocial or environmental stressors, but less was known about acute CVD risk in relation to political events.

The researchers note future studies evaluating stress-relieving interventions may be important for understanding the intersection of political events, associated stress, and acute CVD risk.

Partial funding for the study was provided by a grant from the W.K. Kellogg Foundation. The authors have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Political elections can be hard on the heart, suggests a study that showed a substantial uptick in hospital admissions for acute cardiovascular conditions immediately after the 2020 American presidential election.

The analysis of nearly 6.4 million adults showed that the rate of hospitalization for acute cardiovascular disease (CVD) was 17% higher in the 5 days after the election than in a 5-day period 2 weeks earlier.

The rate of acute myocardial infarction (AMI) was 42% higher, with no significant difference for heart failure or stroke hospital admissions.

“These findings suggest that awareness of the heightened risk of CVD and strategies to mitigate risk during notable political events are needed,” write Matthew T. Mefford, PhD, of Kaiser Permanente Southern California, Pasadena, and colleagues.

The study was published in the April issue of JAMA Network Open.
 

Stress and the heart

In the American Psychological Association Stress in America 2020 survey conducted roughly 3 months before the 2020 presidential election, 77% of adults cited the future of the country as a substantial source of stress, enhanced by the ongoing COVID-19 pandemic, the authors note. More than two-thirds said the election was a substantial source of stress.

Dr. Mefford and colleagues compared CVD hospitalizations at Kaiser Permanente Southern and Northern California hospitals in the 5-day risk window of Nov. 4-8, 2020, with the control window of Oct. 21-25, 2020.

There were 666 CVD hospitalizations (760.47 per 100,000 person-years [PY]) in the risk window, compared with 569 (647.97 per 100,000 PY) in the control window (rate ratio, 1.17; 95% confidence interval, 1.05-1.31).

There were also significantly more hospitalizations for AMI immediately after the election than before (179 vs. 126 AMI hospitalizations; 204.4 vs. 143.5 per 100,000 PY; RR, 1.42; 95% CI, 1.13-1.79).

There was no significant difference between the risk and control periods for hospitalizations because of stroke or heart failure.

The study also suggests higher rates of acute CVD after the election in older adults, men, and White individuals. Political affiliation was not examined in the study.

“Importantly, results were consistent before and after excluding patients with confirmed COVID-19 infection,” the study team notes.

Yet, the potential influence of COVID-19 stressors on increasing CVD risk cannot be ruled out, they say.

However, COVID-19 stressors occurred over a much longer period and are less likely to explain the transient risks observed in the defined risk and control windows that are in close proximity to the 2020 election, the investigators point out.

There is growing evidence that psychological health contributes to CVD.

Previous studies shown a higher risk for acute CVD around population-wide psychosocial or environmental stressors, but less was known about acute CVD risk in relation to political events.

The researchers note future studies evaluating stress-relieving interventions may be important for understanding the intersection of political events, associated stress, and acute CVD risk.

Partial funding for the study was provided by a grant from the W.K. Kellogg Foundation. The authors have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

High rates of antipsychotic switching in first episode psychosis (FEP) suggests first-line prescribing is less than optimal and does not follow recent clinical guidance.

In a large-scale, real-world analysis of U.K. prescribing patterns, researchers found more than two-thirds of patients who received antipsychotics for FEP switched medication, and almost half switched drugs three times.

VladimirSorokin/Getty Images

Although this is “one of the largest real-world studies examining antipsychotic treatment strategies,” it reflects findings from previous, smaller studies showing “antipsychotic switching in first episode psychosis is high,” said study investigator Aimee Brinn, Institute of Psychiatry, Psychology & Neuroscience at King’s College London.

This may reflect reports of poor efficacy and suggests that first-line prescribing is “suboptimal,” Ms. Brinn noted. In addition, olanzapine remains the most popular antipsychotic for prescribing despite recent guidelines indicating it is “not ideal ... due to its dangerous metabolic side effects,” she added.

The findings were presented at the Congress of the Schizophrenia International Research Society (SIRS) 2022.
 

Real-world data

The response to, and tolerability of, antipsychotics differs between patients with FEP; and prescribing patterns “reflect clinician and patient-led decisionmaking,” Ms. Brinn told meeting attendees.

Since randomized controlled trials “do not necessarily reflect prescribing practice in real-world clinical settings,” the researchers gathered data from a large mental health care electronic health record dataset.

The investigators examined records from the South London and Maudsley NHS Foundation Trust (SLaM), which has a catchment area of 1.2 million individuals across four boroughs of London. The group sees approximately 37,500 active patients per week.

The team used the Clinical Interactive Record Search tool to extract data on 2,309 adults with FEP who received care from a SLaM early intervention in psychosis service between April 1, 2008, and March 31, 2019.

They found that 12 different antipsychotics were prescribed as first-line treatment. The most common were olanzapine (43.9%), risperidone (24.7%), and aripiprazole (19.9%).

Results showed that over 81,969.5 person-years of follow-up, at a minimum of 24 months per patient, 68.8% had an antipsychotic switch. The most common first treatment switch, in 17.9% of patients, was from olanzapine to aripiprazole.

Of patients who switched to aripiprazole, 48.4% stayed on the drug, 26% switched back to olanzapine, and 25.6% received other treatment. Overall, 44.7% of patients switched medication at least three times.

Among patients with FEP who did not switch, 42.2% were prescribed olanzapine, 26.2% risperidone, 23.3% aripiprazole, 5.6% quetiapine, and 2.7% amisulpride.

During the post-presentation discussion, Ms. Brinn was asked whether the high rate of first-line olanzapine prescribing could be because patients started treatment as inpatients and were then switched once they were moved to community care.

“We found that a lot of patients would be prescribed olanzapine for around 7 days at the start of their prescription and then switch,” Ms. Brinn said, adding it is “likely” they started as inpatients. The investigators are currently examining the differences between inpatient and outpatient prescriptions to verify whether this is indeed the case, she added.
 

‘Pulling out the big guns too fast?’

Commenting on the findings, Thomas W. Sedlak, MD, PhD, Johns Hopkins University School of Medicine, Baltimore, said the study raises a “number of questions.”

Both olanzapine and risperidone “tend to have higher treatment effect improvements than aripiprazole, so it’s curious that a switch to aripiprazole was common,” said Dr. Sedlak, who was not involved with the research.

“Are we pulling out the ‘big guns’ too fast, or inappropriately, especially as olanzapine and risperidone carry greater risk of weight gain?” he asked. In addition, “now that olanzapine is available with samidorphan to mitigate weight gain, will that shape future patterns, if it can be paid for?”

Dr. Sedlak noted it was unclear why olanzapine was chosen so often as first-line treatment in the study and agreed it is “possible that hospitalized patients had been prescribed a ‘stronger’ medication like olanzapine compared to never-hospitalized patients.”

He also underlined that it is “not clear if patients in this FEP program are representative of all FEP patients.”

“For instance, if the program is well known to inpatient hospital social workers, then the program might be disproportionately filled with patients who have had more severe symptoms,” Dr. Sedlak said.

The study was supported by Janssen-Cilag. The investigators and Dr. Sedlak have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

High rates of antipsychotic switching in first episode psychosis (FEP) suggests first-line prescribing is less than optimal and does not follow recent clinical guidance.

In a large-scale, real-world analysis of U.K. prescribing patterns, researchers found more than two-thirds of patients who received antipsychotics for FEP switched medication, and almost half switched drugs three times.

VladimirSorokin/Getty Images

Although this is “one of the largest real-world studies examining antipsychotic treatment strategies,” it reflects findings from previous, smaller studies showing “antipsychotic switching in first episode psychosis is high,” said study investigator Aimee Brinn, Institute of Psychiatry, Psychology & Neuroscience at King’s College London.

This may reflect reports of poor efficacy and suggests that first-line prescribing is “suboptimal,” Ms. Brinn noted. In addition, olanzapine remains the most popular antipsychotic for prescribing despite recent guidelines indicating it is “not ideal ... due to its dangerous metabolic side effects,” she added.

The findings were presented at the Congress of the Schizophrenia International Research Society (SIRS) 2022.
 

Real-world data

The response to, and tolerability of, antipsychotics differs between patients with FEP; and prescribing patterns “reflect clinician and patient-led decisionmaking,” Ms. Brinn told meeting attendees.

Since randomized controlled trials “do not necessarily reflect prescribing practice in real-world clinical settings,” the researchers gathered data from a large mental health care electronic health record dataset.

The investigators examined records from the South London and Maudsley NHS Foundation Trust (SLaM), which has a catchment area of 1.2 million individuals across four boroughs of London. The group sees approximately 37,500 active patients per week.

The team used the Clinical Interactive Record Search tool to extract data on 2,309 adults with FEP who received care from a SLaM early intervention in psychosis service between April 1, 2008, and March 31, 2019.

They found that 12 different antipsychotics were prescribed as first-line treatment. The most common were olanzapine (43.9%), risperidone (24.7%), and aripiprazole (19.9%).

Results showed that over 81,969.5 person-years of follow-up, at a minimum of 24 months per patient, 68.8% had an antipsychotic switch. The most common first treatment switch, in 17.9% of patients, was from olanzapine to aripiprazole.

Of patients who switched to aripiprazole, 48.4% stayed on the drug, 26% switched back to olanzapine, and 25.6% received other treatment. Overall, 44.7% of patients switched medication at least three times.

Among patients with FEP who did not switch, 42.2% were prescribed olanzapine, 26.2% risperidone, 23.3% aripiprazole, 5.6% quetiapine, and 2.7% amisulpride.

During the post-presentation discussion, Ms. Brinn was asked whether the high rate of first-line olanzapine prescribing could be because patients started treatment as inpatients and were then switched once they were moved to community care.

“We found that a lot of patients would be prescribed olanzapine for around 7 days at the start of their prescription and then switch,” Ms. Brinn said, adding it is “likely” they started as inpatients. The investigators are currently examining the differences between inpatient and outpatient prescriptions to verify whether this is indeed the case, she added.
 

‘Pulling out the big guns too fast?’

Commenting on the findings, Thomas W. Sedlak, MD, PhD, Johns Hopkins University School of Medicine, Baltimore, said the study raises a “number of questions.”

Both olanzapine and risperidone “tend to have higher treatment effect improvements than aripiprazole, so it’s curious that a switch to aripiprazole was common,” said Dr. Sedlak, who was not involved with the research.

“Are we pulling out the ‘big guns’ too fast, or inappropriately, especially as olanzapine and risperidone carry greater risk of weight gain?” he asked. In addition, “now that olanzapine is available with samidorphan to mitigate weight gain, will that shape future patterns, if it can be paid for?”

Dr. Sedlak noted it was unclear why olanzapine was chosen so often as first-line treatment in the study and agreed it is “possible that hospitalized patients had been prescribed a ‘stronger’ medication like olanzapine compared to never-hospitalized patients.”

He also underlined that it is “not clear if patients in this FEP program are representative of all FEP patients.”

“For instance, if the program is well known to inpatient hospital social workers, then the program might be disproportionately filled with patients who have had more severe symptoms,” Dr. Sedlak said.

The study was supported by Janssen-Cilag. The investigators and Dr. Sedlak have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

High rates of antipsychotic switching in first episode psychosis (FEP) suggests first-line prescribing is less than optimal and does not follow recent clinical guidance.

In a large-scale, real-world analysis of U.K. prescribing patterns, researchers found more than two-thirds of patients who received antipsychotics for FEP switched medication, and almost half switched drugs three times.

VladimirSorokin/Getty Images

Although this is “one of the largest real-world studies examining antipsychotic treatment strategies,” it reflects findings from previous, smaller studies showing “antipsychotic switching in first episode psychosis is high,” said study investigator Aimee Brinn, Institute of Psychiatry, Psychology & Neuroscience at King’s College London.

This may reflect reports of poor efficacy and suggests that first-line prescribing is “suboptimal,” Ms. Brinn noted. In addition, olanzapine remains the most popular antipsychotic for prescribing despite recent guidelines indicating it is “not ideal ... due to its dangerous metabolic side effects,” she added.

The findings were presented at the Congress of the Schizophrenia International Research Society (SIRS) 2022.
 

Real-world data

The response to, and tolerability of, antipsychotics differs between patients with FEP; and prescribing patterns “reflect clinician and patient-led decisionmaking,” Ms. Brinn told meeting attendees.

Since randomized controlled trials “do not necessarily reflect prescribing practice in real-world clinical settings,” the researchers gathered data from a large mental health care electronic health record dataset.

The investigators examined records from the South London and Maudsley NHS Foundation Trust (SLaM), which has a catchment area of 1.2 million individuals across four boroughs of London. The group sees approximately 37,500 active patients per week.

The team used the Clinical Interactive Record Search tool to extract data on 2,309 adults with FEP who received care from a SLaM early intervention in psychosis service between April 1, 2008, and March 31, 2019.

They found that 12 different antipsychotics were prescribed as first-line treatment. The most common were olanzapine (43.9%), risperidone (24.7%), and aripiprazole (19.9%).

Results showed that over 81,969.5 person-years of follow-up, at a minimum of 24 months per patient, 68.8% had an antipsychotic switch. The most common first treatment switch, in 17.9% of patients, was from olanzapine to aripiprazole.

Of patients who switched to aripiprazole, 48.4% stayed on the drug, 26% switched back to olanzapine, and 25.6% received other treatment. Overall, 44.7% of patients switched medication at least three times.

Among patients with FEP who did not switch, 42.2% were prescribed olanzapine, 26.2% risperidone, 23.3% aripiprazole, 5.6% quetiapine, and 2.7% amisulpride.

During the post-presentation discussion, Ms. Brinn was asked whether the high rate of first-line olanzapine prescribing could be because patients started treatment as inpatients and were then switched once they were moved to community care.

“We found that a lot of patients would be prescribed olanzapine for around 7 days at the start of their prescription and then switch,” Ms. Brinn said, adding it is “likely” they started as inpatients. The investigators are currently examining the differences between inpatient and outpatient prescriptions to verify whether this is indeed the case, she added.
 

‘Pulling out the big guns too fast?’

Commenting on the findings, Thomas W. Sedlak, MD, PhD, Johns Hopkins University School of Medicine, Baltimore, said the study raises a “number of questions.”

Both olanzapine and risperidone “tend to have higher treatment effect improvements than aripiprazole, so it’s curious that a switch to aripiprazole was common,” said Dr. Sedlak, who was not involved with the research.

“Are we pulling out the ‘big guns’ too fast, or inappropriately, especially as olanzapine and risperidone carry greater risk of weight gain?” he asked. In addition, “now that olanzapine is available with samidorphan to mitigate weight gain, will that shape future patterns, if it can be paid for?”

Dr. Sedlak noted it was unclear why olanzapine was chosen so often as first-line treatment in the study and agreed it is “possible that hospitalized patients had been prescribed a ‘stronger’ medication like olanzapine compared to never-hospitalized patients.”

He also underlined that it is “not clear if patients in this FEP program are representative of all FEP patients.”

“For instance, if the program is well known to inpatient hospital social workers, then the program might be disproportionately filled with patients who have had more severe symptoms,” Dr. Sedlak said.

The study was supported by Janssen-Cilag. The investigators and Dr. Sedlak have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Olanzapine plus samidorphan (Lybalvi) vs. olanzapine alone is associated with less weight gain while achieving similar clinical outcomes in patients with recent-onset severe mental illness, new research suggests. However, at least one expert says the weight difference between the two drugs is of “questionable clinical benefit.”

Last year, the Food and Drug Administration approved the drug for the treatment of adults with schizophrenia or bipolar I disorder, as a maintenance monotherapy or as either monotherapy or an adjunct to lithium or valproate for acute manic or mixed episodes.

In the ENLIGHTEN-Early trial, researchers examined weight-gain profiles of more than 400 patients with early schizophrenia, schizophreniform disorder, or bipolar I disorder.

Results showed those given combination treatment gained just over half the amount of weight as those given monotherapy. They were also 36% less likely to gain at least 10% of their body weight during the 12-week treatment period.

Courtesy Mount Sinai Health System

Potential benefit

“Early intervention with antipsychotic treatment is critical in shaping the course of treatment and the disease trajectory,” coinvestigator Christine Graham, PhD, with Alkermes, which manufactures the drug, told this news organization.

Olanzapine is a “highly effective antipsychotic, but it’s really avoided a lot in this population,” Dr. Graham said. Therefore, patients “could really stand to benefit” from a combination that delivers the same amount of antipsychotic effect, but “reduces the propensity” for clinically significant weight gain, she added.

Dr. Kahn noted in his meeting presentation that antipsychotics are the “cornerstone” of the treatment of serious mental illness, but that “many are associated with concerning weight gain and cardiometabolic effects.”

While olanzapine is an effective medication, it has “one of the highest weight gain” profiles of the available antipsychotics and patients early on in their illness are “especially vulnerable,” Dr. Kahn said.

Previous studies have shown the combination of olanzapine plus samidorphan is similarly effective as olanzapine, but is associated with less weight gain.

To determine its impact in recent-onset illness, the current researchers screened patients with schizophrenia, schizophreniform disorder, or bipolar I disorder. The patients were aged 16-39 years and had an initial onset of active phase symptoms less than 4 years previously. They had less than 24 weeks’ cumulative lifetime exposure to antipsychotics.

Participants were randomly assigned to receive olanzapine plus samidorphan or olanzapine alone for 12 weeks, and then followed up for safety assessment for a further 4 weeks.

A total of 426 patients were recruited and 76.5% completed the study. The mean age was 25.8 years, 66.2% were men, 66.4% were White, and 28.2% were Black.

The mean body mass index at baseline was 23.69 kg/m². The most common diagnosis among the participants was schizophrenia (62.9%) followed by bipolar I disorder (21.6%).
 

Less weight gain

Results of the 12-week study showed a significant difference in percent change in body weight from baseline between the two treatment groups, with a gain of 4.91% for the olanzapine plus samidorphan group vs. 6.77% for the olanzapine-alone group (between-group difference, 1.87%; P = .012).

Dr. Kahn noted this equates to an average weight gain of 2.8 kg (6.2 pounds) with olanzapine plus samidorphan and a gain of about 5 kg (11pounds) with olanzapine.

“It’s not a huge difference, but it’s certainly a significant one,” he said. “I also think it’s clinically important and significant.”

The reduction in weight gain compared with olanzapine was even maintained in patients assigned to olanzapine plus samidorphan who dropped out and did not complete the study, Dr. Kahn reported. “No one really had a weight gain,” he said.

In contrast, patients in the olanzapine groups who dropped out of the study had weight gain larger than their counterparts who stayed in it.

Further analysis showed the proportion of patients who gained 10% or more of their body weight by week 12 was 21.9% for those receiving olanzapine plus samidorphan vs. 30.4% for those receiving just olanzapine (odds ratio, 0.64; P = .075).

As expected, the improvement in Clinical Global Impression–Severity scale scores was almost identical between the olanzapine + samidorphan and olanzapine-only groups.

For safety, Dr. Kahn said the adverse event rates were “very, very similar” between the two treatment arms, which was a pattern that was repeated for serious AEs. This led him to note that “nothing out of the ordinary” was observed.
 

Clinical impact 'questionable'

Commenting on the study, Laura LaChance, MD, a psychiatrist at St. Mary’s Hospital Centre, McGill University, Montreal, said the actual amount of weight loss shown in the study “is of questionable clinical significance.”

A version of this article first appeared on Medscape.com.

Olanzapine plus samidorphan (Lybalvi) vs. olanzapine alone is associated with less weight gain while achieving similar clinical outcomes in patients with recent-onset severe mental illness, new research suggests. However, at least one expert says the weight difference between the two drugs is of “questionable clinical benefit.”

Last year, the Food and Drug Administration approved the drug for the treatment of adults with schizophrenia or bipolar I disorder, as a maintenance monotherapy or as either monotherapy or an adjunct to lithium or valproate for acute manic or mixed episodes.

In the ENLIGHTEN-Early trial, researchers examined weight-gain profiles of more than 400 patients with early schizophrenia, schizophreniform disorder, or bipolar I disorder.

Results showed those given combination treatment gained just over half the amount of weight as those given monotherapy. They were also 36% less likely to gain at least 10% of their body weight during the 12-week treatment period.

Courtesy Mount Sinai Health System

Potential benefit

“Early intervention with antipsychotic treatment is critical in shaping the course of treatment and the disease trajectory,” coinvestigator Christine Graham, PhD, with Alkermes, which manufactures the drug, told this news organization.

Olanzapine is a “highly effective antipsychotic, but it’s really avoided a lot in this population,” Dr. Graham said. Therefore, patients “could really stand to benefit” from a combination that delivers the same amount of antipsychotic effect, but “reduces the propensity” for clinically significant weight gain, she added.

Dr. Kahn noted in his meeting presentation that antipsychotics are the “cornerstone” of the treatment of serious mental illness, but that “many are associated with concerning weight gain and cardiometabolic effects.”

While olanzapine is an effective medication, it has “one of the highest weight gain” profiles of the available antipsychotics and patients early on in their illness are “especially vulnerable,” Dr. Kahn said.

Previous studies have shown the combination of olanzapine plus samidorphan is similarly effective as olanzapine, but is associated with less weight gain.

To determine its impact in recent-onset illness, the current researchers screened patients with schizophrenia, schizophreniform disorder, or bipolar I disorder. The patients were aged 16-39 years and had an initial onset of active phase symptoms less than 4 years previously. They had less than 24 weeks’ cumulative lifetime exposure to antipsychotics.

Participants were randomly assigned to receive olanzapine plus samidorphan or olanzapine alone for 12 weeks, and then followed up for safety assessment for a further 4 weeks.

A total of 426 patients were recruited and 76.5% completed the study. The mean age was 25.8 years, 66.2% were men, 66.4% were White, and 28.2% were Black.

The mean body mass index at baseline was 23.69 kg/m². The most common diagnosis among the participants was schizophrenia (62.9%) followed by bipolar I disorder (21.6%).
 

Less weight gain

Results of the 12-week study showed a significant difference in percent change in body weight from baseline between the two treatment groups, with a gain of 4.91% for the olanzapine plus samidorphan group vs. 6.77% for the olanzapine-alone group (between-group difference, 1.87%; P = .012).

Dr. Kahn noted this equates to an average weight gain of 2.8 kg (6.2 pounds) with olanzapine plus samidorphan and a gain of about 5 kg (11pounds) with olanzapine.

“It’s not a huge difference, but it’s certainly a significant one,” he said. “I also think it’s clinically important and significant.”

The reduction in weight gain compared with olanzapine was even maintained in patients assigned to olanzapine plus samidorphan who dropped out and did not complete the study, Dr. Kahn reported. “No one really had a weight gain,” he said.

In contrast, patients in the olanzapine groups who dropped out of the study had weight gain larger than their counterparts who stayed in it.

Further analysis showed the proportion of patients who gained 10% or more of their body weight by week 12 was 21.9% for those receiving olanzapine plus samidorphan vs. 30.4% for those receiving just olanzapine (odds ratio, 0.64; P = .075).

As expected, the improvement in Clinical Global Impression–Severity scale scores was almost identical between the olanzapine + samidorphan and olanzapine-only groups.

For safety, Dr. Kahn said the adverse event rates were “very, very similar” between the two treatment arms, which was a pattern that was repeated for serious AEs. This led him to note that “nothing out of the ordinary” was observed.
 

Clinical impact 'questionable'

Commenting on the study, Laura LaChance, MD, a psychiatrist at St. Mary’s Hospital Centre, McGill University, Montreal, said the actual amount of weight loss shown in the study “is of questionable clinical significance.”

A version of this article first appeared on Medscape.com.

Olanzapine plus samidorphan (Lybalvi) vs. olanzapine alone is associated with less weight gain while achieving similar clinical outcomes in patients with recent-onset severe mental illness, new research suggests. However, at least one expert says the weight difference between the two drugs is of “questionable clinical benefit.”

Last year, the Food and Drug Administration approved the drug for the treatment of adults with schizophrenia or bipolar I disorder, as a maintenance monotherapy or as either monotherapy or an adjunct to lithium or valproate for acute manic or mixed episodes.

In the ENLIGHTEN-Early trial, researchers examined weight-gain profiles of more than 400 patients with early schizophrenia, schizophreniform disorder, or bipolar I disorder.

Results showed those given combination treatment gained just over half the amount of weight as those given monotherapy. They were also 36% less likely to gain at least 10% of their body weight during the 12-week treatment period.

Courtesy Mount Sinai Health System

Potential benefit

“Early intervention with antipsychotic treatment is critical in shaping the course of treatment and the disease trajectory,” coinvestigator Christine Graham, PhD, with Alkermes, which manufactures the drug, told this news organization.

Olanzapine is a “highly effective antipsychotic, but it’s really avoided a lot in this population,” Dr. Graham said. Therefore, patients “could really stand to benefit” from a combination that delivers the same amount of antipsychotic effect, but “reduces the propensity” for clinically significant weight gain, she added.

Dr. Kahn noted in his meeting presentation that antipsychotics are the “cornerstone” of the treatment of serious mental illness, but that “many are associated with concerning weight gain and cardiometabolic effects.”

While olanzapine is an effective medication, it has “one of the highest weight gain” profiles of the available antipsychotics and patients early on in their illness are “especially vulnerable,” Dr. Kahn said.

Previous studies have shown the combination of olanzapine plus samidorphan is similarly effective as olanzapine, but is associated with less weight gain.

To determine its impact in recent-onset illness, the current researchers screened patients with schizophrenia, schizophreniform disorder, or bipolar I disorder. The patients were aged 16-39 years and had an initial onset of active phase symptoms less than 4 years previously. They had less than 24 weeks’ cumulative lifetime exposure to antipsychotics.

Participants were randomly assigned to receive olanzapine plus samidorphan or olanzapine alone for 12 weeks, and then followed up for safety assessment for a further 4 weeks.

A total of 426 patients were recruited and 76.5% completed the study. The mean age was 25.8 years, 66.2% were men, 66.4% were White, and 28.2% were Black.

The mean body mass index at baseline was 23.69 kg/m². The most common diagnosis among the participants was schizophrenia (62.9%) followed by bipolar I disorder (21.6%).
 

Less weight gain

Results of the 12-week study showed a significant difference in percent change in body weight from baseline between the two treatment groups, with a gain of 4.91% for the olanzapine plus samidorphan group vs. 6.77% for the olanzapine-alone group (between-group difference, 1.87%; P = .012).

Dr. Kahn noted this equates to an average weight gain of 2.8 kg (6.2 pounds) with olanzapine plus samidorphan and a gain of about 5 kg (11pounds) with olanzapine.

“It’s not a huge difference, but it’s certainly a significant one,” he said. “I also think it’s clinically important and significant.”

The reduction in weight gain compared with olanzapine was even maintained in patients assigned to olanzapine plus samidorphan who dropped out and did not complete the study, Dr. Kahn reported. “No one really had a weight gain,” he said.

In contrast, patients in the olanzapine groups who dropped out of the study had weight gain larger than their counterparts who stayed in it.

Further analysis showed the proportion of patients who gained 10% or more of their body weight by week 12 was 21.9% for those receiving olanzapine plus samidorphan vs. 30.4% for those receiving just olanzapine (odds ratio, 0.64; P = .075).

As expected, the improvement in Clinical Global Impression–Severity scale scores was almost identical between the olanzapine + samidorphan and olanzapine-only groups.

For safety, Dr. Kahn said the adverse event rates were “very, very similar” between the two treatment arms, which was a pattern that was repeated for serious AEs. This led him to note that “nothing out of the ordinary” was observed.
 

Clinical impact 'questionable'

Commenting on the study, Laura LaChance, MD, a psychiatrist at St. Mary’s Hospital Centre, McGill University, Montreal, said the actual amount of weight loss shown in the study “is of questionable clinical significance.”

A version of this article first appeared on Medscape.com.

Treatment with deep brain stimulation improved motor function and quality of life, but depression scores increased after 1 year, based on data from 20 adults.

Subthalamic nucleus deep brain stimulation (STN-DBS) has emerged as an effective treatment for Parkinson’s disease symptoms, with evidence supporting improved motor symptoms and quality of life, wrote Francesca Mameli, PsyD, of Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, and colleagues.

Maggiore Policlinico Hospital of Milan

However, the effect of STN-DBS on personality in Parkinson’s disease (PD) has not been well investigated they said.

In a study published in Neuromodulation, the researchers reviewed data from 12 women and 8 men with PD who underwent bilateral STN-DBS.

Depression was assessed via the Montgomery-Asberg Depressive Rating Scale (MADRS), personality characteristics were assessed via the Minnesota Multiphasic Personality Inventory–2 (MMPI-2), and motor disabilities were assessed via UPDRS-III-Motor. The motor disabilities score was obtained in medication on and medication off conditions; the off condition followed a 12-hour overnight withdrawal of dopaminergic medication. Quality of life was assessed via the Parkinson’s Disease Questionnaire–8 (PDQ-8).

After 12 months, scores on the MMPI-2 were significantly higher on the D subscale, increased from a baseline mean of 56.05 to a 12-month mean of 61.90 (P = .015).

Other MMPI-2 scales showing significant increases included the DEP scale, LSE scale, WRK scale, and TRT scale. No differences appeared between male and female patients.

No significant changes occurred from pre-DBS baseline to the 12-month follow-up in MADRS scale assessment, with mean scores of 8.18 and 9.22, respectively.

A 40% improvement in UPDRS measures of motor function occurred among patients in the “medication-off” condition, although there was no significant change following DBS in the medication-on condition, the researchers said. Among 18 patients with PDQ-8 assessments, quality of life scores were significantly higher at 12 months’ post DBS compared to baseline pre DBS (40.15 vs. 30.73, P = .011).

The researchers also examined the relationship between the total electrical energy delivered (TEED) and the occurrence of personality trait shift. In the TEED analysis, “only the energy on the right side was inversely correlated with the changes in depression,” they wrote.

“Because of the complexity of psychiatric phenomena, it would be advisable to take a cautious approach by including psychiatric evaluation by interview for a better selection of patients who score close to the pathological cutoffs in MADRS and MMPI-2,” the researchers wrote in their discussion.

The study findings were limited by several factors including the small sample size, lack of data on the prevalence and severity of apathy, the use of scales based on self-reports, and inability to control for all factors that might affect depressive traits, the researchers noted. In addition, more research is needed to explore the correlation between TEED and personality trait changes, they said.

However, the results support the value of DBS in PD, but emphasize the need to manage expectations, they emphasized. “Expectations should never be unrealistic, and the caring team should ensure not only that patients fully understand the risks and potential benefits of the DBS but also that it will not stop the neurodegenerative progression of the disease,” they said.

The study was supported in part by the Italian Ministry of Health. The researchers had no financial conflicts to disclose.

Treatment with deep brain stimulation improved motor function and quality of life, but depression scores increased after 1 year, based on data from 20 adults.

Subthalamic nucleus deep brain stimulation (STN-DBS) has emerged as an effective treatment for Parkinson’s disease symptoms, with evidence supporting improved motor symptoms and quality of life, wrote Francesca Mameli, PsyD, of Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, and colleagues.

Maggiore Policlinico Hospital of Milan

However, the effect of STN-DBS on personality in Parkinson’s disease (PD) has not been well investigated they said.

In a study published in Neuromodulation, the researchers reviewed data from 12 women and 8 men with PD who underwent bilateral STN-DBS.

Depression was assessed via the Montgomery-Asberg Depressive Rating Scale (MADRS), personality characteristics were assessed via the Minnesota Multiphasic Personality Inventory–2 (MMPI-2), and motor disabilities were assessed via UPDRS-III-Motor. The motor disabilities score was obtained in medication on and medication off conditions; the off condition followed a 12-hour overnight withdrawal of dopaminergic medication. Quality of life was assessed via the Parkinson’s Disease Questionnaire–8 (PDQ-8).

After 12 months, scores on the MMPI-2 were significantly higher on the D subscale, increased from a baseline mean of 56.05 to a 12-month mean of 61.90 (P = .015).

Other MMPI-2 scales showing significant increases included the DEP scale, LSE scale, WRK scale, and TRT scale. No differences appeared between male and female patients.

No significant changes occurred from pre-DBS baseline to the 12-month follow-up in MADRS scale assessment, with mean scores of 8.18 and 9.22, respectively.

A 40% improvement in UPDRS measures of motor function occurred among patients in the “medication-off” condition, although there was no significant change following DBS in the medication-on condition, the researchers said. Among 18 patients with PDQ-8 assessments, quality of life scores were significantly higher at 12 months’ post DBS compared to baseline pre DBS (40.15 vs. 30.73, P = .011).

The researchers also examined the relationship between the total electrical energy delivered (TEED) and the occurrence of personality trait shift. In the TEED analysis, “only the energy on the right side was inversely correlated with the changes in depression,” they wrote.

“Because of the complexity of psychiatric phenomena, it would be advisable to take a cautious approach by including psychiatric evaluation by interview for a better selection of patients who score close to the pathological cutoffs in MADRS and MMPI-2,” the researchers wrote in their discussion.

The study findings were limited by several factors including the small sample size, lack of data on the prevalence and severity of apathy, the use of scales based on self-reports, and inability to control for all factors that might affect depressive traits, the researchers noted. In addition, more research is needed to explore the correlation between TEED and personality trait changes, they said.

However, the results support the value of DBS in PD, but emphasize the need to manage expectations, they emphasized. “Expectations should never be unrealistic, and the caring team should ensure not only that patients fully understand the risks and potential benefits of the DBS but also that it will not stop the neurodegenerative progression of the disease,” they said.

The study was supported in part by the Italian Ministry of Health. The researchers had no financial conflicts to disclose.

Treatment with deep brain stimulation improved motor function and quality of life, but depression scores increased after 1 year, based on data from 20 adults.

Subthalamic nucleus deep brain stimulation (STN-DBS) has emerged as an effective treatment for Parkinson’s disease symptoms, with evidence supporting improved motor symptoms and quality of life, wrote Francesca Mameli, PsyD, of Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, and colleagues.

Maggiore Policlinico Hospital of Milan

However, the effect of STN-DBS on personality in Parkinson’s disease (PD) has not been well investigated they said.

In a study published in Neuromodulation, the researchers reviewed data from 12 women and 8 men with PD who underwent bilateral STN-DBS.

Depression was assessed via the Montgomery-Asberg Depressive Rating Scale (MADRS), personality characteristics were assessed via the Minnesota Multiphasic Personality Inventory–2 (MMPI-2), and motor disabilities were assessed via UPDRS-III-Motor. The motor disabilities score was obtained in medication on and medication off conditions; the off condition followed a 12-hour overnight withdrawal of dopaminergic medication. Quality of life was assessed via the Parkinson’s Disease Questionnaire–8 (PDQ-8).

After 12 months, scores on the MMPI-2 were significantly higher on the D subscale, increased from a baseline mean of 56.05 to a 12-month mean of 61.90 (P = .015).

Other MMPI-2 scales showing significant increases included the DEP scale, LSE scale, WRK scale, and TRT scale. No differences appeared between male and female patients.

No significant changes occurred from pre-DBS baseline to the 12-month follow-up in MADRS scale assessment, with mean scores of 8.18 and 9.22, respectively.

A 40% improvement in UPDRS measures of motor function occurred among patients in the “medication-off” condition, although there was no significant change following DBS in the medication-on condition, the researchers said. Among 18 patients with PDQ-8 assessments, quality of life scores were significantly higher at 12 months’ post DBS compared to baseline pre DBS (40.15 vs. 30.73, P = .011).

The researchers also examined the relationship between the total electrical energy delivered (TEED) and the occurrence of personality trait shift. In the TEED analysis, “only the energy on the right side was inversely correlated with the changes in depression,” they wrote.

“Because of the complexity of psychiatric phenomena, it would be advisable to take a cautious approach by including psychiatric evaluation by interview for a better selection of patients who score close to the pathological cutoffs in MADRS and MMPI-2,” the researchers wrote in their discussion.

The study findings were limited by several factors including the small sample size, lack of data on the prevalence and severity of apathy, the use of scales based on self-reports, and inability to control for all factors that might affect depressive traits, the researchers noted. In addition, more research is needed to explore the correlation between TEED and personality trait changes, they said.

However, the results support the value of DBS in PD, but emphasize the need to manage expectations, they emphasized. “Expectations should never be unrealistic, and the caring team should ensure not only that patients fully understand the risks and potential benefits of the DBS but also that it will not stop the neurodegenerative progression of the disease,” they said.

The study was supported in part by the Italian Ministry of Health. The researchers had no financial conflicts to disclose.

Hospital admission for children with eating disorders approximately tripled during the COVID-19 pandemic, based on data from 85 patients.

Eating disorders are common among adolescents and often require hospital admission for nutritional restoration, according to May Shum of Yale University, New Haven, Conn., and colleagues

During the COVID-19 pandemic, the volume of hospital admissions for adolescents with eating disorders has increased, the researchers wrote in a poster presented at the annual meeting of the Pediatric Academic Societies. This increase may be driven both by interruptions in medical care and increased psychological distress, but data on changes in patient characteristics and hospitalization course are lacking, they said.

The researchers reviewed charts from patients with eating disorders admitted to a single center between Jan. 1, 2017, and June 30, 2021. The majority of the patients were female (90.6%), and White (78.8%), had restrictive eating behaviors (97.2%), and had private insurance (80.0%).

Overall, the number of monthly admissions increased from 1.4 before the onset of the pandemic to 3.6 during the pandemic (P < .001).

Length of stay increased significantly from before to during pandemic cases (12.8 days vs. 17.3 days, P = .04) and age younger than 13 years was significantly associated with a longer length of stay (P < .001).

The number of patients for whom psychotropic medications were initiated or changed increased significantly (12.5% vs. 28.3%, P = .04); as did the proportion of patients discharged to partial hospitalization, residential, or inpatient psychiatric treatment rather than discharged home with outpatient therapy (56.2% vs. 75.0%, P = .04).

No significant differences were noted in demographics, comorbidities, admission parameters, EKG abnormalities, electrolyte repletion, or tube feeding.

The study findings were limited by the use of data from a single center. However, the results suggest an increase in severity of hospital admissions that have implications for use of hospital resources, the researchers said.

“In addition to an increase in hospital admissions for eating disorder management during the pandemic, longer inpatient stays of younger children with higher acuity at discharge is an added strain on hospital resources and warrants attention,” they concluded.
 

Considerations for younger patients

The current study is especially important at this time, Margaret Thew, DNP, FNP-BC, medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, said in an interview. “There have been reports of the rising numbers in eating disorders, but until research has been conducted, we cannot quantify the volumes,” said Ms. Thew, who was not involved in the study. “There have been many reports of the rise in mental health issues during the pandemic, so it seems accurate that the rate of eating disorders would rise,” she said. “Additionally, from a clinical perspective there seemed to be many younger-age patients with eating disorders presenting to the inpatient units who seemed sicker,” she noted.

Ms. Thew said she was not surprised by the study findings. “Working with adolescents with eating disorders we saw the increased numbers of both hospitalizations and outpatient referrals during the pandemic,” said Ms. Thew. “Length of stay was higher across the nation regarding admissions for concerns of eating disorders. These patients are sicker and fewer went home after medical stabilization,” she emphasized.

“Clinicians should be more aware of the rise in patients presenting with eating disorders at younger ages to their clinics and provide early interventions to prevent severe illness and medical instability,” said Ms. Thew. Clinicians also should be more proactive in managing younger children and adolescents who express mood disorders, disordered eating, or weight loss, given the significant rise in eating disorders and mental health concerns, she said.  

Additional research is needed to continue following the rate of eating disorders into 2022, said Ms. Thew. More research is needed on early interventions and recognition of eating disorders for preteens and teens to prevent severe illness, as is research on how the younger patient with an eating disorder may present differently to the primary care doctor or emergency department, she said.

“We may need to study treatment of the younger population, as they may not do as well with admissions into behavioral health facilities,” Ms. Thew added.

The study received no outside funding. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.

Hospital admission for children with eating disorders approximately tripled during the COVID-19 pandemic, based on data from 85 patients.

Eating disorders are common among adolescents and often require hospital admission for nutritional restoration, according to May Shum of Yale University, New Haven, Conn., and colleagues

During the COVID-19 pandemic, the volume of hospital admissions for adolescents with eating disorders has increased, the researchers wrote in a poster presented at the annual meeting of the Pediatric Academic Societies. This increase may be driven both by interruptions in medical care and increased psychological distress, but data on changes in patient characteristics and hospitalization course are lacking, they said.

The researchers reviewed charts from patients with eating disorders admitted to a single center between Jan. 1, 2017, and June 30, 2021. The majority of the patients were female (90.6%), and White (78.8%), had restrictive eating behaviors (97.2%), and had private insurance (80.0%).

Overall, the number of monthly admissions increased from 1.4 before the onset of the pandemic to 3.6 during the pandemic (P < .001).

Length of stay increased significantly from before to during pandemic cases (12.8 days vs. 17.3 days, P = .04) and age younger than 13 years was significantly associated with a longer length of stay (P < .001).

The number of patients for whom psychotropic medications were initiated or changed increased significantly (12.5% vs. 28.3%, P = .04); as did the proportion of patients discharged to partial hospitalization, residential, or inpatient psychiatric treatment rather than discharged home with outpatient therapy (56.2% vs. 75.0%, P = .04).

No significant differences were noted in demographics, comorbidities, admission parameters, EKG abnormalities, electrolyte repletion, or tube feeding.

The study findings were limited by the use of data from a single center. However, the results suggest an increase in severity of hospital admissions that have implications for use of hospital resources, the researchers said.

“In addition to an increase in hospital admissions for eating disorder management during the pandemic, longer inpatient stays of younger children with higher acuity at discharge is an added strain on hospital resources and warrants attention,” they concluded.
 

Considerations for younger patients

The current study is especially important at this time, Margaret Thew, DNP, FNP-BC, medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, said in an interview. “There have been reports of the rising numbers in eating disorders, but until research has been conducted, we cannot quantify the volumes,” said Ms. Thew, who was not involved in the study. “There have been many reports of the rise in mental health issues during the pandemic, so it seems accurate that the rate of eating disorders would rise,” she said. “Additionally, from a clinical perspective there seemed to be many younger-age patients with eating disorders presenting to the inpatient units who seemed sicker,” she noted.

Ms. Thew said she was not surprised by the study findings. “Working with adolescents with eating disorders we saw the increased numbers of both hospitalizations and outpatient referrals during the pandemic,” said Ms. Thew. “Length of stay was higher across the nation regarding admissions for concerns of eating disorders. These patients are sicker and fewer went home after medical stabilization,” she emphasized.

“Clinicians should be more aware of the rise in patients presenting with eating disorders at younger ages to their clinics and provide early interventions to prevent severe illness and medical instability,” said Ms. Thew. Clinicians also should be more proactive in managing younger children and adolescents who express mood disorders, disordered eating, or weight loss, given the significant rise in eating disorders and mental health concerns, she said.  

Additional research is needed to continue following the rate of eating disorders into 2022, said Ms. Thew. More research is needed on early interventions and recognition of eating disorders for preteens and teens to prevent severe illness, as is research on how the younger patient with an eating disorder may present differently to the primary care doctor or emergency department, she said.

“We may need to study treatment of the younger population, as they may not do as well with admissions into behavioral health facilities,” Ms. Thew added.

The study received no outside funding. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.

Hospital admission for children with eating disorders approximately tripled during the COVID-19 pandemic, based on data from 85 patients.

Eating disorders are common among adolescents and often require hospital admission for nutritional restoration, according to May Shum of Yale University, New Haven, Conn., and colleagues

During the COVID-19 pandemic, the volume of hospital admissions for adolescents with eating disorders has increased, the researchers wrote in a poster presented at the annual meeting of the Pediatric Academic Societies. This increase may be driven both by interruptions in medical care and increased psychological distress, but data on changes in patient characteristics and hospitalization course are lacking, they said.

The researchers reviewed charts from patients with eating disorders admitted to a single center between Jan. 1, 2017, and June 30, 2021. The majority of the patients were female (90.6%), and White (78.8%), had restrictive eating behaviors (97.2%), and had private insurance (80.0%).

Overall, the number of monthly admissions increased from 1.4 before the onset of the pandemic to 3.6 during the pandemic (P < .001).

Length of stay increased significantly from before to during pandemic cases (12.8 days vs. 17.3 days, P = .04) and age younger than 13 years was significantly associated with a longer length of stay (P < .001).

The number of patients for whom psychotropic medications were initiated or changed increased significantly (12.5% vs. 28.3%, P = .04); as did the proportion of patients discharged to partial hospitalization, residential, or inpatient psychiatric treatment rather than discharged home with outpatient therapy (56.2% vs. 75.0%, P = .04).

No significant differences were noted in demographics, comorbidities, admission parameters, EKG abnormalities, electrolyte repletion, or tube feeding.

The study findings were limited by the use of data from a single center. However, the results suggest an increase in severity of hospital admissions that have implications for use of hospital resources, the researchers said.

“In addition to an increase in hospital admissions for eating disorder management during the pandemic, longer inpatient stays of younger children with higher acuity at discharge is an added strain on hospital resources and warrants attention,” they concluded.
 

Considerations for younger patients

The current study is especially important at this time, Margaret Thew, DNP, FNP-BC, medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, said in an interview. “There have been reports of the rising numbers in eating disorders, but until research has been conducted, we cannot quantify the volumes,” said Ms. Thew, who was not involved in the study. “There have been many reports of the rise in mental health issues during the pandemic, so it seems accurate that the rate of eating disorders would rise,” she said. “Additionally, from a clinical perspective there seemed to be many younger-age patients with eating disorders presenting to the inpatient units who seemed sicker,” she noted.

Ms. Thew said she was not surprised by the study findings. “Working with adolescents with eating disorders we saw the increased numbers of both hospitalizations and outpatient referrals during the pandemic,” said Ms. Thew. “Length of stay was higher across the nation regarding admissions for concerns of eating disorders. These patients are sicker and fewer went home after medical stabilization,” she emphasized.

“Clinicians should be more aware of the rise in patients presenting with eating disorders at younger ages to their clinics and provide early interventions to prevent severe illness and medical instability,” said Ms. Thew. Clinicians also should be more proactive in managing younger children and adolescents who express mood disorders, disordered eating, or weight loss, given the significant rise in eating disorders and mental health concerns, she said.  

Additional research is needed to continue following the rate of eating disorders into 2022, said Ms. Thew. More research is needed on early interventions and recognition of eating disorders for preteens and teens to prevent severe illness, as is research on how the younger patient with an eating disorder may present differently to the primary care doctor or emergency department, she said.

“We may need to study treatment of the younger population, as they may not do as well with admissions into behavioral health facilities,” Ms. Thew added.

The study received no outside funding. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.