Three Experts’ Different Approaches to Treating PTSD in Veterans

October 4, 2017 · Posted in Current Treatments, Potential Treatments · Comment 

PTSDIn the BNN we have previously described some experts’ preferred treatment algorithms for patients with treatment-resistant post-traumatic stress disorder (PTSD), which is often complicated by traumatic brain injury (TBI). In this article, we update and expand upon these expert views.

David Bakish has worked as Medical Director at the Ottawa Psychopharmacology Clinic and is a former professor of psychiatry at the University of Ottawa in Ottawa, Ontario. In addition, he works with the Canadian military seeing patients with PTSD, substance abuse, and traumatic brain injuries. He uses a symptom-driven approach to PTSD, including 6 to 7 targeted medications added in sequence.

Albert Sattin is a professor of psychiatry and biobehavioral sciences at UCLA, belongs to their Brain Research Institute, and is affiliated with both the Ronald Reagan UCLA Medical Center and the Veterans Affairs Greater Los Angeles Healthcare System. He prefers to treat PTSD with a three-part combination of the blood pressure–lowering drug prazosin, a selective serotonin reuptake inhibitor (SSRI) antidepressant, and the atypical antidepressant mirtazapine.

Murray Raskind pioneered placebo-controlled studies of prazosin for PTSD and served as director of the Veterans Affairs Puget Sound Health Care System Mental Health Service, in addition to serving in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. Raskind’s approach to PTSD includes prazosin, the tricyclic antidepressant amitriptyline, and if needed for sleep, the sedative zolpidem.

Only SSRIs are approved by the US Food and Drug Administration (FDA) for the treatment of PTSD, but these on their own are rarely sufficient to handle the insomnia and other symptoms that accompany PTSD. Exposure therapy, in which patients are gradually led to approach trauma-related memories, feelings, and situations they previously avoided, is the most recommended type of therapy, but it too is often insufficient to treat all the complexities of the illness. Read on for more on each doctor’s approach to treating PTSD. Read more

Deep TMS May Improve Treatment-Resistant Bipolar Depression

October 2, 2017 · Posted in Current Treatments · Comment 

deep tmsDeep transcranial magnetic stimulation (dTMS) is a non-invasive treatment that has been shown to be effective in unipolar depression. It consists of a helmet fitted to the head, which uses magnetic coils to create an electric field in a desired brain region.

A 2017 double-blind randomized study by Diego F. Taveres and colleagues in the journal Neuropsychopharmacology found that 20 sessions of dTMS targeting the left dorsolateral prefrontal cortex produced greater improvement in bipolar depression over 4 weeks of treatment than the same number of sham sessions in which participants wore a helmet that delivered similar sounds and scalp sensations without the electrical effects to the brain. The participants had treatment-resistant bipolar depression that was being treated with medication.

However, dTMS’ effects were not significantly different from those of the sham over four additional weeks of follow-up, nor were remission rates significantly different across the two groups. Out of 50 participants, seven dropped out of the study—two from the sham group, and five from the active dTMS group. But there were no occasions on which a participant switched into mania following treatment.

This study suggests that dTMS has the potential to more rapidly improve treatment-resistant bipolar depression as well as unipolar depression.

Evidence-Based Psychotherapies for Young Children

September 25, 2017 · Posted in Current Treatments · Comment 

TherapyAs many as 7–10% of children under the age of 5 have mood or behavioral problems, and this risk is even higher when a parent has a mood disorder. However, many families are not able to access treatment for these children due to their location, a lack of providers, or insurance problems.

A 2016 article by Mary Margaret Gleason and colleagues in the journal Technical Report in Pediatrics summarizes psychotherapeutic treatments for children that are supported with rigorous evidence. Some of these include infant-parent psychotherapy, video feedback for positive parenting, attachment biobehavioral catch-up (or ABC, in which caregivers are taught to re-interpret the signals of children who previously experienced maltreatment, providing nurturing in response), parent-child interaction therapy, and programs that combine parenting support with illness prevention, such as the Incredible Years series (for behavioral difficulties), the New Forest Programme (for attention-deficit hyperactivity disorder or ADHD), and Helping the Noncompliant Child (for oppositional behavior).

Gleason and colleagues suggest that pediatricians should take the lead in assessing young children and recommending appropriate psychotherapeutic approaches.

One resource available to parents is our own Child Network. It consists of an online portal where parents can provide weekly ratings of their children’s symptoms. These can be provided to the child’s physician to facilitate diagnosis and to clinicians to more effectively evaluate the results of treatment. The data provided to the Child Network will in turn help us understand how children are being treated in the community. There a few initial forms to fill out, but the weekly rating process is quick and can provide a great picture of a child’s wellbeing over time, including evaluating the effectiveness of any treatments.

Generic Seroquel XR Approved

September 20, 2017 · Posted in Current Treatments · Comment 

Earlier this year, the US Food and Drug Administration approved a generic version of Seroquel XR tablets (Quetiapine Fumarate Extended-Release Tablets), which are used to treat both depression and mania in bipolar disorder, schizophrenia, and to augment the effects of antidepressants in unipolar depression. Also known as quetiapine, the generic tablets will be available in 50 mg, 150 mg, 200 mg, 300 mg, and 400 mg doses.

Seroquel XR is taken once per day several hours before bedtime in the acute treatment for bipolar depression (300 mg/day), mania or mixed episodes (300–600 mg/day) or their prevention (400 mg/day); or paired with antidepressants to treat unipolar depression (150–300 mg/day).

The generic tablets, which are expected to be more affordable than Seroquel XR, are produced by Pharmadax Inc.

Some Antacids Cause Kidney Damage with No Prior Symptoms

September 11, 2017 · Posted in Current Treatments · Comment 

kidneyCommonly used antacids such as Prevacid, Nexium, Prilosec, and Protonix can impair kidney function, according to a 2017 article in the journal Kidney International. These drugs, known as proton pump inhibitors or PPIs, should not be taken long-term without monitoring of kidney function. Other antacids that work by blocking histamine H2 receptors do not interfere with kidney function but may not work as well as PPIs.

Researcher Yan Xie and colleagues found that more than half of people who developed chronic kidney damage while taking PPIs showed no earlier acute signs of kidney dysfunction, meaning there may not be signs of kidney function loss until the damage is irreversible. Xie and colleagues suggest that patients and doctors should be more vigilant about monitoring the use of these medications, since waiting for outward signs of declining kidney function is not a reliable way of detecting damage.

More than 15 million Americans use prescription PPIs to reduce gastric acid, bringing relief to heartburn, ulcers, and acid reflux. Millions more buy PPIs over the counter without consulting a doctor about their use.

The study analyzed Department of Veterans Affairs data from 125,596 new users of PPIs and 18,436 new users of H2 blockers. Acute, reversible symptoms of kidney damage, such as reduction in the urine being cleared from the body, fatigue, and swelling of the legs and ankles were seen in less than 20% of the PPI users. However, more than half of those who developed chronic kidney damage and end-stage renal disease never showed these warning signals beforehand. In contrast, only 7.67% of those taking H2 blockers had chronic kidney disease without acute symptoms, and 1.27% had end-stage renal disease, when kidneys can no longer clear waste from the body, and dialysis or a kidney transplant is required.

Xie and colleagues suggest carefully monitoring kidney function in people taking PPIs, even when there are no outward signs of problems. They also suggest carefully evaluating whether PPIs are necessary, since the risk of kidney damage is serious.

Methylphenidate Does Not Cause Mania When Taken with a Mood Stabilizer

September 8, 2017 · Posted in Comorbidities, Current Treatments · Comment 

ADHDMethylphenidate is an effective treatment for attention-deficit hyperactivity disorder (ADHD). Ritalin may be the most commonly recognized trade name for methylphenidate, but it is also sold under the names Concerta, Daytrana, Methylin, and Aptensio. A 2016 article in the American Journal of Psychiatry reports that methylphenidate can safely be taken by people with bipolar disorder and comorbid ADHD as long as it is paired with mood-stabilizing treatment.

The study was based on data from a Swedish national registry. Researchers led by Alexander Viktorin identified 2,307 adults with bipolar disorder who began taking methylphenidate between 2006 and 2014. Of these, 1,103 were taking mood stabilizers including antipsychotic medications, lithium, or valproate, while 718 were not taking any mood stabilizing medications.

Among those who began taking methylphenidate without mood stabilizers, manic episodes increased over the next six months. In contrast, patients taking mood stabilizers had their risk of mania decrease after beginning treatment with methylphenidate.

Viktorin and colleagues suggest that 20% of patients with bipolar disorder may also have ADHD, so it is not surprising that 8% of patients with bipolar disorder in Sweden receive a methylphenidate prescription.

Mood-stabilizing drugs can worsen attention and concentration, so methylphenidate treatment can be helpful if it can be done without increasing manic episodes. However, Viktorin and colleagues suggest that due to the risk of increasing mania, anyone given a prescription for methylphenidate monotherapy should be carefully screened to rule out bipolar disorder.

The researchers confirmed that taking methylphenidate for ADHD while taking a mood stabilizer for bipolar disorder is a safe combination.

Use of Hormonal Contraceptives May Increase Depression Risk in Young Women

September 5, 2017 · Posted in Current Treatments · Comment 

Women, particularly adolescent women, are at increased risk of developing depression if they use hormonal contraceptives, according to a 2016 study in the journal JAMA Psychiatry. The study by Charlotte Wessel Skovlund and colleagues used data from a Danish registry of more than one million women between the ages of 15 and 34 who had no history of depression or other psychiatric disorders. During follow-up (which lasted an average of 6.4 years), 55% of the women were using or had recently used hormonal contraceptives. These women were more likely to be prescribed an antidepressant for the first time, and more likely to be diagnosed with depression compared to women who did not use hormonal contraceptives.

The increased risk of being prescribed an antidepressant varied by contraceptive type. The norgestrolmin patch increased risk by 2.0 times, and the etonogestrel vaginal ring did so by 1.6 times. The levonorgestrel intrauterine device (IUD) made an antidepressant prescription 1.4 times more likely. Progestin-only pills increased risk by 1.34 times and combined oral contraceptive pills increased it by 1.23 times compared to women who did not use oral contraceptives.

The relative risk peaked at around six months after starting hormonal contraceptives.

Patients aged 15–19 were particularly vulnerable to depression. The likelihood of receiving an antidepressant prescription was 1.8 times higher in teens taking combined pills, 2.2 times higher in those taking progestin-only pills, and 3 times higher in teens using hormonal methods of birth control that are not delivered orally compared to those who did not use hormonal contraceptives at all.

Safety of Atypical Antipsychotics in Pregnancy

August 31, 2017 · Posted in Current Treatments · Comment 

pregnant woman

A 2017 article in the Journal of Clinical Psychiatry systematically reviewed data on the risks related to schizophrenia, bipolar disorder, and treatment with atypical antipsychotic medication during pregnancy. The article by researcher Sarah Tosato and colleagues suggests that a mother’s illness may be more harmful to a fetus than treatment for that illness is.

The review analyzed 49 articles about illness-related and atypical antipsychotic–related risks in bipolar disorder and schizophrenia. Tosato and colleagues found that abrupt discontinuation of treatment led to a high risk of relapse in pregnant women with bipolar disorder or schizophrenia.

Schizophrenia was linked to a slight increase in obstetric complications for mothers, while both bipolar disorder and schizophrenia were linked to a slight increase in complications for newborns. Mothers ill with schizophrenia had the highest risk for serious complications, including stillbirth, neonatal or infant death, and intellectual disability in the child.

The researchers reported that untreated bipolar disorder and schizophrenia are risk factors for birth defects, but use of atypical antipsychotics is not. Children’s neurodevelopment also does not seem to be affected by mothers’ use of atypical antipsychotics during pregnancy.

The authors suggest that, given parents agree and understand any risks involved, the least harmful choice of action is to maintain treatment of women with bipolar disorder and schizophrenia during pregnancy at the safest minimum dosage to keep their illness at bay.

Birth Defects from Valproate Lower in Bipolar Disorder than in Epilepsy

August 30, 2017 · Posted in Current Treatments · Comment 

pregnancyThe anticonvulsant valproate increases the risk of serious birth defects in fetuses exposed to it. However, a 2017 report by ANSM, France’s agency for health and product safety, and its national insurance fund for employed workers shows that these risks are lower for women taking valproate for bipolar disorder than for women taking valproate for epilepsy.

In France, the risk of a major fetal malformation was 10.2 per 1000 women in the general population, about twice that (22.2 per 1000) in women taking valproate for bipolar disorder, and about 4 times higher (46.5 per 1000) in women taking valproate for epilepsy. The authors suggest that treatment for bipolar disorder may be more likely to be interrupted during pregnancy, and this could explain the different levels of risk by diagnosis.

Among the risks of defects in the fetuses of women being treated with valproate for epilepsy, the risk of a ventricular septal defect (a hole in the wall separating the lower heart chambers) was 11.2% compared to 2.7% in fetuses not exposed to valproate, while risk of an atrial septal defect (a hole in the wall separating the upper heart chambers) was 19.1% in the fetuses of those prescribed valproate for epilepsy compared to 1.9% in unexposed fetuses. Risk of hypospadias (placement of the urethra opening on the underside of the penis rather than its end) was 22.7% compared to 4.8% in the general population.

Risks of a major malformation were dose dependent in those with epilepsy (but interestingly, not in those with bipolar disorder), meaning the more valproate patients with epilepsy took, the higher their risk of a fetus with birth defects.

The only birth defects that were more common in the fetuses of women taking valproate for bipolar disorder than in fetuses not exposed to valproate were hypospadias (17.5% risk compared to 4.8% in the general population) and craniostenosis, a deformity of the skull (4.2% risk compared to 0.4% in the general population).

The relative safety of valproate in women being treated for bipolar disorder compared to those being treated for epilepsy is good news for some. However, fetal exposure to valproate has also been linked to deficits in cognitive development.

The risk of spina bifida, which causes lifetime paralysis, in a fetus may no longer be such a catastrophic  issue for women taking valproate for bipolar disorder (where the risk did not exceed that of the general population), as was once assumed based on data from women with epilepsy (where the risk is usually 2-4%, but was 8% in this French study). This may be of some comfort to women with bipolar disorder who require valproate treatment to remain stable and wish to become pregnant or in those who experience an unplanned pregnancy.

Antidepressant Use in Pregnancy Does Not Increase Autism Risk

August 29, 2017 · Posted in Current Treatments · Comment 

pregnant woman with a pillTwo large observational studies published in the journal JAMA in 2017 find no link between antidepressant use during pregnancy and risk of an autism spectrum disorder. Previous studies had suggested a link between the two, but may not have sufficiently accounted for confounding factors. In both new studies, autism rates did not differ between siblings exposed to antidepressants in utero and those who were not exposed.

One of the studies, by researcher Ayesha C. Sujan and colleagues, analyzed exposure to antidepressants in the first trimester and neurodevelopmental outcomes in almost 1.6 million Swedish children. Antidepressant use did slightly increase the chance of a preterm birth, but was not linked to autism spectrum disorder, attention-deficit hyperactivity disorder (ADHD), or small size of the fetus.

The researchers suggested that doctors and patients work together to decide how depression should be treated during pregnancy, based on severity of the depression, treatment history, and access to services.

The other study, by researcher Hilary K. Brown and colleagues, analyzed 36,000 births in Ontario, Canada and found no increased risk of autism spectrum disorder based on antidepressant exposure in utero. The study controlled for 500 characteristics such as mother’s education, age, and health history.

The journal JAMA Pediatrics also published a meta-analysis and review of 10 studies on the subject, finding that a woman’s history of psychiatric disorders weakened any link between antidepressant use during pregnancy and risk of autism spectrum disorder in her children. This implies that the underlying illness, not its treatment, may be responsible if there is any link between depression and autism. The meta-analysis was carried out by researcher Antonia Mezzacappa and colleagues.

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