Journal Digest: Pregnancy and Cannabis; Apathy and Psychosis; Community Treatment Orders and Readmission; NIHTB-CB and Intellectual Disability; Varenicline lower Cardiovascular and Psychiatric Hospitalization; Online Mindfulness and Depression

Pregnant Women with Depression More Likely to Use Cannabis

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Pregnant women with a history of depression are nearly four times more likely to use cannabis than those without a depression history, according to a report by researchers at the City University of New York and colleagues. The report, which was published in Drug and Alcohol Dependence, also identified much higher cannabis use among pregnant teens with depression.

“As brain development is ongoing until age 25, cannabis use in this group may increase risks for both mother and offspring,” wrote the study authors. “Our results provide recent, nationally representative estimates suggesting that education and intervention efforts should be targeted at pregnant teens.”

The researchers used data from the annual National Survey on Drug Use and Health (NSDUH) from the years 2005 to 2018. Their samples included 11,623 women aged 12 to 49 who reported being pregnant at the time they took the NSDUH interview.

Among this group of pregnant women, 6.8% reported a major depressive episode in the previous year; 12.7% of pregnant women with depression reported using cannabis in the past month, compared with 3.7% of pregnant women with no depression. Among pregnant women with depression, the rate of use decreased with age: 23.7% for women aged 12 to 17, 16.7% for women 18 to 25, and 8.0% for women 26 and older.

Pregnant women with depression were also more likely than those without depression to use cannabis even if they perceived such use as being risky, the authors noted. “This pattern appears similar to cigarette use among pregnant women with depression and may suggest that depression drives increased use, though other pathways are also possible,” they wrote.

Chronic Apathy Predictors Identified in Patients with Psychosis

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Apathy is a common symptom of psychotic disorders and is associated with poor long-term outcomes for patients. Researchers at Oslo University Hospital in Norway have now tracked 10-year trajectories of apathy in people with first-episode psychosis and identified key predictors of elevated long-term apathy.

The researchers enrolled 198 adults aged 18 to 65 years with first-episode psychosis from inpatient and outpatient hospitals around Oslo and 198 people without psychosis. The participants were assessed seven to 10 years after enrollment; a subset of these participants was also assessed at six months or one year after enrollment.

Average apathy scores for first-episode psychosis patients were 28.7 at baseline (assessed with the Apathy Evaluation Scale self-report version, or AES-S). These scores dropped to 24.6 after one year of treatment, before remaining at about 24 for the study duration. Apathy scores for the controls were 17.6 at baseline and remained stable throughout the study. After seven to 10 years, 37% of first-episode psychosis patients had clinically significant apathy (AES-S score of 27 or higher), compared with 5% of controls.

Further analysis indicated that higher baseline apathy scores or a long period of untreated psychosis prior to diagnosis were associated with higher long-term apathy across the study duration; elevated depression at baseline was also associated with higher apathy, but not for the full 10 years.

“Considering the lack of evidence-based treatments for negative symptoms, efforts to reduce [duration of untreated psychosis] and to treat co-occurring depressive symptoms could help to prevent high levels of apathy in the long term and thus improve functional outcome,” the authors wrote.

This study appeared in the European Archives of Psychiatry and Clinical Neuroscience.

Community Treatment Orders May Increase Hospital Readmission

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An analysis of postdischarge outcomes among people in South London who received inpatient psychiatric care suggests that community treatment orders are associated with increased risk of being readmitted to the hospital. The findings were published in BMJ Open.

A community treatment order, also known as assisted outpatient treatment, refers to a legal order in which a person with severe mental illness adheres to a mental health treatment plan and outpatient monitoring to enable a rapid response if relapse occurs. These orders are a subject of debate, and the data are mixed on their effects on hospitalization and health care costs.

For this latest analysis, researchers at King’s College London and colleagues assessed 4,489 patients discharged from involuntary care between 2008 and 2014. Participants’ outcomes were measured until 2016, enabling at least two years of follow-up for each patient.

Of this group, 830 (18.5%) were given a community treatment order at least once. Patients who were involved in the legal system were five times more likely to receive a community treatment order compared with patients who were not involved with the legal system. Patients taking a long-acting injectable antipsychotic were twice as likely to receive a community treatment order as those taking oral antipsychotics.

The researchers found that patients with a community treatment order were 1.6 times more likely to be readmitted to inpatient care during the analysis period. These patients were also more likely to come back to the hospital sooner (average readmission time of 4.0 years versus 5.8 years for patients without community treatment orders) and spend more time in the hospital (average of 178 days in the two years following first discharge versus 148 days for patients without community treatment orders).

“There are several possible explanations for why those on [community treatment orders] had higher rates of psychiatric hospital admission compared with controls in our study. One plausible explanation is that patients with more severe symptoms or a history of relapse were more likely to receive [community treatment orders],” the authors wrote.

Cognitive Assessment Tool Found Reliable for People with Intellectual Disability

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The National Institutes of Health Toolbox Cognitive Battery (NIHTB-CB) is a reliable tool to assess cognition in most children and young adults with intellectual disability, according to a study in Neurology. Useful for research, the NIHTB-CB is a freely available set of seven tablet-based tests measuring executive function, memory, language, and processing speed.

Researchers at the MIND Institute in Sacramento, Calif., and colleagues tested the NIHTB-CB on 242 individuals aged 6 to 25 with intellectual disabilities such as fragile X syndrome or Down syndrome; all participants were tested twice, one month apart.

The findings revealed that many of the participants with intellectual disability successfully completed the tests, and the tests were reliable (test scores were similar on both occasions). Tests that involved crystallized intelligence (accumulated and fixed knowledge such as vocabulary and object recognition) were more feasible and reliable than those involving fluid intelligence (problem solving). Most of the variability occurred in participants whose intelligence was lower than a typical 5-year-old, suggesting these tests need to be adapted more for use in very low-functioning individuals.

“Besides evaluating the NIHTB-CB as an appropriate assessment for [intellectual disability] in general, the present results demonstrate the sensitivity of the battery to known syndrome-specific cognitive phenotypes,” the authors noted. For example, individuals with fragile X syndrome performed worse on a card-sorting task (that measures executive function) than their overall cognitive level would suggest. This aligns with existing research showing that children with fragile X have more impaired attention and impulse control than children with other types of intellectual disability.

Smokers Taking Varenicline at Lower Risk of Heart, Psychiatric Hospitalization

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People taking the smoking cessation medication varenicline have lower rates of psychiatric hospitalization than those taking other smoking cessation products, according to a study in Addiction. They are also less likely to be hospitalized for cardiovascular problems compared with those taking nicotine replacement therapy (NRT), the study found.

Using the MarketScan database, which contains health insurance claims information on over 100 million people in the United States, the researchers identified 618,497 adults with no history of depression who received a prescription for a smoking cessation pharmacotherapy. This group included 454,698 varenicline users, 131,562 bupropion users, and 32,237 users of prescription NRT. (The researchers used NRT as the control group since it is considered the safest smoking cessation option.)

Compared with those who took NRT, people taking varenicline or bupropion were 20% and 25% less likely, respectively, to be hospitalized for a cardiovascular problem in the 12 months after starting their treatment. People taking varenicline were 35% less likely to be hospitalized for a psychiatric illness in the first year of taking the medication compared with those taking NRT. In contrast, patients taking bupropion had a 21% higher risk of psychiatric hospitalization compared with those taking NRT.

“Given the comorbidities associated with smoking, varenicline should continue to be considered a treatment option for smoking cessation,” the researchers wrote. “These results also provide further support for the FDA’s decision to remove the varenicline boxed warning for neuropsychiatric adverse events.”

Online Mindfulness Program Effective for Students with Depression

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An internet-based intervention that combines mindfulness techniques and cognitive-behavioral therapy principles can help reduce symptoms of depression and anxiety in college students, suggests a trial conducted by researchers at the University of Toronto.

“[S]tudents often experience difficulties in accessing [counseling] services, while counseling centers are overwhelmed due to limited resources,” wrote the researchers in JMIR Mental Health. “New and accessible strategies are needed to address the students’ mental health.”

The research team worked with student focus groups to develop a web-based mental health intervention called Mindfulness Virtual Community (MVC). The MVC featured three components: youth-specific educational and mindfulness-practice videos; an anonymous, peer-to-peer discussion board; and short, group-based online conferences where participants remained anonymous, guided by a mental health professional.

The researchers evaluated the intervention in 113 University of Toronto students. The participants were given access to all of the MVC resources, a partial MVC that included only video modules, or a waitlist control for eight weeks. At the end of the study, students who had full or partial access to MVC interventions reported significantly reduced depression symptoms (assessed with the PHQ-9) and perceived stress compared with the control group. However, only students in the partial MVC group reported greater improvements in anxiety symptoms compared with the control group.

“Anxious subjects, avoidant of health professional contacts, might have responded more positively when assured that the entire program was web-based and did not involve any ‘live’ interactions,” the researchers wrote. “[T]his finding has cost implications given that personnel costs often constitute the largest proportion of web-based intervention costs.” ■