February 2010

Vol. 22. No. 1


Help improve your patients’ physical as well as mental health

I want to alert readers to the upcoming annual meeting of the American Academy of Clinical Psychiatrists, hosted in collaboration with Current Psychiatry, to be held April 8 to 10, 2010, at the Sheraton Hotel and Towers in Chicago. The meeting, “Mood and anxiety disorders: Solving clinical challenges, improving patient care,” offers an opportunity for peer-to-peer learning and Networking. The lineup of topics is impressive: mood and anxiety disorders across the life span; best practices for treating social anxiety disorder, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder; maximizing antidepressant therapy while managing side effects, drug interactions, and suicide risk; and diagnostic challenges regarding the distinctions between unipolar and bipolar depression, atypical depression, and borderline personality disorder. Attendees will receive up to 18 AMA PRA Category 1 Credits™. Richard Balon, MD, is the meeting chair, and I serve as co-chair. The outstanding faculty includes Kiki D. Chang, MD, Marlene P. Freeman, MD, Frederick K. Goodwin, MD, George T. Grossberg, MD, James W. Jefferson, MD, Andrew Nierenberg, MD, Natalie Rasgon, MD, PhD, and Murray B. Stein, MD, MPH. I feel that this will be one of our best meetings yet and I hope to see all of you there.

This issue of Annals of Clinical Psychiatry presents articles that can help improve your patients’ physical as well as mental health. Mitchell Barnett, PharmD, MS, and colleagues analyze Medi-Cal data showing that patients taking second-generation antipsychotics (SGAs) are not being appropriately monitored for metabolic parameters. This has become a significant issue for psychiatrists and their patients after discoveries about SGAs’ association with glucose and lipid abnormalities. The authors suggest that pharmacists trained in medication therapy management become more involved in monitoring patients, an idea worth considering. 

It is worth remembering that medication alone is not fully responsible for a patient’s metabolic problems. As David C. Henderson, MD, and colleagues show, dietary fat intake in patients taking clozapine or risperidone routinely exceeds fat intake by other patients. Clearly, some patients preferentially consume excess dietary fat, magnifying the influence of SGAs on metabolic parameters. 

One conclusion we could draw is that patients have a responsibility to monitor their food intake and should not be passive participants in this process. Other contributions to this issue include new research by Ella J. Daly, MB, MRCPsych, and colleagues on health-related quality of life in depressed patients enrolled in the STAR*D trial; from Dan J. Stein, MD, PhD, and colleagues on the influence of early childhood adversity on the development of hypertension; and from Nancy C. Raymond, MD, and colleagues showing that naltrexone may help reduce compulsive sexual behaviors. Suhayl Nasr, MD, and colleagues report a near 10% prevalence of sleep apnea among psychiatric patients, an alarming figure that may be related to rising obesity rates among our patients. Lastly, Rif S. El-Mallakh, MD, and colleagues compare intermediate-release and extended-release carbamazepine, and show that both are effective treatments in manic and depressed patients with bipolar disorder.



A blinded, randomized comparison of immediate release and extended-release carbamazepine capsules in manic and depressed bipolar subjects

Rif S. El-Mallakh, MD | Mary Ruth Salem, RN, MA | Amarjit Chopra, MD | Gregory J. Mickus, BS | Praveen Penagaluri, MD | Radhika Movva, MD

Background: The anticonvulsant carbamazepine is approved by the FDA for treatment of acute mania. It is available in 2 formulations: immediate- release (IR) and extended-release carbamazepine capsules (ERCC). The relative efficacy of these formulations in acutely ill bipolar patients has not been previously investigated.

Methods: This study is a subanalysis of a 3-month, blinded, equal, random-assignment comparison of adverse effect load of an IR carbamazepine formulation (Tegretol) and ERCC (Equetro) in type I or type II bipolar patients already receiving carbamazepine or clinically determined to benefit from carbamazepine treatment. Dosages were titrated to patients’ clinical needs. Subjects who scored >15 on the Montgomery Åsberg Depression Rating Scale (MADRS) or >14 on the Young Mania Rating Scale (YMRS) were included in this analysis. The primary outcome measures were the relative mood scores at the end of the study.

Results: At the end of 3 months of treatment, all patients improved compared with their baseline, but there was no difference in mood ratings in subjects with an initial MADRS >15 (ERCC, 18.2 ± SD 11.9, vs IR, 12.0 ± 4.5; P = .3) or YMRS >15 (ERCC, 6.5 ± 6.4, vs IR, 4.7 ± 3.1; P = .7). When compared with their baseline, patients receiving IR improved earlier than patients receiving ERCC. There were no differences in overall adverse events in patients receiving IR or ERCC (23.1 ± 13.42 vs 22.3 ± 13.40; P = .9).

Conclusions: Carbamazepine is effective in treating symptoms of both mania and depression, and there are no significant differences in the relative efficacy of the IR or ERCC formulations.


Assessment of monitoring for glucose and lipid dysregulation in adult Medi-Cal patients newly started on antipsychotics

Mitchell Barnett, PharmD, MS | Shannon VonMuenster, PharmD | Heidi Wehring, PharmD | Sarah Popish, PharmD | Karna McDonald, PharmD | Victor M. Walker, RPh | Paul Perry, BPharm, PhD

Background: Because patients receiving antipsychotics are at increased risk for coronary heart disease, standards of care for such patients now include periodic glucose and lipid testing. The objective of this study was to examine rates of glucose and lipid monitoring among adult Medicaid patients initiated on antipsychotic therapy.

Methods: California Medicaid (Medi-Cal) claims of 6601 patients identified as “new” antipsychotic users between July 1, 2004 and June 30, 2005 were analyzed. Rates of glucose and lipid testing were compared for 6 months prior to and post–initiation of antipsychotic therapy. Odds ratios (ORs) for testing associated with first-generation antipsychotic (FGA) and second-generation antipsychotic (SGA) use were determined while controlling for patient level factors.

Results: In a multivariate analysis, SGA patients were more likely than FGA patients to undergo glucose testing (OR, 1.38; 95% confidence interval [CI], 1.13 to 1.70; P < .01) and lipid testing (OR, 1.43; 95% CI, 1.14 to 1.81; P < .01), respectively. SGA patients were also more likely than FGA patients to receive both glucose and lipid testing in the 6 months following initiation of antipsychotic treatment (OR, 1.40; 95% CI, 1.11 to 1.79, P < .01). Conclusion: Although increases in glucose and lipid testing rates were observed among Medi-Cal patients after initiation of antipsychotic therapy, recommended monitoring does not appear to occur universally in this population. Interventions to increase monitoring of these patients are warranted.


Early childhood adversity and later hypertension: Data from the World Mental Health Survey

Dan J. Stein, FRCPC, PhD | Kate Scott, PhD | Josep M. Haro Abad, MD, MPH, PhD | Sergio Aguilar-Gaxiola, MD, PhD | Jordi Alonso, MD, MPH, PhD | Matthias Angermeyer, MD, PhD | Koen Demytteneare, MD, PhD | Giovanni de Girolamo, MD | Noboru Iwata, PhD | José Posada-Villa, MD | Viviane Kovess, Md, PhD | Carmen Lara, MD, PhD | Johan Ormel, PhD | Ronald C. Kessler, PhD | Micheal Von Korff, PhF

Background: Although many studies have indicated that psychosocial factors contribute to hypertension, and that early childhood adversity is associated with long-term adverse mental and physical health sequelae, the association between early adversity and later hypertension is not well studied.

Method: Data from 10 countries participating in the World Health Organization (WHO) World Mental Health (WHM) Surveys (N = 18,630) were analyzed to assess the relationship between childhood adversity and adult-onset hypertension, as ascertained by self-report. The potentially mediating effect of early-onset depression-anxiety disorders, as assessed by the WHM Survey version of the International Diagnostic Interview (WMH-CIDI), on the relationship between early adversity and hypertension was also examined.

Results: Two or more early childhood adversities, as well as early-onset depression-anxiety, were significantly associated with hypertension. A range of specific childhood adversities, as well as early-onset social phobia and panic/agoraphobia, were significantly associated with hypertension. In multivariate analyses, the presence of 3 or more childhood adversities was associated with hypertension, even when early-onset depression-anxiety or current depression-anxiety was included in the model.

Conclusions: Although caution is required in the interpretation of self report data on adult-onset hypertension, the results of this study further strengthen the evidence base regarding the role of psychosocial factors in the pathogenesis of hypertension.


Increased incidence of sleep apnea in psychiatric outpatients

Suhayl Nasr, MD | Burdette Wendt | Shilpa Kora, BSc

Background: The rate of mood disorders in patients in sleep centers has been the subject of many studies, yet little has been published on the incidence of sleep apnea in psychiatric patients.

Methods: A retrospective chart review was performed on 330 consecutively seen psychiatric outpatients. Medication history, demographics, and the results of patients’ most recent Quick Inventory of Depressive Symptomatology (QIDS) were collected. Patients were checked for a history of apnea through a review of session notes and the results of any polysomnogram
that the patient had on file.

Results: Of the patients studied, 9.7% were positive for sleep apnea. They required a significantly higher number of medications (3.2 vs 2.4; P < .001). They also scored significantly higher on 3 items on the QIDS: late insomnia (1.0 vs 0.55; P < .01), reduced energy level (1.2 vs 0.76; P < .02), and decreased general interest (1.0 vs 0.64; P < .04). Middle age in men (age 45 to 64) and higher body mass index both in men and women were also associated with a higher frequency of sleep apnea.

Conclusion: Sleep apnea is more prevalent in psychiatric outpatients than in the general population. Identification of this comorbid condition will likely result in better treatment outcomes.