How common is violence by psychiatric patients? ( Lancet Psych 2021)

The Question

What do evidence suggest as the risk of violence by individuals with different diagnoses? Violence is a broad term encompassing a variety of behaviours. In this narrative review,  Daniel Whiting, Paul Lichtenstein, Seena Fazel looked at officially registered violent crimes ( arrests / conviction) ie in the context of contact with criminal justice system and its associations with mental illnesses.

The public perceive violence in people with mental illness.This perception contributes to stigma towards mental illness . Stigma obviously is associated negative consequences on those with mental illness. Violence risk is a factor that matters a lot in decisions of compulsory admissions and as such the notions of violence can have significant impact on freedom of those with mental illness. There is also significant concern about  violence towards those with mental illness.

Findings 

There is an increased risk of violence in people with schizophrenia spectrum disorders even after adjusting for substance misuse. Odds of homicide is higher than for other violent crimes . The absolute life time risk of perpretation is very low ( o.3%). A consistent finding that we all know from our clinical work is the mediating role of comorbid substance misuse in such crimes. Substance use typically doubles the risk of violence. Sibling studies ( where you compare affected sibling against unaffected siblings to reduce confounding) show that unaffected sibling has an OR of 1.89 as against the general population. Affected sibling’s OR is 4·2 (95% CI 3·8–4·5).  It is worth noting that unaffected siblings are also showing more violent behaviours. 

What about life time risk?

Over a lifetime, 23% of individuals with a diagnosis of schizophrenia in Sweden had a violent conviction.

When is risk more?

The five-year incidence of violent conviction after first diagnosis was 11% in men and 3% in women.In first- episode psychosis, around one in ten individuals perpetrated physical interpersonal violence in the 1–3 years after first contact with clinical services. Over half of patients with violent offending histories committed their first violent crime before illness onset or first diagnosis. In individuals with psychotic illnesses who commit homicide, around 40% do so during the first episode of illness before treatment initiation. This highlights the need for early assessment and monitoring of all at risk symptoms. How much of this PRE ILLNESS/ PRE DIAGNOSIS/ PRE CONTACT violence is due to substance use or socio economic / familial factors or pre-symptoms (like behavioural disinhibition, social dislocation , affective disconnect, traumatic distress etc) of the illness is not known. 

If we look at the big picture of all homicides in a population, individuals with schizophrenia spectrum disorders typically represent less than 10% of all homicide convictions. It is possible that individuals with psychotic disorders are more likely to be convicted than others perhaps due to them revealing intent / leaving more evidences for conviction. 

Stranger Homicide & Schizophrenia

The risk of stranger homicide by those with schizophrenia is very very rare. It is estimated to be one in 14 million. ( ie 0.06 per 100 000 general population). Compare this with death by lightning in the UK ( 0·05 per 100 000 population)!

BPAD

Individuals with bipolar disorder had a 5-fold increased risk of violence compared with the general population. This OR comes down to below 3 when we adjust for sociodemographic factors and substance misuse (adjusted OR 2·8, 95% CI 2·5–3·1). Sibling studies show that the risk of violent crime in unaffected siblings (compared with the general population) is higher, suggesting familial confounding (1·2, 1·1–1·4).Absolute rates of violent crime are estimated at 8% in men and 2% in women with bipolar disorder, of which 70% occur in the 5 years after diagnosis,7 and 11% when using a lifetime outcome.

Depression

It is surprising to see that depressed individuals have a three times increased risk of violent offending after diagnosis, compared with the general population (adjusted OR 3·0, 95% CI 2·8–3·3)

Other diagnoses 

ADHD before the age of 18 years show an increased odds of violence-related arrest of 3·6 (95% CI 2·3–5·7) compared with controls who did not have ADHD.Unaffected siblings also show more violence. 

Autistic spectrum disorders : No consistent association is found . Nearly 30% of those with ASD has comorbid ADHD or Conduct Disorder and this may account for high risk shown in some studies.

Personality disorder is associated with a three times increased risk of violence. As we know, antisocial personality disorder is the most important one in this regard. In terms of absolute risks 8% of individuals with a diagnosis of any personality disorder perpetrated a violent offence in up to 10 years of follow-up.

Substance misuse : A key longitudinal study show Hazard Ratio for violence as 6·2 for men (95% CI 14·6–17·9) and 36·0 for women (27·0–48·0). Evidence for independent associations with violence for individual drugs are more uncertain.Hazard Ratio for violent offending in alcohol use disorders is 9·0 for men [95% CI 8·2–9·9] and 19·8 for women (14·6–26·7)

Conclusions

Some psychiatric disorders are clearly associated with increased relative risk of violence. Absolute risks ( up to 10% each in schizophrenia and personality disorders, and over 10% in substance use disorders ) suggest that these are still very high priority areas for mental health practice. Risk assessment, Risk communication and Risk reduction are integral to good clinical practice. The findings of this review highlight some key areas with in clinical pathways were we might want to invest more to reduce risk of violence.

Article : Whiting D, Lichtenstein P, Fazel S. Violence and mental disorders: a structured review of associations by individual diagnoses, risk factors, and risk assessment. Lancet Psychiatry. 2021 Feb;8(2):150-161. doi: 10.1016/S2215-0366(20)30262-5. Epub 2020 Oct 20. PMID: 33096045. DOI: 10.1016/S2215-0366(20)30262-5

Can switching antipsychotics help reduce weight gain?

The Question

Obesity is a major public health problem. In those with severe mental illness, the prevalence of obesity is twice that of the general population. Obesity, hypertension, dyslipidaemia, and smoking contribute to the three fold increase in mortality observed in severe mental illness. This translates in to a 15 year reduction in life expectancy in this group. Antipsychotic medications are one of the established causes of weight gain. So clinicians and patients always look for weight neutral treatment options. This is a very difficult process as one need to find an effective antipsychotic that is weight neutral in an individual patient. Switching antipsychotic medications involves extremely difficult decision making as the risk of relapse and consequent harm to the individual can be substantial and the person may need resource intensive care to bring back stability. We all try to avoid switching from an otherwise effective medication. Life style interventions are often difficult in this context. Adding Metformin or glucagon-like peptide 1 receptor agonists (eg, exenatide, liraglutide) are other strategies used to combat weight gain. The two key questions here are 1. Is switching effective in reducing weight gain? 2. What is the cost appropriate agent for this purpose? Dan Siskind et al reports the results of a systematic review and meta-analysis in Schizophrenia Bulletin. (Advance publication/online).

The review included randomized controlled trials or observational studies of people with SMI that investigated a switch from any single or combination of antipsychotics to a different antipsychotic monotherapy for ≥4 weeks.Meta-analyses were carried out if at least 2 studies had useable data for the outcome of interest.

Results

61 articles were included in the systematic review; 59 articles contributed to the meta-analyses.Mean study duration was 26.3 ± 19.7 weeks. Most studies included participants with schizophrenia. Study quality in general was graded as low. Lack of blinding in the RCTs, small sample sizes and high drop out rates were the common quality issues.

Two types of analysis were used. Pair wise analysis ( switch vs stay) made comparisons of switching to a specific antipsychotic vs remaining on the previous agent and Before- after meta-analysis summarised ‘before-to-after’ data of switching to a different antipsychotic.

Findings

1. Switching to aripiprazole was associated with a 5.52 kg weight loss in the pairwise meta analysis. Before to after metanalysis showed a mean weight loss of 1.96 kg.
2. Compared to staying on previous antipsychotics, switching to olanzapine was associated with a 2.46 kg weight gain ( pair wise meta analysis). Before after meta analysis showed that switching to olanzapine resulted in a 2.7 kg weight gain.
3. There was no difference in weight after switching to amisulpride. Switch to lurasidone, risperidone/ paliperidone or quetiapine showed no weight change.Patients switched to clozapine gained 2.8 kg.
4. Switching to ziprasidone showed a significant weight loss 
5. Effect on psychotic symptoms: In pairwise analysis, there was no significant difference between switching to aripiprazole or staying on previous antipsychotic for psychotic symptoms. Similar was the case with olanzapine. In before- after metaanalsyis, switching to aripiprazole, paliperidone/risperidone, quetiapine, or ziprasidone were associated with a reduction in psychotic symptoms, while switching to olanzapine did not change psychotic symptoms. 

Conclusions

Aripiprazole had the best evidence for weight loss upon antipsychotic switching; 5.5 kg in the pairwise and 2.0 kg in the before-to-after analysis. Switching to ziprasidone was also associated with weight loss but based on only before-to-after data.Switching to amisulpride, paliperidone/risperidone, quetiapine, or lurasidone had no effect on weight.We need more good quality research to make better informed decisions.

Limitations

Pairwise switch-vs-stay meta-analyses was possible only for aripiprazole and olanzapine. For the other antipsychotics, there were only usable data for before-to-after analyses. Before after analysis has limitations and it can overstate the effects. Quality of studies included are low and hence caution required on conclusions.

Practice implications:

Ziprasidone is not licensed in the UK. Ziprasidone’s potential cardiac effects is a reason for this. Drug reaction with eosinophilia (DRESS) is another rare but serious side effect to worry.

Safety regarding relapse/ psychotic symptoms in relation to switch requires further clarity.

The study:

Schizophrenia Bulletin, sbaa191, https://0-doi-org.pugwash.lib.warwick.ac.uk/10.1093/schbul/sbaa191

Is poor mental health the starting point of many physical disorders?

The study

Socioeconomic status is a powerful predictor of ill health. It is already known that having two or more diseases and developing multimorbidity is more common among the poor. Prof Mika Kivimäki et al investigated the temporal sequence in relation to poor socio-economic status and the emergence of a large group of mental disorders by combining data from two large Finnish cohort studies. The combined sample had 109246 participants. The relationship pattern was then checked with a third cohort ( the famous Whitehall 2 UK cohort). Residential area deprivation ( an aggregate measure of low education,  unemployment rate, and proportion of people living in small rented housing), educational attainment, and employment grade ( in Whitehall study) were the indicators of socioeconomic position. All relationships between socioeconomic status and disorders were adjusted for lifestyle factors ( smoking, risky alcohol use, physical inactivity, and obesity). National electronic records provided hospital treatment and mortality data for all subjects.

Results

low socioeconomic status was strongly associated with one-third of the 56 diseases studied, independent of lifestyle factors. This included 16  strongly interconnected ( directly or indirectly ) conditions (hazard ratio >5 for each disease to be followed by another disease). A cascade can be seen clearly. This started with psychiatric disorders, substance abuse, and self-harm and was followed later by diseases of the pancreas, liver, kidney, vascular and respiratory system, lung cancer, and dementia. The analysis also shows the bidirectional nature of the relationship between mental and physical disorders.

Limitations

The study covers conditions that resulted in hospital treatment only. It is very likely that a larger proportion of the socio-economically disadvantaged population would be still having mental and physical morbidities ( but not requiring hospital treatment ) and these could also follow the same association and cascade pattern ie poor mental health could be a starting point that leads to poor physical health. Adjusting for confounding factors ( lifestyle factors) is conservatory (mostly self-reported parameters only), but still meaningful. The study does not cover children or very old people.

Strengths

This study has been able to look at a wider range of disorders than previous works. It has a very large longitudinal sample size with minimal sample attrition after baseline.

Conclusions

Low socioeconomic status is a risk factor for a spectrum of interconnected diseases and health conditions. The morbidity trajectory is very illuminating of the larger and varied physical health risk of being poor.

This important work highlights the importance of mental health and behavioral problems as the starting points for many physical disorders among the socio-economically disadvantaged.

 

Unfortunately, our current global initiatives and goals do not include socioeconomic disadvantage as a modifiable risk factor. Care for mental disorders and poor mental health should become a priority if we are to promote the better physical health of the population, especially among the disadvantaged classes.

Article

Lancet Public Health. 2020 Jan 30. pii: S2468-2667(19)30248-8. doi: 10.1016/S2468-2667(19)30248-8. [Epub ahead of print] Association between socioeconomic status and the development of mental and physical healthconditions in adulthood: a multi-cohort study.Kivimäki M, Batty GD, Pentti J, Shipley MJ, Sipilä PN, Nyberg ST, Suominen SB, Oksanen T, Stenholm S, Virtanen M, Marmot MG, Singh-Manoux A, Brunner EJ, Lindbohm JV, Ferrie JE, Vahtera J.

 

Marriage can, milkshake cannot?…

Can marriage protect us against dementia?

Researchers at Loughborough University wanted to see whether marriage offers a protective role in dementia.  The study was part of the English Longitudinal Study of Ageing. This is a population-based longitudinal  study of a representative sample of adults aged 50 and older. It began in 2000.  Repeat assessments take place every two years.  2004 assessment was taken as the baseline  for this analysis as this was the first time a measure of loneliness was first introduced in to the data collection.  The primary data was collected by a face-to-face interview.  Additional assessments in subsequent waves are done using  postal questionnaires . Dementia was defined as physician diagnosis of dementia, when participants were not able to provide information,  carers completed the short form IQCODE. On this scale, a score of 3.5 was used to diagnose dementia.  During the face-to-face assessment,   memory  tests (immediate and delayed recall using a word list and   MMSE elements of time orientation)  were carried out. Loneliness was measured using the revised UCLA  scale . Social network was assessed by looking at their actual contacts   with children, family and friends.  Participants also received a score for social networks.

Results

During the follow up period,   220 were diagnosed with dementia that is 3.3 percentage.  Regression analysis showed that marital status was associated with dementia with  HR of 1.77 . Social isolation did not come out as an independent predictor of dementia, However, loneliness was associated with future dementia risk with an HR of 1.44 . i.e. There was 44 percentage increase in the risk of future dementia for every unit change in loneliness.

 Conclusion

this study looked at the risk of dementia in relation to social relationships. Loneliness is positively and independently related to increased risk of future dementia.  Being married / having close relationships are protective factors.

How does this happen?

Studies have often found that married men on average have healthier lifestyles than single men, such as better diets, less alcohol, less smoking and more and earlier health services visits.

Socially isolated and lonely may experience heightened exposure to stress may  lack the social resources to buffer biological changes. isolation and loneliness are both associated with higher cortisol levels and more inflammatory markers.

Social isolation by itself is not a risk factor.   Previous research  ( Wilson et al. 2007, Holwerda et al 2014) ) have shown that loneliness is a predictive factor for dementia onset .  Social isolation , as shown in some previous studies , was not shown to be a risk factor in this study.  It is possible that the differences in social network assessment and scoring may explain this. Present study appears to have a better definition and differentiation of network assessment and loneliness.

Summary of study: 

Loneliness, Social Integration, and Incident Dementia Over 6 Years: Prospective Findings From the English Longitudinal Study of Ageing.Snorri Bjorn Rafnsson,Martin Orrell, Eleonora d’Orsi, Eef Hogervorst,and Andrew Steptoe. J Gerontol B Psychol Sci Soc Sci, 2017, Vol. 00, No. 00, 1–11 doi:10.1093/geronb/gbx08

 

 Milkshakes for dementia?

Diet is considered to be an important modifiable risk factor for dementia and some nutrient interventions has shown some early benefits previously. A multi-nutrient combination which contains DHA, EPA, uridine monophosphate, vitamins (B12, B6, C, E)  , folic acid, phospholipids and selenium has recently been marketed as a medicinal drink.  It is considered that this can provide neuro protection by supplying the rate-limiting compounds  for brain phospholipid synthesis.

LipiDiDiet study group reports the results of an RCT attempting to see whether this milkshake is effective. This was a 24 month randomised controlled, double-blind, parallel group study conducted  across 11 sites in Finland, Germany, Netherlands and Sweden. Patients aged 55 to 85 with an MMSE score of 24 points or higher who met criteria for prodromal Alzheimer’s disease and  had evidence for underlying Alzheimer’s   pathology (CSF/MRI/  FDG PET)  were recruited. Those with   depressive disorders , substance use   disorders, as well as those on  memory  medications or multivitamin components were excluded . Active group were given the nutritional supplement (125 mL once a day  drink ). Control group received 125 ml  of similar flavoured drink ( same calories).The primary efficacy endpoint was the change over 24 months in a composite score of cognitive performance.

 

 Results

311 participants were randomly assigned.   drop out was similar (21-22%) in both groups.   Groups were similar at baseline except for the MMSE score.

There was no statistically significant difference between groups on the primary or secondary outcome criteria  at any time. There was a significantly less reduction in hippocampal volume and less increase in ventricular volume  during the 24 months in the active  group.  There was no statistically significant difference between groups for the whole brain  volumes.

During the 24 month trial period , 37% of control group and 41% of active group were diagnosed with dementia .

Conclusion

The nutrient intervention had no significant effect on the primary endpoints over a two-year period in prodromal Alzheimer’s disease however there are some benefits on brain atrophy measures . The brain effect seen in this study warrants  further research.

Summary of the article :

24-month intervention with a speci c multinutrient in people with prodromal Alzheimer’s disease (LipiDiDiet):a randomised, double-blind, controlled trialHilkka Soininen, Alina Solomon, Pieter Jelle Visser, Suzanne B Hendrix, Kaj Blennow, Miia Kivipelto, Tobias Hartmann, on behalf of the LipiDiDiet clinical study group. Lancet neurology 2017.Published Online. October 30, 2017 http://dx.doi.org/10.1016/ S1474-4422(17)30332-0

A ‘magic’ moment in treating resistant depression?

Psilocybin is a prodrug of Psilocin , a classic psychedelic drug. It is a non selective serotonin agonist ( 2 A receptor). Psychedelics like LSD and Psilocybin were investigated as therapeutic agents in 1960s. Regulatory restrictions prevented assessing therapeutic potentials of these agents. An increasing interest in these possibilities has emerged in the past decade.

 A recent systematic review supported the idea that such agents can be of some benefit in those with anxiety and depression in the context of life threatening disorders (Reiche et al 2017).  If provided with psychological support ,psychedelics are useful in a range of psychiatric conditions (like end of life anxiety, OCD and some addictions). There is growing interest in psychedelic assisted psychotherapy as well. These agents also have anti-inflammatory properties which may also be of significance in treating many inflammatory disorders of neurological system. ( Nichols, 2017)

Robin L Carhart-Harris and colleagues from UCL  wanted to see how brain function changes when psilocybin is given to individuals with resistant depression.  This is the first study that documents  changes in resting-state brain blood flow and functional connectivity post-treatment with psilocybin for treatment-resistant depression. 19 patents with resistant depression participated in this. They  had f MRI before and after the intervention. Two doses of Psilocybin were given one week apart ( 10mg and 25 mg). Arterial spin labelling (ASL) and blood oxygen level dependent (BOLD) resting state functional connectivity (RSFC), were used to measure changes in cerebral blood flow (CBF) and functional connectivity.

Good antidepressant response with Psilocybin :

The mean depression score (QIDS-SR16) for the week prior to the pre-treatment scan was 16.9 ± 5.1, and for the day of the post-treatment scan, it was 8.8 ± 6.2 (change = −8.1 ± 6, p < 0.001).The mean QIDS-SR16 score at baseline (screening) was 18.9 ± 3, and for 5-weeks post-treatment, it was 10.9 ± 4.8 (change = −8 ± 5.1, p < 0.001). All showed some decrease in depressive symptoms at 1 week, with 12 meeting criteria for response . All but one patient showed some decrease in QIDS-SR16 score at week 5 (with one showing no change) and 47% met criteria for response (change = −9.2 ± 5.6 p < 0.001).

Brain correlates of improvement :

Increased RSFC was observed within the default-mode network (DMN) post-treatment.

Reduction in amygdala blood flow was associated with clinical improvement. Increased ventromedial prefrontal cortex & bilateral inferior lateral parietal cortex RSFC was predictive of treatment response at 5-weeks. Decreased parahippocampal-prefrontal cortex RSFC was also predictive of treatment.

Patients scoring highest on ‘peak’ or ‘mystical’ experience had the greatest decreases in para hippocampal RSFC in limbic (e.g. bilateral amygdala) and DMN-related cortical regions.

Acute effects Vs post acute effects :

 Brain activity observed just one-day after a high dose psychedelic experience are very different to those found during the acute psychedelic state . Previous studies have shown decreased DMN integrity under psilocybin ( i.e. acute effect). In this study, increased DMN integrity was observed one-day post treatment with psilocybin. Psilocybin dysregulate cortical connectivity acutely,  and then create a state of enhanced connectivity ( ‘entropic’ brain state / ‘desegregation’= ‘ego dissolution/’openness’). In this regard, we can see some similarities with ECT, where DMN integrity is decreased acutely, followed by a strong normalisation effort resulting in increased coherence/ integrity post acutely. This later changes are related to improvements in mood.

Limitations

This study is limited by its small sample size and absence of a control condition. Larger studies with placebo/ control conditions and longer follow up would be required to establish these exciting positive effects.

Summary of the article: 

Psilocybin for treatment-resistantdepression: fMRI-measured brain mechanisms.  Robin L Carhart-Harris et al. http://www.nature.com/scientific reports. 13 October 2017.

 

Do Statins have antidepressant effects?

Evidence supporting  inflammatory etiology of depression is gaining strength. Inflammation is considered as an operative pathway that links physical disorders with depression. The role of statins in depressive disorders is an interesting one in this context. Statins have become the best selling medication in the history  and hence it is important to know their effects on mood disorders.

Statins inhibit the enzyme HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis in the liver. CVD preventive effects of statin is seen more in those with raised CRP levels to the extent that some authors suggest that CRP is a better marker of CVD preventive effects of statins. Various observations like this suggest that statins have anti-inflammatory properties.

Statins as antidepressant augmenting agents 

In the last 4 years, attempts have been made to see the antidepressant effect of statins. (examples: Ghanizadeh 2013, Haghighi 2014, Gougol 2015 ). All these studies show that adding statin to SSRI augments the antidepressant response significantly. A meta analysis by Salagre et al 2016 confirms these findings. (standard mean difference (SMD) of -0.73; 95% CI -1.04 to -0.42; p \ 0.001)

Statins prevent depressive relapses?

The above experimental findings are supported by epidemiological observations as well. A notable study is the Danish one ( Kohler et al 2016) with 800,000 plus patients showing  that combined treatment with an SSRI and a statin was associated with a 36% decreased risk for hospitalization with depression (hazard rate ratio of 0.64; 95% CI 0.55–0.75) compared with treatment with an SSRI only.

Do statins have primary preventive effects?

Meta analysis of seven observational studies found that statin users were 32% less likely to develop depression compared with non-users (Parsaik et al 2014). Another meta analysis showed that those on statins are better in their mood states. (O’Neil et al 2012). But all observations studies are limited by confounders.

Is there risk of depression if LDL levels are too low?

Among elderly , there is some evidence to suggest that statin may cause cognitive decline and depressive symptoms. An inverse relationship  between LDL cholesterol and depression is suggested ( Mandas et al 2014). Previous reports of suicidal ideation and low cholesterol has been contested in later studies. However, it might still be that, severe depletion of cholesterol may have effects on membrane lipids that are crucial in syntactic signalling.

Class effect ?

It appears that statins observed effects in depression is a class property. However, some epidemiological studies show some difference between agents as well. It might be linked to their ability to cross BBB (for example, atorvastatin crossing easily than others).  The subgroup with higher CRP levels may respond better to combination of statin and SSRI. There is some suggestion that if CRP is elevated, tricyclics might be even more effective. However, this has not been studied yet.

Conclusion

Studies suggest that statin have anti-inflammatory property independent of  lipid lowering effect. This may explain the anti depressant like effect seen when added to SSRI. Factors like inflammatory markers, genetics, type of depression, Cvd comorbidity may impart differential effects. In general, evidence suggest that statins can be helpful in depression.

 

Further reading:

 

Do Statins Have Antidepressant Effects? Köhler-Forsberg O, Gasse C, Berk M, Østergaard SD.CNS Drugs. 2017 May;31(5):335-343

Interactions between pro-inflammatory cytokines and statins on depression in patients with acute coronary syndrome.Kim SW, Kang HJ, Bae KY, Shin IS, Hong YJ, Ahn YK, Jeong MH, Berk M, Yoon JS, Kim JM.Prog Neuropsychopharmacol Biol Psychiatry. 2017 Jul 6

Statins for the treatment of depression: A meta-analysis of randomized, double-blind, placebo-controlled trials.Salagre E, Fernandes BS, Dodd S, Brownstein DJ, Berk M.J Affect Disord. 2016 Aug;200:235-42. doi: 10.1016/j.jad.2016.04.04

Internet and Youth suicide: What do we know?

It is not surprising to observe that internet exerts positive and negative influences over its users. There are increasing concerns over its effect on teenagers and their mental health.  Cyber bullying and self harm are two prominent issues in this regard. Scientific enquiries  are gradually exploring these issues .

Marchant, Hawton & Stewart  et al comprehensively  reviewed  the potential influence  of the internet on self-harm/suicidal behaviour in young people. This systematic review covered all publications that primarily studied internet use by individuals who experienced suicidal ideation, self-harm, or internet use which was clearly related to self-harm content among users under 25. 51 articles were included in this review. A total of 192,950 individuals participated across these studies.

Results

High internet use and internet addiction appear to have largely negative influences. More than two or five hours per day ( different studies) were associated with suicidal ideation.

Self-harm and suicidal ideation were related to searching online for suicide information and that searches for specific methods were related to rates of suicide in young people

Positive influences included lower levels of loneliness.  A potential protective influence of low levels of internet use when compared with no internet use at all was also reported.

Health professionals expressed discomfort about engaging with young people in an online setting and had concerns over duty of care.

Specific processes ( harmful)  related to internet use:

1. Normalisation
2. Glorification
3. Competition:  triggering and competition between users
4. Contagion
5. Information resource:  Harmful information sources for vulnerable individuals

Specific processes ( helpful)

1. A sense of community
2. Crisis support
3. Reduction of social isolation

Comments 

Several major social media platforms  have  implemented policies regarding posts related to self-harm ( Such content may not be searchable, is banned or brings up links to counselling and prevention resources).

On the background of the ‘blue whale challenge’ widely reported in many media, the statement from European Psychiatric Association ( suicidology section) is worth reflecting on. …..Anyway, actually we really don’t know either the game’s existence or its role in child and teenage suicides or acts of self-harm…. Professor Sonia Livingstone from the London School of Economics told WIRED: “The importance of media literacy to identify and reject fake news is vital for everyone, but especially for parents whose anxieties about their children’s safety make them too easily to fall prey to clickbait designed to trap them. The responsibilities of journalists to check their facts and sources has also never been so great, as the Blue Whale scare illustrates clearly.”,…..

Nonetheless, the implications of the phenomenon are important, at least from the sociological point of view, no matter if it is a false news or it is proven in some cases……

…..Every alarming news, every service that drives the macabre storytelling, every act of self-harm and violence automatically may fuel a vicious cycle of suggestion and discomfort……

 

‘Human embroidery’ is now a new ‘self harming art’ that is slowly spreading in China.  The need to show , share , shock and scare is taking an ever  prominent place in our lives. This might be a ‘minority’ phenomenon , but its ‘ normalising’ effect can be huge.

It is important to protect children from online dangers and also let them know the existence of support networks involved in offering help to people who need it…..Health departments should take initiative to create online resources and confidential support networks .

Summary of the article.

A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown.

Marchant A, Hawton K, Stewart A, Montgomery P, Singaravelu V, Lloyd K, Purdy N, Daine K, John A. PLoS One. 2017 Aug 16;12(8):e0181722. doi: 10.1371/journal.pone.0181722. eCollection 2017.

 

Can vegetarian diet make men more unhappy?

Vegetarians generally enjoy a lower risk of cardiovascular disease, diabetes, obesity and some cancers. However, effect on mental health , as far as we know , seems to suggest a different story.  Among Australian women, depressive symptoms were more reported among vegetarians (Baines et al 2007). Another study , again from Australia, showed that lower end meat consumption was associated with doubling the risk of depression and anxiety (Jacka et al 2012). Similar findings were reported from Norway , Germany and Turkey  ( Larssson et al 2001, Michalak et al 2012 etc). It is possible that vegetarian diet may have less Iron, Zinc, Vit B12 and Omega 3 compared to non vegetarian diet and this may explain the observed associations.

JR Hibbeln and colleagues studied whether self-identification of a vegetarian diet was associated with increased risk of depressive symptoms among adult men during the pregnancy of their partners.

Self-report data from 9668 adult male partners of pregnant women in the Avon Longitudinal Study of Parents and Children (ALSPAC) is analysed to see whether diet is associated with depressive symptoms. ALSPAC is an ongoing population based cohort study, based in Avon in the UK, investigating environmental and other influences on the health and development of children. Men completed  the Edinburgh Postnatal Depression Scale (EPDS) as part of assessments of the pregnant women who were recruited to this cohort. Comprehensive background data for these men were also collected.

Results

Multivariate analysis suggest that factors like housing tenure, number of children in the household, religion, family history of depression,alcohol consumption, marital status and employment status were independently associated with depressive symptoms. Vegetarians show more depressive symptoms after adjusting for all the above factors. When EPDS scores were converted to binary variable the association still held positive. Elevated odds ratio for an EPDS score greater than 10 and vegetarianism was 1.71 (95% CI: 1.17, 2.49; p = 0.005).

This is the first large epidemiological study to show a relationship between vegetarian diet and significant depressive symptoms among adult men. The increased risk of depressive symptoms is seen when symptoms are evaluated either as a continuous scale or while using a cut-off of greater than 10 on the EPDS. This association persists even after adjusting for all other known vulnerability factors.

Possible explanations

1. Vegetarians have lower intake of omega 3, Vit B12 and folate . They may be taking more omega 6 (from nuts). Veg diet may be associated with increased intake of phytoestrogens, and possibly more of metabolites of pesticides.

2. It is possible that vegetarians were making a dietary  choice because they had to reduce weight / and or may have medical conditions that prompted them to do so. Such medical conditions may be associated with depression.

4. Vegetarianism MAY BE  an expression / marker of psychiatric/ personality problems in certain populations where vegetarianism  is not the norm. Dissatisfaction with one’s body is a frequent theme among adolescents who adopt vegetarianism in a meat preferring eating culture.

Limitations

No serum levels of nutrients collected in this study.

Reverse causality cannot be completely ruled out.

Vegetarian status was self identified rather than based on food frequency questionnaires. It is known that many self identified vegetarians are found to consume non vegetarian food when detailed dietary habits are collected.

Comments

High meat consumption  is also shown to be associated with depressive symptoms. Such unhealthy dietary patterns often go hand in hand with physical inactivity, smoking and alcohol consumption. It needs to be seen whether the observed  association between vegetarian diet and depressive symptoms holds true in populations where vegetarianism is the main stream dietary practice.

Summary of teh article:

Vegetarian diets and depressive symptoms among men. Hibbeln JR, Northstone K, Evans J, Golding J. J Affect Disord. 2017 Jul 28;225:13-17. doi: 10.1016/j.jad.2017.07.051. [Epub ahead of print] PMID: 28777971

New rapid acting medication for post partum depression

Depression in the post-partum stage is seen in 10-20% of all mothers. It is a leading cause of maternal mortality and has long standing negative consequences on the child. Changes in plasma allopregnanolone ,especially the abrupt decrease post-partum, is linked to the precipitation of depression ².  Plasma allopregnanolone is a neuro active steroid with potent positive modulatory effect on extra synaptic GABA receptors. Rapid metabolism and poor bioavailability prevent the use of the oral form of allopregnanolone. Brexanolone , an intravenous  formulation of allopregnanolone, is showing promise in the treatment of post-partum depression.³

Kanes et al., carried out a randomised double blind, parallel group placebo controlled study across four sites in USA.³ Twenty-one women with severe depression ,within the initial 6 months period post-partum, participated in this study. A single continuous IV infusion of Brexanolone was administered for 60 hours . Outcome Assessments were done on day 30. At the end of 60 hours, the HAMD total score decreased by 21 points in brexanolone group compared with 8.8 points in placebo group. This was more or less maintained up to day 30 (the study end point). At 60 hours, seven out of ten patients receiving brexanolone met remission criteria compared with one in placebo arm.  On day 30, seven patients reached remission on active treatment compared to two with placebo. The medication was well tolerated. Overall side effects were higher in the placebo arm. Tachycardia, sedation, and dizziness were reported with brexanolone.

This study provides the first robust evidence of the effectiveness of brexanolone, an extra synaptic GABAa receptor modulator, in treating post-partum depression. The rapid onset of action is particularly useful given the serious impact (e.g., disrupted bonding)  of the illness on mother and baby . This is a promising start and if replicated is likely to find its way into clinical practice, given the key role played by post-partum depression in maternal mortality.

References

1. Balon R. Has psychopharmacology entered a blind alley? Ann Clin Psychiatry Off J Am Acad Clin Psychiatr. 2017 Aug;29(3):157–8.
2. Nappi RE, Petraglia F, Luisi S, Polatti F, Farina C, Genazzani AR. Serum allopregnanolone in women with postpartum “blues.” Obstet Gynecol. 2001 Jan;97(1):77–80.
3. Kanes S, Colquhoun H, Gunduz-Bruce H, Raines S, Arnold R, Schacterle A, et al. Brexanolone (SAGE-547 injection) in post-partum depression: a randomised controlled trial. Lancet Lond Engl. 2017 Jun 12; doi: 10.1016/S0140-6736(17)31264-3.

Why we should stop using sodium valproate …

France has decided to ban use of sodium valproate among women who are of child bearing age group and not on any efficient contraception. At the moment this applies only for those with bipolar disorder. They wanted to do the same for epilepsy as well, however, lack of alternatives have stopped France from banning it for this indication as well. It is contra indicated in pregnancy for both  epilepsy and bipolar disorder in Australia and New Zealand. Most countries have strict guidelines on prescribing valproate in women of child bearing age group.   It is expected that EU would soon ban valproate prescription for women of childbearing age group following French example.

Valproate is the most teratogenic drug around. Up to 40% of pre school children exposed to valproate in utero have developmental problems. Risk of autism is five times in this group. Risk of malformations is 12% compared with 2-3% in general public.

Valproate victims in France is preparing a class action suit  against the pharma giant Sanofi.Sanofi is refusing to acknowledge  its responsibility or the causation. It is expected that 30,000 children would have to be compensated and the total bill would be more than 400 million euros.

In countries where guidelines are not strictly followed or prescriptions  monitored,  many women could be exposed to these serious risks. Prescribers need to be extra vigilant on these risks and consider alternative medications.

France bans sodium valproate use in case of pregnancy.

Casassus B. Lancet. 2017 Jul 15;390(10091):217. doi: 10.1016/S0140-6736(17)31866-4. No abstract available.

PMID:28721869