Specialized Psychotherapy Found to Reduce Severity of Delusions in Patients With Schizophrenia
Participating in a brief course of individualized metacognitive training—a psychotherapy designed to specifically target delusional beliefs—can reduce the severity of delusions and positive symptoms in patients with schizophrenia, according to a study published Tuesday in Schizophrenia Bulletin.
The study found that patients who received metacognitive training had significant reductions in delusional thinking compared with patients who received cognitive remediation, a program designed to improve cognitive abilities. These improvements were maintained at six months.
The findings “suggest that even brief psychotherapy can help to ameliorate the symptoms of psychosis,” Ryan P. Balzan, Ph.D., of Findlers University in Adelaide, Australia, and colleagues wrote.
Patients aged 18 to 65 with a schizophrenia spectrum diagnosis and delusional beliefs were recruited for the study. Of the 54 patients included in the trial, 52 were taking antipsychotic medications; these patients continued to receive their medication throughout the study.
The patients were randomly assigned to metacognitive training or cognitive remediation. Patients in the metacognitive training group completed four two-hour sessions with a therapist over one month, where they learned techniques for increasing awareness of their own cognitive biases that may contribute to the formation and maintenance of their delusional beliefs (for example, overconfidence and belief inflexibility). Patients in the cognitive remediation group completed four therapist-led, 90-minute to two-hour sessions over the same timeframe, during which they focused on improving working and verbal memory, processing speed, problem-solving, and attention—cognitive domains commonly impaired in patients with schizophrenia.
The researchers assessed the patients’ delusions, positive symptoms, performance in several cognitive domains, and clinical insight (awareness of and attitudes toward mental illness) at the start of the trial, following the completion of the four therapy sessions, and six months later. Two patients did not complete the six-month assessment.
Patients in the metacognitive training group showed significant reductions in delusional and overall positive symptom severity and improved clinical insight relative to patients in the cognitive remediation group. In contrast, compared with those in the metacognitive training group, patients in the cognitive remediation group showed moderate improvement in problem-solving ability but in no other cognitive domains. The authors wrote that this suggests “more CR [cognitive remediation] might be required to be effective in these domains.”
In conclusion, the authors wrote, “While larger multisite trials investigating MCT+ [metacognitive training] are warranted, the present study adds to the growing literature that psychological interventions can be effective in people with psychosis.”
For related information, see the American Journal of Psychotherapy article “Application of Integrative Metacognitive Psychotherapy for Serious Mental Illness.”
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Labels: cognitive remediation, delusions, metacognitive training, positive symptoms, problem solving, Ryan Balzan, schizophrenia, Schizophrenia Bulletin
What Can Physicians Do to Prevent Firearm Violence?
Physicians should routinely ask patients about firearms in their home and whether guns are locked and safely stored, writes James S. Kahn, M.D., a professor of medicine at Stanford University, in an editorial published today in the Annals of Internal Medicine. The editorial was published alongside a position paper from the American College of Physicians on reducing firearm injuries and deaths in the United States.
“Firearm-related violent death is an extraordinary problem made even more alarming by the prevalence of guns in the households of persons with dementia and the variation in firearm injuries related to racial disparities,” Kahn writes. “Yet, many physicians have been unengaged or silent during this epidemic. Why? Perhaps we think firearm violence is outside our realm of influence.”
Yet Kahn says physicians routinely ask patients about their unsafe activities, risky exposures, and addictions. “Nicotine abatement programs, alcohol reduction plans, and HIV prevention efforts begin with questions … about a person’s behavior and are successful when physicians provide information to empower patients, motivating them to prevent disease and avoid disability or death. Guns should be no different.”
Kahn recommends the following advice to patients about creating a safe environment when guns are in the home:
Remove the ammunition from the gun and lock the gun in a secure location.
Lock the ammunition in a separate location from the gun.
Store the keys in a different area from household keys and keep the keys out of reach of children.
Lock up gun-cleaning supplies.
Never leave a gun unattended after removing it from a safe storage place.
Kahn urges physicians to begin the conversation simply by asking, “Do you have guns in the home?” If a patient answers “yes,” the physician can follow up with a question such as “How or where do you typically store your guns?”
“If my patients say their guns are not secured or locked, then we can talk about how they might protect themselves and others from unintentionally finding and firing the guns,” Kahn writes. “We discuss what to teach children to do if they encounter a gun: Stop what they are doing, never touch the gun, leave the area, and tell an adult right away.”
“It would be so easy to normalize this line of inquiry and add these questions to an electronic medical record along with questions about alcohol consumption, drug use, and sexual practices,” Kahn writes. “And it is not difficult to learn how to talk to patients about guns and how to counsel them about safety. We need to routinely ask, ‘Do you have guns in the home?’”
For related information, see the Psychiatric News article “Talking to Patients About Guns Necessary, But Examine Your Beliefs First.”
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Labels: Annals of Internal Medicine, firearm violence, gun safety, guns, James S. Kahn, violence
Augmenting Interpersonal Therapy Early May Speed Improvement in Youth With Depression
Psychiatrists who treat adolescents with depression with interpersonal psychotherapy (IPT-A) should consider augmenting the treatment if there is no significant response to therapy within four weeks, suggests a small study published in the Journal of American Academy of Child & Adolescent Psychiatry.
“Waiting too long to decide whether to change treatment for an insufficient responder could mean prolonged experience of depressive symptoms and associated functional impairments,” wrote Meredith Gunlicks-Stoessel, Ph.D., of the University of Minnesota and colleagues. “On the other hand, augmenting treatment too soon might mean adding treatments that could increase risk of side effects or other burdens before giving the initial treatment sufficient time to work.”
For the study, Gunlicks-Stoessel and colleagues tracked 40 adolescents aged 12 to 17 with depression receiving 12 IPT-A sessions over a 16-week period. The participants were randomly assigned to receive a clinical evaluation after either four weeks or eight weeks, at which point treatment could be augmented if needed. Adolescents who showed an insufficient response to IPT-A (defined as less than a 20% reduction in depression symptom scores after four weeks or less than 40% reduction in depression symptom scores after eight weeks) were randomly assigned to four additional IPT-A sessions or daily fluoxetine (10 mg to 40 mg).
The authors found that the adolescents who received a clinical evaluation after four weeks had lower average depressive symptoms, as measured by the Children’s Depression Rating Scale-Revised, or CDRS-R, after 16 weeks compared with those who received the evaluation at eight weeks.
Additional analysis revealed that adolescents who received additional IPT-A sessions or adjunct fluoxetine beginning at week 4 saw statistically similar symptom improvements at week 16, the authors noted. Adolescents who received additional IPT-A sessions after four weeks saw greater symptom improvements compared with those who received the additional sessions after eight weeks. Adolescents who received fluoxetine experienced similar improvements regardless of when they began the augmentation.
“It may be that the timing of adding fluoxetine is not critical in the way that it appears to be for increasing the dose of IPT-A,” the authors wrote. “At week 4, the adolescent is about to initiate working on the interpersonal problem area and learning new communication and interpersonal problem-solving skills. It may be that meeting twice per week at this time is particularly good timing, as it provides more concentrated skill building and opportunities for engaging in interpersonal experiments in between sessions.”
For related information, see the Psychiatric News article “SSRIs/SNRIs Effective in Children, but Risks, Benefits Vary.”
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Labels: clinical decision, depression, depression in adolescents, fluoxetine, interpersonal therapy, Meredith Gunlicks-Stoessel, psychotherapy, treatment augmentation
Cardioprotective Treatments After Heart Attack Increase Lifespan of Patients With Schizophrenia
The increased risk of mortality in patients with schizophrenia can be reduced with cardioprotective medication, such as antiplatelets, β-blockers, and statins, after a heart attack, suggests a study published in JAMA Psychiatry.
Previous studies have found that patients with schizophrenia die 10 to 15 years younger and have worse outcomes from coronary artery disease than those in the general population.
“Our study suggests that patients with schizophrenia who are treated with cardioprotective treatment after MI [myocardial infarction] have a lower mortality risk compared with patients who are not treated, similar to those treated in the general population,” wrote Pirathiv Kugathasan, M.D., of Aalborg University in Denmark and colleagues. “Cardioprotective medication after myocardial infarction should be carefully managed to improve prognosis.”
The researchers studied all adults aged 30 and older who were treated in Denmark public hospitals with first-time myocardial infarction (MI) during a 20-year period, involving 105,018 individuals, including 684 patients with a prior diagnosis of schizophrenia. The researchers followed patients up to 20 years and collected data on prescriptions received and defined five cardioprotective therapeutic drug groups: antiplatelets, vitamin K antagonists, β-blockers, angiotensin-converting enzyme inhibitors, and statins. The researchers noted use of monotherapy (treatment with one these medication groups), dual therapy (use of two), and triple therapy (use of three or more) as well as the time to all-cause mortality during the follow-up.
Compared with patients in the general population, patients with schizophrenia were less likely to receive prescriptions for cardioprotective medications after MI. Such patients were nearly nine times more likely to die compared with the general population treated; moreover, even those who received treatment were still nearly twice as likely to die as those treated in the general population.
The triple therapy provided the greatest benefit for patients, however, and patients with schizophrenia who received any combination of triple therapy had mortality rates similar to those observed of the general population who received the same treatment.
“Cardiovascular medications are a mainstay for ensuring health and preventing recurrent cardiovascular events after myocardial infarction,” Benjamin G. Druss, M.D., M.P.H., of Emory University wrote in an accompanying editorial. “The findings of the study by Kugathasan et al suggest that these medications can also play a critical role in reducing mortality among individuals with schizophrenia.”
For related information, see the Psychiatric News article “Patients With Serious Mental Illness Need Better Primary Care Integration, Health Advocacy.”
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Labels: antiplatelets, Benjamin Druss, Denmark, heart attack, JAMA Psychiatry, Pirathiv Kugathasan, schizophrenia, statins, β-blockers
Children With Anxiety Disorders Face Higher Risk for Self-Harm, ER Visits, Hospitalization
Children with newly diagnosed anxiety disorders were significantly more likely to experience serious medical events requiring treatment in the emergency room (ER) or inpatient hospitalization than children who did not have these disorders, according to a study published in Depression and Anxiety.
“Within two years following a new anxiety disorder diagnosis, a significant proportion of children have a mental health–related hospitalization, inpatient treated self-harm event, or ER visit, which translates to a sizable number of children, given the prevalence of anxiety disorders,” wrote author Greta A. Bushnell, Ph.D., a postdoctoral fellow in the Department of Epidemiology at Columbia University Mailman School of Public Health, and colleagues. Some 54 million children worldwide are estimated to have an anxiety disorder, according to the Global Burden of Disease Pediatrics Collaboration.
For the study, Bushnell and colleagues identified nearly 200,000 commercially insured children (aged 3 to 17) who were newly diagnosed with anxiety disorder in an office setting and had not received treatment for anxiety. The authors then examined the incidence of mental health–related hospitalization, inpatient treatment for suicide and self-inflicted injury, suicidal ideation, and ER visits in these children over a two-year period. They also examined the incidence of these events in children without an anxiety diagnosis (matched by age, sex, geographical region).
Within two years of diagnosis with anxiety, the children were three times more likely to have had a mental health related–hospitalization than children without an anxiety diagnosis (3.2% vs. 0.9%). Nearly one-third of the children with an anxiety diagnosis were treated in the ER (31.9%) versus about one-fifth of the children without an anxiety diagnosis (21.8%). Children with anxiety were also more than three times more likely to have suicidal ideation (1.7% vs. 0.4%) or receive inpatient treatment for self-harm (0.13% vs. 0.03%).
The rate of serious events were even higher than expected by researchers, Bushnell told Psychiatric News. “For example, more than 3% of youth aged 14 to 17 years had a mental health–related hospitalization in the year following a new anxiety diagnosis. An important next step would be to examine how we can improve follow-up care and treatment to reduce these events,” she said.
“The findings can help inform discussions providers have with patients and caregivers when a child is newly diagnosed with anxiety, including discussions on monitoring anxiety symptoms and when to seek additional care to prevent serious events,” Bushnell added. “Our results draw attention to the importance of follow-up care, particularly in older children with psychiatric comorbidities.”
For related information, see the Psychiatric News article “Peer Program Helps High Schoolers Handle Depression, Anxiety.”
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Labels: anxiety, children, Depression & Anxiety, emergency room, Greta Bushnell, hospitalization, self-harm, suicidal ideation
Support at Home, in Community May Protect Against Emotional Distress, Substance Use in Transgender Youth
Transgender and gender-diverse youth who feel close with their parents are less likely to experience emotional distress and engage in substance use compared with those reporting less connected relationships with parents, according to a study in the American Journal of Preventive Medicine. The study also found that youth who feel safe at school and have stronger relationships with teachers and other adults are less likely to experience depression, suicidality, and engage in substance use.
“Given that transgender and gender-diverse [TGD] youth report lower levels of connectedness and safety, bolstering an explicitly transgender and gender-diverse−friendly network of caring parents, safe and supportive schools, and connections to adults in the community may support efforts to eliminate disparities in depression, suicidality, and substance use,” Amy L. Glower, Ph.D., of the University of Minnesota and colleagues wrote.
For the study, Glower and colleagues examined data from the 2016 Minnesota Student Survey—a survey that asks students about school climate, bullying, out-of-school activities, health and nutrition, emotional and mental health, relationships, substance use, and more. As part of the survey, students in the ninth and 11th grades were asked, “What is your biological sex?” (response options: male/female) and whether they “identify as transgender, genderqueer, genderfluid, or unsure about their gender identity” (yes/no).
The researchers examined associations between eight protective factors (connectedness to parents, adult relatives, friends, adults in the community, and teachers; youth development opportunities; and feeling safe in the community and at school) and depression, suicidality, and substance use (alcohol, binge drinking, marijuana, nicotine) among 2,168 adolescents who identified as transgender, genderqueer, genderfluid, or questioning their gender.
Of the 2,168 included in the analysis, 57.9% met the cutoff score for additional depression screening using the Patient Health Questionnaire-2, 44.9% reported suicidal ideation, and 16.7% reported a suicide attempt; substance use ranged from 11.2% (binge drinking) to 25.9% (any nicotine use). Feeling more connected to parents was related to significantly lower odds of all indicators of emotional distress and substance use relative to those reporting less connected relationships with parents, the authors reported.
“Given that TGD youth report less connectedness with their parents than their cisgender peers, increasing investment in programs offering support and guidance to parents of TGD youth and linking parents to existing supports (e.g., through health care, schools, religious institutions) may be effective ways to bolster the development of these caring relationships,” the authors concluded.
For related information, see the Psychiatric News article “Psychiatrists Need to Prepare to Care for Gender-Variant Patients” and the Psychiatric Services article “Affirming Gender Identity of Patients With Serious Mental Illness.”
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Labels: American Journal of Preventive Medicine, Amy Gower, depression, gender diverse, Patient Health Questionnaire, substance use, suicide, transgender
Haloperidol, Ziprasidone Found Ineffective in Treating Patients With Delirium in the ICU
Neither haloperidol nor ziprasidone, medications commonly used to treat psychosis, had any benefit over placebo in treating patients for delirium in the intensive care unit (ICU), according to a study published Monday in the New England Journal of Medicine.
“For more than 40 years, intravenous antipsychotic medications have been used to treat delirium in hospitalized patients,” wrote E.W. Ely, M.D., of the Vanderbilt University Medical Center and colleagues. “In this double-blind, randomized, placebo-controlled trial of intravenous antipsychotic medications for the treatment of delirium in the ICU, there was no evidence that either haloperidol or ziprasidone led to a shorter duration of delirium and coma.”
The study involved patients with acute respiratory failure or shock who developed hypoactive or hyperactive delirium at 16 U.S. medical centers. Of the 566 patients who developed delirium during the trial, 192 were randomly assigned to receive haloperidol (maximum intravenous dose, 20 mg daily), 190 received ziprasidone (maximum intravenous dose, 40 mg daily), and 184 received placebo. Patients were discontinued from drug or placebo after 14 days or at ICU discharge, whichever occurred first.
Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). The primary endpoint was the number of days alive without delirium or coma during the 14-day intervention period. A secondary endpoint was duration of delirium.
The researchers found no significant difference between the treatment groups on the primary endpoint: the median number of days alive without delirium or coma was 7.9 in the haloperidol group, 8.7 in the ziprasidone group, and 8.5 in the placebo group. Neither haloperidol nor ziprasidone led to a shorter duration of delirium compared with placebo.
“Why did the trial fail to show benefit? It is likely that our concept of delirium is flawed,” suggested Thomas P. Bleck, M.D., of the Department of Neurological Science at Rush Medical College, Chicago, in an accompanying editorial.
“The neurochemistry of sudden alteration in mentation [mental activity] is complex and involves several neurotransmitters as well as structural, immunologic, and network alterations and possible brain infection that is not clinically evident,” he wrote. “The investigators deserve credit for conducting a difficult trial, but it would have been astounding if there were a single magic bullet for the restitution of normal brain function in ICU patients with delirium.”
For related information, see the Psychiatric News article “Point-of-Care EEG Device Could Ease Efforts to Detect Delirium.”
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Labels: delirium, haloperidol, New England Journal of Medicine, ziprasidone
Patients With OUD Who Receive Extended-Release Naltrexone May Be More Likely to Stay in Treatment
Naltrexone is a proven treatment for opioid use disorder (OUD), but its clinical usefulness, when taken orally, has been limited by poor adherence among patients, according to several studies. A study in AJP in Advance now suggests that patients with OUD may be twice as likely to stay in therapy if they receive monthly injections of extended-release naltrexone (XR-naltrexone) following opioid withdrawal compared with daily oral naltrexone.
“These study findings have immediate clinical relevance for treatment of opioid use disorder at a time when an opioid epidemic continues unabated in the United States,” wrote Maria Sullivan, M.D., Ph.D., of Columbia University and colleagues. “Given that postdetoxification outpatient treatment without pharmacotherapy yields poor completion rates, high (60%−90%) relapse rates, and heightened risk of overdose and death, XR-naltrexone may be a viable alternative to prevent relapse in patients seeking treatment for opioid use disorder who do not prefer an agonist approach [such as methadone or buprenorphine].”
Sullivan and colleagues enrolled 60 adults aged 18 to 60 who met DSM-IV criteria for opioid dependence in the study. All participants completed an inpatient medication-assisted opioid withdrawal program and were transitioned to naltrexone therapy. Thirty-two patients were randomly assigned to treatment with oral naltrexone (50 mg/day) and 28 were assigned to treatment with XR-naltrexone (380 mg per injection every four weeks) for 24 weeks.
All participants were asked to visit the clinic three times per week for the first two weeks and then twice weekly for the remainder of the 24-week study. During each clinic visit, the patients took a urine test, discussed any recent substance use, and received a behavioral therapy session. The goal of the behavioral therapy was to educate, motivate, and support patients through the process of opioid detoxification, naltrexone induction, and successful naltrexone maintenance. Therapy goals were reinforced with a reward system whereby patients could win gift vouchers after achieving goals or milestones.
After six months, 12 of the 28 (43%) patients receiving XR-naltrexone had dropped out of treatment, compared with 23 of 32 (72%) patients in the oral naltrexone group. There were no significant differences in side effects between the two groups, other than a higher rate of insomnia among patients taking oral naltrexone. There were nine serious adverse events, but only one was found to be related to medication: one patient receiving XR-naltrexone developed allergic hives and was removed from the study.
“These results support the use of XR-naltrexone combined with behavioral therapy as an effective treatment for patients seeking opioid withdrawal and nonagonist treatment for preventing relapse to opioid use disorder,” the researchers concluded.
To read more about naltrexone, see the Psychiatric News article “Low-Dose Naltrexone May Mitigate Severity of Opioid Withdrawal During Detox.”
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Labels: extended-release naltrexone, Maria Sullivan, naltrexone, opioid use disorder, opioid withdrawal, OUD
Giving Patients Choice of PTSD Treatment Yields Significant Benefit, Study Finds
Adults with posttraumatic stress disorder (PTSD) given a choice between sertraline or prolonged exposure therapy opted for prolonged exposure almost two to one; and while both treatments conferred significant benefits, prolonged exposure provided some advantage over sertraline, reports a study published today in AJP in Advance.
The study aimed to determine whether giving patients diagnosed with PTSD their choice of treatment would affect patient outcomes, wrote Lori A. Zoellner, Ph.D., of the Department of Psychology at the University of Washington and colleagues. According to the authors, the study was the first large-scale trial directly comparing the efficacy of sertraline and prolonged exposure therapy for PTSD.
Some 200 patients with PTSD watched videotaped treatment rationales for both treatments and then indicated a preference for either sertraline or prolonged exposure. They were then randomly assigned to having a choice between treatments or to no choice of treatment. Both groups received up to 10 weeks of acute treatment and up to 24 months of follow-up.
Participants showed a strong preference for prolonged exposure therapy over the medication: of 97 participants given a choice of treatment, 63% chose prolonged exposure therapy and 37% chose sertraline. Participants in the prolonged exposure group received 10 weekly, 90- to 120-minute sessions led by a therapist. Responders were offered continued sertraline up to 24 months or up to two prolonged exposure booster sessions during the follow-up period.
The primary outcome measure was interviewer-rated PTSD symptoms, as measured by the PSS-I—a 17-item interview that uses DSM-IV symptom criteria and yields a severity rating (range, 0–51) and a diagnosis (yes/no). Additional measures included several standard self-assessments for depression, anxiety, and disability.
Both treatment groups showed large gains that were maintained during the 24-month follow-up; however, patients treated with prolonged exposure were significantly more likely to lose their PTSD diagnosis.
The authors noted that patients who received their preferred treatment were more likely to complete treatment (73% vs. 49%), and were more likely to lose their PTSD diagnosis, achieve responder status, and have lower self-reported PTSD, depression, and anxiety symptoms.
“Notably, preference effects were as strong as, if not stronger than, treatment modality effects, which suggests that accommodating patients’ preferences in treating PTSD is as important as, if not more so, than the specific choice of an empirically supported treatment,” the researchers wrote. “Accommodating patient preferences … and developing strategies for enhancing patient buy-in are important next steps in facilitating access, initiation, adherence, and completion of empirically supported treatment for PTSD.”
For related information, see the Psychiatric News article “Propranolol Combined With Reactivation Therapy May Reduce PTSD Symptoms.”
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Labels: ajp in advance, exposure therapy, Lori A. Zoellner, patient preference, posttraumatic stress disorder, PTSD, sertraline
Several Symptoms May Point to Suboptimal Medication Adherence in Patients With Depression
Despite the proven efficacy of antidepressants, a significant number of patients with depression fail to take these medications as prescribed, which can increase the risk of depression relapse, hospitalization, and more. A study in Depression & Anxiety now suggests that patients with major depression who have more severe symptoms, suicidal thoughts, and/or report physical pain may be most likely to report not taking their medications as prescribed.
Carolina Baeza-Velasco, Ph.D., of the University of Paris Descartes and colleagues examined data extracted from hospital admissions at the Department of Emergency Psychiatry and Acute Care of the University Hospital of Montpellier, France, between May 2012 and July 2015. A total of 360 adults aged 18 to 77 who met DSM-IV criteria for a current major depression episode and filled out the Medication Adherence Rating Scale (MARS) questionnaire were included in the study.
The MARS questionnaire asks patients to answer yes or no to 10 questions/statements on medication adherence behavior, beliefs/attitudes about taking medication, and side effects of medication. The researchers divided the study participants into two groups according to how they responded to the four MARS questions on medication adherence behavior—the “optimal adherence group” and the “suboptimal adherence group.” Patients in the optimal adherence group responded no to all four questions, including “Do you ever forget to take your medication?” and “When you feel better, do you sometimes stop taking your medication?”. Of the 360 patients included in the study, 107 (29.7%) were found to be optimally adherent to their medication.
The researchers next compared the responses of patients in the two groups to questions regarding depressive symptoms and suicidal thoughts; history of abuse and/or neglect during childhood; physical pain intensity; and psychiatric history. The number of psychiatric hospitalizations, the score of depression severity, suicidal ideation, reports of negative side effects from medication, and pain were significantly higher in the patients in the suboptimal adherence group compared with those in the optimal adherence group. Patients in the suboptimal adherence group also had less favorable attitudes toward medication and were less likely to be married/living with a partner than patients in the optimal adherence group.
“These results suggest a vicious circle in which more vulnerable patients are less adherent to medication, which could worsen the clinical picture maintaining, in turn, low adherence,” the researchers concluded.
For related information, see the Psychiatric News article “Motivational Pharmacotherapy Can Improve Medication Adherence,” by Roberto Lewis-Fernández, M.D., of Columbia College of Physicians and Surgeons.
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Labels: Carolina Baeza-Velasco, depression, Depression & Anxiety, medication adherence, Medication Adherence Rating Scale, pain, suicidal thoughts
Older Adults Who Engage in Self-Harm Are Often Not Referred to Mental Health Services, Study Finds
Most older adults who engage in self-harm are not referred to mental health services, according to the results of a study conducted in the United Kingdom. The findings, which were published in Lancet Psychiatry, suggest these patients are 20 times more likely to die from unnatural causes within a year compared with older adults who do not engage in self-harm.
“We have identified a group at high risk of premature unnatural death and identified areas of improvement for clinical management of older-aged adults in primary care,” wrote Catherine Morgan, M.D., of the University of Manchester, U.K., and colleagues. “Health care professionals should take the opportunity to consider the risk of self-harm when an older person consults with other health problems, especially when major physical illnesses and psychopathology are both present, to reduce the risk of an escalation in self-harming behaviour and associated mortality. “
Morgan and colleagues analyzed data from the UK Clinical Practice Research Datalink, which contains anonymous patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. They identified 4,124 adults aged 65 years and older with a self-harm episode recorded during calendar years 2001 to 2014. Of these episodes, 3,327 (80.7%) involved ingestion of drugs and 234 (5.7%) involved self-cutting.
For their analysis, the researchers focused on the 2,854 adults with at least 12 months of follow-up data. They examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. They compared the self-harm cohort with a group of similarly aged patients who did not engage in self-harm.
Within 12 months of their initial self-harm episode, just 335 (11.7%) of 2,854 older adults were referred to mental health services, 1,692 (59.3%) were prescribed an antidepressant, and, of these, 336 (11.8%) received a tricyclic antidepressant, which can be fatal when taken in overdose.
In the year after the first self-harm episode, 412 (14.4%) individuals had another self-harm episode, of whom 344 (83.5%) had one repeat episode and 68 (16.5%) had two or more episodes. A total of 908 (37.0%) deaths occurred in the self-harm cohort compared with 12,683 (25.9%) deaths in the comparison cohort, of which 54 (5.9%) were unnatural deaths and 36 (4.0%) were deaths by suicide in the self-harm cohort versus 275 (2.2%) unnatural deaths and 12 (<0.1%) deaths by suicide in the comparison cohort, the authors reported.
“After self-harm in an older adult, improvement of referral rates [to specialty mental health care] and consideration of possible alternative medication, with particular avoidance of TCAs [tricyclic antidepressants], might reduce the risk of escalating self-harm behavior and associated mortality risk,” the authors wrote.
For related information, see the American Journal of Psychiatry article “Suicide Following Deliberate Self-Harm.”
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Labels: antidepressants, Catherine Morgan, Lancet Psychiatry, older adults, self-harm, suicide, tricyclic antidepressant
Methylphenidate May Lead to Improvements in Youth With Disruptive Behavior Disorder, Study Suggests
Methylphenidate (MPH) may be a potential treatment option for youth with disruptive behavior disorder, suggests a study published in the Journal of the American Academy of Child & Adolescent Psychiatry.
Research has shown that youth with disruptive behavior disorder are less likely than others to anticipate the negative consequences of their behaviors, which may contribute to behavioral problems. Studies also show that people with disruptive behavior disorder tend to have lower activity in the amygdala—a brain region known to be involved in emotional learning, including fear response.
Koen Van Lith, M.D., of the Vrije Universiteit Amsterdam and colleagues tested whether MPH might increase amygdala activity in youth with disruptive behavior disorder, including oppositional defiant and/or conduct disorder. The researchers chose MPH since this medication is known to increase amygdala activity in children with attention-deficit/hyperactivity disorder.
Van Lith and colleagues conducted a clinical study of 42 boys aged 14 to 17 who were diagnosed with disruptive behavior disorder. The adolescents completed a fear-learning task (learning to associate a visual stimulus with a mild electric shock) 90 minutes after taking either a single dose of MPH (0.3 mg/kg to 0.4 mg/kg) or placebo. Twenty-one adolescents with no behavioral problems were also included as a comparison group; these participants were given no medication before testing. All the participants underwent functional MRI scanning while performing the fear-learning task to measure amygdala activity.
The adolescents with disruptive behavior disorder who took placebo had much lower amygdala activity during the fear-learning task compared with healthy controls. In contrast, the adolescents with disruptive behavior disorder who took MPH had amygdala activity that was similar to the adolescents with no behavioral problems.
“This is promising for MPH as a possible treatment option in DBD [disruptive behavior disorder],” Van Lith and colleagues wrote. “Because amygdala functioning is important for decision making and moral judgment, MPH might improve clinical outcomes, although future studies should establish whether increased amygdala function after MPH administration indeed improves behavioral outcomes.”
To read more about treating disruptive behaviors in youth, see the Psychiatric News article “Experts Search for Meds to Help Youth With DMDD.”
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Posted by Psychiatric News Alert at 10:28 AM
Labels: amygdala, antisocial behavior, child and adolescent psychiatry, conduct disorder, disruptive behavior, fear conditioning, methylphenidate, oppositional defiant disorder
Candidates Announced for APA's 2019 Election
The APA Nominating Committee, chaired by APA Immediate Past President Anita Everett, M.D., today announced the candidates for the Association's 2019 election.
Jeffrey Geller, M.D., M.P.H.
Philip Muskin, M.D., M.A.
Jeffrey Akaka, M.D.
Sandra DeJong, M.D., M.Sc.
Ramaswamy Viswanathan, M.D., D.M.Sc.
Minority/Underrepresented (M/UR) Trustee
Rahn Bailey, M.D.
Robert Cabaj, M.D.
Area 3 Trustee
Kenneth Certa, M.D.
Barry Herman, M.D.
Roger Peele, M.D.
Barbara Weissman, M.D.
Melinda Young, M.D.
Resident-Fellow Member Trustee-Elect
Lisa Harding, M.D.
Daniel Hart, M.D.
Michael Mensah, M.D., M.P.H.
The deadline for candidates who wish to run by petition is November 15. All candidates and their supporters are encouraged to review APA's Election Guidelines. For more election information, please visit the Election section on APA's website or email election@psych.org.
The slate of candidates who have been nominated is considered public but not official until it is approved by the APA Board of Trustees at its December meeting. APA members may cast their ballots from January 2 to January 31, 2019.
Labels: Akaka, American Psychiatric Association 2019 election, Bailey, Cabaj, Certa, DeJong, Geller, Harding, Hart, Herman, Mensah, Muskin, Peele, Viswanathan, Weissman, Young
Heart Valve Surgery May Lead to Postoperative Cognitive Deficits
Patients who undergo heart valve surgery are at a heightened risk of cognitive decline in the first few months after surgery, suggests a paper published yesterday in the Journal of the American Geriatrics Association.
“Aortic valve surgery, which is performed more commonly in older adults, entails greater risk of early cognitive dysfunction within the first month after surgery than mitral valve surgery, but cognition in both groups appears to converge by six months,” wrote Mark Oldham, M.D., of the University of Rochester Medical Center and colleagues.
Oldham and colleagues conducted a meta-analysis of 12 clinical studies that had assessed the cognitive scores of adults before and after undergoing heart valve surgery. A total of 12 clinical studies, which included 450 patients who had early cognitive assessments (one week to one month after surgery) and 722 patients with intermediate assessments (two to six months after surgery), were included in the analysis. The researchers identified no studies that explored long-term cognitive changes after heart valve surgery, which they noted is a major research gap.
The analysis revealed that patients who underwent heart valve surgery experienced moderate cognitive decline in the first month after surgery that improved slightly by six months out. Patients who underwent mitral valve surgery experienced mild but progressive decline over six months, while those who underwent aortic valve surgery had greater early cognitive dysfunction, followed by partial recovery. The authors noted that patients receiving aortic valve surgery were about 11 years older on average, which could have influenced these outcomes.
“These findings call for further investigation aimed at refining risk stratification and prevention strategies in this group, in which cognitive vulnerability is widely underrecognized,” Oldham and colleagues concluded.
To read more about this topic, see the Psychiatric News article “Escitalopram May Reduce Risk of Heart Problems.”
(Image: iStock/kupicoo)
Labels: cognition, cognitive decline, cognitive deficits, geriatric psychiatry, heart surgery, heart valve, Journal of the American Geriatrics Association, Mark Oldham, postoperative
Shared Decision Making With Patients Can Improve Treatment Engagement, Medication Adherence
Providing patients with a computer-based, shared decision-making tool may promote ongoing treatment engagement and adherence to antipsychotic medication regimens, according to a study in Psychiatric Services in Advance.
Shared decision making is a model of patient-provider communication that requires the active participation of both patient and clinician in information sharing, leading to a treatment decision made and agreed upon by both parties. It combines evidence on treatment options with the values and preferences of patients and their families.
This study focused on a specific tool called CommonGround, an offering on the My Collaborative Health Outcomes Information System (MyCHOIS), a web-based platform developed by the New York State Office of Mental Health (NYSOMH). Molly T. Finnerty, M.D., of NYSOMH and colleagues examined the effects of MyCHOIS-CommonGround on treatment engagement, and for patients with schizophrenia, adherence to antipsychotic medication regimens.
Some 472 Medicaid patients completed shared decision-making reports using MyCHOIS-CommonGround, summarizing their symptoms, functioning, and concerns, with the help of peer staff. Later, during a medication appointment, the clinician and patient reviewed the report and worked together to develop a shared decision. Also studied were 944 similar Medicaid patients who did not use the program. Among participants, schizophrenia was the most prevalent diagnosis (40%), and about one-third of the patients had a comorbid substance use disorder.
While there were no differences between the two groups at baseline, during the follow-up year, the MyCHOIS–CommonGround users had a higher level of ongoing engagement in outpatient mental health service compared with the control group (months with use of a service, 8.54 versus 6.95), the researchers wrote. Furthermore, at the one-year follow-up, there was a significant increase in ongoing treatment engagement for the MyCHOIS–CommonGround users group and a significant decrease in engagement for the control group. Patients with schizophrenia who used MyCHOIS-CommonGround were also found to be significantly more adherent to their antipsychotic regimen during the follow-up year than those in the control group (9% more days with medication).
“It is important to establish the benefit of shared decision making beyond the ethical considerations upon which it was founded, in part to inform implementation decisions. Implementation of shared decision-making programs, such as CommonGround, can be challenging and requires leadership and staff commitment and upfront and ongoing resources,” Finnerty and colleagues wrote. “Shared decision making is a promising approach to enhancing patient-centered care, improving the use of services, and ultimately improving outcomes of care.”
For related information, see the Psychiatric Services article “Consumer Outcomes After Implementing CommonGround as an Approach to Shared Decision Making.”
(Image: iStock/ake1150sb)
Labels: antipsychotics, CommonGround, Molly T. Finnerty, Psychiatric Services in Advance, schizophrenia, shared decision making, substance use disorder, treatment engagement
Mental Health Problems Predict Tobacco Use in Youth
Youth and young adults with internalizing problems such as depression and anxiety and externalizing problems such as attention-deficit/hyperactivity disorder may be more likely to begin using tobacco products than those without these disorders, according to a study in the Journal of the American Academy of Child & Adolescent Psychiatry.
“[T]he need for early and specific tobacco product use screening, as well as screening across the spectrum of mental health problems, as tools to prevent tobacco product use onset is apparent,” wrote Wilson Compton, M.D., M.P.E., deputy director of the National Institute on Drug Abuse, and colleagues. “Providing incentives to providers to link these two screening mechanisms could increase the overall integration of these services in clinical practice.”
For the study, Compton and colleagues relied on data obtained from youth and young adults who were participants in the longitudinal Population Assessment of Tobacco and Health (PATH) Study. Specifically, the authors analyzed data from 9,067 youth (12 to 17 years) and 1,466 young adults (18 to 24 years) who reported having never used tobacco products at the beginning of the study (Wave 1).
At Wave 1, the study participants completed the Global Appraisal of Individual Needs-Short Screener, which assesses internalizing and externalizing problems, and answered questions about drug and alcohol use. At Wave 2 (approximately one year later), the participants were again asked about their use of tobacco products (including cigarettes, electronic nicotine delivery systems, traditional cigars, cigarillos, filtered cigars, pipe, hookah, smokeless tobacco, snus pouches, bidis, kreteks, and dissolvable tobacco) over the past 12 months.
After adjusting for sociodemographics, alcohol or drug use, and externalizing problems, youth and young adults with high severity internalizing problems were found to be 1.5 times more likely to begin use of any tobacco product compared with those with no/low/moderate severity internalizing problems. Youth and young adults with high severity externalizing problems were 1.3 times more likely to begin use of any tobacco product compared with those with no/low/moderate severity externalizing symptoms.
Additional analysis revealed that youth and young adults with high severity internalizing problems were about 1.8 times more likely to report new use of multiple tobacco products. The “findings of a dose-response relationship between internalizing problems and onset of exclusive and poly-tobacco use, respectively, suggest that youth and young adults with internalizing problems were not only more likely to begin using tobacco products compared to those without internalizing problems, but were also more likely to begin using with multiple tobacco products,” the authors wrote.
They concluded, “This study demonstrates that mental health problems predict the onset of tobacco use among youth and young adults in a nationally representative sample, and across a wide range of tobacco products beyond cigarettes. … In addition to screening for tobacco product use, health care providers should screen for a range of mental health problems as a predictor of tobacco use.”
For related information, see the Psychiatric News article “FDA’s ‘Real Cost’ Campaign Cuts Cigarette Smoking by Teens.”
(Image: iStock/prudkov)
Labels: externalizing problems, internalizing problems, Journal of the American Academy of Child & Adolescent Psychiatry, PATH Study, smoking, tobacco use, Wilson Compton, young adults, youth
Women’s Psychiatry Expert Discusses Importance of Addressing Patients’ Sexual Harassment
Asking patients about their history with sexual harassment and abuse should be a routine part of psychiatric care, said APA Past President Nada Stotland, M.D., during her presentation at this year’s IPS: The Mental Health Services Conference. The comments were part of a wide-ranging lecture about important social issues facing women psychiatrists today.
Stotland, who is an expert on reproductive psychiatry and women’s issues, told the audience that psychiatrists can play key roles in helping people deal with and recover from their experiences of sexual harassment and/or sexual abuse. While she noted that identifying a patient’s sexual harassment history is important, she emphasized that such questions must be asked with empathy and sensitivity. If a patient has had such an experience, the psychiatrist’s focus should be on helping the patient deal with her reactions to her experience, such as self-recrimination, shame, guilt, and/or rage. “We need to validate their reactions,” she said.
Stotland recommended that psychiatrists should primarily use psychotherapy during the early stages of therapy and prescribe medications to patients with severe, acute symptoms. Once a good rapport has been reached, medications can be given on a case-by-case basis.
Risk of sexual harassment is not limited to patients, and Stotland also provided some suggestions for women psychiatrists to help protect themselves.
“Before accepting any job, get as much information as possible about the power structure of the employer and its sexual harassment history,” she stressed. Stotland added that women should also be aware of what support services are available at the institution or in the surrounding area should any problems arise.
To read more about sexual harassment in psychiatry, see the Psychiatric News article “Sexual Harassment Still Occurs in Psychiatry, Says Women’s Caucus Leader” and the Psychiatric Services article “Gold Award: Integrated Psychiatric Treatment for Survivors of Intimate Partner Violence at the Bronx Family Justice Center.”
Labels: IPS, mental health, Nada Stotland, sexual abuse, sexual harassment, women psychiatrists
More African Americans With Schizophrenia Could Receive Clozapine Despite Lower White Blood Cell Counts
More African Americans with schizophrenia who are not prescribed the antipsychotic clozapine because of low white blood cell counts could potentially use the drug safely, according to Deanna Kelly, Pharm.D., and Gopal Vyas, D.O.
Kelly is the director of the Treatment Research Program at the Maryland Psychiatric Research Center (pictured left), and Vyas is a psychiatrist at the Treatment Research Center. They spoke yesterday at APA’s IPS: The Mental Health Services Conference in Chicago.
Clozapine has been shown repeatedly to be the best medication for treatment-resistant schizophrenia. Yet Kelly and Vyas explained that African Americans with schizophrenia are much less likely to receive clozapine and more likely to have the medication discontinued because of neutropenia, or low white blood cell counts. Clozapine is known to increase the risk for agranulocytosis—a condition of extremely low white blood cell counts that can be life threatening—and patients using clozapine are required to undergo periodic blood monitoring. Many African-American patients who never received the drug or were taken off it, however, may have benign ethnic neutropenia (BEN), a condition that occurs in about 25% to 50% of people of African ancestry and up to 38% of people of Middle-Eastern descent.
Kelly and Vyas said that the standards for determining when a patient has neutropenia have largely been drawn from European Caucasian populations.For instance, up until 2015, the Food and Drug Administration required clozapine to be discontinued when neutrophil counts fell below 1500/uL. But individuals with BEN are liable to have naturally occurring neutrophil counts that fall below that standard and are not at greater risk of agranulocytosis.
In 2015, the FDA lowered the threshold for interrupting clozapine treatment from an absolute neutrophil count of 1,500/uL to 1,000/uL. New guidelines have been issued for patients believed to have BEN, which are intended to make it easier to prescribe and continue clozapine use for these patients.
“Clozapine is underutilized due to many reasons, and its use in African-descent patients is very low,” Kelly said. “The underuse most likely is attributed to BEN, but clozapine use in BEN does not increase the risk for agranulocytosis or infection related to using clozapine.”
For related information see the Psychiatric News article “New Clozapine Guidelines Likely to Limit Treatment Interruptions.”
(Image: Mark Moran)
Labels: African Americans, BEN, benign ethnic neutropenia, clozapine, low blood cell counts.
APA Praises Congressional Passage of Opioid Treatment and Prevention Package
A bipartisan legislative package passed yesterday by Congress takes many important steps toward combating the opioid crisis with a broad range of opioid treatment and prevention programs, said APA in a statement.
“Opioid use disorder has taken a heavy toll on the health and well-being of Americans,” commented APA President Altha J. Stewart, M.D. “APA is grateful to see bipartisan support for increased access to treatment for substance use disorders [SUD], including expanded access to residential treatment and medication-assisted treatment.”
APA was disappointed, however, that the bill failed to include a critical revamp of a federal regulation known as 42 CFR Part 2 to align it with the Health Insurance Portability and Accountability Act. The changes for which APA had lobbied would have allowed for better care coordination, improved patient safety, and reduced stigma for SUD treatment while still preserving patient confidentiality, Stewart said. These measures are contained in the OPPS Act (HR 6082), which passed the House with overwhelming bipartisan support earlier this year. “We urge the Senate to hold a separate vote on the OPPS Act to ensure that these reforms become law.”
After passing the Senate 98 to 1, the legislation—The SUPPORT for Patients and Communities Act (HR 6)—now awaits President Trump’s signature. One year has passed since President Trump declared the opioid epidemic a national emergency, yet overdose deaths continue to climb, surpassing 72,000 in 2017, according to the latest provisional government estimates. That number represents a nearly 10 percent increase from the previous year.
HR 6 includes a number of provisions for which APA had lobbied, including the following:
Telemedicine: eliminates telehealth facility fees and waives geographic requirements for treatment of SUD for Medicare patients; also directs the Attorney General to issue final regulations within one year specifying the limited circumstances in which a special registration to use telemedicine to treat SUD may be issued and the procedure for obtaining a special registration.
Mental health and substance use treatment parity: mandates coverage of mental health and substance use disorder services for the 9.4 million low-income children enrolled in the State Children’s Health Insurance Program.
Workforce investment: creates a new student loan repayment program for SUD treatment providers (up to $250,000 per individual) who agree to serve for six years in underserved areas or areas with higher-than-average overdose rates.
Pain management: supports innovative medical research at the National Institutes of Health to combat the opioid crisis.
The legislation also lifts the ban on states from using Medicaid funds to treat SUD patients in larger residential facilities. States will now be able to amend their plans to cover institutional SUD treatment for up to 30 days per patient in a 12-month period.
The opioid package does not allot funding for its measures. In a separate measure last week, a FY2019 appropriations package provided $3.8 billion for the opioid crisis, a $206 million increase from 2018 funding levels.
For related information, see “APA Praises Congress for Passing Bill That Funds Mental Health and Substance Use Services.”
(image: iStock/Moussa81)
Labels: Altha Stewart, confidentiality, HIPAA, HR 6, HR 6082, opioid use disorder, substance use disorder, Support for Patients and Communities Act
EEG Readings Not Recommended for Predicting Depression-Treatment Response
Quantitative electroencephalography (QEEG) does not appear to be a reliable tool to predict how a person with major depression will respond to treatment, according to a meta-analysis published today in AJP in Advance.
QEEG recordings—which are direct measures of the brain’s electrical waves—have been considered promising biomarkers in psychiatry. Taking a QEEG is easier and less expensive than conducting a full brain scan, another tool being used to find biomarkers for depression. But in their analysis, Alik Widge, M.D., Ph.D., of the University of Minnesota and colleagues indicated that while QEEG is better than random chance, its overall accuracy is not good enough for widespread use.
“This conclusion is likely not surprising to experts in QEEG, who are familiar with the limitations of this literature,” Widge and colleagues wrote. “It is important, however, for practicing psychiatrists to understand the limitations, given the availability of QEEG as a diagnostic test. At present, marketed approaches do not represent evidence-based care.”
Widge and colleagues analyzed 76 studies published between January 2000 and November 2017 involving QEEG readings as biomarkers for predicting response to depression treatment. Fifty-seven studies looked at medication response, 14 looked at transcranial magnetic stimulation (TMS) response, and six looked at other treatments like electrical stimulation.
Overall, the use of QEEG was about 76 percent accurate at discriminating people who would or would not respond to a given depression treatment. There were no significant differences between the treatment types (medication, TMS, other) or in the specific QEEG biomarker that was used. However, the authors found that this accuracy rating was primarily buoyed by a handful of small studies that produced strong results. The authors also noted that most of the studies analyzed did not validate their biomarker tests on independent samples, which likely means the 76 percent rating is an overestimate.
“Our results do not imply that QEEG findings are not real; they call into question the robustness and reliability of links between symptom checklists and specific aspects of resting-state brain activity. If future studies can be conducted with an emphasis on rigorous methods and reporting, and with specific attempts to replicate prior results, QEEG still has much potential,” the authors concluded.
For related information, see the Psychiatric News article “Will Imaging Guide Future Depression Care?”
(image: iStock/Rungruedee Malasri)
Labels: biomarker, brain activity, depression, depression treatment, EEG, electroencephalography, prediction of response, treatment response
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In the preface, dated January 12th 1738-39, to his Diary James comments that while the life story of some of the leading lights of his time, and before, had been recorded in writing, those of less illustrious standing rarely saw fit to pen for posterity accounts of their own lives. This observation was made in his fortieth year, a time traditionally to take stock, and, in current terminology, coinciding perhaps with a mid-life crisis. It may be argued, of course, that in James's time "mid-life" was closer to 30, but whatever the underlying reason, James sorely rued the general lack of written family records. He therefore set out to at least remedy this deficiency as regards the people and events of his immediate and extended family and his circle of acquaintances.
Conscious of his modest literary talents, and since he would
"not be so exact in methodizing every part as if it were designed for public view..."
we are given to understand that this was to be a very personal account, for immediate family consumption only.
Prior to the start of the Diary proper, James "fills us in" on the background to the family, giving accounts of his and his mother's families, going back a few generations. The actual entries span the years 1718-1760. For the years 1718-1738 James relied on notes he had kept up to that time. From then on he would have maintained the diary as an on-going project. It is interesting to note, despite his exhortation for more people to recognise the value of keeping meticulous records of family affairs, that the frequency of entries drops off considerably after 1738!
The final Diary entry is dated 31st December 1760. Our Diarist lived a for a further 13� years, which begs the question as to why such an abrupt ending. It may be that James assiduously continued with his family chronicle, and that the manuscript has been lost (or is awaiting rediscovery!?). The spasmodic nature of the entries in the latter part of his life suggest that he may have lost interest, or had not had the time to maintain his Diary on a more regular basis.
It was James's hope that succeeding generations would think fit to preserve his notes, and
"...thereto annex an account of such things worthy of note...in the day of your pilgrimage..."
so that future generations would have a true account of their predecessors. Nothing has come to light to show that any of the later family members fulfilled his wish.
What the Diary Tells Us
James's Diary, by his own admission and intent, concentrates its focus on his own family. In this respect it is a far more intimate account than that of another Fretwell-related Diarist, John Hobson, and from a genealogical perspective, much more useful.
On each re-reading of the Diary more is understood about the life and times of James. Notwithstanding the inherent dangers of interpreting attitudes and events from such a distance in time, the following may be confidently posited from James's account.
Geographic Horizons
James's life was circumscribed by a relatively small geographic area. Apart from a short time in London in his youth, and occasional business trips away from "base", he did not move far afield. The map on the right shows the principal places cited by James in his Diary. Two distinct enclaves can be identified - representing the respective "home territory" of the Fretwells and the Woodhouses. The map on the left, showing the whole of Yorkshire, puts into the span of this territory into perspective.
Whether from choice, a sense of duty, or economic dependence, the Fretwells and Woodhouses appear to have been a very close-knit bunch, and this is particularly so within James's immediate family. He had a especially strong bond with his beloved mother, but James also took a lively interest in all the family's comings and goings, and was genuinely concerned for their welfare. By far the greatest proportion of the Diary entries refer to the marriages and births, visits to and by, and the deaths and burials of family members.
James and his siblings received their earliest education from their mother. James draws a comparison between those, like his mother, for whom this responsibility was undertaken as a labour of love, and others who neglected their teaching duties. Apart from reliance on mothers for educating the children, other family members were asked to assist. Thus we find various Aunts taking on the role of teacher, and for some time James undertook to oversee the education of his 'slow' nephew.
Having mastered the basics at home, and 'graduated' from Dame School, James and his brothers continued their schooling away from home - at Kirk Sandall, Stoney Stainton, and Doncaster - which meant that they were boarded out. The next stage was to find appropriate apprenticeships, which were negotiated between the family and the chosen "Master". James went to London, while his brother found a place closer to home.
James's family was principally involved in the timber trade. The Woodhouses included tradesmen and "professionals" among their ranks. However, the range of occupations tended to be limited, with incoming husbands likely to follow the same trade as their fathers-in-law. Regardless of the callings in life, there was a degree of dependence upon relatives for training and apprenticeships as the following table shows.
Relationship with James
Richard Fretwell
Gt Grandfather
James Fretwell
Trained as a Carpenter, but chief business was Timber Merchant
John Bower
Husband of Gt Aunt Elizabeth Fretwell
John Bower jnr
Cousin (removed)
Reuben Woodhouse
Gt Uncle (by marriage)
Apprenticed to Mercer and Grocer of Barnsley.
Set up for himself as Butter Trader, Linen Draper and Grocer
Benjamin Fretwell
Gt Uncle
Tanner, apprenticed to Stephen Husband
Horse Dealer
William Fretwell
Timber Merchant
Stephen Husband
Legal Clerk Apprenticeship with Uncle John Woodhouse;
Timber Merchant (and ship owner)
John Woodhouse
Attorney, Sherrifs Court, London
John Fretwell
Timber Merchant (and Farmer?)
William Woodhouse
Apprenticed to Upholsterer in London
? Hill
Apprenticed to a Cheesemonger in London
Apprenticed to a Chandler and Grocer, Doncaster
Thomas Routh
Husband of Cousin Ann Wasteneys
Linen Draper and Grocer
Michael Woodhouse
Thomas Foulston
Husband of Cousin Elizabeth Fretwell
Grocer and Chandler
Husband of Niece Mary Woodhouse
Fundamental to the Fretwells' lives was their faith. Although not specifically stated, from references James makes to Quakers, we can assume that the family were strongly Anglican. Second only to references to family matters are James's frequent entries concerning attendance at church services, and the merits or otherwise of various Ministers. Records are kept of the choice of Bible verses for sermons and funeral services, and occasionally James has taken the trouble to write them out in full. On numerous occasions, when threatened by some actual or potential danger, James's gives thanks to the Lord for deliverance.
Competent and prudent management skills were essential qualifications for the ideal wife and mother. To her fell the responsibility of providing an efficiently run and harmonious household. Such was the household maintained by James's mother and doubtless her standards were the yardstick by which he makes comparisons of other women in the Diary.
James never married. Did he not find anyone who could measure up to his ideal, as personified by his mother? Speculation, while diverting, must remain just that. There is no hint whatsoever in the Diary to substantiate this theory, or any other reason as to why James remained a bachelor. With no wife to run his household he was reliant, as were single men of his time, upon female members of his family to take care of him. Before her marriage, his sister Mary ran his household. At various times James took lodgings, presumably when there were no 'free' female relatives upon which he could call. But later in life he found lodgings somewhat tiresome and returned to his own house, having agreed to take on his 'unmanageable" niece as housekeeper.
From his own writing, James comes across as a conscientious, caring, and eminently respectable man. It may being doing him an injustice, but he also comes across as a serious, even dour man, lacking any sense of humour. If he indulged in any light hearted pursuits, he does not mention them, except for one instance of accompanying his brother to the Doncaster fair. His taste might have been for a quieter lifestyle, in which he found fulfilment from his family and the few close friends he mentions in the Diary.
As a business man James we would expect James to take an interest in affairs beyond his domestic environment. There are passing references in his Diary to such events as the adoption of the Gregorian calendar in 1752; local elections; the final quashing of the Jacobites and the the victory over the French forces at Quebec. He talks about the enclosures he made on his lands, and his attendances before the Commissioners at Doncaster regarding the enclosure of common lands. We hear also of the re-opening of the markets for horned cattle in 1756 which had been closed for a number of years due to distemper. One of the last entries refers to the death of George II and the the proclamation at Pontefract of George III.
According to James, he was a sickly child, and the state of his health occupied his mind throughout his life. Thus we have accounts of bouts of illness, and the cures sought to remedy them. He makes reference to one of the scourges of the day - small pox - which afflicted members of his own family. We are also reminded that rabies was prevalent at that time from an account of a mad dog which bit him and his sister.
As is the case today, travel in the 18th century was fraught with danger. It would be interesting to compare statistics for road fatalities today to those of James's time. There are a number of incidents of people falling from their horses, or being 'run over' by horses, recorded in the Diary. That the number of accidents occurred when the rider was 'under the influence' suggest that the current campaigns against drinking and driving would have been well understood in James's time.
Mortality is a constant theme throughout the Diary. James, in tune with the general philosophy of the day, treats the passing of so many of his family fatalistically. It was God's will and indeed, in many cases death was a blessed relief from the trials of life. Particularly poignant is the dispassionate reporting of so many instances of still births or of babies dying so soon after birth - a stark reminder of the difficulties of pregnancy and child birth in the 18th Century. From the early loss of his brothers, we are also reminded that even if children survived past infancy and adolescence, premature death in early adulthood was a frequent occurrence.
This page was last updated on 12 June, 2011


Home Somaliland Somaliland: Somali aid community faces up to a new reality of recurring...
Somaliland: Somali aid community faces up to a new reality of recurring drought
Northwestern Somaliland and Djibouti were also struck by an unprecedented cyclone last year, bringing a year’s worth of rain in only a few days, which killed animals and flooded crops.
This year, rains started late and were insufficient, resulting in drought conditions across Somalia. The Famine Early Warning Systems Network estimates that 2.2 million people will experience crisis and emergency food insecurity through September.
In agropastoral areas, maize and sorghum production is expected to reach only about half of normal levels this year. Meanwhile, funding for food assistance is falling seriously short.
A key strategy in building resilience in the region is to promote climate-smart agriculture. Since a lack of water is the main problem, aid groups are working with communities to set up basic rainwater harvesting systems that store water in underground tanks or plastic-lined pits, to help keep crops alive during dry periods.
HARGEISA, Somaliland — If she were to meet someone from her past life, Halima Dahir Mahmoud is not sure they would recognize her. She’s lost weight and is constantly stressed. She was once a nomadic herder who would roam the Ethiopian countryside with her 200 sheep and goats, and 50 camels. Now she lives in a displacement camp on the outskirts of Somaliland’s capital city of Hargeisa.
“One of the things I miss the most is the fresh air,” she said.
A few years ago, her animals started dying because of a regional drought. Eventually, there were none left. Her family left Ethiopia and walked 12 hours until they reached the displacement camp where they now live.
“If you experience drought year after year, you become weak and vulnerable.”
— Mohamed Abdalle Hussein, director of administration and finance, Somaliland National Disaster Preparedness and Food Reserve Authority
In the past, she had more agency over her own life, she said. Her family lived off of their livestock, selling a few when they needed cash. Now they are dependent on aid.
Drought has burdened the region year after year since 2015, killing off livestock and crops. Globally, there has been an increase in the intensity and frequency of extreme weather events. In the Horn of Africa, scientists have linked climate change to frequent drought conditions.
“We’ve faced five years of consecutive drought in this country. Livelihoods have collapsed,” said Mohamed Abdalle Hussein, director of administration and finance at the National Disaster Preparedness and Food Reserve Authority in Somaliland — a region that unilaterally declared independence from Somalia in 1991, although this is not internationally recognized.
In the past, there was typically a buffer zone of good rainy seasons in between droughts that allowed people to recover and rebuild their assets, Hussein said.
“Drought is a common disaster we’ve always faced, but the interval has changed. Before, it was a five to seven-year interval between [periods] when we experienced drought. Now that interval has decreased to one to two years,” he said. “If you experience drought year after year, you become weak and vulnerable.”
With this new reality, the aid sector and local governments are faced with the need to shift the existing emergency response to a development approach that responds to long-term displacement and increases resilience among communities, with a focus on how to preserve their livelihoods.
Horn of Africa burdened with crisis after crisis
Drought, floods, and cyclones — as climate change increases its influence over weather conditions in the region, unpredictable and destructive events are expected to become the new norm.
Adapting to new conditions
In the past decade, the Horn of Africa has been hit by repeated disasters. A famine in southern Somalia in 2011 killed nearly 260,000 people, and another was narrowly averted in 2017.
As part of an Irish Aid-funded program, Concern Worldwide is also encouraging farmers to diversify crops. Adding crops with shorter timeframes between planting and harvesting, as well as drought-tolerant crops, can help insulate farmers against climatic shocks, said Abubakar Ismail, agriculture project officer at Concern. Crop rotation also improves soil fertility, which increases yield.
A demonstration nursery of a lead farmer near Borama, Somaliland. Photo by: Sara Jerving / Devex
Concern is also teaching techniques such as crop spacing, creating sheltered nurseries, using organic fertilizers and pesticides, proper post-harvest treatment, and constructing soil bunds — embankments constructed from dirt — to conserve the topsoil and surface runoff water. It works with “lead farmers” in communities, helping them to create demonstration plots to showcase the techniques. The hope is that other farmers in the area visit the plots to learn how to change their own practices.
Farming is seen as a more resilient livelihood option than herding livestock given the region’s new weather patterns: “There are more drought-resistant crops than drought-resistant animals,” Lena Voigt, area coordinator for Concern Worldwide, explained.
But because pastoralism is a dominant way of life in many parts of Somalia, there is a lot of capacity-building needed in developing the agriculture sector and convincing people to adopt this type of livelihood, she said.
No way back
Yurub Hussein Mohmoud lives in a displacement camp that’s taken on a more permanent look — 350 concrete housing units constructed by UN-Habitat with support from the Japanese government. She’s lived in the camp for four years following the death of all her livestock from drought.
For Mohmoud, there is no turning back to her life of agropastoralism. She prefers life in the displacement camp where she has her own shop selling food, shampoo, diapers, cigarettes, and camel’s milk.
Mohmoud is involved in a EU Emergency Trust Fund for Africa project aimed at creating long-term solutions for displaced populations. As part of the program, she received a year-long training to develop her business skills, was placed in a women’s savings and loans group, and received a cash injection of $165 to jumpstart her shop.
“There is a huge difference between the woman standing in the hot sun, digging holes in the ground, and the woman that takes a shower in the morning and comes to her shop,” she said, laughing. “I’m happier where I am now.”
A displacement camp outside of Hargeisa, Somaliland. Photo by: Sara Jerving / Devex
Beyond business grants like these, a major part of the humanitarian response in recent years has been the use of cash transfers, often through mobile money, that aim to provide life and livelihood-saving support to vulnerable families across Somalia.
But these are humanitarian cash transfers, meaning they are delivered for short periods of time. This can make it difficult for families to invest in the long-term rebuilding of their livelihoods.
Moving forward, there are hopes these transfers could evolve into a national social safety net program, eventually led by the federal government, which would include providing cash transfers to targeted individuals throughout the year.
“It would be good to have a safety net — a long-term, predictable safety net in Somalia — that would cover the basic needs of a good proportion of the population on a constant basis,” said Alessandro Bini, director of the Somali Cash Consortium.
The expectation is that, if consistent cash transfers are provided throughout the year, there will be less of a need for large emergency responses during droughts or other emergencies.
Conversations are ongoing with both the humanitarian and development donor communities and the Somali government on the scale and scope of a potential program, Bini said. Ongoing challenges include the varying funding mandates of different donors, government capacity, the lack of national identity cards, and financial sustainability.
The humanitarian sector has a consistent caseload of between 500,000 and 1 million people in need of aid in Somalia, said Quentin Le Gallo, technical assistant for Regional Drought Coordination for the EU’s humanitarian arm.
“They need longer-term assistance and solutions,” he said. “The idea is, if we have a safety net, there would be triggers and early warning systems in place so that once the situation starts to deteriorate, then we can act quickly to protect the assets of these people.”
Editor’s note: The Somali Cash Consortium facilitated Devex’s travel and logistics for this reporting. Devex retains full editorial independence and control of the content.
Sara Jerving
Sara Jerving is Devex’s East Africa Correspondent based in Nairobi. She is a reporter and producer, whose work has appeared in The Wall Street Journal, the Los Angeles Times, Vice News, Bloomberg Businessweek, The Nation magazine, among others. Sara holds a master’s degree in business and economic reporting from Colum
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Titanic Belfast named Europe's top visitor attraction - ahead of Eiffel Tower and the Colosseum
First Minister Arlene Foster joins celebrations with Titanic Belfast's vice-chairman Conal Harvey (left) and chief executive Tim Husbands as it is named as Europe's leading visitor attraction at the World Travel Awards. Photo: William Cherry / Press Eye
TITANIC Belfast has beaten off competition from the likes of the Eiffel Tower, the Colosseum in Rome and even Buckingham Palace to be named as Europe’s leading visitor attraction at the prestigious World Travel Awards held in Sardinia.
It's the first time an attraction in Northern Ireland has won the top prize in the 23-year history of the tourism 'Oscars’.
Titanic Belfast chief executive Tim Husbands said he was "absolutely thrilled" that, after only four years in operation, the attraction - which last month welcome its three-millionth visitor - had gazumped many of Europe’s most iconic landmarks.
"This is a true honour," he said.
"We know what we offer at Titanic Belfast is something our city and country can be proud of and are delighted that this is has been recognised on an international level.
"We are looking forward to welcoming the national and international visitors that this award will attract to Belfast and Northern Ireland. We would like to thank everyone who has supported and voted for us.”
First Minister Arlene Foster said: “In just four short years Titanic Belfast has become a global brand which has put Northern Ireland on the map for all the right reasons, and this official confirmation that it is now Europe’s leading tourist attraction is well deserved.
"The award is further proof that the investment and imagination that went into this attraction keeps paying dividends for the whole of Northern Ireland.”
Deputy First Minister Martin McGuinness added: “Titanic Belfast being voted Europe’s leading visitor attraction is a phenomenal achievement. The story of the Titanic is known around the globe and it is only right and proper we have a world class visitor attraction to match.”
The accolade comes on the back of a record-breaking August for Titanic Belfast as it experiences significant visitor numbers growth from France, Germany, USA and China.
Since opening in 2012 the Belfast attraction it has welcomed guests including Queen Elizabeth II, former US Secretary of State Hillary Clinton, Titanic director James Cameron, Taoiseach Enda Kenny and major celebrities including Adele and Michael Bublé.
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Episode 236: Extreme Makeover
October 7, 2013 May 1967, Ron Sproatambition, bangor, general hospital, mythology, personal space, pretty girl in peril, retconDanny Horn
“Vicki thinks it might be her imagination. But somehow, she connects the two… and they add up to Willie.”
Maggie’s disappeared from the hospital! Last week, the nurse thought that Maggie had died, and ran to get the doctor. When they came back into the room a moment later, the window was open and Maggie was gone.
So there are a lot of mysteries going on, and we’ll get some answers by the end of the day. But at the moment, the most pressing questions are: Why is there a camera in the hallway, and why does everybody keep touching Sam?
Sam is understandably upset. His daughter wasn’t in great shape when he checked her into the hospital, but at least she was alive and he knew where she was. Now she’s either dead, missing or both, and he’s probably still going to have to pay the deductible.
His first impulse is to run outside and yell Maggie’s name a bunch of times, like people usually do on soap operas, but Dr. Woodard grabs him and says, “Leave it to us,” as if the search and rescue mission is part of the hospital’s quality care initiative.
Joe suggests that Maggie may have wandered back to the cemetery on Eagle Hill. He pats Sam’s arm, and says that he’ll go check it out.
Apparently, Sam won’t listen to anyone unless they’re currently touching him. It’s the new rule.
As Sam staggers back into the room, we see that a camera’s been filming them in the hallway. Is the local news team here already?
Obviously, Sam is just shattered; he can’t believe this is happening. Woodard responds by putting his hands on Sam’s shoulders, like they teach you to do in medical school.
Then Burke rushes in, and we see the camera in the hallway again. They cut to that camera for a shot of Burke and Woodard at the door. When they cut back to Sam, the other camera is still in the shot.
This suggests an interesting new way to interpret the show. Maybe Dark Shadows is actually a reality show, and everyone is aware that the cameras are there. That would explain so many things.
By the time Joe comes back from the cemetery, Burke is all up on Sam again. They can’t keep their hands off him; they’re insatiable. Three different guys have fondled him in the last ten minutes.
Burke reminds them that Vicki had a hunch that Willie was responsible for last week’s mysterious phone call, telling them that Maggie was in the graveyard.
Except that Vicki never actually said that. Burke’s talking about a conversation that happens in tomorrow’s episode, and it’s the sheriff who suggests that Willie made the call, not Vicki. They’ve been filming episodes out of order lately, and this is the first sign that the characters are starting to experience some wibbly-wobbly time jumps.
By the way, look at this amazing shot. The characters are all standing in a line, everybody’s found their light, and they look fantastic. They also did a nice artsy thing at the beginning of the episode, with all three cameras doing close-ups on Sam, Joe and Woodard, and cutting back and forth between them to indicate urgency.
Of course, then they couldn’t quite get the main camera back in focus for the group shot, so you can see them adjust the focus a second later.
But the point is: They tried.
By way of comparison, check out this contemporary episode of General Hospital. They start a basic two-shot at 3:00, and they stay on that camera for a full two and a half minutes. The characters walk back and forth across the set, and have six different conversations without cutting to a close-up, like it’s a stage play. They’re finally forced to go to another shot when a character walks through a door where the camera can’t follow.
Meanwhile, on Dark Shadows, they’re making television.
Lela Swift is the director for all five episodes this week. She’s got a silly vampire script, no money for retakes and a daytime-TV audience with low expectations, but she’s still setting up visually interesting shots. On General Hospital, the director just points the camera at whoever’s talking. Swift shows up and actually does her damn job.
And that’s one reason why YouTube only has one General Hospital episode from 1967, and the entire run of Dark Shadows is available on Netflix, Hulu and DVD. The people who made Dark Shadows actually cared.
So let’s go over to the Old House, where Burke and Joe are following a lead. Barnabas says that Willie’s gone to Bangor for the night, and he won’t be back until morning. That might be the least convincing alibi of all time.
But Barnabas says “I find this all completely mystifying,” so I guess it’s not possible to go to Bangor and kidnap Maggie in the same night. What was I thinking?
As soon as the Hardy Boys drive away, Barnabas calls out, “It’s all right. They’re gone. You’re safe… safe here with me.” And then a hypnotized Maggie walks into the room and takes Barnabas’ hand.
WHICH IS UNBELIEVABLY AWESOME.
Barnabas brings Maggie upstairs to Josette Collins’ room, which he and Willie have painstakingly restored. Josette’s portrait is hanging above the fireplace, and there are candles and flowers everywhere. It’s a fantastic set.
“You see?” Barnabas says. “It’s just as you left it, long, long ago. Nothing has changed. Even we haven’t changed.”
Maggie sits at the window. Barnabas purrs, “But perhaps you’ve changed. You’re more lovely, my dear Josette, then I remember.”
The girl reacts: “Josette?”
Barnabas assures her, “Yes… From now on, that will be your name. A name of great beauty. In time, you will learn to think like her, act like her. You will become her.”
And there you go. This is the moment that redefines Dark Shadows. It sets us on the road to understanding and eventually embracing this undead monster, and accepting him as the protagonist of the show.
We’ve seen Josette’s ghost sporadically over the last six months; her big moment was in December 1966, when she was the spiritus ex machina who stepped in when Vicki was kidnapped. We didn’t hear a lot about Josette’s backstory, except that she lived in the Old House, she was married to Jeremiah Collins, and she’d died in some vaguely tragic way.
Now the ratings are going up, and the producers need to figure out how to keep Barnabas on the show. This is how they do it — by sticking the vampire straight into the middle of the Collins family’s origin myth.
Remember that endless soliloquy that Barnabas delivered the other day about the beautiful young woman running away from her lover, and throwing herself off the cliff on Widows’ Hill? That was Josette, and she was running away because Barnabas wanted to turn her into a vampire.
This wasn’t their original intention when they introduced Barnabas. In his second episode, Barnabas talked to Josette’s portrait, and strongly implied that she’d died before he was born. They’re coming up with this plot point on the fly, reaching out for whatever they can use to keep the show going for another day.
This is an incredible retcon, a moment of pure inspiration, and it’s going to drive the story for the next four years. It’s been a slow start, and it’s going to be slow for a little while longer. But this is where Dark Shadows begins.
Tomorrow: Cold Case.
More Dark Shadows bloopers to watch out for:
Woodard explains: “The nurse and I walked into Maggie’s room; the room was empty. And that room that the nurse had left open just a crack was wide open.” He means the window was left open.
Joe comes into the hospital room and reports, “I was all over Eagle. Hill. Cemetery grounds. Nothing.”
There’s a loud squeak when Burke and Joe leave Maggie’s hospital room.
Dark Shadows episode guide – 1967
← Episode 235: The Waiting Room	Episode 237: Cold Case →
8 thoughts on “Episode 236: Extreme Makeover”
Joanne Georgiades says:
The barnabas and josette story was always heartbreakingly bittersweet n made barnabus a sympathetic character
There’s a perfectly simple explanation for all the Sam-fondling; they’re just getting a grip on David Ford so they can turn him toward the camera if need be, or pinch him when he’s supposed to start (or stop) talking.
Tom Hartley says:
So the way you make a character sympathetic is by having him abduct and brainwash a young girl.
Yeah. The sympathetic part doesn’t really kick in for a while, and there are ways in which it never really happens at all. “Sympathetic” turns out to be a very complicated concept.
This is a stunning episode (especially the scenes in Josette’s room). One of the best DS periods for me.
And you’re spot-on again with another observation: Lela Swift does a magnificent job. And hats off to the set designer. Josette’s room is splendid. (Willie and Barnabas sure do FAST renovations and clean-up, though).
Finally, this new material is just a blessing for Kathryn Leigh Scott. I didn’t know until I viewed the pre-Barnabas episodes starting this past summer, but Maggie was much of anything until now. Now she’s riveting.
DS had a lot of defining moments, but this one may have been its ultimate. Past, present, future intersect when those two enter Josette’s room for the first time.
I believe that’s a teleprompter in the hallway, not a camera (you can see the script rolling). Also, Barnabas says Willie will be back the next evening, not the next morning (I know, that’s a tiny, tiny point).
Additional bloopers: In Act I, after Dr. Woodard says he doesn’t think Maggie had the strength to walk to Eagle Hill (Joe wants to look for her there), Sam says, “Well, she had the strength not to walk out of this hospital.” Obviously he meant she had the strength TO walk out.
In Act IV, as Maggie is sitting at Josette’s vanity and looking into the mirror, there is a shuffling noise on the set, and you can see someone’s reflection moving in the mirror behind Maggie. The camera tries to make a quick shift to the right to block the reflection but is unsuccessful.
Lindy Mumade says:
So are we to suspect that Barnabas did the Maggie-to-Josette makeover involving restyling her hair from a simple ponytail to the ringlets pulled back with a ribbon? Or did she stop at a hair salon on the way from the hospital to the Old House?
Willie has undreamed-of talents. A true Renaissance Man.
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