Longitudinal study of insomnia, suicidal ideation, and psychopathology in schizophrenia

OBJECTIVE

Insomnia is a common comorbidity in schizophrenia. Increasing cross-sectional evidence suggests an association between insomnia and suicidal ideation (SI) and symptom severity in schizophrenia. We investigated longitudinal associations over 3 months between insomnia, suicidal ideation, and symptom severity in a group of patients with chronic schizophrenia.

METHOD

We performed a secondary analysis of data from n = 305 participants from the Preventing Relapse Oral Antipsychotics Compared to Injectables Evaluating Efficacy (PROACTIVE) schizophrenia trial using regression models.

RESULTS

The prevalence of moderate-to-severe insomnia was 17.7 % at baseline and 13.6 % at 3 months, respectively. The prevalence of SI was 22 % at baseline and 22.5 % at 3 months. After controlling for potential confounders, improved SI from baseline to 3 months was associated with both baseline moderate-to-severe insomnia (OR = 3.81, 95 % CI 1.11-13.12, p = 0.034) and improvement in insomnia (OR = 3.50, 95 % CI 1.23-9.92, p = 0.013). Worsening SI from baseline to 3 months was associated with worsening insomnia (OR = 3.50, 95 % CI 1.23-9.92, p = 0.013), but not baseline insomnia. Improvement in BPRS total score from baseline to 3 months was associated with improvement in insomnia (β = 0.17, p = 0.029), but not baseline insomnia.

CONCLUSION

Insomnia is common in patients with chronic schizophrenia and insomnia showed significant associations with SI and psychopathology. Clinicians should consider insomnia when assessing suicide risk in patients with schizophrenia.

Sleep Problems, Suicidal Ideation, and Psychopathology in First-Episode Psychosis

BACKGROUND AND HYPOTHESIS

Insomnia occurs frequently in the clinical course of schizophrenia. A growing literature has found associations between insomnia, suicidal ideation and behavior, and psychopathology in schizophrenia. We explored associations between sleep problems, suicidal ideation, and psychopathology in a cohort of patients with first-episode psychosis.

STUDY DESIGN

We performed a secondary analysis of data for n = 403 subjects with data from the Recovery After an Initial Schizophrenia Episode study using regression models.

STUDY RESULTS

The prevalence of sleep problems and suicidal ideation at baseline was 57% and 15%, respectively. After controlling for potential confounders, in the study baseline sleep problems were associated with increased odds of suicidal ideation with evidence of a dose-dependent relationship (OR = 2.25, 95% CI 1.15-4.41, P = .018). Over 24 months, sleep problems at any time point were associated with an over 3-fold increased odds of concurrent suicidal ideation (OR = 3.21, 95% CI 1.45-7.14, P = .004). Subjects with persistent sleep problems were almost 14 times more likely to endorse suicidal ideation at least once over the study than those without sleep problems (OR = 13.8, 95% CI 6.5-53.4, P < .001). Sleep problems were also a predictor of higher Positive and Negative Syndrome Scale total (β = 0.13-0.22), positive (β = 0.14-0.25), and general (β = 0.16-0.27) subscale scores at baseline and multiple follow-up visits (P < .01 for each).

CONCLUSIONS

Sleep problems are highly prevalent and associated with suicidal ideation and greater psychopathology in first-episode psychosis. Formal assessment and treatment of insomnia appear relevant to the clinical care of patients with psychosis as a predictor of suicidal ideation and symptom severity.

Meta-analysis of a family history of diabetes in schizophrenia

OBJECTIVE

Type 2 diabetes (T2DM) is common in patients with schizophrenia and non-affective psychosis. These patients also have an increased prevalence of a family history of T2DM. We performed a systematic review and meta-analysis of the association between a family history of T2DM and schizophrenia.

METHOD

We searched electronic databases from inception until July 2022 for studies of a family history of T2DM or gestational diabetes in patients with schizophrenia and controls. We performed random effects meta-analysis, calculating odds ratios (ORs) and 95 % confidence intervals (CI) and meta-regression analyses.

RESULTS

Nine studies were included, comprising 2953 patients with non-affective psychosis and 4484 controls. Schizophrenia was associated with an over two-fold increased odds of a family history of T2DM or gestational diabetes (OR = 2.18, 95 % CI 1.61-2.96, p < 0.01). In meta-regression analyses, age, sex, study quality score, and year of publication were all unrelated to the association.

CONCLUSION

We found that patients with schizophrenia had a 2.2-fold increased odds of a family history of T2DM versus controls. This association may be relevant to both the pathophysiology of schizophrenia and the reported increased risk of development of diabetes with antipsychotic treatment.

Integrated Devices: A New Regulatory Pathway to Promote Revolutionary Innovation

Policy Points Current medical device regulatory frameworks date back half a century and are ill suited for the next generation of medical devices that involve a significant software component. Existing Food and Drug Administration efforts are insufficient because of a lack of statutory authority, whereas international examples offer lessons for improving and harmonizing domestic medical device regulatory policy. A voluntary alternative pathway built upon two-stage review with individual component review followed by holistic review for integrated devices would provide regulators with new tools to address a changing medical device marketplace.

The Role of the Autonomic Nervous System in the Mediation of the Resolution of Suicidal Ideation With Electroconvulsive Therapy: A Hypothesis and Review of Heart Rate Variability Over a Course of Electroconvulsive Therapy

ABSTRACT

Longitudinal observational studies have shown a meaningful decrease in suicidal thinking and suicidal behavior after receipt of electroconvulsive therapy (ECT). The antisuicide effect of ECT may be related to success in the global relief of the presenting syndrome such as depressive or psychotic illness. However, it is possible that the antisuicide effect is specific to ECT per se, over and above the relief of the clinical syndrome. Electroconvulsive therapy is associated with many observable neurochemical and physiologic effects, and some of these may plausibly be specifically linked to an antisuicide effect. The phenomenon of physiologic hyperarousal has been named as a candidate mechanism driving the risk for suicide. Hyperarousal is associated with decreased neuropsychological executive function responsible for response inhibition and can lead to impulsive action. The level of arousal within the autonomic nervous system (ANS) can be assayed with the pupillary light reflex, electrodermal activity, or with heart rate variability (HRV). This article summarizes the literature on the effects of ECT on HRV 24 to 72 hours after a course of ECT and finds evidence for increases in HRV, which indicates lower levels of arousal in the ANS. This finding suggests that ECT-related reductions in ANS arousal, presumably with corresponding improvements in response inhibition, may be one mechanism whereby ECT reduces risk for suicide.

Applications of Artificial Intelligence in Health Care Delivery

Health care costs now comprise nearly one-fifth of the United States' gross domestic product, with the last 25 years marked by rising administrative costs, a lack of labor productivity growth, and rising patient and physician dissatisfaction. Policy experts have responded with a series of reforms that have - ironically - increased patient and physician administrative burden with little meaningful effect on cost and quality. Artificial intelligence (AI), a topic of great consternation, can serve as the "wheat thresher" for health care delivery, empowering and freeing both patients and physicians by decreasing administrative burden and improving labor productivity. In this Viewpoint, we discuss three principal areas where AI poses an unprecedented opportunity to reduce cost, improve care, and markedly enhance the patient and physician experience: (1) automation of administrative process, (2) augmentation of clinical practice, and (3) automation of elements of clinical practice.

Role of Patient Sorting in Avoidable Hospital Stays in Medicare Advantage vs Traditional Medicare

Importance

Unlike traditional Medicare (TM), Medicare Advantage (MA) plans limit in-network care to a specific network of Medicare clinicians. MA plans thus play a role in sorting patients to a subset of clinicians. It is unknown whether the performance of physicians who treat MA and TM beneficiaries is different.

Objective

To examine whether avoidable hospital stay differences between MA and TM can be explained by the primary care clinicians who treat MA and TM beneficiaries.

Design, Setting, and Participants

This was a cross-sectional study of a nationally representative sample of MA and TM beneficiaries in 2019 with any of 5 chronic ambulatory care-sensitive conditions (ACSCs). The relative risk (RR) of avoidable hospital stays in MA compared with TM was estimated with inverse probability of treatment-weighted Poisson regression, both without and with clinician fixed effects. The degree to which the estimated MA vs TM difference could be explained by patient sorting was calculated by comparing the 2 RR estimates. Data were analyzed between February 2022 and April 2023.

Exposure

Enrollment in MA.

Main Outcome and Measures

Whether a beneficiary had avoidable hospital stays in 2019 due to any of the ACSCs. Avoidable hospital stays included both hospitalizations and observation stays.

Results

The study sample comprised 1 323 481 MA beneficiaries (mean [SD] age, 75.4 [7.0] years; 56.9% women; 69.3% White) and 1 965 863 TM beneficiaries (mean [SD] age, 75.9 [7.4] years; 57.1% women; 82.5% White). When controlling for the primary care clinician, the RR of avoidable hospital stays in MA vs TM changed by 2.6 percentage points (95% CI, 1.72-3.50; P < .001), suggesting that compared with TM beneficiaries, MA beneficiaries saw clinicians with lower rates of avoidable hospital stays. This effect size was statistically significant to explain the 2% lower rate of avoidable hospital stays in MA than in TM.

Conclusions and Relevance

In this cross-sectional study of MA and TM beneficiaries, the lower rate of avoidable hospital stays among MA beneficiaries than TM beneficiaries was attributable to MA beneficiaries visiting clinicians with lower rates of avoidable hospital stays. The patient sorting that occurs in MA plays a critical role in the lower rates of avoidable hospital stays compared with TM.

Daytime autonomic nervous system functions differ among adults with and without insomnia symptoms

STUDY OBJECTIVES

We gathered data to determine whether daytime assays of the autonomic nervous system would differ between persons with no vs modest insomnia symptoms and would correlate with the severity of insomnia symptoms in patients.

METHODS

This report is composed of 2 studies. Study 1 conducted pupillary light reflex (PLR) measurements in community volunteers who were not seeking medical care. Study 2 contrasted PLR and heart rate variability in a different sample of community volunteers and a comparison sample of adults seeking outpatient care for insomnia and psychiatric problems. All measurements were taken between 3 and 5 pm.

RESULTS

In Study 1, volunteers with modest insomnia symptom severity had a more rapid PLR average constriction velocity compared with those with no symptoms. In Study 2, lower heart rate variability, indicating higher levels of physiologic arousal, generally were in agreement with faster PLR average constriction velocity, both of which indicate higher levels of arousal. Insomnia symptom severity was highly correlated with faster average constriction velocity in the patient sample.

CONCLUSIONS

These studies suggest that (1) daytime measurements of the autonomic nervous system differ between persons with modest vs no insomnia symptoms and (2) insomnia symptom severity is highly correlated with PLR. Daytime measurement of autonomic nervous system activity might allow for daytime point-of-care measurement to characterize the level of physiologic arousal to define a hyperarousal subtype of insomnia disorder.

CITATION

McCall WV, Looney SW, Zulfiqar M, et al. Daytime autonomic nervous system functions differ among adults with and without insomnia symptoms. J Clin Sleep Med. 2023;19(11):1885-1893.

A review of clinical studies of electrodermal activity and transcranial magnetic stimulation

There is a growing body of evidence indicative of changes in autonomic nervous system (ANS) activity in patients with disorders of the central nervous system (CNS). Non-invasive measures of the ANS, including heart rate variability (HRV), electrodermal activity (EDA), and pupillary light reflex (PLR) may have value as markers of symptom severity, subtype, risk profile, and/or treatment response. In this paper we provide an introduction into the anatomy and physiology of EDA and review the literature published after 2007 in which EDA was an outcome measure of cortical stimulation with transcranial magnetic stimulation (TMS). Eleven studies were included and considered regarding the potential of EDA as an outcome measure reflecting ANS activity in TMS research and treatment. These studies are summarized according to study population, experimental methodology, cortical region targeted, and correlation with other measures of ANS activity. Results indicate that EDA changes vary with the frequency and target of TMS. Inhibitory TMS to the dorsolateral prefrontal cortex (dlPFC) was the most common paradigm in these studies, consistently resulting in decreased EDA.

Predictors of successful anti-inflammatory drug trials in patients with schizophrenia: A meta-regression and critical commentary

Given evidence pointing toward a role for immune dysregulation in the pathogenesis of schizophrenia, anti-inflammatory agents are promising adjunctive treatments that have potential to support a causal relationship for inflammation and psychopathology and lead to novel treatments for individuals. Indeed, previous meta-analyses have demonstrated small-to-medium effect sizes (ES) in favor of various anti-inflammatory agents, though there is significant heterogeneity and challenges in the interpretation of this literature. Identifying predictors, including sociodemographic variables, trial duration, and/or symptoms themselves, of successful anti-inflammatory trials may help identify which patients who might benefit from these compounds. We performed a meta-regression analysis of 63 adjunctive anti-inflammatory trial arms (2232 patients randomized to adjunctive anti-inflammatory agents and 2207 patients randomized to placebo).Potential predictors of effect size estimates for changes in psychopathology scores from baseline to endpoint included geography, trial duration, sample size, age, sex, race, smoking, body mass index, illness duration, age of onset of psychosis, study quality score and psychopathology scores (total and subscale) at baseline. Geography (β = 0.31, p = 0.011), smaller sample size (β = 0.33, p = 0.009), and higher study quality score (β = 0.44, p < 0.001) were significant predictors of larger ES estimates for change in total psychopathology in favor of anti-inflammatory agents. Smaller sample size (β = 0.37, p = 0.034) and higher study quality score (β = 0.55, p = 0.003) were significant predictors of larger ES estimates for change in negative psychopathology in favor of anti-inflammatory agents. Higher study quality score (β = 0.46, p = 0.019) was a significant predictor of larger ES estimates for change in general psychopathology in favor of anti-inflammatory agents. These findings should be interpreted with caution given concerns of publication bias regarding the geographic differences and small study effects. The lack of an association with other demographic variables should be seen as a primary limitation of the literature that needs to be considered in future studies. The association with study quality score suggests that future anti-inflammatory trials must consider demographic variables known to be associated with inflammation (e.g., BMI and smoking) and evidence of increased baseline inflammation should be incorporated in study design. Moreover, evidence of target engagement and endpoints thoughts to be associated with increased inflammation should be considered as well.

Improving Health Care Quality Measurement to Combat Clinician Burnout

This Viewpoint explores a critical source of administrative burden and physician frustration—the explosive growth of health care quality metrics—and how improving these metrics could combat clinician burnout.

The 510(k) Third Party Review Program: Promise and Potential

Every year, the Food and Drug Administration (FDA) clears approximately 3,000 medical devices for marketing via the 510(k) pathway. These constitute 99% of all devices approved for human use and includes the premarket review of many devices incorporating newer technology such as artificial intelligence (AI), machine learning (ML), and other software. As the complexity of these novel technologies and the number of applications is expected to increase in the coming years, statutory changes such as the 2016 21st Century Cures Act, regulations, and guidance documents have increased both the volume and complexity of device review. Thus, the ability to streamline the review of less complex, low-to-moderate risk devices through the 510(k) pathway will maximize the FDA's capability to address other important, future-oriented regulatory questions. For over twenty five years, third party review organizations have served a defined function to assist with the review of 510(k) applications for a set of enumerated device classes. This paper reviews the history of FDA device regulation, the evolution of the 510(k) review pathway, and the recent history of the 510(k) third party review program. Finally, the paper addresses policy concerns from all stakeholders - including the FDA - along with policy suggestions to improve the third party review program and FDA device regulation writ large.

Medicare Modernization-The Urgent Need for Fiscal Solvency

This Viewpoint describes how reforms to Medicare built around a transition from volume to value may be helpful for improving fiscal solvency.

Reproducibility of the pupillary light reflex over short intervals in psychiatric patients and community volunteers

The pupillary light reflex (PLR) is a method for measuring dynamic responses within the autonomic nervous system, and would have potential value as a point of care test in a psychiatry clinic if reproducible results could be obtained in a short period of time. We collected PLR from adult community volunteers and depressed outpatients with the purpose of demonstrating (1) that valid data could be obtained >90% of the time from both the community volunteers and the patients, and (2) that reproducible results could be obtained with repeated measurement over short periods of time. Valid data were captured for 90.3% of 76 participants, allowing for two attempts of the PLR per participant. Success rates were similar for depressed patients and community volunteers. Eighteen of these 76 participants provided repeated paired measurements after 5 and 10 minutes of dark adaptation, producing high correlations for maximal constriction velocity (MCV) between assay 1 and 2 (Pearson's r=0.71, p<0.001), but there was a significant 8% increase in velocity for MCV between assay 1 and 2 (∆=0.34+0.59 mm/sec, p<0.05). In contrast, PLR measurements were stable when tested in a separate cohort of 21 additional participants at 10 and 15 minutes of dark adaptation with a MCV Pearson's correlation of r=0.84, p<0.001, with a non-significant 1% difference between the two time points. These findings indicate an acceptable rate of collecting valid and reproducible PLR data when contrasting 2 measurements of PLR after 10 or 15 minutes of dark adaptation in depressed and suicidal patients. This article is protected by copyright. All rights reserved.

Meta-analysis of insomnia, suicide, and psychopathology in schizophrenia

PURPOSE OF REVIEW

Insomnia is common in schizophrenia. Insomnia has been associated with suicidal ideation and behavior, as well as greater severity of psychopathology, in schizophrenia. This review performs a meta-analysis of associations between insomnia, suicide, and psychopathology in patients with schizophrenia.

RECENT FINDINGS

We searched major electronic databases from inception until November 2022 for studies of insomnia, suicide, and psychopathology in patients with schizophrenia. Random effects meta-analysis calculating odds ratios (ORs, for suicide) and effect sizes (ESs, for psychopathology) and 95% confidence intervals (CIs) were performed. Ten studies met the inclusion criteria, comprising 3428 patients with schizophrenia. Insomnia was associated with a significant increased odds of suicidal ideation (OR = 1.84, 95% CI 1.28-2.65, P  < 0.01) and suicide attempt or death (OR = 5.83, 95% CI 1.61-2.96, P  < 0.01). Insomnia was also associated with total (ES = 0.16, 95% CI 0.09-0.23, P  < 0.01), positive (ES = 0.14, 95% CI 0.08-0.20, P  = 0.02), and general (ES = 0.17, 95% CI 0.08-0.27, P  < 0.01) psychopathology. In meta-regression analyses, BMI was negatively associated with suicidal ideation. Otherwise, age, sex, and study year were all unrelated to the associations.

SUMMARY

Insomnia is associated with suicide and psychopathology in schizophrenia. Formal assessment and treatment of insomnia appears relevant to the clinical care of schizophrenia.

The Local Market of Major Teaching Hospitals

OBJECTIVE

The purpose of this study was to describe the local communities served by major teaching hospitals.

METHODS

Using a dataset of hospitals around the United States provided by the Association of American Medical Colleges, we identified major teaching hospitals (MTHs) using the Association of American Medical Colleges' definition of those with an intern-to-resident bed ratio above 0.25 and more than 100 beds. We defined the local geographic market surrounding these hospitals as the Dartmouth Atlas hospital service area (HSA). Using MATLAB R2020b software, data from each ZIP Code Tabulation Area from the US Census Bureau's 2019 American Community Survey 5-Year Estimate Data tables were grouped by HSA and attributed to each MTH. One-sample t tests were used to evaluate for statistical differences between the HSAs and the US average data. We further stratified the data into regions as defined by the US Census Bureau: West, Midwest, Northeast, and South. One-sample t tests were used to evaluate for statistical differences between MTH HSA regional populations with their respective US regional population.

RESULTS

The local population surrounding 299 unique MTHs covered 180 HSAs and was 57% White, 51% female, 14% older than 65 years old, 37% with public insurance coverage, 12% with any disability, and 40% with at least a bachelor's degree. Compared with the overall US population, HSAs surrounding MTHs had higher percentages of female residents, Black/African American residents, and residents enrolled in Medicare. In contrast, these communities also showed higher average household and per capita income, higher percentages of bachelor's degree attainment, and lower rates of any disability or Medicaid insurance.

CONCLUSIONS

Our analysis suggests that the local population surrounding MTHs is representative of the wide-ranging ethnic and economic diversity of the US population that is advantaged in some ways and disadvantaged in others. MTHs continue to play an important role in caring for a diverse population. To support and improve policy related to the reimbursement of uncompensated care and care of underserved populations, researchers and policy makers must work to better delineate and make transparent local hospital markets.

Long-Acting Injectable Antipsychotics and Infections in Schizophrenia

PURPOSE

Antipsychotics, particularly long-acting injectable (LAI) agents, are associated with decreased all-cause mortality. Antipsychotics are also associated with an increased prevalence of infections. We performed a systematic review and meta-analysis of the risk of infections in patients with schizophrenia treated with LAIs versus placebo.

METHODS

We systematically searched PubMed and Food and Drug Administration package inserts for placebo-controlled studies of LAI antipsychotic use in schizophrenia. Random effects meta-analysis calculating odds ratios and 95% confidence intervals for any and site-specific infections were performed.

RESULTS

The total study sample consisted of 2559 subjects with schizophrenia, with 867 receiving placebo and 1692 LAI antipsychotics. Long-acting injectable antipsychotic use was associated with a significant 1.75-fold increased odds of any infection versus placebo (2.4% vs 1.5%; odds ratio, 1.75; 95% confidence interval, 1.16-2.66; P = 0.008), although findings for specific infections did not reach statistical significance. The association between LAIs and infection was unrelated to study duration, age, sex, body mass index, and total psychopathology.

CONCLUSIONS

Our findings suggest that LAIs are associated with a small, but significant, increased risk of infections. This association may be due to immunomodulatory effects of antipsychotics.

Meta-analysis of clozapine and insomnia in schizophrenia

INTRODUCTION

Insomnia commonly occurs in schizophrenia, and insomnia is associated with suicide risk. Clozapine has anti-suicidal properties and beneficial effects on sleep. We performed a meta-analysis of insomnia in randomized controlled trials (RCTs) of patients with schizophrenia treated with clozapine. We hypothesized that compared to clozapine there is an increased odds of insomnia in patients treated with other antipsychotics.

METHODS

We systematically searched PubMed, PsycINFO, and Web of Science databases. We included RCTs, in English, with data on insomnia in patients with schizophrenia treated with clozapine versus other antipsychotics. Data were pooled using a random effects model.

RESULTS

Eight RCTs (1952 patients: 922 on clozapine and 1030 on other antipsychotics) met inclusion criteria. Patients treated with other antipsychotics versus clozapine had a significant increased odds of insomnia (22.3 % versus 12.4 %, OR = 2.20, 95 % CI = 1.64-2.94, p < 0.01). Olanzapine, quetiapine, risperidone, and ziprasidone were each associated with significant increased odds of insomnia compared to clozapine. In meta-regression analyses, clozapine dose, publication year, sex, trial duration, and study quality score were unrelated to the association; however, there was a significant association with age. The observed ORs for insomnia from RCTs were almost perfectly correlated with reported ORs from pharmacovigilance data.

CONCLUSION

Clozapine is associated with significantly less insomnia compared to other antipsychotics. Findings provide additional evidence for improvement in sleep as a potential pathway underlying clozapine's anti-suicidal properties. A greater mechanistic understanding of this association is needed.

Longitudinal study of inflammation and relapse in schizophrenia

INTRODUCTION

The clinical course of schizophrenia is often characterized by recurrent relapses. Blood inflammatory markers are altered in acute psychosis, and may be state markers for illness relapse in schizophrenia. Few studies have investigated longitudinal, intra-individual changes in inflammatory markers as a predictor of relapse. In the present study, we explored this association in a relapse prevention trial in patients with schizophrenia.

METHODS

We analyzed blood inflammatory markers in 200 subjects, with a mean 11 samples per subject, during the 30 month Preventing Relapse in schizophrenia: Oral Antipsychotics Compared to Injectable: eValuating Efficacy (PROACTIVE) trial. Associations between longitudinal changes in inflammatory markers and relapse were analyzed using a within-subjects design.

RESULTS

70 (35 %) of subjects relapsed during the study period. There were no significant differences in mean inflammatory marker levels based on relapse status (yes/no). Baseline levels of inflammatory markers did not predict incident relapse. Among subjects who relapsed, there was a significant decrease in mean blood IL-6 (n = 38, p = 0.019) and IFN-γ (n = 44, p = 0.012) levels from the visit before the relapse to the visit after relapse.

CONCLUSION

Although there was some evidence for inflammation as a potential state marker for acute psychosis, we did not find significant evidence for its utility as a relapse-predictive marker.

Implementing Competitive Bidding in the Medicare Program: An Expressway to Solvency

The Medicare program faces increasing budgetary pressures, with recent estimates suggesting that the Medicare Hospital Insurance Trust will be insolvent as soon as 2028. Simultaneously, the Medicare Advantage (MA) program, a managed competition model, continues to grow its market penetration as beneficiaries increasingly choose private plans over traditional fee for service (FFS) Medicare. With the relative cost of the 2 forms of Medicare a subject of debate, policy experts have proposed a variety of policy options to address the program's budgetary pressures and place it on a firmer fiscal footing. This paper explores the implementation of one of these proposals in greater detail: fully transitioning the entire Medicare program to a competitive bidding model in order to reduce overall program costs and improve price competition. Current MA plan bidding methodology is explored, followed by a description of prior proposed competitive bidding models. Implementation challenges are addressed, along with specific policy considerations to protect beneficiaries who wish to remain in FFS Medicare.

Comparing spending across Medicare programs

As Medicare Advantage increasingly becomes the dominant form of Medicare, meaningful and accurate comparisons with traditional fee-for-service Medicare will be increasingly important for both beneficiaries and policy makers. Recent debate among policy experts, government advisory bodies, and health plans highlights the need to create standardized comparison between the 2 Medicare programs. Supplemental benefits, Part B cost-sharing differences, and prescription drug benefits should be valued with a series of structured comparisons. Making this information transparent to beneficiaries through the plan finder would improve beneficiary decision-making. Finally, pragmatic comparisons would support policy makers in making improvements to Medicare Advantage program policy, undertaking comparative program evaluation, and engaging in Medigap plan oversight.

Recurrent antimicrobial exposure and acute psychosis

BACKGROUND

There is an increased prevalence of recent antimicrobial exposure in patients with acute psychosis. We previously found recurrent urinary tract infections (UTIs) in some patients with psychosis. We evaluated the prevalence of recurrent antimicrobial exposure in acutely ill inpatients with psychosis.

METHODS

We performed a retrospective chart review of 85 patients age 18 to 65 with multiple hospitalizations for acute psychosis. Antimicrobial exposure was defined as occurring within 3 days of each psychiatric hospitalization. Recurrent infections were defined as antimicrobial exposure during ≥2 separate hospitalizations for acute psychosis.

RESULTS

The prevalence of recurrent antimicrobial exposure was 26% (22/85), including 25% (13/51) in patients with schizophrenia and 26% (9/34) in patients with psychotic mood disorders. Patients with schizophrenia and recurrent antimicrobial exposure were significantly more likely to have visual hallucinations in admissions with infection vs without (31% vs 14%, respectively, P = .04).

CONCLUSIONS

We found that a subset of patients with schizophrenia and psychotic mood disorders has recurrent infections at the time of hospitalization for acute psychosis. Findings replicate an association between recurrent UTIs and acute psychosis. Although the mechanism of this association remains unclear, findings provide additional evidence that infections may be relevant to illness relapse in some patients with psychosis.

What Should "Shopping" Look Like in Actual Practice?

In health care, lack of transparency about the cost of health care services to patients during clinical encounters has contributed to increased costs and high out-of-pocket expenses. Federal policy has responded to the need for more transparency and spurred discussion about ethics and the clinician's role in being transparent with patients at the point of service. This article investigates and encourages state, private market, and federal policy efforts to address what health care costs patients. This article also applies the ethical framework of principlism to cases and considers what a "shoppable service" model would demand of clinicians in practice.

Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis

OBJECTIVES

To characterize individual participant level response distributions to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration from 1979 to 2016.

DESIGN

Individual participant data analysis.

POPULATION

232 randomized, double blind, placebo controlled trials of drug monotherapy for major depressive disorder submitted by drug developers to the FDA between 1979 and 2016, comprising 73 388 adult and child participants meeting the inclusion criteria for efficacy studies on antidepressants.

MAIN OUTCOME MEASURES

Responses were converted to Hamilton Rating Scale for Depression (HAMD17) equivalent scores where other measures were used to assess efficacy. Multivariable analyses examined the effects of age, sex, baseline severity, and year of the study on improvements in depressive symptoms in the antidepressant and placebo groups. Response distributions were analyzed with finite mixture models.

RESULTS

The random effects mean difference between drug and placebo favored drug (1.75 points, 95% confidence interval 1.63 to 1.86). Differences between drug and placebo increased significantly (P<0.001) with greater baseline severity. After controlling for participant characteristics at baseline, no trends in treatment effect or placebo response over time were found. The best fitting model of response distributions was three normal distributions, with mean improvements from baseline to end of treatment of 16.0, 8.9, and 1.7 points. These distributions were designated Large, Non-specific, and Minimal responses, respectively. Participants who were treated with a drug were more likely to have a Large response (24.5% v 9.6%) and less likely to have a Minimal response (12.2.% v 21.5%).

CONCLUSIONS

The trimodal response distributions suggests that about 15% of participants have a substantial antidepressant effect beyond a placebo effect in clinical trials, highlighting the need for predictors of meaningful responses specific to drug treatment.

Prepare for Health Care 2030

By 2030, nobody will accept poor results in health care. In most cases of chronic illness, people will benefit from becoming active partners in their own health care journey. Medical professionals will focus on communication skills to become trusted navigators rather than impersonal technicians. Patient advocates and multidisciplinary teams will be key sources of support in a borderless healthcare system. Patients and paymasters will drive these innovations. Doctors will recognise them as an opportunity to avoid burnout. There is room for optimism. The healthcare system has the potential to deliver better outcomes at a lower cost.

Insomnia and suicide as reported adverse effects of second-generation antipsychotics and mood stabilizers

STUDY OBJECTIVES

Insomnia and suicide ideation/behavior/death (SIB) are common in psychiatric disorders. There is evidence that clozapine and lithium have antisuicidal properties and beneficial effects on sleep. We investigated the reported odds of spontaneously reported psychiatric adverse drug reactions of insomnia and SIB in adults for second-generation antipsychotics (SGAs) and mood stabilizers compared to clozapine and lithium, respectively.

METHODS

We searched the U.S. Food & Drug Administration Adverse Event Reporting System from inception through February 2021 for which an SGA or mood stabilizer was the suspected agent of a psychiatric adverse drug reaction.

RESULTS

We investigated 10 SGAs and 5 mood stabilizers. Compared to clozapine, other SGAs were associated with a significantly increased reported odds of insomnia (reported odds ratio [rOR] = 2.41-9.70) and SIB (rOR = 1.18-2.72). Compared to lithium, there was a significantly increased reported odds of SIB (rOR = 1.17-1.70) for other mood stabilizers and odds of insomnia (rOR = 1.66) for lamotrigine. The insomnia and SIB rORs for SGAs and mood stabilizers were positively correlated.

CONCLUSIONS

Our results are consistent with evidence for antisuicidal properties of clozapine and lithium. Findings also raise the possibility of beneficial effects on sleep as one potential pathway underlying the antisuicidal properties for these agents. Future studies are needed to identify underlying biological mechanisms that contribute to these associations.

CITATION

Miller BJ, McCall WV. Insomnia and suicide as reported adverse effects of second-generation antipsychotics and mood stabilizers. J Clin Sleep Med. 2022;18(2):517-522.

Insomnia, suicidal ideation, and psychopathology in Chinese patients with chronic schizophrenia

OBJECTIVES

Insomnia occurs frequently in the clinical course of schizophrenia. A growing literature has found associations between insomnia, suicidal ideation, and psychopathology in patients with schizophrenia. We explored these associations in a cross-sectional study of a large sample of patients with chronic schizophrenia in China. We hypothesized that insomnia would be associated with an increased odds of current suicidal ideation and higher current psychopathology scores.

METHODS

We recruited 328 inpatients with chronic schizophrenia, all of whom were prescribed psychotropics. We investigated relationships between current insomnia, suicidal ideation over the past two weeks, and current psychopathology for subjects using regression models.

RESULTS

After controlling for multiple potential confounding factors, current insomnia was an indicator of a significant, 2.5-fold increased odds of suicidal ideation (OR = 2.56, 95% CI 1.10-5.95, p = 0.029). Insomnia was also a significant indicator of lifetime suicide attempt (OR = 1.07) as well as higher Positive and Negative Syndrome Scale total (β = 0.134, p = 0.017), positive (β = 0.154, p = 0.006) and general (β = 0.145, p = 0.010) subscale scores.

CONCLUSION

Insomnia is associated with suicidal ideation, lifetime suicide attempt, and higher psychopathology scores in inpatients with chronic schizophrenia. Formal assessment of insomnia appears relevant to the clinical care of patients with schizophrenia as an indicator of suicidal thinking and behavior, depression, and symptom severity.

Insomnia and inflammation in phase 1 of the clinical antipsychotic trials of intervention effectiveness study

Insomnia and inflammation are both common in schizophrenia. In the general population, insomnia is associated with inflammation. In n=519 subjects from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial, terminal insomnia was investigated as an indicator of inflammation using non-parametric ANCOVA. After controlling for potential confounders, insomnia was significantly associated with higher blood IL-6 (F=4.12, p=0.007) and leptin (F=9.67, p<0.001) with large effect sizes (d=1.03 and d=0.79, respectively). Findings suggest that the assessment of insomnia is relevant to studies of inflammation in schizophrenia, and germane to trials of adjunctive hypnotics and anti-inflammatory agents in these patients.

Electronic nicotine delivery systems: the need for continued regulatory innovation

The recent surge in electronic nicotine delivery systems (ENDS) or electronic cigarette use among both adolescents and adults challenged tobacco regulatory frameworks worldwide. In this article, we review recent US Food and Drug Administration regulatory approaches to tobacco products, including attempts to regulate nicotine concentration and address youth use. We examine recent drives to promote a harm reduction approach in other product markets such as opioids, where the use of methadone and related therapies promote the public health. We describe the potential of a harm reduction framework for ENDS regulation based on tiered nicotine exposure standards coupled with risk-based product distribution controls that would enable ENDS products to meet the 'Appropriate for the Protection of the Public Health' standard required for tobacco product market entry. A harm reduction approach to ENDS regulation could help countries achieve the laudable public health goals of transitioning existing combustion cigarette users to ENDS products while preventing adolescent ENDS use and subsequent nicotine addiction.

Monitoring for myocarditis during treatment initiation with clozapine

OBJECTIVE

Clozapine use is associated with myocarditis. In this study, we investigated what clinical signs and symptoms, and/or laboratory test(s), alert clinicians to presumptive myocarditis (PrMy) most accurately and at the earliest time point. We also investigated the incidence of PrMy during the initial exposure to clozapine versus in patients restarted on clozapine after extended interruption of prior prolonged treatment.

METHODS

100 patients admitted to state psychiatric hospital started on clozapine were recruited into the study. 76 patients were treated with clozapine for the first time and 24 patients were restarts. Creatine kinase (CK), troponin I (TROP), eosinophil count (EOS), and C-reactive protein (CRP) were obtained at baseline and weeks 1, 2, 3, and 4. Descriptive statistics were calculated for demographic and clinical variables. Student's t test and chi-squared test were used to compare means and proportions between initial exposure and restart groups.

RESULTS

Clinical features and laboratory tests suggestive of PrMy were seen in 4 patients (5.3%) in initial exposure group and none in restart group. 3.5% of TROP levels were abnormal in initial exposure group and no abnormal levels were found in the restart group. 30% and 46% of CK, 23% and 39% of CRP, and 14% and 23% of EOS were abnormal in initial exposure group and restart groups, respectively.

CONCLUSIONS

PrMy was common (5.3%) during clozapine initiation. Prospective management through serial laboratory monitoring with weekly TROP levels was sensitive enough to allow for timely clozapine discontinuation.

Inflammation, hippocampal volume, and cognition in schizophrenia: results from the Northern Finland Birth Cohort 1966

Increased blood interleukin-6 (IL-6) levels are a replicated abnormality in schizophrenia, and may be associated with smaller hippocampal volumes and greater cognitive impairment. These findings have not been investigated in a population-based birth cohort. The general population Northern Finland Birth Cohort 1966 was followed until age 43. Subjects with schizophrenia were identified through the national Finnish Care Register. Blood IL-6 levels were measured in n = 82 subjects with schizophrenia and n = 5373 controls at age 31. Additionally, 31 patients with schizophrenia and 63 healthy controls underwent brain structural MRI at age 34, and cognitive testing at ages 34 and 43. Patients with schizophrenia had significantly higher median (interquartile range) blood IL-6 levels than controls (5.31, 0.85-17.20, versus 2.42, 0.54-9.36, p = 0.02) after controlling for potential confounding factors. In both schizophrenia and controls, higher blood IL-6 levels were predictors of smaller hippocampal volumes, but not cognitive performance at age 34. We found evidence for increased IL-6 levels in patients with midlife schizophrenia from a population-based birth cohort, and replicated associations between IL-6 levels and hippocampal volumes. Our results complement and extend the previous findings, providing additional evidence that IL-6 may play a role in the pathophysiology of schizophrenia and associated brain alterations.

Immune-inflammatory markers and psychosis risk: A systematic review and meta-analysis

Subclinical inflammation has been associated with psychosis; however, it remains unknown whether this phenomenon appears also in the premorbid phase. Therefore, we performed a systematic review and meta-analysis of studies comparing peripheral blood levels of C-reactive protein (CRP) and cytokines between individuals at risk of psychosis and controls. Moreover, we tested the hypothesis that the levels of these markers may be different in high-risk converters versus non-converters. Two independent reviewers searched electronic databases until Dec 16th, 2020. After reviewing publication records, 16 studies (548 high-risk individuals and 559 controls) were included. Random-effects meta-analyses with Hedges' g as the effect size estimate were performed. Individuals at clinical risk of psychosis had significantly higher levels of interleukin-6 (IL-6) compared to controls (g = 0.33, 95%CI: 0.06-0.60, p = 0.018). Heterogeneity was not significant in this subgroup analysis. Changes in the levels of IL-6 in subjects at familial risk of psychosis were not significant (g = 0.04, 95%CI: -0.24 to 0.31, p = 0.798). The use of antidepressants was associated with significantly higher levels of IL-6 in high-risk individuals (Beta = 1.56, 95%CI: 0.60-2.53, p = 0.001). No significant differences in the levels of immune-inflammatory markers were found between high-risk converters and non-converters. Our findings suggest that individuals at clinical risk of psychosis show subclinical inflammation in terms of elevated IL-6 levels. This phenomenon might be related to the use of antidepressants. The present meta-analysis does not support the usefulness of single immune-inflammatory markers in predicting transition to psychosis.

Insomnia, Suicidal Ideation, and Suicide Attempts in the Clinical Antipsychotic Trials of Intervention Effectiveness

Objective: Insomnia occurs frequently in the clinical course of schizophrenia. There is a robust association between insomnia and suicide in other psychiatric disorders. Several previous studies found associations between insomnia and suicidal ideation, suicide attempt, and psychopathology in schizophrenia. We explored these associations in a cross-sectional study of a large sample of patients with schizophrenia. Methods: In February 2020, we investigated relationships between current insomnia, suicidal ideation over the past 2 weeks, suicide attempt in the past 6 months (assessed by either the Calgary Depression Scale for Schizophrenia or self-report), and current psychopathology for subjects with baseline data from the Clinical Antipsychotic Trials of Intervention Effectiveness (DSM-IV schizophrenia trial conducted 2001-2004) using regression models. Results: After controlling for multiple potential confounding factors, terminal insomnia was associated with significant, 2.7-fold increased odds of current suicidal ideation (OR = 2.7, 95% CI = 2.0-3.6, P < .001). Initial/middle insomnia was associated with a significant, 5.5-fold increased odds of suicide attempt in the past 6 months (OR = 5.5, 95% CI = 1.4-21.1, P = .013). Terminal insomnia was also a significant indicator of higher Positive and Negative Syndrome Scale total (β = 0.12, P < .001), positive subscale (β = 0.11, P < .001), and general psychopathology subscale (β = 0.14, P < .001) scores. There were no other significant associations between insomnia, suicidal thinking or behavior, and psychopathology. Conclusions: Insomnia is associated with suicidal ideation, recent suicide attempt, and greater psychopathology in schizophrenia. Findings provide additional evidence that formal assessment of insomnia is relevant to the clinical care of patients with schizophrenia as an indicator of suicidal ideation and behavior, as well as symptom severity. Trial Registration: ClinicalTrials.gov identifier: NCT00014001.

Time to Revisit a Voluntary FDA Comparative Effectiveness Pathway

Given the renewed policy focus on drug pricing and pharmaceutical innovation, this article examines the historical backdrop of efforts to integrate comparative effectiveness research into the FDA drug review process. Noting previous policy efforts over a decade ago, we characterize industry challenges and suggest a path forward.

The pupillary light reflex as a point-of-care test for suicide risk: Preliminary results

The pupillary light reflex (PLR) reflects physiologic arousal, and a potential point-of-care biomarker of suicide risk. We collected data from 9 healthy controls, 6 non-suicidal depressed patients, 7 with prior suicide attempts but not presently suicidal, and 8 depressed patients who were actively suicidal. The pupillary maximum constriction velocity (MCV) was similar between the non-suicidal depressed patients and healthy controls (the "Never suicidal" group). Patients with prior attempt resembled the patients expressing active suicidal ideation (the "Ever suicidal" group). MCV was a significant predictor within a logistic regression model of participants who were "Ever suicidal" versus "Never suicidal".

Prenatal exposure to viral infection and neuropsychiatric disorders in offspring: A review of the literature and recommendations for the COVID-19 pandemic

The SARS-CoV-2 virus has emerged as a striking 21st century pandemic. Communities across the globe have experienced significant infection rates and widespread psychosocial stress and trauma, leading to calls for increased allocation of resources for mental health screening and treatment. In addition to the burden of psychosocial stress, there is increasing evidence of direct viral neuroinvasion of the central nervous system through physical contact with the nasal mucosa. In a parallel fashion, there is a significant body of ongoing research related to the risk of in utero viral transmission and the resulting neurodevelopmental impact in the fetus. Aberrant neurodevelopment secondary to viral transmission has previously been related to the later development of psychosis, schizophrenia, and schizophrenia spectrum disorders, generating the hypothesis that this population of individuals exposed to SARS-CoV-2 may see an increased incidence in future decades. We discuss the current understanding of the possible neurotropism and vertical transmission of SARS-CoV-2, and relate this to the history of viral pandemics to better understand the relationship of viral infection, aberrant immune response and neurodevelopment, and the risk for schizophrenia disorder.

Evaluating the Hypothesis That Schizophrenia Is an Inflammatory Disorder

The investigation of immune system abnormalities in schizophrenia, although ongoing for decades, has become a popular area of research. The authors present a selected review of studies informing on schizophrenia as a potential inflammatory disorder, emphasizing replicated findings. The authors summarize evidence for inflammation over the illness course, discuss relationships between inflammation and psychopathology, present studies of imaging of neuroinflammation, consider inflammation as a marker of treatment response and treatment target, and review potential mechanisms for the effects of inflammation on the brain in schizophrenia. Although there is not clear and convincing evidence to support the assertion that schizophrenia is an inflammatory disorder, this area of study shows promise toward a greater understanding of the etiopathophysiology of this heterogeneous disorder.

Meta-analysis of cytokine and C-reactive protein levels in high-risk psychosis

OBJECTIVE

Schizophrenia is associated with aberrant blood cytokine and C-reactive protein (CRP) levels. However, less is known about alterations in these markers prior to the onset of psychosis. We performed a meta-analysis of blood cytokines and CRP in subjects at high-risk for psychosis.

METHOD

We identified articles by systematic searches of PubMed, PsycINFO, and Web of Science databases, and the reference lists of identified studies. Eight studies met the inclusion criteria, including seven studies of high-risk psychosis versus controls, and four studies of high-risk subjects who converted to a psychotic disorder versus non-converters.

RESULTS

Blood IL-6 levels were significantly higher (SMD = 0.31, 95% CI 0.02-0.59, p = 0.04) and blood IL-1β levels were significantly lower (SMD = -0.66, 95% CI -1.27 to -0.05, p = 0.05) in subjects at high-risk for psychosis versus controls. Between-study heterogeneity was not significant for either IL-1β or IL-6, and there was no evidence of publication bias. There was a non-significant trend for higher blood IL-12 levels in converters versus non-converters (SMD = 0.86, 95% CI -0.06-1.79, p = 0.07).

CONCLUSION

We found limited evidence for blood cytokine and CRP alterations in subjects at high-risk for psychosis. Our findings should be interpreted with caution in light of a small number of studies, cumulative sample size, and heterogeneity of high-risk criteria, but warrant investigation in larger samples. This includes studies of subjects at high-risk of developing psychosis and controls, as well as the potential of inflammation as a predictor of conversion to psychosis. These findings have important potential implications for our understanding of the pathophysiology of schizophrenia.

Psychosis as an adverse effect of antibiotics

Adverse neuropsychiatric effects of antibiotic medications have been well documented. There is evidence suggesting a direct relationship between acute psychosis and antibiotic exposure. Conversely, the tetracycline antibiotic minocycline has been associated with improvements in psychopathology in patients with psychotic disorders. The purpose of the present study was to investigate the prevalence of spontaneously reported adverse drug reactions (ADRs) of psychotic symptoms in adults for antibiotics and the odds of psychosis compared to minocycline for individual antibiotics and antibiotic classes. We searched the publicly available U.S. F.D.A. Adverse Event Reporting System (FAERS) from inception through March 2020 for which an antibiotic was the suspected agent of an adverse drug reaction (ADR). We investigated 23 different antibiotics, comprising 183,265 adverse event reports and 2955 psychosis ADRs. For individual antibiotics, the prevalence of psychosis ADRs ranged from 0.3 to 3.8%. Fifteen antibiotics were associated with a significantly increased odds of psychosis (OR ​= ​1.67-9.48), including penicillins, fluoroquinolones, macrolides, cephalosporins, and doxycycline. Our results suggest that psychosis is a potential adverse effect of antibiotic treatment, but risks vary by specific agents. Future studies in this area are needed to identify specific underlying biological mechanisms that contribute to these associations. Findings may also inform on clinical decisions regarding the selection of antibiotic therapy in vulnerable patient populations.

Acutely ill psychiatric inpatients and antimicrobial exposure

BACKGROUND

Patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) have increased infections. We explored the association between recent antimicrobial exposure and acute psychiatric illness.

METHODS

We performed a retrospective chart review of 267 acutely ill patients age 18 to 65. There were 92 patients with schizophrenia, 42 with bipolar disorder, 61 with MDD, and 72 with alcohol use disorders (hospitalized controls). Recent antimicrobial exposure was defined as occurring within 3 days of psychiatric hospitalization.

RESULTS

The prevalence of recent antimicrobial exposure was significantly increased in acutely ill patients with schizophrenia (16%), bipolar disorder (21%), and MDD (18%) compared with patients who had alcohol use disorders (4%, P ≤ .01 for each). After controlling for potential confounders, participants with schizophrenia or mood disorders were 5 to 7 times more likely to have recent antimicrobial exposure than participants with alcohol use disorders (schizophrenia: odds ratio [OR] = 4.5, 95% confidence interval [CI] 1.0-21.0, P = .053; bipolar disorder: OR = 6.9, 95% CI 1.3-35.7, P = .022; MDD: OR = 5.7, 95% CI 1.2-28.3, P = .032). Among participants with mood disorders, the association was stronger for participants with depression and affective psychosis compared with participants with alcohol use disorders.

CONCLUSIONS

We found an increased prevalence of recent antimicrobial exposure in acutely ill patients with schizophrenia and mood disorders. The findings provide additional evidence that infections are relevant to acute psychiatric illness.