Bullying in Middle Schools
Bullying is a common occurrence in middle schools and affects both boys and girls alike. Bullies often have delinquency and aggression problems. Recent surveys suggest that 80% of middle school students view bullying as a problem.
Students in 7th and 8th grade at five schools in California, Florida, Maryland, and North Carolina responded to 14 items from the Child Abuse Prevention Services Survey. Fabianna Pergolizzi of Project Bully in Miami Beach, Florida, and colleagues (five of whom are high school students and the youngest presenters in the history of the American Psychiatric Association), analyzed 587 surveys and found that 40% of students admitted to bullying others at some point, with teasing and exclusion occurring more frequently than threatening or hitting. Seven percent reported bullying incidents to an adult, while 40% of witnesses to bullying who did not report on it reasoned that it was not their business (Figure). Though bullying affected boys and girls at the same rate, girls were more likely to ignore the bully and felt safer in school than did boys (82% versus 67%), whereas boys were more likely to retaliate with pushing or hitting the bully. Twenty-five percent of students reported being a victim of Internet harrassment, and 15% admitted to ever being a cyberbully. Most girls reported ignoring or blocking the cyberbully, while boys were more likely to either counter-bully or do nothing.
In addition to the apathy of students who witness bullying and the number of girls who are actively participating in bullying, the study authors were surprised about the prevalence of cyberbullying, stating that the incidence of online harassment is worthy of further investigation given electronic media’s increasing popularity among this age cohort.
Although many students reported being victims or perpetrators of mostly non-physical forms of bullying, >50% did not report on such incidents. Therefore, anti-bullying education and awareness of bullying’s negative effects would be beneficial to students, teachers, school staff, and parents. Ms. Pergolizzi, on behalf of the authors of the study, explained that primary care physicians (PCPs) can benefit from administering a bullying survey to their adolescent patients, especially those in middle school, to assess the need for possible psychological intervention.
“PCPs should sensitize youths to the problems of bullying, help them understand that taking a stand and safely intervening is the appropriate way to proceed, and advise them on bully prevention strategies,” Ms. Pergolizzi said. “PCPs could seek opportunities to collaborate with schools to develop education programs for students and parents that address bullying victims and perpetrators, and legislators to pass state-level anti-bullying laws.”
One forum highlighted by the authors of the study is Child Abuse Prevention Services in Roslyn, New York (516-621-0552 or mediaatCAPS@optonline.net), which can provide PCPs with resources related to bullying that are available to the medical community.
Funding for this research was provided by an unrestricted educational grant from NEMA Research Inc. (APA 2007, Poster NR 175). —DC
Aripiprazole Effective as Adjunct to Antidepressant Therapy in Patients With Major Depressive Disorder
Many patients with major depressive disorder (MDD) do not achieve symptom remission once they have had an inadequate response to >1 antidepressant trial. These patients often achieve partial response, continue to experience residual MDD symptoms, show reduced functioning, and face a poorer prognosis. However, antidepressant augmentation with atypical antipsychotics used in conjunction with antidepressants has been shown to be effective in treating MDD and treatment-resistant depression (TRD).
The atypical antipsychotic aripiprazole—an agonist at dopamine (D)2/D3 and serotonin (5-HT)1A receptors as well as antagonist at 5-HT2A receptors associated with MDD—has been shown to be effective as an adjunctive therapy in depression treatment. However, the drug’s efficacy in MDD and/or TRD treatment had not been evaluated in randomized, double-blind, placebo-controlled studies. Robert M. Berman, MD, of Bristol-Myers Squibb in Wallingford, Connecticut, and colleagues, recently evaluated the efficacy and safety of adjunctive aripiprazole in 362 patients with TRD.
Patients eligible for the study were 18–65 years of age; had a major depressive episode that lasted ≥8 weeks and met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text-Revision criteria; and had reduced symptom response to ≥1 but ≤3 antidepressant trials for >6 weeks, which indicated TRD.
After an 8-week prospective antidepressant treatment phase, patients with MDD (defined as a score of ≥18 on the Hamilton Rating Scale for Depression [HAM-D]) who showed incomplete response to either escitalopram, fluoxetine, paroxetine controlled release, sertraline, or venlafaxine extended release, took aripiprazole 2–20 mg/day or placebo as adjunctive treatment for 6 weeks. Incomplete response was defined as a HAM-D score of ≥14, a <50% reduction in HAM-D scores, or a Clinical Global Impression-Improvement (CGI-I) score of ≥3. The study’s primary endpoint was defined as a mean change in Montgomery-Asberg Depression Rating Scale (MADRS) total score from the study beginning to termination.
Berman and colleagues found that the mean reduction in MADRS scores was significantly greater for patients taking aripiprazole (n=184) than those taking placebo (n=178) from week 2 through the end of the study period (Figure). In addition, mean CGI-I scores showed significant improvements for patients taking aripiprazole compared to patients taking placebo. The authors found that aripiprazole was well-tolerated by patients. Adverse effects occurring in ≥10% of all patients were akathisia, headache, and restlessness. Weight gain was found in ≥7% of all patients.
“The study is promising and offers new options to patients with major depression who have had an inadequate response to standard single antidepressant treatment,” study co-author Arif Khan, MD, said.
Berman and colleagues said that future studies should evaluate the long-term safety of aripiprazole in patients with MDD and/or TRD.
Funding for this research was provided by Bristol-Myers Squibb and Otsuka. (APA 2007, Poster NR 310). —CP
Study of Psychiatric Inpatients with Suicidal Ideation Aims to Resolve Inconsistencies Concerning Antidepressant Use
Some antidepressants are shown to increase suicidality, while others have demonstrated a clinically significant reduction in suicidality. The difference is partly due to inconsistencies in clinical approaches to examining this area of interest. John C. Chelf, MD, of the Laureate Psychiatric Research Center in Tulsa, Okalahoma, and colleagues, recognized the complications caused by lack of widely accepted gold-standard design elements, and centered their study methodology on two main goals. The first goal was too better understand suicide ideation during a high-risk period, defined as the 2 months following inpatient admission for suicide crisis stabilization. The second goal was to examine potential predictor variables, which may be helpful in designing future studies.
Chelf and colleagues recruited 112 depressed patients, all recently admitted to an inpatient crisis stabilization center for suicidal ideation. Patients, between 18–64 years of age were all deemed by clinical staff to be at moderate-to-high suicide risk at admission, received diagnoses of non-psychotic depressive disorder, and were recruited for this study one day after admission.
Patients were discharged as outpatients after 3–5 days as inpatients, and were tracked naturalistically for 2 months following initial admission to the crisis center. The main outcome measure was the Beck Scale for Suicide Ideation (BSI), which was administered to patients at admission, at study enrollment, daily through day 7, and at days 14, 28, and 56. Covariates included depression severity at enrollment, age of onset, substance use, and medication exposure. Approximately 60% of patients were female, 86% were Caucasian, 67% were diagnosed with major depressive disorder, and 28% were diagnosed with any anxiety disorder.
BSI scores dropped from 20.2 post-admission to 10.3 at day 2 (95% CI). Following that initially steep decline, BSI scores stabilized, decreasing slowly to 7.0 after 2 months. Significant independent predictors for less improvement in suicidality by day 2 of hospitalization included higher education levels, comorbid anxiety disorder, and atypical antipsychotic exposure during hospitalization. Significant independent predictors for less improvement in suicidality after discharge included a history of recurrent depression and more prior psychiatric visits (Table).
Although 17% of patients demonstrated minimal improvement at discharge, a majority of them improved during the 2-month follow-up phase. Overall, suicidal ideation decreased most significantly during the first 2 days following admission. Implications of this study for other clinical trials, as the authors suggest, include a recruitment strategy geared toward adults who are unlikely to show a clinically significant drug effect; studies must also address comorbid anxiety disorders and history of depression.
Funding for this research was provided by the Warren Medical Research Center in Tulsa, Oklahoma. (APA 2007, Poster NR 397). —LS
Increased Cognitive Impairment Shown in Patients With Treatment-Resistant Depression
Patients with treatment-resistant depression (TRD) experience continuous depressive symptoms, respond poorly to various treatment approaches, and are at an increased risk for disability, morbidity, and mortality. Although prior research has shown that neurologic impairments are associated with the various forms of depression, including TRD and particularly during a major depressive episode, there is little research on the severity of cognitive impairment in patients with TRD when compared to patients without the disorder.
Philip D. Harvey, PhD, of the Mount Sinai School of Medicine in New York City, and colleagues, evaluated the presence of cognitive impairment in 497 patients with TRD and impairment severity when compared to patients without TRD. As cognitive impairment is a major determinant of disability, the authors sought to determine if patients with TRD are at increased risk for disability due to cognitive deficits.
Patients with TRD met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depressive disorder (MDD), showed treatment non-responsive depression from a single or recurrent episode with or without psychotic features, and had a score of ≥20 on the 17-item Hamilton Rating Scale for Depression at baseline. Patients with treatment non-response were defined as not exhibiting symptom response to ≥1 but ≤3 antidepressants (other than citalopram and escitalopram) for >6 weeks. Patients were excluded from the study due to current substance abuse, mental retardation, seizure disorder, or major head injury.
Study patients with and without TRD were evaluated using several computerized neuropsychological assessment tools that measured attention, working memory, distractibility, executive functions, learning, and motor speed, and results between the two groups were compared. Assessment tools included Auditory Number Sequencing (repeating a series of numbers in order from lowest to highest), the Face Memory Test (selecting target computer-generated faces from ones intended to distract the patient), and the Tapping Speed Test (patients pressed a key as fast as possible for a given duration).
Two hundred and seventy two patients with TRD and 63 patients without TRD met criteria for study inclusion. Harvey and colleagues found that patients with TRD performed significantly poorer than patients without the disorder on all cognitive assessment tools except two measures of the Set-Shifting Test, which gauged learning, executive function, and processing speed. While rates of cognitive impairment were lower than rates found in patients with untreated MDD, TRD patient impairment rates were higher than the expected rates for MDD patients experiencing symptom remission. In addition, the authors found that motor speed, episodic memory, and attention were most impaired in TRD patients.
The authors concluded that these results will aid in the understanding of the determinants of disability due to TRD and be useful for interpreting results from later studies, which should focus on impairment and its response to various forms of treatment. Study limitations included analysis limited to patients ≤55 years of age and cognitive assessments not being completed for all patients in the study.
Funding for this research was provided by Janssen. (2007 APA, Poster NR 503). —CP
Impact of Depression on Work Productivity
Absenteeism from work is more easily measured than work productivity when employees are present. However, both absenteeism and poor work performance due to depression and/or other medical or psychiatric conditions affect companies that employ such individuals as well as the direct costs of health care.
Ronald C. Kessler, PhD, at Harvard Medical School in Boston, Massachusetts, and colleagues, examined the comparative effects of depression and related comorbid conditions on absenteeism and work performance using a survey of 7,538 employees at a large United States firm, in addition to integrated medical and pharmacy claims data. The World Health Organization’s Health and Work Performance Questionnaire was used to assess workplace outcomes. During the 6-month period before the survey, regression methods helped assess the effects of the target health problems related to absenteeism and work performance. Socio-demographics and claims-based measures were controlled for, and results were weighted to adjust for differential survey non-response.
Two surveys were conducted, the first involving employees surveyed between October and December of 2005, and the second involving employees surveyed from September 2004 to September 2005. The mean age of employees in the first survey was 40.31±7.68 years, and the mean age of those in the second survey was 37.7±8.17 years.
Results of the study found that depression, among all physical and mental conditions affecting ≥5% of the population, had the largest adverse effect on overall work performance, amounting to approximately 6–8 missed work days per year. Other conditions that affected work performance included fatigue, anxiety, headaches, obesity, and chronic sleeping problems. Depression, in the absence of comorbid conditions, still had significant adverse effects. While comorbid anxiety, sleep disturbance, and fatigue increased the adverse affects of depression on workplace productivity, they had little effect on work performance of individuals who did not experience depression (Figure).
According to both surveys, employees with depression caused excessive annual healthcare costs (survey #1 mean=$4,132; survey #2 mean=$3,504). Employees with depression with comorbid fatigue and/or sleep problems caused significantly higher costs than those with depression alone (survey #1 mean=$6,665; survey #2 mean=$5,306). Healthcare costs were also significantly raised when employees experienced comorbid depression, fatigue and/or sleep problems, and anxiety (survey #1 mean=$7,131; survey #2 mean=$5,029). Healthcare costs for employees with both depression and anxiety were not significantly different than those for employees with depression alone.
Employees with depression and comorbid conditions have an economic impact on both reduced work productivity and increased healthcare costs. Treating depression and related conditions with pharmacotherapy reportedly results in positive effects on work performance and employees being present at work.
Funding for this research was provided by Eli Lilly. (APA 2007, Poster NR 317). —DC
FDA Approves Pregabalin for the Treatment of Fibromyalgia
The United States Food and Drug Administration pregabalin capsules CV (Lyrica, Pfizer) for the treatment of fibromyalgia. Dosing should be initiated at 75 mg BID and can be increased to 150 mg BID with 1 week. The recommended dose of pregabalin for fibromyalgia is 300–450 mg/day.
Approval was based on the findings of a 14-week, double-blind, placebo-controlled trial and a 6-month, randomized, withdrawal study of ~1,800 patients. Patients who met the American College of Rheumatology criteria for fibromyalgia (history of widespread pain for 3 months, and pain present at >11 of the 18 and specific tender point sites) were enrolled. The majority of patients in both studies found significant improvement in their symptoms of fibromyalgia. In the first study, between 68.1% and 77.8% of patients receiving pregabalin 300–600 mg/day found improvement in their fibromyalgia symptoms. In the second study, 53% of patients maintained a therapeutic response through week 26.
The most common dose-related side effects found in the studies included mild-to-moderate dizziness, sleepiness, blurred vision, weight gain, dry mouth, and swelling of the hands and feet.
For more information, please review the medication’s full prescribing information: www.lyrica.com. —CN
Posters were drawn from the 160th Annual Meeting of the APA (May 19–24, 2007, San Diego, California). Psychiatric Dispatches is written by Dena Croog, Christopher Naccari, Carlos Perkins, Jr., and Lonnie Stoltzfoos.