Journal Digest

• Training physicians to follow clinical guidelines significantly improved the symptoms of children with attention-deficit/hyperactivity disorder (ADHD) in the primary care setting, but did not significantly change their functional impairment. The ADHD Collaborative, a quality-improvement initiative, provided training on ADHD treatment for community-based physicians, including pediatricians and family practice clinicians, and analyzed the outcomes of 785 children with ADHD treated by 158 physicians at 47 practices who participated in the initiative. The patients were aged 7 to 11.

ADHD symptoms, as measured by parent- and teacher-rated scales, showed significant reduction from baseline to three months after the treatment started. The improvement was sustained over time. However, the children's functional impairments rated by parents and teachers in reading, writing, mathematics, and overall school performance did not change significantly over 12 months despite treatment. The authors suggested that children with ADHD need to be taught additional learning, organization, and positive social skills to reverse their functional impairments significantly.

• Attachment-based family therapy (ABFT) reduced suicidal ideation and depressive symptoms in suicidal teens more effectively than usual care. Sixty-six adolescents aged 12 to 17 with suicidal ideation and at least moderate depression participated in a study at the Children's Hospital of Philadelphia and were randomly assigned to either enhanced usual care (n=31) or ABFT (n=35) for three months. Patients receiving enhanced usual care were referred to appropriate therapists and received weekly safety monitoring via telephone by the study staff.

ABFT was provided on the basis of a semistructured treatment protocol and involved weekly sessions with the adolescent alone, with parents alone, and with both. All patients were assessed at baseline and at six, 12, and 24 weeks (three months after the end of the treatment period).

The change in depressive symptoms over time, as measured by the Beck Depression Inventory II, did not differ significantly between the ABFT and usual-care groups. However, ABFT patients showed significantly greater reduction in self-reported suicidal ideation indicated by their Suicidal Ideation Questionnaire scores, including at the 24-week follow-up assessment.

Treatment retention was also significantly better in the ABFT patients, who attended a mean number of 9.7 sessions, compared with usual-care patients with a mean of 2.9 sessions. The authors concluded that ABFT is a potentially effective approach for suicide prevention, but its efficacy needs confirmatory research.

• Oxytocin inhalation, which allows the molecule to enter the brain, increased prosocial behaviors in adults with Asperger's syndrome or high-functioning autism in a French study.

Thirteen patients aged 17 to 39 were tested for cooperative behaviors in a computer-simulated ball-tossing game with three fictitious players. The three simulated players were programmed to each send 70 percent, 30 percent, and 10 percent of its tosses to the subject. The subject was told that each participant, including himself or herself, would receive 2 euros for each ball received. A group of 13 healthy control subjects, while playing the computer game, soon recognized the player most likely to reciprocate and preferentially sent balls to that player. After they received a dose of placebo, the autistic subjects tossed their balls with even frequencies to all three virtual players, which differed significantly from healthy controls, who were tested once without either placebo or oxytocin.

After receiving one dose of 24 IU oxytocin nasal inhalation, however, the autistic subjects sent significantly more balls to the most cooperative player, and this pattern became indistinguishable from that of healthy controls.

In a separate test, the autistic subjects spent significantly more time gazing at photos of human faces, especially the eye region, after receiving oxytocin inhalation than after a dose of placebo. The gaze time was measured using an eye-movement tracking device. However, patients receiving oxytocin remained significantly below healthy controls in their face-gazing duration.

• Many adults who were prescribed opioid painkillers saved leftover tablets, and some gave the leftover medication to others, according to a recent telephone survey conducted by the Utah Department of Health (UDH). About 21 percent of the respondents who participated in the health survey reported that they were prescribed an opioid medication for pain in the previous year. Among the respondents who received prescription opioids, 72 percent had leftover medication, and 71 percent of these respondents said they had kept it, 25.2 percent had disposed of it, and 2.3 percent had given it to someone else.

The survey found that 3.2 percent of the respondents reported using more than the dosage prescribed, and 1.8 percent reported taking an opioid medication not prescribed for them. The use of other people's opioid medication was most common among people aged 35 to 44. Utah laws consider sharing controlled substances a felony. Nevertheless, deaths related to prescription pain medications increased nearly sixfold from 1999 to 2007 in the state, where the rate of nonmedical use of pain medications was the highest in the United States in 2005. To minimize the risk of nonmedical use of prescription opioids, UDH issued guidelines in 2009 to urge clinicians to counsel patients about disposing of unused pain medication and not to prescribe more opioid medication than appropriate for the condition.

• Alcohol drinking patterns have no significant influence on the symptom severity and outcomes of patients with bipolar disorder, a recent study found. Adult Dutch patients with a diagnosis of bipolar I or II disorder were recruited and followed for up to 52 weeks between June 2003 and November 2005. Patients recorded their mood and alcohol consumption daily, while clinicians assessed their symptoms, functioning, and quality of life at monthly visits. Study participants were classified into three groups based on alcohol use in the first four weeks: no/incidental alcohol use, moderate use, and excessive use. A total of 137 patients provided at least two months of follow-up data and were included in the analysis.

Although the three groups continued to have large differences in alcohol consumption throughout the one-year follow-up, there was no significant difference among the groups on any of the self-reported or clinician-assessed bipolar outcome measurements, including the number of days of illness, severity of depression or mania, clinician's clinical global impressions of symptoms and functioning, and quality of life.

Neither moderate nor excessive drinking worsened patients' bipolar symptoms and outcomes compared with no or incidental drinking. The authors concluded that the conventional recommendation of alcohol abstinence may not be applicable for at least some patients with bipolar disorder.

• Migraine with or without aura is associated with significantly higher risks of cardiovascular diseases including myocardial infarction, stroke, and claudication, according to a large case-control study.

Adults suffering from migraine (n=6,102) and controls (n=5,243) without migraine were compared for self-reported cardiovascular diseases. People with migraine had more cardiovascular risk factors, including diabetes, hypertension, and high cholesterol, than did controls. Patients with migraine with aura showed a broader association with cardiovascular diseases and risk factors, but those with migraine without aura were also at significantly elevated risks compared with controls.

The authors cautioned that the clinical use of these findings is yet to be clarified, but recommended that clinicians pay particular attention to the cardiovascular health of patients with migraine.

Bigal ME, Kurth T, Santanello N, et al. Migraine and Cardiovascular Disease: A Population-Based Study. Neurology. 2010;74:628-635.