Military Personnel With Suicidal Ideation Less Likely to Store Firearms Safely at Home

Military personnel who have firearms at home and a history of thoughts of death or self-harm are less likely to store their firearms in a safe manner than those with no such history, a study in JAMA Network Open has found.

Craig J. Bryan, Psy.D., of the National Center for Veterans Studies at the University of Utah and colleagues examined the firearm storage practices of 1,652 active-duty military personnel who were seen in military primary care clinics between July 2015 and August 2018. They used the Behavioral Risk Factor Surveillance System to ask participants about firearm ownership and defined safe storage as keeping firearms locked up and unloaded. They used the Self-injurious Thoughts and Behaviors Interview to assess participants’ lifetime history of suicidal ideation and attempts and item 9 of the Patient Health Questionnaire-9 to assess whether the participants had thoughts of death or self-harm in the preceding two weeks. 

Of 1,652 study participants, 590 (36%) reported a firearm in or around their home. The researchers found that participants who had recent thoughts of death or self-harm were 39% less likely to have a firearm in the home than participants who did not have such thoughts. However, among all participants who reported keeping firearms in the home, those with a lifetime history of suicidal ideation were 53% less likely to store their firearms safely than those with no such history, and those with recent thoughts of death or self-harm were 74% less likely to store their firearms safely. 

“This highlights the importance of emphasizing safe storage of personally owned firearms, including temporary removal of access to firearms for high-risk personnel,” the researchers wrote. “Further research focused on firearm availability and storage practices among military personnel is warranted.”

For related news, see the Psychiatric News article “How to Reduce Risk of Suicide by Firearms.”

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LAIs May Lower Rehospitalization Risk in Older Patients With Schizophrenia

Older people with schizophrenia who are treated with long-acting injectable antipsychotics (LAIs) are less likely to be rehospitalized than their peers who are treated with oral antipsychotics, suggests a study in the American Journal of Geriatric Psychiatry.

Ching-Hua Lin, M.D., Ph.D., of the Kaohsiung Municipal Kai-Syuan Psychiatric Hospital in Taiwan and colleagues followed 1,168 patients aged 60 years or older who were discharged from the public psychiatric hospital between 2006 and 2017. The patients had either schizophrenia or schizoaffective disorder, 151 were discharged on LAIs, and 1,017 were discharged on oral antipsychotics. The researchers reviewed rehospitalizations that occurred within a year of discharge for both groups of patients, including those who had exhibited significant psychotic symptoms, dangerous or violent behavior, or a decline in functioning.

Eighty-one patients (53.6%) in the LAIs group and 672 (66.1%) in the oral antipsychotics group were rehospitalized within one year of discharge. Patients in the LAIs group had a significantly longer time to rehospitalization, a median of 257 days compared with a median of 115 days for those in the oral antipsychotics group. When reviewing the patients’ records, the researchers found that shorter hospitalizations and fewer hospitalizations prior to the study were also associated with a longer time between discharge and rehospitalization.

Lin and colleagues noted several limitations to their study, notably that the follow-up was only one year, and longer follow-up may reveal other differences between the two groups. Additionally, all patients were discharged from a single facility in Taiwan, so results may not be generalizable to other facilities and countries.

“In the future, further studies focusing on factors associated with risk of rehospitalization and effective interventions to prevent rehospitalization should be explored,” they wrote.

For related news, see the Psychiatric Services article “Comparison of Injectable and Oral Antipsychotics in Relapse Rates in a Pragmatic 30-Month Schizophrenia Relapse Prevention Study.”

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Refugees at Greater Risk of Developing Psychotic Disorders, Meta-Analysis Finds

The risk for schizophrenia and other psychotic disorders is higher among refugees than native populations and nonrefugee migrants, suggests a report published today in JAMA Psychiatry.

“Refugees do not migrate deliberately but are forced to migrate and have possibly faced traumatic experiences before and during migration,” wrote Lasse Brandt, M.D., of Charité-University Medicine Berlin and colleagues. Migration combined with separation from social networks, social exclusion and discrimination, limited access to medical care, poverty, and more may make refugees especially vulnerable to developing mental illness, they added.

Previous studies have pointed to migration as a risk factor for developing nonaffective psychoses, such as schizophrenia, schizoaffective disorder, and schizophreniform disorders. Brandt and colleagues wanted to know how the incidence of these mental illnesses in refugee migrants compared with incidence in both nonrefugee migrants and native groups in a host country.

Based on an analysis of nine studies published between 2004 and 2018, which included 540,000 refugees in Canada, Denmark, Norway, and Sweden, the researchers found that refugee migrants were 40% more likely to have a first diagnosis of nonaffective psychoses than nonrefugee migrants and 140% more likely than native populations of the host country.

“We believe that these findings highlight the need for psychiatric prevention strategies and outreach programs for refugees,” concluded Brandt and colleagues.

The researchers noted several study limitations; for example, eight of the nine studies were from Scandinavian countries, questioning whether the findings are applicable to other regions. Additionally, “despite the similarity in geographic location and study methods among included studies, their heterogeneity [across studies] was considerably high,” they wrote.

Nonetheless, in an accompanying editorial, Kristina Sundquist, M.D., Ph.D., of Lund University in Sweden noted, “because the risk of nonaffective psychoses in refugees was significantly increased (both compared with nonrefugee migrants and the native population) in countries with a generous welfare system and almost universal health care coverage, … refugees in other parts of the world may have even higher relative risks for several psychiatric disorders, including nonaffective psychoses.” She added, “The observed risk increases of nonaffective psychoses in refugees highlight the need for extended support, which may include psychiatric care specifically tailored for this vulnerable subgroup in the population. Support to refugees may also encompass other health-promoting efforts to prevent psychiatric disorders from occurring.”

For related information, see the Psychiatric News article “GWU Group Helps Train Refugee Aid Workers.”

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Youth Who Use E-Cigarettes May Be More Likely to Use Marijuana, Study Finds

Adolescents and young adults who use e-cigarettes are more likely to use marijuana, according to a meta-analysis published Monday in JAMA Pediatrics.

“These findings, which show a significant association between two psychoactive substances that have long-term deleterious effects on the brain, have important public health implications: Addressing [e-cigarette] use and doing so early may be an effective way of delaying onset of marijuana use,” Nicholas Chadi, M.D., M.P.H., of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital and colleagues wrote.

Chadi and colleagues searched several databases for studies comparing rates of marijuana use among youth aged 10 to 24 years with and without a history of e-cigarette use. They also searched through abstracts and reports from major substance use and tobacco prevention associations and conferences and summary reports on the health effects of e-cigarettes.

A total of 21 studies, including three longitudinal studies representing 14,364 participants and 18 cross-sectional studies representing 113,863 participants, were included in the meta-analysis.

The authors found that youth who used e-cigarettes were more than three times as likely to be using or have used marijuana. Additional analysis revealed e-cigarette users under 18 were more likely to use marijuana compared with e-cigarette users over 18.

“While the long-term health outcomes of using newer [electronic nicotine-delivery systems] devices is not yet well understood, e-cigarette liquids contain several known toxins. Chronic exposure accruing over a lifetime for individuals who initiate use early is a particular concern,” the researchers wrote. “It is well established that the younger the age at onset of substance use, the higher the likelihood of developing a substance use disorder later in life.”

For related information, see the Psychiatric News article “FDA Warns Some E-Cigarette Users Having Seizures, Particularly Youth.”

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Behavior Modification Found to Be Effective for Managing Pediatric Aggression

A behavior modification program that features positive and negative incentives reduced the use of psychotropic medications and/or physical interventions to manage agitated outbursts in children hospitalized for aggression, compared with a program that relied on verbal de-escalation techniques. The findings were published online by the Journal of the American Academy of Child & Adolescent Psychiatry.

“[O]ur data support the effectiveness of the [behavior modification program] and suggest that verbal attempts to calm the raging child can be counterproductive,” wrote Gabrielle Carlson, M.D., of the Renaissance School of Medicine at Stony Brook University and colleagues.

Carlson and colleagues assessed research and medical records of five cohorts of children admitted to Stony Brook’s 10-bed children’s psychiatric inpatient unit for aggressive behavior between 2008 and 2018. During this time, the facility transitioned away from a behavior modification program (BMP)—which involved collaborative problem-solving therapy coupled with positive rewards for good behavior and “time outs” for bad behavior—to reduce aggression. The unit switched to a program that used verbal de-escalation or distraction to talk children down from what the authors described as “intensely emotional situations.” Carlson and colleagues noted the switch was due to a perceived inability to provide enough incentives for good behavior as well as a belief that “time outs” were a form of physical restraint.

The final analysis included 347 children admitted during BMP use and 163 admitted during de-escalation use. The researchers found that the use of medications like sedatives or antipsychotics to reduce agitation was significantly lower when BMP was in use. “As needed” medical sedation was used 163 times per 1,000 patient-days when BMP was used compared with 483 times per 1,000 patient-days when de-escalation was used. The need for seclusion or physical restraint also was lower with BMP than with de-escalation (17 times versus 65 times, respectively, per 1,000 patient-days).

“Perhaps the increased attention given to the agitated child by continually talking to him/her, encouraging skill use, and sometimes giving children what they wanted to limit frustration inadvertently reinforced the unwanted behaviors,” wrote Carlson and colleagues as a possible explanation for why verbal de-escalation strategies increased the use of medication and/or restraint. They also suggested that under the de-escalation strategy children may have learned that aggression was a good way to avoid doing an unpleasant task, since staff sometimes let children get their way to calm them. However, the authors also noted the differences seen in outcomes between the two approaches may have been the result of the staff being less familiar with the technique. “It is possible that staff wasn’t adequately trained to execute de-escalation interventions correctly, biasing findings in favor of [BMP],” they wrote.

To read more about this topic, see the American Journal of Psychiatry article “Brain Mechanisms of Attention Orienting Following Frustration: Associations With Irritability and Age in Youths.”

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Clinicians Warned to ‘Be Alert’ to Ramifications of Conversion Therapy

Despite outspoken opposition to conversion therapy—practices that seek to change an individual’s sexual orientation or gender identity—by multiple professional medical organizations, only 18 states, Puerto Rico, and Washington, D.C., have banned conversion therapy for minors. As a result, it is estimated that more than 16,000 LGBTQ adolescents in the United States will undergo conversion therapy with a licensed health care professional by the time they reach 18 years of age, according to the Williams Institute at the UCLA School of Law.

In an article published yesterday in the New England Journal of Medicine, Carl G. Streed Jr., M.D., M.P.H., of Boston Medical Center and colleagues traced the history of the emergence of conversion therapy and later recognition by the medical community of its harmful effects. They cautioned clinicians to “be alert” to the needs of patients who may have received conversion therapy.

“Studies of adults who underwent conversion therapy earlier in life document a range of health risks,” Streed and colleagues wrote. Some of these health risks were highlighted by a 2018 study comparing LGBTQ young adults who had been encouraged to attend conversion therapy with those who had not, the authors noted. The study found youth whose parents or caregivers encouraged conversion therapy or reported being sent to therapists and religious leaders for conversion interventions were more likely to have depression, suicidal thoughts, suicidal attempts, less educational attainment, and less weekly income than those who had not been encouraged to seek or exposed to conversion therapy.

“Clinicians can be alert to the profile of a typical conversion-therapy participant. Patients involved in conversion therapy may not volunteer relevant information to a health care provider and may go out of their way to conceal their participation,” Streed and colleagues wrote. “Many survivors of conversion therapy will need treatment for posttraumatic stress disorder and post-religious trauma.”

Many medical professional organizations have acknowledged the risks of conversion therapy and oppose its use, the authors noted. Since 1998, APA has opposed any psychiatric treatment, such as “reparative” or conversion therapy, which is based upon the assumption that homosexuality is a mental disorder or that a patient should change his/her homosexual orientation. Other medical organizations to voice opposition to the use of conversion therapy include the AMA, the World Psychiatric Association, the American Psychological Association, the American Academy of Pediatrics, and the American College of Physicians.

“Beyond ending harmful practices [of conversion therapy], supporting the acceptance and inclusion of people of all gender identities, gender expressions, and sexual orientations is critical,” Streed and colleagues wrote. Clinicians should take steps to educate themselves about LGBTQ patients, including the ramifications of conversion therapy, they continued.

“According to a draft of the U.S. Joint Statement on Conversion Therapy, a consensus statement being prepared by more than a dozen health care organizations, medical officials should take into account developmental considerations for each stage of the lifespan when caring for patients and should be prepared to offer supportive therapies and provide accurate information and resources for all LGBTQ patients and their families,” they concluded. “We believe it is vital for clinicians to understand both the scientific and the ethical hazards of conversion therapy and appropriate responses for survivors and at-risk patients and to help create supportive environments for all LGBTQ persons.”

For related information, see the Psychiatric News article “SAMHSA Report Calls for End to ‘Conversion’ Therapy for Youth” and APA’s most recent position statement on conversion therapy.

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Time for Action on Firearm Violence Is Now, Says APA

APA on Wednesday joined six other physician and health professional organizations in calling for action to address the public health epidemic of firearm-related injury and death.

“Our nation is in the midst of an epidemic of firearm-related injuries and deaths, and we must treat this as a public health crisis,” APA President Bruce Schwartz, M.D., said in a press release. “We see the long-lasting mental health impact firearm-related violence and injury has on our patients every day, and it is time for us to come together as a nation to address this epidemic.”

The call to action was published yesterday in the Annals of Internal Medicine. In the article, Schwartz and leaders from the AMA, American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, and the American Public Health Association outlined several specific policy recommendations to prevent firearm-related injury and death in the United States. These recommendations include the following:

• Comprehensive criminal background checks for all firearm sales.
• Further research into the causes and consequences of firearm injury and death.
• Improved access to mental health care and caution against broadly including all individuals with a mental health disorder in a category of individuals prohibited from purchasing firearms.
• Removal of barriers to physician counseling of patients about the health risks of firearms.
• Reasonable laws and regulations governing firearms with high-capacity magazines and other features for rapid firing.
• Enactment of extreme risk protection order laws, which allow families and law enforcement to petition a judge to temporarily remove firearms from individuals at imminent risk for using them to harm themselves or others.

“Across the United States, physicians have daily, firsthand experience with the devastating consequences of firearm-related injury, disability, and death. We witness the impact of these events not only on our patients, but also on their families and communities,” they wrote. “As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society.”

“The house of medicine is unified in this call,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in the press release. “The time for action is now.”

For related information, see the Psychiatric News articles “Most Americans Agree That Gun Violence Is Public Health Problem, Call for Action” and “Gun Violence: The Parkland Survivors and the End of Learned Helplessness?”

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