Study Finds 60% of Privately Insured Youth With PTSD Receive Psychotherapy

Although the majority of privately insured youth diagnosed with a new episode of posttraumatic stress disorder (PTSD) receive psychotherapy—considered the first-line treatment for pediatric PTSD—treatment gaps remain, according to a report in Psychiatric Services.

The report found while about 6% of youth with PTSD were prescribed pharmacotherapy, more than a third received neither psychotherapy nor psychopharmacology.

Rene Soria-Saucedo, M.D., Ph.D., of the Boston University School of Public Health and colleagues analyzed data from the MarketScan Commercial Claims and Encounter database for children and adolescents aged 6 to 18 who received a new diagnosis of PTSD in 2012. A total of 7,726 youth were included in the analysis.

Overall, 59% of youth received psychotherapy alone, 2.7% received combination treatment (psychotherapy and pharmacology), and 5.9% received pharmacotherapy. Of the youth prescribed medications for PTSD, most (71.3%) received antidepressants, followed by antipsychotics (21.6%) and benzodiazepines (7.1%). Youth who received pharmacotherapy were more likely to be older, to be female, to have been previously hospitalized, and to have a larger number of comorbidities.

“There is a strong and consistent empirical support for the safety and effectiveness of psychotherapy, particularly TF-CBT [trauma-focused cognitive-behavioral therapy], for PTSD,” Soria-Saucedo and colleagues wrote. “Further research is needed to understand the rationale behind the prescription of pharmacotherapy for PTSD among children and develop initiatives to expand psychotherapy access, especially in the primary care setting,” the researchers wrote.

For related information, see the Psychiatric News article “SAMHSA Child Mental Health Event Promotes Trauma-Informed Approach.”

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Report Reveals Patterns of Potentially Unsafe Use of Zolpidem

Despite FDA recommendations that the hypnotic zolpidem be used for short-term treatment of insomnia, most patients report sustained use, according to a report published today in JAMA Internal Medicine. The report also found evidence that women may be taking zolpidem above the recommended dose.

In 2013 the FDA recommended that manufacturers of some zolpidem products update their medication labels to lower the recommended initial dose of the medication for women after evidence at the time suggested that women eliminate zolpidem more slowly from their bodies than men. The FDA informed manufacturers that the recommended dose of zolpidem for women should be lowered from 10 mg to 5 mg for immediate-release products (Ambien, Edluar, and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR); the FDA recommended that health care professionals also consider prescribing the lower doses for men, according to the 2013 safety announcement.

“These precautions were intended to reduce the risks of next-day impairment, abnormal behavioral changes, and dependency,” study authors Thomas J. Moore, A.B., of the Institute for Safe Medication Practices and Donald R. Mattison, M.D., M.S., of Risk Sciences International in Ottawa, Canada, explained in the JAMA Internal Medicine report. Moore and Mattison used the U.S. Medical Expenditure Panel Survey for 2015 to examine how patterns of reported use compared with the FDA recommendations.

Overall, 3.8 million adults aged 18 to 85 years reported filling one or more prescriptions for zolpidem in 2015. Women were nearly twice as likely as men to report taking zolpidem, they noted. Additional analysis revealed that 68% of women were taking 10 mg immediate release or 12.5 mg extended-release products—above the recommended initial dose of 5 mg and 6.25 mg, respectively. More than 68% of those exposed to zolpidem reported sustained use (defined as three or more prescriptions or use over 61 days or more); the sustained-use zolpidem group reported a median of 192 days’ supply.

“Although efficacy declines substantially after 14 days of continuous administration, most zolpidem patients reported sustained use, with increased risk of dependence, given that zolpidem is a class IV-controlled substance,” the authors wrote.

For more on hypnotics, see the Psychiatric News article “Study Finds Rising Long-Term Use of Hypnotics.”

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Avatar-Guided Virtual Reality Therapy Found to Reduce Fear of Heights

A brief psychological therapy using virtual reality (VR) can help people overcome their fear of heights, reports a randomized, clinical study published this week in The Lancet Psychiatry. The VR therapy used a digital avatar as the coach; there was no human therapist involved.

“Immersive virtual reality therapies that do not need a therapist have the potential to dramatically increase access to psychological interventions,” said lead author Daniel Freeman, Ph.D., of the University of Oxford in a press release. “We need a greater number of skilled therapists, not fewer, but to meet the large demand for mental health treatment, we also require powerful technological solutions.”

For this study, 100 people with clinically diagnosed fear of heights, or acrophobia, using DSM-5 criteria were divided into two groups: one participated in the VR coaching program; the other received no treatment. All participants scored higher than 29 on the Heights Interpretation Questionnaire (HIQ), which the researchers considered as the threshold indicating a moderate fear of heights.

The VR therapy involved six 30-minute sessions over two weeks. In the first session, the virtual coach provided background information about acrophobia and how to treat it from a cognitive perspective to develop memories of safety that counteract fear associations.

The remaining sessions had the participants tour a virtual 10-story office complex and take part in activities to break down their fears while the coach provided empathic encouragement, repeated key learning points, and sought feedback on whether the participant felt safer than before. As the program progressed, the activities became more challenging, starting with simple tasks like watching a safety barrier gradually lower over the edge of a drop and then moving on to more difficult tasks like walking out on a high platform.

At the end of the study, the VR participants had an average reduction of 24.5 points on their HIQ scores compared with a 1.2-point reduction among the controls. At the two-week follow-up, 34 of the 49 VR participants had HIQ scores of 29 or lower. No adverse side effects were reported, and 44 of the 49 participants completed all six sessions.

To read more about VR, see the Psychiatric News article “Virtual Reality May Soon Become Clinical Reality in Psychosis Care.”

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APA Awarded $14.2 Million Grant to Improve Treatment for Serious Mental Illness

APA has been awarded a five-year, $14.2 million grant to create an educational and support system to expand access to care for the 11 million adults in this country who have serious mental illness.

The funding for the project, known as the Clinical Support System for Serious Mental Illness (CSS-SMI), was awarded by the Substance Abuse and Mental Health Services Administration. Serious mental illnesses are those that substantially interfere with major life activities and include schizophrenia, bipolar disorder, and major depressive disorder. At least one-third of people with these diagnoses do not receive treatment.

“This grant will allow APA to take a leading role in addressing serious mental illness in this country,” said APA President Altha Stewart, M.D., in a statement. “The CSS-SMI project will help us disseminate best practices for treating people who have serious mental illness and increase their access to care. I am excited to see the project unfold over the next five years.”

The project will offer expert consultation services and learning opportunities nationwide to enable clinicians—such as physicians, nurses, recovery specialists, peer-to-peer specialists, and others—to provide evidence-based care using state-of-the-art technology to treat or assist people with serious mental illness. Components include a call center as well as sophisticated internet- and app-based technologies to promote best practices in caring for these individuals, including the use of APA’s PsychPRO mental health registry.

In addition to APA, 29 partner organizations and individuals will provide expertise on clinical content, educational resources, and strategic guidance. Partners include the Academy of Consultation-Liaison Psychiatry, American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, and the American Association of Community Psychiatrists.

Detailed information will appear in a future issue of Psychiatric News.

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Highlights From APA’s 2018 Annual Meeting: Issue #3

As ECT Marks 80th Birthday, Experts Reflect on Its Future
Researchers are using neuroimaging to determine additional ways to make this proven treatment for treatment-resistant depression even safer and more effective.

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Assembly Seeks Help for Members Appealing Insurance Denials
At its meeting in May, the APA Assembly took action on a number of issues important to the Association, the field of psychiatry, and its patients. Among them was a proposal to help members appeal denied insurance claims.

Read More >


Equine Therapy Helps Patients Overcome Range of Psychiatric Disorders
In this millennia-old practice, equine-assisted therapy promotes patients’ physical, occupational, and emotional growth.

Read More >


Identities Should Be Additive, Not ‘Either/Or,’ Say Speakers
Self-reflections shared by three speakers highlight how women of color face unique discrimination and biases.

Read More >


Taking Some Antipsychotics During Pregnancy May Raise Risk of Gestational Diabetes
Women who continue use of the antipsychotic drugs olanzapine and quetiapine during pregnancy have an increased risk of gestational diabetes, according to a study in AJP in Advance that was released at the APA Annual Meeting.

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ED-Administered Safety Planning Intervention Reduces Suicidal Behaviors

A brief clinical intervention in the emergency department (ED) along with structured follow-up phone calls can reduce suicidal behaviors in patients and  encourage them to use mental health services, according to a study published today in JAMA Psychiatry.

Barbara Stanley, Ph.D., of Columbia University and colleagues enrolled 1,640 adults who had been admitted to one of nine Veterans Administration EDs who had had a suicidal crisis (but who did not subsequently require inpatient hospitalization) between 2010 and 2015. Four of the EDs continued to provide their usual care for the patients, while the other five implemented a safety-planning intervention combined with telephone follow-up. 

Safety planning provides patients with a written safety plan that includes coping skills, strategies to make their environment safer, and a list of people who can provide support. The telephone follow-up consisted of at least two postdischarge contacts with a patient to monitor suicide risk, review the safety plan, and encourage continued treatment.

Six months after ED discharge, fewer patients in the safety planning group engaged in suicidal behavior compared with the usual care group (3.03% vs. 5.29%, respectively). Recipients receiving the safety-plan intervention and follow-up also had more than double the odds of attending at least one outpatient mental health visit after discharge. 

The increased visits with outpatient mental health services were not solely responsible for the reduced suicidal behaviors, the authors noted; other components of the safety-planning intervention were also contributing to patient improvements.

“Our findings are promising and indicate that safety planning and active outreach—a set of low-burden strategies—are useful components of effective suicide prevention,” Stanley and colleagues wrote. “Importantly, using the low-burden intervention in this project and others was associated with about the same reduction in suicidal behavior as more intensive and costly psychosocial interventions. If implemented broadly, [this intervention] has the potential to reduce suicidal behavior and enhance behavioral health treatment engagement, particularly during high-risk periods following ED discharge.”

To read more on this topic, see the Psychiatric News article “Emergency Department Intervention May Reduce Suicide Attempts in At-Risk Patients.” 

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Opioid Prescribing for Teens Exceeded CDC 2016 Guidelines for Adults

Between 2005 and 2016, opioid prescriptions for adolescents generally were written for longer than three days, and the number of prescriptions filled for four and five day supplies increased, according to a report in Psychiatric Services in Advance.

These trends occurred prior to the issuance of guidelines for opioid prescribing by the Centers for Disease Control and Prevention (CDC) in 2016 but during a period of increasing national awareness of the opioid epidemic, according to lead author Mir M. Ali, Ph.D., of the Center for Behavioral Health Statistics and Quality at the Substance Abuse and Mental Health Services Administration and colleagues. The CDC did not provide explicit opioid-prescribing guidance for individuals under age 18 in 2016 but did recommend that opioids be prescribed even more cautiously for adolescents than for adults.

Ali and colleagues measured the number of days for which opioids were prescribed for adolescents aged 12 to 17 covered by Medicaid or commercial insurance by using the 2005-2016 IBM MarketScan commercial and Medicaid databases. They identified all oral prescriptions filled by adolescents for the most commonly prescribed opioids: hydrocodone, hydromorphone, oxycodone, codeine, methadone, tramadol, and morphine. They measured average days’ supply per prescription using the following categories: one, two or three, four or five, six or seven, eight to 15, 16 to 30, and greater than 30 days.

For adolescents with Medicaid insurance, a supply of two or three days was the most common prescription range until 2016, decreasing from 50.5% of prescriptions filled in 2005 to 36.7% in 2016. Over the same period, the percentage of prescriptions with a supply of four or five days increased from 30.2% to 37.7%; even in 2016, the percentage of prescriptions written for between four days and more than 30 days exceeded 50 percent. The pattern for adolescents with commercial insurance followed similar patterns for adolescents with Medicaid, according to the report.

The rate of prescriptions written for a one-day supply remained at 1.0% to 2.0% until 2016, when the CDC guidelines were issued. In that year, they increased to 3.6%, according to the report.

The latter trend is hopeful. “The uptick in one-day opioid prescriptions in 2016 … may indicate that some prescribers are increasingly trying to minimize prescribing to adolescents,” the researchers stated. “As states increasingly impose days’ supply restrictions for adolescents that are often more restrictive than those for adults and as those restrictions are strictly enforced, it is possible that the increasing trend of prescribing a supply of four or five days of opioids for adolescents might reverse.”

For related information, see the Psychiatric News article “Psychiatrists Can Play Vital Role in Stemming Opioid Crisis.”

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