Repeated Media Exposure to Mass Violence Linked to Posttraumatic Stress Symptoms

Tomorrow marks the 20th anniversary of the school shooting in Columbine, Colo., that claimed the lives of 15 people, and the media have already begun to bombard viewers with images and footage of the massacre’s aftermath. Although it’s natural to turn to the news to get information about such events, watching coverage of them over and over may be harmful to mental health, according to a study in Science Advances. The researchers, led by Roxane Cohen Silver, Ph.D., at the University of California, Irvine, found that media exposure to traumatic events may make viewers more emotionally sensitive to news reports of other, similar events, and cause anxiety and worry about future occurrences.

In the study, 4,165 U.S. adults responded to four surveys over the span of three years. They completed the first survey two to four weeks after the bombings at the Boston Marathon in 2013, with subsequent surveys six months later, at the second anniversary of the bombings, and five days after the Pulse nightclub shootings in Orlando, Fla., in 2016. The surveys were designed to capture participants’ responses to both tragedies and examine how responses to the Boston bombings affected their reactions to news coverage of the Orlando shootings.

The researchers found that media exposure to the Boston bombings was associated with symptoms of posttraumatic stress and with worry about future events, even two years after the bombings. Furthermore, the more worry and posttraumatic symptoms participants had, the more coverage of the Orlando shootings they watched, which led to even more distress.

“Given the apparent role that worry about the future plays in perpetuating this cycle of sensitivity to distress, this cycle may contribute to a prolonged physiological stress response that heightens risk for stress-related diseases,” Silver and colleagues wrote.

The researchers called upon the media to consider how it covers mass violence and traumatic events.

“Our findings suggest that media organizations should seek to balance the sensationalistic aspects of their coverage (e.g., providing more informational accounts as opposed to lengthy descriptions of carnage) as they work to inform the public about breaking news events,” they wrote. “This may reduce the impact of exposure to one event, reducing the likelihood of increased worry and media-seeking behavior over time.”

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Certain Variations of CBT Found as Effective as Individual CBT

Group, telephone, and guided self-help formats of cognitive-behavioral therapy (CBT) are as effective as individual CBT to treat depression, according to a study published yesterday in JAMA Psychiatry. However, guided self-help CBT is associated with a higher rate of dropouts than the other formats.

“This study suggests that group, telephone, and guided self-help treatments … may be considered as alternatives to individual CBT,” wrote Pim Cuijpers, Ph.D., of Vrije University in the Netherlands and colleagues. “Applying effective and acceptable CBT in a range of different formats will make CBT easier to implement, disseminate, and deliver across different settings and diverse patient populations.”

Cuijpers and colleagues used a technique known as a network meta-analysis to compare 155 clinical trials involving CBT for the treatment of depression. These trials included CBT delivered in individual, group, telephone-based, guided self-help (in which a therapist provides some assistance), and unguided self-help (no therapist contact) formats. The self-help categories grouped together both internet and non-internet (for example, book) delivery methods. These studies also included two types of control groups: usual care and wait list.

The comparisons showed that individual, group, guided self-help, and telephone CBT were all statistically more effective than unguided self-help CBT, as well as wait-list and usual-care controls. No significant differences were found between individual, group, guided self-help, and telephone CBT.

“Unguided self-help differs from the others in that it is the only modality that does not involve at least some contact with a helping person,” wrote Holly Swartz, M.D., and Jay Fournier, Ph.D., of the University of Pittsburgh School of Medicine, in an accompanying editorial. “This finding is consistent with other reports suggesting that individuals with depression benefit more from psychotherapy when there is at least a modicum of human interaction.”

The researchers also assessed differences in acceptability based on the responses of participants who dropped out for any reason. There were no differences in acceptability between individual, group, telephone, and unguided CBT, but guided self-help CBT was less acceptable than both individual and group CBT and both control conditions.

“It is not clear why the acceptability of guided self-help CBT was lower compared with that for the other formats,” Cuijpers and colleagues wrote. “Maybe the absence of direct contact with a professional makes it easier to stop the treatment because there is less personal-relationship pressure to continue with the treatment or the study. However, lower acceptability would then also be expected to happen in unguided CBT, which we did not find. More research is needed to examine this issue.”

To read more about different CBT modalities, see the Psychiatric News article “Guided Online CBT Benefits Patients With Depression, Anxiety.”

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APA Members: Register by May 1 to Vote in Caucus Elections

APA members have formed seven Minority and Underrepresented (M/UR) Caucuses, which provide networking opportunities, advance treatment of minority patient populations, advocate for minority mental health issues, provide representation in APA governance, and foster communication among members who share interests. To vote in one of the caucuses holding elections later this year—the Caucus of Black Psychiatrists and the Caucus of International Medical Graduates—members must join one of the caucuses and select it as the caucus in which they want to vote by May 1.

(Note: While APA members may join more than one caucus, they can vote for the leadership of only one caucus. APA members who are already a registered caucus member must still select the caucus in which they wish to vote.)

To join a caucus or update your caucus membership, please log in to your member profile. Details on the nominations and election processes will be provided to caucus members who register by May 1.

There are seven M/UR caucuses: American Indian/Alaska Native/Native Hawaiians, Asian Americans, Blacks, Hispanics, LBGTQ members, International Medical Graduates, and Women. Membership is open to all APA members who are interested in topics concerning psychiatrists or patients belonging to these seven groups.

For more information on the caucus leadership positions that will be open for election later this year, check out the Minority and Underrepresented (M/UR) Caucus Elections webpage or email caucuselections@psych.org. 

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Women Speakers Underrepresented at Medical Conferences but Numbers on Rise

The proportion of women speakers at medical conferences increased between 2007 and 2017 but continues to be well below 50%, reflecting continued underrepresentation of women in medicine generally, according to an analysis in JAMA Network Open.

“[T]he perceived gender gap in speakers at physician conferences likely represents the overall gender gap in academic medicine rather than a bias specific to conferences,” wrote Shannon M. Ruzycki, M.D., of the University of Calgary and colleagues.

Ruzycki and colleagues analyzed meeting programs and faculty lists of medical and surgical meetings in 2007 and from 2013 through 2017. Each list of names was analyzed using a validated web-based tool that can identify names in a text-based document and predict whether the first name belongs to a woman. The proportion of women speakers was compared with the average proportion of practicing physicians in the United States and in Canada.

There were 701 meeting programs available for analysis. Of those, 82 meetings (12%) had more than 50% women speakers. In addition, the average proportion of conference speakers who were women significantly increased from 2007 to 2017—24.6% to 34.1%.

The mean proportion of women physicians practicing in the United States and Canada saw a similar increase, from 26.1% in 2007 to 32.4% in 2015 (the last year for which data on the sex of practicing physicians were available, according to the study authors).

Ruzycki and colleagues noted that the presence of women role models in careers dominated by men can increase the engagement of young women.

“Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated,” they wrote. “Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine."

For related information, see the Psychiatric News article “Panel Discusses Obstacles Facing Women in Medicine.”

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Smoking Cessation Program Tailored to Patients With SMI Reduces Smoking, Improves Health

A smoking cessation intervention tailored to people with severe mental illness (SMI) such as schizophrenia can lead to reduced smoking and improved physical health in the short term, reports a study published in Lancet Psychiatry.

Compared with patients with SMI who received standard smoking cessation treatment, patients who received the tailored intervention that combined behavioral and pharmacological therapy were more than twice as likely to have successfully quit smoking at six months. These improvements, however, were maintained by only 15% of the patients at the 12-month mark.

“The results of the SCIMITAR+ [Smoking Cessation Intervention for Severe Mental Illness] trial will be helpful in informing clinical practice, since we have shown that quitting can be achieved for people who use mental health services just as it can for the general population of smokers,” wrote Simon Gilbody, D.Phil., of the University of York and colleagues. “Clinicians should therefore ask all of their patients about smoking status and offer referrals to effective smoking cessation services.”

The study included 526 adults with SMI (which included schizophrenia, schizoaffective disorder, and bipolar disorder) who smoked at least five cigarettes a day. All study participants expressed an interest in reducing or quitting smoking. The participants were randomly assigned to receive usual care (access to smoking cessation medications and a telephone helpline) or a tailored cessation intervention for 12 months. The tailored intervention included cessation medications and behavioral therapy adapted to meet the needs of people with SMI; these adaptations included providing assessments and nicotine replacement before setting a quit date, providing home visits, and providing additional face-to-face support following smoking relapse.

The tailored intervention was well received; 234 of the 265 participants (88%) assigned to the intervention attended at least one therapeutic session over 12 months, with an average attendance of 6.4 sessions. After six months, 14% of the participants in the intervention group had successfully quit (which was confirmed with a carbon monoxide breath test) compared with 6% of participants in the usual care group. At 12 months, the participants in the intervention group maintained a higher quit rate compared with usual care (15% versus 10%), though the difference was no longer statistically significant.

“This finding is in line with research in the general population that shows that long-term cessation of smoking is difficult to achieve and remains a challenge in treatment for nicotine dependence in any population,” Gilbody and colleagues wrote.

Among secondary assessments, physical health scores were higher in the intervention group compared with the usual care group after six months, though this improvement also disappeared after 12 months. There were no differences in depression or anxiety scores between the two groups at either six or 12 months, which the authors noted as supportive evidence that smoking cessation interventions are not detrimental to mental health.

For related information, see the Psychiatric News article “Schizophrenia Patients Show Cognitive Improvements After Smoking Cessation.”

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Developmentally Adapted Cognitive Processing Therapy Effective for Youth With Abuse-Related PTSD

Adolescents and young adults with a history of childhood sexual and/or physical abuse and symptoms of posttraumatic stress disorder (PTSD) benefitted considerably from developmentally adapted cognitive processing therapy (D-CPT) compared with those in a wait-list group with treatment advice, according to a study published in JAMA Psychiatry. Both study groups showed a significant reduction in PTSD symptom severity, but the outcome of posttreatment assessment was enhanced for those participants receiving D-CPT.

Although cognitive processing therapy is one of the most extensively studied treatments for adult PTSD, “CPT has rarely been tested in traumatized youth and has not been adapted to the specific needs of young people with a history of abuse,” wrote Rita Rosner, D.Phil., of the Catholic University of Eichstätt-Ingolstadt in Germany and colleagues.

For the study, the researchers randomly assigned 88 adolescents and young adults (aged 14 to 21 years) who were seeking treatment in outpatient clinics in Germany to either the D-CPT group or wait-list group with treatment advice. Those in the D-CPT treatment group completed at least 30 50-minute sessions over the course of 16 to 20 weeks. CPT therapy was adapted for adolescents and young adults with childhood abuse by beginning with a commitment phase to enhance treatment motivation and therapeutic alliance as well as a phase on emotion-management techniques. These were followed by an intense CPT phase (15 sessions in four weeks) to address fluctuating motivation in adolescents. Special consideration to developmental tasks, such as career choice and romantic relationships, was also integrated. Participants in the control group were advised to seek treatment outside the trial until after the three-month follow-up, at which time they received D-CPT.

The primary outcome of PTSD severity was assessed using the Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV (CAPS-CA) before treatment, at eight weeks, posttreatment, and at a three-month follow-up. Participants in the D-CPT group had a lower posttreatment mean CAPS-CA score than controls (24.7 versus 47.5, respectively). These treatment effects were maintained through the three-month follow up. Secondary outcomes of self-reported PTSD severity, depression, borderline symptoms, behavior problems, and dissociation also showed greater and stable improvement in D-CPT participants.

These results were comparable to effect sizes reported for CPT in adults. However, treatment effects were not noted until the mid-treatment assessment during the high-intensity CPT phase. The authors wrote, “This finding further challenges the need for a stabilization phase or emotion-regulation training before trauma-focused treatment, at least in adolescents with abuse-related PTSD.”

For related information, see the Psychiatric News article “Beyond PTSD: The Complexity of Diagnosis and Treatment for Teens in Child Welfare Custody.”

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Pregnant Women May Be Less Likely to Get Depression Treatment Than Other Women

More than half of pregnant women who are depressed may not get depression treatment, according to a study published Wednesday in Psychiatric Services in Advance.

The researchers analyzed results from the 2011-2016 National Survey on Drug Use and Health, zeroing in on the 12,360 women of reproductive age (18 to 44 years) who reported symptoms of a major depressive episode during the past year according to DSM-IV criteria. These women were asked whether there was a time during the past year when they needed mental health treatment or counseling but did not get it and, if so, why not. Researchers then compared the responses of women in the sample who were pregnant (3%) with those who were not (97%).

The researchers found that 51% of pregnant women and 43% of nonpregnant women with depression did not get treatment. Financial concerns, including the cost of the treatment, were cited by both groups of women as the primary reason for not receiving needed mental health treatment or counseling, according to study author Maria X. Sanmartin, Ph.D. (pictured above), an assistant professor at Hofstra University, and colleagues.

“It is surprising that 51% of pregnant women with major depressive episode did not receive any mental health treatment,” Sanmartin told Psychiatric News. “OB-GYNs should be asking about patients’ mental health status, raising patient awareness, and at least be offering patients the opportunity to receive mental health treatment.”

Sanmartin said pregnant women with a major depressive episode reported high prevalence of past-month substance use, including alcohol use (23%), marijuana use (17%), and misuse of prescription pain relievers (6%).

These are among the other findings reported in the study:

• About 40% of pregnant women reported having an unmet need for mental health care treatment or counseling versus 34% of the nonpregnant women.
• Financial concerns, including cost of care, were the most commonly cited reason among the women for not getting mental health care (22% of pregnant women versus 18% of nonpregnant women). Pregnant women with a depressive disorder were more likely to be low income, receive public insurance benefits, and were less likely to have a college degree.
• Prescription medication was the most prevalent form of treatment among pregnant women (40%), despite treatment guidelines recommending evidence-based psychosocial interventions and contact with psychiatrists before initiating pharmacological treatment.

“Although care and intervention before pregnancy would be ideal, greater barriers exist among pregnant women and warrant attention,” the researchers wrote. “Integrated health care delivery models between primary health care and behavioral health, mental health screening during pregnancy, and telepsychiatry services are important tools to pursue in tackling major depressive episodes among women.”

For more information, see the Psychiatric News article “APA Releases New Statement on Perinatal Disorders.”

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