Long-Term Use of Antidepressants Doesn’t Increase Dementia Risk, Study Finds

While the long-term use of most antidepressants does not appear to increase the risk of dementia, long-term use of the selective serotonin reuptake inhibitor (SSRI) paroxetine may, suggests a study in the Journal of the American Geriatrics Society.

Laura Heath, Ph.D., of the University of Washington and colleagues examined the health data of 3,059 older adults who were part of Kaiser Permanente Washington’s Adult Changes in Thought (ACT) study, a longitudinal study tracking brain changes prior to the onset of dementia.

The investigators used this longitudinal data to compare dementia rates in patients with cumulative antidepressant use, which was divided into four categories of medication exposure over the previous decade: none, low (1 to 90 days), medium (90 days to one year), high (1 to 3 years), and very high (3+ years). Antidepressants were also grouped into five categories: paroxetine, other SSRIs, serotonin antagonist and reuptake inhibitors (SARIs), tricyclic antidepressants, and all other antidepressants.

Heath and colleagues identified no association between antidepressant use and dementia risk for most groups of antidepressants, regardless of how much medication people took. In contrast, some patients with a history of paroxetine use (high and low use groups) were found to be at a statistically significant increased risk of dementia compared with those with no antidepressant use; patients in the medium and very high categories also showed higher risk, but it was not significant. The authors suggested these findings point to paroxetine posing a dementia risk that is not based on cumulative exposure to the medication.

The authors also found that patients with a low exposure to SARIs such as trazodone had a slightly lower risk of dementia. Some preclinical evidence has hinted that trazodone might have neuroprotective properties, but this connection needs further investigation, the authors said.

“Given the primary results and the sensitivity analyses that showed higher risk of dementia … in [paroxetine] users with depression than in nonusers with depression, who may already be at higher risk of dementia because of depression, our findings suggest that some caution may be warranted in prescribing paroxetine for depression in older adults,” the authors concluded.

For related information, see the Psychiatric News article “Long-Term SSRI Use May Slow Progression to Alzheimer’s Dementia.”

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APA Awarded CMS Funding to Develop Quality Measures

APA has received an award from the Centers for Medicare and Medicaid Services (CMS) to help develop mental health and substance use quality measures for CMS’s Quality Payment Program (QPP).

The QPP is the updated reimbursement system for CMS that was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA authorized CMS to provide incentives that encourage physicians to focus on quality, value of care, and patient health.

APA is working with the National Committee for Quality Assurance (NCQA), a nonprofit organization that is experienced at developing quality measures. APA will use the funding to develop and improve quality measures for mental health and substance use disorders, including patient-reported outcomes, patient experience, care coordination, and measures of appropriate use of services. Another goal is to minimize the burden of measurement by eliminating redundancies and low-value quality measures from the QPP. APA will use its PsychPRO registry to test these quality measures. PsychPRO is a CMS Qualified Clinical Data Registry.

“APA is proud to take a leading role in shaping quality measures for our field,” said APA CEO and Medical Director, Saul Levin, M.D., M.P.A. “This grant will help us ensure that patients are receiving the highest standards of psychiatric care and that providers can easily report and be reimbursed for providing high quality services.”

APA is one of seven organizations chosen to receive this three-year award.

(Psychiatrists can learn more about PsychPRO here. The deadline to join the registry to meet the 2018 reporting requirements is October 1.)

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Arthritis Found Highly Prevalent in Older Individuals With Depression

More than half of individuals over age 50 who have depression and more than two-thirds of those with severe depression also have arthritis, according to a report in the International Journal of Geriatric Psychiatry.

“[I]t may be critical for mental health care providers to provide regular arthritis‐related pain assessments and evidence‐based treatments for co‐occurring arthritis in older adults with or at risk for depression,” wrote lead author Jessica Brooks, M.D., a professor of psychiatry at the Geisel School of Medicine and Centers for Health and Aging at Dartmouth College, and colleagues.

The researchers analyzed data from 4,792 men and women over age 50 (average age, 64.5 years) who participated in the National Health and Nutrition Examination Survey. As part of this survey, participants were asked whether they had ever been told by a doctor they had arthritis, and depression symptoms were assessed using the Patient Health Questionnaire.

A total of 2,094 participants (43.7%) reported doctor‐diagnosed arthritis. The prevalence of arthritis increased with the severity of depression: 55.0%, 62.9%, and 67.8% in participants with minor, moderate, and severe depression, respectively. The rate of arthritis was lowest in participants with no depression (38.2%).

The researchers noted that arthritis and disability are known risk factors for depression in older adults. The association between depression and arthritis may be linked to reduced physical activity, as well as to common biological mechanisms that result in inflammation.

“To provide streamlined care and cost‐effective care, future research in geriatric psychiatry is needed to develop and test pilot integrated biopsychosocial strategies and interventions targeting both arthritis and depressive symptoms for delivery by mental health professionals in primary care and specialty care services,” the authors concluded.

For related information, see the chapter on pain in The American Psychiatric Association Publishing Textbook Of Psychosomatic Medicine And Consultation-Liaison Psychiatry, Third Edition and the Psychiatric Services article “Peer-Led Self-Management of General Medical Conditions for Patients With Serious Mental Illnesses: A Randomized Trial.”

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Anxiety Linked to Cognitive Decline in Older Adults, Study Shows

Symptoms of anxiety in women appear to be associated with a decline over time in executive function—the ability to plan ahead and organize one’s thoughts, according to a report in The American Journal of Geriatric Psychiatry.

Among both men and women 65 years and older, anxiety appears to predict a decline in verbal memory, which refers to the ability to remember words.

“Adequate treatment of anxiety symptoms could potentially beneficially influence the risk for developing neurodegenerative disease,” wrote Sebastian Köhler, Ph.D., an associate professor of psychiatry at Maastricht University, and colleagues.

Köhler and colleagues analyzed data on 918 participants who were 50 years of age or older in the Maastricht Aging Study, a longitudinal population-based study of factors associated with cognitive aging in the Netherlands.

The researchers measured the anxiety symptoms of the participants at baseline, using the anxiety subscale of the Symptom Check List-90 (SCL-90). The researchers recorded anxiety scores along a continuous scale of severity; they classified patients in the highest quartile as having “high anxiety.” The participants also underwent neuropsychological testing, which measured executive function, memory, speed of information processing, and verbal fluency. During a 12-year follow-up, the cohort was tested every three years.

Overall, being in the highest quartile on anxiety symptoms (“high anxiety”) did not predict a faster decline in executive functioning over time. However, among women, increasing severity of anxiety was associated with a worse cognitive trajectory. A similar sex-specific effect was found for processing speed and verbal fluency.

In contrast, faster decline in verbal memory was associated with “high anxiety” irrespective of sex but was more pronounced in those 65 years and older.

“Further longitudinal research is needed to fully understand the relationship between anxiety and cognition including potentially mediating mechanisms,” the researchers wrote.

For more information, see the Psychiatric News article “Worsening Anxiety in Older Adults May Precede Alzheimer's.”

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Burnout Found to Be Common Among U.S. Resident Physicians

Symptoms of burnout and regret over career choice are common among second-year resident physicians (PGY-2) in the United States, but these symptoms vary according to specialty, reports a study published today in JAMA. Overall, 45% of PGY-2 residents reported symptoms of burnout and 14% reported career choice regret.

“The findings suggest the prevalence of burnout symptoms among resident physicians may be similar to that of practicing physicians (48.8%) and higher than other U.S. workers (28.4% as assessed in 2014 using the same single-item measures adapted from the MBI [Maslach Burnout Inventory]),” wrote Liselotte N. Dyrbye, M.D., M.H.P.E., of the Mayo Clinic and colleagues.

The residents had previously completed questionnaires at the start of medical school and again four years later. In addition to collecting general demographic information, the questionnaire administered during the fourth year of medical school asked participants about anxiety, empathy during clinical encounters, and social support during medical school. The PGY-2 questionnaire asked participants about the frequency of experiencing burnout-related feelings or emotions (“I feel burned out from my work” and “I’ve become more callous toward people since I started this job”) and career choice regret.

Of the 3,574 residents included in the analysis, 1,615 (45.2%) reported at least one symptom of burnout at least weekly. In terms of career and specialty choice regret, 14.1% of the residents reported they would “definitely not” or “probably not” choose to become a physician again, and 7.1% indicated they would “definitely not” or “probably not” choose the same specialty if given the chance to revisit their career and specialty choice.

“Training in the fields of urology, neurology, emergency medicine, or general surgery (relative to internal medicine) and being female were independently associated with a higher RR [relative risk] for reported symptoms of burnout,” Dyrbye and colleagues wrote. “Higher anxiety and lower empathy during year 4 of medical school also were associated with higher RRs for reported symptoms of burnout during residency.”

In a separate article in JAMA, Lisa S. Rotenstein, M.D., M.B.A., of Harvard Medical School and colleagues describe the results of systematic review of studies on the prevalence of burnout in practicing physicians (physicians in training were not included) published before June 1, 2018. Burnout prevalence data, extracted from 182 studies involving 109,628 physicians in 45 countries, were included in the analysis.

The review revealed “remarkable variability in published prevalence estimates of burnout, with estimates of overall burnout ranging from 0% to 80.5%. This wide range reflected the marked heterogeneity in the criteria used to define and measure burnout in the literature, with at least 142 unique definitions for meeting overall burnout or burnout subscale criteria identified,” the authors wrote.

The findings “highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools to assess the effects of chronic occupational stress on physicians,” Rotenstein and colleagues concluded.

To learn more about individual and organizational interventions for burnout, check out APA’s Wellness Toolkit.

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Mental Health Needs of Blacks Are Not Being Met, Says APA President

There is a mental health crisis in the black community, which calls for improved cultural competency training for all psychiatrists as well as more openness among blacks to talk about these issues, said APA President Altha Stewart, M.D. She spoke on Thursday at a session on mental health at the 48th legislative conference of the Congressional Black Caucus Foundation (CBCF), an organization aimed at advancing the global black community by developing leaders, informing policy, and educating the public.

Cultural competency training is aimed at helping health care providers understand patients’ values, beliefs, and behaviors so they can customize treatment to meet patients’ social, cultural, and linguistic needs. For black Americans, this means becoming more aware of the impact of community stressors and how these factors are contributing to their mental health problems, said panelists at the first-ever CBCF panel devoted to mental health in the black community. These factors include violence and trauma, racism, implicit bias, poverty, and limited access to educational, recreational, and employment opportunities, said Stewart, who is also the director of the Center for Health in Justice Involved Youth at the University of Tennessee Health Science Center. “Just being a black person in America can keep you in a constant state of rage,” she said, quoting James Baldwin.

There are only about 2,000 black psychiatrists nationwide, Stewart pointed out. “There are not enough black psychiatrists in America to serve all the black people who need mental health care.” She called for all psychiatrists to become more culturally competent, and for all to encourage young blacks with an interest in STEM (Science, Technology, Engineering, and Mathematics) to enter the mental health field. “Medicine needs their voice. We need their presence.”

Patricia Newton, M.D., M.P.H., CEO and medical director of the Black Psychiatrists of America, told attendees that less than half of blacks with mental disorders get the care they need; that number drops to one-quarter when blacks of Caribbean descent are taken into account.

Blacks are also more likely to be subjected to implicit—or unconscious—bias by clinicians, Newton added. “Very often, our people are misdiagnosed.” For example, blacks with depression are often misdiagnosed with schizophrenia and blacks grieving the loss of a loved one, who say they’ve experienced a “visitation,” have been diagnosed as psychotic, due to cultural and religious misunderstandings, she said. Making matters worse, blacks are more likely to be hospitalized for psychosis than to receive community treatment, she said.

Mental illness, suicide, and sexual abuse are seriously underreported among blacks, Stewart said, because these topics are taboo in churches, throughout the community, and even within families. “You can’t get an accurate reporting of what you’re not talking about.”

She encouraged black people to educate themselves about mental illness using reputable sources, openly discuss issues of mental health, and identify people in the community who need help. “We have to dispel the myth that mental illness doesn’t happen to us in the black community, that it’s a ‘white folks’ disease.’ We are suffering in silence and in pain.”

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APA Joins Health Organizations in Lawsuit Against Expansion of Short-Term Health Plans

Joining a coalition of seven mental health and health advocacy groups, APA filed suit today in federal court to invalidate a Trump administration rule on short-term, limited duration health plans.

The coalition argued in its complaint that the final rule, issued last month by three federal agencies, violates the plain-English meaning of “short-term” by allowing the sale of the plans for up to 364 days at a time (up from three months) and “limited duration” by allowing renewals for up to three years (up from 12 months). The plans are sold in the individual market to those without employment-based or government-sponsored insurance.

The coalition also argued that the rule is unlawful because it arbitrarily creates an unauthorized “alternative” to Affordable Care Act (ACA)-compliant plans and violates the ACA by undercutting compliant plans and making them increasingly unaffordable. APA was joined in the lawsuit by the National Alliance on Mental Illness, Mental Health America, National Partnership for Women & Families, Association for Community Affiliated Plans, AIDS United, and Little Lobbyists, according to a news release. 

Short-term health plans may be less expensive than comprehensive plans, but they are not required to cover “essential health benefits,” such as mental health and substance use disorder services, prescription drugs, hospitalization, emergency services, or maternity care. Similarly, short-term plans are not subject to important consumer safeguards or antidiscrimination rules and can deny coverage for any preexisiting condition; set higher premiums based on age, gender, or health status; retroactively cancel coverage; and deny renewals. Short-term plans may also increase uncompensated care for health care providers, the coalition wrote.

“This rule jeopardizes the insurance coverage of many Americans with complex medical needs that require strong, predictable insurance protection and care,” APA President Altha Stewart, M.D., said in a statement. “Without this coverage, patients with complex medical needs will suffer and often end up in emergency rooms, raising health care costs. We call upon the Administration to drop this rule and enforce the protections of the Affordable Care Act.”

For more information, see the Psychiatric News article “Trump Expands Low-Cost, Short-Term Health Plans.”

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