Tuesday, October 26, 2021

Hospitalizations of Youth With Eating Disorders Rose During Pandemic, Report Shows

More than 18 months since COVID-19 first led to lockdowns across the United States, data are beginning to emerge that reveal the harmful effects of the pandemic on some people with eating disorders. A report appearing in the October issue of Pediatrics describes how the number of children and adolescents admitted for eating disorders at a children’s hospital in Michigan rose steadily during the first 12 months of the pandemic.

“An increase in severely ill adolescents with [eating disorders] during COVID-19 is likely to present challenges for patients, their families, and their providers because demand for treatment (access to which is already limited by pandemic precautions, as well as a lack of providers predating the pandemic) is likely to increase, perhaps dramatically,” wrote Alana K. Otto, M.D., M.P.H., of the University of Michigan and colleagues.

Otto and colleagues performed a chart review of youth aged 10 to 23 years admitted to C.S. Mott Children’s Hospital in Ann Arbor, Mich., between March 1, 2017, and March 31, 2021, for medical complications of restrictive eating disorders, including anorexia nervosa, atypical anorexia nervosa, and avoidant or restrictive food intake disorder.

The researchers compared data on youth admitted to the hospital from March 2017 through March 2020 (before the COVID-19 pandemic) with data on youth admitted to the hospital from April 2020 through March 2021 (during the COVID-19 pandemic).

There were 297 admissions of youth for medical complications related to eating disorders among 248 patients during the study period. The researchers found that while the number of admissions decreased in April 2020, the number of admissions per month increased significantly over time. The total number of admissions during the first 12 months of the COVID-19 pandemic (April 1, 2020, through March 31, 2021) was more than double the mean number of admissions per year for the same time frame (April 1 through March 31) for the previous three years, the authors noted. The highest counts were observed near the end of the study period, nine to 12 months after the pandemic began.

“[A]lthough anecdotal, our recent clinical experience suggests adolescents with new [eating disorders] frequently report their [eating disorder] behaviors began when pandemic precautions were implemented because, for example, they found themselves with nothing else to do or with more time to engage in diet and/or exercise behaviors they had previously considered but not acted on,” they wrote. Also, because of the interruption of social relationships, the youth may have turned to social media, which has been suggested to contribute to the development of eating disorders, according to the authors.

“Although our findings reflect the experience of a single institution, they are in keeping with emerging reports suggesting a developing epidemic within the pandemic, one with the potential to have profound negative effects on the mental and physical health of adolescents around the globe,” they continued. “It is unclear how long these effects may last.”

For related information, see the Psychiatric News article “Eating Disorders: Current Knowledge and Treatment Update.”

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Register Now: First Town Hall on Social Determinants of Mental Health to Be Held November 3

Join APA leaders for two town halls featuring presentations on the importance of the social determinants of mental health (SDoMH) in psychiatry, the efforts of the APA Presidential Task Force on SDoMH, and the opportunity to engage with task force members. The first town hall, scheduled for Wednesday, November 3, will explore SDoMH in the context of clinical practice, research, and education.

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Monday, October 25, 2021

Stimulants May Pose Short-Term Cardiovascular Risks in Older Adults

Older adults prescribed stimulant medications appear to be at an elevated risk of cardiovascular problems in the first 30 days after beginning the treatment, according to a study published today in JAMA Network Open. However, these risks decrease over time, with no evidence of increased cardiovascular risk at six months and one year after initiating treatment.

“Although stimulants are most commonly used among children and youth for the treatment of attention-deficit/hyperactivity disorder (ADHD), an increase in stimulant use among older adults in recent years has been observed,” wrote Mina Tadrous, PharmD., Ph.D., of the University of Toronto and colleagues. Doctors may prescribe stimulants off label to older adults for the treatment of depression, poststroke recovery, motor function, and fatigue, they noted. There is evidence that stimulants can increase resting heart rate and systolic blood pressure, but few studies have examined the cardiovascular impact of stimulants in older adults.

Tadrous and colleagues used hospital and prescription databases to assess the cardiovascular outcomes of 6,457 Ontario residents aged 66 years and older who received a new prescription for a stimulant (for example, amphetamine, methylphenidate, lisdexamfetamine, or dextroamphetamine) between January 1, 2002, and March 31, 2015. These adults were matched with a control group of 24,853 similarly aged adults who did not take any stimulants during this time. Adults in both groups were followed for up to 365 days or until they experienced a cardiovascular event (myocardial infarction, stroke, transient ischemic attack, or ventricular arrhythmia), died, or stopped taking stimulants.

Compared with the control group, older adults who took stimulants had a 40% increased risk of any cardiovascular event 30 days after starting their prescription. Among individual outcomes, stimulant use was not associated with any heart attack risk but was associated with a 60% increased risk of stroke/transient ischemic attack and a 300% increased risk of ventricular arrhythmia. Adults who took stimulants did not experience any increased cardiovascular risk compared with controls at 180 or 365 days after starting medication, except for continued arrhythmia risk at 180 days.

“These findings suggest that safety considerations should be included when stimulants are prescribed to older adults,” the authors concluded.

To read more on this topic, see the Psychiatric News article “To Improve Safety in Older Patients, Consider Deprescribing.”

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Register Now: First Town Hall on Social Determinants of Mental Health to Be Held November 3

Join APA leaders for two town halls featuring presentations on the importance of the social determinants of mental health (SDoMH) in psychiatry, the efforts of the APA Presidential Task Force on SDoMH, and the opportunity to engage with task force members. The first town hall, scheduled for Wednesday, November 3, will explore SDoMH in the context of clinical practice, research, and education.

REGISTER

Friday, October 22, 2021

TMS May Help Reduce Symptoms of Depression, PTSD in Veterans

Transcranial magnetic stimulation (TMS), a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain, may help relieve symptoms of depression and posttraumatic stress disorder (PTSD) in veterans, a study in the Journal of Affective Disorders has found.

Michelle R. Madore, Ph.D., of VA Palo Alto Healthcare System and colleagues analyzed data from 770 patients who had major depressive disorder and received at least one TMS session at any of 27 Veterans Administration sites from October 2017 to March 2020. Of these patients, 68.4% also met the criteria for a diagnosis of PTSD. The researchers defined an adequate dose of TMS as 30 sessions over the course of six to eight weeks. Among all patients, 340 received an adequate dose of TMS.

The researchers used the nine-item Patient Health Questionnaire (PHQ-9) and the PTSD symptom checklist from DSM-5 (PCL-5) to assess the patients’ mental health before and after the study period.

Among the 340 patients who received all 30 TMS sessions, scores on the PHQ-9 dropped from a mean of 18.34 before treatment to a mean of 11.29 after treatment, suggesting an improvement in their major depressive disorder. In this group, 245 had also met the criteria for PTSD at baseline with a mean PCL-5 score of 52.67, indicating moderate PTSD severity. After TMS, the mean PCL-5 score in this subset was 33.74. Furthermore, 113 (46.1%) of these patients no longer met PTSD criteria.

“These data demonstrate the importance of delivering an entire TMS treatment series,” Madore and colleagues wrote. “Future studies will need to evaluate the relationship between the number of sessions required for optimal outcomes; however, since remission is the goal of antidepressant treatment, patients can be empirically recommended to receive six weeks of TMS.”

For related information, see the American Journal of Psychiatry article “Whither TMS: A One-Trick Pony or the Beginning of a Neuroscientific Revolution?

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Thursday, October 21, 2021

Inflammation May Be Linked to Specific Depression Symptoms, Study Suggests

Systemic inflammation appears to be associated with some but not all symptoms of depression, according to a report in AJP in Advance.

The pooled cohort study by Philipp Frank, M.Sc., of University College London and colleagues found that in individuals with depression, inflammation was associated with such physical symptoms as changes in appetite, loss of energy and motivation, and sleep problems. “In contrast, we found strong evidence against an association with a number of exclusively emotional symptoms, including fearfulness, feeling bothered by things, hopelessness about the future, and feeling life had been a failure,” the researchers wrote.

The findings point to the importance of “a more targeted, symptom-focused approach to exploring the link between systemic inflammation and depression, particularly in anti-inflammatory drug trials,” they added.

The report was based on data from 15 independent population-based cohort studies from multiple countries that examined the relationship between inflammation and depressive symptoms in adults. The analysis included more than 56,000 people 18 years and older who had blood samples collected at the start of their respective studies and answered questions about 24 individual depressive symptoms across five domains: physical, emotional, cognitive, perception of self, and self-harm. The concentration of C-reactive protein (CRP) in the blood samples was assessed in all 15 studies, and three studies also measured interleukin-6 (IL-6).

The pooled analysis revealed that the prevalence of depressive symptoms in the sample ranged from 1.1% (suicidal ideation) to 21.5% (sleep problems). Higher concentrations of CRP were associated with an increased risk of experiencing four physical symptoms (changes in appetite, felt everything was an effort, loss of energy, and sleep problems) and one cognitive symptom (little interest in doing things), Frank and colleagues reported. The association between CRP and these physical and cognitive symptoms remained after controlling for a variety of factors that also contribute to inflammation, including age, chronic illness, and adverse child events. Higher levels of IL-6 were also associated with an increased risk of experiencing these physical and cognitive symptoms.

“Our results lend support to the sickness behavior theory, which posits that peripherally localized inflammatory activity can initiate a cascade of initially adaptive depressive-like symptoms in a subset of people,” Franks and colleagues wrote. “These include a lack of energy (lethargy), changes in appetite, sleepiness, reduced social exploration, and, at times, confusion.”

For related information, see the American Journal of Psychiatry editorial “Using the Power of a Giant Wisely: Confirming Inflammation in Depression.”

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Wednesday, October 20, 2021

Children’s Medical Groups Declare National Emergency on Child and Adolescent Mental Health

Three children’s advocacy organizations, including the American Academy of Child and Adolescent Psychiatry (AACAP), on Tuesday declared a national state of emergency in child and adolescent mental health requiring urgent government action.

AACAP, along with the American Academy of Pediatrics and the Children’s Hospital Association, said that social isolation and other effects of the COVID-19 pandemic—including uncertainty, fear, and grief—have exacerbated longstanding problems affecting youth’s mental health. A report in Pediatrics this month showed that more than 140,000 U.S. children have experienced the death of a primary or secondary caregiver during the COVID-19 pandemic, with children of color disproportionately impacted.

“We were concerned about children’s emotional and behavioral health even before the pandemic. The ongoing public health emergency has made a bad situation worse,” said AACAP President Gabrielle A. Carlson, M.D., in a news release. “We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and suicidality that will have lasting impacts on them, their families, their communities, and all of our futures. We cannot sit idly by. This is a national emergency, and the time for swift and deliberate action is now.”

According to a report by the Centers for Disease Control and Prevention (CDC), emergency department visits for mental health emergencies rose by 24% for children aged 5 to 11 years and 31% for youth aged 12 to 17 years between March and October 2020. More recently, the CDC reported that emergency department visits for suspected suicide attempts increased nearly 51% among girls aged 12 to 17 years in early 2021 compared with the same period in 2019.

Among other actions, the organizations are urging policymakers to take the following steps to support youth and their families:

  • Make funding available so all families can access mental health services.
  • Increase access to telehealth.
  • Support effective models of school-based mental health care.
  • Accelerate integration of mental health care in primary care pediatrics.
  • Address ongoing challenges of the acute care needs of children and adolescents.
  • Promote and pay for trauma-informed care services.

The organizations stated in the declaration: “We must identify strategies to meet these challenges through innovation and action using state, local, and national approaches to improve the access to and quality of care across the continuum of mental health promotion, prevention, and treatment.”

For related information, see the Psychiatric News article “Long-Term Impact on Children, Adolescents Constitutes Public Health Emergency.”

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Tuesday, October 19, 2021

Survey Highlights Strengths and Challenges of Telehealth for Addiction

Telehealth may help to engage more patients in addiction treatment by improving access and convenience, but there is limited evidence that patients with substance use disorder benefit more from services delivered via telehealth than in-person care, concluded a report in Psychiatric Services in Advance.

“The COVID-19 public health crisis forced the addiction treatment system to pivot from delivering most addiction treatment in person to delivering treatment via telehealth,” wrote Tami L. Mark, Ph.D., M.B.A. of RTI International in Rockville, Md., and colleagues. They noted that federal and state agencies temporarily eased many telehealth restrictions to enable this transition. “Of special relevance to addiction treatment are requirements for in-person visits to prescribe buprenorphine and for in-person intake and physical exam to initiate methadone treatment. Policymakers and payers are now considering which of these flexibilities should be maintained.”

Mark and colleagues first conducted a literature review comparing the effectiveness of in-person addiction treatment with telehealth (telephone or videoconferencing for assessment, diagnosis, and/or treatment). Of the eight studies identified, seven found no significant differences between these two modalities for outcomes such as treatment retention, treatment satisfaction, substance use rates, or the strength of the therapeutic alliance. However, one observational study reported that telehealth facilitated methadone prescribing and improved treatment retention among patients with opioid use disorder.

The researchers next conducted an online survey of leaders at addiction treatment organizations throughout California and received 100 responses. The results indicated that addiction professionals were evenly split with regard to the effectiveness of telehealth versus in-person individual counseling; 46% said that telehealth was equal to or more effective than in-person care, and 45% said that telehealth was less effective than in-person care. However, there was less support for telehealth in group counseling; 62% said it was less effective than in-person group therapy while only 25% said telehealth group therapy was equal to or more effective than in-person care. More than half of the respondents said that they believed telehealth was less effective than in-person care for providing intensive outpatient treatment or medication management.

“Telehealth may allow patients to more easily begin and stay in addiction treatment, which has been a longstanding challenge,” said Mark in a news release. “However, research is needed to confirm this benefit. As providers pivot to hybrid telehealth models—offering both telehealth and in-person treatment—they need information to help target telehealth to the most appropriate services and patients.”

To read more on this topic, see the Psychiatric News article “Telehealth Options for Treating Patients With SUD Expand.”

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Monday, October 18, 2021

Plenary Speakers at APA’s Fall Conference Focus on Social Determinants of Mental Health

APA’s two-day virtual Mental Health Services Conference was held Thursday and Friday, October 14 and 15. Summaries of the plenary addresses appear below. 

SAMHSA Partners With States to Target Social Determinants of Mental Health

In collaboration with states and communities, the federal government is committed to addressing social determinants of health (SDOH) and mental health, said Miriam E. Delphin-Rittmon, Ph.D., assistant secretary for mental health and substance use and administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA). She made her remarks last Thursday at the opening plenary session of APA’s virtual 2021 Mental Health Services Conference.

“We know that having access to high-quality mental health care isn’t enough if people lack access to education, housing, and transportation,” she said. 
Delphin-Rittmon outlined SAMHSA’s initiatives and priorities specifically targeting SDOH. Among these is the Resiliency in Communities After Stress and Trauma, which assists high-risk youth and families in communities impacted by civil unrest. This program offers violence prevention and community youth engagement programs, as well as linkages to trauma-informed behavioral health services. She also described the Food and Mood Project, which aims to promote emotional wellness and reduce the impact of mental health and substance use issues in the Midwest and mountain states through strategies—such as school gardens—that address the link between behavioral health and food or food insecurity, and/or cultural food diversity. 

Delphin-Rittmon was joined by Sonja Gaines, M.B.A., deputy executive commissioner for Intellectual and Developmental Disability and Behavioral Health Services at the Texas Health and Human Services Commission, and Keri L. Waterland, Ph.D., director of the Division of Behavioral Health and Recovery at Washington State Health Care Authority. Gaines and Waterland shared examples of several innovative projects in their states that are aimed at addressing social determinants of mental health. These efforts are funded by SAMHSA. 

Delphin-Rittmon said, “We are here to be partners with APA and look forward to our ongoing collaboration addressing social determinants of health.”

Economist Encourages Framing of Mental Health as a Form of Capital

Taking an economics framework and applying it to the delivery of mental health can help psychiatrists better connect with decision-makers to help drive key policies, an economics scholar said during last Friday’s plenary session.

“It’s important to conceptualize mental health as a form of capital because without it, people cannot do the work they need to do; they cannot be productive,” explained Peter Q. Blair, Ph.D., M.Sc., an assistant professor at the Harvard Graduate School of Education and principal investigator of the Blair Economics Lab. “We want to think specifically and concretely about how to help and best serve those who are marginalized and experiencing severe symptoms. But we also want to think preemptively about mental health as a form of capital—that we need to invest in proactively or it will depreciate over time.” 

Blair said that mental health is not merely the absence of psychiatric symptoms, it also includes the ability to realize one’s capacity for agency and contribute to the larger society with dignity, Blair said. He discussed the role of educational opportunity, occupational skill attainment, and meaningful employment as instrumental components to mental health. Blair pointed out that even among those with the most serious mental illness, most want to work.

Blair also talked about the importance of psychiatrists investing in their mental health in the same way they invest in their physical health (through regular checkups and exercise) and education (through continuing coursework). 

Session moderator and psychiatrist Sarah Y. Vinson, M.D., founder of the Lorio Psych Group, said that shifting one of the profession’s focuses to prevention would require reimagining. “In medicine as a whole, and in psychiatry too, there’s more of a focus on pathology, on diagnoses, on illness.  People don’t [seek mental health services] until there’s a problem. ... Part of our challenge is we’re dealing with a system where we don’t have the resources to do the task we have.”

Blair pointed out that that mental illness can disproportionately affect marginalized populations. He delved into the social determinants of health and how racism has held back minority populations. He is working to channel the public outrage over the murder of George Floyd by police officers last May into action. For example, he is urging Fortune 500 companies to recognize the systemic racism inherent in today’s national employment market. One major barrier to economic mobility for Black people is the requirement for a college degree as a condition of employment, and so Blair is promoting the hiring of rising STARS, or individuals who have acquired Skills Through Alternative Routes.

Further coverage of the conference will appear in a future issue of Psychiatric News.
 

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