Wednesday, March 3, 2021

Rewards for Behavioral Change May Be Effective for Alcohol Use Disorder in Native Populations

Contingency management, in which patients are rewarded for behavioral change, may be an effective strategy for increasing alcohol abstinence in American Indian and Alaska Native adults, a study in JAMA Psychiatry has found.

Michael G. McDonnell, Ph.D., of the Elson S. Floyd College of Medicine at Washington State University, Spokane, and colleagues analyzed data from 158 American Indian and Alaska Native adults who had at least one or more days of high alcohol use (more than three drinks) within the last 30 days and a current diagnosis of alcohol dependence. All patients in the study submitted urine samples twice per week for 12 weeks after a four-week observation period and completed follow-up interviews at one, two, and three months afterward. All patients received treatment as usual, which included culturally adapted individual and group addiction counseling on an outpatient basis, or referral for intensive outpatient addiction treatment that was not culturally adapted. Cultural adaptations included receiving care from tribal members and receiving materials in the patients’ native languages.

Patients were divided into two groups: the contingency management group and the control group. Those in the contingency management group received incentives through prize drawings when their urine samples indicated alcohol abstinence. Those in the control group drew for prizes each time they submitted a urine sample regardless of whether the sample indicated abstinence from alcohol. Prizes included positive affirmations; $1, $20, and $80 cash rewards; gift cards; and more.

At 16 weeks, 59.4% of patients in the contingency management group submitted an alcohol-negative urine sample, compared with 38.3% in the control group. Those in the contingency management group had a 1.70-fold higher likelihood of submitting alcohol-abstinent urine samples than those in the control group.

“Our findings demonstrate that contingency management is a low-cost, feasible, and culturally adaptable incentive program that leads to modest improvements in alcohol abstinence during a 12-week intervention period,” McDonnell and colleagues wrote. “Policymakers and health care professionals may consider investing in contingency management as a strategy for improving the treatment of alcohol use disorder among American Indian and Alaska Native adults.”

For related information, see the American Journal of Psychiatry article “A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness.”

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Tuesday, March 2, 2021

Study Highlights Rising Number of Older U.S. Men Dying by Suicide

Suicide rates among men aged 65 years and older in the United States have been steadily rising since 2007, according to a study in the American Journal of Preventive Medicine. The report revealed that men who are White, aged 85 years or older, and living in rural areas may be at greatest risk.

Sanae El Ibrahimi, Ph.D., of the University of Nevada and colleagues analyzed suicide data from 1999 to 2018 reported to the Centers for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database. The authors analyzed the data according to age group (65 to 74, 75 to 84, and ≥85 years), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic American Indian/Alaska Native, and Asian/Pacific Islander), methods of suicide, and the urbanization level (from rural to large metropolitan) of the county where decedents resided.

From 1999 to 2018, 106,861 men aged ≥65 years died of suicide in the United States—an age-adjusted rate of 31.4 per 100,000 people. While the data revealed that suicide rates fell annually by about 1.8% from 1999 to 2007, the rates rose steadily by 1.7% a year for the next decade.

“There are many potential contributors to the … shift [in suicide rates] around 2007, one of which could [have been] the start of the economic recession (i.e., the Great Recession) in the United States,” El Ibrahimi and colleagues wrote. “On the basis of their limited earning potential and high rates of unemployment, older adults may be left with fewer alternatives to supplement income, remain in their homes, be more socially isolated, and avoid associated hardships.”

Additional analysis revealed that the rate of suicide among men older than 85 years (48.8 per 100,000 people) was almost double the rate among those aged 65 to 74 years (24.7 per 100,000 people). Within the racial/ethnic groups, the lowest suicide rates were observed among men who were Black, with low variation across the urbanization levels (between 9 and 11 per 100,000 people), whereas the highest rate was observed among men who were White residing in the most rural communities (41.4 per 100,000 people).

The distribution of suicide by urbanization level and methods of suicide showed a higher rate of suicide by firearms in more rural than in more urban areas (34.8 per 100,000 in the most rural counties versus 19.2 per 100,000 in large central metropolitan counties).

“As the number of older people increases in the United States, the number of suicides by older people is also expected to increase,” El Ibrahimi and colleagues wrote. “Specific interventions are needed to change the existing trends in suicide prevalence among [older] male adults.”

For related information, see the Psychiatric News article “Psychoanalyst Examines How Culture Influences Suicide.”

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Monday, March 1, 2021

Diversifying Academic Psychiatry Workforce Requires More Than Talk, Psychiatrists Say

Increasing diversity, equity, and inclusion (DEI) in academic psychiatry requires that DEI leaders be given a voice in the highest levels of decision making and backed with resources necessary to institute an effective response for cultural change. So wrote a group of leaders from public and private psychiatry departments across the country in an article in the March issue of the American Journal of Psychiatry.

“DEI leaders are being summoned for one-on-one and programmatic consultation, antiracist curriculum development, antibias training, and skill acquisition,” wrote Ayana Jordan, M.D., Ph.D. (pictured above), of Yale University and colleagues. “However, many of these institutions do not provide the appropriate resources or support necessary to institute an effective response for cultural change. This lack of scaffolding leads to an exacerbation of the ‘minority tax,’ thereby placing more duress on the very same people adversely affected by structural racism.” (The “minority tax” is defined as the extra, financially uncompensated duties and responsibilities that are often placed on minority academics in the name of diversity.)

Implementing strategic decisions related to antiracism and diversity is key to excellence in research, clinical care, and education, Jordan and colleagues continued. Drawing on their own extensive experiences advocating at seven psychiatric departments in the country, the authors provided several recommendations for how departments can effectively support DEI leadership:

  • Make clear the roles and responsibilities of the DEI position when the position is first presented to potential candidates, with responsibilities commensurate with financial effort provided.
  • Elevate DEI leaders to the status of a vice or associate chair in the department to signify the importance of the role. Include this leader in all departmental leadership meetings.
  • As with all leadership positions, set a term limit for the position; the recommended option is a 10-year maximum term with an evaluation after five years.
  • Ensure additional salary support, discretionary funds, and staff to carry out planned DEI efforts.

“The recruitment and retention of Black, Indigenous, and people of color (BIPOC) faculty in academic medicine remains a challenge,” wrote former APA President Altha Stewart, M.D., in an accompanying editorial describing the historical context of the lack of diversity in today’s workforce. “[L]eaders in key positions must recognize some of the unintentional but well-institutionalized barriers in their systems and implement strategies that create more balanced, equitable, and welcoming environments for these individuals.”

To learn more, listen to AJP Executive Editor Michael Roy’s interview with Jordan and co-author Christina Mangurian, M.D., M.A.S., of the University of California, San Francisco.




Don’t Miss Out on Lowest Fees for APA’s Annual Meeting

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Friday, February 26, 2021

New Drug Combination Shows Promise for Schizophrenia in Phase 2 Trials

A new drug combination appears to significantly reduce symptoms of schizophrenia compared with placebo, according to the results of a phase 2 trial published this week in the New England Journal of Medicine.

The drugs are xanomeline, which has shown promise for Alzheimer’s disease, and trospium chloride, which is approved for overactive bladder and has been shown to reduce some of the gastrointestinal side effects of xanomeline.

Steven K. Brennan, M.D., chief medical officer of Karuna Pharmaceuticals, and colleagues randomly assigned 90 adults aged 18 to 60 with schizophrenia to receive twice-daily xanomeline-trospium and 92 patients to receive placebo for five weeks. For inclusion in the trial, patients were required to have a baseline Positive and Negative Syndrome Scale (PANSS) total score of 80 or more, with a score of at least 5 on one positive symptom item or at least 4 on two positive symptom items. (Positive symptoms refer to delusions, hallucinations, and other acute symptoms of psychosis; negative symptoms refer to symptoms such as social and emotional withdrawal.)

The study was funded and sponsored by Karuna Pharmaceuticals, which is investigating the drug combination.

The primary end point was the change from baseline to week 5 in the total score on the PANSS. Secondary endpoints included specific scores on the PANSS and scores on the Clinical Global Impression–Severity (CGI-S) scale.

The change in the PANSS total score from baseline to week 5 was significantly better in the xanomeline-trospium group: Scores dropped 17.4 points in the group receiving the drug combination versus 5.9 points in the placebo group. The results for the secondary end points, including PANSS positive and negative symptom subscores as well as CGI-S scores, were also significantly better in the xanomeline-trospium group than in the placebo group.

The most common adverse events associated with the drug combination were constipation, nausea, dry mouth, dyspepsia, and vomiting. None of these adverse events resulted in the participants’ discontinuation of xanomeline-trospium, and all of the adverse events were rated by site investigators as mild or moderate in severity.

William Carpenter, M.D., editor of Schizophrenia Bulletin and chair of the DSM-5 Task Force on Psychotic Disorders, told Psychiatric News that the results are potentially important because xanomeline-trospium targets different brain receptors than most other schizophrenia medications. Xanomeline acts on the cholinergic system, which regulates involuntary actions of the body such as muscle contraction and the dilation of blood vessels, but also influences memory and attention.

Carpenter said future research needs to determine whether more adverse events and more serious side effects are seen in larger samples over a longer period and whether the pattern of beneficial effects seen in the trial will also be seen when the drug combination is compared with other antipsychotics. Researchers also need to better pinpoint how xanomeline works in the brain to treat schizophrenia.

“What is exciting at this point is that it is not another ‘me-too’ drug,” Carpenter said.

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Register today through March 1 for the best rates available for APA’s online 2021 Annual Meeting. The meeting, which will be held Saturday to Monday, May 1 to 3, will include 135 scientific sessions led by experts with live Q&As, poster sessions, Virtual Exhibit Gallery, Product Theaters, opportunities for member engagement, and more. Pulitzer Prize–winner Isabel Wilkerson, author of The New York Times bestsellers The Warmth of Other Suns and Caste: The Origins of Our Discontents, will be the keynote speaker at the 2021 Annual Meeting Opening Session on Saturday, May 1. National Institute of Allergy and Infectious Diseases Director Anthony Fauci, M.D., will deliver the William C. Menninger Memorial Convocation Lecture on Sunday, May 2.




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Thursday, February 25, 2021

Youth With ADHD May Have Increased Risk for Psychotic Disorders

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) may be at increased risk for subsequent psychotic disorders, according to a report published Wednesday in JAMA Psychiatry.

Given that psychotic disorders have a major effect on functioning, “early detection and appropriate management are essential to improve the prognosis of children diagnosed with ADHD,” wrote Mika├»l Nourredine, M.D., M.Sc., of the Centre Hospitalier Le Vinatier in Bron, France, and colleagues. The findings suggest that patients with ADHD need follow-up even after 18 years of age, the authors noted.

Nourredine and colleagues searched the MEDLINE, Scopus, PsycInfo, and Web of Science databases for original, peer-reviewed studies that included children and adolescents younger than 18 with ADHD, as well as a control group with no ADHD. For the purposes of this meta-analysis, a study had to include data on diagnoses of psychotic disorders (including schizophrenia, schizophreniform disorder, schizotypal personality disorder, schizoaffective disorder, delusional disorder, or brief psychotic disorder) that occurred after the ADHD diagnosis.

The authors identified 12 studies in which a diagnosis of ADHD was present and psychotic disorder was the outcome of interest, representing 124,095 children/adolescents with ADHD and 1.7 million controls. The prevalence of psychotic disorders among the ADHD population ranged from 0.7% to 12.5%, while the prevalence among the control population ranged from 0% to 4.2%. Altogether, the studies suggested that children and adolescents with ADHD were nearly five times as likely to be subsequently diagnosed with a psychotic disorder as those without ADHD.

“Many potential mechanisms could underlie the association between ADHD and subsequent psychosis,” the authors wrote, including shared genetic susceptibility, social or environmental factors, or prenatal factors such as diabetes during pregnancy or neonatal complications. The authors also noted the possible association between psychostimulant treatment and later risk of psychotic disorders, as well as the possibility that children and adolescents with early signs of a psychotic disorder may be misdiagnosed with ADHD.

More research is needed, the authors concluded, particularly studies with long follow-up periods to determine when psychotic disorders are most likely to develop, and studies that consider what may be linking psychotic disorders and ADHD.

For related information, see the Psychiatric News article “Study Finds Higher Risk of Psychosis With Amphetamines for ADHD.”

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Wednesday, February 24, 2021

Mental Illness, Substance Use Disorders Found Common Among Individuals Who Die Suddenly

More than half of individuals living in a large metropolitan county in North Carolina who died suddenly outside the hospital had at least one diagnosed mental illness or substance use disorder in the previous five years, and more than one-third had two or more, according to a report in Psychiatric Services in Advance.

Among those with mental and/or substance use disorders, cardiovascular, respiratory, and metabolic conditions were common, wrote Jessica Ford, Ph.D., of the Department of Veterans Affairs in Greenville, N.D., and colleagues.

Ford and colleagues screened for sudden deaths attended by emergency medical services in Wake County, N.C., from March 1, 2013, to February 28, 2015. Deaths were considered sudden if the circumstances before death suggested an “abrupt pulseless condition” in the absence of any terminal disease (such as cancer or liver disease), drug overdoses, death from trauma, or other nonnatural cause.

Of 1,592 deaths that the researchers identified, there were 399 cases of sudden death. Of these, 270 had available medical records. The average age at death was 53. Chronic comorbid conditions, including hypertension, diabetes, coronary disease, and respiratory disease, were common among those with and without mental illness who died suddenly.

More than half (59%) of the individuals who died suddenly had at least one documented mental disorder or substance use disorder in their medical record, and 39% had more than one mental disorder or substance use disorder. Yet only 41% of the individuals had a documented referral to a mental health professional, and 33% had a documented visit with a mental health professional.

Although referrals to and treatment by mental health professionals were uncommon, almost one-half (46%) of individuals who died suddenly had prescriptions for psychotropic medications. Among those with mental illness, more than 75% of individuals had received prescriptions for psychotropic medications.

“The observed combination of mental disorders and medical conditions in sudden-death victims implies the need for collaborative care involving mental health and clinical professionals to help prevent sudden death among working-age adults,” Ford and colleagues concluded.

For related information, see the Psychiatric News article “Patients With Serious Mental Illness Need Better Primary Care Integration, Health Advocacy.”

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Tuesday, February 23, 2021

Connecting With Older Adults By Phone May Reduce Loneliness, Depression, Anxiety During Pandemic

Older adults who received regular phone calls from a young adult a few months into the COVID-19 pandemic experienced greater improvements in loneliness, depression, and anxiety after four weeks compared with older adults who did not receive these calls. The findings were published today in JAMA Psychiatry.

“The use of lay callers, deliberate but brief approach on training, and the use of ubiquitous telephones made the approach easily deployable and scalable,” wrote Maninder K. Kahlon, Ph.D., of the University of Texas at Austin and colleagues.

The study included 240 participants aged 27 to 101 who were homebound, had at least one chronic condition, and were receiving services for food through Meals on Wheels Central Texas. More than 60% of the participants were at least 65 years, 56% were living alone, 79% were women, 39% identified as Black or African American, and 22% identified as Hispanic or Latino. The participants were randomly assigned to receive phone calls from the same volunteer for a four-week period (intervention group) or no calls until after the four-week follow-up (control group).

The volunteers, aged 17 to 23, attended one hour of training by videoconference on how to engage participants in conversation on topics of their choice and were asked to watch less than one hour of videotaped instructions on the program. For the first five days of the program, the volunteers called all participants every day at the time they requested. After the first week, the participants also chose the frequency of calls, with a minimum of two and maximum of five a week. According to the researchers, most participants chose to be called five times a week.

Kahlon and colleagues evaluated the participants on measures of loneliness (including the UCLA Loneliness Scale), depression (eight-item Patient Health Questionnaire for Depression, or PHQ-8), anxiety (Generalized Anxiety Disorder scale, or GAD-7), and more at the beginning of the study as well as four weeks later.

Participants in the intervention group improved from a mean of 6.5 to 5.2 on the UCLA Loneliness Scale and in the control group, from 6.5 to 6.3. Depression decreased from a mean of 6.3 to 4.8 on the PHQ-8, and in the control arm, increased from a mean of 6.2 to 6.3. For participants in the intervention group, anxiety decreased from a mean of 5.9 to 4.1 on the GAD-7, and in the control arm, increased from a mean of 5.8 to 6.0.

Kahlon and colleagues noted that additional studies are needed to assess whether the participants continued to experience benefits after the program ended and/or if a longer program would lead to greater improvements. “Additionally, future research might explore the effect of this program when participants are screened for mental health conditions or stratified based on age,” they added. “It may be particularly interesting to assess whether the program can play a protective role for those at risk of clinical anxiety or depression.”

For related information, see the Psychiatric News article “COVID-19 Guidance to Help Our Patients and Ourselves.”

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