Tuesday, September 29, 2020

Women With First-Episode Psychosis Not Getting Targeted Care They Need

Specialty team–based services for first-episode psychosis (FEP) have the potential to improve outcomes among patients with schizophrenia. In an article in Psychiatric Services, psychiatrists Maria Ferrara, M.D., and Vinod H. Srihari, M.D., of Yale University described several factors that may disadvantage women in terms of both access to and quality of care in FEP services.

Age of onset: Although many FEP services target young adults, research suggests the onset of psychosis may occur later in women. To meet the needs of women of all ages, the authors suggested that FEP programs consider increasing the maximum age at which a patient can receive FEP services. They acknowledged that designing psychosocial interventions to address the needs of younger adults and women across the lifespan may be challenging. Older women, some of whom may be pregnant or have children, might require “more intensive care planning, as well as sustained social worker support for childcare, involvement with child protective services, and consideration of economic needs.”

Clinical presentation: Compared with men experiencing FEP, women tend to present with more mood symptoms, which can lead to a misdiagnosis of psychosis due to a primary affective disorder—often a criterion for exclusion from FEP services. Women also tend to have better overall functioning at the onset of psychosis, which can lead to delays in services. To address this issue, the authors recommended FEP services support the needs of women with concomitant psychosis and mood symptoms, reevaluate their diagnoses, and refer women to other services only after preliminary treatment and several months of careful longitudinal assessment.

Pathways to care: Symptom-onset differences also result in women being less likely than men to be referred to FEP programs. “FEP services should be sensitive to these gender differences and target outpatient health facilities (for example, primary care and obstetric and gynecologic clinics) where women with underrecognized psychosis may be found,” they wrote. “To increase the likelihood that [women caring for children and/or elderly relatives] will access and accept care, services should integrate their outreach and engagement activities to settings where relevant services (for example, social services and child care) are co-located and readily available.”

Sexual and reproductive health: Psychosis symptoms often tend to first emerge during the period of greatest fertility for women. “FEP services should routinely provide education to help prevent sexually transmitted diseases and unintended pregnancies. Shared decision-making around family planning is also critical when medications with potential teratogenic risks are prescribed,” they wrote. Additionally, FEP services should consider collaborating with pediatric, primary care, and obstetric services to ensure patients who are pregnant or planning a pregnancy receive coordinated care during the peripartum period.

Preventive medicine: Research shows that women with schizophrenia are less likely to receive Pap test screenings for cervical cancer and mammograms for breast cancer compared with women without the disorder. “FEP services should consider providing education and care coordination to facilitate appropriate access to preventive measures (for example, human papillomavirus vaccination, breast self-examination, and diagnostic imaging),” they recommended.

“[W]omen with FEP have specific needs that can be proactively addressed to refine the current expansion of FEP services in the United States,” Ferrara and Srihari concluded.

For related information, see the Psychiatric Services article “Targeting Gender and Age in First-Episode Psychosis Services: A Commentary on Ferrara and Srihari.”

(Image: iStock/bymuratdeniz)

Monday, September 28, 2020

Fetal Exposure to Alcohol Associated With Behavioral, Psychological Problems in Offspring

Children who were exposed to any amount of alcohol in the womb are more likely to be impulsive and diagnosed with separation anxiety and oppositional defiant disorder compared with children who were not exposed to alcohol in the womb, reports a study in AJP in Advance.

“To our knowledge, this is the largest examination of prenatal alcohol exposure and psychological, behavioral, and neurodevelopmental outcomes in preadolescence,” wrote Briana Lees, B.Psych., of the University of Sydney, Australia, and colleagues. The authors noted their study reaffirmed the many risks of heavy drinking during pregnancy, but “children with even the lowest levels of exposure demonstrate poorer psychological and behavioral outcomes as they enter adolescence.”

Lees and colleagues analyzed data from 9,719 children aged 9 to 11 who are part of the Adolescent Brain and Cognitive Development (ABCD) study, which aims to track brain development in a nationally diverse population of children from preadolescence to young adulthood. For ABCD, all children and their parents complete psychological and cognitive assessments periodically, and the children receive periodic brain scans.

Among the 9,719 children included in the analysis, 26% were exposed to alcohol during pregnancy. Compared with children with no alcohol exposure, those with any exposure had statistically greater average scores on the Child Behavior Checklist (CBCL), which measures emotional and behavioral problems, and greater impulsivity scores. Children with any exposure to alcohol were 21% more likely to have received a diagnosis of separation anxiety disorder and 17% more likely to have received a diagnosis of oppositional defiant disorder.

The researchers next grouped the children based on their mothers’ drinking habits during pregnancy: abstinent, light drinking during first seven weeks of pregnancy (about two drinks a week), light drinking throughout pregnancy (about one drink a week), and heavy drinking during first seven weeks of pregnancy (about five drinks a week). Women who drank heavily throughout pregnancy comprised less than 1% of the sample and were excluded from this analysis.

Compared with children whose mothers did not drink alcohol during pregnancy, children from all the other groups had higher scores on the CBCL and elevated risks of separation anxiety disorder and oppositional defiant disorder. Children whose mothers were light drinkers throughout pregnancy were also more likely to develop a phobia, while children whose mothers drank heavily in early pregnancy were more likely to report aggression, rule-breaking behaviors, withdrawn or depressed behavior, and to have a diagnosis of attention-deficit/hyperactivity disorder.

“Similar to previous conclusions drawn on the effects of prenatal alcohol exposure, our results suggest that there is no safe threshold for alcohol consumption during pregnancy,” Lees and colleagues concluded.

For related information, see the Psychiatric News article “Strategy Emerges to Combat Effects of Prenatal Alcohol Exposure.”

(Image: iStock/kieferpix)

Friday, September 25, 2020

Serious Mental Illness on Rise Among Residents of Assisted-Living Communities

The prevalence of serious mental illness (SMI) among people who live in assisted-living communities is rising faster than in the community at large, suggests a study in the American Journal of Geriatric Psychiatry.

“This increased prevalence of SMI in [assisted living] has implications for the provision of mental health services in this setting, a topic that is largely underexplored other than in broad strokes,” wrote Cassandra L. Hua, Ph.D., of the Brown University School of Public Health and colleagues.

The researchers analyzed data from the Medicare Master Beneficiary Summary File, a ZIP code history file, OASIS home health assessment data, Medicare Part B claims, a national list of state licensed assisted-living communities, and a Residential History File. They separated the population into three groups: those who lived in the community at large, in a nursing home, or in assisted living on December 31 of each year from 2007 to 2017.

Over the 10-year period studied, the prevalence of SMI in assisted living increased by 54%, compared with an increase of 39% in the community at large. However, the prevalence of SMI rose the fastest in nursing homes, increasing 77%.

The prevalence of SMI in assisted living varied widely between states, ranging from 3.2% in Wyoming to 33.1% in New York.

“Given that Medicaid coverage of [assisted living] varies by state, funding for [assisted-living] services may remain suboptimal in many locations,” Hau and colleagues wrote. “Future research can empirically investigate the relationship between state Medicaid policy and changes in the prevalence of SMI in [assisted living].”

People with SMI had a higher prevalence of medical conditions such as obesity, COPD, and diabetes, and they were more likely to have at least six chronic conditions compared with people without SMI.

“The prevalence of health concerns may be a concern because … [assisted-living] communities are not required to provide round the clock nursing services, although 54% have an RN or LPN on staff,” the researchers wrote. “More research is needed into the mental health and medical care needs for this population.”

(Image: iStock/Obencem)


Register for Tomorrow’s Virtual State Advocacy Conference

With state legislatures increasingly focused on policies affecting mental health and access to care, now is a critical time for APA members to learn important state advocacy skills and get involved in advocacy. APA’s State Advocacy Conference will equip members to effectively engage their state lawmakers. The conference, which is open to all APA members, will take place virtually tomorrow, Saturday, September 26. The registration fee is $50; residents may register for $25. APA designates this live activity for a maximum of 4 AMA PRA Category 1 Credits.

Register Now

Thursday, September 24, 2020

Successful APA Advocacy Ensures Veteran Patient Safety Regarding MH Care

After significant APA advocacy, the House Veterans’ Affairs Committee removed a proposal to implement a pilot program allowing clinical psychologists to prescribe and manage medications for veterans who seek care in the Veterans Health Administration.

After learning about the proposal, APA issued an advocacy alert that resulted in over 1,000 members sending more than 3,000 letters to their elected officials on Capitol Hill, opposing the proposal and urging lawmakers to ensure veterans receive the highest quality mental health care possible. Similarly, APA leadership, as well as government relations and policy staff members, vigorously lobbied members of Congress on and off the House and Senate Veterans Affairs Committees and engaged in conversations with top staff at the VA.

The House proposed the pilot program in legislation on veteran suicide prevention that was intended to be a companion bill to the Senate-passed suicide prevention package that had cleared the upper chamber earlier this summer. The House passed its legislation this week without the provision allowing psychologists to prescribe or manage medications.

“We will continue our work with the VA, Congress, and partner organizations to improve the mental health and substance use care available to our veterans through the VHA and beyond,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We must work with policymakers on genuine solutions that promote the recruitment and retention of critically needed psychiatrists, psychologists, and other mental health providers who are in short supply within the VA system. Meanwhile, with the help of our members, we have avoided the enactment of a false solution that could have put many veterans at risk, without any improvement in access to the care they truly need.”

On average, 20 veterans die by suicide every day. Often, veterans’ mental illnesses occur alongside complex comorbidities. A 2019 study in the Journal of the American Heart Association found that veterans diagnosed with posttraumatic stress disorder (PTSD) were 41% more likely to develop cardiovascular diseases than those without PTSD. Additionally, smoking, depression, anxiety disorders, sleep disorders, type 2 diabetes, obesity, high blood pressure, and cholesterol were significantly more prevalent among patients with PTSD.

“We believe that nothing is more important than ensuring that veterans are given high quality mental and physical health care by qualified, appropriately educated, and trained medical clinicians, not more prescribers and more prescriptions,” Levin said. “Veterans have gone above and beyond by serving our country and should not be subjected to a lower standard of care than other patients across the country.”

(Image: David Hathcox)

Wednesday, September 23, 2020

Problematic Internet Use, Gaming May Point to Students Experiencing Mental Health Symptoms

College students whose academic performance has been negatively impacted by internet use or computer gaming are at higher risk of mental health problems than students without problematic internet use/computer gaming behaviors, according to a report in Depression & Anxiety.

“These findings suggest that querying students about whether their internet use or computer gaming has negatively affected their academic functioning might be a strategy for identifying students at risk for [mental health] problems,” wrote Courtney Stevens, Ph.D., of Willamette University and colleagues. “This approach may be particularly useful as internet use is likely less stigmatized than other [mental health] symptoms or diagnoses and because students and universities tend to gauge outcomes not by [mental health] status but through students’ ability to function academically.”

Stevens and colleagues analyzed data from 43,003 undergraduates aged 18 and older who participated in the 2017 American College Health Association‐National College Health Assessment—a 30-minute survey on such topics as substance use/abuse, sexual health, physical health, and more. As part of the survey, students were specifically asked about the past-year frequency of 11 mental health symptoms, including hopelessness, loneliness, overwhelming anxiety, sadness, anger, intentional self-harm, and attempted suicide. Students were also asked about problematic internet use, which the authors defined as “internet use and computer gaming negatively impacted academic performance.”

About 10% of students reported problematic internet use/computer gaming over the previous 12 months (with most indicating the most serious consequence of this behavior was receiving a lower grade on an exam or important project).

Overall, 93% of the students surveyed reported at least one of the 11 mental health symptoms during the year. Students reporting problematic internet use/computer gaming exhibited consistently elevated rates of all mental health symptoms relative to students not reporting problematic internet use/computer gaming. For instance, students who reported problematic internet use/computer gaming were more than twice as likely to report feeling “hopeless,” “so depressed it was difficult to function,” “overwhelmed,” “exhausted,” “very lonely,” or “very sad” in the past year. Similarly, students who reported problem internet use/computer gaming were about 1.5 times as likely to report that in the past year they had engaged in intentional self‐harm, had seriously considered suicide, or attempted suicide.

“Whereas screen time monitoring has been discussed extensively for young children, there is little guidance for older adolescents or college students where screen time and internet use are normalized and generally unscrutinized,” the authors continued. “Colleges may wish to consider offering workshops or other educational strategies to help students develop self‐awareness and regulatory strategies for engaging with internet use in a healthy way.”

For related information, see the Psychiatric News article “CBT Intervention May Reduce Addictive Internet Use.”

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Tuesday, September 22, 2020

Nonfatal Opioid Overdoses Rose During COVID-19 Pandemic, Report Suggests

Data from an emergency department in Richmond suggests that the number of nonfatal opioid-related overdoses may have risen during the first few months of the COVID-19 pandemic, particularly among people who are Black. The findings were published in JAMA.

Taylor A. Ochalek, Ph.D., of Virginia Commonwealth University (VCU) and colleagues compared the number of nonfatal opioid overdoses recorded in electronic medical records from VCU’s Emergency Department from March to June 2019 with those that occurred from March to June 2020—the first few months of the COVID-19 pandemic. They found nonfatal opioid overdoses increased from 102 between March and June 2019 to 227 between March and June 2020. The increase in nonfatal opioid overdose visits occurred at the same time that the emergency department experienced a significant decline in the total number of emergency department visits, the authors reported.

“This data is from the Richmond area, but it confirms what we’re hearing anecdotally from across the U.S.,” F. Gerard Moeller, M.D., director of the Wright Center and director of the VCU Institute for Drug and Alcohol Studies, said in a press release. “The pandemic is more than a crisis of one disease. Its ripple effects will be felt for some time in the form of secondary health impacts like addiction.”

Further analysis of patient characteristics of those who experienced a nonfatal opioid overdose during the three-month period in 2019 versus the three-month period in 2020 revealed that while patients in both periods were about the same age (mean ages 42.2 years and 44.0 years, respectively) and predominantly male (70% and 73%, respectively), the percentage of Black patients rose from 63% in 2019 to 80% in 2020.

“While the use of records from March to June across two years serves as a control for underlying seasonal variation in overdose, the generalizability of these findings is limited by the small sample size and reporting of a single emergency department,” wrote Danielle F. Haley, M.P.H., Ph.D., of Boston University School of Public Health and Richard Saitz, M.D., M.P.H., of Boston University School of Medicine in an accompanying editorial. Nonetheless, they noted that the study by Ochalek and colleagues is “consistent with the hypothesis that the U.S. COVID-19 epidemic has been accompanied by an increase in substance use with important consequences (nonfatal overdose), with a signal of greater effect among people who are Black.”

They continued, “There has been a historic failure to deliver effective treatments for opioid use disorder, despite long-standing evidence of efficacy, in the absence of the additional burden COVID-19 has placed on U.S. health care infrastructure. Given this, combined with the racial/ethnic and socioeconomic disparities in opioid overdose and COVID-19–related morbidity and mortality, the introduction of policies alone will be insufficient to mitigate the effect of the COVID-19 pandemic on overdoses. It is critical to identify how best to translate these policies into clinical practice, expand infrastructure, and address the broader social and structural determinants of health that create disparities in access to health care.”

For related information, see the Psychiatric News article “Patient’s Race May Influence Access to MH Care Following Overdose.”

(Image: iStock/FangXiaNuo)

Monday, September 21, 2020

Tips on Reopening Psychiatric Practices During Pandemic

As psychiatrists begin to reopen their offices during the COVID-19 pandemic, there are many questions about how to do so safely. In the latest issue of Psychiatric News, risk management consultant Anne Huben-Kearney, R.N., B.S.N., M.P.A., offers some advice

“Take into consideration your health and that of your patients and whether to continue with telepsychiatry, reopen your practice to see patients in person, or have a hybrid practice,” Huben-Kearney wrote. “Safety for your patients and for yourself is paramount, now more than ever.”

For psychiatrists who are preparing to resume seeing patients in person, Huben-Kearney suggested the following:

  • Continue to follow the Centers for Disease Control and Prevention guidelines on social distancing, masks, and hand hygiene as well as state and local restrictions. 
  • Ensure adequate masks and hand sanitizer for office staff and patients. Demonstrate use of both, including using the hand sanitizer when your patient enters the session room. 
  • Reorganize your office to allow for physical distancing. Try to avoid more than one patient in the office at a time, and allow enough time between patients to wipe down surfaces.
  • Outdoor sessions may be an option with written patient consent, but you need to be able to ensure auditory and visual confidentiality. 

Huben-Kearney also offered some guidance for psychiatrists who want to continue telepsychiatry sessions with patients, including those who live out of state:

  • Keep track of when and to what degree the state governors rescind executive orders, especially regarding licensure across state lines. 
  • Monitor when the Drug Enforcement Administration resumes compliance with the Ryan Haight Act, which requires health care professionals to conduct an initial, in-person examination of a patient before electronically prescribing a controlled substance.
  • Initiate an application for permanent licensure in the states where your patients are located. Psychiatrists should be sure to check the status of their state’s COVID-19 guidelines (APA has compiled state-issued guidance here). They should also check the Interstate Medical Licensure Compact (IMLC), which allows states to work together to streamline the multi-state licensing process.
  • Ensure that you have a HIPAA-compliant platform with a Business Associate Agreement to ensure your protection in case of a data breach. 

Finally, continue “to ensure patient screening, both for in-person and telepsychiatry sessions,” Huben-Kearney concluded. “Ensure compliance with the standard of care, which is the same whether care is provided in person or via telemedicine.”

To read more on this topic, see the Psychiatric News article “Reopening Your Practice During Pandemic.” 

(Image: iStock/miodrag ignjatovic)

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The content of Psychiatric News does not necessarily reflect the views of APA or the editors. Unless so stated, neither Psychiatric News nor APA guarantees, warrants, or endorses information or advertising in this newspaper. Clinical opinions are not peer reviewed and thus should be independently verified.