Pregnancy Linked to Lower Risk of Alcohol Use Disorder

A woman’s pregnancy may lower her risk of alcohol use disorder during pregnancy and for at least two years following childbirth, according to a study published yesterday in AJP in Advance.

Alexis C. Edwards, Ph.D., of Virginia Commonwealth University and her colleagues evaluated the risk of alcohol use disorder in 322,029 pregnant women from Sweden born between 1975 and 1992. They compared the women’s risk with that of nonpregnant controls in the general Swedish population and with nonpregnant female relatives. They also compared the risk each woman had during and after her pregnancy with the risk she had before her pregnancy. Finally, they assessed risk in the male partners living with the women. The researchers defined alcohol use disorder either by ICD codes in Swedish medical registers or by registrations in the Swedish Crime Register.

In the first analysis, the researchers matched each of the case-study women to five random control women who were born in the same month and year. They found that the case-study women were 68% less likely to have an alcohol use disorder when pregnant compared with their nonpregnant peers.

The researchers then matched 104,550 of the case-study women with 120,938 female cousins, and 40,045 case-study women with 41,567 female siblings. They found that case-study women were about 70% less likely than their nonpregnant cousins and 77% less likely than their nonpregnant sisters to have an alcohol use disorder.

The researchers also found that the case-study women were about 75% less likely to have an alcohol use disorder while they were pregnant than they were six to 12 months before they got pregnant. While the protective effects of pregnancy decreased over time, the women remained less likely to have alcohol use disorder two years after childbirth.

“[These results] suggest that even if a pregnancy is planned [six] to 12 months in advance, the actual pregnancy still represents a period of substantial reduction in risk of alcohol use disorder. This relationship was borne out in the postpartum periods as well,” Edwards and her colleagues wrote.

The researchers noted that the male partners were also less likely to have an alcohol use disorder while the women were pregnant, but their risk reduction was less pronounced.

“The discrepancy in risk reduction across mothers and fathers may be attributable to concerns about alcohol’s direct effect on the fetus,” Edwards and colleagues wrote. “In conjunction with evidence from alcohol use disorder treatment programs that include cash or prize rewards for abstinence, this putative protective role of pregnancy suggests that qualitatively different factors have the potential to motivate reduction in alcohol misuse, which may broaden the possibilities for intervention in alcohol use disorder treatment.”

For related information, see the Psychiatric News article “Gap Closing Between Men, Women in Alcohol Consumption Patterns.”

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CMS Delays Simplified E/M Payment Structure in Final Rule on 2019 Fee Schedule

For 2019, the Centers for Medicare and Medicaid Services (CMS) has reduced administrative burdens on physicians associated with documentation and preserved separate payments for each of the existing levels of evaluation and management (E/M) services used to describe care for new and established patients in outpatient settings.

These provisions are part of the final rule on the 2019 Medicare Physician Fee Schedule, released by CMS in early November. In its original August proposal, CMS proposed a single “flat payment rate” for level 2 through level 5 E/M services provided in outpatient settings. This change would have resulted in physicians being paid a single rate for those services regardless of the complexity of the work a patient requires.

CMS is delaying the implementation of the proposed simplified payment structure until 2021 and has modified its original proposal. In 2021, CMS plans to collapse the payment for levels 2 through 4 for outpatient visits but will retain a separate payment amount for level 5 services.

In the meantime, CMS has adopted several of the documentation changes for which APA advocated in comments it submitted on the proposed rule. Beginning on January 1, 2019, CMS will no longer require physicians to document medical necessity for treating patients in their home rather than in the office; no longer require physicians to re-record elements of a patient’s history and exam when there is documentation that those items have been reviewed and updated; and will allow physicians to indicate that they have reviewed and verified information on the chief complaint and history that are already documented in the record by ancillary staff or the patient. These changes are expected to reduce administrative burden on physicians associated with documentation.

Physicians are to continue using either the 1995 or 1997 documentation guidelines for E/M code selection.

The fee schedule also includes important changes to requirements around electronic health records, the Merit-Based Incentive Payment System, and the use of quality measures.

Staff at APA are continuing to analyze the fee schedule. Members who have questions should contact the APA Practice Management Helpline at (800) 343-4671. Look for the December 21 issue of Psychiatric News for complete coverage of the fee schedule.

Detailed information on the fee schedule is posted at the CMS website.

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Psychotic Experiences May Increase Risk of Suicidal Behaviors, Meta-Analysis Finds

People who have hallucinatory experiences and delusional beliefs may be more likely to think about, attempt, and die by suicide than those without psychotic experiences, suggests a meta-analysis published today in JAMA Psychiatry.

“Psychotic experiences are reported by 5% to 8% of the general adult population,” wrote Kathryn Yates, M.Sc., of the Department of Psychiatry at the Royal College of Surgeons in Ireland and colleagues. “While initial research focused on an increased risk for psychotic disorder in individuals who report PEs [psychotic experiences], much subsequent research has demonstrated that PEs are associated with high risk for a broad range of mental disorders and poor mental health outcomes in general.”

Yates and colleagues conducted a systematic review and meta-analysis of 10 longitudinal population studies that examined the association between psychotic experiences and subsequent suicidal ideation, suicide attempts, and/or death by suicide. The studies included 84,285 people from 23 countries. The follow-up periods for the studies ranged from one month to 27 years.

The researchers found that individuals who reported psychotic experiences had an increase in the odds of future suicidal ideation (odds ratio, 2.39), future suicide attempt (odds ratio, 3.15), and future death by suicide (odds ratio, 4.39).

To investigate whether co-occurring psychopathology fully mediated the association between psychotic experiences and suicidal behaviors, Yates and colleagues conducted a secondary analysis of three studies on the association between psychotic experiences and suicidal ideation. In these three studies, the authors reported adjusted odds ratios for co-occurring psychopathology; the pooled odds ratio was 1.59. Yates and colleagues also analyzed data from five studies on the association between psychotic experiences and suicide attempt. In these five studies, the authors reported adjusted odds ratios for co-occurring psychopathology; the pooled odds ratio was 2.68.

“Our findings suggest that there is a psychosis-associated subtype of suicidal behavior that extends well beyond the previously established association between psychotic disorder and suicidal behavior,” the researchers wrote. “Further research is necessary to understand whether specific types of PEs (for example, perceptual abnormalities versus unusual thought content) are more closely associated with suicidal behavior, whether suicidal behavior is a risk factor for later PEs (in addition to PEs being a risk marker for later suicidal behavior), and the interplay between the many potential mechanisms that contribute to the PE-suicidality association.”

For related information, see the Psychiatric News article “Hallucinations Can Be Marker for Variety of Psychiatric Disorders in Youth.”

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Exposure to Trauma Raises Risk of Psychotic Experiences by Age 18, Study Suggests

Children and adolescents who are exposed to any kind of trauma before the age of 17 are more likely to have psychotic experiences by age 18, according to a report in JAMA Psychiatry.

“Novel interventions that aim to address how trauma affects the mechanisms underlying the development of psychotic experiences could improve mental health outcomes,” wrote Jazz Croft, M.Sc., of the University of Bristol, United Kingdom, and colleagues.

Croft and colleagues analyzed data from the Avon Longitudinal Study of Parents and Children, a large population-based birth cohort in the United Kingdom of women who had an expected delivery date between April 1, 1991, and December 31, 1992. The total sample comprised 14,775 live births.

Exposure to traumatic events in early childhood (0 to 4.9 years), middle childhood (5 to 10.9 years), or adolescence (11 to 17 years) was determined by the responses of participants or their parents to 121 questions about traumatic events. When the participants were age 12 and 18, they were asked about psychotic experiences using the psychosis-like symptoms semi-structured interview (PLIKSi). The PLIKSi questions assessed the presence of 12 psychotic experiences, including hallucinations, delusions, and experiences of thought interference.

In those with psychotic experiences at age 18 years, 83.8% reported exposure to trauma compared with 62.6% without psychotic experiences. Children with any exposure to trauma before age 17 were slightly more than three times as likely as those without trauma exposure to have psychotic experiences by age 18, according to the study.

Moreover, there appears to be a dose-response relationship between trauma and psychosis. Exposure to three or more types of trauma by the age of 17 was associated with a 4.7-fold increase in the odds of having psychotic experiences. Additionally, exposure to trauma during early and middle childhood as well as adolescence was associated with a higher risk of developing psychotic experiences than exposure within only one or two of these periods.

“This study indicates that, assuming the association is accurate and causal, a substantial proportion of participants would not have developed psychotic experiences if they had not been exposed to traumatic experiences during childhood,” the researchers wrote.

For related information, see the Psychiatric News article “CBT For Ultra-High Risk Patients Lowers Risk for Psychosis” and the American Journal of Psychiatry article “Childhood Trauma and Psychosis in a Prospective Cohort Study: Cause, Effect, and Directionality.”

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Study Examines Why Patients May Not Discuss Suicidal Thoughts During Doctor Visits Prior to Suicide Attempt

Thousands of people in the United States die by suicide each year, and studies show many of them visited with a doctor in the month prior to death. A study published in Psychiatric Services in Advance suggests one reason patients may not report suicidal thoughts during a doctor appointment is a fear of what will happen if they disclose.

“There are many reasons that patients may not report suicidal ideation to health care providers prior to a suicide attempt, but no research has qualitatively explored this topic from the patient perspective,” Julie Richards, M.P.H., of Kaiser Permanente Washington Health Research Institute in Seattle and colleagues wrote.

Richards and colleagues invited adults enrolled in Kaiser Permanente Washington with a probable suicide attempt within 60 days of having reported no thoughts of self-harm to participate in in-person or telephone interviews. Self-harm thoughts were assessed from patient responses to question 9 of the Patient Health Questionnaire (PHQ-9). Of 42 adults identified as eligible for the study, 26 agreed to be interviewed; 15 of the participants identified as women and 20 as white.

During the interviews, the participants were asked to describe what happened at the time of their injury and other open-ended questions about the circumstances, including emotional state, relationships, and alcohol and/or drug use. The participants were also asked questions about why they may not have reported any suicidal thoughts on the PHQ-9, as well as what actions might have prevented the suicide attempt and specifically what the health care system could do differently.

Many participants said they were not experiencing suicidal thoughts at the time they answered the PHQ-9. About a third (n=10) of participants reported using alcohol at the time of the suicide attempt, and several described unplanned suicide attempts following an episode of heavy episodic drinking. Given this correlation between alcohol and suicide attempt, the authors suggested that screening for heavy episodic drinking may help identify individuals who might make unplanned suicide attempts.

Many participants also chose not to report suicidal thoughts because of fears related to the outcome of their disclosure. Common concerns cited included confidentiality, anticipated stigma, and possible loss of autonomy. Other reasons patients hid their true feelings included a desire to avoid causing worry for others or that their feelings did not exactly match the description on the PHQ-9.

With regard to the question about how health systems could help prevent suicide, many participants stated that physicians should listen and express concern in a nonjudgmental way and without overreacting. They said that perceived overreactions, particularly mentions of psychiatric hospitalization, can damage their faith in the health care system’s ability to provide patient-centered care for mental illness.

“This finding highlights a complex issue for providers, who may support hospitalization because of fear of the patient’s safety and their own culpability in the event of suicide,” Richards and colleagues wrote. “However, a core ethical challenge is that increasing the patient’s safety in the short run may not be the best long-term solution; the best protection for patients and providers may be collaborative development and documentation of a safety plan.”

To read more about this topic, see the Psychiatric News article “Data Mining May Help Identify Suicide Risk.”

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Recent Exposure to Police Violence Linked With Mental Health Problems

Experiencing police violence is associated with a higher risk for suicide attempts, suicidal thinking, and psychotic experiences, according to a study published today in JAMA Network Open. The study, which was based on a cross-sectional, general population survey of 1,000 residents of Baltimore and New York City from October through December 2017, also suggests that people of color and sexual minorities are more likely to experience police violence.

In their research, Jordan E. DeVylder, Ph.D., of the Graduate School of Social Services at Fordham University and colleagues evaluated data from the Survey of Police-Public Encounters II, which asked survey respondents about past experiences with police violence over the past 12 months. The types of police violence included physical violence with a weapon, physical violence without a weapon, psychological violence (threats, intimidation, and more), sexual violence, and neglect (not responding to calls for assistance, responding too late, and more). The survey respondents were also asked to report psychological distress (including feelings of hopelessness, agitation, and depression), suicidal thinking, suicide attempts, and psychotic experiences.

During the study period, 14.9% of respondents said that they experienced police neglect, 13.2% experienced psychological violence, 7.5% experienced physical violence without a weapon, 4.6% experience physical violence with a weapon, and 3.2% experienced sexual violence. Compared with non-Hispanic whites, people of color had more than a fourfold increased risk of experiencing police violence with a weapon and more than a threefold increased risk of experiencing the other forms of police violence. Those who identified as homosexual or bisexual had nearly a twofold increased risk of psychological violence. With the exception of sexual violence, exposures to police violence varied by age, and most exposures occurred among those 44 years or younger.

Physical violence with a weapon and sexual violence were associated with the greatest increase in risk for suicide attempts, suicidal thinking, and psychotic experiences. Physical violence with a weapon was associated with more than a sevenfold increase for suicide attempts, nearly a threefold increase in risk for suicidal thinking, and more than a fourfold increase in risk for having psychotic experiences. Sexual violence was associated with more than a sixfold increase in risk for suicide attempts and psychotic experiences and nearly a fourfold increase in risk for suicidal thinking. Physical and sexual violence were associated with greater distress than the other forms of police violence.

“Police violence in the United States constitutes a public health problem that is important to address because of the expanse of its potential mental health consequences and the limited attention it has received from policymakers and researchers,” DeVylder and colleagues wrote. These “[f]indings suggest the need for clinicians to be attuned to the prevalence of police violence among patient populations, especially racial/ethnic minorities, males, young adults, and economically disadvantaged individuals.”

For related information, see the Psychiatric News article “Study Exposes Mental Health Effects of Police Shootings on Black Communities.”

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Reducing Firearm Deaths Requires Greater Attention to Suicide Prevention

Mental health advocates must work to ensure that suicide is front and center of conversations about gun violence, Jeffrey Swanson, Ph.D., a professor of psychiatry at Duke University, wrote in a commentary in Psychiatric Services. Swanson is an expert in the epidemiology of gun violence.

“The national conversation about gun violence tends to focus on senseless rampages by troubled young men while public officials pay lip service to an oversimplified, gun-ignoring solution: ‘fix mental health’,” Swanson noted. However, “suicide is a public health problem that is twice the size of the homicide problem—13.4 versus 6.1 deaths per 100,000 people in 2016, and the number of suicide decedents dwarfs the number of mass shooting victims.”

Swanson noted that the suicide crisis “sits squarely at the intersection of inadequate (or poorly implemented) gun laws and a failing mental health care system.” Mental illness is most often the reason that people try to end their own lives, and access to a firearm used to die by suicide is most often the reason they do not survive, he wrote. “Although there is lingering social stigma and moral approbation associated with suicide, there is also a growing public understanding that most suicides (unlike most homicides) result from a serious mental illness for which the person bears no blame.”

Swanson pointed to the enactment of risk-based, time-limited gun removal laws as a good example of an intervention that would reduce gun violence and suicide deaths. A number of states have laws that use a civil court process to give police officers clear legal authority to search for and remove firearms from people who pose a significant risk of harming themselves or others. The law can be used to prevent acts of gun violence toward others, but the most common use is to separate guns from someone in a suicidal crisis, Swanson wrote.

“We have known for decades that people with serious mental illnesses carry a risk of suicide many times greater than that of people who do not have these illnesses. We have also known that guns are an extremely lethal means of intentional self-injury; nearly 90% of suicide attempts involving firearms result in death, compared with less than 10% of suicide attempts using most other methods,” he wrote.

“Better identification and more effective treatment delivered to people with severe mood disorders, alcohol problems, and other psychiatric maladies would surely prevent many from trying to hurt themselves. And keeping guns out of the hands of suicidal individuals could prevent many more from dying. We should use the levers of public policy to do much more on both fronts.”

For related information, see the Psychiatric News article “Resource Document Offers Clinicians Guidance on Risk-Based Gun Removal Laws.”

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Meditation May Be as Effective as Exposure Therapy at Helping Veterans With PTSD

Transcendental meditation, which involves the silent repetition of a personal mantra to achieve restful alertness and avoid distracting thoughts, may be as effective as prolonged exposure therapy at reducing symptoms of posttraumatic stress disorder (PTSD) in veterans, according to a study in Lancet Psychiatry.

“The benefit of exposing people with PTSD to traumatic memories has been regarded as an important, if not essential, part of the therapeutic process,” wrote Sanford Nidich, Ed.D., of the Maharishi University of Management Research Institute in Iowa and colleagues. “Our findings provide further evidence that PTSD treatments can be effective without an exposure component. Because trauma exposure can be difficult for patients, similarly effective treatments that do not require exposure could be appealing to veterans and other groups with PTSD.”

Nidich and colleagues enrolled 203 veterans who had a current diagnosis of PTSD resulting from an event experienced during active military service. The participants were randomly assigned to receive 12 sessions of transcendental meditation, exposure therapy, or PTSD health education (served as the control group) over 12 weeks. The meditation and health education sessions were provided in group settings, while the exposure therapy was given in one-on-one settings.

The researchers used the clinician-administered PTSD scale (CAPS) and participant self-report to assess PTSD symptoms at the start of the study and again after 12 weeks. The study participants were also asked about depressive symptoms using the nine-item Patient Health Questionnaire (PHQ-9).

In head-to-head comparisons, both transcendental meditation and exposure therapy were superior to health education at reducing clinician- and patient-rated PTSD symptoms, as well as depressive symptoms; 61% of veterans receiving transcendental meditation, 42% of those receiving exposure therapy, and 32% of those receiving health education showed a clinically relevant improvement in symptoms (defined as at least a 10-point drop in their CAPS scores).

“The implementation of TM [transcendental meditation] training at military medical facilities in the USA has shown remarkable acceptance, excellent retention rates, attendance, and compliance,” wrote Vernon Barnes, Ph.D., of Augusta University in an accompanying editorial. “TM training could have a substantial effect on health as an adjunct to the standard of care and might have considerable value to improve the quality of life for military service members.”

For related information, see the Psychiatric Research & Clinical Practice article “A Multisite Randomized Controlled Trial of Mindfulness-Based Stress Reduction in the Treatment of Posttraumatic Stress Disorder.”

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E-Cigarette Use Among U.S. Youth Keeps Climbing, Report Shows

Past-month use of e-cigarettes among high schoolers skyrocketed nearly 80% since 2017, and among middle schoolers, nearly 50%, according to the 2018 National Youth Tobacco Survey (NYST). The results were published Thursday in the Morbidity and Mortality Weekly Report.

E-cigarettes (electronic cigarettes) are battery-powered devices that heat and vaporize a liquid containing nicotine that is derived from tobacco and typically, fruit or candy flavors. In 2018, just over 1 in 5 high schoolers (3.05 million students) and 1 in 20 middle schoolers (570,000 students) reported using e-cigarettes in the past 30 days.

The considerable increase in overall youth tobacco use—the highest in seven years—reversed a recent decline in overall use, according to the report. In fact, 27% of high schoolers reported current use of any tobacco product (38% increase from 2017), and 7% of middle schoolers (29% increase) did so.

The data were collected for the annual report from March to May 2018; it is a cross-sectional, voluntary survey conducted by paper and pencil in schools aimed at determining the prevalence of past-month use and frequency of use of various tobacco products, including flavored products.

“These new data show that America faces an epidemic of youth e-cigarette use, which threatens to engulf a new generation in nicotine addiction,” Health and Human Services Secretary Alex Azar said in a statement. The rise prompted the Food and Drug Administration (FDA) to announce plans to issue an advanced rulemaking proposal seeking to ban menthol in traditional combustible tobacco products, including cigarettes and cigars. More than half of youth smokers use menthol-flavored cigarettes; such a ban would take several years to advance.

In a statement, FDA Commissioner Scott Gottlieb, M.D., said he would direct the agency’s Center for Tobacco Products to revisit the compliance policy for flavored e-cigarette products—except for mint and menthol flavors. Specifically, he is seeking to limit the sale of certain flavored e-cigarettes, allowing their sale only in age-restricted, in-person locations, such as vape shops, and if sold online, under heightened practices for age verification. Such restrictions would not apply to mint and menthol-flavored e-cigarettes. In addition, “we must evaluate our regulatory approach to flavored cigars,” he said.

The rise in youth e-cigarette use is likely led by the popularity of cartridge-based, or “pod mod,” e-cigarettes, such as JUUL, according the NYTS report. They are slim and shaped like a USB flash drive, and they easier to use and conceal than previous e-cigarettes. At the same time, they are high in nicotine content and come in candy and fruit flavors that appeal to youth.

For related information, see the Psychiatric News article “E-Cigarette Use Rising Sharply.”

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‘Lazy Eye’ May Impact Youth's Self-Perception at School and Play

Amblyopia, or “lazy eye,” may affect how some children see themselves in terms of their ability to do well in school, make friends and be social, and play sports, according to a study published today in JAMA Ophthalmology.

Amblyopia is a condition in which one eye has reduced vision due to misalignment or blur, and the poor vision is not caused by a problem with the eye’s health and cannot be corrected with lenses.

Eileen E. Birch, Ph.D., of the Retinal Foundation of the Southwest in Dallas and colleagues assessed self-perception in 81 children aged 8 to 13 years. The children were divided into three groups: the amblyopia group, the nonamblyopia group, and the control group. There were 50 children in the amblyopia group. The 13 children in the nonamblyopia group had mild strabismus (eye misalignment), anisometropia (unequal focus between eyes), or both. Nearly all of the children in the first two groups wore glasses. The 18 children in the control group had no vision or eye problems, and none wore glasses.

Birch and her colleagues assessed the children’s self-perception using the Self-Perception Profile for Children, which covers five domains: scholastic, social, and athletic competence; physical appearance; and behavioral conduct. It also includes a separate measurement of children’s overall sense of their worth as a person. The researchers also evaluated reading and motor skills in the amblyopia group.

Scores for physical appearance, behavioral conduct, and global self-worth did not differ significantly among all three groups. However, compared with the control group, children in the amblyopia group had significantly lower scores for scholastic and athletic competence. The researchers found that the slower the children’s reading speeds were, the lower their scores were on self-perceived scholastic competence. They also found that the less accurate the children were at aiming and catching, the lower their scores were on self-perceived scholastic, social, and athletic competence.

“These findings suggest that lower self-perception is associated with slower reading speed and worse motor skills and may highlight the wide-ranging effects of altered visual development on children with amblyopia in their everyday lives,” the researchers wrote.

Like the children in the amblyopia group, the children in the nonamblyopia group had significantly lower scores for social and athletic competence than the children in the control group. However, unlike the amblyopia group, their scores for scholastic competence did not significantly differ from those of the control group. The researchers noted that the small size of the nonamblyopia group limited their ability to determine subtle differences between the amblyopia and nonamblyopia groups.

In their discussion, the researchers considered possible reasons for the lower scores in the amblyopia and nonamblyopia groups.

“Because the children with and without amblyopia differed from controls in their self-perception of social and athletic domains, it is possible that wearing eyeglasses contributed to their altered self-perception of social and athletic competence,” Birch and colleagues wrote. “However, for the scholastic domain, only the children with amblyopia had lower scores, which was consistent with an effect solely due to amblyopia.”

In a commentary on the study, Joseph L. Demer, M.D., Ph.D., noted that further study on the impact of vision problems on youth is needed. “Amblyopia remains the largest threat to vision among children, and it is a major cause of visual loss among patients of all ages. Birch et al. are to be commended and encouraged for their work in this vital area.”

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APA 2019 Election Update

There has been a change in the lineup of candidates running for president-elect in APA’s 2019 election. Philip Muskin, M.D., M.A., has withdrawn his candidacy. Appearing on the ballot for that race will be Jeffrey Geller, M.D., M.P.H., of Worcester, Mass., and Theresa Miskimen, M.D., of Piscataway, N.J. More information about the 2019 election, including APA’s election guidelines, can be found here.

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Glutamate Levels May Predict Outcomes of Patients at Risk of Psychosis

Changes in hippocampal function are believed to play a role in the onset of psychosis. A study published today in JAMA Psychiatry suggests that the concentration of the neurotransmitter glutamate and several other metabolites in the hippocampus may offer clues about patients who are most likely to transition to psychosis.

The findings suggest that measuring hippocampal metabolites could help psychiatrists better predict outcomes in patients at risk of developing psychosis.

For the study, Matthijs G. Bossong, Ph.D., of the University Medical Center Utrecht in the Netherlands and colleagues used an imaging technique known as proton magnetic resonance spectroscopy (1 H-MRS) to measure baseline levels of glutamate and several other metabolites in 86 individuals at high risk for psychosis and 30 healthy controls. On the day of the scanning, the researchers used several scales to assess the participants’ functioning as well as symptoms of anxiety and depression. About 18.5 months later, the researchers met face to face with 57 of the 86 participants in the high-risk group to assess whether the patients had transitioned to psychosis; they also assessed the overall functioning in this group.

In total, 12 people in the clinical high-risk group experienced a first episode of psychosis; 19 showed “good overall functioning” (Global Assessment of Function, or GAF, scale equal to or greater than 65), whereas 38 of the 57 had “poor functional outcome” (GAF less than 65), Bossong and colleagues reported. The group of patients who transitioned to psychosis were found to have had significantly higher hippocampal glutamate levels at the start of the study than those patients who did not transition. These patients also had significantly higher levels of the metabolites myo-inositol and creatine than those who did not develop psychosis. Moreover, patients with higher levels of hippocampal glutamate at baseline were found to have lower levels of overall functioning at follow-up, the authors reported.

“The findings indicate that adverse clinical outcomes in individuals at high risk for psychosis may be associated with an increase in baseline hippocampal glutamate levels, as well as an increase in myo-inositol and creatine levels,” the authors wrote.

“Pharmacological treatments that engage glutamatergic targets have been generally unsuccessful for treatment of psychotic, negative, and cognitive symptoms of schizophrenia,” Juan R. Bustillo, M.D., of the University of Mexico and colleagues wrote in an accompanying editorial. “However, because schizophrenia is highly heritable and glutamatergic-associated genes are among the most involved, in vivo glutamate measurements may still assist the delineation of subgroups of patients with vulnerable disease stages.”

For related information, see the Psychiatric News article “Multimodal Approach May Improve Ability to Predict Transition to Psychosis.”

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Antipsychotics May Increase Risk of Pneumonia, Meta-Analysis Suggests

Patients who take antipsychotics may be at an increased risk of pneumonia, according to a systematic review and meta-analysis published in the Journal of Psychopharmacology.

After performing a search of several databases, Olubanke Dzahini, B.Pharm., M.Sc., of the Institute of Pharmaceutical Science at King’s College London and colleagues included 14 studies with a total of 206,899 patients in the meta-analysis. By compiling, comparing, and contrasting data from these studies, the researchers sought to assess the overall risk of pneumonia in patients who took first- or second-generation antipsychotics compared with those who did not take antipsychotics. They also examined the risk of pneumonia in patients who took one of six antipsychotics (clozapine, haloperidol, olanzapine, quetiapine, risperidone, and zotepine) compared with those who did not take these medications.

Compared with those who had not taken antipsychotics, those who took first-generation antipsychotics had a 69% increased risk of pneumonia, and those who took second-generation antipsychotics had a 93% increased risk. Those who had taken any of the antipsychotics included in the analysis had an 83% increased risk of pneumonia. However, the researchers found that antipsychotic use did not significantly affect the fatality rate from pneumonia compared with no antipsychotic use.

When the researchers analyzed the data on the six antipsychotics, they found that patients who took these medications had a significantly increased risk of pneumonia compared with those who did not take the medications.

Although antipsychotic use was associated with a higher risk of pneumonia, the researchers stopped short of claiming causality, citing a lack of data from randomized, controlled trials and a failure of observational studies to control for relevant confounders like tobacco use and weight. Yet they suggested ways that antipsychotics may contribute to risk.

“Antipsychotics could increase the risk of aspiration pneumonia through multiple mechanisms, including specific impairment of the protective swallowing and cough reflexes, sedation, hypersalivation, and changes in pharyngeal and laryngeal muscle tone,” the researchers wrote.

The researchers emphasized the importance of considering patients’ existing risk factors for pneumonia, including older age, chronic respiratory disease, cerebrovascular disease, dysphagia, obesity, and smoking. “Clinicians need to be vigilant for the occurrence of pneumonia in all patients who commence antipsychotics. The potential risk needs to be balanced out against the potential benefits of antipsychotic treatment in an individual,” they wrote.

For related information, see the Psychiatric News article “GI, Pulmonary Illnesses: Most Cited for Hospitalizing Clozapine Patients.”

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APA Speaks Out Against Trump Administration’s Efforts to Undercut Women’s Preventive Care

APA joined four other medical specialty organizations on Thursday to urge the Trump administration to reverse actions taken this week that will limit women’s access to contraception.

The organizations spoke out just one day after the Trump administration issued a pair of federal rules that allow some employers to opt out of a requirement under the Affordable Care Act to provide birth control coverage for their employees. The new rules allow some employers to deny coverage on religious or moral grounds.

“By undercutting women’s access to contraception, a key preventive service, at no out-of-pocket cost in private insurance plans, the final rules conflict with our firmly held belief that no woman should lose the coverage she has today,” they said.

The other four organizations that joined with APA were the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American College of Physicians.

“These rules create a dangerous new standard for employers to deny their employees coverage based on their own moral objections. This interferes in the personal health care decisions of our patients and inappropriately inserts a patient’s employer into the patient-physician relationship,” they cautioned. Additionally, the rules also “open the door to moral exemptions for other essential physician-recommended preventive services, such as immunizations.”

The groups also warned of the harmful effects of reducing women’s access to contraceptives on public health. “We know that when women have unintended pregnancies, they are more likely to delay prenatal care, resulting in a greater risk of complications during and following pregnancy for both the woman and her child. The final rules reject these facts and the corresponding recommendations of the medical community, jeopardizing many women’s ability to maintain a vital component of their health care,” they said.

“Our organizations, which represent more than 423,000 physicians and medical students, stand together in opposition to the administration’s final rules, the Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act and the Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act. … We urge the administration to immediately withdraw these rules and instead focus on policies to expand access to evidence-based health care for all Americans.”

The final rules are set to take effect in January 2019.

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Psychiatrists May Have Greater Obligation to Warn in States With Gun Restraining Order Laws

Psychiatrists practicing in one of the many states that have enacted gun violence restraining order laws may have a greater obligation to warn family members or law enforcement in cases of suicidal patients who own firearms, according to an article published in Psychiatric Services.

In the wake of mass shooting tragedies around the country, 13 states have enacted gun violence restraining order laws, also known as extreme risk protective orders (ERPOs). The first five states to put such laws into effect were Connecticut, followed by Indiana, California, Washington, and Oregon, with the remaining states enacting them in 2018.

These laws allow petitioners to have firearms removed from individuals at risk of harming themselves or others, and more states are considering such an approach, wrote William Frizzell, M.D., and Joseph Chien, D.O., of the Department of Psychiatry at Oregon Health and Science University.

Psychiatrists and mental health professionals should determine how such laws might apply to practices in their states. “From a medical-legal perspective, invoking an ERPO law might be seen as a prudent, and perhaps even expected, intervention for suicidal patients with firearms. It might even be viewed as an extension of Tarasoff-like duties in cases of potential gun violence against others,” Frizzell and Chien wrote.

Because most of these laws are new, research is limited, but existing evidence shows that seizing guns from troubled individuals is associated with a reduction in deaths by suicide and provides a needed “cooling-off period,” Frizzell and Chien wrote. The authors called for more research to clarify the effects of these laws to inform legislators in other states about the potential benefits to public health.

Although the laws vary somewhat by state, all allow law enforcement officials—or in some cases family members—to initiate gun removal from individuals who pose a risk to themselves or others and require a low burden of proof. While most of the laws specifically exclude mental health professionals as potential petitioners, Maryland’s law does permit psychiatrists, licensed psychologists, and certain others to initiate gun removal. Some states make the presence of mental illness a central factor, whereas other states disallow its consideration by courts. Other factors, such as criminal history, history of domestic violence, and history of drug or alcohol abuse may be considered by the courts.

The authors pointed out that psychiatrists and mental health clinicians routinely interface with individuals who make statements about using a firearm to inflict injury, and such professionals should consider their duty to warn and protect in these cases. “In other words, now that there exists a legal mechanism for the removal of firearms … mental health providers implicitly could be obligated to recommend an ERPO or at least inform family or law enforcement if they believe an ERPO petition might be warranted,” Frizzell and Chien wrote.

The authors noted that psychiatrists must weigh the patient’s level of risk for gun violence against other considerations, such as patient confidentiality and Second Amendment rights. “In some cases, advising others about initiating an ERPO may be the clinically correct decision—and could save lives,” they concluded.

For related information, see the Psychiatric News article “Resource Document Offers Clinicians Guidance On Risk-Based Gun Removal Laws.”

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Number of College Students Seeking MH Care Nearly Doubles Over Decade

Over the past decade, the percentage of students at U.S. college campuses seeking mental health care has increased significantly—from 19% in 2007 to 34% in 2017, according to a study published Monday in Psychiatric Services. The most common location for the college students to receive these services was on campus, the study found.

“This study provides the most comprehensive evidence to date regarding upward trends in mental health service utilization on U.S. campuses over the past 10 years,” wrote Sarah Ketchen Lipson, Ph.D., Ed.M., of Boston University School of Public Health and colleagues. “To better meet the mental health care demand from students and reduce strain on existing services, campuses may wish not only to expand capacity but also to increase the use of preventive and digital mental health services, such as those delivered via mobile apps.”

For the study, Lipson and colleagues analyzed 10 years of data collected for the Healthy Minds Study—an annual web-based survey examining mental health, use of mental health services, and related issues among undergraduate and graduate students. Students at participating institutions were randomly recruited to participate in the survey by email and were required to be at least 18 to participate.

Of the 155,026 students (56.5% female; 74.0% white) from 196 campuses included in the sample, 26.9% screened positive for depression, and 8.2% reported suicidal ideation within the past year. Students most commonly reported receiving services for mental health care on campus, with rates increasing from 6.6% in 2007 to 11.8% in the 2016-2017 academic year. The rate of students reporting past-year treatment increased from 18.7% in 2007 to 33.8% in 2016-2017, with similar patterns for both therapy/counseling and medication use. The proportion of students with a diagnosed mental health condition also increased over this period, from 21.9% in 2007 to 35.5% in 2016-2017.

Between 2007 and 2017, students reported less stigma regarding mental illness: the percentage of students who agreed with such statements as “most people think less of a person who has received mental health treatment” (perceived stigma) or “I would think less of a person who has received mental health treatment” (personal stigma) dropped from 64.2% to 46.0% and from 11.4% to 5.7%, respectively.

“The trends revealed in this study have strained counseling centers across the country, given that many are underresourced and operate at full capacity with waitlists for much of the year,” the researchers wrote. “There are a multitude of approaches to consider for alleviating this strain, including universal prevention programs and rapid referral to community treatment.”

For more on what colleges can do to help students seeking mental health care, see the Psychiatric News article “Duck Syndrome, Social Media, and Struggling Together” by Matthew C. Fadus, M.D.

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Negative Thoughts, Fears Linked to Risk of Suicide in Patients With Psychosis

Negative thoughts about psychotic experiences and fears of losing mental control may heighten the risk of suicide in patients with psychosis who were not taking antipsychotics, suggests a report in Schizophrenia Bulletin.

“Overall, our findings emphasize the importance of clinicians promoting a recovery-focused and appropriately optimistic outlook when working with people with psychosis, taking care to avoid providing information that might heighten negative illness appraisals and/or fears of losing mental control,” wrote Paul Hutton, Ph.D., of the Edinburgh Napier University in the United Kingdom and colleagues.

Hutton and colleagues analyzed data on 68 patients in a pilot trial designed to assess the effects of cognitive therapy on individuals with schizophrenia who had not taken antipsychotics for at least six months. At the start of the study and follow-ups at nine and 18 months, the researchers measured the patients’ psychotic symptoms using the Positive and Negative Symptom Scale; they also measured negative beliefs and attitudes using the Personal Beliefs About Experiences Questionnaire and the Metacognitions Questionnaire-30.

The researchers found that symptoms of psychosis were more likely to be linked to suicidal thinking at nine to 18 months when the patients held negative thoughts and fears. Negative thoughts and fears about consequences of symptoms leading to loss of mental control accounted for 37 percent of the association between those symptoms and suicidal thinking, according to the report.

According to the researchers, the findings call for randomized, control trials of special therapies that address negative cognitive beliefs, such as metacognitive therapy, metacognitive reflection and insight therapy, and cognitive analytic therapy to examine their effect on suicidal thinking.

“Consistent with previous findings that fears of mental disintegration are strongly associated with suicide in psychosis, our results suggest that the way people appraise their symptoms and their consequences, including whether they [have] heighten[ed] concerns about losing mental control, may partly determine whether [their symptoms] lead to thoughts of suicide,” Hutton and colleagues wrote.

For related information, see the Psychiatric News article “Upping Our Game Against Suicide” by APA Past President Anita Everett, M.D.

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Gene Risk Scores May Predict Antipsychotic Response in Patients With First-Episode Psychosis

A study published today in AJP in Advance suggests that calculating the polygenic risk score (PRS) of a patient with first-episode psychosis can offer clues as to whether he or she will respond to antipsychotics. A PRS involves adding up the total number of genetic variants associated with schizophrenia risk in an individual’s DNA.

“Polygenic risk scores represent the combined effects of many thousands of genetic variants across the entire genome, and better represent the very complex genetic nature of schizophrenia,” said lead study author Jian-Ping Zhang, M.D., Ph.D., an assistant professor at the Feinstein Institute for Medical Research, in a press release.

Zhang and colleagues first analyzed DNA samples from 510 patients with first-episode psychosis who were participating in one of four clinical trials testing antipsychotic medications (two trials in the United States and two in Europe). The researchers identified how many genetic variants associated with the risk of developing schizophrenia each participant had. The total number of variants was used to calculate a polygenic risk score. They next compared the patients’ PRS score with how well they responded to the assigned antipsychotic (which in these four studies included amisulpride, aripiprazole, haloperidol, olanzapine, quetiapine, risperidone, and ziprasidone). The patients were considered to have responded to treatment if they experienced a reduction of 50% or more in total symptom scores from baseline to the 12-week follow-up.

The researchers found that the higher the PRS score a patient had, the more likely he/she would not respond to antipsychotic medication. When the researchers grouped the patients from all of the trials according to high and low PRS scores, they found 60.9% of patients in the low PRS group responded to antipsychotics compared with 52.1% in the high PRS group. The difference was even greater when only the two clinical trials involving people of European ancestry were analyzed; combining these two cohorts, the response rate in the low PRS group was 61.8% compared with 45.8% in the high PRS group.

“The results we found open the door for ‘precision medicine’ approaches to psychiatry, and more specifically, the use of polygene scores as a new technology for the treatment of psychiatric disorders,” said study co-author Todd Lencz, Ph.D., also of the Feinstein Institute, in the press release.

For related information, see the Psychiatric News article “Genetic Variant May Foretell Cognitive Response to Antipsychotics.”

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Meta-Analysis Finds Group CBT Optimal Psychotherapy for Children, Adolescents With Anxiety

Group therapy may work best for children and adolescents with anxiety, a meta-analysis of various psychotherapies found, with group cognitive-behavioral therapy (CBT) showing the greatest effectiveness in reducing anxiety symptoms. The report was published this week in JAMA Psychiatry.

“The results of our analysis suggest that psychotherapy delivered in a group format may generally result in better outcomes than when delivered individually,” wrote Xinyu Zhou, Ph.D., of Chongqing Medical University in China and colleagues. The benefit “may be attributed to the additional exposure of social stimuli and interaction in the group format and thus increasing the efficacy of psychotherapy.”

Zhou and colleagues searched various databases for studies that compared any structured psychotherapy with another (or a control condition) for the acute treatment of anxiety disorders in children and adolescents (18 years or younger). The meta-analysis included 6,625 participants who received one of 11 distinct psychotherapies.

Most (93) of the 101 trials included in the meta-analysis assessed various forms of CBT (individual and/or group CBT, CBT with parental involvement, parent-only CBT, and self-help forms of CBT). Eight studies assessed forms of behavioral therapy (BT), including individual and/or group BT or individual BT with parental involvement.

The authors examined the efficacy of the various psychotherapies, as measured by the change in anxiety symptoms from baseline to the end of therapy and from baseline to the end of follow-up (≤12 months). The authors also examined post-therapy changes in quality of life and functional improvement and the acceptability of the therapies, defined as the proportion of patients who discontinued for any reason during the acute phase of treatment.

The meta-analysis revealed that most psychotherapies were significantly more effective than the wait-list condition posttreatment and at follow-up. However, only group CBT was found to be significantly more effective than other psychotherapies posttreatment and at short-term follow-up. In terms of quality of life and functional improvement, CBT delivered in various ways was significantly beneficial, compared with psychological placebo and the wait-list condition.

The authors found that self-help CBT, such as internet-assisted CBT and bibliotherapy CBT, could be useful clinical tools, since they were more effective at reducing anxiety symptoms than wait-list conditions. However, participants receiving bibliotherapy were 2.5 times to more than 9 times more likely to discontinue treatment, compared with other psychotherapies and control conditions.

“This network meta-analysis suggests that group CBT might be considered as the initial choice of psychotherapy for anxiety disorders in children and adolescents; however, more research is needed to confirm such conclusions,” the researchers wrote.

For related information, see the Psychiatric News article “Childhood Anxiety Can Be Treated—the Challenge is to Recognize It.”

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