More Seasons of NFL Play May Be Associated With Increased Risk of Cognitive Problems, Depression

The more seasons that NFL players spend playing in the league, the greater their risk of cognitive problems and depression, according to a study published today in The American Journal of Sports Medicine. Former NFL players who reported more concussion symptoms during playing years were at a particularly elevated risk for cognitive problems and depression and anxiety even 20 years after retirement compared with those who reported fewer symptoms, the authors noted.

“Our findings confirm what some have suspected—a consistently and persistently elevated risk for men who play longer and who play in certain positions,” lead author Andrea Roberts, Ph.D., of the Harvard T.H. Chan School of Public Health said in a press statement. “Our results underscore the importance of preventing concussions, vigilant monitoring of those who suffer them, and finding new ways to mitigate the damage from head injury.”

The findings were based on analysis of the responses of 3,506 former NFL players (average age 53 years) to a survey sent by mail or email. Former players were asked about the positions they most often played professionally, the number of seasons they played, and the number of times they experienced concussion symptoms during their careers. The players were also asked how often they experienced cognitive difficulties over the past week and whether they experienced symptoms of depression or anxiety over the past two weeks and/or were taking medication for depression or anxiety. (Cognition-related quality of life was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition–General Concerns. The Patient Health Questionnaire-4 was used to measure depression and anxiety symptoms.)

One in eight survey respondents was categorized as having poor cognition-related quality of life/severe cognitive impairment. Every five seasons of professional play was associated with a nearly 20% increased risk of cognitive problems—with running backs, defensive lineman, and line backers at a more elevated risk of cognitive impairment than kickers and punters. About 1 in 4 respondents reported symptoms or was taking medications for depression or anxiety, and nearly 1 in 5 respondents reported symptoms or was taking medications for both conditions. Length of career also increased risk of depression, with every five years of professional play increasing risk by 9%; there was no relationship between length of career and risk of anxiety.

Former players reporting the greatest number of concussion symptoms were found to be at a 22.3-fold greater risk of cognitive impairment, 6.0-fold greater risk of depression, and 6.4-fold greater risk of anxiety compared with the former players with the lowest number of concussion symptoms, the authors reported.

Roberts and colleagues highlighted several limitations of the study, including the fact the findings relied on respondents’ ability to recall events that for some occurred decades earlier. Nonetheless, they concluded, “Concussion history and life in football appear to be associated with cognitive and mental health complaints. … Active players, along with medical professionals who care for them, might consider their future health in deciding whether to continue a football career following concussion.”

For related information, see the Psychiatric News article “Study Finds High Prevalence of CTE, Other Disorders in Former Football Players.”

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1 of 3 Study Participants Found to Drop Out of SUD Treatment Studies

Roughly 30% of people who participate in studies of in-person psychosocial treatment programs for substance use disorders (SUDs) drop out, a meta-analysis in Addiction has found. Dropout rates varied depending on variables such as patient characteristics, the type of substance targeted, and the number and length of treatment sessions.

“The results can be used to establish a base dropout rate against which existing and new treatments can be compared, allow for more careful planning of clinical trials with respect to dropout expectations, and determine which populations or study design characteristics might be at elevated risk for dropout,” Sara N. Lappan, Ph.D., of the University of Alabama at Birmingham School of Public Health and colleagues wrote.

The researchers used data from 151 studies to estimate dropout rates and identify predictors of dropout. The studies were published between 1969 and 2016, included a total of 26,243 participants, and described treatments for SUDs involving alcohol, cannabis, cocaine, heroin, major stimulants in general, methamphetamine, opioids, tobacco, and use of multiple substances.

When comparing studies on treatments for specific drugs, the researchers found that dropout rates were highest for those that targeted cocaine, methamphetamines, and major stimulants in general. The researchers noted that there are no approved medications for treating stimulant dependence, so symptoms of withdrawal may hinder patients’ ability to complete treatment.

The researchers suggested that one reason for increased dropout in psychosocial SUD treatment studies could be participants’ higher level of disinhibition.

“Indeed, behavioral disinhibition is a predictor of addiction onset, and addictive substances elicit disinhibitory states acutely during the period of … intoxication and chronically via changes to cortical regions implicated in cognitive-behavioral control,” they wrote.

Studies that included a greater number of treatment sessions and longer treatment sessions had higher rates of dropout, as well. Lappan and colleagues noted that the more treatment sessions a program has, the more opportunities there are to drop out.

“Nevertheless, we do not advocate here for fewer and briefer sessions in the treatment of SUD,” they wrote. “Rather, there may be a ‘Goldilocks Zone’ with regard to number of treatment sessions and session length wherein dropout is minimized and efficacy is maximized.”

Lappan and colleagues acknowledged limitations to their meta-analysis, notably that many of the studies were conducted in controlled settings and designed to test the efficacy of treatment in ideal conditions. Therefore, “the current results are unlikely to completely generalize to all real-world populations and settings. Clinical judgement is required to determine the relevance of the present findings to real-world practice,” they wrote.

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Psychiatrists Offer Recommendations to Help Older Adults With Mental Disorders

As the percentage of U.S. adults older than 65 years continues to grow, so too does the need for preventing mental illness among older adults as well as improving clinical services and outcomes for older patients with psychiatric disorders. So said psychiatrists Warren D. Taylor, M.D., M.H.Sc., of Vanderbilt University Medical Center and Charles F. Reynolds III, M.D., of the University of Pittsburgh in an article published today in JAMA Psychiatry.

“There will never be enough geriatricians, so we need collaborative approaches that allow us to improve treatment and reduce disease burden,” Taylor and Reynolds wrote. “Research in these areas requires transdisciplinary and translational team-based science, where psychiatrists and psychologists work with geroscientists, implementation scientists, and social scientists.”

They outlined several areas of emphasis for research that could help reduce the burden of psychiatric illness in older adults:

• Expand suicide prevention efforts, including early identification of those at greatest risk. Despite a rise in suicide rates in other populations, older adults have the highest risk of suicide completion, they noted.
• Develop strategies to prevent the recurrence of psychiatric disorders such as mood and anxiety disorders, which are common in older populations. “While we have substantial information about the acute treatment of these disorders, we know far less about how to keep someone well and avoid future episodes,” they wrote.
• Determine best ways to treat older patients for substance use disorders. This includes careful consideration of possible untreated general medical conditions and risk of cognitive impairment in these patients.
• Continue to investigate the impact of mental illness on general medical disorders. “Beyond addiction, other mental disorders negatively affect the outcomes of medical disorders, including cardiovascular disease and diabetes. Further research is needed to elucidate the biological mechanisms underlying these observations and to identify specific targets where intervention may improve both mental and physical prognosis,” they wrote.
• Elucidate the contribution of mental disorders to cognitive decline and dementia risk. Depression and other mental disorders accelerate cognitive decline and increase risk of dementia. The mechanism underlying this relationship remains unclear, which complicates efforts to reduce this risk and preserve long-term cognitive function in this population, they wrote.

Although “these challenges are daunting … [w]e have a moral obligation to care for the most vulnerable in our society,” Taylor and Reynolds concluded. “We need better research and clinical services focused on mental disorders in the elderly, along with integrated interventions promoting resilience, wellness, and successful aging.”

For related information, see The American Psychiatric Publishing Textbook Of Geriatric Psychiatry, Fifth Edition and the Psychiatric Services article “Gold Award: Providing Accessible, Affordable, and Stigma-Free Behavioral Health Care for Older New Yorkers.”

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Sertraline-Olanzapine Combo Found to Reduce the Risk of Relapse in Patients With Psychotic Depression

A study in JAMA supports the combined use of an antidepressant and antipsychotic for maintenance treatment of patients with psychotic depression. In this 36-week study, patients with psychotic depression who achieved remission while taking sertraline plus olanzapine were far less likely to relapse if they continued on this combination therapy compared with those who discontinued olanzapine.

An antidepressant-antipsychotic combination is a frontline strategy for the acute treatment of psychotic depression, but once patients respond, there is no clear-cut long-term strategy, explained study author Alistair Flint, M.B., of the University of Toronto and colleagues. “This is a critical question because premature discontinuation of antipsychotic medication has the risk of relapse of a severe life-threatening disorder. In contrast, the unnecessary continuation of an antipsychotic agent exposes a patient to potentially serious adverse effects.”

For the study, Flint and colleagues relied on data from the second part of a large multistage trial known as The Study of the Pharmacotherapy of Psychotic Depression. The participants included 126 adults aged 18 and older with psychotic depression who had achieved remission or “near remission” of their symptoms following up to 12 weeks of sertraline (150 mg/day to 200 mg/day) and olanzapine (15 mg/day to 20 mg/day) combination therapy. Remission was defined as the absence of delusions and hallucinations as well as a score of 10 or less on the Hamilton Depression Rating Scale (HDRS) for two consecutive weeks; “near remission” was defined as the absence of delusions and hallucinations, an HDRS score of 11 to 15 with a drop in HDRS score of 50% from baseline, and being rated as “very much improved” or “much improved” on the Clinical Global Impression scale.

After remaining on both medications for eight additional weeks, the participants were randomly assigned to either continue their combination therapy of sertraline and olanzapine or have their olanzapine pills switched over to placebo pills over a four-week period. The participants were monitored for up to 36 weeks.

At the end of the trial, 20.3% of patients randomized to olanzapine and 54.8% randomized to placebo experienced at least one relapse. Patients who continued taking olanzapine experienced greater increases in weight gain than those who discontinued olanzapine.

“Relapses resulted in a high frequency of psychiatric hospitalization, highlighting the severity and cost of this disorder and the importance in preventing relapse,” Flint and colleagues wrote.

For related information, see the Psychiatric News article “Benefits of Maintenance Antipsychotics Outweigh Risks, International Panel Concludes.”

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APA Welcomes Administration’s Proposal to Coordinate Care for SUD and General Medical Care

APA and a group of nearly 50 health care organizations are welcoming a proposed rule to change federal regulations that govern the confidentiality of patient records created by federally assisted substance use disorder treatment programs.

The Department of Health and Human Services (HHS) issued the proposed rule today in the Federal Register. It would revise regulations known as “42 CFR Part 2” to support coordinated care among different health care professionals who treat patients with substance use disorders (SUDs) while maintaining privacy safeguards (for instance, patients would still need to give consent in order for their records to be shared). APA is reviewing the rule and will be submitting comments.

First formulated in the 1970s, the 42 CFR Part 2 regulations restrict the sharing of medical records related to substance use treatment. The regulations were originally intended to protect patient confidentiality, but they make it difficult for health care professionals to know whether a patient is being treated for or has a history of substance use disorder.

As part of the Partnership to Amend 42 CFR Part 2, APA and the other health care organizations have been calling for alignment of 42 CFR Part 2 with the Health Insurance Portability and Accountability Act (HIPAA) regulations to allow for information sharing by health care professionals involved in the care of a patient with SUD. The partnership hailed today’s proposed changes as an important step toward integrating mental health and substance use disorder treatment and general medical care for patients with SUD.

“We appreciate the support provided by the administration to align 42 CFR Part 2 with HIPAA and its efforts through regulation to better allow information to flow between health care professionals to provide safer and better care for our patients with substance use disorders,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a press statement. “This is a good step forward in breaking down barriers for people with substance use disorders to receive effective integrated care. We will continue to work with the administration and Congress to address the remaining barriers.”

(In June, the AMA House of Delegates voted to support alignment of 42 CFR Part 2 with HIPAA, a significant victory for the APA delegation to the House.)

According to HHS, the proposed rule is the first of four regulations that have been identified in HHS's “Regulatory Sprint to Coordinated Care,” which seeks to promote value-based outcomes for patients by examining federal regulations that impede coordinated care among health care professionals.

HHS has prepared a fact sheet about the proposed rule. For related information, see the Psychiatric News articles “APA Pushes to Reform Outdated Regulation Jeopardizing Care for SUD Patients” and AMA Backs Alignment of Regs Governing SUD Treatment Records With HIPAA.

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APA Speaks Out Against Administration Effort to Replace Flores Settlement

APA is speaking out against the Trump administration’s attempt to nullify a longstanding legal settlement that limits the time that migrant children can be kept in detention.

The Department of Homeland Security today issued a rule that seeks to replace the Flores Settlement Agreement, the federal consent decree that has set basic standards for the detention of migrant children and teenagers by the United States since 1997. The new rule could expand family detention and increase the time children spend in custody.

According to a report in The Washington Post, Homeland Security officials said the rule would eliminate a 20-day cap for detaining migrant children and create a new license regime that would make it easier for federal officials to expand family detention nationwide. The new rule will require the approval of a federal judge.

APA President Bruce Schwartz, M.D., said in a statement that the move will harm children. “A substantial body of research shows that stressful events during childhood can lead to long-term developmental, learning, and health problems, not to mention a heightened risk of depression, anxiety, and posttraumatic stress disorder,” he said. “The Flores Settlement Agreement was intended to protect the well-being of children who are detained by immigration authorities, but the new rule would endanger their mental health by eliminating the 20-day limit on detainment and weakening licensing requirements of detention centers.”

Flores is a 1997 legal settlement of lawsuits filed on behalf of minors by immigration advocates against what was then known as the Immigration and Naturalization Service (INS) for alleged maltreatment of migrant children. The settlement requires the government to release children from immigration detention without unnecessary delay to their parents, other adult relatives, or licensed programs. It also requires immigration officials to provide detained minors a certain quality of life, including food, drinking water, and medical assistance in emergencies.

“The children and families seeking asylum at the U.S. borders are already coping with the effects of the stress and trauma of leaving their home countries,” Schwartz said. “Compounded by the current conditions of detention centers, we urge the administration to consider the long-lasting, harmful impacts of this policy and withdraw this rule.”

For related information see the Psychiatric News article, "APA Maintains Pressure on Administration Regarding Welfare of Migrant Children."

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Risk for Psychiatric Disorders, Suicide Higher in Children With IBD

Children with inflammatory bowel disease (IBD) may be at higher risk for psychiatric disorders and suicide attempt, according to a large, population-based study published in JAMA Pediatrics.

The risk for psychiatric disorders and suicide among children with IBD was greater when compared with siblings without IBD, indicating that the risk is likely related to IBD itself and not to genetic or environmental factors shared with siblings.

"Particularly concerning is the increased risk of suicide attempt," wrote Agnieszka Butwicka, M.D., Ph.D., of the Karolinska Institute in Sweden and colleagues. "Long-term psychological support should therefore be considered for patients with childhood-onset IBD."

The study included all children born in Sweden between 1973 and 2013. Researchers compared those who were diagnosed with ulcerative colitis (n=3,228), Crohn's disease (n=2,536), or IBD-unclassified (n=700) before age 18 with 323,200 matched controls and 6,999 siblings without IBD. The average age at diagnosis of IBD was 14.

The primary outcome was any psychiatric disorder and suicide attempt during a median follow up of nine years. Secondary outcomes were diagnoses of specific disorders including psychotic, mood, anxiety, eating, and personality disorders as well as substance use, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, and intellectual disability.

The risk of any psychiatric disorder was increased in all IBD subgroups, with a hazard ratio (HR) of 1.6. This increased risk for any psychiatric disorder was especially high the first year after an IBD diagnosis (HR=3.5). While the risk for suicide was increased throughout the follow-up period (HR=1.4), the risk was significantly higher five or more years after an IBD diagnosis (HR=1.5).

IBD also was significantly associated with mood disorders, anxiety disorders, eating disorders, personality disorders, ADHD, and autism spectrum disorders.

“This high risk of psychiatric disorders was observed among individuals with very early onset IBD and those whose parents had a history of psychiatric disorders, suggesting that these groups may be particularly vulnerable,” the researchers wrote. "The highest risk of anxiety and mood disorders during the first year after a diagnosis of IBD suggests the need for psychological support for these patients.”

For related information, see the Psychiatric News article "Childhood Stomach Pains May Foretell Adult Psychiatric Disorders."

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Depression, Substance Use Rising Among Former Cigarette Smokers

The prevalence of depression and substance use is rising among former cigarette smokers, potentially putting them at risk for relapsing to smoking, a study in the American Journal of Preventive Medicine has found. Moreover, this increase could threaten the progress that has been made at a population level in reducing cigarette use.

Keely Cheslack-Postava, Ph.D., of Columbia University, and colleagues analyzed data from the National Survey on Drug Use and Health (NSDUH) to determine trends in major depression, alcohol use, and marijuana use among more than 67,000 adult former smokers. The NSDUH is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration that asks participants about substance use, mental health, and more.

In 2016, 6.04% of former smokers had experienced a major depressive episode within the previous year, up from 4.88% in 2005. From 2002 to 2016, past-year marijuana use nearly doubled from 5.35% to 10.09%, and past-month binge alcohol drinking increased from 17.22% to 22.33%.

“What seems of potential interest here from a tobacco control perspective is that recent data suggest that depression, marijuana use, and alcohol misuse among former smokers are associated with significantly increased risk for relapse to cigarette use,” the researchers wrote.

“Addressing risk factors for smoking relapse that are increasing among former smokers may aid them in long-term abstinence and avoidance of relapse to smoking and the consequent harmful consequences of active smoking,” they continued. “Therefore, former smokers should be continually monitored for relapse to smoking as well as for behaviors that are related to smoking relapse. In addition, public health and clinical interventions can target modifiable risk factors and reduce the likelihood of relapse.”

For information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco.”

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Mitral Valve Prolapse More Prevalent in Patients With Panic Disorder, Study Finds

Mitral valve prolapse (MVP), which occurs when the valve between the left upper and lower chambers of the heart does not close properly, is significantly more common in patients with panic disorder/agoraphobia, according to a meta-analysis in Psychosomatics (The Journal of Consultation-Liaison Psychiatry). The findings confirm longstanding speculation that the two conditions are linked.

"This highlights the need of a careful cardiac examination in patients with [panic disorder], many of which also suffer from MVP,” wrote Umit Tural, M.D., and Dan V. Iosifescu, M.D., M.Sc., of The Nathan S. Kline Institute for Psychiatric Research at NYU Langone Health.

Also known as “click-murmur syndrome” because it creates a murmur in the heartbeat, MVP is not life threatening in most cases and typically does not require treatment. However, severe cases of MVP can lead to serious complications such as stroke and have been linked to sudden cardiac arrest.

The meta-analysis included 14 studies comprising 1,146 participants. To be included in the analysis, the study must have included patients diagnosed with either panic disorder or agoraphobia (PD/A) and healthy controls and must have reported the prevalence of MVP in the PD/A groups. (PD and agoraphobia were considered together because the two conditions, as described in DSM, often overlap and share common symptoms.)

Based on the analysis, prevalence of MVP was nearly three times higher in patients with panic disorder or agoraphobia compared with healthy controls: 27.2% versus 9.2%, respectively. Patients with PD/A had more than twice the risk of MVP compared with controls. Age did not significantly modify the risk, according to the study.

Beyond the immediate clinical implications, the findings raise a host of questions for further research about biological explanations for the strong association between MVP and panic disorder, whether the association is causal, and how MVP may modify the course of panic disorder or affect response to treatment.

“Clinicians treating patients with [panic disorder] should be aware of the high prevalence of MVP and of its possible consequences,” Tural and Iosifescu concluded. “However, more studies are needed to explore the biologic shared mechanisms between MVP and PD/A.”

For related information, see the Psychiatric News article “Cardioprotective Treatments After Heart Attack Can Help Patients With Schizophrenia Live Longer.”

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Childhood Abuse May Impact Development of Close Social Bonds as Adults

Adults who experienced significant abuse or neglect during childhood may exhibit a preference for more “personal space” and discomfort with some types of social touching, reports a study in AJP in Advance.

“This sensory dysregulation may explain why individuals with severe childhood maltreatment often suffer from difficulties in establishing and maintaining close social bonds later in life,” wrote Ayline Maier, M.Sc., of the University of Bonn in Germany and colleagues. “Our results may have important implications for the understanding and effective treatment of childhood maltreatment and associated psychopathology.”

Maier and colleagues enrolled 92 adults who were not taking psychotropic medications and who had varying exposure to childhood maltreatment as assessed by the 25-item Childhood Trauma Questionnaire, which measures emotional, physical, and sexual abuse as well as emotional and physical neglect. The sample was divided into three groups: 33 adults with low childhood maltreatment (average score of 26), 30 adults with moderate maltreatment (average score of 36), and 29 with high maltreatment (average score of 63).

All participants completed an interpersonal distance assessment, whereby they slowly moved toward an unfamiliar person until they felt uncomfortable, and a social touch assessment, in which they received either slow or fast hand movements on their shins while undergoing MRI testing.

The data showed that adults in the high-maltreatment group reported a significantly greater amount of ideal personal space between them and another person than those with low maltreatment (about 35.5 inches versus 31.5 inches apart). The adults with high childhood maltreatment also reported more discomfort with fast shin touches compared with adults with low maltreatment. This increased discomfort correlated with greater activity in the sensory regions of the frontal cortex, suggesting that the brain is preparing a flight-or-fight decision in response to the touch, Maier and colleagues wrote.

Cognitive-behavioral therapy approaches do not directly address sensory-related discomfort that many of these individuals experience, the researchers noted. However, previous research has shown the effectiveness of massage for patients who have been sexually abused or have PTSD. The researchers concluded that the use of body-based interventions “could help individuals with a history of childhood maltreatment to facilitate their participation in social interactions by learning to tolerate and enjoy the comforts of social touch in a safe environment.”

To read more about this topic, see the Psychiatric News article “Prospective Study Delves Deeper Into Mental Health Effects of Childhood Trauma.”

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Military Personnel With Suicidal Ideation Less Likely to Store Firearms Safely at Home

Military personnel who have firearms at home and a history of thoughts of death or self-harm are less likely to store their firearms in a safe manner than those with no such history, a study in JAMA Network Open has found.

Craig J. Bryan, Psy.D., of the National Center for Veterans Studies at the University of Utah and colleagues examined the firearm storage practices of 1,652 active-duty military personnel who were seen in military primary care clinics between July 2015 and August 2018. They used the Behavioral Risk Factor Surveillance System to ask participants about firearm ownership and defined safe storage as keeping firearms locked up and unloaded. They used the Self-injurious Thoughts and Behaviors Interview to assess participants’ lifetime history of suicidal ideation and attempts and item 9 of the Patient Health Questionnaire-9 to assess whether the participants had thoughts of death or self-harm in the preceding two weeks. 

Of 1,652 study participants, 590 (36%) reported a firearm in or around their home. The researchers found that participants who had recent thoughts of death or self-harm were 39% less likely to have a firearm in the home than participants who did not have such thoughts. However, among all participants who reported keeping firearms in the home, those with a lifetime history of suicidal ideation were 53% less likely to store their firearms safely than those with no such history, and those with recent thoughts of death or self-harm were 74% less likely to store their firearms safely. 

“This highlights the importance of emphasizing safe storage of personally owned firearms, including temporary removal of access to firearms for high-risk personnel,” the researchers wrote. “Further research focused on firearm availability and storage practices among military personnel is warranted.”

For related news, see the Psychiatric News article “How to Reduce Risk of Suicide by Firearms.”

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LAIs May Lower Rehospitalization Risk in Older Patients With Schizophrenia

Older people with schizophrenia who are treated with long-acting injectable antipsychotics (LAIs) are less likely to be rehospitalized than their peers who are treated with oral antipsychotics, suggests a study in the American Journal of Geriatric Psychiatry.

Ching-Hua Lin, M.D., Ph.D., of the Kaohsiung Municipal Kai-Syuan Psychiatric Hospital in Taiwan and colleagues followed 1,168 patients aged 60 years or older who were discharged from the public psychiatric hospital between 2006 and 2017. The patients had either schizophrenia or schizoaffective disorder, 151 were discharged on LAIs, and 1,017 were discharged on oral antipsychotics. The researchers reviewed rehospitalizations that occurred within a year of discharge for both groups of patients, including those who had exhibited significant psychotic symptoms, dangerous or violent behavior, or a decline in functioning.

Eighty-one patients (53.6%) in the LAIs group and 672 (66.1%) in the oral antipsychotics group were rehospitalized within one year of discharge. Patients in the LAIs group had a significantly longer time to rehospitalization, a median of 257 days compared with a median of 115 days for those in the oral antipsychotics group. When reviewing the patients’ records, the researchers found that shorter hospitalizations and fewer hospitalizations prior to the study were also associated with a longer time between discharge and rehospitalization.

Lin and colleagues noted several limitations to their study, notably that the follow-up was only one year, and longer follow-up may reveal other differences between the two groups. Additionally, all patients were discharged from a single facility in Taiwan, so results may not be generalizable to other facilities and countries.

“In the future, further studies focusing on factors associated with risk of rehospitalization and effective interventions to prevent rehospitalization should be explored,” they wrote.

For related news, see the Psychiatric Services article “Comparison of Injectable and Oral Antipsychotics in Relapse Rates in a Pragmatic 30-Month Schizophrenia Relapse Prevention Study.”

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Refugees at Greater Risk of Developing Psychotic Disorders, Meta-Analysis Finds

The risk for schizophrenia and other psychotic disorders is higher among refugees than native populations and nonrefugee migrants, suggests a report published today in JAMA Psychiatry.

“Refugees do not migrate deliberately but are forced to migrate and have possibly faced traumatic experiences before and during migration,” wrote Lasse Brandt, M.D., of Charité-University Medicine Berlin and colleagues. Migration combined with separation from social networks, social exclusion and discrimination, limited access to medical care, poverty, and more may make refugees especially vulnerable to developing mental illness, they added.

Previous studies have pointed to migration as a risk factor for developing nonaffective psychoses, such as schizophrenia, schizoaffective disorder, and schizophreniform disorders. Brandt and colleagues wanted to know how the incidence of these mental illnesses in refugee migrants compared with incidence in both nonrefugee migrants and native groups in a host country.

Based on an analysis of nine studies published between 2004 and 2018, which included 540,000 refugees in Canada, Denmark, Norway, and Sweden, the researchers found that refugee migrants were 40% more likely to have a first diagnosis of nonaffective psychoses than nonrefugee migrants and 140% more likely than native populations of the host country.

“We believe that these findings highlight the need for psychiatric prevention strategies and outreach programs for refugees,” concluded Brandt and colleagues.

The researchers noted several study limitations; for example, eight of the nine studies were from Scandinavian countries, questioning whether the findings are applicable to other regions. Additionally, “despite the similarity in geographic location and study methods among included studies, their heterogeneity [across studies] was considerably high,” they wrote.

Nonetheless, in an accompanying editorial, Kristina Sundquist, M.D., Ph.D., of Lund University in Sweden noted, “because the risk of nonaffective psychoses in refugees was significantly increased (both compared with nonrefugee migrants and the native population) in countries with a generous welfare system and almost universal health care coverage, … refugees in other parts of the world may have even higher relative risks for several psychiatric disorders, including nonaffective psychoses.” She added, “The observed risk increases of nonaffective psychoses in refugees highlight the need for extended support, which may include psychiatric care specifically tailored for this vulnerable subgroup in the population. Support to refugees may also encompass other health-promoting efforts to prevent psychiatric disorders from occurring.”

For related information, see the Psychiatric News article “GWU Group Helps Train Refugee Aid Workers.”

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Youth Who Use E-Cigarettes May Be More Likely to Use Marijuana, Study Finds

Adolescents and young adults who use e-cigarettes are more likely to use marijuana, according to a meta-analysis published Monday in JAMA Pediatrics.

“These findings, which show a significant association between two psychoactive substances that have long-term deleterious effects on the brain, have important public health implications: Addressing [e-cigarette] use and doing so early may be an effective way of delaying onset of marijuana use,” Nicholas Chadi, M.D., M.P.H., of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital and colleagues wrote.

Chadi and colleagues searched several databases for studies comparing rates of marijuana use among youth aged 10 to 24 years with and without a history of e-cigarette use. They also searched through abstracts and reports from major substance use and tobacco prevention associations and conferences and summary reports on the health effects of e-cigarettes.

A total of 21 studies, including three longitudinal studies representing 14,364 participants and 18 cross-sectional studies representing 113,863 participants, were included in the meta-analysis.

The authors found that youth who used e-cigarettes were more than three times as likely to be using or have used marijuana. Additional analysis revealed e-cigarette users under 18 were more likely to use marijuana compared with e-cigarette users over 18.

“While the long-term health outcomes of using newer [electronic nicotine-delivery systems] devices is not yet well understood, e-cigarette liquids contain several known toxins. Chronic exposure accruing over a lifetime for individuals who initiate use early is a particular concern,” the researchers wrote. “It is well established that the younger the age at onset of substance use, the higher the likelihood of developing a substance use disorder later in life.”

For related information, see the Psychiatric News article “FDA Warns Some E-Cigarette Users Having Seizures, Particularly Youth.”

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Behavior Modification Found to Be Effective for Managing Pediatric Aggression

A behavior modification program that features positive and negative incentives reduced the use of psychotropic medications and/or physical interventions to manage agitated outbursts in children hospitalized for aggression, compared with a program that relied on verbal de-escalation techniques. The findings were published online by the Journal of the American Academy of Child & Adolescent Psychiatry.

“[O]ur data support the effectiveness of the [behavior modification program] and suggest that verbal attempts to calm the raging child can be counterproductive,” wrote Gabrielle Carlson, M.D., of the Renaissance School of Medicine at Stony Brook University and colleagues.

Carlson and colleagues assessed research and medical records of five cohorts of children admitted to Stony Brook’s 10-bed children’s psychiatric inpatient unit for aggressive behavior between 2008 and 2018. During this time, the facility transitioned away from a behavior modification program (BMP)—which involved collaborative problem-solving therapy coupled with positive rewards for good behavior and “time outs” for bad behavior—to reduce aggression. The unit switched to a program that used verbal de-escalation or distraction to talk children down from what the authors described as “intensely emotional situations.” Carlson and colleagues noted the switch was due to a perceived inability to provide enough incentives for good behavior as well as a belief that “time outs” were a form of physical restraint.

The final analysis included 347 children admitted during BMP use and 163 admitted during de-escalation use. The researchers found that the use of medications like sedatives or antipsychotics to reduce agitation was significantly lower when BMP was in use. “As needed” medical sedation was used 163 times per 1,000 patient-days when BMP was used compared with 483 times per 1,000 patient-days when de-escalation was used. The need for seclusion or physical restraint also was lower with BMP than with de-escalation (17 times versus 65 times, respectively, per 1,000 patient-days).

“Perhaps the increased attention given to the agitated child by continually talking to him/her, encouraging skill use, and sometimes giving children what they wanted to limit frustration inadvertently reinforced the unwanted behaviors,” wrote Carlson and colleagues as a possible explanation for why verbal de-escalation strategies increased the use of medication and/or restraint. They also suggested that under the de-escalation strategy children may have learned that aggression was a good way to avoid doing an unpleasant task, since staff sometimes let children get their way to calm them. However, the authors also noted the differences seen in outcomes between the two approaches may have been the result of the staff being less familiar with the technique. “It is possible that staff wasn’t adequately trained to execute de-escalation interventions correctly, biasing findings in favor of [BMP],” they wrote.

To read more about this topic, see the American Journal of Psychiatry article “Brain Mechanisms of Attention Orienting Following Frustration: Associations With Irritability and Age in Youths.”

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Clinicians Warned to ‘Be Alert’ to Ramifications of Conversion Therapy

Despite outspoken opposition to conversion therapy—practices that seek to change an individual’s sexual orientation or gender identity—by multiple professional medical organizations, only 18 states, Puerto Rico, and Washington, D.C., have banned conversion therapy for minors. As a result, it is estimated that more than 16,000 LGBTQ adolescents in the United States will undergo conversion therapy with a licensed health care professional by the time they reach 18 years of age, according to the Williams Institute at the UCLA School of Law.

In an article published yesterday in the New England Journal of Medicine, Carl G. Streed Jr., M.D., M.P.H., of Boston Medical Center and colleagues traced the history of the emergence of conversion therapy and later recognition by the medical community of its harmful effects. They cautioned clinicians to “be alert” to the needs of patients who may have received conversion therapy.

“Studies of adults who underwent conversion therapy earlier in life document a range of health risks,” Streed and colleagues wrote. Some of these health risks were highlighted by a 2018 study comparing LGBTQ young adults who had been encouraged to attend conversion therapy with those who had not, the authors noted. The study found youth whose parents or caregivers encouraged conversion therapy or reported being sent to therapists and religious leaders for conversion interventions were more likely to have depression, suicidal thoughts, suicidal attempts, less educational attainment, and less weekly income than those who had not been encouraged to seek or exposed to conversion therapy.

“Clinicians can be alert to the profile of a typical conversion-therapy participant. Patients involved in conversion therapy may not volunteer relevant information to a health care provider and may go out of their way to conceal their participation,” Streed and colleagues wrote. “Many survivors of conversion therapy will need treatment for posttraumatic stress disorder and post-religious trauma.”

Many medical professional organizations have acknowledged the risks of conversion therapy and oppose its use, the authors noted. Since 1998, APA has opposed any psychiatric treatment, such as “reparative” or conversion therapy, which is based upon the assumption that homosexuality is a mental disorder or that a patient should change his/her homosexual orientation. Other medical organizations to voice opposition to the use of conversion therapy include the AMA, the World Psychiatric Association, the American Psychological Association, the American Academy of Pediatrics, and the American College of Physicians.

“Beyond ending harmful practices [of conversion therapy], supporting the acceptance and inclusion of people of all gender identities, gender expressions, and sexual orientations is critical,” Streed and colleagues wrote. Clinicians should take steps to educate themselves about LGBTQ patients, including the ramifications of conversion therapy, they continued.

“According to a draft of the U.S. Joint Statement on Conversion Therapy, a consensus statement being prepared by more than a dozen health care organizations, medical officials should take into account developmental considerations for each stage of the lifespan when caring for patients and should be prepared to offer supportive therapies and provide accurate information and resources for all LGBTQ patients and their families,” they concluded. “We believe it is vital for clinicians to understand both the scientific and the ethical hazards of conversion therapy and appropriate responses for survivors and at-risk patients and to help create supportive environments for all LGBTQ persons.”

For related information, see the Psychiatric News article “SAMHSA Report Calls for End to ‘Conversion’ Therapy for Youth” and APA’s most recent position statement on conversion therapy.

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Time for Action on Firearm Violence Is Now, Says APA

APA on Wednesday joined six other physician and health professional organizations in calling for action to address the public health epidemic of firearm-related injury and death.

“Our nation is in the midst of an epidemic of firearm-related injuries and deaths, and we must treat this as a public health crisis,” APA President Bruce Schwartz, M.D., said in a press release. “We see the long-lasting mental health impact firearm-related violence and injury has on our patients every day, and it is time for us to come together as a nation to address this epidemic.”

The call to action was published yesterday in the Annals of Internal Medicine. In the article, Schwartz and leaders from the AMA, American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, and the American Public Health Association outlined several specific policy recommendations to prevent firearm-related injury and death in the United States. These recommendations include the following:

• Comprehensive criminal background checks for all firearm sales.
• Further research into the causes and consequences of firearm injury and death.
• Improved access to mental health care and caution against broadly including all individuals with a mental health disorder in a category of individuals prohibited from purchasing firearms.
• Removal of barriers to physician counseling of patients about the health risks of firearms.
• Reasonable laws and regulations governing firearms with high-capacity magazines and other features for rapid firing.
• Enactment of extreme risk protection order laws, which allow families and law enforcement to petition a judge to temporarily remove firearms from individuals at imminent risk for using them to harm themselves or others.

“Across the United States, physicians have daily, firsthand experience with the devastating consequences of firearm-related injury, disability, and death. We witness the impact of these events not only on our patients, but also on their families and communities,” they wrote. “As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society.”

“The house of medicine is unified in this call,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in the press release. “The time for action is now.”

For related information, see the Psychiatric News articles “Most Americans Agree That Gun Violence Is Public Health Problem, Call for Action” and “Gun Violence: The Parkland Survivors and the End of Learned Helplessness?”

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College Program May Change Student Attitudes About Mental Illness

Years after the launch of a campus program to reduce stigma around mental illness at Indiana University, some college students there reported less prejudice toward people with mental illness, according to a study in the Journal of the American Academy of Child & Adolescent Psychiatry. The students also reported a greater willingness to talk about mental illness after exposure to the program.

“A long-term, community-based, student empowerment approach with institutional supports is a promising avenue to reduce stigma on college campuses, develop the next generation of mental health leaders, and potentially reduce societal levels of stigma in the long run,” wrote Bernice A. Pescosolido, Ph.D., of Indiana University (IU) and colleagues.

The U(niversity) Bring Change to Mind (UBC2M) program is a student-led effort to create “safe and stigma-free zones” on college campuses that was developed and launched in 2014. Through UBC2M, Indiana University students led such activities as biweekly club meetings; academic and on-campus events, including guest and student speakers who talked about personal experiences with mental illness; an annual campus anti-stigma campaign competition; and an annual UBC2M gala.

To examine the impact of the program, Pescosolido and colleagues invited first-year students to complete a web-based survey on stigma. The survey asked students to consider how strongly they agreed with statements reflecting prejudice toward people with mental illness, such as the following: “I am frightened to be around persons with a history of mental illness” (general prejudice) and “Students who have a history of mental illness should not be admitted to IU” (college-specific prejudice). The students were asked to complete the web-based survey again during their third year. A total of 1,193 students completed both waves of the survey.

Significant changes in stigma occurred, on average, for about 11% to 14% of the population, the authors reported. Student participation in multiple UBC2M events was associated with reductions in both general and college-specific prejudice toward people with mental illness; these reductions were the greatest in respondents who reported participation in four or more UBC2M-sponsored events since the initial survey.

There was no significant change in general or college-specific prejudice toward people with mental illness in respondents who reported only general awareness of UBC2M (for example, familiarity with program logo and/or exposure to program through social media). However, regardless of the respondents’ level of active involvement with UBC2M activities, those aware of the program reported feeling more open to talk about mental health problems and stigma issues on campus when surveyed during their third year.

“Our finding that active and passive engagement predict more favorable normative beliefs about [mental health] (e.g., perceptions of campus mental health culture, mental health conversation partners) suggests that the program may also shift the larger campus culture [toward greater understanding of mental illness]. Because normative beliefs have a powerful effect on individuals’ attitudes and beliefs, this shift may lead to more widespread and potentially longer lasting stigma reduction.”

For related information, see the Psychiatric News article “Anxious, Stressed, and Lonely College Students Seek Out Campus MH Services” and the Psychiatric Services article “Increased Rates of Mental Health Service Utilization by U.S. College Students: 10-Year Population-Level Trends (2007–2017).”

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Psychotic Symptoms in Childhood May Increase Risk of Poor Mental Health in Young Adulthood

Psychotic symptoms in childhood may indicate an increased risk for mental health problems and poor social outcomes in young adulthood, according to a study in Schizophrenia Bulletin.

Antonella Trotta, Ph.D., of King’s College London and colleagues analyzed data from the Environmental Risk Longitudinal Twin Study to determine whether psychotic symptoms at age 12 were associated with mental, social, and physical outcomes at age 18. As part of this study, 1,116 pairs of same-sex twins were asked at age 12 whether they had experienced psychotic symptoms such as delusions and hallucinations. The participants were interviewed again at age 18 to assess a variety of factors, including their physical health, symptoms of mental illness, life satisfaction, and educational attainment.

The researchers found that children who had psychotic symptoms at age 12 were more likely to have psychotic symptoms, depression, or anxiety at age 18 than their peers who did not have psychotic symptoms at age 12. They were also more likely to have attempted suicide or engaged in self-harm, be obese, smoke cigarettes, be lonely, and report a lower quality of life.

When the researchers compared the twins within families with each other, however, they found “that most of the associations between childhood psychotic symptoms and poor outcomes in young adulthood were explained by familial factors suggesting that early psychotic phenomena could not be considered to be causing later problems.” The exceptions were psychotic symptoms, loneliness, and the overall risk of mental health problems in young adulthood, which were still strongly associated with psychotic symptoms in childhood.

“This finding does not undermine the prognostic significance of childhood psychotic symptoms but indicates that merely reducing the occurrence of these symptoms will not improve mental health and functional outcomes in young adulthood,” the researchers wrote. “These early [psychotic] symptoms may, therefore, act as a useful way of identifying children who are at risk for an array of poor outcomes in young adulthood and who may benefit from preventive interventions. However… such interventions would need to be targeted at [family-wide risk] factors rather than the psychotic symptoms themselves.” 

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

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