Free, Online Training Programs May Decrease Stigma Toward Patients With SUD

Free, online training courses may improve the ability of health care workers in low-resource settings to screen individuals for substance use disorders and provide treatment, according to a report in Psychiatric Services in Advance.

“Our findings contribute to the literature demonstrating that web-based training is an efficient, cost-effective, and fast-emerging means of delivering education and can be as effective in decreasing stigma as the best-practice, in-person forms of training, with the advantage of being more efficient and accessible,” wrote Veronic Clair, M.D., Ph.D., of the Africa Mental Health Foundation and University of British Columbia in Vancouver and colleagues.

Clair and colleagues surveyed 97 health care workers across 14 health care facilities in Kenya who took one of two online-based training courses. This group included 58 lay health care workers who took a substance use screening course and 39 primary care physicians who took a substance use disorders management course. Both courses were developed by the Africa Mental Health Foundation and NextGenU.org, an online portal offering free, accredited educational courses.

Both courses consist of modules that cover the following topics: how to screen for substance use disorder, address stigma related to substance use, and communicate with patients and their families. The management course includes a module on best practices for treating substance use disorder in primary care settings. Each trainee was also assigned a local mentor (a trained psychologist or physician) they could reach out to in person, via phone, and/or online for assistance.

The overall completion rate for both courses was 50%, which the authors noted far exceeds the 8% completion average typically seen for open online courses. The course completers scored high on the final exams for the screening and management courses (average scores of 90% and 88%, respectively).

“The training was acceptable and feasible and was shown in our study to be effective in improving not only [participants’] knowledge, but also skills and attitudes across a wide range of ages, education levels, socioeconomic and professional backgrounds, facility types (from primary care centers to outpatient hospital departments), and locations (large urban centers, small urban areas, and rural settings),” Clair and colleagues wrote.

The participants who completed the courses reported significant decreases in their negative attitudes toward patients with substance use disorders (except for alcohol use disorder). Most participants said they would prefer to take another NextGenU.org-based course over a traditional classroom-based course, and all said that they would recommend these particular courses to their peers.

For related information, see the Psychiatric Services article “Testing a Web-Based, Trained-Peer Model to Build Capacity for Evidence-Based Practices in Community Mental Health Systems.”

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Alcohol Consumption May Increase Dementia Risk in Older Adults

Heavy drinking may increase the risk of developing dementia in older adults who already have mild cognitive impairment, according to a study published today in JAMA Network Open. Mild cognitive impairment causes a small but noticeable change in memory and thinking, whereas dementia interferes with a person’s ability to carry out everyday activities.

Majken K. Jensen, Ph.D., of the Harvard T.H. Chan School of Public Health and colleagues used data from the Ginkgo Evaluation of Memory Study to track the development of dementia in 3,021 people aged 72 years and older. The study was conducted from 2000 to 2008, and the average follow-up for participants was six years. At the beginning of the study, all participants underwent a series of tests to determine their cognitive ability. None of the participants had dementia when they entered the study, but 473 had mild cognitive impairment. Participants underwent cognitive testing every six months (using the Modified Mini-Mental State Examination and the Clinical Dementia Rating scale) until the end of the follow-up period, they were diagnosed with dementia, or they died, whichever came first.

Among participants who had mild cognitive impairment at the beginning of the study, those who drank more than 14 drinks a week were more likely to develop dementia than those who drank fewer than one drink a week. The association between alcohol intake and cognitive decline was affected by the presence of mild cognitive impairment at the start of the study.

“These results suggest that while caring for older adults, physicians should carefully assess the full dimensions of drinking behavior and cognition when providing guidance to patients about alcohol consumption,” the researchers concluded.

For related information, see the American Journal of Psychiatry article “A Geriatrics Perspective on Dementia Prevention and Treatment.”

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Sleep Apnea in Veterans With Serious Mental Illness Linked to Other Comorbidities

People with serious mental illness (SMI) and sleep apnea (a condition that causes breathing to stop and start repeatedly throughout the night) have a higher rate of general medical and psychiatric comorbidities than people with SMI and no sleep apnea, according to a study published in Psychosomatics.

“Appropriate detection, diagnosis, and management of sleep apnea may help to reduce morbidity and mortality risk in individuals with SMI,” wrote Isabella Soreca, M.D., of the VA Pittsburgh Healthcare System and colleagues.

The researchers used an administrative dataset of 33,818 U.S. veterans who visited a primary care doctor at the Department of Veterans Affairs in Pittsburgh in 2007. They analyzed medical records from 2001 to 2011 of this group of patients; these records included general medical, psychiatric, and sleep diagnoses. SMI diagnoses were defined using the International Classification of Diseases (ICD-9) codes for schizophrenia, schizoaffective disorder, and/or bipolar disorder. A sleep apnea diagnosis was defined by the presence of two or more lifetime diagnoses of a breathing-related sleep disorder. Researchers evaluated whether the patient had a chronic condition associated with sleep apnea, such as a cardiac, hypertension, vascular, respiratory, upper gastrointestinal, and/or endocrine-metabolic condition.

Of the veterans with SMI, 13.7% also had sleep apnea; 8.4% of those without SMI had sleep apnea.

“On average, veterans with both SMI and sleep apnea had a significantly higher number of medical comorbidities than those with SMI but no sleep apnea, as well as those with sleep apnea but no SMI,” the researchers wrote. Additionally, those with SMI had a notably higher rate of chronic medical comorbidities even though they were generally younger than those without SMI. Of those with SMI, 19% were between the ages of 40 and 49, compared to just 6% of those without SMI.

“[O]ur data show high prevalence of sleep apnea in veterans with SMI, even in younger groups,” Soreca and colleagues wrote. “The higher prevalence of sleep apnea at an earlier age could be one of the pathways to high cardiovascular morbidity and premature mortality in veterans with SMI and may offer a new target intervention for risk reduction.”

For related information, see the American Journal of Psychiatry Residents’ Journal article “Screening for Sleep Apnea in Psychiatry.”

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Taking Steps to Prevent Pneumonia Could Reduce Risk of Death Associated With Clozapine

Deaths related to the use of the antipsychotic clozapine—already associated with a lower number of deaths than other antipsychotics—could be further reduced by better awareness among clinicians, patients, and families of the risk for pneumonia associated with aspiration (inhalation of saliva).

So say Jose De Leon, M.D., of the Mental Health Research Center at Eastern State Hospital, in Lexington, Ky., and colleagues in an editorial in Schizophrenia Bulletin.

They reviewed data from VigiBase, the global database of the World Health Organization (WHO), which showed that a high percentage of deaths among people who took clozapine were from pneumonia.

Clozapine is widely underprescribed despite a large body of evidence that it is the most effective antipsychotic, especially for patients who have not responded adequately to other treatments, according to the authors. Moreover, a recent meta-analysis also published in Schizophrenia Bulletin found that patients continuously treated with clozapine had a significantly lower mortality rate compared with patients on other antipsychotics.

Vigibase includes 20 million reports of spontaneously reported adverse drug reactions from the drug agencies of 134 countries. De Leon and colleagues searched the database for reports of adverse drug reactions associated with clozapine. They found 4,951 reports of pneumonia during clozapine treatment; 1,654 involved patient deaths. This was the highest of all clozapine-related deaths, indicating that when death related to clozapine occurs (which is relatively rare) there is a 33% chance that pneumonia will be the cause.

“The association between clozapine and increased risk of pneumonia is partly explained because all antipsychotics can interfere with swallowing, increasing the potential for aspiration,” they wrote. “The potential for aspiration and aspiration pneumonia during antipsychotic treatment may be further increased by sedation and hypersalivation. As clozapine is more prone to cause sedation and hypersalivation than other antipsychotics, it is not surprising that it may be more strongly associated with pneumonia.”

To decrease deaths associated with pneumonia, De Leon and colleagues offer the following recommendations for medical professionals:

• Use lower doses of clozapine when possible to decrease risk of hypersalivation, sedation, and swallowing disturbances.
• Educate patients and their families about the risk of pneumonia with clozapine use so they know to contact their clinician when infection occurs.
• Decrease dosage of clozapine when the patient has pneumonia.

William Carpenter, M.D., editor of Schizophrenia Bulletin, reiterated that clozapine is underused and emphasized that the drug does not place patients at greater risk for death compared with other antipsychotic medications. “Using minimally effective dosing may reduce this risk, and reduction of clozapine dosing during infection should be considered,” he said.

For related information, see the Psychiatric News article “Experts Brainstorm How to Expand Clozapine Use.”

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Combining Sleep Aid, Antidepressant May Benefit Some Suicidal Patients

Patients with major depressive disorder who are experiencing insomnia and suicidal thoughts may benefit from taking the hypnotic zolpidem in addition to a selective serotonin reuptake inhibitor (SSRI), according to a study in AJP in Advance.

“Insomnia symptoms are a driver of suicidal ideation,” wrote William V. McCall, M.D., of the Medical College of Georgia at Augusta University and colleagues. The findings suggest that “hypnotic medications are effective for insomnia in suicidal outpatients with major depressive disorder and that the resolution of suicidal ideation positively covaries with resolution of insomnia symptoms.”

The researchers designed an eight-week study with 103 patients aged 18 to 65 who had major depressive disorder, suicidal thoughts, and insomnia and had started to take one of three SSRIs (fluoxetine, sertraline, or citalopram). These patients were randomized into two groups: one group took controlled-release zolpidem (zolpidem-CR), and the other took placebo. During follow-up visits at weeks 1, 2, 4, 6, and 8, the researchers evaluated the participants for suicidal thoughts (using the Scale for Suicide Ideation and the Columbia–Suicide Severity Rating Scale, or C-SSRS), insomnia (using the Insomnia Severity Index), depression (using the Hamilton Depression Rating Scale), adverse events, and more.

Beginning the first week, patients in the zolpidem-CR group reported greater improvements in insomnia compared with those taking placebo; these improvements were predominantly in participants who had reported severe insomnia at the start of the trial.

“We did not find that adding zolpidem-CR to an SSRI provided an advantage in decreasing suicidal ideation scores on the Scale for Suicide Ideation, but we did find an advantage for zolpidem-CR in the suicide ideation score on the C-SSRS. As with the effect in insomnia scores, the effect of zolpidem-CR on C-SSRS suicide ideation scores was numerically greater in those patients with severe baseline insomnia,” McCall and colleagues wrote.

Over the course of the trial, the participants in the zolpidem-CR and placebo groups also showed significant improvements in measures of depression, quality of life, dysfunctional beliefs and attitudes about sleep, and more. However, there were no differences between the treatment groups on any of these outcomes.

“Although the results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia, they suggest that coprescription of a hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients, especially in patients with severe insomnia,” the authors concluded.

For related information, see the Psychiatric News article “Overlapping Symptoms Complicate Diagnosis, Treatment of Psychiatric and Sleep Disorders.”

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Loss of Consciousness, Confusion Following Mild TBI May Predict Delayed Recovery

Patients who lose consciousness and/or become dazed and confused following mild traumatic brain injury (mTBI) are less likely to fully recover within one month compared with mTBI patients without such symptoms, reports a study in the Journal of Neuropsychiatry and Clinical Neurosciences. Patients who experienced both loss of consciousness and a confused state had the highest risk of incomplete recovery one month after sustaining the injury. Among patients who had only one of these symptoms, loss of consciousness was a stronger indicator of incomplete recovery than a confused state.

These findings point to “additional risk factors for incomplete recovery post-mTBI, which will help identify patients who are in need of early psychosocial, rehabilitation, and psychiatric interventions,” wrote Durga Roy, M.D., of Johns Hopkins University School of Medicine and colleagues.

The findings come from an analysis of 407 adults who were admitted to either the Johns Hopkins Bayview Medical Center or Johns Hopkins Hospital emergency room for an mTBI due to blunt head trauma. Eighty-three of these adults lost consciousness (defined as complete or near-complete lack of responsiveness to people and other stimuli at the time of injury), 64 experienced an altered mental state (defined as being dazed, confused, or disoriented within 24 hours of injury), 127 experienced both, and 133 experienced neither. Functional recovery—which reflects how quickly and fully a patient resumes daily life activities, such as employment and social activities—was assessed via telephone or in-person interviews one, three, and six months after the head injury, using the Glasgow Outcome Scale–Extended (GOSE).

After one month, the odds of an incomplete recovery were 45% for patients who did not lose consciousness or have an altered mental state, 55% for patients who lost consciousness, 62% for patients with an altered mental state, and 70% for patients with both loss of consciousness and altered mental state. After adjusting for other clinical variables, Roy and colleagues calculated that loss of consciousness was associated with 2.17 times increased risk of incomplete functional recovery while an altered mental state was associated with 1.80 times increased risk of incomplete recovery after one month. Loss of consciousness also increased the risk of incomplete recovery at three months (though an altered mental state did not), and neither symptom increased the risk of incomplete recovery at six months.

For related information, see the Psychiatric News article “FDA Clears the Way for First Blood Test to Evaluate Head Injuries.”

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Obstructive Sleep Apnea May Increase Depression, Anxiety Risk

Obstructive sleep apnea (OSA) is associated with an increased risk of developing depression and anxiety in adults, a study in JAMA Otolaryngology-Head & Neck Surgery has found. OSA is a condition in which the muscles of the throat relax during sleep and block the airway, which causes breathing to stop and start repeatedly throughout the night. 

Jong-Yeup Kim, M.D., Ph.D., and colleagues at Konyang University in Korea analyzed the health records of 985 adults from the Korea National Health Insurance Service–National Sample Cohort in South Korea database. Between January 2004 and December 2006, 197 patients were diagnosed with OSA. The researchers matched these patients with 788 patients of similar age, sex, income, and more who were not diagnosed with OSA to compare diagnoses of affective disorders between the two groups over the follow-up period.

Over nine years of follow-up, patients who were diagnosed with OSA were nearly three times as likely to develop a depressive disorder and nearly twice as likely to develop an anxiety disorder than those who were not diagnosed with OSA. Women with OSA were more likely to develop these conditions than men.

Kim and colleagues cited prior research of possible reasons why risk of depression and anxiety may be higher in people with OSA, including reduced oxygen saturation (how much oxygen is attached to red blood cells) and increased daytime sleepiness.

“Further studies appear to be needed to validate [our] findings and explore possible underlying mechanisms,” they wrote. “Clinicians may consider taking specific precautions to reduce the risks of development of depressive or anxiety disorders among patients with OSA.”

For related information, see the Psychiatric News article “Overlapping Symptoms Complicate Diagnosis, Treatment of Psychiatric and Sleep Disorders” and the Journal of Neuropsychiatry and Clinical Neurosciences article “Update on Obstructive Sleep Apnea: Implications for Neuropsychiatry.”

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Patients With Fewer Mental Health Symptoms May Fare Worse When Clinicians Leave

As it can both be costly and negatively impact care quality, clinician turnover is a concern within community behavioral health settings. When it comes to patient outcomes, though, a 12-month study published in Psychiatric Services in Advance observed mixed, and surprising, results, suggesting that turnover could have different impacts on patients depending on their initial symptoms.

Researchers found that turnover was associated with harmful effects for patients who were functioning well at the start of the study, yet, “Curiously, we also found that turnover was associated with no changes or positive changes” in patients with more difficulties at baseline, wrote Annalee Johnson-Kwochka, M.S., of Indiana University-Purdue University Indianapolis and colleagues. Patients “who are doing better may have more to lose when clinicians leave,” they noted.

Johnson-Kwochka and colleagues used observational data collected as part of a larger randomized, controlled trial from two community behavioral health centers (one in an urban setting and the other in a rural setting) for their analysis. As part of the trial, patients at the behavioral health centers identified the clinician they saw the most. The researchers also evaluated the participants for symptoms of depression (using the nine-item Patient Health Questionnaire), anxiety (using the Generalized Anxiety scale), and overall physical and mental health functioning (using the 12-item Short Form Health Survey) at the beginning of the study, after six months, and after 12 months. Of the 328 patients included in the analysis, 24% experienced clinician turnover.

Not only was turnover associated with clinical decline for those who had higher functioning at baseline, older patients also experienced a sharper decline.

“An important secondary finding [of this study] was that for physical health functioning, the relationship with turnover was moderated by age,” the researchers wrote. “Thus, for those who are younger, turnover may affect functioning less, possibly because their physical health may be more resilient in the face of disruptions in care.”

For related information, see the Psychiatric Services article “Clinicians’ Perceptions of How Burnout Affects Their Work.”

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Meta-Analysis Highlights Potential Mental Health Benefits of Obesity Treatment for Youth

Despite the known benefits of weight loss for children and adolescents who are obese, some studies suggest that youth who diet may be at an increased risk of depression. A meta-analysis published Monday in JAMA Pediatrics suggests obesity treatment in youth is not associated with an increased risk of depression or anxiety; rather, the analysis points to the mental health benefits of such programs for this population.

“Structured and professionally run obesity treatment with a dietary component is associated with improvements in depression and anxiety for most participants,” wrote Hiba Jebeile, M.Nutr.Diet., of the University of Sydney and colleagues. “Treatment of weight concerns should be considered within the treatment plan for young people with depression and obesity.”

To examine the relationship between obesity treatment interventions and anxiety/depression symptoms in youth who were overweight, the authors searched through electronic databases for studies of interventions for youth who were overweight/obese published between 1987 and 2018. Only studies that evaluated outcomes in youth who participated in interventions with a dietary component (such as nutritional education) and assessed youth for anxiety/depression before and after participating in the intervention were included in the analysis. (Studies evaluating online interventions, pharmacotherapy, and bariatric surgery were not included in the analysis). A total of 44 studies, with a combined sample of 3,702 youth with a mean age range of 5.6 to 16.6 years (BMI range of 24.6 to 44.9), met these inclusion criteria. The duration of the interventions included in the analysis ranged from two weeks to 15 months.

The meta-analysis revealed a small reduction in depressive symptoms in the participants after the intervention, which the authors noted was maintained six months to 16 months from baseline. Similarly, anxiety symptoms were lower in study participants following the interventions and at follow-up.

“Interventions with weekly or fortnightly contact with the study team showed the greatest reduction in depressive symptoms, and longer intervention duration was associated with a larger reduction in anxiety. This may be due to the regular and extended support of a health care team,” Jebeile and colleagues wrote. Additionally, “interventions with a structured exercise program had a greater reduction in anxiety than physical activity education alone. A similar trend, although not statistically significant, was found for depressive symptoms.” They noted that the exercise programs, often delivered in a group format, were offered to participants several times per week, increasing their contact with study personnel and peers.

They concluded, “Overall, obesity treatment interventions are not associated with increased symptoms of depression and anxiety. However, clinicians should be aware that a small proportion of participants may be at risk of developing worsening pathology. Identification of these young people and provision of additional support may improve treatment outcomes.”

For related information, see the Psychiatric News article “Researchers Examine Link Between Mood, Food, and Obesity.”

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Slower Development of Working Memory in Adolescents Associated With Motor Vehicle Crashes

A person’s working memory—which helps one manage complex tasks and maintain attention when faced with distractions—is believed to be a critical element of safe driving. A study in JAMA Network Open has found that adolescents who were involved in a motor vehicle accident had slower development of their working memory than adolescents who were not involved in a crash.

“Monitoring WM [working memory] development across adolescence as part of routine assessment could help to identify at-risk drivers, as well as opportunities for intervention,” wrote Elizabeth A. Walshe, Ph.D., of the Annenberg Public Policy Center at the University of Pennsylvania and colleagues. “Attention and driving-skill deficits due to insufficient [working memory] may be one of the most modifiable risk factors—via experience and skill training.”

Walshe and colleagues analyzed data from a longitudinal study of 118 youth in Philadelphia, who received regular assessments of working memory, sensation seeking, substance dependence, and more between the ages of 11 and 20. A follow-up survey on driving experience identified 84 participants who had a driver’s license and were included in the analysis, and 25 of these drivers reported they had been involved in at least one crash.

All 118 youth performed better on working memory tasks as they grew older, as reflected in their scores rising over time. Additional analysis revealed that working memory gains appeared to slow in the 25 drivers with a crash history; that is, their total score rose less and less each year as they aged. In contrast, the drivers with no crashes showed steady gains in their total scores over time. The youth involved with crashes reported more reckless driving behaviors (like speeding) on average; however, even when factoring in this difference, the authors found that adolescents with slower memory gains had a greater risk of crashing.

Other developmental traits such as the youths’ baseline working memory score, their IQ, or their impulsivity levels were not associated with car crashes, the authors noted.

The rate at which working memory develops “may be an important underlying mechanism of age-graded risk for crashes during adolescent development. However, we do not yet know whether or how [working memory] development may predict crashes and need to further investigate factors that lead to differential trajectories of growth in [working memory] to identify high-risk groups,” Walshe and colleagues wrote. “Future studies should also investigate the role of [working memory] development in the observed increased risk for unsafe driving and crashes among atypically developing populations (e.g., ADHD).”

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Methamphetamine Involved in Rising Number of Heroin Treatment Admissions

Methamphetamine is involved in an increasing number of treatment admissions for heroin, especially among adolescents, a study in Addiction has found.

“The phenomenon of increasing methamphetamine use among people using opioids is of great concern,” Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H., of the Centers for Disease Control and Prevention and colleagues wrote. “Methamphetamine use carries its own risks, including a range of physical and mental health consequences such as psychosis and other mental disorders; cognitive and neurologic deficits; cardiovascular and renal dysfunction; transmission of HIV, viral hepatitis, and sexually transmitted infections; and increased mortality.”

The researchers analyzed data from more than 3.5 million treatment admissions for heroin between 2008 and 2017. The data came from the Treatment Episode Data Set, a national database that provides information on the admissions of people aged 12 years and older to federally funded substance use treatment centers. The percentage of primary heroin treatment admissions reporting methamphetamine use rose each year from 2.1% in 2008 to 12.4% in 2017, an increase of 490%.

In 2017, individuals aged 12 to 24 had the highest rates of admissions for heroin use involving methamphetamine of all the age groups examined: 27.8% of heroin treatment admissions for adolescents aged 12 to 17 years involved methamphetamine, and 17.4% of heroin treatment admissions for young adults aged 18 to 24 involved methamphetamine.

“Not only do these findings highlight a need to focus intervention and treatment efforts aimed at reaching younger age groups, but together with the finding that early age of heroin initiation was associated with methamphetamine use at treatment admission, these findings underscore the importance of expanding policies, programs, and practices that can prevent initiation of these substances in the first place,” the researchers wrote.

Among women, 15.1% of heroin treatment admissions involved methamphetamine in 2017, compared with 10.8% in men. The researchers noted that prior research suggests that females use more methamphetamine and transition from recreational use to dependence more quickly than males.

“Given the increase in risk for negative health outcomes among people using both substances, comprehensive prevention, treatment, and harm-reduction strategies that address the poly-substance nature of opioid use and are appropriately tailored to specific demographic groups and at-risk populations are needed,” Jones and colleagues wrote.

For related information, see the Psychiatric Services article “Use of Drug Treatment Services Among Adults With Opioid Use Disorder: Rates, Patterns, and Correlates.”

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Mothers’ Stress Early in Life Found to Negatively Impact Their Children

A study in AJP in Advance provides further evidence that the detrimental effects of adverse life experiences can carry across generations. Researchers found that children of mothers who experienced stressful events during childhood had greater biological signs of stress and were more likely to have behavioral problems at 18 months.

“[O]ur data, when combined with findings from other studies, confirm maternal life-course experiences as a potent predictor of offspring mental and physical well-being,” wrote Kyle Esteves, M.P.H., of Tulane University School of Medicine and colleagues. “Our results suggest that screening for maternal ACEs [adverse childhood events] in obstetric, pediatric, and child mental health settings may provide an important indicator of risk for both the mother and the child, especially during infancy.”

Esteves and colleagues recruited 237 pregnant women for the study. During a prenatal assessment, study participants were asked to indicate the presence or absence of 10 types of childhood adversity, including abuse, parental mental illness, and divorce on the Adverse Childhood Experiences questionnaire. The women also completed anxiety, depression, and stress assessments during the prenatal assessment.

The mothers and their children returned for follow-up assessments when the children were 4, 12, and 18 months. At these visits, the researchers screened the mothers for postnatal depression and collected cheek swabs from the children for telomere analysis. Telomeres are the protective caps on the ends of chromosomes, and their length is considered a biomarker of biological stress and aging (shorter telomeres are associated with a broad range of age-related diseases). Child behavior was also assessed at the 18-month visit.

The final analysis included 155 mother-child pairs who completed at least two of the three assessments (103 pairs completed all three assessments). The results showed that higher scores on the Adverse Childhood Experiences questionnaire in mothers correlated with shorter telomeres in the children at all time points. Higher scores also correlated with more externalizing problems (for example, temper tantrums) in the children at 18 months, but not internalizing problems (for example, being quiet and withdrawn). Maternal depression also increased the risk of externalizing problems and internalizing problems; however, higher Adverse Childhood Experiences scores remained associated with shorter telomeres and more externalizing problems, even when accounting for maternal postnatal depression.

“Encouraging the widespread utilization of practical screening tools that have clinical utility and capture stressors across the life course and the broader environment in which children develop may enhance our ability to understand the origins of early mental illness and the effectiveness, rather than the efficacy, of current intervention and prevention efforts,” Esteves and colleagues noted. Additionally, such efforts could help identify ways to buffer the negative effects of maternal early adversity, they added.

For related information, see the Psychiatric News article “Researchers Tackle Complexity of Intergenerational Stress Transmission.”

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Getting Patients to Exercise Could Reduce Population Burden of Mental Illness

Could more rigorous efforts on the part of physicians and health systems to encourage people to exercise lower the population-wide burden of mental illness?

In an editorial in JAMA Psychiatry, the author of a study published last year showing that even relatively modest regular exercise has significant beneficial effects on an individual’s mental health said that including exercise in the treatment of mental illness could improve rates of recovery and reduce illness burden.

“[C]linical psychiatry has an ever-increasing need for strategies to reduce the population burden of mental illness,” wrote Adam Chekroud, Ph.D., of Yale University and Alisa Trugerman, Ph.D., of Altru Consulting. “Exercise may be one such strategy, but we are a long way from realizing this potential.”

Chekroud was one of the authors of a study in Lancet Psychiatry last year showing how the specific type, duration, and frequency of physical exercise affects mental health. The study, which received widespread publicity, suggested that an exercise regimen specifically tailored to a person’s needs, capabilities, and lifestyle could have a measurable impact on the individual’s mental health.

In the JAMA Psychiatry editorial, Chekroud and Trugerman wrote that when applied to the entire population, exercise could have a significant effect on reducing the population burden of mental illness. They noted that though the benefits are compelling, the uptake of exercise remains well below federal guidelines: According to the U.S. Centers for Disease Control and Prevention, less than half of the U.S. population reaches the recommended 150 minutes of moderately vigorous physical activity per week, and 30% of the population does no exercise at all.

These are among the areas in which the authors called for action:

• Educate doctors about how best to prescribe exercise as part of mental health treatment: “We should help train, support, and incentivize clinicians to prescribe exercise actively and in detail,” they wrote. “Professional organizations, health system training programs, and medical school curricula could each be another avenue for increasing professional awareness about how and when to use exercise as an additional therapeutic strategy in mental health treatment.”
• Reform insurance reimbursement practices: “Although clinicians are paid for providing psychotherapy or medication treatment options, there is little financial imperative or logistical support encouraging them to help their patients to exercise,” Chekroud and Trugerman wrote. “This lack of a reimbursement structure for exercise may contribute to an implicit message that exercise is less worthwhile than medication or therapy. …”
• Help patients overcome barriers to exercise: “Many symptoms of mental illness serve as barriers to exercising, such as low mood, lack of motivation, and fatigue,” they wrote. “As with many chronic conditions, structured encouragement and adherence monitoring are critical. Aligning the specific type of exercise with the patient’s preference may improve adherence, as could passive wearable or smartphone technologies.”

Chekroud and Trugerman concluded: “The future holds promise. … Along with digital cognitive-behavioral therapy and traditional self-guided educational resources, one could devise a highly scalable and cost-effective active waitlist or lightweight treatment program that requires less time from clinicians. If delivered alongside psychotherapy or medication management protocols, the augmentation of exercise and digital content might also lead to faster patient recovery.”

For related information, see the Psychiatric News article “Minimal Exercise May Help Prevent Future Depression” highlighting the American Journal of Psychiatry article “Exercise and the Prevention of Depression: Results of the HUNT Cohort Study.”

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Homophobic Bullying May Increase Suicidal Thoughts in Heterosexual Youth

Adolescents who identify as lesbian, gay, and bisexual report higher rates of bullying than heterosexual youth, and these elevated rates of bullying are associated with higher rates of depression and suicide. A study in the Journal of the American Academy of Child & Adolescent Psychiatry now suggests that heterosexual youth who are victims of homophobic bullying are also more likely to report sadness/hopelessness and consider, plan, and/or attempt suicide compared with heterosexual youth who are not victims of this type of bullying.

Mike C. Parent, Ph.D., of the University of Texas at Austin and colleagues examined data from the 2017 Youth Risk Behavior Survey. Specifically, Parent and colleagues analyzed the responses of youth from the seven states that included the following item on the survey: “During the past 12 months, have you ever been the victim of teasing or name calling because someone thought you were gay, lesbian, or bisexual?” (This question was asked in Arkansas, Colorado, Florida, Illinois, North Carolina, North Dakota, and Rhode Island.) The survey also asked youth about experiences with sadness and hopelessness and suicidal thoughts, plans, and attempts.

Of the 21,871 youth who completed this survey in these states, 15,234 identified as heterosexual; 16.4% of the heterosexual youth in the sample reported general bullying, and 7.1% reported homophobic bullying. In comparison, 24.4% of youth who did not identify as heterosexual reported general bullying, and 22.9% reported homophobic bullying.

After controlling for the effect of general bullying, the researchers found that heterosexual adolescents who reported experiencing homophobic bullying had 3.0 times increased odds of feeling sad, 3.4 times increased odds of considering suicide, 3.0 times increased odds of planning suicide, and 3.1 times increased odds of attempting suicide, compared with youth who did not report homophobic bullying.

“The present study adds to our understanding of homophobic bullying by focusing on the experiences of heterosexual adolescents,” Parent and colleagues wrote. “Future work should examine in more detail the manifestations and effect of such bullying on heterosexual adolescents, and effective messaging to enhance bullying prevention efforts that focus on anti-LGB [lesbian, gay, bisexual] climates and include heterosexual adolescents.”

For related information, see the Psychiatric News article “Bullying Found to Increase Risk for Adolescent Suicide Attempts Worldwide.”

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Patients With Severe Alcohol Withdrawal May Benefit From Phenobarbital, Study Suggests

Phenobarbital, a long-acting barbiturate, may be an effective alternative to benzodiazepines for the treatment of severe alcohol withdrawal symptoms such as hallucinations and seizures, according to a study published in Psychosomatics.

“Considerable data exist on the effectiveness of benzodiazepines for the management of [alcohol withdrawal syndrome],” wrote Mladen Nisavic, M.D., of Massachusetts General Hospital and colleagues. However, since benzodiazepines target the same receptors as alcohol, some people with chronic heavy alcohol use may have developed a tolerance to benzodiazepines in addition to a tolerance to alcohol, the authors noted. In addition, benzodiazepines may pose health risks for some patients, including those with respiratory problems.

Nisavic and colleagues conducted a retrospective assessment on all patients admitted to Massachusetts General Hospital between July 2007 and July 2011 who received either phenobarbital or a benzodiazepine for alcohol withdrawal syndrome. They identified 419 patients who received a benzodiazepine and 143 who received phenobarbital treatment; 16 of the patients who initially received a benzodiazepine were subsequently switched to phenobarbital while one patient was transitioned from phenobarbital to a benzodiazepine.

The patients who started on phenobarbital were significantly more likely to have a history of documented alcohol withdrawal syndrome compared with those started on benzodiazepines (91% vs. 73%); phenobarbital patients were also more likely to have a history of withdrawal-related seizures (73% vs. 45%) and/or present with a seizure on arrival to the hospital (14% vs. 7%).

Despite having more health complications related to alcohol withdrawal, the patients given phenobarbital showed similar treatment outcomes—which included rates of seizures, hallucinations, delirium, or admission to an intensive care unit—as patients given a benzodiazepine. Furthermore, the 16 patients initially treated with a benzodiazepine but then transitioned to phenobarbital showed significantly better outcomes following the switch.

“Given the concordance of our data and the literature, it appears that phenobarbital is a feasible alternative for [alcohol withdrawal syndrome] management, especially in patients with prior known complex [alcohol withdrawal syndrome], and in patients who fail to respond to conventional [benzodiazepine]-based treatment,” Nisavic and colleagues wrote.

For related information, see the Psychiatric News article “APA Releases Practice Guideline for AUD Pharmacotherapy.”

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Risks of Antipsychotics for Treatment of Delirium May Outweigh Benefits, Review Finds

There may be no benefits to treating hospitalized patients experiencing delirium with antipsychotics, suggests a review published this week in the Annals of Internal Medicine.

Delirium—which is characterized by sudden changes in attention, decreased awareness, and cognitive impairment—is known to be associated with worse patient outcomes, wrote Roozbeh Nikooie, M.D., of Johns Hopkins University School of Medicine and colleagues. Such outcomes include increased length of stay in the hospital, long-term cognitive impairment, and mortality.

Although the first-generation antipsychotic haloperidol and second-generation antipsychotics are commonly used to treat hospitalized patients for delirium, the benefits and risks of this treatment strategy remain unclear, the authors wrote. They conducted a systematic review of 26 studies that compared outcomes of hospitalized adults with delirium who were treated with haloperidol, a second-generation antipsychotic (such as risperidone, quetiapine, or olanzapine), or placebo. The studies included 16 randomized, controlled trials involving 1,768 participants and 10 observational studies involving 3,839 participants.

The authors found that patients had similar delirium duration, sedation status, hospital length of stay, and mortality regardless of whether they received an antipsychotic or placebo. (There was insufficient evidence regarding the effect of these medications on cognitive function or delirium severity.) When comparing patients who received haloperidol with those who received second-generation antipsychotics, the authors found that the groups appeared similar in terms of their cognitive function, delirium severity, sedation status, hospital length of stay, and mortality.

While there was “little evidence of harm for haloperidol and second-generation antipsychotics with short-term use for treating delirium in adult inpatients …, potentially harmful cardiac effects tended to occur more frequently with use of antipsychotics, particularly prolongation of the QT interval with second-generation antipsychotics versus placebo or haloperidol,” the authors noted.

Nikooie and colleagues highlighted several limitations of the review: “Some large studies in this review were conducted in critically ill patients, which may affect generalizability of the findings. Moreover, most RCTs [randomized, controlled trials] excluded patients with underlying neurologic or cardiovascular issues, which can potentially underestimate the harms in routine clinical practice.” Nonetheless, they concluded, “Current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.”

For related information, see the American Journal of Psychiatry article “The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.”

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Hearing Aids May Reduce Risk of Depression, Anxiety, Dementia in Older Adults

Older adults who use hearing aids may be less likely to develop depression, anxiety, and dementia for at least three years after a hearing loss diagnosis compared with those who do not begin using hearing aids, according to a study published Wednesday in the Journal of the American Geriatrics Society. In addition, these individuals appear less likely to get injured in a fall.

“By providing enhanced hearing input, HAs [hearing aids] may facilitate greater social engagement, lower levels of effort to recognize sounds and speech, lower levels of depression or anxiety symptoms, higher levels of physical balance, and greater feelings of independence and self-efficacy,” wrote Elham Mahmoudi, Ph.D., and colleagues at the University of Michigan.

Mahmoudi and colleagues examined insurance claims data from 114,862 adults aged 66 and older who received a hearing loss diagnosis between 2008 and 2013. All the adults included in the analysis remained on the same coverage—a Medicare managed care plan that includes partial coverage for hearing aids—for at least three years after receiving the diagnosis of hearing loss.

The analysis showed that about 11% of women and 13% of men diagnosed with hearing loss began using hearing aids. Over the next three years, the adults who used hearing aids had an 18% reduced risk of being diagnosed with Alzheimer’s/dementia, 11% reduced risk of being diagnosed with anxiety or depression, and a 13% reduced risk of having an injurious fall compared with adults without hearing aids.

“Although [hearing aids] are expensive, the medical costs of many conditions that could be prevented or delayed by using [hearing aids] are substantially more expensive,” the authors concluded. “Any delay in diagnosis of [Alzheimer’s] or dementia could not only lead to large cost savings, but also improve the health and well-being of older adults.”

To read more about this topic, see the American Journal of Psychiatry article “Sensation and Psychiatry: Linking Age-Related Hearing Loss to Late-Life Depression and Cognitive Decline.”

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Children With ADHD May Be More Likely to Report Concussion Symptoms

Children with ADHD who play sports may be more likely to report a greater number of concussion-like symptoms and perform worse on balance tests when administered a common concussion assessment than those who do not have ADHD, according to a report in the Journal of Pediatrics. Children in the study were assessed using the Child Sport Concussion Assessment Tool Fifth Edition (Child SCAT5).

“These findings highlight the challenges of interpreting Child SCAT5 performance in children with ADHD following a concussion or suspected concussion and illustrate the value of administering the measure to children to document their pre-injury performance,” wrote Nathan Cook, Ph.D., of Harvard Medical School and colleagues. “[P]roviders using the Child SCAT5 following a concussion or suspected concussion should anticipate that children with ADHD are likely to endorse several symptoms when given concussion symptom rating scales and may also demonstrate balance weaknesses even if they have recovered or were never injured in the first place.”

Cook and colleagues analyzed data obtained from a study of 464 middle school athletes aged 11 to 12, who received preseason testing with the Child SCAT5. Of the total sample, 28 (6%) children reported having been diagnosed with ADHD. For the study, the authors compared how 27 children with ADHD performed on the Child SCAT5 with those without ADHD who were of the same age and sex, played the same sport, and reported the same concussion history.

The children with ADHD reported an average 13.33 concussion symptoms compared with an average of 6.44 reported by children without ADHD. They also reported significantly greater severity of symptoms than children without ADHD. Some of the common symptoms reported by the children with ADHD were those that are commonly associated with ADHD, such as difficulty paying attention and getting distracted easily; however, children with ADHD also more commonly reported headaches, dizziness, feeling nauseous, and neck pain—symptoms not commonly attributed to ADHD.

Children with ADHD also performed worse on the Child SCAT5 balance assessment, committing more errors on average when required to stand on one leg than controls. In contrast, the groups performed similarly on cognitive tests that are part of the Child SCAT5.

“It is important for pediatricians and other providers treating children and adolescents to understand factors and comorbidities that influence results on pediatric concussion assessments,” Cook and colleagues wrote. “This information can help inform concussion diagnosis, evaluation of recovery from the injury, and return-to-activity decisions.”

For related information, see the Psychiatric News article “Saliva Biomarkers May Predict How Long Concussion Symptoms Will Last in Youth.”

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Immune System Response May Offer Clues About Psychosis, Study Suggests

Analyzing white blood cell counts and levels of C-reactive protein (CRP)—a protein sent to the blood in response to inflammation—in patients with psychosis may offer clues about psychosis severity and treatment response, suggests a study in Schizophrenia Bulletin.

Johann Steiner, M.D., of Otto von Guericke University Magdeburg in Germany and colleagues analyzed blood collected from 253 patients hospitalized for psychosis; this included 129 patients experiencing a first episode of psychosis (FEP) and 124 patients with schizophrenia. All FEP patients were drug-naïve while patients with schizophrenia were unmedicated for at least six weeks prior to the start of the study. White blood cell counts and CRP levels in patients with psychosis were compared with those of people without psychiatric disorders at the start of the study.

Steiner and colleagues found that neutrophils, monocytes, and CRP levels were significantly higher in patients with psychosis compared with those without psychosis at baseline. In contrast, eosinophils were lower at baseline in patients with psychosis. Patients with higher neutrophil counts at baseline tended to report a greater number of positive symptoms on the Positive and Negative Syndrome Scale (PANSS-P), they noted. CRP levels at baseline correlated with PANSS-P in FEP patients but not in patients with schizophrenia.

A total of 163 patients with psychosis then received antipsychotics for six weeks. Although neutrophil counts and CRP levels decreased in these patients following six weeks of medication, these counts remained elevated compared with people without psychosis. In contrast, eosinophil counts increased in patients with psychosis to the point where they did not differ from controls after six weeks of medication. Additional analysis revealed that the degree of positive symptom improvement after treatment correlated with the amount of change in neutrophil, CRP, and/or eosinophil levels.

“[O]ur analysis of routine laboratory parameters such as neutrophil count and CRP levels identified a subgroup of acutely psychotic FEP and [schizophrenia] patients with signs of innate immune system activation,” Steiner and colleagues concluded. “The decline of neutrophils or CRP and rising eosinophils from baseline to follow-up may be considered as markers of treatment response, as these changes correlated with improvement of PANSS-P.”

For related information, see the Psychiatric News article “PET Reveals Inflammatory Response in Schizophrenia, High-Risk Patients.”

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