Self-Guided Online CBT May Benefit Patients With Insomnia

People with insomnia may find significant relief of their symptoms through self-guided, internet-based cognitive-behavioral therapy (iCBT), a study in the Journal of Affective Disorders suggests. This could help address a need in communities where mental health professionals are in short supply, the researchers wrote.

Ashlee B. Grierson of St. Vincent’s Hospital in Sydney, Australia, and colleagues measured the effectiveness of an iCBT program consisting of four online lessons. The lessons were presented as an illustrated story about a male character with insomnia who learns about the condition and ways to manage his symptoms. After each lesson, participants were asked to download a summary of key concepts introduced in the lesson and practice activities. Of the 317 people who enrolled in the program, 118 completed all four lessons.

Participants completed the Insomnia Severity Index (ISI) and the Kessler 10-item Psychological Distress Scale online before each lesson. They also took the World Health Organization 5-item Well-Being Index assessment before the first lesson, and those who completed the program took it again before the fourth lesson.

Overall, the participants reported large improvements in their insomnia symptoms, moderate improvements in their psychological distress, and small improvements in their general well-being. Among the participants who started the study with ISI scores 15 or above (considered the cutoff for clinical insomnia), 65% remitted (ISI below 15) following iCBT treatment.

The authors noted that their findings suggest that iCBT is a scalable and cost-effective way to disseminate the psychotherapy considered to be the gold standard for insomnia. “Unguided iCBT-I offers the benefits of being accessible at times convenient to the user (for example, outside of business hours), at a low cost, and in a confidential and private environment. Additionally, treating as many patients as possible with the least intensive but still clinically effective care allows for more substantial resources (for example, face-to-face and guided online programs) to be allocated to those who require additional care.”

For related information, see the American Journal of Psychiatry article “Proof of Concept for an Adaptive Treatment Strategy to Prevent Failures in Internet-Delivered CBT: A Single-Blind Randomized Clinical Trial With Insomnia Patients.”

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Today Is Your Last Chance to Vote in APA’s 2020 Election

Have you voted in APA’s 2020 election yet? If not, take a moment to do so now: Voting ends today, January 31. Learn about this year’s slate of candidates, their priorities, and backgrounds on the APA elections page and watch video interviews of the candidates for president-elect and secretary. Click here to vote now and be part of the process.

FDA Warns Untreated Constipation From Clozapine Use Can Lead to Serious Bowel Complications

The FDA on Tuesday issued an updated warning that constipation caused by the antipsychotic clozapine may increase the risk of serious bowel complications in some patients.

Constipation is already an identified side effect of clozapine, but “serious and fatal events continue to be reported,” according to the FDA’s website. The medication affects how the intestines function in most patients, and an uncommon but serious problem is complete blockage of the bowel. The risk is greater with clozapine compared with other schizophrenia medications, the FDA wrote.

Higher doses of clozapine and the use of clozapine in combination with anticholinergics and/or other medications known to cause constipation, including opioids, can further increase this risk, the agency warned.

The FDA reviewed cases from 2006 to 2016, some of which were reported to the agency’s Adverse Event Reporting System while others were identified through medical literature in the same time period. They identified 10 cases involving constipation “that resulted in hospitalization, surgery, and five deaths.” The total daily dose of clozapine in these cases ranged from 200 mg to 600 mg, and the time to onset of serious bowel events ranged from three days to six months.

The adverse events “included death of the colon wall (necrotizing colitis), blockage of blood flow to the intestines (intestinal ischemia), death of part of the intestine (intestinal necrosis), and abdominal distention leading to bowel obstruction (volvulus),” according to the FDA website.

The FDA is requiring a new warning and updates about the risk to be added to the prescribing information of all clozapine products. The agency has also recommended that health care professionals evaluate bowel function in patients before starting them on clozapine, and to question patients about their bowel movements throughout treatment. “Consider prophylactic laxative treatment when starting clozapine in patients with a history of constipation or bowel obstruction,” the FDA wrote. Physicians should also avoid co-prescribing the medication with anticholinergic medications.

Health care professionals should report adverse events involving clozapine or other medicines to the FDA MedWatch program.

For related information, see the Psychiatric News article “Updated Clozapine REMS Program Requires Certification With Few Exceptions.”

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Your Chance to Vote in APA’s 2020 Election Ends Tomorrow

Have you voted in APA’s 2020 election yet? If not, take a moment to do so now: Voting closes on Friday, January 31. Learn about this year’s slate of candidates, their priorities, and backgrounds on the APA elections page and watch video interviews of the candidates for president-elect and secretary. Click here to vote now and be part of the process.

Risk Calculator Predicts Youth Likely to Experience Recurrence of Bipolar Symptoms

It is possible to predict whether youth with a history of bipolar disorder will experience a recurrence of symptoms using a risk calculator that factors in patient characteristics commonly measured in clinical practice.

That’s the finding from a report that appears in the Journal of the American Academy of Child and Adolescent Psychiatry. “The risk calculator offers a potentially useful clinical and research tool to predict the individual progression of the illness and guide treatment,” wrote Boris Birmaher, M.D., of the University of Pittsburgh School of Medicine and colleagues.

The researchers created a bipolar relapse risk calculator that assessed 11 potential predictors of symptom recurrence, based on existing scientific literature. These predictors included a patient’s age and family history, severity of previous mood episode of illness, length of time of recovery since last mood episode, and more.

They used this risk calculator to assess 363 youth (mean age 13 years) with a history of bipolar disorder who were currently in recovery (defined as at least two months with no or minimal mood symptoms). The researchers evaluated any changes in the participants’ psychiatric symptoms on average every seven months for a median of 12.5 years.

Over the course of the study, approximately 80% of participants had at least one recurrence of depressive or manic symptoms and 60% had two or more recurrences. The risk calculator was able to predict which youth would experience a mood recurrence within six months or five years with 72% and 82% accuracy, respectively. The calculator was slightly better at predicting future hypomania compared with future depression. The most important factors in predicting recurrence of mood episodes were shorter periods of recovery, younger age at assessment, earlier mood onset, and history of more severe depression.

“A clinician could utilize the risk calculator … to predict the person-level risk for recurrences [whether depressive or hypomanic] at different points of time after recovery,” Birmaher and colleagues wrote. “This information can inform the management of individual patients and is valuable for the patients and their families to enhance their understanding of illness prognosis and become more involved in their treatment. For example, a high-risk score may indicate the need for more frequent follow-ups, and more intensive treatment to avoid recurrences.”

For related information, see the Psychiatric News article “Preventing and Treating Mood Disorders Starting in Childhood.”

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Transcranial Direct Current Stimulation Found to Improve Cognition in Patients With Depression

Both high and low doses of transcranial direct current stimulation (tDCS) may improve cognition in patients with depression, according to a study in Depression & Anxiety.

“Research has found that unipolar depression can reduce processing speed, decrease attention, and impede executive function, and that bipolar disorder can adversely affect working memory,” wrote Shawn M. McClintock, Ph.D., M.S.C.S., of UT Southwestern Medical Center and colleagues. Although previous studies have suggested that tDCS has antidepressant effects, less was known of the neurocognitive effects of the therapy.

This study enrolled 130 adults 18 and older with unipolar or bipolar depression who had been experiencing a major depressive episode for at least four weeks. The participants were randomized to receive 20 sessions (given on consecutive weekdays over four weeks) of either high-dose tDCS (2.5 mA for 30 minutes) or low-dose tDCS (0.034 mA for 30 minutes). Afterwards, all participants had the option to continue with four weeks of open-label, high-dose tDCS treatment.

At baseline, after four weeks, and after eight weeks, the researchers assessed participants’ mood as well as verbal learning, memory, selective attention, auditory attention, working memory, psychomotor processing speed, visuospatial attention, and verbal fluency.

Participants in the high- and low-dose tDCS groups experienced mood improvements over the eight-week period. “The study found across all patients and time, that there were improvements in verbal learning and memory, selective visual attention, auditory attention, and information processing speed in both the low- and high-dose tDCS conditions, which were independent of mood effects,” McClintock and colleagues wrote.

They concluded, “The tDCS associated neurocognitive effects require further investigation and replication, which is clinically important as such investigation could provide information to develop personalized tDCS therapeutic approaches to target specific cognitive functions and improve the utility and efficacy of this noninvasive neuromodulation treatment.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Noninvasive Brain Stimulation: Challenges and Opportunities for a New Clinical Specialty.”

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Youth Suicide Rates Higher in Areas With Greater Poverty, Study Finds

Youth suicide rates are higher in U.S. counties with elevated poverty rates, according to a study published today in JAMA Pediatrics. The association between suicide and county-level poverty was particularly prominent for suicides by firearms.

“As pediatric suicide rates in the United States continue to increase, understanding of the upstream contributors to pediatric suicide, including poverty-related factors, appears to be needed so that suicide prevention efforts can focus on the youths at highest risk,” wrote Jennifer Hoffmann, M.D., of the Ann & Robert H. Lurie Children’s Hospital of Chicago and colleagues.

For the study, the researchers analyzed 2007-2016 death certificate data for youth (aged five to 19) collected by the Centers for Disease Control and Prevention along with income data from the National Census Bureau. They found youth suicide rates were higher in counties with greater poverty. For example, compared with counties in which less than 5% of the population lived below the federal poverty level ($21,027 in annual household income for a family of four in 2007 and $24,339 in 2016), counties with poverty rates of 20% or more had 1.37 times as many suicides by youth each year.

The researchers then analyzed the three most common methods of suicide during the study period (firearms, poisoning, and suffocation). They found no association between the rate of suicide by suffocation or poisoning and poverty levels. Among firearm suicides, the suicide rate increased with increasing levels of poverty compared with the lowest levels of poverty.

“The independent association between county poverty concentration and pediatric suicide … should prompt research into potential mediators through which poverty might convey an elevated suicide risk,” Hoffman and colleagues wrote. “On a more societal level, strategies that combat poverty, such as increasing the minimum wage, may be part of a multipronged strategy to consider for reducing youth suicide.”

To read more on this topic, see the Psychiatric News article “Rise in Youth Suicide Rates Confounds Experts.”

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Buprenorphine Use for Treating OUD Rising, Except in Youth

The rate of buprenorphine use to treat opioid use disorder more than doubled between 2009 and 2018, according to a study in JAMA. However, this trend did not hold true for patients aged 15 to 24 years, in whom buprenorphine use declined.

Mark Olfson, M.D., M.P.H., of Columbia University and colleagues analyzed data from the IQVIA Real World Data: Longitudinal Prescription database to determine the number of buprenorphine prescriptions filled by people aged 15 to 80 years old between 2009 and 2018, excluding formulations that were not approved for treating opioid use disorder. The researchers defined a new episode of buprenorphine use as a prescription fill that took place at least 180 days after the last buprenorphine fill. The episode of buprenorphine use ended 30 days after a prescription fill ended and the patient did not obtain a refill or new prescription.

The annual rate of buprenorphine use episodes increased from 1.97 per 1,000 people in 2009 to 4.43 per 1,000 in 2018. The largest increase occurred in adults aged 35 to 44 years, from 2.41 episodes of use to 8.34 episodes of use per 1,000 people. However, buprenorphine use decreased in patients aged 15 to 24 years, from 1.76 to 1.40 episodes per year per 1,000 people. Patients in this age group who received buprenorphine prescriptions were also more likely to receive prescriptions for doses lower than the recommended dose of 16 mg/dl, and less likely to maintain their prescriptions for 180 days or more.

The “[f]indings suggest a widening treatment gap for young people and underscore the importance of improving buprenorphine treatment services for this age group,” the researchers wrote. They added that these changes took place during a period when young people had increasing rates of opioid-related overdose deaths.

For related information, see the Psychiatric News article “Most Youth With OUD Who Need Medication Treatment Do Not Receive It.”

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Adults in Pain More Likely to Use Cannabis Without Prescription, Study Finds

Adults who experience pain are more likely to use cannabis without a prescription and have cannabis use disorder than those without pain, according to a study published yesterday in AJP in Advance.

“These results suggest that, among adults with pain, frequent nonmedical cannabis use and cannabis use disorder are growing problems,” wrote Deborah S. Hasin, Ph.D., of the New York State Psychiatric Institute and colleagues. “[T]he need remains for other interventions to manage pain that do not incur risk of another substance use disorder (i.e., cannabis use disorder) as an adverse treatment outcome.”

Hasin and colleagues analyzed data from two national surveys of adults: the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions and the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. Both surveys used the Alcohol Use Disorder and Associated Disabilities Interview Schedule to assess substance use and substance use disorders. As part of these surveys, the respondents were asked about their use of cannabis without a prescription or other than prescribed (nonmedical use). Respondents were also asked to rate how much pain interfered with their “normal work” during the previous four weeks.

Between the 2001-2002 and 2012-2013 surveys, the prevalence of pain among U.S. adults increased from 19.3% to 20%. Pain was associated with significantly greater risk for any nonmedical cannabis use in both surveys.

The prevalence of frequent cannabis use (defined as use at least three times a week) did not differ by pain status in the 2001-2002 survey. But frequent cannabis use was significantly more prevalent in those with pain compared with those without pain in the 2012-2013 survey (5.03% compared to 3.45%).

Cannabis use disorder (defined as meeting DSM-IV criteria for cannabis dependence or abuse) was also more prevalent in respondents with pain compared with those without. In the 2012-2013 survey, the prevalence of cannabis use disorder was 4.18% in those with pain compared with 2.74% in those without.

“Extrapolating to the number of U.S. adults potentially affected, approximately 1.5 million more adults with pain were frequent nonmedical cannabis users in the 2012-2013 period than in the 2001-2002 period, and approximately 0.9 million more adults with pain had past year cannabis use disorder in the 2012-2013 period than in the 2001-2002 period,” the authors wrote.

“Psychiatrists and other mental health professionals treating patients with moderate to severe pain should be informed about the potential risks of cannabis, including cannabis use disorder, provide information about these risks to their patients, and monitor patients for signs and symptoms of cannabis use disorder,” they concluded.

For related information, see the Psychiatric News article “National Academies Issues Report on Health Effects of Cannabis.”

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Digital CBT Found Effective for Reducing Insomnia During Pregnancy

Digital cognitive-behavioral therapy (CBT) is a safe and effective approach for reducing insomnia symptoms in pregnant women, reports a study published today in JAMA Psychiatry.

“Although sleep disturbance during pregnancy may be viewed as normative and innocuous, research indicates that it is associated with an increased risk of adverse maternal outcomes, including depression and preterm birth,” wrote Jennifer Felder, Ph.D., of the University of California, San Francisco, and colleagues. “A digital CBT-I [CBT for insomnia] program may be of particular interest for pregnant women, who report a preference for mental health care that includes flexible options and for whom timely intervention may be particularly important.”

Felder and colleagues randomly assigned 208 women who were up to 28 weeks pregnant and had insomnia to receive either digital CBT-I or standard insomnia treatment for 10 weeks. The digital CBT-I program consisted of six weekly tutorials on topics including the following: proper sleep hygiene, relaxation techniques, and stimulus control (how to associate a bed as a cue for sleep). The CBT-I program provided automated reminders to complete each session and automated help based on a person’s progress. The participants also had access to a moderated online community and a library of sleep education materials. The women receiving standard care had access to treatments including prescription/over-the-counter sleep medications, herbal remedies, counseling, and/or peer support groups.

After 10 weeks, the women who received CBT-I reported significantly greater improvements in their insomnia symptoms compared with women receiving standard treatment. The average scores on the Insomnia Severity Index (ISI) of the women in the CBT-I group dropped 0.59 points every week, compared with 0.23 points a week for the standard-care group. Remission rates, defined as ISI scores of 7 or less, were significantly higher among those in the digital CBT-I group (44.0%) versus those in the standard treatment group (22.3%). Women receiving digital CBT-I also reported greater reductions in depressive symptom severity and anxiety symptom severity compared with women receiving standard treatment. Additionally, the benefits of CBT-I over standard care for insomnia, depression, and anxiety remained when the patients were re-assessed eight weeks later.

“Given the widespread nature of insomnia in pregnancy, the scalability of this intervention, its low-risk profile, and its demonstrated efficacy, digital CBT-I has great promise as a treatment for insomnia in pregnant women,” Felder and colleagues concluded.

To read more on this topic, see the Psychiatric News article “Online CBT for Insomnia Offers Long-Term Benefit.”

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Have You Voted in APA’s 2020 Election Yet?

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Family Therapy May Delay Mood Episodes in Youth at High Risk of Bipolar Disorder

Family therapy focused on building communication and problem-solving skills may benefit youth at high risk of bipolar disorder, according to a report in JAMA Psychiatry. Specifically, the study found that youth with mood symptoms and a family history of bipolar disorder who participated in a four-month program with their parents (and, when possible, siblings) had longer periods between symptoms of depression, mania, hypomania, or mixed episodes (mood episodes) than those who participated in a program with less intensive family involvement.

Previous studies show that youth at highest risk of progressing to bipolar disorder early in life are those with mood symptoms and with a family history of the disorder. Still, there is “little agreement on what treatments are most effective in preventing symptom progression among high-risk children,” wrote David J. Miklowitz, Ph.D., of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues.

For the current study, Miklowitz and colleagues recruited 127 youth aged 9 to 17 years with major depressive disorder or unspecified (subthreshold) bipolar disorder, active mood symptoms, and at least one first- or second-degree relative with bipolar disorder I or II. The youth and their families were randomly assigned to one of two treatments over a four-month period: family-focused therapy or enhanced care. Youth and families assigned to family-focused therapy participated in 12 60-minute sessions of psychoeducation, communication-enhancement training (which the authors described as “practicing active listening or expressing positive or negative feelings”), and problem-solving skills training. Youth and families assigned to enhanced care participated in three 60-minute family psychoeducation sessions a week; then only the youth participated in three monthly sessions on mood management.

The researchers evaluated the participants’ symptoms at the start of the study, every four months for the first year, and every six months for up to four years. Of the 127 youth who participated in the study, 75 had major depressive disorder and 52 had unspecified bipolar disorder.

Youth in the group that received family-focused therapy had longer intervals between mood episodes compared with youth in enhanced care. “Specifically, FFT [family-focused therapy] was associated with longer intervals to depressive episodes but did not differ from enhanced care in time to manic or hypomanic episodes, conversions to bipolar disorder, or symptom trajectories,” the authors noted.

“Delaying or preventing episodes of mood disorder may have enduring effects on psychosocial functioning for youth with high-risk syndromes, as well as among parents in terms of the considerable burden of caregiving for a young person with early-onset BD [bipolar disorder],” they concluded.

For related information, see the Psychiatric News article “Researchers Sum Up Current Knowledge of Bipolar Disorder, Call for More Study.”

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Have You Voted in APA’s 2020 Election Yet?

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Help APA Understand How Burnout Affects Different Groups

APA’s Committee on Well-being and Burnout wants to know more about psychiatrists’ experiences with burnout and/or depression.

APA members are urged to complete a new survey/self-assessment tool developed by the committee that includes questions about demographics (age, gender, geographic location, minority status, and other variables) and practice setting (private practice, group practice, community mental health center, academic medical center, etc.). The survey also includes questions about burnout using the Oldenburg Burnout Inventory and the Patient Health Questionnaire-9 (PHQ-9) to screen for depression. The survey can be completed in under 20 minutes.

All data will be kept anonymous.

“We hope to learn more about well-being and burnout among psychiatrists in general and among minority and underrepresented psychiatrists, specifically,” said Uchenna Okoye, M.D., M.P.H., a member of the committee.

An earlier online survey created by the committee established that burnout was a significant issue among APA members. In a 2018 report to the Board of Trustees, the committee stated that of the more than 1,900 psychiatrists who had taken the survey, 73% scored above 35 on the Oldenburg Burnout Inventory—indicating they were at risk for burnout. The survey also found that 15% of the respondents had a PHQ-9 score greater than 10, which indicates the presence of moderate to severe depression. Burnout scores were correlated with gender (women typically had higher scores), recent medical school graduation, and perceived inability to control one’s schedule. Among non-depressed respondents, burnout scores were slightly lower for psychiatrists who worked in academic and academic-affiliated practice settings.

The new survey will help drill down further to understand whether burnout affects members of minority groups differently. “We know a lot about burnout, but we don’t know much about the rates or causes of burnout in minority and underrepresented psychiatrists,” Okoye said. “If you belong to one or more minority or underrepresented groups—for example, if you are a woman, belong to a racial or ethnic minority, are an international medical graduate, identify as LGBTQ+, or belong to another group—your voice may not have been heard in this national conversation.”

Past APA President Carol Bernstein, M.D., also a member of the committee, said research on how burnout affects particular groups will help all psychiatrists affected by the problem. “I urge members to log onto the survey,” she said. “Understanding more about this issue and developing potential strategies to address it are important for the field of psychiatry, and for all of us in it.”

Click here to learn more about what APA is doing to address burnout.

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Study Shows Benefits of Long-Term Antipsychotic Use for Patients With Schizophrenia

Long-term antipsychotic use is associated with substantially decreased mortality compared with no antipsychotic use, especially among patients treated with clozapine, according to a report in World Psychiatry, the journal of the World Psychiatric Association.

Moreover, long‐term antipsychotic use does not increase the likelihood that a patient will experience severe illness leading to hospitalization, wrote Heidi Taipale, Ph.D., of the Karolinska Institute in Sweden and colleagues.

People with schizophrenia have a shorter average life expectancy than the general population. Taipale and colleagues wanted to know if these differences may be partly due to adverse effects associated with antipsychotics, such as weight gain.

They used data from a Finnish national registry on 62,250 patients treated for schizophrenia between 1972 and 2014. Specifically, they analyzed the association between periods of antipsychotic use and no antipsychotic use with hospitalization and/or death.

Hospitalization was classified as either “somatic” hospitalization (all hospitalizations except psychiatric and cardiovascular hospitalizations) or “cardiovascular” hospitalization. Three causes of death were analyzed: all‐cause mortality, cardiovascular mortality, and suicide death.

There was no increased risk of somatic or cardiovascular hospitalization associated with periods of antipsychotic use compared with periods of non-use. Cardiovascular deaths, suicide deaths, and all‐cause deaths were significantly lower in patients using any antipsychotics compared with those using none and was lowest for those using clozapine. The cumulative mortality rates during 20-year follow‐up were 46.2% for non‐use, 25.7% for any antipsychotic use, and 15.6% for clozapine use, according to the report.

“Antipsychotics reduce symptoms of schizophrenia, and this may be a major factor for decreased suicide mortality,” the researchers wrote. “Relief of stress may also have a beneficial effect on cardiovascular mortality. Smoking and high blood pressure are among the most important risk factors for cardiovascular death, and antipsychotics, especially clozapine, decrease blood pressure and possibly also the rate of smoking.”

For related information, see the American Journal of Psychiatry article “On the Continued Benefit of Antipsychotics After the First Episode of Schizophrenia” and the Psychiatric Services article “Psychiatry’s Role in Improving the Physical Health of Patients With Serious Mental Illness: A Report From the American Psychiatric Association.”

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Study Takes Closer Look at Violence Targeting People With Psychiatric Disorders

A study appearing today in JAMA Psychiatry found that fewer than 7% of patients with psychiatric disorders in Sweden had either been subjected to violence severe enough to require specialist medical treatment or had perpetrated violence.

Amir Sariaslan, Ph.D., of the University of Oxford and colleagues identified 250,419 individuals from Sweden’s National Patient Register who were born between 1973 and 1993 and had been diagnosed psychiatric disorders. Psychiatric disorders included anxiety disorders, depression, bipolar disorder, schizophrenia, personality disorders, alcohol use disorder, and drug use disorder. The patients were matched by age and sex to individuals in the general population (n = 2,504,190) and to their full biological siblings who did not have psychiatric disorders (n = 194,788).

The researchers tracked whether these patients were subjected to violence (defined as an outpatient visit, inpatient episode, or death associated with an injury purposefully inflicted by other persons) or perpetuated violence (defined as a violent crime conviction) until they migrated, died, or reached the end of the study period on December 31, 2013. Data on convictions were pulled from Sweden’s National Crime Register.

Compared with the general population, patients with psychiatric disorders were more likely to be subjected to violence and to perpetrate violence, the authors found. Patients with psychiatric disorders were three to four times more likely than their siblings without psychiatric disorders to be either subjected to violence or perpetrate violence.

The researchers also found that “the risks of subjection to and perpetration of violence varied across specific psychiatric disorders and were highest in persons with substance use disorders.” After adjusting for comorbid substance use disorders and personality disorders, they added, those diagnosed with schizophrenia “were no more likely than their siblings without psychiatric disorders to be subjected to violence.”

In an accompanying editorial, past APA President Paul S. Appelbaum, M.D., noted that the data on patients targeted by violence may be incomplete as many may not have sought medical attention

“Although violence perpetrated by people with mental disorders accounts for only a small proportion of violent incidents, to the extent that the frequency of such events can be diminished, people with the potential to be targeted by violence and incipient perpetrators will benefit,” Appelbaum wrote. He added that reducing the likelihood that someone with a mental disorder will be the target of violence “will benefit them directly and is likely to make it easier for them to reintegrate into the community.”

For related information, see the Psychiatric News article “Former APA President Calls for New Paradigm for Studying Violence, Mental Illness.”

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College Students in States With Legalized Marijuana Report Greater Use of Drug

College students in states where recreational use of marijuana is legal appear to be using marijuana more frequently than peers in states where such use is not legal, according to a report in Addiction.

“Identifying whether [recreational marijuana legalization] affects different patterns of use is important from the perspectives of policy evaluation and prevention implications,” wrote Harold Bae, Ph.D., and David C. R. Kerr, Ph.D., of Oregon State University. “The present findings suggest that [recreational marijuana legalization] may increase the likelihood of patterned marijuana use… .”

Bae and Kerr analyzed the responses of undergraduates aged 18 to 26 to the National College Health Assessment survey between 2008 and 2018. This anonymous survey asks students about a variety of issues, including mental and sexual health as well as alcohol, tobacco, and substance use. Specifically, Bae and Kerr were interested in how students responded to questions about the number of times they used marijuana in the past 30 days and whether these responses varied according to marijuana laws in the states where the students attended college.

The final sample included 234,669 students who attended 135 college in seven U.S. states where recreational use of marijuana was legalized, and 599,605 students who attended 454 colleges in 41 states where recreational use was not legal. The researchers found that students who attended college in states where recreational use of marijuana is legal were 23% more likely to report marijuana use than students in states where such use is not legal. The students in states with legal recreational marijuana were 18% more likely than those in states where such use is not legal to report frequent marijuana use—defined as using marijuana on at least 20 of the past 30 days.

Additional analysis revealed that the effects of legalized marijuana were stronger among students who were female, 21 and older, and resided off campus.

“Only more granular studies of the local nuances of how [recreational marijuana legalization] is implemented can fully illuminate these laws’ impacts and what adjustments will be needed to promote public health,” Bae and Kerr wrote. “Nevertheless, even using blunt tools, we find support for a general conclusion that college students … are reacting to [recreational marijuana legalization].”

For related information, see the Psychiatric News article “Legalization of Marijuana Could Lead to Public Health Concerns, Study Suggests.”

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Shortened CBT Program May Help Youth With Anxiety Problems

Youth with anxiety problems can benefit from as few as five sessions of cognitive-behavioral therapy (CBT) delivered at school, suggests a study published in the Journal of the American Academy of Child & Adolescent Psychiatry.

Studies in multiple countries including the United States have shown that school-based CBT programs that identify and treat youth considered at risk of disorders like depression or anxiety can be effective. A typical course of CBT involves eight to 12 sessions, which can be difficult to implement in a school setting, wrote Bente Storm Mowatt Haugland, Ph.D., of the University of Bergen in Norway and colleagues.

Haugland and colleagues tested whether a condensed CBT program called Vaag could be as effective as standard CBT. Vaag involves five CBT sessions that total 5.5 hours; the first four sessions (which includes one joint youth-parent session) are given over four weeks, and the final session is given five weeks later.

A total of 313 adolescents aged 12 to 16 in junior high schools throughout Norway reporting anxiety symptoms were invited to participate in the study. Ninety-one of the students received the brief CBT therapy, 118 students received standard CBT (10 sessions that totaled 15 hours), and 104 were placed on a waitlist for 10 weeks.

After 10 weeks, the youth who received CBT (whether brief or standard) had significantly greater reductions in their anxiety symptoms (measured with the Spence Children’s Anxiety Scale or SCAS) compared with those on the waitlist. When compared head to head, brief CBT was determined to be slightly less effective than standard CBT (7.1-point reduction in SCAS scores compared with a 10.5-point reduction, respectively).

“Even though key CBT principles and skills were the same in both programs, we compared two programs differing not only in length, but to some degree also in content,” wrote Haugland and colleagues. “This may make it difficult to determine whether the slightly different efficacy is due to the content or to the duration of the interventions.”

They added, “We need to reach adolescents who struggle with anxiety at an earlier time in their lives. The present study indicates that this may be achieved through school-based targeted CBT interventions.”

To read more about this topic, see the Psychiatric News article “Childhood Anxiety Can Be Treated—The Challenge Is to Recognize It.”

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Patients With Psychosis, Nonopioid SUDs More Likely to Receive Referral to Specialist

Primary care visits involving a diagnosis of psychosis or a substance use disorder not involving opioids are more likely to result in referrals to specialists than visits involving other behavioral health conditions like depression, a study in Psychiatric Services in Advance suggests.

“Referral patterns for behavioral health diagnoses are an important component of high-quality primary care,” wrote Kimberley H. Geissler, Ph.D., and John E. Zeber, Ph.D., of the University of Massachusetts. “Optimizing referral patterns is a key way to improve coordination of care and resource allocation.”

Geissler and Zeber analyzed data drawn from 20,000 primary care visits described in the 2011-2015 National Ambulatory Medical Care Survey. The researchers wanted to determine whether primary care physicians had different referral rates for visits with a primary behavioral health diagnosis compared with other visits, and to see if referral rates differed depending on what kind of behavioral health diagnosis the patients had. They grouped diagnoses for behavioral health conditions as psychoses, opioid use disorder, substance use disorder, depression, and all other behavioral diagnoses.

Overall, a primary behavioral health diagnosis was present in 3.5% of primary care visits. In general, visits with behavioral health diagnoses were more likely to result in referrals. However, when the researchers looked at specific categories of behavioral health conditions, they found that only visits with a diagnosis of psychosis or substance use disorder that did not involve opioids were significantly more likely to result in a referral compared with visits without a behavioral health diagnosis. Visits with a diagnosis of depression or another behavioral health condition were no more likely to result in a referral than visits without a behavioral health diagnosis.

“Our findings document clinically meaningful differences in [primary care physician] referral rates for patients with primary behavioral health diagnoses, which vary substantially by behavioral health condition,” Geissler and Zeber wrote. “In future studies, researchers should examine whether referral rates represent adequate treatment for behavioral health conditions and influences on these referral patterns.”

For related information, see the Psychiatric Services article “Primary Care–Mental Health Integration in the VA: Shifting Mental Health Services for Common Mental Illnesses to Primary Care.”

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Energy Drink Consumption Among Youth Associated With Tobacco, Alcohol Use

Youth who drink energy drinks (beverages that contain high levels of caffeine) may be more likely to start drinking alcohol or using tobacco, suggests a study published in the Journal of Psychopharmacology. 

“Aggressive marketing tailored toward youth through carefully crafted campaigns, including sponsorship of events that appeal to this age group (for example, snowboarding), and product placement in video games and social media has resulted in exponential growth of their sales among minors in recent years,” wrote Artur Galimov, M.D., of Keck School of Medicine of the University of Southern California and colleagues. 

The researchers collected data from a longitudinal study of 3,071 youth aged 9 to 17 in 44 German schools. Galimov and colleagues analyzed survey data on energy drink, tobacco, and alcohol use obtained from these youth at two time points about 12 months apart. As part of the study, youth were asked to rate their interest in sensation seeking (“How often do you do dangerous things to have fun?”) and substance use (“Have you ever been curious about trying cigarettes/e-cigarettes or e-hookah/hookah/alcohol?”). They were also asked to rate their amount of school stress (determined by how much they reported agreeing with such statements as “I have too much to do for school” and “I find school assignments very difficult.”)

Baseline energy drink consumption was associated with significantly higher odds of initiating any tobacco, cigarette, e-cigarette, hookah, and alcohol use. After one year, 29.2% of the 1,061 students who had ever consumed an energy drink had begun to use tobacco, and 30.1% had begun to use alcohol. Among the 2,010 students who had never consumed energy drinks, 5.6% had initiated any type of tobacco use at the one-year follow up, and 10.4% had used alcohol.

Students who drank energy drinks were also more likely to report school stress.

“Hence, the effects of [energy drinks] may become a means of coping with increasing and stressful demands in adolescents’ lives,” the authors wrote. 

“Further research is needed to understand whether these associations may be causal,” the authors concluded. 

For related information, see the American Journal of Psychiatry article “Neural Predictors of Initiating Alcohol Use During Adolescence.” 

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Psychotic Experience In Adolescence Associated With Psychotic Disorder as Young Adults

The majority of young people diagnosed with a psychotic disorder by age 24 have had a psychotic-like experience at age 12 or later, yet many have never sought professional help, according to a report in AJP in Advance.

Sarah A. Sullivan, Ph.D., of the University of Bristol, United Kingdom, and colleagues analyzed data on 3,866 adults aged 24 years who had been assessed at age 12, 18, and 24 as part of the Avon Longitudinal Birth Study. The researchers inquired about psychotic experiences using the Psychosis-Like Symptoms Interview.

Participants were diagnosed as having a psychotic disorder at age 24 if they had a definite psychotic experience not attributable to the effects of sleep or fever; if they had a psychotic experience regularly (at least once a month) over the previous six months; and if they rated the experience as either very distressing or having a very negative impact on their social or occupational functioning and/or if the experience led them to seek help from a professional source.

Of the total sample, 313 young people (8.1%) had had a definite psychotic experience, and 177 (4.6%) had had a suspected psychotic experience at age 12 or later. Of those with a definite psychotic experience, 268 (6.9%) had experienced a hallucination, and 91 (2.4%) a delusion. Forty-six individuals (1.2%) had experienced both.

One-hundred and nine participants met criteria for a psychotic disorder at age 24. Participants who had had a definite psychotic experience at age 12 were 6.8 times as likely to have a psychotic disorder at age 24 as those who did not.

“30% of participants who met our criteria for a psychotic disorder had not sought professional help for their experiences, indicating a significant and important unmet public health need in adolescents and young adults in the general population,” Sullivan and colleagues wrote.

“The use of individual-level interventions to reduce the individual and population health burden of psychotic illnesses requires identification of individuals at high risk,” they wrote. “Our study demonstrates that approximately 60% of those who met criteria for a psychotic disorder at age 24 had a self-reported psychotic experience at age 12, indicating that onset of odd or unusual experiences, even if they do not meet interviewer-rated criteria for being psychotic, are present from childhood in the majority of people who develop a psychotic disorder by their mid-20s.”

For related information, see the Psychiatric News article “Evidence Supporting Early Psychosis Treatment Grows as Programs Gain Ground in Communities.”

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Patients With Treatment-Resistant OCD Found to Improve After Deep Brain Stimulation

Deep brain stimulation (DBS) may lead to improvements in patients with treatment-resistant obsessive-compulsive disorder (OCD), reports a study published today in AJP in Advance.

In the open study of 70 OCD patients who received DBS of a region called the ventral anterior limb of the internal capsule (vALIC), Damiaan Denys, M.D., Ph.D., of the University of Amsterdam and colleagues found that during the first year following the procedure, patients on average experienced significant improvements in symptoms of OCD, anxiety, and depression. The findings support the results of a DBS trial involving 16 OCD patients reported in 2010, the authors noted.

Although pharmacotherapy and cognitive-behavioral therapy (CBT) have been shown to benefit many patients with OCD, 10% of patients experience treatment-resistant OCD, Damiaan Denys, M.D., Ph.D., of the University of Amsterdam and colleagues wrote. DBS uses electrical pulses from implanted electrodes to regulate activity in specific regions of the brain. 

To be included in the trial, patients had to have a primary diagnosis of OCD and a five-year history of OCD. The patients also had a history of “no or insufficient response” to multiple treatments, including two selective serotonin reuptake inhibitors (SSRIs) at maximum dosages, at least one attempt at augmenting SSRIs with an atypical antipsychotic, and CBT, the authors wrote. DBS electrodes were implanted bilaterally into the vALIC of all patients included in the trial, and two weeks after surgery, DBS was activated.

The researchers assessed the patients’ responses to DBS every two weeks to optimize the treatment, such as adjusting the voltage of the electrodes or contact point configurations. They used the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to assess OCD symptoms before DBS surgery, two weeks after the DBS implantation, monthly up to six months after surgery, and at a follow-up at 12 months. The researchers also assessed anxiety symptoms in the patients using the Hamilton Anxiety Rating Scale (HAM-A) and depression symptoms using the Hamilton Depression Rating Scale (HAM-D). The patients were asked about side effects at each visit.

The authors reported that from baseline to follow-up at 12-months, the patients’ mean Y-BOCS score decreased by 40%. Over this same period, the mean HAM-A score decreased by 55%, and the mean HAM-D scores decreased by 54%. 

The researchers categorized the patients as responders if they experienced a ≥35% decrease in scores on the Y-BOCS; partial responders if the Y-BOCS score decreased between 25% and 34%; and nonresponders if the Y-BOCS score decreased less than 25%. At 12 months, 52% of the patients met the criteria for responders; 17%, partial responders; and 31%, nonresponders. The most common side effects reported by patients included hypomania, agitation, impulsivity, and sleeping disorders, but most of these symptoms resolved within weeks, the authors wrote.

“Our study confirms our previous finding that DBS of the vALIC is an effective and tolerable treatment for refractory OCD,” Denys and colleagues concluded.  “Investigating predictors of success could improve DBS selection …,” they added. 

For related information, see the chapter “Brain Stimulation Treatments for Mood Disorders” in Gabbard’s Treatments of Psychiatric Disorders.

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Early Treatment Key to Rapid Concussion Recovery

Young athletes who sustain a concussion are more likely to achieve a speedy recovery if they start receiving clinical care right away, according to a study published today in JAMA Neurology. On average, athletes who were evaluated and began treatment within seven days of their head injury recovered within 51 days, compared with 66 days for athletes who were evaluated eight or more days postinjury.

“[O]nce care was established, time to recovery did not differ for athletes evaluated within the first week of injury compared with those evaluated 2 to 3 weeks postinjury,” wrote Anthony Kontos, Ph.D., of the University of Pittsburgh Medical College (UPMC) and colleagues. The similarity in treatment time indicates the delay in receiving initial care was the primary factor for taking longer to recover, Kontos and colleagues added.

The researchers assessed the recovery time of 162 youth aged 12 to 22 who attended a sports medicine clinic for a concussion between August 2016 and March 2018. Of this group, 98 were evaluated within seven days of concussion (the early group), and 64 were evaluated eight to 20 days after the injury (the late group). The athletes were considered to have recovered from the concussion and cleared to return to active sports if they met the following conditions: showed no concussion-related symptoms at rest; performed at his/her preinjury levels on cognitive, visual, and vestibular (balance/orientation) tests; and had no increase in symptoms after physical activity.

Sixty-three of the 162 athletes recovered within 30 days, while 99 athletes took more than 30 days to recover. The researchers found that athletes in the late group were 5.8 times as likely to require more than 30 days of recovery as those in the early group. The only other factor that was associated with a longer recovery time was the presence of having visual vertigo (dizziness triggered by moving objects) during the initial evaluation. The authors suggested the lengthened recovery in these instances occurs because patients are referred for vestibular therapy, which takes additional time. 

“Among athletes playing at a competitive level, earlier care may lead to fewer games or competitions missed. Similarly, it is reasonable to speculate that student athletes may benefit from fewer missed days of school and may not fall behind in academic achievement if seen earlier,” Kontos and colleagues wrote.

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

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