Fear of Missing Out Linked to Adolescents’ Addiction to Social Media

Fear of missing out—the fear that others may be having fun or rewarding experiences from which one is absent—may make adolescents more sensitive to feeling stress or negative emotions when their friends don’t react to their social media posts, suggests a study in Addictive Behaviors. The researchers wrote that this in turn may prompt excessive social media use and social media addiction as adolescents strive to feel like they belong to a peer group.

Matteo Angelo Fabris of the University of Turin and colleagues studied the relationships between fear of missing out (FoMO), emotional symptoms, and social media addiction in 472 adolescents aged 11 to 19 years. To assess the adolescents’ fear of missing out, they used the FoMO scale, which consists of 10 statements designed to capture a participant’s fears, worries, and anxieties about being out of touch with events, experiences, and conversations among others in their social circle. The researchers used similar assessments to determine the adolescents’ sensitivity to stress in response to being neglected by their peers online, such as whether they would feel stress if their social media posts did not receive any “likes.” The assessments also captured the adolescents’ sensitivity to negative attention online, such as negative comments or a loss of followers on social media, and the adolescents’ overall perceptions of their own emotional distress. Finally, the researchers evaluated the adolescents for social media addiction.

The researchers found that adolescents with high levels of fear of missing out were more likely to experience stress at being ignored or receiving negative comments on social media. They were also more likely to experience greater emotional distress overall and social media addiction.

“[S]pending increasing amounts of time on social media is likely to represent a cognitive-emotional regulation strategy aimed at managing the stress associated with failing to fulfill psychological needs of belonging and popularity,” the researchers wrote. “However, such [a] strategy can be dysfunctional, leading to addictive social media behaviors, and ultimately, an increase in emotional symptoms.”

For related information, see the Psychiatric News article, “Using Many Social Media Platforms Linked With Depression, Anxiety Risk.”

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Medication Treatment for OUD Linked With 80% Lower Risk of Fatal Overdose

Patients with opioid use disorder (OUD) who receive treatment with methadone or buprenorphine have a significantly lower risk of dying from an opioid overdose compared with patients receiving nonmedication treatment, according to a study in Addiction.

“Compared with patients in nonmedication treatment, those in medication treatment had an 80% lower hazard of overdose death during care,” wrote Noa Krawczyk, Ph.D., of the NYU School of Medicine, and colleagues. The risk of fatal overdose significantly increased, however, in the first few weeks following discharge, regardless of the treatment type.

The researchers used outpatient substance use specialty treatment records from 48,274 patients in Maryland from 2015 to 2016 and cross-referenced the data with opioid overdose death records. Treatment records were divided into two categories: those of patients who had received methadone or buprenorphine and those of patients who had received nonmedication treatment, such as psychotherapy, group and individual counseling, and educational programming. A treatment period could not be interrupted by more than two weeks.

There were 371 deaths from opioid overdose during the study period. The opioid overdose rate was lowest when patients were receiving medication treatment, with a rate of .48 deaths per 1,000 person-years. In contrast, the rate for patients who received nonmedication treatment was 4.13 deaths per 1,000 person-years. Also, patients who had received medication treatment stayed, on average, in treatment longer—248 days versus 22 days.

After medication treatment, the rate of overdose deaths increased to 17.21 deaths per 1,000 person-years, “indicating an overall protective effect of being in treatment, regardless of type,” the authors wrote. The risk of overdose immediately after treatment highlights the need to combine care with overdose education and harm-reduction modalities, such as naloxone training and distribution.

In addition, the findings “support efforts to increase expansion of and access to medications in community settings as a means of reducing overdose risk,” the authors continued. “Policymakers should ensure substance use treatment systems make opioid agonist medications (buprenorphine and methadone) highly accessible to all patients who present with OUD and focus efforts on promoting engagement and retention in these programs.”

For related information, see the Psychiatric Research and Clinical Practice article “Pharmacological and Behavioral Treatment of Opioid Use Disorder.”

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Adverse Childhood Experiences Linked to Social Deficits in People at High Risk for Psychosis

Among people at high risk of psychosis, adverse childhood experiences, especially emotional abuse, diminish the ability to recognize other people’s facial emotions as adults—a common social deficit in patients with schizophrenia, according to a report in Schizophrenia Bulletin.

The relationship was strongest among those high-risk patients who went on to develop schizophrenia. The study “confirms that emotional abuse seems to be an important risk factor for the subgroups who go on to develop psychosis,” wrote Stefania Tognin, Ph.D., M.Sc., of the Institute of Psychiatry at King’s College and colleagues.

The study involved 309 people at clinical high risk of psychosis and 51 healthy controls. The ability to recognize facial expressions was measured using a computerized task in which participants are shown images of four faces representing four emotions: angry, happy, fearful, and neutral. Adverse childhood experiences were measured using the three standardized tests of emotional abuse, childhood trauma, and bullying.

During the two-year follow-up, 65 of the high-risk individuals went on to convert to psychosis.

For the high-risk group, the experience of emotional abuse in childhood was significantly associated with lower scores on the computerized test of facial recognition. When results were broken out by subgroup, emotional abuse was associated with worse facial recognition in those who converted to psychosis, but not in the healthy controls or the high-risk patients who did not convert.

Additionally, the number of happy to angry misattributions appeared to be related to the incidence of later transition to psychosis. “This suggests that individuals who go on to develop psychosis are more likely to interpret happy … faces as angry,” Tognin and colleagues wrote.

They noted that the findings could aid in developing interventions to address social deficits among high-risk individuals that result from childhood experiences and prevent transition to psychosis.

For related information, see the American Journal of Psychotherapy article “Social Adversity in the Etiology of Psychosis: A Review of the Evidence.”

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Report Finds Rates of U.S. Deaths From Alcohol Use ‘Accelerating’

Deaths in the United States due to alcohol consumption appear to be rising, according to a report in JAMA Network Open.

“The rate of alcohol-induced deaths, largely due to alcoholic liver disease, increased substantially among men and women in the United States from 2000 to 2016, especially in more recent years,” wrote Susan Spillane, Ph.D., of the National Institutes of Health and colleagues.

Spillane and colleagues analyzed data from the death certificates of U.S. residents (older than 15 years) who died between 2000 and 2016. The authors defined alcohol-induced deaths as those “due to alcohol consumption … [that] could be avoided if alcohol were not involved,” such as alcoholic liver disease, alcohol related mental and behavioral disorders, and accidental poisoning by alcohol.

Between 2000 and 2016, 425,045 alcohol-induced deaths occurred, the authors reported. The rate of death due to alcohol-induced causes increased overall from 2000 to 2016 at an average annual percentage change of 1.4% among men and 3.1% among women.

The largest increases in alcohol-induced deaths were observed among American Indian and Alaska Native men (average annual percentage change, 3.3%), American Indian and Alaska Native women (average annual percentage change, 4.2%), and white women (average annual percentage change, 4.1%).

“Although declines occurred among black women from 2000 to 2007, black men from 2000 to 2012, and Latino men from 2000 to 2013, these promising trends reversed course, and rates of alcohol-induced mortality increased from 2013 to 2016 in all examined racial/ethnic groups,” the authors wrote.

Spillane and colleagues continued, “[A]lcohol consumption levels are unlikely to fully explain mortality trends. Lack of access to high quality care for alcohol misuse and alcohol-associated diseases plays an important role in mortality vs. morbidity. … Because many of the consequences of alcohol consumption occur later in life, large increases in alcohol-induced deaths among younger age groups portend substantial future increases in alcohol-related disease.”

For related information, see the American Journal of Psychiatry article “Neurofunctional Domains Derived From Deep Behavioral Phenotyping in Alcohol Use Disorder.”

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Most Emergency Department Patients With Mental Health Problems Don’t Receive Timely Follow-up Care

Less than half of individuals who were seen in an emergency department (ED) in Ontario for a mental health–related issue had a follow-up visit with a physician within two weeks after discharge, according to a study published today in Psychiatric Services in Advance. Those who had a substance use disorder were even less likely to have a follow-up visit with a physician during this period compared with those who did not have a substance use disorder, the study found.

“Whether individuals present voluntarily because of subjective distress or involuntarily (for example, with police escort) because of acute risk, psychiatric ED visits suggest an urgent need for care,” wrote Lucy Barker, M.D., of the University of Toronto and colleagues. “[Y]et mental health–related crises cannot usually be managed in a single visit. Urgent outpatient mental health care is crucial for ongoing assessment and management and for preventing repeat visits to the ED and other negative outcomes.”

Barker and colleagues accessed health data from the Ontario health system for this study. They identified all people aged 19 and older who came to an ED with a psychiatric issue but were not admitted to the hospital from April 2010 through March 2012. They next assessed how many of these patients had a follow-up visit with any physician for mental health care within 14 days of ED discharge. 

The final sample included 143,662 adults. Of these, 40.2% had a follow-up mental health visit within 14 days of ED discharge.

“ED visits related to substance use represented more than one-fifth of the total ED presentations (22%), and only 1 in 4 received any follow-up care in the 14-day follow-up period (and only approximately 3% received follow-up care from a psychiatrist),” Barker and colleagues wrote. “Rates of follow-up with a psychiatrist were also low among those with the serious mental disorders of schizophrenia and bipolar disorder, where about 1 in 4 and 1 in 3 received follow-up, respectively.”

They concluded, “The gaps that we observed in mental health care continuity in Ontario highlight the need for systemwide and coordinated solutions to successfully transition patients … from the ED to outpatient care. … In particular, for those presenting with substance use disorders, for whom there may only be a short window of motivation to seek care and a similarly short window before rapid deterioration occurs, provider- and system-level barriers to addictions care … warrant careful attention.”

For related information, see the Psychiatric News article “Emergency Department Intervention May Reduce Suicide Attempts in At-Risk Patients.”

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Tendency Toward Negative Moods in Preadolescence Linked to Eating Disorders in Young Adulthood

Negative affectivity, a tendency toward feeling negative emotions such as anger or sadness, may increase the risk of developing eating disorders in young adulthood, a study in the International Journal of Eating Disorders has found.

Annelies E. van Eeden, M.D., of Parnassia Psychiatric Institute in the Netherlands and colleagues used data from the Tracking Adolescents’ Individual Lives Survey (TRAILS), a Dutch community cohort study tracking youth from preadolescence to adulthood. Over the course of TRAILS, participants had assessments at ages 11, 13, 16, 19, 22, and 26 years. Their temperaments were assessed at age 11 using the Early Adolescent Temperament Questionnaire–Revised, and their BMIs were measured at every visit. At ages 19, 22, and 26 years they were screened for eating disorders.

Participants with negative affectivity at age 11 generally weighed more than those who did not have negative affectivity, and they were roughly 30% more likely to have been diagnosed with an eating disorder by the time they were 19 years old. Those with greater negative affectivity also gained more weight in adolescence and young adulthood than their peers.

“This could induce unhealthy … strategies in order to manage the weight and consequently lead to the development of disordered eating and eating disorders,” the researchers wrote.

For related information, see the Psychiatric News articles “Binge-Eating Risk Factors in Adolescents Vary by Socioeconomic Status” and “Researchers Estimate Prevalence of Eating Disorders Among Children.”

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Cognitive Benefits of Exercise in Patients With Schizophrenia Sustained Over One Year, Study Shows

Several studies have found that patients with schizophrenia experience cognitive benefits from exercise. A study in Psychiatric Research suggests schizophrenia patients who participate in a 12-week aerobic exercise program may continue to experience cognitive benefits months after the program ends.

“These findings encourage the incorporation of [aerobic exercise] in psychosocial treatment regimens [for schizophrenia],” wrote Takeshi Shimada, Ph.D., of the Medical Corporation Seitaikai Mental Support Soyokaze Hospital in Japan and colleagues.

Shimada and colleagues conducted a randomized trial in which patients were recruited from a psychiatric hospital in Nagano, Japan. Forty participants with schizophrenia and other schizoaffective disorders aged 20 to 65 were randomly assigned to one of two groups: one group received treatment as usual, which consisted of meetings with a psychiatrist, medication, case management, and rehabilitation programs over a 12-week period; the other group participated in a 12-week aerobic exercise program in addition to receiving treatment as usual. Participants in the exercise program attended one group class (involving exercise videos) and one individual session (involving treadmill or stationary bike) a week, each lasting an hour.

Shimada and colleagues used the Brief Assessment of Cognition in Schizophrenia (BACS) to evaluate the participants’ verbal memory, working memory, motor speed, verbal fluency, attention, and executive function. The researchers also measured participants’ intrinsic motivation (defined as sense of purpose, motivation, and curiosity), psychiatric symptoms, social functioning, and functional outcome. Assessments took place at baseline, after the 12-week aerobic exercise intervention, then at six months and a year later.

Immediately after the aerobic exercise intervention, participants showed significant improvements in cognition, intrinsic motivation, psychiatric symptoms, and relationships with others. A year later, compared with the group that received treatment as usual only, those who also participated in aerobic exercise classes “showed significant, sustained improvements in several cognitive domains [including working memory, verbal fluency, attention, and executive function] as assessed by the BACS,” Shimada and colleagues wrote.

The aerobic exercise group also showed improved intrinsic motivation in the one-year follow-up, with a mean score on the Quality of Life Scale of 9.95 versus 6.75 in the treatment as usual group.

“Such sustained improvement in intrinsic motivation might further promote improvement and maintenance of cognition,” the authors wrote. The study, they added, “provides encouragement to the theory that [aerobic exercise] training is a feasible and well accepted intervention.”

For related information, see the American Journal of Psychiatry article “Therapeutic Potential of Physical Exercise in Early Psychosis.”

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Youth Who Stay in ED Overnight for Mental Health Problems Often Discharged Without Psychiatric Evaluation

Two-thirds of children and adolescents who had to stay in an emergency department (ED) for at least 24 hours with a mental health complaint had suicidal thoughts or behaviors, yet many did not receive a formal psychiatric evaluation by a psychiatrist with treatment recommendations, according to a report in JAMA Pediatrics.

Staying overnight in the emergency department without receiving care, known as boarding, is a significant problem related to the shortage of inpatient psychiatric beds. Erin O’Donnell, M.D., of the Division of Pediatric Emergency Medicine at Johns Hopkins University School of Medicine and colleagues analyzed data on 573 children and adolescents (average age of 14) who stayed at least 24 hours with a mental health complaint at one urban pediatric ED. Most of the patients were African American, resided within city limits, and had no long-term physical conditions.

On average, patients stayed in the ED for 54 hours. The most common chief complaints included suicidal ideation or suicidal attempt and behavior disorder. Many patients had a history of psychiatric problems, with only 74 (12.9%) having no previous psychiatric diagnosis. Nearly half of the patients also had a history of being seen in the ED for mental health concerns.

A total of 378 (66%) of the youth answered positively to suicide-screening questions. Yet only 295 (51.5%) received a formal psychiatric evaluation by a psychiatrist with treatment recommendations. A total of 97 patients (16.9%) for whom hospitalization was initially recommended were discharged home.

“Identifying that almost half of patients had prior mental health–related ED visits together with previous studies revealing that patients fail to receive care from mental health clinicians prior to ED presentation underscores the importance of improving access to outpatient services,” O’Donnell and colleagues wrote. “Given that a sizable portion of boarding patients were discharged home, further efforts are needed to optimize the therapeutic care delivered in the ED and to identify interventions aimed at preventing repeated crises.”

For more information, see the Psychiatric News article “Resource Document on ED Boarding Spells Out Best Practices.”

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Severe Infection Associated With Increased Risk of Substance-Induced Psychosis

People with a history of severe infection such as hepatitis or sepsis may be more likely to develop substance-induced psychosis than people without such history, suggests a report in AJP in Advance.

Previous research by Carsten Hjorthøj, Ph.D., M.Sc., of Copenhagen University Hospital and colleagues revealed that people with substance-induced psychosis—psychosis that occurs during intoxication and resolves after use of the substance is terminated—are more likely to develop schizophrenia compared with the general population. “However, relatively little is known about the etiology and exact pathophysiological mechanisms of substance-induced psychoses, apart from the obviously necessary component cause of having used the substance in question,” they wrote.

For the current study, Hjorthøj and colleagues analyzed data from nationwide Danish registers that included all people born in Denmark since 1981. The authors were able to obtain information about individuals who experienced substance-induced psychosis, infections, and/or schizophrenia, as well as information about parental substance use disorders and psychosis. The final sample included 2,256,779 individuals, for whom 3,618 cases of substance-induced psychosis were recorded.

Any infection increased the risk of substance-induced psychosis (hazard ratio=1.30), the authors reported. “The risk of substance-induced psychosis was doubled the first two years after a severe infection and remained increased for more than 20 years,” they wrote. “Hepatitis in particular appeared to have such an association, with a more than threefold increase in substance-induced psychosis after adjustment for substance use disorder and other potential confounders.” Additional analysis revealed that hepatitis following substance-induced psychosis is associated with an increase in the risk of conversion to schizophrenia.

The findings support “the hypothesis of an immune-related component not just for schizophrenia but for psychosis in general,” the authors continued. “If the exact mechanisms underlying the psychotogenic properties of infections or the immune response can be identified, this is likely to lead to improvements in treatment for psychotic disorders. … Our findings may also hold direct relevance in terms of secondary and tertiary prevention of both substance-induced psychosis and later conversion to schizophrenia.”

For related information, see the American Journal of Psychiatry study “Rates and Predictors of Conversion to Schizophrenia or Bipolar Disorder Following Substance-Induced Psychosis.”

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Secondhand Smoke May Raise Risk of Depressive Symptoms in Adolescents

Adolescents who are exposed to secondhand smoke may be more likely to develop symptoms of depression, a study in the American Journal of Preventive Medicine has found. The risk is also dose-dependent, meaning that the more secondhand smoke to which an adolescent is exposed, the higher the risk.

“Smoking has been linked with depressive symptoms in adolescents, but data on secondhand smoking and depressive symptoms in low- and middle-income countries are scarce,” wrote Louis Jacob, Ph.D., of the University of Versailles Saint-Quentin-en-Yvelines in France and colleagues. “This is an important omission as enforcement of tobacco control policy legislation is weaker in [low- and middle-income countries] compared with high-income countries.”

The researchers analyzed data from the 2003-2008 Global School-Based Student Health Survey of more than 37,000 adolescents aged 12 to 15 years who had never smoked and who lived in 22 low- or middle-income countries. To determine participants’ exposure to secondhand smoke, they were asked, “During the past seven days, on how many days have people smoked in your presence?” To determine whether participants had experienced symptoms of depression, they were asked, “During the past 12 months, did you ever feel so sad or hopeless every day for two weeks or more in a row that you stopped doing your usual activities?”

Overall, 53.6% of the participants had been exposed to secondhand smoke on at least one day in the past week, and 24.5% had experienced depressive symptoms in the past year. Nearly 29% of participants who were exposed to secondhand smoke every day over the past week had experienced depressive symptoms compared with 23% of those who were not exposed to secondhand smoke. Compared with those who were not exposed to secondhand smoke over the previous week, those who were exposed on at least three days were 48% more likely to have experienced depressive symptoms, while those who were exposed on all seven days were 63% more likely to have experienced depressive symptoms.

The researchers wrote that the increased risk of depressive symptoms in adolescents exposed to secondhand smoke may stem from increased levels of perceived stress because of physical discomfort, the association between secondhand smoke and chronic physical conditions in childhood and adolescence such as asthma, and/or the effects of nicotine on neurotransmitters and inflammation.

“If corroborated by further longitudinal studies, these findings suggest that reducing [secondhand smoke] exposure may be important not only for the prevention of physical diseases such as ischemic heart disease, lung cancer, and asthma, but also for adolescent depressive symptoms in [low- and middle-income countries],” the researchers wrote.

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Psychiatric Medications Not Associated With Poorer Weight Loss Following Bariatric Surgery

Psychiatric medications do not appear to interfere with weight loss in obese patients who have had bariatric surgery, according to a report in Psychosomatics, the journal of the Academy of Consultation-Liaison Psychiatry.

Moreover, serotonin-norepinephrine reuptake inhibitors (SNRIs) may be associated with greater weight loss than other types of antidepressants one year after bariatric surgery, according to Michael Hawkins, M.D., of the Scarborough Health Network-Centenary Site in Ontario and colleagues.

Comorbid psychiatric illness is common among obese patients who have bariatric surgery, and some antidepressants are known to cause weight gain. Hawkins and colleagues sought to determine whether psychiatric medications affected the amount of weight lost following surgery.

They analyzed data on 190 patients who had bariatric surgery. Of these, 61 were taking psychiatric medications before surgery, and 50 continued taking psychiatric medications one year after surgery. Antidepressants and benzodiazepines/hypnotics were the most common medications taken by patients before and after surgery.

They found no significant difference in total weight loss between patients taking a psychiatric medication before surgery compared with those who were not; nor was there a difference in weight loss among those taking a psychiatric medication one year after surgery compared with those who were not. Among patients taking antidepressants, those taking SNRIs lost significantly more weight than patients taking serotonin selective reuptake inhibitors (36.4% vs. 27.8%).

“This longitudinal study suggests that psychiatric medication use was not associated with poorer [percent total weight loss] at one year after bariatric surgery,” wrote the researchers. “Within class, antidepressant use may have differential effects on weight loss after bariatric surgery and warrants further investigation.”

For related information, see the Psychiatric News article “SGAs Increase Teen Abdominal Fat, Decrease Insulin Sensitivity.”

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APA Announces Results of 2020 Election

APA’s Committee of Tellers has approved the following results of APA’s 2020 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting on March 14 and 15 in Washington, D.C.




President-elect
Vivian B. Pender, M.D.

Treasurer
Richard F. Summers, M.D.

Trustee-At-Large
Michele Reid, M.D.

Area 2 Trustee
Glenn A. Martin, M.D.

Area 5 Trustee
Jenny Boyer, M.D., Ph.D., J.D.

Resident-Fellow Member Trustee-elect
Sanya Virani, M.D., M.P.H.

“I congratulate Dr. Pender and all of today’s successful candidates on their election,” said APA President Bruce Schwartz, M.D. “I look forward to collaborating with them as APA works to improve access to and quality of mental health care for all.”

Pender’s term as APA president-elect will begin this April at the conclusion of the APA Annual Meeting in Philadelphia, when current President-elect Jeffrey Geller, M.D., M.P.H., begins his one-year term as president.

“APA members and the profession of psychiatry will be well served by the leadership of Dr. Pender,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “I have known her for years, and her dedication and passion for psychiatry will greatly benefit APA during her tenure.”

Complete results of the election will be reported in the March 6 issue of Psychiatric News.

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Exposure to Mother’s Heightened Immune Response in Womb May Increase Schizophrenia Risk

Exposure to a mother’s heightened immune response early in pregnancy may increase an individual’s risk of developing schizophrenia, suggests a study in Lancet Psychiatry.

“We found that higher concentrations of proinflammatory cytokines [TNFα, IL-1β, and IL-6] in specifically the first half of pregnancy were associated with a risk for psychosis among offspring, implicating an earlier timepoint in gestation than previously understood,” wrote Dana Allswede, M.S., and Tyrone Cannon, Ph.D., of Yale University and colleagues. “These three cytokines are potent proinflammatory proteins that have a critical role in the initial response to infection and in initiating and sustaining inflammatory responses.”

The findings were based on data collected for the National Collaborative Perinatal Project (NCPP)—a large-scale prospective longitudinal study. As part of this study, pregnant women from across the United States provided blood samples at prenatal visits and birth from 1958 to 1965.

Allswede, Cannon, and colleagues focused on the women and offspring in the Philadelphia cohort of NCPP, which included 9,236 surviving offspring of 6,753 pregnant women. The researchers examined medical records to determine whether the offspring developed psychotic disorders by adulthood. They also analyzed the concentrations of the following cytokines in the maternal blood samples: TNFα, IL-1β, IL-5, IL-6, IL-8, IL-10, and IL-17a.

The final sample included 90 offspring who later developed psychosis, 79 siblings who did not have psychotic disorder, and 273 matched controls who did not have psychosis. The researchers found that concentrations of proinflammatory cytokines TNFα, IL-1β, and IL-6 were significantly higher in the maternal blood samples of the offspring who later developed psychosis compared with maternal blood samples of the matched controls. “These differences were greatest in the first half of pregnancy …, with no difference observed during the second half of pregnancy,” the authors noted. Siblings and the matched controls did not significantly differ for any of the cytokines.

“Understanding which environmental factors interact with maternal inflammation to increase the risk for psychotic conditions in the offspring, and the pathways through which they act, might provide a framework for early intervention (whether at the maternal, paternal, or childhood level) and build momentum for a much-needed preventive approach to neuropsychiatric disorders,” wrote Bruno Agustini, M.D., Ph.D., and Michael Berk, Ph.D., M.B.B.Ch., of Deakin University in an accompanying editorial.

For related information, see the American Journal of Psychiatry article “Maternal Bacterial Infection During Pregnancy and Offspring Risk of Psychotic Disorders: Variation by Severity of Infection and Offspring Sex.”

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Computer Model Might Help Identify Patients at Risk of Not Taking Their Antidepressants

Using electronic health records, researchers have developed a computer program that can predict which patients are at risk of not taking their prescribed antidepressants with about 70% accuracy. The study was published in Translational Psychiatry.

“Treatment discontinuation may reflect a range of features, from depression-associated amotivation and hopelessness to failure to perceive a benefit to concerns about cost,” wrote Melanie Pradier, Ph.D., of Harvard University and colleagues. “However heterogeneous, the consequences of treatment discontinuation are substantial, contributing to poor treatment outcomes and depression chronicity.”

To build the computer program, Pradier and colleagues analyzed electronic health record data of adult patients aged 18 to 80 who received at least one antidepressant prescription between 2008 and 2014. The study included 51,683 patients who had a diagnosis of a depressive disorder and began treatment with one of nine common antidepressants (bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine) and at least one follow-up visit 90 days or more after their first prescription.

The final sample included 70,121 prescription initiations (as many patients switched antidepressants during treatment). Of these prescriptions, 23.77% were associated with a discontinuation of treatment (for example, no prescription refill and no evidence in the medical record of any nonpharmacological depression treatment). Paroxetine was associated with the highest discontinuation rate (27.71%) while venlafaxine was associated with the lowest (20.78%).

The computer program then analyzed patients’ sociodemographic features and medical history to predict the risk of discontinuation for each of the nine antidepressants. Overall, the program was able to predict the patients who would discontinue an antidepressant with 69% accuracy. For individual medications, the model’s accuracy ranged from 62% for paroxetine to 80% for escitalopram.

Pradier and colleagues highlighted two possible applications for their program: “[T]he risk for discontinuation predicted by the machine-learned model might help in prioritizing interventions aimed at retention in treatment and adherence, including making follow-up phone calls, deploying mobile applications, … or simply scheduling an earlier return visit,” they wrote. Alternatively, these models might be applied in settings where multiple medications would be equally reasonable choices for a patient. “Here, all other things being equal, the clinician might prefer the medication with the lowest risk of treatment discontinuation for that patient.”

For related information, see the Psychiatric News article “Tips for Recognizing, Treating Symptoms of SSRI Discontinuation.”

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Family Conflict, Low Parental Supervision Risk Factors for Suicidality in Children, Study Finds

Family conflict and low parental supervision are associated with suicidality in children, according to a study published today in JAMA Network Open.

“Although many factors that influence a child’s risk for suicide may not necessarily be directly modifiable, family conflict and parental monitoring present targets for intervention,” wrote Danielle C. DeVille, M.A., of the Laureate Institute for Brain Research and colleagues.

DeVille and colleagues analyzed baseline data from the Adolescent Brain Cognitive Development (ABCD) study, a longitudinal study supported by the National Institute of Mental Health that is tracking children from across the United States over a period of 10 years. As part of the ABCD study, 11,814 children (aged 9 and 10) and their caregivers were asked whether the children had current or past suicidal thoughts and/or had ever tried to hurt themselves. Suicidality categories included passive suicide ideation (a wish to be dead), nonspecific active suicidal ideation (wanting to end one’s own life without considering a method or plan to do so), active suicidal ideation, or past suicide attempts. Nonsuicidal self-injury (NSSI) was defined as intentional self-inflected damage to the body without suicidal intent. Children were placed in a given suicidality category if either they or their caregiver reported the behavior.

The researchers gathered information on family and home environments, including parental surveys that detailed the extent to which the parents supervised and/or tracked their children. They also collected the children’s reports of family conflict, including fighting, anger, criticism, competitiveness, yelling, and/or temper within the family.

Overall, 6.4% of the children had a lifetime history of passive suicidal ideation; 4.4% had nonspecific active suicidal ideation; 2.4% had active ideation with a method, intent, or plan; 1.3% had a past suicide attempts; and 9.1% had a NSSI. Additional findings include the following:

• High family conflict was significantly associated with suicidal ideation and NSSI.
• Low parental monitoring was significantly associated with ideation, attempts, and NSSI.
• Most children’s reports of suicidality and NSSI were either unknown or not reported by their caregivers; for 77% of the children who reported suicidal ideation, their caregivers denied all forms of suicidal ideation or attempts. (Families with a history of depression were less likely to have suicidality reports in which the child and parent didn’t agree.)
• Rates of suicidal ideation and NSSI were higher in boys, though there was no significant difference between boys and girls in the prevalence of suicide attempts.
• Greater financial problems were found among children who reported suicidal ideation, suicide attempts, and NSSI.
• No significant differences were found on the basis of race or ethnicity.

“The high levels of parent-child discordance in the reporting of ideation, suicide attempts, and NSSI observed in the current study may have important clinical implications,” the authors wrote. “Our findings highlight the need to ensure that suicide assessments are conducted with children directly rather than solely with the child’s caregivers.”

For related information, see the Psychiatric News article “Preteen Suicides: Rare, Mysterious, and Devastating.”

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Pain Linked to Increased Risk of Hazardous Drinking in Smokers

Experiencing frequent or intense pain is linked to hazardous drinking in people who smoke tobacco, a study in the American Journal on Addictions has found. The study also suggests that the impact of pain on a person’s mood may be partly to blame.

“Relative to the general population, smokers are four times more likely to be dependent on alcohol and are more likely to experience severe pain,” wrote Lisa R. LaRowe, M.S., of Syracuse University in New York and colleagues. To examine the relationship between pain and alcohol use among smokers, the researchers analyzed measurements of pain and alcohol use in 225 people who smoked at least 15 tobacco cigarettes a day, with an average of 22 tobacco cigarettes a day.

Participants rated the amount of bodily pain they experienced in the four weeks prior to the study on a 6-point scale, with 0 representing “none” and 5 representing “very severe.” They also rated the intensity of their pain over the previous 24 hours on a scale of 0 to 10, with 10 representing the most severe. The researchers used the Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol Urge Questionnaire to determine how much alcohol the participants drank, whether the participants’ alcohol use was hazardous, and whether the participants experienced a strong urge to drink. The researchers also measured the intensity of the participants’ negative emotions via the negative affect subscale of the Positive and Negative Affect Schedule.

Approximately 35% of participants who reported experiencing pain in the prior four weeks scored above the AUDIT cut-off for hazardous drinking, compared with 19% of those who reported experiencing no pain in the prior four weeks. Each one-point increase in pain severity was associated with a 47% greater likelihood of screening positively for hazardous drinking. Moreover, the higher participants scored on pain intensity, the more likely they were to experience negative moods. In turn, the more negative moods they had, the greater the urge they had to drink alcohol.

“These findings provide initial evidence that smokers with greater pain severity may also report hazardous patterns of alcohol use,” the researchers wrote. “The observed indirect association between pain intensity and urge to drink via a negative affect adds to a growing literature indicating that pain can be a potent motivator of substance use in general, and alcohol use in particular.”

For related information, see the American Journal of Psychiatry article “U.S. Adults With Pain, a Group Increasingly Vulnerable to Nonmedical Cannabis Use and Cannabis Use Disorder: 2001–2002 and 2012–2013.”

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Experts Say Coronavirus Outbreak Demands Swift Mental Health Response

Mental health care is urgently needed for patients and health care workers affected by coronavirus, wrote Yu-Tao Xiang, M.D., of the University of Macau in China and colleagues in an editorial published Tuesday in Lancet Psychiatry. The authors suggest that the lessons learned from the 2003 severe acute respiratory syndrome (SARS) outbreak can guide the mental health response to coronavirus.

The outbreak of the 2019 novel coronavirus pneumonia (2019-nCoV) has garnered international attention and produced a wave of anxiety. Officials in China, where the outbreak originated, and elsewhere have enacted a range of measures to combat the spread of the virus. Yet, according to Xiang and colleagues, mental health care for patients affected by the virus and those caring for them have largely gone unaddressed.

“The observations of mental health consequences and measures taken during the 2003 SARS outbreak could help inform health authorities and the public to provide mental health interventions to those who are in need,” Xiang and colleagues wrote.

To meet the mental health needs of those affected by the 2019-nCoV outbreak, Xiang and colleagues recommend the following:

• Authorities should clearly and regularly communicate accurate updates about the 2019-nCoV outbreak to health workers and patients in order to address their sense of uncertainty and fear.
• Mental health workers should regularly screen suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals caring for infected patients for depression, anxiety, and suicidality.
• Multidisciplinary mental health teams established by health authorities at regional and national levels (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) should deliver mental health support to patients and health workers.
• Secure services should be set up to provide psychological counseling using electronic devices and applications for affected patients, as well as their families and members of the public. Using such communication channels between patients and families should be encouraged to decrease isolation.

“In any biological disaster, themes of fear, uncertainty, and stigmatization are common and may act as barriers to appropriate medical and mental health interventions,” Xiang and colleagues wrote. “Based on experience from past serious novel pneumonia outbreaks globally and the psychosocial impact of viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are crucial and pressing goals for the health response to the 2019-nCoV outbreak.”

For related information, see the book Disaster Psychiatry: Readiness, Evaluation, and Treatment, from APA Publishing.

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Many Older U.S. Adults Who Died By Suicide Did Not Have Known Mental Illness, Study Suggests

Many U.S. adults 65 and older who died of suicide between 2003 and 2016 did not have a known mental illness, according to a report in the American Journal of Preventive Medicine. The majority those who died of suicide were reported as having physical health problems—a precipitating circumstance that was more commonly documented for older adults without known mental illness.

“Suicide risk increases with age, and evidence exists for the underdiagnosis and undertreatment of suicide risk in older adults,” wrote Timothy J. Schmutte, Psy.D., and Samuel T. Wilkinson, M.D., both of Yale School of Medicine.

To better understand the similarities and differences between older adults with and without known mental illness who died of suicide, Schmutte and Wilkinson analyzed data from the National Violent Death Reporting System (NVDRS). This U.S. database contains extensive information on the characteristics of suicide decedents and the circumstances that precipitated their deaths. Known mental illness was defined as whether a decedent was identified as having a current mental health problem based on law enforcement or coroner/medical examiner reports.

Of the 26,884 suicide deaths recorded during the study period, 83.2% occurred in men. Most older men (69.1%) and women (50.2%) who died of suicide did not have a known mental illness.

Most suicide deaths involved firearms, which were disproportionately used by decedents without known mental illness (81.6% of men and 44.6% of women) compared with those with known mental illness (70.5% of men and 30.0% of women).

“[T]his study highlights a need for prevention efforts that address a broad range of risk factors for late-life suicide. ... Targeted community efforts to reduce stigma and improve help-seeking in older adults, particularly men, and other population-based strategies (for example, legislation that reduces access to handguns) may be effective at reaching vulnerable adults and reducing suicide rates,” Schmutte and Wilkinson wrote.

For related information, see the Psychiatric News article “Loss of Partner to Suicide Increases Risk of Mental Health Problems, Death.”

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Optimizing Stimulant Treatment May Help Reduce Aggression in Children With ADHD

Children with attention-deficit/hyperactivity disorder (ADHD) who also have aggression problems might benefit from adjustments to their stimulant regimen and behavioral therapy, reports a study in the Journal of the American Academy of Child and Adolescent Psychiatry. If these interventions do not adequately reduce aggressive behaviors, additional treatment with the antipsychotic risperidone or the mood stabilizer divalproex may be advised, the study found.

Joseph Blader, Ph.D., of the University of Texas Health Science Center at San Antonio and colleagues enrolled 175 children aged 6 to 12 with ADHD and either oppositional defiant disorder or conduct disorder for the study. Although the children had been taking stimulant medication for at least 30 days, all the children had clinically significant aggressive behavior—defined as a score of >24 on the parent-reported Retrospective-Modified Overt Aggression Scale (R-MOAS).

At the beginning of the trial, all children received extended-release methylphenidate tablets whose effects last up to 12 hours. The researchers adjusted the stimulant dose for each child weekly until they found the most effective dose. Children who were experiencing problems in the evening (poor appetite or sleep) while taking the extended-release methylphenidate were switched to a shorter eight-hour methylphenidate formulation; children who experienced negative side effects on methylphenidate were switched to extended-release amphetamine tablets. All children and their parents also received family-based behavioral therapy during this optimization phase, which lasted until aggression symptoms went away or the child reached the maximum dose on their best tolerated medication (the average time of optimization was 69 days).

Of the sample, 151 completed the stimulant-optimization phase, 96 of whom achieved a remission of their aggression symptoms (R-MOAS <15). Forty-five children who continued to show high aggression following this first phase were randomly given risperidone, divalproex, or placebo in addition to their stimulant medication and family therapy for eight more weeks.

After eight weeks, children taking either risperidone or divalproex had statistically greater reductions in their aggression symptoms than those taking placebo. Due to the small sample size, though, the researchers could not determine whether risperidone or valproate was superior at reducing aggression. Children taking risperidone experienced more weight gain than those taking divalproex or placebo.

These results reinforce the clinical value of optimizing first-line stimulant therapy for youth with ADHD and aggression by methodically adjusting their medication dose and providing family-based behavioral therapies, Blader and colleagues wrote. “Given the adverse-effect liabilities of adjunctive medications, it is important to improve ADHD care so that clinicians initiate antipsychotic and other co-therapies as sparingly as possible. For those who do not experience sufficient benefit from thoroughly implemented initial treatments, this study adds to the emerging evidence base that such adjunctive medications may be helpful,” they continued.

To read more on this topic, see the Psychiatric News article “Many Youth With ADHD Fail to Take Stimulants as Prescribed.”

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