Geller Testifies on Mental Health Needs During Pandemic and Beyond

During a virtual U.S. House subcommittee hearing today, APA President Jeffrey Geller, M.D., M.P.H., urged Congress to take action to curb the mental health impact of the COVID-19 pandemic.

“We expect that, even after the infectious aspect of this pandemic is over, we’re going to have a mental health pandemic that could go on for quite some time,” Geller told the U.S. House Committee on Energy & Commerce’s Subcommittee on Health.

The hearing, titled “High Anxiety and Stress: Legislation to Improve Mental Health During Crisis,” addressed 22 pieces of legislation related to mental health care pending before Congress. Geller expressed APA’s support for legislation that would achieve the following:

• Require the Department of Health and Human Services to collect, analyze, and make publicly available data on race and ethnicity related to COVID-19 testing, hospitalization, and mortality as well as the mental health effects of the pandemic.
• Enforce the parity law, which requires insurers to cover mental health at the same levels as physical health.
• Continue expanded telehealth rules beyond the COVID-19 emergency.
• Strengthen congressional efforts to prevent suicide.
• Ensure that patients who present in the Emergency Department with suicidal ideation or who have attempted suicide are screened and referred to appropriate mental health treatment.
• Boost resources for call centers, 24/7 mobile crisis units, and crisis stabilization programs.

Geller especially expressed APA’s support for the Telemental Health Expansion Act of 2019 (HR 5201), introduced by Reps. Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio). The legislation would permanently exempt tele-mental health services from Medicare’s geographic restrictions, such as requiring patients to travel to a qualifying “originating site” for appointments.

He also highlighted the Mental Health Parity Compliance Act (HR 3165), sponsored by Reps. Katie Porter (D-Calif.), Gus Bilirakis (R-Fla.), and Rep. Donald Norcross (D-N.J.). This legislation would ensure that health insurance plans comply with the Mental Health Parity and Addiction Treatment Act of 2008.

During the question-and-answer portion of the hearing, Geller stressed that he believes a campaign is urgently needed to reduce prejudice and discrimination toward people with mental illness and called on Congress to help such an effort.

The only bill addressed during the hearing that APA opposed was the Medicare Mental Health Access Act (HR 884), introduced by Rep. Judy Chu (D-Calif.), which would define psychologists as physicians under Medicare. In his written testimony, Geller noted that the bill “would further fragment care by creating unnecessary and dangerous silos between all health care providers who should be working collaboratively.”

Geller testified along with former Rep. Patrick Kennedy, founder of the Kennedy Forum; Arthur C. Evans Jr., Ph.D., CEO of the American Psychological Association; and Arriana Gross, a member of the National Youth Advisory Board of the Sandy Hook Promise Students Against Violence Everywhere Promise Club.

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Get Off the Sidelines: Serve Your Profession as APA Trustee
Nominate yourself or a colleague

As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

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Study Documents Neurological, Psychiatric Complications From COVID-19

While previous studies and case reports have found that COVID-19 patients have experienced vascular and neurological problems, a new study in the Lancet Psychiatry reports that patients are also showing symptoms of psychiatric disorders, including psychosis and depression.

The study was the result of a collaborative effort of specialists in the United Kingdom to document COVID-19 complications.

“To our knowledge, this is the first systematic, nationwide U.K. surveillance study of the breadth of acute complications of COVID-19 in the nervous system,” wrote Aravinthan Varatharaj, M.R.C.P., of University Hospital Southampton and colleagues.

Earlier this year, researchers created a U.K.-wide online portal through which specialists in neurology, psychiatry, stroke medicine, and neurointensive care could enter clinical data on COVID-19 patients who developed nervous system–related complications. The complications were classified in four broad areas: a cerebrovascular event (such as a stroke or brain hemorrhage), altered mental status (a change in behavior, cognition, or consciousness), peripheral neurological issue (weakness and/or pain in body nerves or muscles), or other.

The researchers focused on data entered between April 2 and April 26—the first three weeks that the portal accepted submissions. Full clinical details on 125 patients were analyzed.

Of this group, 77 patients experienced a cerebrovascular event (primarily stroke), 39 experienced altered mental status, six experienced peripheral problems, and three experienced other nervous system–related complications. Among the 39 patients with altered mental status, 16 were diagnosed with encephalopathy (brain inflammation), and 23 were diagnosed with a psychiatric disorder. Ten of these 23 patients developed psychosis, six developed cognitive problems, and seven developed mood problems including depression and mania.

A greater percentage of younger patients were affected by altered mental status than cerebrovascular events, Varatharaj and colleagues noted. For instance, 49% of the patients who experienced altered mental status were under age 60, whereas 18% of patients who experienced a cerebrovascular event were under 60.

“Our study population represents a snapshot of hospitalized patients with acute neurological or psychiatric complications associated with COVID-19. Larger, ideally prospective, studies should identify the broader cohort of COVID-19 patients both in and outside hospitals ... to determine clearer estimates of the prevalence of these complications and individuals at risk,” the authors concluded.

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Psychiatric News continues to report news and information relevant to psychiatrists about the COVID-19 pandemic. We will highlight these articles for you as they become available online:

Psychological Stress May Not Be Only Route Of COVID-19’s Psychiatric Burden

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COVID-19 Takes Toll on Mental Health of Hospital Health Professionals

The COVID-19 pandemic is taking a psychological toll on health care professionals who work in large, urban medical centers, raising their risk for poor health down the road, suggests a study in General Hospital Psychiatry. Nearly 6 in 10 health professionals in the COVID-19 Healthcare Provider Study, an ongoing survey of health care workers at Columbia University Irving Medical Center in New York, screened positive for symptoms of acute stress. Nearly half screened positive for symptoms of depression, and a third screened positive for symptoms of anxiety.

“Sustained COVID-19-related psychological distress is expected to have downstream impacts on health care workers' physical health,” wrote Ari Shechter, Ph.D. of the Columbia University Irving Medical Center and colleagues. “There is an association between clinical workplace environmental stressors and long-term cardiometabolic risk, and stress can influence health in ways that are both direct (systemic inflammation, arterial damage, increased blood pressure) and indirect (maladaptive coping such as substance use, poor sleep). Sustained psychological distress and poor sleep may disturb the body's physiological stress response system, thereby contributing to further health risk.”

The findings are based on an analysis of responses from 657 physicians, residents/fellows, nurses, nurse practitioners, and physician assistants who completed the survey between April 9 and April 24. The survey was designed to assess the participants’ COVID-related stress as well as their sense of meaning and purpose, their coping behaviors, and the kind of wellness resources they were interested in receiving. Researchers also used standard screening tools such as the Primary Care PTSD screen, the Patient Health Questionnaire-2, and the 2-item Generalized Anxiety Disorder scale.

Among participants, 74% reported great distress over fears of transmitting the virus to their family and friends; 71% reported sleep disturbances and getting less than six hours of sleep per night; 65% reported feeling lonely at least several days a week; and more than 60% reported concerns over the health of their family and friends, maintaining social distancing from family, and uncertainty over their colleagues’ COVID-19 status. However, 61% reported feeling a greater sense of meaning or purpose.

Participants used a range of coping behaviors to manage their stress, with 59% turning to physical activity and exercise; roughly 25% engaging in talk therapy, yoga, faith-based religion and/or spirituality; and/or meditating, and 16% participating in virtual provider support groups. Approximately 14% did not engage in any of the coping behaviors listed in the survey. Roughly 33% of participants expressed interest in online-self-guided counseling with access to a therapist, and 28% expressed interest in traditional individual counseling or therapy.

“These findings should inform the development and implementation of interventions to mitigate the impact of sustained psychological distress on long-term mental and physical well-being in health care workers,” the researchers wrote. “The lessons learned from the COVID-19 pandemic should help decision-makers at all levels of government, hospital management, and the community to promote readiness to protect health care workers as we navigate this and future public health crises.”

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Psychological Stress May Not Be Only Route Of COVID-19’s Psychiatric Burden

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Price of Antipsychotics Varies Significantly Between Pharmacies, Study Finds

The price of antipsychotic medications varies significantly between pharmacies, sometimes by differences of over $1,000, according to a study published in Psychiatric Services in Advance.

Carrie R. Kriz, M.S., Leigh Anne Nelson, Pharm.D., B.C.P.P., and colleagues from the University of Missouri-Kansas City collected data by calling 281 pharmacies in the Kansas City area and requesting the cash price of a 30-day supply of six generically available antipsychotic medications. Each call included requests for the cash price of two medications at the specific strength and number of doses to “mimic a patient’s interaction and limit questions from the pharmacy,” the authors wrote. (Pharmacy students called each pharmacy three separate times to obtain prices for all six medications.)

The medications were the second-generation antipsychotics risperidone at 4 mg per day, olanzapine at 20 mg per day, quetiapine at 600 mg per day, ziprasidone at 160 mg per day, and aripiprazole at 20 mg per day and the first-generation antipsychotic haloperidol at 10 mg per day.

Of the pharmacies called, 265 responded to phone queries between April 25, 2017, and May 25, 2017. There were significant pricing variations between all types of pharmacies, including nationwide chains, grocery store pharmacies, and independent pharmacies. Haloperidol had the lowest price difference ($20-$102.99), while aripiprazole had the highest difference ($29.99-$1,345). There were also significant differences in price for olanzapine ($16-$1,314) and quetiapine ($20-$1,105.75).

Compared with independent pharmacies, chain pharmacies had the highest prices for most medications. Prices at grocery store pharmacies and independent pharmacies averaged $180 and $415 lower than those at chain pharmacies, respectively.

Some states have website databases meant to publicly report pharmacies’ medication prices, but these databases can be unreliable, the authors noted. Additionally, “[i]ndividuals with schizophrenia often have co-occurring cognitive deficits, and thus the utility of websites for price comparisons by these individuals remain questionable,” they wrote.

Prescription coupon websites may be a resource to save money on medications, but the authors pointed out that studies show individuals with severe mental illness are less likely to use the internet. Those individuals may also find it difficult to identify and contact multiple pharmacies to check prices. “Therefore, the best outcome for patients may be a combination of counseling patients on how to obtain low-priced medications and provision by health care providers of medication coupons to patients,” the authors wrote.

According to the authors, further research is necessary, particularly to determine if socioeconomic or neighborhood characteristics contribute to price variability. “By understanding where and how patients can access low-cost antipsychotic medications, providers may be able to provide patients with the best possible treatment option at the lowest cost,” the authors concluded.

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Get Off the Sidelines: Serve Your Profession as APA Trustee
Nominate yourself or a colleague

As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

Access Nomination Requirements and Form

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Threefold Increase Seen in Children Visiting Emergency Departments for Deliberate Self-Harm

The percentage of children presenting to emergency departments (EDs) with mental illness and substance use disorders rose dramatically between 2007 and 2016, with visits related to deliberate self-harm increasing by more than 300%, according to a report in Pediatrics.

“We observed that children were presenting at EDs in all locations with all pediatric volumes, whether they were specialized or not,” said lead author Charmaine Lo, Ph.D., M.P.H., senior research scientist at National Children’s Hospital, in a video presentation about the study that accompanies the report. “In fact, most visits were to nonspecialized, nonchildren hospital EDs,” she added.

Lo and colleagues analyzed data from the 2007 to 2016 Nationwide Emergency Department Sample, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. They looked at visits for children aged 5 to 17 years who presented with mental disorders, substance use disorders, and/or who presented for deliberate self-harm. They also looked at visits according to geographic location of the hospital, the volume of children regularly seen at the hospital, and whether the hospital was a specialized children’s hospital or not.

The authors found that over the 10-year study period, the total number of pediatric ED visits was stable, but pediatric ED visits for all mental health disorders rose 60% and visits related to substance use disorder rose 159%. ED visits for deliberate self-harm increased by 329% during this time.

“Although the increased rate of pediatric mental health visits was greatest among high-pediatric-volume EDs, our results show that all EDs, regardless of pediatric volume, experienced increased visits by children for mental health disorders,” Lo and colleagues wrote. “It will be important to focus future mental health preparedness efforts and resources on all hospital EDs, particularly smaller-volume and rural EDs, and not just on children’s hospital EDs.”

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Hispanic Community and COVID-19: Addressing Health Inequalities Can No Longer Be Delayed

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Risk of Injury Greater in Young Children Who Have Parent With Serious Mental Illness

Young children who have at least one parent with a serious mental illness (SMI), such as schizophrenia, major depression, or bipolar disorder, may be more prone to injuries than those whose parents do not have SMI, according to a report published yesterday in JAMA Pediatrics. The risks of serious injury were highest in infants and decreased over time.

Shiow-Wen Yang, M.D., Ph.D., of Cathay General Hospital in Taiwan, Ann Vander Stoep, Ph.D., of the University of Washington, and colleagues made use of four Taiwanese national databases to access medical and birth data. They included 1,999,322 single-child births between January 1, 2004, and December 31, 2014, in their final analysis and tracked outcomes of each child up to age 5. The sample included 90,917 children who had at least one parent diagnosed with an SMI; this included parents diagnosed both before and after the child’s birth.

Within the study cohort, 54.1% were injured. A greater proportion of children who were exposed to a parent with SMI (61.0%) than those who were not exposed to parent with SMI (53.8%) sustained injuries, Stoep and colleagues reported.

After adjusting for sociodemographic factors, Stoep and colleagues calculated that, by age 5, children exposed to a parent with SMI were 14% more likely to sustain an injury, 49% more likely to require hospitalization for an injury, and 82% more likely to die by injury than children not exposed to a parent with SMI. As a control, the authors found that rates of appendicitis, a medical condition not influenced by behavior, did not differ based on parental SMI.

“[E]ffective management of parental SMI may have beneficial effects for child health,” Stoep and colleagues concluded. “Reducing stigma toward mental health treatment, enhancing parenting skills, and enacting home safety interventions for parents with SMI may contribute to a reduction in injury risk for their children.”

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Get Off the Sidelines: Serve Your Profession as APA Trustee
Nominate yourself or a colleague

As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

Access Nomination Requirements and Form

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HHS, CMS to Host Sessions on Applying for Provider Relief, Information on COVID-19

1. Help on Applying for Provider Relief

The Department of Health and Human Services (HHS) earlier this month launched the Enhanced Provider Relief Fund Payment Portal to distribute $15 billion in CARES Act Provider Relief Fund payments to eligible Medicaid and Children’s Health Insurance Program (CHIP) physicians and organizations. The new portal was developed for providers who did not receive payments under the previous general distribution.

Among the providers who may be eligible for this funding include opioid treatment and behavioral health providers, assisted living facilities, and other home and community-based service providers, according to an HHS press release. “To be eligible for this funding, health care providers must not have received payments from the $50 billion Provider Relief Fund General Distribution and either have directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for healthcare-related services between January 1, 2018, to May 31, 2020.”

HHS will host two webcasts this week for physicians and other health care professionals who are interested in learning more about the application process to acquire these funds (registration is required):

• Tuesday, June 23, at 2 p.m. ET
• Thursday, June 25, at 2 p.m. ET

“At this time, this portal will serve as the point of entry for providers who have received Medicaid and CHIP payments in 2017, 2018, 2019, or 2020 and who have not already received any payments from the $50 billion Provider Relief Fund General Distribution,” the agency wrote in FAQs. The site is open to all providers who want to apply for a Provider Relief Fund payment, regardless of network affiliation or payer contract, the agency noted.

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2. Next COVID-19 Stakeholder Engagement Call:
Tuesday, June 23, 5 p.m.-6 p.m. ET

The Centers for Medicare and Medicaid Services hosts stakeholder engagement sessions to share information related to the agency’s response to COVID-19. These sessions are open to members of the health care community and are intended to provide updates, share best practices among peers, and offer an opportunity to ask questions of CMS and subject matter experts. Conference lines are limited so you are invited to join via audio webcast on your computer or smartphone web browser.

Toll-Free Attendee Dial In: 833-614-0820

Access Passcode: 5775248

Audio Webcast link

All call recordings and transcripts are posted on the CMS podcast page.

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Reinventing Networking During Era of Social Distancing

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Brief Suicide Prevention Interventions May Reduce Subsequent Attempts

A meta-analysis of 14 studies found that brief suicide prevention interventions for patients at risk of suicide are associated with reduced subsequent suicide attempts and increased linkage to follow-up care, but not with reduced depression symptoms. The findings were published yesterday in JAMA Psychiatry.

“All of these studies show that we have evidence-based treatments in our arsenal to fight the suicide epidemic that work in different settings and different populations,” wrote Nadline M. Melhem, Ph.D., and David Brent, M.D., of the University of Pittsburgh School of Medicine in an accompanying editorial. “What we need to do next is to implement them at the appropriate point of contact in the health care system and train clinicians to deliver them.”

Stephanie K. Doupnik, M.D., M.S.H.P., of the University of Pennsylvania and colleagues conducted a review of clinical trials that involved brief suicide prevention interventions that could be delivered in a single encounter. They searched databases including Ovid MEDLINE, Scopus, CINAHL, PsychINFO, and Embase for studies published between 2000 and 2019. The studies were eligible for inclusion if they examined an intervention delivered in a single in-person encounter to patients with identified suicide risk, included a comparison group, measured patient outcomes, and were available in English.

The authors ultimately evaluated 14 studies representing outcomes for 4,270 patients. Seven of these studies measured suicide attempts, nine measured linkage to follow-up care, and six measured depression symptoms. The researchers identified four main components of interventions: brief contact interventions, including phone calls, postcards, and letters; care coordination, such as scheduling an outpatient mental health appointment; safety planning interventions, such as identifying internal coping strategies to distract from suicidal thoughts and urges; and other therapeutic interventions, such as motivational interviewing and therapies focused on improving problem-solving skills.

Brief suicide interventions were associated with a 3.5% reduction in subsequent suicide attempts, while the rate of linkage to follow-up care increased by 22.5%. Reduction in depression symptoms at follow-up was not statistically significant, however.

In their editorial, Melhem and Brent noted that it is not surprising that brief interventions did not reduce depression symptoms, which is an important predictor of suicide attempts. “However, interventions including more than a single encounter are needed to result in a sustained reduction in depression symptoms,” they wrote.

They concluded: “As the world is now grappling with the coronavirus disease 2019 pandemic and its potential effects on mental health and the suicide epidemic in the United States, we need to be prepared with brief suicide preventive interventions that every clinician could deliver face to face or through telemedicine.”

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Get Off the Sidelines: Serve Your Profession as APA Trustee
Nominate yourself or a colleague

As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

Access Nomination Requirements and Form

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Callous-Unemotional Traits May Predict Future Risk of Gun Use By Some Youth

Callous-unemotional traits displayed in male adolescents after a first arrest may predict an increased risk of carrying and using a gun during a crime over a four-year period, according to a study published yesterday in AJP in Advance.

Callous-unemotional traits, such as limited guilt and reduced empathy, are found in 25% to 30% of adolescents with serious conduct problems, wrote Emily L. Robertson, M.A., of Louisiana State University and colleagues. “These adolescents display more persistent and severe aggression and violent offending, use aggression for personal gain, engage in behavior that causes more harm toward victims, display conduct problems that are more stable, and have worse treatment outcomes,” they wrote.

To examine the relationship between callous-unemotional traits in adolescents and risk of future gun carrying and use, the authors analyzed a sample of 1,215 male adolescents aged 13 to 17 years who were arrested for the first time for what the authors described as “an eligible offense of moderate severity.” (The authors noted that 77.2% of the participants were never incarcerated at any point in the study.)

The youth completed the self-report version of the Inventory of Callous-Unemotional Traits (a 24-item instrument) at baseline and answered questions about how many of their peers carried and/or owned a gun. At follow-ups every six months for 36 months and then again at 48 months, the youth were asked about their own experience of carrying a gun and use of a gun during a crime.

After controlling for other risk factors, youth with greater callous-unemotional traits were found to be more likely to carry a gun and to use a gun during a crime in the four years after their initial arrest than those with fewer of these traits. Every one-point increase in callous-unemotional traits was associated with a 7.6% increase in the likelihood of carrying a gun and a 6.9% increase in the probability of using a gun during a violent crime, according to the study.

“The present study has important implications regarding the risk factors for gun carrying and use in adolescent boys in the juvenile justice system,” Robertson and colleagues noted. “First, interventions to reduce gun violence need to consider methods that have proven effective for youths with elevated callous-unemotional traits, who often do not respond as well to traditional mental health treatments. Second, our findings demonstrate the importance of considering callous-unemotional traits in future gun violence research because they may moderate the influence of other known risk factors, such as peer gun use, and lead to underestimates of the impact of this risk factor in the majority of youths, who do not have elevated callous-unemotional traits.”

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Expect a ‘Long Tail’ of Mental Health Effects From COVID-19

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Black Psychiatrists Call on White Colleagues to Dismantle Racism in Profession, APA at Town Hall Meeting

Last night APA hosted the first of a series of member town hall meetings to address structural racism in the organization’s history, among colleagues, in current psychiatric practice, and in the education of medical students and early career psychiatrists. A distinguished panel of Black psychiatrists and a guest physician spoke to more than 500 APA members about what must be done to dismantle the processes and institutions that confer advantages upon white people and impede the lives and livelihoods of Black people, not only in the profession of psychiatry, but in the nation as a whole.

APA President Jeffrey Geller, M.D., M.P.H., began with a discussion of racism dating back nearly to the inception of American psychiatry. He described two alleged diseases theorized by nonpsychiatrist and Mississippi physician Samuel Cartwright in the mid-1800s: drapetomania, the desire to flee from servitude, and dysaesthesia aethiopica, a lack of work ethic.

“Cartwright’s theories were embraced in the slave states and mocked in the free states, including in medical journals,” Geller said. “The APA was silent, and that is our shame. They were silent then, and we have been silent for 176 years.”

Danielle Hairston, M.D., president of the APA Caucus of Black Psychiatrists and the psychiatry residency training director at Howard University College of Medicine, answered a question posed by a member who registered for the town hall, “How can we support Black residents and students?”

“You can start by validating that racism exists and validating their experiences. When a student or trainee is telling you that something [racist] is happening, listen,” she said. “When there are no black residents in your program, … do something to prioritize diversity, discuss sponsorship and mentorship, and invest in diversity as part of your recruitment.”

Walter E. Wilson Jr., M.D., M.H.A., a member of APA’s Council of Minority Mental Health and Health Disparities and a second-year fellow in child and adolescent psychiatry at Vanderbilt University, spoke about the term “all lives matter” as a response to the Black Lives Matter movement. He described an analogy he had seen online.

“If you distill American society into one neighborhood, and each house represents a different racial or ethnic group, oftentimes African Americans end up asking for help throughout the community for emergencies associated with their house, and others respond with, ‘Well, all houses matter,’” he explained. “The problem with that is that the African American house is on fire. It has been on fire for 400 years. We were forced to live in a house that was smaller than the other houses, we were forced to be firefighters, and then we were blamed for the fire.”

Ayana Jordan, M.D., Ph.D., ECP trustee-at-large on the APA Board of Trustees, directed many of her comments toward white psychiatrists, emphasizing that racism is something white people must actively address. She called for open, authentic dialogue and active change in dismantling racism in psychiatry.

“I am asking that we as a member-led organization enter into a liberated space together. No, it’s not safe. Yes, you may get your feelings hurt,” she said. “But as psychiatrists we understand that in conflict, often therein lies the work which can indeed yield growth. … At some point, you must wrestle with the truth that is deeply embedded in the foundation and roots of this organization and inherent in the practice of psychiatry: that of anti-Black racism.”

Thea L. James, M.D., an associate professor of emergency medicine at Boston Medical Center/Boston University School of Medicine, discussed disparities in health care and how they are rooted in disparities in other areas of life.

“Perpetual cycles of hospital admissions, ER visits, and poor health outcomes persist because they are just downstream consequences of root causes upstream like lack of income, unstable housing, and lack of access to healthy, affordable foods,” she said.

Geller announced that he had established a presidential task force to address structural racism throughout psychiatry. The task force consists of 10 members, five of whom are members of the Board of Trustees.

“The goal of this group is to create actions, not position statements, not white papers, but actions,” Geller said.

Psychosocial Therapies Found to Boost Immune Function

Psychosocial interventions can improve the function of the immune system, according to a meta-analysis published in JAMA Psychiatry. These findings may be particularly timely in light of the COVID-19 pandemic, as people with weaker immune systems are at higher risk of worse outcomes from COVID-19.

“These [improvements] were most consistent for CBT [cognitive-behavioral therapy] and for interventions incorporating multiple psychotherapies,” wrote Grant Shields, Ph.D., of the University of California, Davis, and colleagues. “Moreover, they did not differ by participants’ age, sex, or intervention duration. Finally, we found that these associations persisted for at least six months following treatment cessation.”

Shields and colleagues reviewed placebo-controlled studies that looked at the effects of a psychosocial intervention on some measure of immune health. Most of the studies involved testing psychosocial interventions in people with cancer or HIV.

The final sample included 56 studies that encompassed eight types of interventions: behavior therapy (which seeks to help patients understand and change problematic behaviors), cognitive therapy (which teaches patients how to change negative thoughts or mindset), CBT (which combines elements of cognitive and behavior therapy), CBT plus additive support (such as telephone follow-ups), bereavement or supportive therapy, psychoeducation, other psychotherapy (such as stress management), or multiple interventions. The studies also featured seven immune system biomarkers: proinflammatory cytokine levels, anti-inflammatory cytokine levels, antibody levels, white blood cell counts, white blood cell activity, viral load (for example, HIV levels), and other outcomes (for example, number of postoperative infections).

Overall, the participants who received any psychosocial intervention experienced a 14.7% increase in positive immune outcomes (for example, lower viral loads) and an 18.0% decrease in harmful outcomes (for example, proinflammatory cytokines) compared with those who did not receive a psychosocial intervention. The immune improvements were strongest among patients who received CBT or multiple psychosocial interventions. Among the biomarkers, a reduction in proinflammatory cytokines was the most robust improvement associated with psychosocial interventions.

“Given the effectiveness and relative affordability of psychosocial interventions for treating chronic disease, we suggest that psychosocial interventions may represent a viable strategy for reducing disease burden and improving human health. Looking forward, additional research is needed to elucidate the mechanisms through which psychosocial interventions exert relatively long-lasting, beneficial effects on the immune system and health,” the authors concluded.

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Time for Action: APA to Hold Town Hall Tonight on Structural Racism

APA President Jeffrey Geller, M.D., M.P.H., will lead a virtual town hall tonight (Monday, June 15), at 8 p.m. EDT with distinguished panelists on the topic of structural racism. Panelists include Danielle Hairston, M.D.; Thea James, M.D.; Ayana Jordan, M.D., Ph.D.; and Walter E. Wilson Jr., M.D., M.H.A. The discussion will be followed by a Q&A session with APA members about the way forward for our organization.

Learn More and Register Now

Volunteering May Boost Longevity, Mental Health in Adults Over 50

Volunteering at least two hours a week may increase longevity and improve mental health in adults over age 50, suggests a study in the American Journal of Preventive Medicine.

“The growing older adult population possesses a vast array of skills and experiences that can be leveraged for the greater good of society via volunteering,” wrote Eric S. Kim, Ph.D., of the Harvard T.H. Chan School of Public Health and colleagues. “[P]olicies and interventions aimed at encouraging more volunteering might be an innovative way of simultaneously enhancing society and fostering a trajectory of healthy aging.”

To arrive at their conclusion, the researchers studied data from approximately 13,000 participants in the Health and Retirement Study, a large, ongoing study of adults aged 50 years and older in the United States that began in 2006. Study researchers interview participants upon their enrollment, after which the participants complete a questionnaire about various aspects of their health. One question asks the participants whether they had spent any time in the previous 12 months doing volunteer work for religious, educational, health-related, or other charitable organizations, and if so, how much time the participants devote to their volunteer activities.

During the four-year follow-up, participants who volunteered 100 hours a year or more had a 44% lower risk of dying and a 17% lower risk of limitations in their physical functioning than those who did not volunteer. They also had higher positive affect, optimism, and sense of purpose in life and lower depressive symptoms, hopelessness, and loneliness than those who did not volunteer. There was no evidence that volunteering was associated with other outcomes such as the number of chronic conditions participants had or whether volunteering was associated with life satisfaction.

(Image: iStock/Wavebreakmedia)

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Time for Action: APA to Hold Town Hall on Structural Racism

APA President Jeffrey Geller, M.D., M.P.H., will lead a webinar town hall on Monday, June 15, at 8 p.m. EDT with distinguished panelists on the topic of structural racism. Panelists include Danielle Hairston, M.D.; Thea James, M.D.; Ayana Jordan, M.D., Ph.D.; and Walter E. Wilson Jr., M.D., M.H.A. The discussion will be followed by a Q&A session with APA members about the way forward for our organization.

Learn More and Register Now

Suicide Risk Increases Immediately After Gun Purchase

A study published in the New England Journal of Medicine expands on past research on the association between access to guns and suicide, finding that handgun ownership is associated with an elevated risk of suicide by firearm, particularly immediately after the gun is acquired.

Since the COVID-19 pandemic began, gun sales have sharply increased, an accompanying commentary pointed out. In March, Americans bought nearly two million guns, marking the second-highest monthly total since 1998, when the Federal Bureau of Investigation (FBI) began publishing such data.

“How will the current surge of gun purchases affect firearm-related violence?” wrote Chana A. Sacks, M.D., M.P.H., and Stephen J. Bartels, M.D., in their commentary. “With an additional 2 million guns now in households across the country at a time of widespread unemployment, social isolation, and acute national stress that is unprecedented in our lifetime, we urgently need to find out.”

Lead author David M. Studdert, LL.B., Sc.D., of the Stanford Law School and School of Medicine and colleagues tracked firearm ownership and mortality over 12 years (2004-2016) among 26.3 million adults in California. They used the California Statewide Voter Registration Database to form the cohort, as the database updates its information on registered voters in the state every year.

The researchers then used the California Department of Justice’s Dealer Record of Sale for details on which cohort members acquired handguns and when. Additionally, the California Death Statistical Master Files provided records of all deaths reported during the study period.

In total, 676,425 members of the cohort acquired one or more handguns during the study period, and 17,894 died of suicide, of which 6,691 were suicides by firearm. “Handgun owners had lower rates of all-cause mortality than nonowners but substantially higher rates of suicide,” the authors wrote.

The rate of suicide by firearm among handgun owners peaked immediately after the gun purchase (within 30 days) but remained relatively higher 12 years later. Fifty-two percent of all suicides by firearm among handgun owners occurred more than a year after acquisition of a gun.

Women accounted for only 16% of all suicides by firearm, but the rate of suicide by any method among female handgun owners was seven times higher compared with female nonowners. The corresponding suicide rate among male handgun owners was three times as high as that of nonowners.

The findings have several implications for clinical care and suicide prevention, wrote Sacks and Bartels in their commentary. Assessments of suicide risk should include questions about recent gun ownership and access to firearms, for example, and women, as well as men, should be questioned about gun ownership, they wrote.

“Fifty-nine people were killed in the mass shooting in Las Vegas in 2017, the deadliest in U.S. history. Approximately the same number die each day in the United States from suicide by firearm,” Studdert and colleagues concluded. “Many of these deaths are preventable.”

(Image: iStock/artas)

Time for Action: APA to Hold Town Hall on Structural Racism

APA President Jeffrey Geller, M.D., M.P.H., will lead a webinar town hall on Monday, June 15, at 8 p.m. EDT with distinguished panelists on the topic of structural racism experienced by Black Americans. The panelists include Danielle Hairston, M.D.; Thea James, M.D.; Ayana Jordan, M.D., Ph.D.; and Walter E. Wilson Jr., M.D., M.H.A. The discussion will be followed by a Q&A session with APA members about the way forward for our organization.

Learn More and Register Now

Veterans With Schizophrenia or Bipolar Disorder at Increased Risk of Dementia, Study Finds

Veterans with schizophrenia or bipolar disorder are significantly more likely to develop dementia than veterans without these disorders, according to a study published today in Psychiatric Services in Advance.

“The VHA [Veterans Health Administration] serves an aging patient population, and it is important to understand risk factors for incident dementia among VHA patients,” wrote Eileen  Ahearn, M.D., Ph.D., of the William S. Middleton Department of Veterans Affairs (VA) Hospital in Madison, Wisconsin, and colleagues. “The study reported here confirmed prior studies indicating that individuals with bipolar disorder or schizophrenia have increased risk of dementia onset, even when the analysis controls for general medical comorbidities.”

Using the VHA’s medical database, Ahearn and colleagues identified over 3.6 million veterans without a dementia diagnosis who received VHA health care services between 2004 and 2005. The researchers then evaluated whether these patients (93% men; 7% women) had been diagnosed with either bipolar disorder or schizophrenia. Most of these individuals had not been diagnosed with bipolar disorder or schizophrenia and were categorized by the researchers as having no serious mental illness (SMI). The cohort was followed for up to 10 years to assess for onset or incident of dementia.

The mean incidence of dementia was 11.2 cases per 1,000 person-years for men with no SMI, 11.5 cases per 1,000 person-years for men with bipolar disorder, and 15.1 cases per 1,000 person-years for men with schizophrenia. The mean incidence of dementia was 4.0 cases per 1,000 person-years for women with no SMI, 4.1 cases per 1,000 person-years for women with bipolar disorder, and 8.4 cases per 1,000 person-years for women with schizophrenia.

After adjusting for age, substance use, and comorbid conditions associated with dementia risk (including diabetes and hypertension), Ahearn and colleagues found that the incidence rate ratios for dementia were 2.92 for veterans with a baseline diagnosis of schizophrenia and 2.26 for those with a baseline diagnosis of bipolar disorder, compared with veterans with no SMI. Veterans diagnosed with schizophrenia or bipolar disorder also developed dementia at a younger age (68.5 and 67.9, respectively) compared with those with no SMI (78.8).

“Primary care and mental health clinicians should be educated about the elevated risk of dementia among VHA patients with schizophrenia or bipolar disorder,” Ahearn and colleagues wrote. “They should be alert to memory or other cognitive complaints in this patient population and should initiate an evaluation for dementia when there are signs or symptoms of possible cognitive impairment.” 

(Image: iStock/Ridofranz)

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Has COVID-19 Financially Impacted Your Practice?

APA is conducting a survey on the financial impacts of COVID-19 on your practice to inform our advocacy work on your behalf. Survey responses are not personally identifiable and will be used only in the aggregate. Click here to take the survey.

Prenatal Choline Supplements May Protect Offspring if Mother Contracts Viral Infection

Taking choline supplements during pregnancy may reduce the negative impact of viral respiratory infections on offspring, according to a study published in the Journal of Psychiatric Research.

“The new analysis may provide information relevant to potential COVID-19 effects on fetal brain development and their interaction with higher prenatal maternal choline levels,” wrote Robert Freedman, M.D., of the University of Colorado School of Medicine and colleagues.

Previous studies showed that infection in pregnant women can affect fetal brain development and may increase the risk of attention-deficit/hyperactivity disorder, autism spectrum disorder, and schizophrenia in offspring. Freedman and others have also found evidence to suggest higher levels of maternal choline—a vitamin B nutrient found in various foods and dietary supplements—may help mitigate these risks to infants.

It is recommended that pregnant women get 500 mg of choline daily, according to Freedman and colleagues. For the current study, the researchers compared choline levels measured at 16 weeks’ gestation in 36 pregnant women who had developed moderate to severe respiratory infections by week 16 with 53 mothers who reported no inflections. When the infants reached three months of age, the mothers completed the Infant Behavior Questionnaire-Revised Short Form (IBQ-R). The questionnaire asks parents to rate infants on measures of attention and engagement with parents, fearfulness and sadness, activity, and more.

Mothers with viral respiratory infections in early gestation were younger and more likely to be depressed and anxious, the researchers reported. Infants of mothers who had contracted a viral respiratory infection and had higher gestational choline serum levels (defined as ≥7.5 mM) scored higher in their ability to maintain attention and bond with parents compared with infants whose mothers had contracted an infection but had lower choline levels (< 7.5 mM). The increased maternal anxiety and depression in the mothers with respiratory viral infections did not appear to be associated with their infants’ ability to maintain attention and bond with parents, Freedman and colleagues wrote.

The authors noted that the effects of choline on infant development following COVID-19 infection “are as yet unknown, and no mother in this study had an infection requiring intensive care medical support for COIVD-19.” However, they concluded, “phosphatidylcholine or choline supplements along with other prenatal vitamins may help buffer the fetal brain from the possible detrimental impact of the current pandemic and decrease the risk of the children’s future mental illness.”

(Image: iStock/Mikumi)

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Consider Becoming an APA Trustee
Nominate yourself or a colleague

As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

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AMA President and Psychiatrist Vows to Continue Work for Equity and Justice

“Our country—indeed our world—is being challenged as never before,” said outgoing AMA President Patrice Harris, M.D., in her farewell address during AMA’s virtual meeting of the House of the Delegates yesterday. Physicians and the public are being “[c]hallenged by a novel virus for which there is not yet a specific treatment or vaccine, challenged by a lack of resources and personal protective equipment [PPE], challenged by a political climate that is highly polarized, challenged by the rampant spread of misinformation and disinformation.”

While nationwide protests continued to rage against police brutality in the aftermath of the killing of George Floyd, Harris—who is the first African American woman president of the AMA—vowed to continue to work for “equity and justice within the walls of our exam rooms, the health delivery system, the halls of Congress, and our justice system.”

Harris, who continues to be the chair of the AMA Task Force to Reduce Opioid Abuse, also vowed to work “to ensure that mental health is integrated into overall health and that there is action to address the physical and psychological consequences of early traumatic experiences.”

Harris referenced remarks in her November address at the AMA Interim Meeting in Orlando, Fla.—three months before pandemic lockdowns were initiated—in which she said physicians would always “match the moment,” rising to every occasion and continuing to earn public confidence in an era of mistrust.

“Little did any of us realize at the time how dramatically we would be put to the test,” she said. “But ‘match the moment’ we have. Physicians are working long hours in offices and hospitals, sleeping in their basements or hotels so they do not infect family members, working overtime to develop vaccines and treatments, countering the endless false narratives circulating across media channels, and reopening medical practices so we can meet the postponed health needs of our patients.”

“We applaud Dr. Harris for the completion of a successful year as the leader of the AMA,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “She served during a trying time in medicine as the COVID-19 pandemic began to arrive on our shores. She led the AMA as it pushed for resources for doctors on the front lines and for regulatory changes in Washington to help deliver care to those in need. She was an advocate for promoting evidence-based approaches to the pandemic. We are proud that a psychiatrist was able to lead the AMA during this time of great anxiety.”

Harris outlined several key organizational activities and achievements that AMA pursued during her presidential year. These include the following:

• Urgently lobbying Congress and the Trump administration to accelerate the production of PPE, test kits, and ventilators.
• Advocating for regulatory changes to facilitate remote patient visits.
• Supporting inclusion of financial support for small and independent practices in economic relief bills approved by Congress.
• Consistently calling on politicians, media outlets, and government officials to focus on science and evidence in all decision-making.

At a time of enormous national unrest, Harris vowed to be a hopeful supporter and leader of positive change. “My promise to you is that I will be guided by the direction of Dr. Martin Luther King Jr. in his final Sunday sermon—‘to remain awake through a great revolution.’ And so, as I speak to you for the last time as president of the American Medical Association. … Please know that this ‘psychiatrist is in.’ ”

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How Has COVID-19 Impacted You and Your Practice Financially?

APA is conducting a survey to understand the financial impacts of COVID-19 on your practice. This information will inform our advocacy work on behalf of our members. Information you share is not personally identifiable and will be used only in the aggregate. Click here to take the survey.

APA Releases Guidance on Admittance, Discharge of Psychiatric Patients During COVID-19

The APA Board of Trustees has issued guidance on how hospitals should manage patients in psychiatric inpatient settings during the COVID-19 pandemic. The guidance was developed “in response to efforts to either deny admittance to or prematurely release psychiatric patients under the guise of avoiding COVID-19 infection,” according to an APA press release.

“It is simply irresponsible to prematurely release patients with serious mental illness from psychiatric inpatient settings into communities ill prepared to treat them,” said APA President Jeffrey Geller, M.D., M.P.H. “Every patient should be in an environment where they receive treatment, care, and supervision appropriate to their needs. Inpatient psychiatric units and hospitals are not hotbeds of COVID-19 infection and in many instances are the safest alternative in the community.”

The guidance states the following:

• Premature discharge of patients from psychiatric hospitals and inpatient psychiatric units is unreasonable as this practice exposes patients, families, and the community at large to the risks of harmful and adverse outcomes irrespective of communicable disease outbreaks.
• During communicable disease outbreaks, referral of patients to any psychiatric setting should balance efforts to match patients’ mental health needs with the appropriate level of care while considering the potential risks of the communicable disease at each level of care.
• Each level of psychiatric care during such outbreaks should provide safe and appropriate treatment, including adequate protection from the risk of infection from the communicable disease.

“The guidance provided by the APA Board is intended to help our psychiatrist members ensure that their patients who need inpatient treatment can continue to get that treatment during this pandemic,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We will continue to advocate for the best treatment for our patients while protecting them during this pandemic.”

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How Has COVID-19 Impacted You and Your Practice Financially?

APA is conducting a survey to understand the financial impacts of COVID-19 on your practice. This information will inform our advocacy work on behalf of our members. Information you share is not personally identifiable and will be used only in the aggregate. Click here to take the survey.

Survey Shows Drastic Increase of Anxiety, Depression Since Pandemic Began

According to Mental Health America (MHA), the number of people who screened positively for depression and anxiety using MHA’s free and anonymous online screening tool has shot up dramatically since the COVID-19 pandemic began.

Using November 2019 to January 2020 average results as a baseline, MHA determined that 88,405 more people screened positive on depression and anxiety screenings than expected between mid-to-late February and May.

More than 211,000 people took the screenings in May, compared with 69,626 in April, yet “severity continued to track equal to or higher than our pre-pandemic baselines,” according to an MHA presentation of the data.

MHA has had a free, anonymous online screening program since 2014. Visitors to MHA’s website can take screening tests for depression, anxiety, postpartum depression, eating disorders, psychosis, and other psychiatric disorders. MHA tells visitors that the screens are meant to be “a quick snapshot of your mental health,” according to the website, and urges them to see a mental health clinician for a full assessment and to talk about treatment options.

The tests are “the same evidence-based mental health screening tools that are used by most clinicians,” according to a June 2 news release. The source of the depression test is the Patient Health Questionnaire-9 (PHQ-9), and the source for the anxiety test is the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ).

Additional findings from MHA’s data include the following:

• More than 21,000 people considered self-harm or suicide in May, a jump from 7,061 in April.
• The impacts on mental health have been pronounced in people younger than 25. Roughly 9 in 10 people under 25 screened positive for moderate-to-severe depression, and 8 in 10 screened positive for moderate-to-severe anxiety, according to the presentation.
• Screeners for both anxiety and depression reported that the main factor contributing to their mental health problems in both April and May was loneliness or isolation.

In the news release, MHA President and CEO Paul Gionfriddo said the suicide and self-harm numbers reported in May are especially striking. “When you consider that a total of 45,000 to 50,000 Americans die by suicide every year and nearly half that number reported suicidal or self-harm thinking in just May alone, this has to be a wake-up call to policymakers to act now to prevent this,” he said.

“Our May screening numbers were unprecedented,” Gionfriddo said in the release. “And what is most troubling is that the numbers—consistent with the numbers from the U.S. Government’s Census Bureau—demonstrate not only that there is not yet any relief from the mental health impacts of the pandemic, but that the impacts actually seem to be spreading and accelerating.”

(Image: iStock/franckreporter)

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Serve Your Profession as an APA Trustee
Nominate yourself or a colleague

As chair of APA’s Nominating Committee, Immediate Past President Bruce Schwartz, M.D., is seeking to diversify the elected leadership of APA and invites all members to consider running for one of the open Board of Trustee offices in APA’s 2021 election: president-elect; secretary; early-career psychiatrist trustee-at-large; minority/underrepresented representative trustee; Area 1, 4, and 7 trustees; and resident-fellow member trustee-elect. You may nominate yourself or a colleague—the important point is that you get involved! The deadline is Tuesday, September 1.

(Image: iStock/IIIerlok_Xolms)