Digital CBT May Reduce Eating Disorder Symptoms in College Women

A digital cognitive-behavioral therapy (CBT) intervention that includes personal coaching may help to reduce several symptoms of eating disorders in college women. As reported today in JAMA Network Open, women who received the digital CBT had greater reductions in negative eating-related thoughts or beliefs and the frequency of binge eating compared with women who were referred to usual university care.

“Current treatment delivery efforts for [eating disorders] on college campuses are hindered by factors such as limited counseling center capacity and access to evidence-based treatments. College students report additional barriers, including lack of time and stigma,” wrote Ellen Fitzsimmons-Craft, Ph.D., of Washington University in St. Louis and colleagues. “Digital technologies, highlighted as the future of psychiatry, have the potential to improve mental health care on college campuses by overcoming [these] barriers.”

Fitzsimmons-Craft and colleagues recruited women who had screened positive for a DSM-5 eating disorder excluding anorexia nervosa (which requires more intense medical monitoring) from 27 universities across the country. In total, 690 women were randomly assigned to participate in the online CBT program Student Bodies–Eating Disorders (SB-ED) or receive usual care, which involved a referral and encouragement to attend their university counseling center.

The women in the SB-ED group received access to the self-help CBT program for eight months with a personal coach. SB-ED includes modules that teach such skills as improving body image, regulating emotions, addressing shape-checking behaviors, and challenging negative thoughts. The program also includes meal planning and tracking tools and a personal log. The coaches provided regular feedback and support using an in-program chat function. 

The primary assessment was change in the Eating Disorder Examination-Questionnaire (EDE-Q), which assesses the severity of negative eating-related thoughts or beliefs. The investigators also measured changes in binge eating, compensatory behaviors (vomiting, laxative use, excess exercise), depressive symptoms, and academic problems (such as withdrawing from courses or taking a leave of absence). 

After eight months, EDE-Q scores decreased from 3.62 to 2.70 in the SB-ED group and 3.55 to 3.05 in the usual care group, which was a significant difference. The women in the SB-ED group also reported fewer binge-eating and compensatory behaviors as well as fewer depressive symptoms. There was no difference between SB-ED and usual care in terms of the total number of women who achieved abstinence from all eating disorder behaviors, withdrew from a course, or took a leave of absence.

“Finally, with regard to realized treatment access, the [SB-ED] intervention was far superior,” Fitzsimmons-Craft and colleagues wrote. “83% of students offered the intervention began it, whereas only 28% of students in the control group reported seeking treatment for their ED at any point.”

For related information, see Handbook of Assessment and Treatment of Eating Disorders, by APA Publishing.

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Drug Company Payments to Doctors Linked to Higher Pimavanserin Prescribing, Medicare Costs

Higher physician payments from drug manufacturer Acadia for Nuplazid (pimavanserin) are associated with increased pimavanserin prescription volume and Medicare costs, a study in Psychiatric Services in Advance has found. Pimavanserin is approved by the U.S. Food and Drug Administration for the treatment of hallucinations and delusions associated with Parkinson’s disease psychosis. Physician payments include payments for speaking, consulting, education, food, travel, and lodging.

“Our study adds to the growing evidence of the association between pharmaceutical industry payments to physicians and physician prescribing,” wrote Hemalkumar B. Mehta, M.S., Ph.D., of the Johns Hopkins Bloomberg School of Public Health and colleagues.

The researchers analyzed 2016 and 2017 data from the Centers for Medicare and Medicaid Services (CMS) Open Payments database and the CMS Part D Prescriber Public Use Files. The Open Payments database contains information on financial payments made by drug and medical device companies to physicians and teaching hospitals. The Part D prescriber data provide information on physician specialties and which drugs they prescribe to Medicare Part D beneficiaries.

The researchers found that physicians receiving payments wrote 46% more prescriptions for pimavanserin than those who did not receive payments, and their total prescriptions were 71% more costly to Medicare, totaling a median of $66,311 compared with a median of $38,716 for those who did not receive payments. Of 1,609 physicians who prescribed pimavanserin, 45% had received payments totaling $6,369,922. Each $10,000 in physician payments was associated with a 14% increase in pimavanserin prescription volume. Every $100 in physician payments was associated with a $175.84 increase in Medicare pimavanserin expenditures.

Half of the physicians who prescribed pimavanserin were neurologists, who received a combined $4,764,689. Seven percent of the physicians who prescribed pimavanserin were psychiatrists, who received a combined $1,462,615. Overall, psychiatrists received higher payments than neurologists, with a median of $13,543 compared with $5,890. However, Medicare expenditures associated with pimavanserin prescribing were lower for psychiatrists than for neurologists. Other medical specialists received a combined total of $142,618. The bulk of the payments, more than $5.6 million, were for speaking, consulting, and education, with the rest for food, travel, and lodging.

The researchers noted several possible reasons for the association between consulting and speaking fees paid to physicians and higher pimavanserin prescription volume.

“Physicians receiving industry payments are often content experts or key opinion leaders; in this study, physicians may have been selected on the basis of their experience treating Parkinson’s disease,” they wrote. “These prescribers also may have participated in clinical trials of the product or have otherwise interacted with pharmaceutical company representatives.”

For more information, see the Psychiatric News article, “Experts Discuss Challenges of Treating Neuropsychiatric Symptoms of Dementia.”

Social Services Staff Found to Experience Mental Health Problems a Year After Mass Shooting

In a neighborhood where a mass shooting had occurred less than a year before, one-third of social services staff screened positive for mental health disorders, according to a study published in JAMA Network Open.

Eleven months after the shooting at the Tree of Life synagogue on October 27, 2018, in Pittsburgh, Rafael J. Engel, Ph.D., of the University of Pittsburgh and colleagues reached out to nonprofit organizations in the synagogue’s neighborhood. Eight executives of the social service agencies and educational institutions emailed surveys to their staffs aimed at measuring mental health symptoms , comprising 374 individuals.

The survey screened for depression, suicidal ideation, generalized anxiety disorder, posttraumatic stress disorder, alcohol misuse, marijuana use, and drug use for nonmedical reasons. Among the screening measures used were the Patient Health Questionnaire-2, Generalized Anxiety Disorder-7, and Primary Care for PTSD Screen for DSM-5.

Of the 167 staff members who completed the online survey, 33.3% screened positive for at least one of the mental health disorders.

• 24.4% screened positive for alcohol misuse
• 21.8% screened positive for marijuana use
• 19.9% screened positive for posttraumatic stress disorder
• 19.2% screened positive for generalized anxiety disorder
• 10.9% screened positive for depression
• 9.6% screened positive for suicidal ideation
• 9% screened positive for nonmedical drug use.

There was no statistically significant difference between the participants’ mental health screening results and their work position. “The extent to which there are positive mental health and substance use screens and no differences by work position suggests that a mass shooting is a collective trauma and the professionals within an organization are not immune from the effects, regardless of position,” the authors wrote.

“There are devastating ripple effects for communities that suffer a mass casualty event," Engel told the news outlet UPI in an interview. “We tend to focus on the immediate period after a mass shooting and, unfortunately, the individuals who work at agencies in the communities where mass-shootings occur are often overlooked.”

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Internet Searches for 'Anxiety' Soared in First Month of COVID Pandemic

The number of internet searches on Google for information about “anxiety” or “panic” skyrocketed in the period immediately after the declaration of a national emergency in response to COVID-19, according to a research letter published in JAMA Internal Medicine.

The number vastly exceeded the expected number of searches based on historical trends.

“Although this study cannot confirm that any search was linked to a specific acute anxiety event or panic attack, it provides evidence of the collateral psychological effects stemming from COVID-19,” wrote lead author John W. Ayers, Ph.D., of the Division of Infectious Disease and Global Health at the University of California and colleagues.

The researchers used Google Trends to analyze the percentage of internet searches that used the terms “anxiety” or “panic” in combination with the term “attack”—such as “panic attack,” “signs of anxiety attack,” or “anxiety attack symptoms”—between March 13, when President Trump declared a national emergency, and May 9. It was the period when physical distancing guidelines were imposed, the Centers for Disease Control and Prevention began urging the use of face masks, and the number of deaths from COVID-19 in the United States began to surpass that in other countries. 

The researchers compared results with historical trends from January 1, 2004, to March 12, 2020. They found that anxiety-related searches for information increased 11% during the study period compared with the period from 2004 to March 12—translating into approximately 375,000 more searches than expected. The highest spike in acute anxiety queries occurred on March 28, with 52% more queries than expected.

The number of anxiety-related searches returned to expected levels on April 15. In light of the findings, Ayers and colleagues offer three recommendations:

• Monitoring of these trends should continue as changes during the pandemic may spark new increases in acute anxiety.
• Communities, states, and health systems should prioritize responses to anxiety during the pandemic. For instance, Illinois launched “Call4Calm,” a hotline to help people cope with acute anxiety related to COVID-19. Such programs could be expanded nationally.
• Google and other tech companies providing internet search tools should prominently link mental health search results with ways people can access help, such as the Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline.

For related information, see the Psychiatric News article “Netflix Drama About Teen Suicide Prompts Related Google Searches.”

APA Traces History of Racism in Psychiatry and the Nation in Second Member Town Hall

Just a few days before the 57th anniversary of the civil rights March on Washington, where Martin Luther King Jr. gave his “I Have a Dream Speech,” APA hosted the second in a series of town hall meetings to address structural racism in psychiatry. A distinguished panel of Black psychiatrists spoke to approximately 425 APA members about how the Black Lives Matter movement is an outgrowth of the civil rights initiatives of the 1960s, what anti-racism is, and the impact of racial injustices within the organization, the profession, and the country.

APA President Jeffrey Geller, M.D., M.P.H., described how the actions and ideals put forth in the March on Washington are not only relevant, but necessary today.

“The tradition of advocacy and organizing continues because racial injustices are very much alive in the United States,” Geller said. “Beyond the appalling scenes of police brutality and the deaths of innocent Black people, the systemic impact of racism hits home in the house of medicine and psychiatry as health inequities and racism impact Black people, Latinos, indigenous people, Asian-Americans, and others.”

Geller called upon the APA Board of Trustees to address racism within APA and psychiatry. He noted that Board members are predominantly white and that they must take initiative and be proactive in confronting and dismantling structural racism.

“We cannot turn to the Black members of the Board to guide us. That would take them out of the role of being Board members with us,” Geller said. “It would signify our lack of understanding that racism is about us [whites].”

Aletha Maybank, M.D., M.P.H., the AMA’s chief health equity officer and group vice president, described how the harmful legacy of segregation is evident today in the housing, health, and economic status of many Black individuals. She also spoke of the importance of providing space in which young people may use their voices to propel societal change.

“I really don’t feel we would be here today if it weren’t for the young people of the Black Lives Matter movement,” Maybank said. “The young people who speak … continue with the tradition of the civil rights movement, but in their own way because they’re young [and] it’s a new time. I feel they are leading with great power, great purpose, and great authenticity and truth. … We, as we get older, need to step aside and allow them to have that place of leadership.”

Kevin M. Simon, M.D., the 2020-2021 Recognizing and Eliminating disparities in Addiction through Culturally informed Healthcare (REACH) scholar, described anti-racism as supporting anti-racist policy through action or the expression of anti-racist ideas.

“It has to be something that becomes part of your daily routine,” said Simon, who is completing a fellowship training in child and adolescent psychiatry and addiction medicine at the Boston Children's Hospital/Harvard Medical School. “Much like we ask patients to practice behavioral techniques, we have to practice being anti-racist.”

Former APA President Altha J. Stewart, M.D., discussed critical junctures in history when psychiatrists, as represented by APA and its precursor, the Association of Medical Superintendents of American Institutions for the Insane, failed to address racism. These touch points in history include the years before, during, and after the Civil War, the years of the “separate but equal” doctrine, and the Jim Crow era.

“[Now] we have this very important moment in time where what we do will be looked back upon by generations in the future,” said Stewart, who is senior associate dean for community health engagement at the University of Tennessee Health Science Center. “When they ask what did we do to move the needle, what did we do to improve the psychological well-being of [Black people] in this country, I’d like to say that we took the bull by the horns, addressed these issues head on, and did the hard work … that is emotional, that makes you vulnerable, that can be challenging, but that is not too difficult for psychiatrists.”

She added that psychiatrists are primed for doing the work of dismantling racism both in the profession and in society at large.

“Our wheelhouse is in the difficult place. We are the people that people bring their most private, chaotic thoughts, and we help sort that out,” she said. “We have to be on the front lines of doing that for psychiatry, for America, and for the American Psychiatric Association.”

The next town hall will be held Monday, November 16. APA’s town hall meetings on structural racism are archived for members at https://www.psychiatry.org/psychiatrists/meetings/addressing-structural-racism-town-hall.

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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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Several Antihypertensive Medications Associated With Reduced Depression

Adults who take blood pressure medications are not at an increased risk of depression, according to a report published today in Hypertension. In fact, nine of the 41 medications assessed in the study were associated with a decreased incidence of depression.

The medications that were found to protect against depression were amlodipine, atenolol, bisoprolol, carvedilol, enalapril, propranolol, ramipril, verapamil, and verapamil combinations.

Studies have shown that about 30% of people with hypertension or other cardiovascular problems have comorbid depression. Moreover, individuals with both disorders have worse mortality and a poorer quality of life and need more health care services.

“It is, therefore, important to prevent the development of depression in people with hypertension and cardiovascular and cerebrovascular diseases, and widely used treatment interventions should be thoroughly evaluated,” wrote Lars Vedel Kessing, M.D., D.M.Sc., of the University of Copenhagen and colleagues.

Kessing and colleagues used Danish health registry data to assess the incidence of depression and use of antihypertensive medications among all Danish adults who had no history of depression over a 10-year period starting in January 2005. The participants were then divided into groups based on the number of antihypertensive prescriptions they received during the study period. The study encompassed 41 antihypertensive medications in four drug classes: angiotensin agents, calcium antagonists, beta-blockers, and diuretics.

The researchers found that adults who had never been prescribed an antihypertensive had about a 40% to 50% reduced risk of depression compared with adults who had received such prescriptions. However, among adults who did take antihypertensives, the amount of medication usage did not affect depression risk for any of the 41 medications analyzed. For nine of the medications tested, in fact, longer use was associated with reduced depression rates.

The medications associated with reduced depression included two angiotensin agents (enalapril and ramipril), three calcium antagonists (amlodipine, verapamil, and verapamil combination), and four beta-blockers (propranolol, atenolol, bisoprolol, and carvedilol); no diuretics were associated with reduced risk of depression.

“Real-life population-based data suggest a positive effect of continued use of nine individual antihypertensive agents,” wrote the researchers. “This evidence should be used in guiding prescriptions for patients at risk of developing depression including those with prior depression or anxiety and patients with a family history of depression.”

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Register Now for Tonight’s ‘Structural Racism, Part 2: The March Continues’

APA Past President Altha Stewart, M.D., AMA Chief Health Equity Officer and Group Vice President Aletha Maybank, M.D., M.P.H., and 2020-2021 REACH Scholar Kevin Simon, M.D., will join APA President Jeffrey Geller, M.D., M.P.H., for a virtual town hall tonight (Monday, August 24) at 8 p.m. ET to commemorate the 57th anniversary of the March on Washington. This is the second in a series of town halls on structural racism planned by Dr. Geller.

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Time Is Now for Addressing Racism in Medical Education

As APA leaders continue to work to eliminate systemic racism within psychiatry, a group of psychiatry resident leaders recognized with APA/APA Foundation Minority Fellowships described an action plan they believe will reduce racism in medical education in the most recent issue of Psychiatric News.

“Many health care institutions and medical schools, including the AMA, have released statements condemning police brutality and racism. However, such statements ring hollow without action,” the APA/APAF Minority Fellows wrote. “We believe that one of the first steps in combating systemic racism in the medical field is addressing issues within our training institutions.” They outlined the following actions as key steps forward in dismantling racism in medical education:

1. Create networks and communities that encourage open discussion for minority and marginalized providers.
2. Support the recruitment and retention of a diverse workforce through inclusion initiatives that are adequately funded, appropriately staffed, and well integrated.
3. Support intentional mentorship and sponsorship of trainees of color into leadership positions.
4. Support continued training for health care providers on how to productively address racist or biased behaviors as they occur in health care and educational settings.
5. Support educational research and scholarship that focuses on identifying best practices on training in implicit bias, structural racism, and cultural humility.
6. Increase resources including financial and protected time for research and academic endeavors around race, culture, and socioeconomic disparities.
7. Review current medical curricula, didactic and clinical based, with the goal of better understanding how racist ideas are embedded within and using that knowledge to make the needed changes.
8. Increase the use of holistic review processes by medical training institutions, including the further de-emphasis of standardized testing such as the MCAT and USMLE.
9. Increase awareness and evaluation of racial/ethnic disparities in certain academic awards, such as the Alpha Omega Alpha Honor Medical Society, with appropriate changes or removals of these items.
10. Support institutional systems for reporting incidents that negatively impact individuals from minority or underrepresented groups. Aggregate anonymous data from these systems should be used to help analyze, identify, and address systemic needs.
11. Increase training opportunities in diverse and socioeconomically disadvantaged areas. We recommend the utilization of innovative technologies and systems to aid in this endeavor.

“As leaders in undergraduate and graduate medical education, our duty is to ensure that future physicians lead in anti-racist work and are aware of the biases that can affect their care to individuals,” they continued. “We believe that the implementation of these items will begin to dismantle the current racist underpinnings within our education, help to improve treatment and experiences of people of color in medicine, and consequently work to better the treatment of all patients.”

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Register Now to Attend ‘Structural Racism, Part 2: The March Continues’: August 24

APA Past President Altha Stewart, M.D., AMA Chief Health Equity Officer and Group Vice President Aletha Maybank, M.D., M.P.H., and 2020-2021 REACH Scholar Kevin Simon, M.D., will join APA President Jeffrey Geller, M.D., M.P.H., for a virtual town hall on Monday, August 24, at 8 p.m. ET to commemorate the 57th anniversary of the March on Washington. This is the second in a series of town halls on structural racism planned by Dr. Geller.

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40% of U.S. Adults Reported Worsening Mental Health in Late June Due to Pandemic, CDC Finds

U.S. adults reported worsening mental health associated with the COVID-19 pandemic, according to a study published in the Morbidity and Mortality Weekly Report. Young adults, individuals who identified as Black and/or Hispanic, essential workers, and unpaid adult caregivers reported disproportionately worse mental health outcomes.

“Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently,” wrote Mark É. Czeisler of the Turner Institute for Brain and Mental Health in Melbourne, Australia; Emiko Petrosky, M.D., of the Centers for Disease Control and Prevention COVID-19 Response Team; and colleagues.

The researchers conducted web-based surveys of 5,470 adults aged 18 and older across the United States from June 24 to 30. The surveys used the Patient Health Questionnaire to assess whether respondents had symptoms of anxiety and/or depressive disorders and the Impact of Event Scale to assess trauma- and stressor-related disorder symptoms. Respondents were also asked if they had started or increased substance use to cope with stress or emotions related to the pandemic and if they had seriously considered suicide in the past 30 days.

Overall, 40.9% of respondents reported symptoms of at least one adverse mental health condition, including anxiety, depression, and increased use of substances to cope with stress related to the pandemic. About a quarter of the respondents reported symptoms of trauma- and stressor-related disorders (including posttraumatic stress disorder, acute stress disorder, and adjustment disorders) related to the pandemic.

The percentage of respondents who reported having seriously considered suicide in the past 30 days was significantly higher among those aged 18 to 24 years, members of minority/racial ethnic groups, self-reported unpaid adult caregivers, and essential workers. “Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic,” the authors wrote.

Compared with results of similar surveys conducted in 2019, the prevalence of anxiety disorder symptoms was three times higher, while the prevalence of depressive disorder was four times higher.

“Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions,” the authors concluded. “Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation, might reduce COVID-19-related mental health consequences.”

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Brief Video Presentation Humanizing Schizophrenia Diminishes Stigma

People who watched a 90-second video of a young woman describing her experience with schizophrenia had a lower rate of stigma toward people with schizophrenia than those who did not watch this video. The findings were published in Schizophrenia Bulletin.

“Stigma creates a huge barrier for people with psychosis to getting care, and studies show that 70% of people with serious mental illness do not seek out treatment,” lead author Doron Amsalem, M.D., of the New York State Psychiatric Institute (NYSPI) and Columbia University told Psychiatric News. The length of time that people with psychosis go without treatment impacts their long-term outcome. “Before we talk about treatments, let’s help people be comfortable with seeking out care,” Amsalem said.

Amsalem and colleagues used a crowdsourcing tool to recruit 1,203 individuals aged 18 to 30 who were living in the United Sates. The participants were randomly assigned to view the 90-second video, read a text version of the same patient’s story, or to a control group that did not see the video or read the text.

The video featured a 22-year-old African American woman with schizophrenia who talked not just about her symptoms and her treatment, but about how her condition affected her daily life. The 90-second video was an abbreviated version of an 11-minute video created by the Center for Practice Innovation at ONTrackNY, the coordinated first-episode psychosis (FEP) treatment program at NYSPI. “The purpose [of the video] was to humanize the illness,” Amsalem told Psychiatric News.

The researchers then assessed stigma among the three groups using a web-based questionnaire that looked at five domains of stigma:

• Social distance assesses whether someone would be willing to be friends with someone with psychosis or schizophrenia or have a person with schizophrenia marry into their family.
• Social restriction determines a participant’s perception of whether a person with schizophrenia should marry and have children.
• Separateness measures perceptions of whether and how much an individual with schizophrenia is different from other people.
• Stereotyping assesses perceptions of whether people with schizophrenia are able to perform certain functions (make treatment decisions or manage their own finances) or are capable of violence.
• Perceived recovery measures participants’ beliefs that a person with schizophrenia can follow through on a treatment plan and reach recovery goals.

The researchers found that across all five domains, the video-based intervention group had lower rates of stigma than the control group that did not view the patient video or read the vignette. The video group also had lower rates of stigma on measures of social distance, stereotyping, and social restriction than the group who read the patient vignette; there was no difference on measures of separateness and perceived recovery between these two groups. The group who read the vignette had lower rates of stigma than the control group across all five domains.

“This simple, brief, easy to disseminate video-based intervention has the potential to increase the likelihood of seeking services, improve access to care among people with FEP and ultimately reduce DUP [duration of untreated psychosis],” the researchers wrote.

For related information, see the Psychiatric News article “Stigma Linking Mental Illness, Violence Has Increased, Study Finds.”

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Clozapine Found Most Likely of Common Antipsychotics to Reduce Risk of Suicide in Patients With Schizophrenia

Compared with other common antipsychotics, clozapine appears most likely to decrease the risk of suicidal outcomes in patients with schizophrenia, according to a report in Schizophrenia Bulletin.

The findings were based on two nationwide register-based cohort studies of 61,889 patients with schizophrenia who lived in Finland and 29,823 patients with schizophrenia who lived in Sweden. Heidi Taipale, Ph.D., of the University of Eastern Finland and colleagues specifically focused on patients who took the following first- or second-generation antipsychotics: clozapine, olanzapine, quetiapine, risperidone, risperidone (long-acting injectable), aripiprazole, perphenazine, zuclopenthixol (long-acting injectable), haloperidol, and levomepromazine. Each patient served as his or her control in the study, with the authors comparing suicide attempt/death during periods the patient was taking antipsychotics with periods the patient was not taking antipsychotics.

About 7% of the patients in the Finnish and Swedish cohorts attempted suicide or died by suicide during the study period.

“Compared with no use of antipsychotics, clozapine use was the only antipsychotic consistently associated with a decreased risk of suicidal outcomes in within-individual analyses,” the authors wrote. The risk for attempted or completed suicide was 36% lower when the patients in the Finnish cohort were taking clozapine and 34% lower when patients in the Swedish cohort were taking clozapine. “No other antipsychotic was associated with a reduced risk of attempted and/or completed suicide,” they wrote. In contrast, patients who took adjunctive benzodiazepines and benzodiazepine-related Z-drugs were at an increased risk of attempted or completed suicide.

“Clozapine is the only pharmacological treatment associated with a substantially decreased risk of attempted or completed suicide [in patients with schizophrenia] and should be considered as first-line treatment for patients with suicidal ideation or behavior,” the authors concluded.

For related information, see the Psychiatric News article “The Appropriate Use of Medications in Suicidal Patients.”

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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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Olanzapine/Samidorphan Combo Found to Reduce Antipsychotic-Induced Weight Gain

Patients with schizophrenia taking the antipsychotic olanzapine in combination with the opioid-receptor drug samidorphan gained less weight and had smaller waistline increases than patients taking olanzapine alone, according to a study published in AJP in Advance. In addition, the combination drug was as effective as olanzapine alone at improving schizophrenia symptoms and had a similar safety profile.

This study was sponsored by Alkermes, maker of samidorphan.

Cristoph Correll, M.D., of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and colleagues randomly assigned 561 adult patients with schizophrenia to receive 24 weeks of olanzapine/samidorphan (10mg/10mg daily in week 1, 20 mg/10 mg daily afterward) or olanzapine (10mg daily in week one, 20 mg daily afterwards). All the participants had a body mass index between 18 and 30 at baseline and reported weight stability of at least three months.

After 24 weeks, the average medication-induced weight gain was 4.21% in the olanzapine/samidorphan group and 6.59% in the olanzapine group, respectively. “Not only were patients less likely to gain any weight with combined olanzapine/samidorphan, but also the risk of clinically significant weight gain (of ≥7% and of ≥10%) was reduced by 50% relative to olanzapine,” the authors wrote.

Patients taking the combination therapy also had smaller increases in waistline circumference after 24 weeks compared with those taking olanzapine alone (2.36 cm vs. 4.47 cm). “Waist circumference is a proxy for central fat accumulation, and increases in waist circumference have been associated with a greater risk of cardiovascular disease and diabetes, even independently of weight,” the authors wrote.

Despite the differences between the two groups in weight gain and waist circumference, there was no difference between the groups in measures of triglycerides, cholesterol, glucose, and insulin.

“Initial weight gain has still been observed with combined olanzapine/samidorphan over the first four to six weeks, and this must be factored into any benefit-risk assessment,” the researchers wrote. “However, by mitigating weight gain after this initial period and reducing the number of patients who have substantial increases in weight and waist circumference, combined olanzapine/samidorphan mitigates one of the key safety risks of olanzapine that has limited its clinical use.”

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

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Yoga May Help Relieve Anxiety Symptoms, But CBT Is More Effective

Yoga may help relieve symptoms for patients with generalized anxiety disorder, but group cognitive-behavioral therapy (CBT) should remain a first-line treatment, suggests a study in JAMA Psychiatry.

Naomi M. Simon, M.D., M.Sc., of New York University Grossman School of Medicine and colleagues compared the six-month response rates of 155 patients who were randomized to 12 weeks of Kundalini yoga, CBT, or education about stress. Stress education included lectures on the physical and psychological impact of stress, the effects of lifestyle behaviors such as smoking or drinking alcohol on stress, and the importance of exercise and diet. All interventions were delivered to groups of four to six patients by two instructors during 12 120-minute sessions. Patients also had 20 minutes of homework each day. The researchers measured the patients’ response using the Clinical Global Impression-Improvement Scale, which assesses a patient’s functioning, before and after initiating treatment. Patients whose scores were 1 or 2 were considered to have responded to treatment.

At three months, response rates were 70.8% for the CBT group, 54.2% for the yoga group, and 33% for the stress-education group. At six months, the response rate was 76.7% for the CBT group, 63.2% for the yoga group, and 48% for the stress education group.

The researchers wrote that overall, this finding confirms the effectiveness of group CBT for general anxiety disorder as a first-line treatment, but that Kundalini yoga may have some short-term anti-anxiety benefits for some patients.

“Given the increasing costs of health care and barriers to accessing trained mental health care professionals, … yoga may still have a role to play in [generalized anxiety disorder] management as an intervention that is more easily accessible,” the researchers wrote. “Future studies should identify individual characteristics that make a patient more prone to respond to yoga vs. CBT, including treatment preference and attitudes toward mental health care, which could inform how yoga might be integrated into a stepped-care personalized approach to anxiety disorders.”

For more related information, see the Psychiatric News article “Specific Exercise Characteristics Linked to Better Mental Health.”

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HHS Extends Deadline for Provider Relief Fund Applications; Learn More at Webinar This Afternoon

The Department of Health and Human Services (HHS) has extended the deadline for health care professionals to apply for the second phase of distribution of COVID-19 Provider Relief Funds to Friday, August 28. Additionally, HHS is allowing certain health care professionals who missed the deadline for the first-phase distribution in June to apply for the new distribution.

The Provider Relief Fund was created by Congress under the Coronavirus Aid, Relief, and Economic Security (CARES) Act passed in March. Eligible health care professionals—including those who bill Medicare, Medicaid, Medicaid managed care, or the Children’s Health Insurance Program—can receive up to 2% of their patient revenue. Relief fund payments do not need to be repaid to the U.S. government, assuming recipients comply with the terms and conditions.

The initial deadline for the second-phase distribution was June 20. In a statement on July 31, HHS Secretary Alex Azar extended the deadline to August 28, while also allowing certain health care professionals who missed the first distribution to use the August 28 deadline to apply for the second distribution. Those who missed the first distribution but are unsure of their eligibility for the second are encouraged to apply.

The agency has posted a six-step guide to applying for the fund, which provides information on determining eligibility, validating one’s tax ID number, applying for funding, receiving a payment, attesting to payment, and reporting on use of funds. HHS is holding a webinar on the relief fund today, August 13, at 3 p.m. ET. The webinar will be recorded and archived on the HHS website.

“HHS’s administration of the Provider Relief Fund has been focused on distributing funding in a way that is fast, fair, and transparent,” Azar said in the July 31 statement. “Extending the deadline for Medicaid providers and giving certain Medicare providers another shot at funding is another example of our work with providers to ensure as many as possible receive the support they need.”

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Contribute to Strengthening APA’s Leadership
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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Learning About Alzheimer’s Risk Does Not Negatively Affect Older Adults’ Mental Health in Short Term, Study Suggests

Older individuals who are informed by health care professionals that they have elevated levels of the protein amyloid—a known risk factor for Alzheimer’s disease—do not appear to experience adverse short-term psychological responses compared with those who learn their amyloid levels are normal, according to a report in JAMA Neurology.

“We found that trial participants who did not have cognitive impairment and received an elevated amyloid result were no more likely than those receiving a not elevated amyloid result to experience depression, anxiety, or catastrophic reactions in the short term,” wrote lead author Joshua Grill, Ph.D., of the University of California, Irvine, and colleagues.

Grill and colleagues analyzed data from the Anti-Amyloid Treatment in Asymptomatic AD (A4) Study, an ongoing randomized clinical trial of the medication solanezumab for Alzheimer’s that began in 2014. As part of the trial, participants aged 65 to 85 years underwent brain scans to assess amyloid levels. The sample consisted of 1,167 individuals who learned that they had elevated levels of amyloid, and 538 participants who were told their amyloid levels were normal.

Before and after disclosure of amyloid status, participants completed the Geriatric Depression Scale, the State-Trait Anxiety Inventory, and the Columbia Suicide Severity Rating Scale. The average period between being informed of amyloid status and completing the follow-up psychological assessments was between 41 and 56 days for all participants.

The researchers found that participants who learned they had elevated amyloid levels did not report significantly higher scores on these assessments compared with those who learned their status was normal.

In contrast, scores on a scale measuring concerns about Alzheimer’s increased significantly in those with elevated amyloid, indicating that individuals with elevated amyloid levels understood that their biomarker result conferred increased risk for dementia.

“This perception of increased risk … did not appear to be associated with adverse psychological reactions, namely anxiety or depression,” the researchers wrote. “Whether such associations develop over time will be a key area of future research.”

For related information, see the Psychiatric News article “Are Amyloid and Tau Good Biomarkers For Alzheimer’s Disease?”

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Follow-up Care Within 7 Days of Psychiatric Hospital Discharge Reduces Suicide Risk in Youth

Youth on Medicaid who have a follow-up mental health visit within seven days of discharge from a psychiatric hospital appear to be at lower risk of suicide in the six months following hospitalization compared with those who do not receive such timely care, reports a study published today in JAMA Network Open.

“High rates of suicide after psychiatric hospital discharge have persisted and failed to decrease for decades,” wrote Cynthia A. Fontanella, Ph.D., of the Department of Psychiatry and Behavioral Health at The Ohio State University Wexner Medical Center and colleagues. “These findings support existing quality indicators and highlight the need to improve transitions from inpatient to outpatient mental health care.”

Fontanella and colleagues analyzed Medicaid claims data from 33 states on youth aged 10 years to 18 years who had been admitted to psychiatric hospitals between January 1, 2009, and December 31, 2013. (These states were selected because of the quality and completeness of the managed care claims, the authors noted.) The researchers specifically focused on youth who had inpatient admissions of 1 to 30 days, were discharged home, and were continuously enrolled in Medicaid during the 180 days before the admission and the 30 days after hospital discharge.

To determine deaths by suicide within eight to 180 days of discharge, the researchers linked the Medicaid data with data from the National Death Index. They defined an outpatient mental health visit as “any Medicaid-reimbursed behavioral health visit with a primary mental health diagnosis…, including visits for psychotherapy or pharmacotherapy, partial hospitalization, rehabilitation, and other community-based services, such as case management.”

Of the 139,694 youth admitted to a psychiatric hospital during the study period, 56.5% received a mental health visit within seven days of hospital discharge. Follow-up care within seven days was associated with a 56% lower risk of suicide (adjusted relative risk, 0.44) during the postdischarge period.

Youth who had longer lengths of stay at the hospital, had previously accessed outpatient mental health care, and/or were in foster care were more likely to have received follow-up care within seven days of discharge from a psychiatric hospital. In contrast, youth who were non-Hispanic Black; were older; and/or had a history of comorbid chronic medical conditions, deliberate self-harm, or substance use disorders were less likely to have received follow-up care within seven days of discharge.

In a commentary accompanying the study, David A. Brent, M.D., of the University of Pittsburgh School of Medicine and colleagues reflected on the finding that Black youth were less likely receive a follow-up mental health appointment within one week of discharge from a psychiatric hospital. “This is particularly worrisome because, from 2007 to 2017, the rate of suicide attempts increased 74% and the rate of suicide deaths increased 89% among Black youth, increases that greatly exceeded those for white youth,” Brent and colleagues wrote.

“The goal of such research is not merely to document the sources of disparities but to devise actionable interventions and policies that bridge these gaps in care,” they continued. “We need to label these disparities as what they are: unacceptable. Just as we must address the gaps that occur between transitions in care, we must also bridge gaps that are defined by race, ethnicity, and class, so that all people receive the care that they need and deserve. In so doing, we can reverse the disturbing upward trend in suicide in U.S. youth in general, and in Black youth in particular.”

For related information, see the Psychiatric News article “Alarming Black Youth Suicide Trend Must Be Addressed, Experts Say.”

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APA Wants You! Consider Running for Office
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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Cannabis Use During Pregnancy Linked to Increased Autism Risk in Children

Women who use cannabis while pregnant have an elevated risk of having children with autism spectrum disorder (ASD), according to a study published today in Nature Medicine.

“Children with prenatal cannabis exposure had an increase of 50% in the risk of an autism diagnosis over the study period, and these associations were robust after controlling for confounding,” wrote Daniel Corsi, Ph.D., of the University of Ottawa and colleagues.

Corsi and colleagues analyzed the health outcomes of over 500,000 children born in Ontario between April 1, 2007, and March 31, 2012, by linking pregnancy data from Ontario’s birth registry to health administrative databases in Canada’s various provinces. Among the mothers, 0.6% reported using cannabis while pregnant.

The investigators monitored health outcomes in the children for an average of 7.4 years. During the study period, 2.2% of children with prenatal cannabis exposure were diagnosed with ASD, compared with a rate of 1.4% among all children. After adjusting for factors such as age, income, and other substance use, the investigators found that women who used cannabis during pregnancy had 1.5 times the risk of having a child with ASD. Cannabis use during pregnancy was also associated with 1.1 times the risk of an ADHD diagnosis and 1.2 times the risk of intellectual disability or a learning disorder, but these risks were not statistically significant after adjusting for other variables.

“Although findings of an increased risk for childhood neurodevelopmental disorders are of substantive interest, we emphasize a cautious interpretation,” Corsi and colleagues wrote. They noted that while their study factored in several important variables that are also associated with developmental risks (such as prenatal exposure to substances other than cannabis), there may be other contributing factors they overlooked.

For related information, see the Psychiatric News article “Cannabis Use During Pregnancy on the Rise.”

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Targeted Behavioral Pain Management May Improve Chronic Pain in Patients With Substance Use Disorder

Behavioral pain management techniques that focus on the interplay between chronic pain and the potential for substance abuse may improve pain tolerance and lower pain intensity in patients who have substance use disorder (SUD), suggests a study in JAMA Psychiatry.

Mark A. Ilgen, Ph.D., of the VA Center for Clinical Management Research in Ann Arbor, Mich., and colleagues compared pain tolerance and intensity of 470 adults over 12 months. All patients were in treatment for SUD and had chronic pain. Patients were randomized to receive either the Improving Pain During Addiction Treatment (ImPAT) intervention or supportive psychoeducation control in addition to treatment as usual for their SUD and chronic pain. ImPAT emphasizes the link between pain and poor functioning and the risk of using substances to cope with pain. Treatment using this approach focuses on conceptualizing and responding to pain with the goal of also preventing relapses to substance use. Although supportive psychoeducation also focuses on ways of responding to pain, it is less specific than ImPAT and does not emphasize ways to avoid misusing substances to cope with pain.

Patients in both groups attended eight one-hour group sessions over four weeks. The researchers measured the patients’ pain using the first item of the Numeric Rating Scale of Pain Intensity, which measures pain on a scale of 0 to 11. They also measured the patients’ pain tolerance using the ischemic pain task, which involves doing handgrip exercises while blood flow to the arm is restricted by a blood pressure cuff.

At 12 months, men in the ImPAT group experienced a median increase of 0.25 points in pain tolerance but a median increase of 0.11 points in pain intensity compared with their peers in the supportive psychoeducation group. In the same time frame, women in the ImPAT group experienced a median decrease of 0.22 points in pain intensity but a median decrease of 0.07 points in pain tolerance compared with their peers in the psychoeducation group. The ImPAT intervention did not appear to affect the risk of relapsing to substance use, as relapse rates were similar in both groups.

“These findings highlight the potential benefits of [the ImPAT] approach on pain-related outcomes for SUD treatment settings and raise the possibility that integrating behavioral pain management and SUD services could be particularly beneficial for the large number of individuals with co-occurring pain and SUDs,” the researchers wrote. “However, the effect sizes were small, and we did not detect an effect of the ImPAT condition on SUD outcomes, highlighting the need for future work to continue to look at ways to enhance integrated pain and SUD treatment effects to improve clinical outcomes in the high-risk group of patients with both pain and SUDs.”

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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Adults May Require Different Interventions for Loneliness Depending on Age

The factors impacting adults’ feelings of loneliness change depending on their phase in life, suggesting there is no “one-size-fits-all” intervention to reduce loneliness, according to a study published in BMC Public Health.

“[T]he factors associated with loneliness vary across different age groups and therefore policymakers and intervention developers should take these factors into account in efforts to reduce loneliness among adults,” wrote Thanée Franssen, M.Sc., of Maastricht University in the Netherlands and colleagues.

The authors used data from the Adult Health Monitor Limburg 2016, a population-based health survey that monitors the self-reported health of adults in the Netherlands between the ages of 19 and 65. The authors split the 26,342 adult participants into three groups: young (19 to 34 years), early middle-aged (35 to 49 years), and late middle-aged (50 to 65 years).

The survey collected information on participants’ demographics (including gender, education, marital status, ethnicity, and employment status), social environment (including living arrangement; volunteer work; frequency of contact with family, friends, or neighbors; and whether they feel excluded from society), and health factors (including any limitations in daily activities due to health problems, chronic disease diagnoses, and levels of psychological distress). The researchers used the Dutch Mental Health Continuum-Short Form to determine participants’ psychological, emotional, and social well-being, and the De Jong-Gierveld Loneliness Scale to measure loneliness.

Overall, 44.3% of adults reported experiencing loneliness, broken down as 39.7% of young adults, 43.3% of early middle-aged adults, and 48.2% of late middle-aged adults. The authors identified some universal factors that influenced loneliness regardless of age group, including living alone, frequency of contact with neighbors, perceived social exclusion, psychological distress, and psychological and emotional well-being.

Other factors were present in specific age groups only. Young adults showed the strongest association between loneliness and their frequency of contact with friends. Being female with an intermediate to high level of education was associated with lower levels of loneliness among young adults only, while having a job was significantly associated with lower levels of loneliness among early middle-aged adults. Among late middle-aged adults, being married was associated with lower levels of loneliness.

In a blog post for BMC Public Health, Franssen explained how the different factors impacting loneliness by age may be especially evident during the COVID-19 pandemic. “For example, young adults are not able to interact with their friends or classmates face to face anymore. Early middle-aged adults have to work from home, while supervising their children and worrying about their aging parents, whereas for late middle-aged adults visiting their loved ones has become impossible,” she wrote. “So, whatever age you are, the risk of loneliness is always there, lurking in the background. And maybe now more than ever.”

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APA Wants You! Consider Running for Office
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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Adult Anxiety and Poorer Function Linked to Childhood Depression But Can Be Prevented

Children or teenagers with depression are more likely to have higher rates of anxiety and worse social functioning as adults than those without a history of depression, according to a report in the Journal of the American Academy of Child and Adolescent Psychiatry.

However, children who receive specialty mental health services have a significantly reduced risk of adult psychiatric diagnoses, particularly anxiety, wrote William E. Copeland, Ph.D., a professor of psychiatry at the University of Vermont, and colleagues.

“In our study, children/adolescents who had met criteria for depression and had also received specialty mental health services were almost half as likely to receive an anxiety diagnosis as adults compared to their depressed peers who did not receive specialty mental health services,” they wrote.

A total of 1,420 participants in the Great Smoky Mountains Study were interviewed up to eight times between the ages 9 and 16 to assess for depressive disorders, associated psychiatric comorbidities, and childhood adversities (including low socioeconomic status, family dysfunction, abuse and neglect, and peer victimization) using the structured Child and Adolescent Psychiatric Assessment. They were interviewed again at ages 19, 21, 25, and 30 using the structured Young Adult Psychiatric Assessment Interview for psychiatric outcomes and functional outcomes.

A total of 7.7% of participants met criteria for a depressive disorder in childhood/adolescence. “Childhood/adolescent depression status was strongly associated with all types of other childhood psychiatric disorders and with most types of childhood adversities,” Copeland and colleagues wrote. 

They found that childhood/adolescent depression was associated with higher rates of adult anxiety and depression and substance use disorders later in life. It was also associated with worse adult functional outcomes including poorer physical health, risky and/or criminal behavior, poorer financial status and/or educational performance, and poorer social function.

However, Copeland and colleagues also found that specialty mental health services for children could have long-term effects: Just 31.8% of children who had received mental health services had anxiety as adults, compared with 57.5 % of those who did not. (The effects of mental health services did not extend to other functional outcomes.)

“[E]fforts to reduce the public health burden of depression should focus on reducing children’s cumulative exposure to depression and depressive symptoms,” they wrote. “The optimal strategy will likely involve public policies that target psychosocial risk factors associated with depression symptoms (for example, caregiver instability, maltreatment).”

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APA Survey on Racism Closes Tomorrow (August 6)

The APA Presidential Task Force to Address Structural Racism Throughout Psychiatry invites you to complete the second in a series of surveys on how racism impacts the field of psychiatry. Your answers will be anonymous. They will be used to inform the Task Force’s work and may be anonymously cited in future work. The survey closes tomorrow, Thursday, August 6.

High-Dose Vitamin D Supplements Do Not Prevent Depression in Older Adults, Study Finds

Long-term use of a high-dose daily vitamin D3 supplement does not appear to be any more effective than placebo at preventing depression in adults aged 50 years or older, according to a study appearing today in JAMA.

Although observational studies have suggested individuals with lower levels of vitamin D may be at higher risk of late-life depression, “the findings do not support a role for supplemental vitamin D3 in depression prevention among adults,” wrote Olivia I. Okereke, M.D., S.M., of Massachusetts General Hospital and colleagues.  

Okereke and colleagues analyzed data collected from a subset of adults who were participants in the Vitamin D and Omega-3 Trial (VITAL)—a randomized clinical trial examining the effects of vitamin D3 and fish oil supplements on the prevention of cancer and cardiovascular disease in 25,871 adults in the United States. Participants were excluded from the current study (called Vitamin D and Omega-3 Trial-Depression Endpoint Prevention, or VITAL-DEP) if they had clinically relevant depressive symptoms, defined as an eight-item Patient Health Questionnaire (PHQ-8) score of ≥10; had core features of depression for two or more weeks within the past two years; were currently receiving treatment for depression; had alcohol or substance use disorder within the past year; or had schizophrenia or psychotic disorder, bipolar disorder, or another major psychiatric or neurological condition.

In total, the VITAL-DEP study included 18,353 middle aged and older adults (mean age 67.5 years) without depression at baseline who were randomly assigned to take either vitamin D3 (2,000 IU/d of cholecalciferol) or placebo daily for the duration of the trial (median 5.3 years). 

Each year the participants were mailed questionnaires that asked for updates on major illnesses or adverse events, health and lifestyle factors, and study adherence. The PHQ-8 was included in six annual questionnaire forms. Okereke and colleagues specifically focused on the participants’ reports of receiving a depression diagnosis, new treatment (medication, counseling, or both) for depression, or presence of clinically relevant depressive symptoms (PHQ-8 score ≥10 points). The participants were followed up until the occurrence of depression or clinically relevant depressive symptoms, death, or the end of the trial, whichever came first.

There were no significant differences between groups in risk of depression or clinically relevant depressive symptoms (609 cases of depression or clinically relevant depressive symptoms in vitamin D3 group; 625 in the placebo group), the authors reported. Additionally, there was no significant difference between treatment groups for change in mood scores over time (average PHQ-8 scores rose by 0.20 points in the vitamin D3 group and 0.16 points in the placebo group).

More information on nutritional supplements appears in the book The APA Publishing Textbook of Psychiatry, Seventh Edition in the chapter “Complementary and Integrative Psychiatry.”

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Help Diversify APA's Leadership
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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