Prenatal Cannabis Exposure May Increase Risk of Mental Illness in Offspring, Study Suggests

Children of women who used cannabis while they knew they were pregnant may be at greater risk of symptoms of mental illness than children of women who did not use cannabis during pregnancy, according to a report in JAMA Psychiatry. For instance, youth who were exposed to cannabis in the womb were more likely to report more psychotic-like experiences, as well as problems with aggressive behavior, depression, and anxiety than those without such exposure.

“[P]regnant women, and even those contemplating pregnancy, should be discouraged from using any cannabis by health care professionals, dispensaries, and others,” wrote Ryan Bogdan, Ph.D., of Washington University in St. Louis and colleagues.

Bogdan and colleagues analyzed data from 11,489 children enrolled in the Adolescent Brain and Cognitive Development (ABCD) study—an ongoing study tracking the brain development of U.S. children through adolescence. Based on retrospective prenatal cannabis use reported by parents or caregivers of children in the study, the researchers divided the ABCD study participants into three groups: no exposure to cannabis (n=10,834), exposure to cannabis prior to maternal knowledge of pregnancy only (n=413), and exposure to cannabis after maternal knowledge of pregnancy (n=242). The average age of children in the study was 10.

The researchers used several validated questionnaires to measure outcomes in children including the Prodromal Questionnaire–Brief Child to assess child-reported psychotic-like experiences and the Child Behavior Checklist to assess internalizing problems (for instance, depression and anxiety) and externalizing problems (for instance, aggressive behavior) as well as attention, thought, sleep, and social problems.

The researchers found that children whose mothers had used cannabis before or after they learned they were pregnant were more likely to have psychotic-like experiences and increased internalizing and externalizing problems compared with children who had no prenatal exposure. Exposure later in pregnancy, after mothers had learned of their pregnancy, was related to greater psychiatric problems in children even after adjusting for possible variables such as family demographics.

“It is clear that more studies on the association between prenatal cannabis exposure and offspring developmental outcomes are needed to examine potential causal effects, moderating or protective factors, and biological mechanisms,” the researchers wrote. “Similar to the effective messaging surrounding the adverse consequences of alcohol and tobacco exposure during pregnancy, education regarding the potential harms associated with prenatal cannabis use is necessary.”

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

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Women With First-Episode Psychosis Not Getting Targeted Care They Need

Specialty team–based services for first-episode psychosis (FEP) have the potential to improve outcomes among patients with schizophrenia. In an article in Psychiatric Services, psychiatrists Maria Ferrara, M.D., and Vinod H. Srihari, M.D., of Yale University described several factors that may disadvantage women in terms of both access to and quality of care in FEP services.

Age of onset: Although many FEP services target young adults, research suggests the onset of psychosis may occur later in women. To meet the needs of women of all ages, the authors suggested that FEP programs consider increasing the maximum age at which a patient can receive FEP services. They acknowledged that designing psychosocial interventions to address the needs of younger adults and women across the lifespan may be challenging. Older women, some of whom may be pregnant or have children, might require “more intensive care planning, as well as sustained social worker support for childcare, involvement with child protective services, and consideration of economic needs.”

Clinical presentation: Compared with men experiencing FEP, women tend to present with more mood symptoms, which can lead to a misdiagnosis of psychosis due to a primary affective disorder—often a criterion for exclusion from FEP services. Women also tend to have better overall functioning at the onset of psychosis, which can lead to delays in services. To address this issue, the authors recommended FEP services support the needs of women with concomitant psychosis and mood symptoms, reevaluate their diagnoses, and refer women to other services only after preliminary treatment and several months of careful longitudinal assessment.

Pathways to care: Symptom-onset differences also result in women being less likely than men to be referred to FEP programs. “FEP services should be sensitive to these gender differences and target outpatient health facilities (for example, primary care and obstetric and gynecologic clinics) where women with underrecognized psychosis may be found,” they wrote. “To increase the likelihood that [women caring for children and/or elderly relatives] will access and accept care, services should integrate their outreach and engagement activities to settings where relevant services (for example, social services and child care) are co-located and readily available.”

Sexual and reproductive health: Psychosis symptoms often tend to first emerge during the period of greatest fertility for women. “FEP services should routinely provide education to help prevent sexually transmitted diseases and unintended pregnancies. Shared decision-making around family planning is also critical when medications with potential teratogenic risks are prescribed,” they wrote. Additionally, FEP services should consider collaborating with pediatric, primary care, and obstetric services to ensure patients who are pregnant or planning a pregnancy receive coordinated care during the peripartum period.

Preventive medicine: Research shows that women with schizophrenia are less likely to receive Pap test screenings for cervical cancer and mammograms for breast cancer compared with women without the disorder. “FEP services should consider providing education and care coordination to facilitate appropriate access to preventive measures (for example, human papillomavirus vaccination, breast self-examination, and diagnostic imaging),” they recommended.

“[W]omen with FEP have specific needs that can be proactively addressed to refine the current expansion of FEP services in the United States,” Ferrara and Srihari concluded.

For related information, see the Psychiatric Services article “Targeting Gender and Age in First-Episode Psychosis Services: A Commentary on Ferrara and Srihari.”

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Fetal Exposure to Alcohol Associated With Behavioral, Psychological Problems in Offspring

Children who were exposed to any amount of alcohol in the womb are more likely to be impulsive and diagnosed with separation anxiety and oppositional defiant disorder compared with children who were not exposed to alcohol in the womb, reports a study in AJP in Advance.

“To our knowledge, this is the largest examination of prenatal alcohol exposure and psychological, behavioral, and neurodevelopmental outcomes in preadolescence,” wrote Briana Lees, B.Psych., of the University of Sydney, Australia, and colleagues. The authors noted their study reaffirmed the many risks of heavy drinking during pregnancy, but “children with even the lowest levels of exposure demonstrate poorer psychological and behavioral outcomes as they enter adolescence.”

Lees and colleagues analyzed data from 9,719 children aged 9 to 11 who are part of the Adolescent Brain and Cognitive Development (ABCD) study, which aims to track brain development in a nationally diverse population of children from preadolescence to young adulthood. For ABCD, all children and their parents complete psychological and cognitive assessments periodically, and the children receive periodic brain scans.

Among the 9,719 children included in the analysis, 26% were exposed to alcohol during pregnancy. Compared with children with no alcohol exposure, those with any exposure had statistically greater average scores on the Child Behavior Checklist (CBCL), which measures emotional and behavioral problems, and greater impulsivity scores. Children with any exposure to alcohol were 21% more likely to have received a diagnosis of separation anxiety disorder and 17% more likely to have received a diagnosis of oppositional defiant disorder.

The researchers next grouped the children based on their mothers’ drinking habits during pregnancy: abstinent, light drinking during first seven weeks of pregnancy (about two drinks a week), light drinking throughout pregnancy (about one drink a week), and heavy drinking during first seven weeks of pregnancy (about five drinks a week). Women who drank heavily throughout pregnancy comprised less than 1% of the sample and were excluded from this analysis.

Compared with children whose mothers did not drink alcohol during pregnancy, children from all the other groups had higher scores on the CBCL and elevated risks of separation anxiety disorder and oppositional defiant disorder. Children whose mothers were light drinkers throughout pregnancy were also more likely to develop a phobia, while children whose mothers drank heavily in early pregnancy were more likely to report aggression, rule-breaking behaviors, withdrawn or depressed behavior, and to have a diagnosis of attention-deficit/hyperactivity disorder.

“Similar to previous conclusions drawn on the effects of prenatal alcohol exposure, our results suggest that there is no safe threshold for alcohol consumption during pregnancy,” Lees and colleagues concluded.

For related information, see the Psychiatric News article “Strategy Emerges to Combat Effects of Prenatal Alcohol Exposure.”

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Serious Mental Illness on Rise Among Residents of Assisted-Living Communities

The prevalence of serious mental illness (SMI) among people who live in assisted-living communities is rising faster than in the community at large, suggests a study in the American Journal of Geriatric Psychiatry.

“This increased prevalence of SMI in [assisted living] has implications for the provision of mental health services in this setting, a topic that is largely underexplored other than in broad strokes,” wrote Cassandra L. Hua, Ph.D., of the Brown University School of Public Health and colleagues.

The researchers analyzed data from the Medicare Master Beneficiary Summary File, a ZIP code history file, OASIS home health assessment data, Medicare Part B claims, a national list of state licensed assisted-living communities, and a Residential History File. They separated the population into three groups: those who lived in the community at large, in a nursing home, or in assisted living on December 31 of each year from 2007 to 2017.

Over the 10-year period studied, the prevalence of SMI in assisted living increased by 54%, compared with an increase of 39% in the community at large. However, the prevalence of SMI rose the fastest in nursing homes, increasing 77%.

The prevalence of SMI in assisted living varied widely between states, ranging from 3.2% in Wyoming to 33.1% in New York.

“Given that Medicaid coverage of [assisted living] varies by state, funding for [assisted-living] services may remain suboptimal in many locations,” Hau and colleagues wrote. “Future research can empirically investigate the relationship between state Medicaid policy and changes in the prevalence of SMI in [assisted living].”

People with SMI had a higher prevalence of medical conditions such as obesity, COPD, and diabetes, and they were more likely to have at least six chronic conditions compared with people without SMI.

“The prevalence of health concerns may be a concern because … [assisted-living] communities are not required to provide round the clock nursing services, although 54% have an RN or LPN on staff,” the researchers wrote. “More research is needed into the mental health and medical care needs for this population.”

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Register for Tomorrow’s Virtual State Advocacy Conference

With state legislatures increasingly focused on policies affecting mental health and access to care, now is a critical time for APA members to learn important state advocacy skills and get involved in advocacy. APA’s State Advocacy Conference will equip members to effectively engage their state lawmakers. The conference, which is open to all APA members, will take place virtually tomorrow, Saturday, September 26. The registration fee is $50; residents may register for $25. APA designates this live activity for a maximum of 4 AMA PRA Category 1 Credits.

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Successful APA Advocacy Ensures Veteran Patient Safety Regarding MH Care

After significant APA advocacy, the House Veterans’ Affairs Committee removed a proposal to implement a pilot program allowing clinical psychologists to prescribe and manage medications for veterans who seek care in the Veterans Health Administration.

After learning about the proposal, APA issued an advocacy alert that resulted in over 1,000 members sending more than 3,000 letters to their elected officials on Capitol Hill, opposing the proposal and urging lawmakers to ensure veterans receive the highest quality mental health care possible. Similarly, APA leadership, as well as government relations and policy staff members, vigorously lobbied members of Congress on and off the House and Senate Veterans Affairs Committees and engaged in conversations with top staff at the VA.

The House proposed the pilot program in legislation on veteran suicide prevention that was intended to be a companion bill to the Senate-passed suicide prevention package that had cleared the upper chamber earlier this summer. The House passed its legislation this week without the provision allowing psychologists to prescribe or manage medications.

“We will continue our work with the VA, Congress, and partner organizations to improve the mental health and substance use care available to our veterans through the VHA and beyond,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We must work with policymakers on genuine solutions that promote the recruitment and retention of critically needed psychiatrists, psychologists, and other mental health providers who are in short supply within the VA system. Meanwhile, with the help of our members, we have avoided the enactment of a false solution that could have put many veterans at risk, without any improvement in access to the care they truly need.”

On average, 20 veterans die by suicide every day. Often, veterans’ mental illnesses occur alongside complex comorbidities. A 2019 study in the Journal of the American Heart Association found that veterans diagnosed with posttraumatic stress disorder (PTSD) were 41% more likely to develop cardiovascular diseases than those without PTSD. Additionally, smoking, depression, anxiety disorders, sleep disorders, type 2 diabetes, obesity, high blood pressure, and cholesterol were significantly more prevalent among patients with PTSD.

“We believe that nothing is more important than ensuring that veterans are given high quality mental and physical health care by qualified, appropriately educated, and trained medical clinicians, not more prescribers and more prescriptions,” Levin said. “Veterans have gone above and beyond by serving our country and should not be subjected to a lower standard of care than other patients across the country.”

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Problematic Internet Use, Gaming May Point to Students Experiencing Mental Health Symptoms

College students whose academic performance has been negatively impacted by internet use or computer gaming are at higher risk of mental health problems than students without problematic internet use/computer gaming behaviors, according to a report in Depression & Anxiety.

“These findings suggest that querying students about whether their internet use or computer gaming has negatively affected their academic functioning might be a strategy for identifying students at risk for [mental health] problems,” wrote Courtney Stevens, Ph.D., of Willamette University and colleagues. “This approach may be particularly useful as internet use is likely less stigmatized than other [mental health] symptoms or diagnoses and because students and universities tend to gauge outcomes not by [mental health] status but through students’ ability to function academically.”

Stevens and colleagues analyzed data from 43,003 undergraduates aged 18 and older who participated in the 2017 American College Health Association‐National College Health Assessment—a 30-minute survey on such topics as substance use/abuse, sexual health, physical health, and more. As part of the survey, students were specifically asked about the past-year frequency of 11 mental health symptoms, including hopelessness, loneliness, overwhelming anxiety, sadness, anger, intentional self-harm, and attempted suicide. Students were also asked about problematic internet use, which the authors defined as “internet use and computer gaming negatively impacted academic performance.”

About 10% of students reported problematic internet use/computer gaming over the previous 12 months (with most indicating the most serious consequence of this behavior was receiving a lower grade on an exam or important project).

Overall, 93% of the students surveyed reported at least one of the 11 mental health symptoms during the year. Students reporting problematic internet use/computer gaming exhibited consistently elevated rates of all mental health symptoms relative to students not reporting problematic internet use/computer gaming. For instance, students who reported problematic internet use/computer gaming were more than twice as likely to report feeling “hopeless,” “so depressed it was difficult to function,” “overwhelmed,” “exhausted,” “very lonely,” or “very sad” in the past year. Similarly, students who reported problem internet use/computer gaming were about 1.5 times as likely to report that in the past year they had engaged in intentional self‐harm, had seriously considered suicide, or attempted suicide.

“Whereas screen time monitoring has been discussed extensively for young children, there is little guidance for older adolescents or college students where screen time and internet use are normalized and generally unscrutinized,” the authors continued. “Colleges may wish to consider offering workshops or other educational strategies to help students develop self‐awareness and regulatory strategies for engaging with internet use in a healthy way.”

For related information, see the Psychiatric News article “CBT Intervention May Reduce Addictive Internet Use.”

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Nonfatal Opioid Overdoses Rose During COVID-19 Pandemic, Report Suggests

Data from an emergency department in Richmond suggests that the number of nonfatal opioid-related overdoses may have risen during the first few months of the COVID-19 pandemic, particularly among people who are Black. The findings were published in JAMA.

Taylor A. Ochalek, Ph.D., of Virginia Commonwealth University (VCU) and colleagues compared the number of nonfatal opioid overdoses recorded in electronic medical records from VCU’s Emergency Department from March to June 2019 with those that occurred from March to June 2020—the first few months of the COVID-19 pandemic. They found nonfatal opioid overdoses increased from 102 between March and June 2019 to 227 between March and June 2020. The increase in nonfatal opioid overdose visits occurred at the same time that the emergency department experienced a significant decline in the total number of emergency department visits, the authors reported.

“This data is from the Richmond area, but it confirms what we’re hearing anecdotally from across the U.S.,” F. Gerard Moeller, M.D., director of the Wright Center and director of the VCU Institute for Drug and Alcohol Studies, said in a press release. “The pandemic is more than a crisis of one disease. Its ripple effects will be felt for some time in the form of secondary health impacts like addiction.”

Further analysis of patient characteristics of those who experienced a nonfatal opioid overdose during the three-month period in 2019 versus the three-month period in 2020 revealed that while patients in both periods were about the same age (mean ages 42.2 years and 44.0 years, respectively) and predominantly male (70% and 73%, respectively), the percentage of Black patients rose from 63% in 2019 to 80% in 2020.

“While the use of records from March to June across two years serves as a control for underlying seasonal variation in overdose, the generalizability of these findings is limited by the small sample size and reporting of a single emergency department,” wrote Danielle F. Haley, M.P.H., Ph.D., of Boston University School of Public Health and Richard Saitz, M.D., M.P.H., of Boston University School of Medicine in an accompanying editorial. Nonetheless, they noted that the study by Ochalek and colleagues is “consistent with the hypothesis that the U.S. COVID-19 epidemic has been accompanied by an increase in substance use with important consequences (nonfatal overdose), with a signal of greater effect among people who are Black.”

They continued, “There has been a historic failure to deliver effective treatments for opioid use disorder, despite long-standing evidence of efficacy, in the absence of the additional burden COVID-19 has placed on U.S. health care infrastructure. Given this, combined with the racial/ethnic and socioeconomic disparities in opioid overdose and COVID-19–related morbidity and mortality, the introduction of policies alone will be insufficient to mitigate the effect of the COVID-19 pandemic on overdoses. It is critical to identify how best to translate these policies into clinical practice, expand infrastructure, and address the broader social and structural determinants of health that create disparities in access to health care.”

For related information, see the Psychiatric News article “Patient’s Race May Influence Access to MH Care Following Overdose.”

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Tips on Reopening Psychiatric Practices During Pandemic

As psychiatrists begin to reopen their offices during the COVID-19 pandemic, there are many questions about how to do so safely. In the latest issue of Psychiatric News, risk management consultant Anne Huben-Kearney, R.N., B.S.N., M.P.A., offers some advice. 

“Take into consideration your health and that of your patients and whether to continue with telepsychiatry, reopen your practice to see patients in person, or have a hybrid practice,” Huben-Kearney wrote. “Safety for your patients and for yourself is paramount, now more than ever.”

For psychiatrists who are preparing to resume seeing patients in person, Huben-Kearney suggested the following:

• Continue to follow the Centers for Disease Control and Prevention guidelines on social distancing, masks, and hand hygiene as well as state and local restrictions. 
• Ensure adequate masks and hand sanitizer for office staff and patients. Demonstrate use of both, including using the hand sanitizer when your patient enters the session room. 
• Reorganize your office to allow for physical distancing. Try to avoid more than one patient in the office at a time, and allow enough time between patients to wipe down surfaces.
• Outdoor sessions may be an option with written patient consent, but you need to be able to ensure auditory and visual confidentiality. 

Huben-Kearney also offered some guidance for psychiatrists who want to continue telepsychiatry sessions with patients, including those who live out of state:

• Keep track of when and to what degree the state governors rescind executive orders, especially regarding licensure across state lines. 
• Monitor when the Drug Enforcement Administration resumes compliance with the Ryan Haight Act, which requires health care professionals to conduct an initial, in-person examination of a patient before electronically prescribing a controlled substance.
• Initiate an application for permanent licensure in the states where your patients are located. Psychiatrists should be sure to check the status of their state’s COVID-19 guidelines (APA has compiled state-issued guidance here). They should also check the Interstate Medical Licensure Compact (IMLC), which allows states to work together to streamline the multi-state licensing process.
• Ensure that you have a HIPAA-compliant platform with a Business Associate Agreement to ensure your protection in case of a data breach. 

Finally, continue “to ensure patient screening, both for in-person and telepsychiatry sessions,” Huben-Kearney concluded. “Ensure compliance with the standard of care, which is the same whether care is provided in person or via telemedicine.”

To read more on this topic, see the Psychiatric News article “Reopening Your Practice During Pandemic.” 

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Researchers Warn of Post-Lockdown Influx of Alcohol-Related Emergencies Among Youth

Hospitals and emergency services should be prepared for a possible influx of adolescents and young adults with alcohol-related emergencies as their localities open up after COVID-19 lockdowns, suggests a study in the Journal of Adolescent Health. The study found that the proportion of alcohol-related emergency department (ED) visits to two Italian hospitals jumped for this population in the weeks following the end of this spring’s lockdown compared with the same time frame in 2019.

Veronica Grigoletto, M.D., of the University of Trieste and colleagues analyzed data on ED visits of patients aged 13 to 24 years that occurred during the following periods:

• The last three weeks of lockdown, April 10, 2020, to May 3, 2020
• The first three weeks after reopening, May 4, 2020, to May 27, 2020
• April 10, 2019, to May 3, 2019
• May 4, 2019, to May 27, 2019

When the researchers compared the number of ED visits by adolescents and young adults for the three weeks after reopening with that of the same time frame for 2019, they found that although the total number of ED visits in this age group was lower in 2020, a greater proportion of those visits were related to alcohol intoxication. From May 4 to May 27, 2019, 506 adolescents and young adults visited the ED, and 15 of those patients (2.96%) came because of alcohol abuse. In the three weeks after reopening in 2020, 221 patients in that age group visited the ED, and 25 of those patients (11.31%) came because of alcohol abuse.

“Considering that the reference population did not change and that other emergency facilities are not available in the area, these numbers seem to reflect an actual change in the relative impact of severe alcohol intoxication on ED arrivals,” the researchers wrote. They added that transitioning after lockdown “demands rapid adjustment and appropriate reintegration strategies, requiring mental skills that not everyone is able to implement.”

“Excesses belong to the typical pattern of behavior of adolescents and young adults, but to this extent, they may even result in life-threatening events,” they wrote. To that end, they suggested that both pediatric and adult services be prepared for a possible upswing in post-lockdown emergencies related to alcohol abuse.

For related information, see the Psychiatric News article “Pandemic Creates Challenges, New Opportunities for Treating Patients With Substance Use Disorder.”

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To Protect Public Health, U.S. Must Prioritize Worker Safety During COVID-19 Pandemic

The COVID-19 pandemic presents an enormous worker safety crisis to those caring for patients and others providing public-facing services, according to a Viewpoint article published in JAMA. Today is World Patient Safety Day, and the article highlights the importance of ensuring the safety of health workers, today’s theme.

U.S. employers are required under law to provide their employees with safe workplaces, and the Occupational Safety and Health Administration (OSHA) is tasked with enforcing the law, wrote David Michaels, Ph.D., M.P.H., of the Milken Institute School of Public Health, and Gregory Wagner, M.D., of the Harvard T.H. Chan School of Public Health.

“While OSHA could be making an important contribution to reversing the spread of the SARS-CoV-2 virus and mitigate risk to workers, their families, and communities, the federal government has not fully utilized OSHA’s public safety authority in its efforts to reduce the risk of COVID-19,” the authors wrote.

As of September 16, more than 155,000 hospital and nursing home staff have been infected by COVID-19 at work, and nearly 700 have died, according to the Centers for Disease Control and Prevention. “As the epidemic has spread, many other workers, including emergency responders, corrections officers, transit workers, and workers in meat and poultry factories, farms, grocery stores, and warehouses, also have been infected by SARS-CoV-2,” Michaels and Wagner wrote.

“As businesses reopen, not only ‘essential’ workers but all workers need to be protected,” they continued. “Unprotected workers will inevitably bring the virus from work to their homes and communities, setting back efforts to decrease the spread of infection, reduce morbidity and mortality, and rebuild the economy.”

All workplaces must have clear COVID-19 prevention plans, Michaels and Wagner wrote, that include the following:

• Workplaces should be designed to eliminate crowding and allow physical distancing.
• Employees should be provided with personal protective equipment (PPE).
• Workplaces should have enhanced ventilation and adequate hand sanitation and hand-washing facilities.
• Potentially contaminated surfaces should be disinfected.
• Workers should be screened for COVID-19.
• Adequate paid sick leave or unemployment compensation should be provided for those who cannot work due to COVID-19 concerns.

The authors urged the federal government to increase PPE production and OSHA to issue an emergency temporary standard (ETS) “that would require every employer to develop and implement an infection control plan,” they wrote. The federal government should also provide subsidies to businesses to meet the requirements of an ETS.

“The unprecedented nature of the COVID-19 pandemic requires strong and immediate action, including by government agencies, unions, employers, and workers,” the authors concluded. “Failure to exert leadership and develop effective policy in this area, including involving and engaging all affected groups and constituencies in stopping workplace spread of the virus, has had and will likely continue to have serious repercussions, not just for workers, but for the health and economy of the nation.”

For related information, see the Psychiatric News article “Psychiatrists Respond to MH Needs of Patients, Frontline COVID-19 Workers.”

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Older Physicians Experience Less Work-Related Stress, Psychological Distress Than Younger Colleagues

Physicians experience higher rates of psychological distress and suicidal ideation than the general population, but the experience of age may act as a buffer for older physicians, a study in the American Journal of Geriatric Psychiatry suggests. The study also found that work-life conflict declined as physicians grew older.

Chanaka Wijeratne, M.D., of the University of Notre Dame, Australia, and colleagues analyzed data from 10,038 physicians who responded to the National Mental Health Survey of Doctors and Medical Students, which was conducted in Australia. They divided responses into three groups according to physician age: younger (40 years old and younger), middle aged (41 to 60 years old), and older (61 years old or older). Physicians were asked whether they had experienced suicidal ideation and/or had been given a diagnosis of anxiety or depression over the preceding 12 months. They were also asked if they were distressed over work stressors such as conflict between study/career and family/personal responsibilities, finances and debt, long work hours, sleep deprivation, and difficult relations with senior colleagues, among others. They were asked to rate their distress over these stressors as “not at all stressed,” “not that stressed,” or “very stressed.” Physicians also answered questions about feelings of exhaustion, cynicism toward their work, whether they felt they were effective at work, and their drinking habits.

Compared with middle-aged and younger physicians, older physicians reported fewer workplace stressors that made them feel “very stressed,” and they were less likely to report distress over work-life conflict. As a group, older physicians felt less distress over work-related stressors in general, less exhaustion, less cynicism toward their work, and greater personal efficacy at work compared with their younger and middle-aged peers, and they were less likely to report suicidal ideation or a diagnosis of anxiety or depression over the preceding 12 months. However, their likelihood of reporting distress increased if they had a history of mental illness. There were no significant differences in high-risk drinking between groups, although younger physicians were more likely to engage in moderate-risk drinking compared with their middle-aged and older colleagues.

“Whilst the extant literature has suggested that physicians experience poor mental health, it can be seen that it needs to be considered more broadly in the context of age and career stage as there is an improvement in physicians’ reporting of psychological distress, suicidal ideation, burnout, and experience of workplace stress as they age,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “Well-Being, Burnout, and Depression Among North American Psychiatrists: The State of Our Profession.”

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Suicide Rates Peak Among Veterans Shortly After Transition to Civilian Life, Study Finds

Suicide rates among veterans peaked six to 12 months after they left the military, and those at higher risk included veterans who were younger, were male, had a shorter length of service, were not married, or were separated from the Marine Corps or Army, according to a study published in JAMA Network Open.

“National leaders at the highest levels of the U.S. government have been concerned about suicide rates among service members transitioning to civilian life,” wrote Chandru Ravindran, M.S., of the Center of Excellence for Suicide Prevention and colleagues. “We believe this cohort study provides much needed data to help inform prevention efforts among this veteran cohort.”

The authors used data from the VA/Department of Defense Identity Repository to identify 1.8 million veterans who served in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard. The participants separated (meaning they were either discharged or transitioned to a Reserve component category) from active duty between January 1, 2010, and December 31, 2017. Mortality data were obtained through the VA/Department of Defense Mortality Data Repository. Service members were followed for six years from the date they left service.

“Through the end of the study period, 3,030 suicides (2,860 men and 170 women) were identified as having occurred within 6 years of separation from the military,” wrote the authors. “The highest suicide rates were observed in year 1, but they increased over the first 6 months and generally peaked in the 6 to 12 months after separation. This pattern was true for service members who left the Army, Marine Corps, or Air Force; the rates for those who last served in the Navy peaked 3 to 6 months after their transition.”

Veterans who had served in the Marine Corps or Army had a higher risk of suicide compared with those who had left the Navy or Air Force, and male veterans had a higher risk compared with females. The rate of suicide was 4.5 times higher among those who were 17 to 19 years old compared with those who were over 40 when they transitioned from the military. Also, those who had served for fewer than two years had a statistically higher rate of suicide over the study period compared with those who had served longer.

“[W]ithin the high-risk cohort of transitioning service members, suicide prevention resources are especially important in the first year and remain important for at least 6 years given that the rates did not decline substantially within the study period,” the authors wrote. “Prevention efforts may be helpful for younger service members with fewer than 2 years of military service. Furthermore, service branch remains a risk factor for many years after transition and could be examined for more focused suicide prevention efforts.”

For related information, see the Psychiatric News article “Brief Test May Help Pinpoint Soldiers Likely to Attempt Suicide.”

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Sexual Minorities More Likely to Experience Comorbid SUDs, Psychiatric Disorders Than Heterosexuals

Adults who identify as gay, lesbian, or bisexual with alcohol or tobacco use disorder are more likely to have another psychiatric illness than adults who identify as heterosexual, according to a report in AJP in Advance.

“[I]t is important for clinicians to know that psychiatric comorbidities are more often present than not among sexual minorities who present with an alcohol or tobacco use disorder,” wrote Rebecca Evans-Polce, Ph.D., of the University of Michigan and colleagues. “This research suggests that integrated substance use and mental health prevention and treatment programs are needed, particularly for individuals who identify as sexual minorities.”

Evans-Polce and colleagues used data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions–III. As part of the survey, participants were asked questions about past-year alcohol use disorder and tobacco use disorder. The researchers analyzed data from 35,796 participants who had reported information on their sexual orientation (options included heterosexual, gay or lesbian, bisexual, or not sure) and other psychiatric conditions. Psychiatric disorders were grouped as mood disorders, anxiety disorders, or posttraumatic stress disorder (PTSD).

Among all survey respondents, 5,042 reported alcohol use disorder, and 7,188 reported tobacco use disorder in the past year. Of this group, 34.0% of adults with alcohol use disorder and 35.6% with tobacco use disorder also had a mood disorder, anxiety disorder, or PTSD. The researchers found that psychiatric comorbidities were more prevalent among members of sexual minorities; for example, 51.2% of gay or lesbian adults and 55.2% of bisexual adults who met the criteria for a past-year alcohol use disorder had a psychiatric disorder compared with 32.9% of heterosexual individuals.

Evans-Polce and colleagues also found that among members of sexual minorities, the number of stressful life events, number of adverse childhood experiences, and frequency of discrimination due to sexual orientation all contributed to the risk of comorbid psychiatric and alcohol and/or tobacco use disorders. Greater social support slightly reduced the risk of comorbid tobacco use disorder and anxiety disorders as well as comorbid tobacco use disorder and mood disorders.

“Clinicians should be cognizant of the challenges faced by sexual minorities and should consider these factors as part of their initial assessment and treatment,” Evans-Polce and colleagues wrote. “Importantly, treatment environments should be affirming of sexual minority status. Clinicians should examine their policies and practices to ensure that they are not engaging in discriminatory practices.”

For related information, see the Psychiatric Services article “Stress, Coping, and Context: Examining Substance Use Among LGBTQ Young Adults With Probable Substance Use Disorders.”

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E-Cigarette Use Tied to Sleep Deprivation in Young Adults

E-cigarette use, also known as vaping, may be associated with an increased risk of sleep deprivation in young adults aged 18 to 24 years even after they quit, a study in Addictive Behaviors has found. The study also suggests that e-cigarette use is rising in this age group.

Sina Kianersi, D.V.M., of the Indiana University School of Public Health and colleagues analyzed data from 18,945 young adults who participated in the Behavioral Risk Factor Surveillance System (BRFSS) in 2017 and 2018. The BRFSS is an annual telephone survey of adults living in the United States and its territories in which participants report on their health behaviors. Kianersi and colleagues drew their data from responses to questions that asked respondents how many hours they sleep in a 24-hour period; whether they have ever used an e-cigarette or other vaping device; and whether they currently use e-cigarettes or other vaping devices and, if so, how often. Sleep deprivation was defined as less than seven hours of sleep.

In 2018, 47% of young adults had ever used an e-cigarette, up from 39% the year before. In 2018, roughly 16% of young adults currently used e-cigarettes, up from 10% the year before. For both years, roughly 34% of young adults experienced sleep deprivation. Compared with young adults who had never used e-cigarettes, those who used e-cigarettes every day were 1.42 times more likely to report sleep deprivation. Those who had used e-cigarettes in the past and stopped were 1.17 times more likely to report sleep deprivation than those who never used e-cigarettes.

“Those who use e-cigarettes on a daily basis might consume higher doses of nicotine, compared to some days, former, and never users, and therefore get fewer hours of sleep,” the researchers wrote. They added that nicotine withdrawal is associated with sleeping more, which could explain why former e-cigarette users were less likely to report sleep deprivation than current e-cigarette users even though former e-cigarette users still had an elevated risk.

“Future studies with longitudinal designs and more precise measurement of different aspects of sleep will be critical to better understand the strength, magnitude, and causal nature of these relationships,” they wrote.

For related information, see the Psychiatric News article “National Academies Report Details Health Impact of E-Cigarettes.”

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Suicide-Related ED Visits in United States Continue to Rise

The rate of emergency department (ED) visits related to suicidal ideation or attempt increased for all age groups between 2008 and 2017, according to a Healthcare Cost and Utilization Project statistical brief. Today is World Suicide Prevention Day, and the brief’s findings highlight the need to work to prevent death by suicide.

“Suicide is a major and growing public health concern in the United States, ranking among the top 10 leading causes of death.” wrote Pamela L. Owens, Ph.D., of the Agency for Healthcare Research and Quality and colleagues. “From 2001 to 2017, the suicide rate increased 31%, from 10.7 to 14.0 per 100,000 population. In 2017, this equated to more than 47,000 deaths.”

The authors’ findings included the following:

• The rate of ED visits related to suicidal ideation or suicide attempt in 2017 was highest among those aged 15 to 19 (952.5 per 100,000 population), 20 to 24 (719.3 per 100,000 population), and 25 to 44 (642 per 100,000 population).
• Overall, the rate of ED visits related to suicide was higher among males compared with females in 2017. However, among those aged 10 to 19, the rate was higher among females.
• Overall, the highest rate of suicide-related ED visits was for females aged 15 to 19 years.
• Medicaid and Medicare were the most frequent payers for ED visits related to suicide.
• In 2017, nearly 65% of ED visits related to suicide resulted in a hospital admission or transfer to another facility, compared with only 17% of other ED visits.

“Suicide is preventable,” the authors wrote. “Suicidal thoughts or actions are indications of extreme distress and require immediate intervention. [EDs] are an important site of care to identify individuals at risk, to provide timely support and intervention, and, in some cases, to facilitate entry into more intensive treatment. Information on trends in ED utilization related to suicidal ideation or suicide attempt can help inform resource needs and target prevention efforts.”

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Today Is World Suicide Prevention Day; Help Stop Needless Deaths

Each year more than 45,000 people die by suicide. But there is hope—new research is revealing who is at greatest risk, and this understanding will help psychiatrists save lives.

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Depression Symptoms Soar During Pandemic, Study Finds

The prevalence of symptoms of depression in U.S. adults during a two-week period of the COVID-19 pandemic was more than three times higher than before the pandemic, according to a report in JAMA Network Open.

Moreover, people with a lower income, savings of less than $5,000, and greater exposure to COVID-19 stressors were more likely to have depressive symptoms than people who did not fall into those categories.

“These findings suggest that there is a high burden of depression symptoms in the United States associated with the COVID-19 pandemic and that this burden falls disproportionately on individuals who are already at increased risk,” wrote Sandro Galea, M.D., Dr.PH., of Boston University School of Public Health and colleagues.

Between March 31 and April 13, Galea and colleagues surveyed a nationally representative sample of 1,470 U.S. adults aged 18 or older about COVID-19 exposure, life stressors, and mental health using the COVID-19 and Life Stressors Impact on Mental Health and Well-being study questionnaire. COVID-19 stressors included, among others, the loss of a job, the death of someone close due to COVID-19, and financial difficulties. Depression symptoms were assessed using the Patient Health Questionnaire-9.

The prevalence of depression symptoms reported during the COVID-19 pandemic was then compared with that reported by 5,065 participants in the 2017-2018 National Health and Nutrition Examination Survey (NHANES).

The researchers found that a total of 382 participants (27.8%) had depression symptoms during COVID-19 compared with 458 participants (8.5%) before COVID-19. Higher levels of depression symptoms were observed in all demographic groups during COVID-19 compared with before, and across all levels of severity—mild, moderate, and severe.

Compared with individuals with an annual household income of $75,000 or more, those with a household income of $19,999 or less had 2.4-fold increased odds of depression symptoms. Individuals with household savings less than $5,000 had 1.5-fold increased odds of depression symptoms. Experiencing more COVID-19 stressors was also associated with greater odds of depression symptoms compared with people with low stressor exposure.

In an editorial accompanying the study, Ruth Shim, M.D., M.P.H., director of cultural psychiatry at the University of California, Davis, emphasized the need to address socioeconomic factors and their impact on mental health. “The study … might remind us of the importance of investing (both during and after the COVID-19 pandemic) in stable housing, unemployment benefits, access to healthy food, and policies that end discrimination and exclusion to effectively manage a highly disabling, common mental health condition that will likely only increase in prevalence as the pandemic rages on.”

For related information, see the Psychiatric News article “Expect a ‘Long Tail’ of Mental Health Effects From COVID-19.”

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World Suicide Prevention Day Is Tomorrow; Help Stop Senseless Deaths

Each year more than 45,000 people die by suicide. But there is hope—new research is revealing who is at greatest risk, and this understanding will help psychiatrists save lives.

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Considering Mental Health Apps? APA App Advisor Can Help

As the number of mental health apps available for download continues to rise, psychiatrists are likely to receive questions from patients on the risks and benefits of these products. To help psychiatrists and other mental health professionals when selecting apps, APA has created the APA App Advisor—a website that guides users through questions to consider when evaluating mental health apps.

The APA App Advisor is an outgrowth of a mobile app evaluator put forth by an APA work group in 2017. Last December, APA brought together a diverse expert panel to assess the evaluation tool and consider ways to enhance it. The panel included not just psychiatrists but also psychologists, social workers, nurse practitioners, medical students, and people with lived experience of mental illness.

“We wanted to make sure a lot of different voices were heard,” John Torous, M.D., director of the Digital Psychiatry Division at Beth Israel Deaconess Medical Center and chair of the expert panel, told Psychiatric News.

The panel recommended the following questions as a good “jumping off” point when considering any mental health app:

• On which platforms/operating systems does the app work? Does it also work on a desktop computer?
• Has the app been updated in the last 180 days?
• Is there a transparent privacy policy that is clear and accessible before use?
• Does the app collect, use, and/or transmit sensitive data? If yes, does it claim to do so securely?
• Is there evidence of specific benefit from academic institutions, end-user feedback, or research studies?
• Does the app have a clinical/recovery foundation relevant to your intended use?
• Does the app seem easy to use?
• Can data be easily shared and interpreted in a way that is consistent with the stated purpose of the app?

The App Advisor features written and video tutorials on the evaluation tool, including some basics on navigating it. It also includes sample evaluations of 11 popular mental health and well-being apps conducted by panel members.

Torous emphasized that APA is not endorsing any of these apps by evaluating them. “These evaluations are aimed at giving psychiatrists a sense of what to look for when reviewing an app so they can make the most informed decision for their patient and practice,” he said.

For related news, see the Psychiatric Services article “Smartphone Apps for College Mental Health: A Concern for Privacy and Quality of Current Offerings.”

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One 20-Minute Call May Encourage Medication Treatment, Lower Overdose Risk in Patients With OUD

Receiving a 20-minute phone call from a trained peer counselor may help prompt people who have overdosed on opioids to begin medication treatment and lower their risk of another opioid overdose, suggests a study in Drug and Alcohol Dependence.

Theresa Winhusen, Ph.D., of the University of Cincinnati College of Medicine and colleagues compared the rates of medication treatment enrollment, opioid overdose, and opioid use in 80 patients who were randomized to receive either standard education or education with a personalized call. Standard education consisted of an information packet with three reports that were generated from the patient’s responses to two surveys, the Personal Opioid-Overdose Risk Survey and the Opioid Overdose and Treatment Awareness Survey (OOTAS). Those in the intervention group received the standard education as well as the phone call. All patients received a naloxone nasal spray kit.

Peer counselors were enrolled in a medication treatment program for at least a year; had not used opioids for at least a year; and had experienced, witnessed, or lost a family member or friend to an overdose. They completed practice calls as part of their training, and they were required to score at least 90% on the OOTAS. All told, training and certification as a peer counselor took four hours. During the phone call with the patient, the peer counselor discussed medication treatment and answered the patient’s questions. The peer counselors were provided with guidelines for the calls, but the calls were not scripted.

At 12-month follow-up, 32.5% of patients who had received a call had begun medication treatment for opioid use disorder, compared with 17.5% of those who did not receive a call. Those who had received a call also had a lower rate of opioid overdose, 12.5% compared with 32.5% among those who had not received a call. However, there were no significant differences between opioid use between the groups, as shown by urine drug screenings conducted at different points throughout the 12 months.

“In the current era of COVID-19, it is notable that this intervention was designed to be implemented by phone, thus eliminating the need for in-person contact,” the researchers wrote. “[T]he results from this randomized pilot trial suggest that a brief, telephone-delivered intervention has promise for increasing [medication for opioid use disorder] enrollment and decreasing recurring opioid overdoses in individuals surviving an opioid overdose. Further development and testing of this … intervention, particularly in light of the current U.S. opioid epidemic, seems warranted.”

For related information, see the Psychiatric News article “SAMHSA Issues Guidance on OUD Treatment During COVID-19.”

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Risk of Type 2 Diabetes Among Youth Who Initiate SSRI Treatment Found to Be Small

Children and adolescents who initiate treatment with selective serotonin reuptake inhibitors (SSRIs) may have a small increased risk of developing type 2 diabetes, particularly if they are publicly insured, according to a study published Wednesday in JAMA Psychiatry.

“The magnitude of association was more modest than previously reported, and the absolute risk was small,” wrote Jenny Sun, Ph.D., and Sonia Hernández-Díaz, M.D., Dr.P.H., of the Harvard T.H. Chan School of Public Health and colleagues. “This potential risk, which is much lower in magnitude than the other known risk factors for [type 2 diabetes], should be weighed against the known benefits and risks of SSRI treatment to help inform treatment decision-making in the pediatric population.”

Researchers used U.S. claims data on more than 1.5 million patients from two databases. The Medicaid Analytic eXtract (MAX) database included information from 2000 to 2014 of patients enrolled in Medicaid and the Children’s Health Insurance Program. The IBM MarketScan database consisted of information from 2003 to 2015 of privately insured patients. Patients with evidence of antidepressant use, diabetes-related conditions, pregnancy, hospice care, or serious medical conditions were excluded.

Researchers identified patients aged 10 to 19 with diagnoses commonly treated with SSRIs, such as depression, generalized or social anxiety disorder, panic disorder, or obsessive-compulsive disorder. They compared patients who initiated SSRI treatment with those who had a diagnosis indicating such treatment, but who had not initiated treatment.

In total, 316,178 patients initiated SSRI treatment in the MAX database group, and 211,460 started the treatment in the IBM group. Among publicly insured patients, the rate of type 2 diabetes was 2.32 cases per 1,000 person-years among those patients who initiated SSRI treatment, and 1.65 cases per 1,000 person-years among those patients who did not receive the treatment. The association strengthened with longer treatment periods, corresponding to 6.6 additional cases of type 2 diabetes per 10,000 patients continuously treated for at least two years. There was no meaningful increased risk for type 2 diabetes among privately insured patients.

“The increased risk of [type 2 diabetes] was observed in publicly insured patients, who are of lower socioeconomic status and represent a population with greater overall medical burden, more comorbidities, and a higher prevalence of risk factors for [type 2 diabetes],” the authors wrote. “When making treatment decisions in young patients, this potential small risk of [type 2 diabetes], along with other potential adverse effects of SSRIs such as nausea and sleep disturbances, should be weighed against the benefits of treating pediatric depression and anxiety disorders.”

For more information, see the Psychiatric News article “Exposure to Antipsychotics May Increase Risk of Type 2 Diabetes in Youth.”

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APA Releases Updated Practice Guideline for Treatment of Patients With Schizophrenia

Yesterday, APA released a new evidence-based guideline on treating patients with schizophrenia.

The APA Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, replaces the previous practice guideline released in 2004. It is also the first APA guideline for an entire disorder that uses standards set forth by the Institute of Medicine in 2011 to ensure clinical guidelines meet high standards of transparency and scientific rigor.

As with APA’s previous guidelines, clinical recommendations were made by a diverse group of experts following a systematic evaluation of relevant literature. The expert work group made 24 recommendations spread across the topics of patient assessment and treatment planning, pharmacotherapy, and psychosocial interventions.

For the key first step of patient assessment, the guideline recommends that patients with schizophrenia receive a thorough evaluation, including assessments of a patient’s physical health; cognitive health; their risk of harming themselves or others; and substance use, including nicotine. Afterward, physicians and patients should work together on a comprehensive, person-centered treatment plan that includes evidence-based pharmacological and nonpharmacological treatments.

The guideline reaffirms that patients diagnosed with schizophrenia should be treated with an antipsychotic medication and that patients whose symptoms improve while taking an antipsychotic medication should continue with maintenance antipsychotic treatment. With the exception of clozapine—recommended as the first choice for treatment-resistant schizophrenia, patients with high suicide risk, and patients with a high risk of aggressive behavior—the guideline does not make any recommendations about specific oral or long-acting injectable antipsychotics. The guideline, does, however, include detailed tables with dosing considerations, metabolic properties, and potential side effects of all FDA-approved antipsychotics.

“Although there may be clinically meaningful distinctions in response and tolerability of different antipsychotic medications in an individual patient, there is no definitive evidence that one antipsychotic will have consistently superior efficacy compared with another, with the possible exception of clozapine,” the work group wrote.

Among psychosocial interventions, the guideline strongly recommends that patients receive cognitive-behavioral therapy for psychosis, education about schizophrenia, and supported employment services. The guideline also strongly recommends that patients experiencing their first episode of psychosis are treated in a coordinated specialty care program. If possible, patients should also receive interventions aimed at developing their self-management skills.

All the outlined recommendations “should be made in collaboration with the patient, whenever possible, and should incorporate the patient’s personal and sociocultural preferences and values in order to enhance the therapeutic alliance, adherence to treatment, and treatment outcomes,” the work group wrote.

To read more about this topic, check out APA’s Schizophrenia Resource Center.

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Discrimination May Increase Risk of Severe Alcohol Use in Minorities

Racial and ethnic discrimination may increase the risk that members of minority groups will experience severe alcohol use disorder (AUD), according to a report in Drug and Alcohol Dependence.

“Our findings [should] prompt researchers and practitioners to consider the extent to which systems of oppression can impact the pathogenesis, trajectories, and recoveries (including relapse) of AUD, and how shifting policies and practices can move toward the dismantling of oppression that give rise to illnesses,” wrote Joseph E. Glass, Ph.D., M.S.W., of Kaiser Permanente Washington Health Research Institute and colleagues.

The authors analyzed data from 17,115 racial/ethnic minorities who participated in the National Epidemiological Survey on Alcohol-Related Conditions III (NESARC-III), a national survey that took place in 2012-2013. This included the responses of individuals who identified as American Indian or Alaskan Native; Asian, Native Hawaiian, or Other Pacific Islander; Black or African American; and Hispanic or Latino.

During in-person interviews, participants were evaluated using the AUD and Associated Disabilities Interview Schedule-5. (AUD severity levels were classified as mild, moderate, or severe: endorsing 2−3, 4–5, or ≥6 DSM-5 criteria, respectively.) The participants were also asked how often in the past year they felt they had “experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior” because of their race or ethnicity. Specifically, the participants were asked about discrimination in several situations, including when receiving health care treatment, when applying for housing and jobs, and when interacting with the police.

In comparison with those who did not experience discrimination, those who experienced any discrimination had a 1.5-fold greater risk of mild AUD, a 1.6-fold greater risk of moderate AUD, and a 2.3-fold greater risk of severe AUD. “We found no evidence to suggest that the strength of the association between racial/ethnic discrimination and AUD severity varied across race/ethnic group or poverty status,” the authors noted.

“Strategies to reduce risk for severe AUD should include efforts to minimize the occurrence and impact of interpersonal and institutional racism,” they concluded.

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Help Determine APA’s Future
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 today, September 1.

Access Nomination Requirements and Form