Compliance Dates Extended for Information Blocking, Health IT Certification Requirements in 21st Century Cures Act Final Rule

This past May, the federal Office of the National Coordinator for Health IT (ONC) released a final rule outlining provisions about Interoperability and Information Blocking under the 21st Century Cures Act. The rule details ways in which physicians, software developers, and others are to share patient data electronically. While the original compliance date for the information-blocking provision was set for Monday, November 2, and was subsequently pushed back to Tuesday, February 2, 2021, the ONC has now released an interim final rule outlining new compliance deadlines due to the COVID-19 pandemic. The change is intended to give physicians, payers, software developers, and health systems additional flexibility in adapting technology and practice workflows required by the rule.

These new deadlines push compliance for the information-blocking provision to Monday, April 5, 2021. This will give physicians and hospital systems more time to adapt to the requirements around the new definition of “Electronic Health Information,” information blocking, and the eight exceptions to information blocking detailed in the rule. APA has summarized the requirements of the rule, and that information can be found here. More information about the delayed implementation timeline for information blocking can found in this ONC fact sheet and a press release from the Department of Health and Human Services.

Finally, the ONC also has announced that it will hold a webinar on the delayed implementation of its final rule. The webinar, which will tell you more about what this means for your practice, is scheduled for Monday, November 2, at 3 p.m. ET. Register now.

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Save the date: Update on 2021 Changes to Billing and Documentation for Outpatient E/M Services
Tuesday, November 17, 8 p.m. ET

Join this webinar to learn about the changes to billing and documentation for Outpatient E/M services that will take effect on January 1, 2021. The webinar will include how to select the appropriate CPT code based on medical decision making or time, a review of the necessary documentation, and a Q&A portion with APA’s CPT coding and documentation experts.

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Depression Care Suboptimal for Patients With Comorbid Substance Use Disorders, Study Finds

Patients with co-occurring depression and substance use disorders may be less likely to receive optimal depression treatment than those with depression alone, according to a study published today in AJP in Advance.

“Best practices support providing individuals with depression and substance use disorders treatment for both disorders, with integrated or concurrent treatments to target both disorders simultaneously,” wrote Lara N. Coughlin, Ph.D., of the University of Michigan and colleagues. “[O]ur study … indicates a treatment gap in guideline-concordant depression treatment among those with substance use disorders compared with those without.”

Coughlin and colleagues analyzed data from patients who had received care from the U.S. Veterans Health Administration. Specifically, they focused on veterans diagnosed with a new episode of depression during fiscal year 2017. Patients were categorized as having a comorbid substance use disorder if they had received a substance use disorder diagnosis during the year prior to the depression diagnosis.

Patients who received an antidepressant prescription within 90 days of the depression diagnosis that provided antidepressant medication for at least 84 of the 114 days following the initial prescription were considered by the authors to have received “adequate acute-phase” medication treatment. Those who continued antidepressant medication for 180 of the first 231 days following the initial prescription were considered to have received “adequate continuation-phase” medication treatment. Similarly, the authors examined whether the patients had participated in a psychotherapy session for depression that occurred within 90 days of the index depression diagnosis (acute-phase treatment) and at least three psychotherapy sessions occurring in the 12 weeks following the first therapy session (continuation-phase treatment).

Of the 53,034 patients diagnosed with a new episode of depression during fiscal year 2017, 28,081 (52.9%) of these patients received any antidepressant treatment, and 18,484 (34.9%) received any psychotherapy for depression within 90 days following their diagnosis. Of this cohort, 7,516 (14.2%) had a substance use disorder diagnosis in the year before the depressive disorder diagnosis.

After taking patient demographic and clinical characteristics of the study participants into account, the authors found that “patients with substance use disorders had lower odds of adequate acute-phase treatment (21% and 13% lower for antidepressant and psychotherapy, respectively) and lower odds of adequate continuation of treatment (26% and 19% lower for antidepressant and psychotherapy, respectively) for depression” compared with patients with no substance use disorders.

“Although the magnitude of difference (approximately 20% lower odds) may seem modest, both depression and substance use disorders are highly prevalent, such that even modest differences amount to large numbers of individuals,” they added.

Coughlin and colleagues offered several recommendations to increase optimal depression treatment of patients with co-occurring depression and substance use disorders, including additional training for health care professionals and enhancing integrated care.

For related information, see the Psychiatric Services article “Association Between Quality Measures and Perceptions of Care Among Patients With Substance Use Disorders.”

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Save the date: Update on 2021 Changes to Billing and Documentation for Outpatient E/M Services
Tuesday, November 17, 8 p.m. ET

Join this webinar to learn about the changes to billing and documentation for Outpatient E/M services that will take effect on January 1, 2021. The webinar will include how to select the appropriate CPT code based on medical decision making or time, a review of the necessary documentation, and a Q&A portion with APA’s CPT coding and documentation experts.

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Women May Continue to Experience Symptoms of Postpartum Depression 3 Years After Giving Birth

Some women may continue to experience depressive symptoms up to three years after having a baby, according to a study published Wednesday in Pediatrics. The risk appears to be higher for women who have a history of depression and/or gestational diabetes.

The findings suggest that primary care physicians should assess postpartum mothers more regularly and for a more extended period than has been previously recommended. The American Academy of Pediatrics (AAP) currently recommends that primary care pediatricians screen mothers for depression at children’s one-, two-, four-, and six-month well visits.

“Assessing mothers multiple times early and late in the postpartum period and extending the postpartum period to at least two years after birth would provide a clearer picture of mothers whose symptoms are persisting or increasing, and mothers who had not already sought treatment could be connected with resources,” wrote Diane L. Putnick, Ph.D., of the Eunice Kennedy Shriver National Institute of Child Health and Human Development and colleagues.

The researchers analyzed data on 4,866 mothers in the UpState Kids Study, a population-based birth cohort study conducted between 2008 and 2010 to evaluate the impact of infertility treatment on child growth and development up to age 3. Maternal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS-5), when the children were 4, 12, 24, and 36 months of age.

Putnick and colleagues looked at the following four groups of mothers with varying trajectories of depression:

• persistently low levels of depression at all four assessments
• low levels of depression at 4-month assessment that increased over time
• high levels of depression at 4- and 12-month assessments that decreased over time
• persistently high levels of depression at all four assessments

A total of 218 (4.5%) of the women had persistently high levels of depressive symptoms, while 398 (8.2%) had low levels of depressive symptoms that increased over time; 613 women (12.6%) had high levels of depressive symptoms at four months that decreased over time.

Together, 25.3% of the study sample had elevated depressive symptoms at some point during the three-year postpartum period. Younger mothers, those who did not have a college degree, and those with a history of depression and/or gestational diabetes appeared to be at highest risk for persistently higher symptoms of depression.

“Routine well-child visits may need to be extended for pediatricians to have the time to assess the mother’s mental health and risk factors, in addition to the child’s health and development,” the researchers wrote. “Mothers’ mental health is critical to child well-being and development.”

For related information, see the Psychiatric News article “Pandemic Has Compromised Mental Health of New Moms.”

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Prescribing of Antipsychotics to Young Children Is Declining, Study Suggests

The percentage of young children with private insurance who were prescribed antipsychotics declined from 2009 to 2017, according to a study published in the Journal of the American Academy of Child and Adolescent Psychiatry. This decline “may reflect a trend towards more cautious prescribing,” wrote Greta A. Bushnell, Ph.D., of Rutgers School of Public Health and colleagues.

While several antipsychotics have been approved by the FDA for use in children with schizophrenia, bipolar disorder, and tic disorders, the number of off-label antipsychotic prescriptions to treat conduct disorder, attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression in children began to climb in the late 1990s, noted Bushnell and colleagues. As these numbers grew, concerns mounted over the unknown developmental and other long-term adverse effects of antipsychotics on young children. Several efforts have since been made to curtail inappropriate antipsychotic prescribing to young people, including peer review prior authorization before atypical antipsychotics can be prescribed to young children insured by Medicaid.

For the current study, the authors examined trends in antipsychotic prescribing to children aged 2 to 7 years who were privately insured, as recorded in a commercial claims database. The authors specifically focused on children who received prescriptions for first- and second-generation antipsychotics from 2007 through 2017. To estimate annual antipsychotic use, the researchers divided the number of children who were dispensed at least one antipsychotic medication during each study year by the total number enrolled with prescription coverage in July of that year.

There were 301,311 antipsychotic prescriptions filled for children aged 2 to 7 between 2007 and 2017. The authors found that prescription antipsychotic use grew from 0.27% (27 per 10,000 children) in 2007 to 0.29% in 2009, before dropping to 0.17% in 2017—a decline of 0.017% per year. Antipsychotic use was highest in boys aged 6 to 7 years, rising from 2007 (0.85%) to a peak in 2009 (1.01%) and declining through 2017 (0.59%). In girls aged 6 to 7 years, antipsychotic use was 0.27% in 2007, peaked at 0.30% in 2009, and declined to 0.18%.

“Despite these encouraging trends, however, much antipsychotic use in young children continues to take place in children diagnosed only with conditions lacking effectiveness and safety data,” the authors noted. The most common diagnoses among children prescribed antipsychotics were pervasive developmental disorder, including intellectual disabilities; conduct or disruptive disorder; and ADHD.

“Guidelines recommend careful assessment before children initiate antipsychotics and recommend psychosocial services before antipsychotic treatment or combining pharmacological and psychosocial treatments when possible. Yet, fewer than half of young children receiving antipsychotic treatment had a visit with a psychiatrist or a psychotherapy claim, a finding consistent with reports in privately insured children from a decade earlier,” the authors added. “These findings, and the remaining substantial number of children treated with antipsychotics who do not receive psychosocial mental health interventions, suggest that there remains room for improvement in the community treatment of young children with antipsychotic medications.”

For related news, see the Psychiatric Services article “Designing Safer Use of Antipsychotics Among Youths: A Human-Centered Approach to an Algorithm-Based Solution.”

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Flexible Assertive Community Treatment Shows Promise for Patients With SMI

A model of assertive community treatment that provides flexible, multidisciplinary support to people with serious mental illness (SMI) in crisis may be able to reduce the number of times these patients are hospitalized, suggests a study by Danish researchers in Lancet Psychiatry. The flexible treatment model did not impact total time patients spent in hospitals, however.

Community-based approaches for people with SMI in Denmark typically involve two tracks: frequent outreach, including home visits, by assertive community treatment (ACT) teams to patients with the most serious mental illness or less frequent contact between stabilized patients and members of community mental health teams (CMHT). Flexible assertive community treatment (FACT) was designed as a team-based approach that could adjust the intensity of care quickly depending on the patient’s status.

Camilla Munch Nielsen, M.P.H., of Copenhagen University Hospital and colleagues compared the mental health outcomes of 887 CMHT patients and 130 ACT patients who were transitioned to FACT teams with 1,210 patients who continued with CMHT and 333 patients who continued with ACT, respectively. Participants were followed for two years, and outcomes included the frequency of outpatient visits, number of inpatient admissions, total bed days, the use of coercive measures in hospitals, self-harm attempts, and death by any cause.

The researchers found that outpatient contacts were about 15% higher for those patients who received FACT compared with their respective control groups. In addition, patients who transitioned from CMHT to FACT had 16% fewer hospital admissions than those who remained in CMHT, while patients who transitioned from ACT to FACT had 29% fewer hospital admissions than those who remained in ACT. There were no statistically significant differences in any of the other four outcomes assessed.

“The relative costs and benefits of the FACT model need to be evaluated, particularly considering that our results suggest that its implementation might facilitate more intensive support to be delivered but no reduction in psychiatric bed days,” Nielsen and colleagues wrote. “Furthermore, we recommend that ongoing research consider clinical outcomes such as functional or symptomatic outcomes, quality of life, and patient satisfaction.”

For related information, see the Psychiatric Services report “Association Between Hospitalization and Delivery of Assisted Outpatient Treatment With and Without Assertive Community Treatment.”

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Americans Report Increasing Rates of Anxiety, APA Poll Finds

Sixty-two percent of Americans reported feeling more anxious this year compared with last year, according to a public opinion poll released this week by APA. In the past three years, between 32% and 39% reported feeling more anxious compared with the year prior.

“It’s not surprising that more Americans are anxious, given the circumstances we all find ourselves in this year,” APA President Jeffrey Geller, M.D., M.P.H., said in a news release. “However, given the huge jump in anxiety, coupled with the impact the pandemic is having on those who were already living with mental illness or substance use disorders, the most important thing that we can do as a country is to invest in our mental health system.”

The APA-sponsored poll was conducted September 14 to 16 through an online survey of a demographically representative U.S. sample of 1,004 adults aged 18 or older. The survey has a margin of error of +/- 3.1 percentage points.

Some of the top causes of anxiety that respondents reported included keeping themselves or their families safe (80%), COVID-19 (75%), gun violence (73%), and the 2020 presidential election (72%). Compared with a APA poll in March on COVID-19 and mental health, there was little change in the percentage of respondents reporting that the COVID-19 pandemic has had a serious impact on their mental health (36% in March vs. 37% in September).

Fifty-seven percent of respondents reported that they were more anxious about the outcome of the presidential election than prior election years, and 61% indicated that the impact of politics on their daily lives was making them extremely or somewhat anxious.

The poll also showed that 67% of Americans are somewhat or extremely anxious about the impact of climate change on the planet, and more than half were somewhat or extremely anxious about the impact of climate change on their own mental health.

The poll also asked respondents about the impacts of racism on mental health: 76% strongly or somewhat agreed that systemic racism impacts the mental health of Americans, especially people of color.

“The impact of structural inequities on the mental health of the Black community is far reaching, and each of us as psychiatrists has a vital role to play in tackling these issues,” Geller said. “On a basic level, we must continue to strive to diversify the ranks of our profession and provide culturally responsive care to our patients.”

Regarding gun violence, 83% of respondents agreed that gun violence represents a public health threat, while 78% said Congress should do more to address gun violence, including violence from mass shootings.

For related information, see the Psychiatric News article “COVID-19 Pandemic is Taking MH Toll, Finds APA Poll.”

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How Does Racism Impact Your Practice? APA Task Force Survey Closes Today

The APA Presidential Task Force on Structural Racism Throughout Psychiatry is fielding a short survey on the impacts of racism on psychiatric practice. Help inform the task force’s important work and share your thoughts by the end of the day today, Friday, October 23. Learn more about the task force and view the results of its previous two surveys on the task force webpage.

TAKE SURVEY

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Candidates for APA's 2021 Election Announced

The APA Nominating Committee, chaired by Immediate Past President Bruce Schwartz, M.D., has reported the following slate of candidates (in alphabetical order) for APA’s 2021 election. This slate is considered official and approved by the Board of Trustees.

The deadline for candidates who wish to run by petition is November 10. All candidates and their supporters are encouraged to review the updated Election Guidelines. Candidates’ photos and the addresses of their personal websites will be published in the December 18 issue of Psychiatric News. APA voting members may cast their ballots from January 4 to February 1, 2021.

For more election information, please visit the Election section of the APA website.

President-Elect
Rebecca W. Brendel, M.D., J.D.
Jacqueline Maus Feldman, M.D.

Secretary
Rahn K. Bailey, M.D.
Sandra M. DeJong, M.D., M.Sc.

Early Career Psychiatrist Trustee
Elie Aoun, M.D.
Tanuja Gandhi, M.D.
Abhisek Chandan Khandai, M.D., M.S.
Lan Chi Le Vo, M.D.

Minority/Underrepresented Representative Trustee
Oscar E. Perez, M.D.
Felix Torres, M.D., M.B.A.

Area 1 Trustee
Eric M. Plakun, M.D.
Maureen Sayres Van Niel, M.D.

Area 4 Trustee
To Be Announced

Area 7 Trustee
Annette M. Matthews, M.D.
Mary Hasbah Roessel, M.D.

Resident-Fellow Member Trustee-Elect
Souparno Mitra, M.D.
Lindsay M. Poplinski, D.O.
Urooj Yazdani, M.D.

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COVID-19 Pandemic Presents ‘Urgent Opportunity’ to Implement Suicide Prevention Strategies

While the COVID-19 pandemic has increased the risks associated with suicide, actionable steps can be taken now by key players to mitigate these risks, wrote Christine Moutier, M.D., of the American Foundation for Suicide Prevention, in a column in JAMA Psychiatry.

“[O]utcomes related to suicide will be greatly influenced by investments and actions taken now and in the coming months on the part of policymakers, health care and community leaders, and citizens,” she wrote. “This is a moment in history when suicide prevention must be prioritized as a serious public health concern.”

Moutier outlined factors that increase the risk of suicide due to the pandemic and strategies for mitigating these risks that fall into eight broad categories:

• Mental illness—The federal government should invest now and after the COVID-19 pandemic ends in increasing access to mental health care, including ensuring telemental health services are continued and strengthened.
• Isolation, loneliness, and bereavement—Health care systems, hospitals, and clinics should provide caring contacts and virtual check-ins for people living alone. Community leaders should expand community-level services for elderly individuals, people living alone, and any other marginalized people.
• Acute suicidal crisis—The federal government should increase investment in crisis services, such as the three-digit 988 National Suicide Prevention Lifeline in the United States. Communities should work to reform the current crisis response system to move away from a punitive response to mental health crises.
• Access to means—Mental and public health experts can engage in suicide prevention education efforts with gun owners. Health care professionals can be trained in Counseling on Access to Lethal Means (CALM), and advocacy organizations can launch advertising campaigns to make home environments safer for at-risk family members.
• Alcohol consumption—Federal, state, and local governments should launch public messaging regarding safe drinking and mental health and crisis services and foster partnerships between alcohol distilleries/distributors and suicide prevention organizations.
• Financial stressors—Federal and state governments can target safety-net resources for populations with disproportionate financial and health effects of COVID-19 and provide unemployment support and retraining opportunities.
• Domestic violence—Communities should widely promote access to support services for victims of domestic violence. One example is the National Domestic Violence Hotline and the Crisis Text Line.
• Irresponsible media reporting—Reporters and other media professionals should keep messages focused on suicide as a preventable cause of death and promote resources for help and support.

“If specific strategies can be maximally implemented with COVID-19–specific threats to population mental health and suicide risk in mind, this pandemic may not only provide a sense of urgency, but a path forward to address suicide risk at national and community levels,” Moutier concluded.

For related information, see the Psychiatric News article “Experts Warn Efforts to Contain COVID-19 May Increase Suicide Risk.”

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Study Identifies Predictors of Treatment-Resistant Schizophrenia, Clozapine-Resistant Schizophrenia

A study out of Hong Kong that tracked patients with first-episode psychosis over a 12-year period points to several characteristics of patients that may predict those most likely to develop treatment-resistant schizophrenia. As described in the report in Schizophrenia Bulletin, such characteristics include age, duration of untreated symptoms, and social function.

“Specific interventions including relapse prevention and early initiation of clozapine during the early course of illness may reduce the rate of [treatment-resistant schizophrenia] and improve patient outcomes,” wrote Sherry Kit Wa Chan, M.B.B.S., of the University of Hong Kong and colleagues.

Using a hospital database in Hong Kong, the researchers identified 617 patients with a diagnosis of first-episode schizophrenia-spectrum disorders enrolled in early intervention services. These patients were matched by sex, diagnosis, and age with 617 patients with first-episode psychosis who had received standard care services. Outcomes in these patients were tracked for 12 years.

Patients were considered to have treatment-resistant schizophrenia if they met the following criteria: scored ≥4 on any Positive and Negative Syndrome Scale for Schizophrenia (PANSS) positive symptom item for at least 12 weeks with a moderate functioning impairment (Social and Occupational Functioning Assessment Scale <60) and had a history of at least two trials of antipsychotics above a chlorpromazine equivalent dose of at least 600 mg/d for at least six weeks. Patients were considered to have clozapine-resistant treatment-resistant schizophrenia if they had taken clozapine (350 mg/d) for at least six weeks and continued to score ≥4 on the Clinical Global Impressions Schizophrenia scale and had any PANSS positive symptom item scored ≥4 for at least 12 weeks.

Of the 1,234 patients with first-episode schizophrenia-spectrum disorders followed for 12 years, 13% had been prescribed clozapine, and 15% had treatment-resistant schizophrenia.

An analysis of data on 450 patients—including 157 with treatment-resistant schizophrenia and 293 without treatment-resistant schizophrenia—revealed several differences between these two groups: “Patients with younger age of onset, poorer premorbid social adjustment during adulthood, longer duration of first episode, a greater number of relapses, and a higher level of [daily defined dose] of antipsychotic medication in the first 24 months had an increased risk of developing TRS [treatment-resistant schizophrenia] earlier,” the authors reported.

“Among the TRS patients prescribed clozapine, 25% were clozapine resistant (CR-TRS). The CR-TRS patients had a poorer premorbid social adjustment in late adolescence and longer delay of clozapine initiation compared with non-CR-TRS. CR-TRS had poorer clinical and functional outcomes at 12-year follow-up. Significantly more non-TRS patients died from suicide compared with patients prescribed with clozapine.”

The researchers noted that although the development of treatment-resistant schizophrenia was similar in patients who had received early intervention services and standard care, patients in early intervention services were started on clozapine sooner than those patients in standard care.

For related information, see the Psychiatric News article “More Studies on Duration of Untreated Psychosis Needed.”

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Large Genetic Alzheimer’s Study of African American Individuals Uncovers Differences in Risk Factors From Whites

In a large analysis of nearly 8,000 African American genome samples, researchers have uncovered more than two dozen genetic variants associated with the risk of Alzheimer’s. The findings were published today in JAMA Neurology.

Most of these variants were linked with biological processes already implicated in the development of Alzheimer’s—such as the immune response and fat metabolism—noted Brian W. Kunkle, Ph.D., M.P.H., of the University of Miami Miller School of Medicine and colleagues. However, the variants themselves were different from those previously identified in White individuals. Additionally, the analysis pointed to a possible relationship between the kidney system and Alzheimer’s in African American individuals.  

The findings suggest that while the molecular pathways implicated in the development of Alzheimer’s disease in African Americans are similar to those in Whites, the variants influencing these pathways may differ, the authors noted. 

Kunkle and colleagues analyzed genome data from 2,748 African American individuals with Alzheimer’s disease and 5,222 African American individuals without Alzheimer’s disease to look for variants associated with disease risk. Their analysis confirmed the relationship between several genetic variants and Alzheimer’s found in smaller studies, but also found nearly 20 new genetic Alzheimer’s links—most of which have not been implicated in White individuals. 

Of the eight biological pathways implicated by these new variants in African American individuals, seven have been previously implicated in genetic studies of White individuals. The novel pathway implicated in African American individuals was kidney system development. Interestingly, variants associated with the production of amyloid and tau proteins—which have been found in genome studies of White individuals—were not identified in this study. 

While Kunkle and colleagues noted that while additional research is needed, the findings “significantly help to disentangle [Alzheimer’s disease] etiology in African American individuals, aid to clarify the molecular mechanisms underlying observed health disparities, and help to pinpoint molecular targets for therapeutic intervention in this ethnic group.”

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Preterm Birth Linked to Childhood Depression

Preterm birth before 28 weeks of gestation may be linked to childhood depression, suggests a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

Subina Upadhyaya, M.P.H., and colleagues at the University of Turku in Finland analyzed data from several large Finnish health care databases to identify 37,682 cases of childhood depression in people born between January 1987 and December 2007. These patients were diagnosed before December 2012, when they were at least 5 years old. The researchers then matched these patients with 148,795 control patients without childhood depression.

Compared with patients born at full term, the odds of developing childhood depression were 89% higher in those who were born at 25 weeks of gestation or less, 162% higher in those born at 26 weeks of gestation, and 93% higher in those born at 27 weeks of gestation.

“The potential mechanisms underlying depression in extremely preterm children and adolescents may be related to the causes of preterm birth, including genetic predispositions, pathologies during pregnancy, immature brain development in infants born extremely preterm, and psychosocial risks related to the postnatal hospital environment and later growth environment of preterm infants,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “Prenatal Primary Prevention of Mental Illness by Micronutrient Supplements in Pregnancy.”

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How Does Racism Impact Your Practice? APA Task Force Wants to Know

The APA Presidential Task Force on Structural Racism Throughout Psychiatry is fielding a new short survey on the impacts of racism on psychiatric practice. Help inform the task force’s important work and share your thoughts by Friday, October 23. Learn more about the task force and view the results of its previous two surveys on the task force webpage.

TAKE SURVEY

Psychotherapy Combined With Medication May Prevent Recurrence in Patients With Bipolar Disorder

When combined with pharmacotherapy, manualized psychosocial interventions were associated with a lower risk of illness recurrence in patients with bipolar disorder compared with pharmacotherapy alone, a meta-analysis in JAMA Psychiatry found.

“There is increasing recognition that pharmacotherapy alone cannot prevent recurrences of bipolar disorder or fully alleviate post-episode symptoms or functional impairment,” wrote David J. Miklowitz, Ph.D., of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues.

Miklowitz and colleagues identified 39 randomized clinical trials involving 3,863 participants aged 12 years or older with bipolar disorder in which psychotherapy combined with pharmacotherapy was compared with treatment as usual (defined as pharmacotherapy with routine monitoring visits). The primary outcome was episode recurrence of any type—depressed, manic, or mixed—among participants in the first 12 months after the trial began.

“In our analysis, family therapy [cognitive-behavioral therapy], and group psychoeducation—all modalities that include patients as active participants—were associated with significantly improved outcomes compared with [treatment as usual] with regard to recurrence prevention and depression stabilization,” the authors wrote.

Additionally, the authors found that psychoeducation interventions with guided practices of illness management skills in a family or group format were associated with reduced illness recurrences compared with the same strategies in an individual format. Cognitive-behavioral therapy, family or group therapy, and interpersonal therapy were associated with stabilizing depressive symptoms compared with treatment as usual. 

“What do our findings suggest about treating outpatients with bipolar disorder? When the goals center on prevention of recurrences, patients should be engaged in family or group psychoeducation with guided skills training and active tasks to enhance coping skills (e.g., monitoring and managing prodromal symptoms) rather than being passive recipients of didactic education,” they wrote.

“Miklowitz and colleagues’ contribution may further serve as a call to action to enhance availability and uptake of these treatments in the community,” wrote Tina R. Goldstein, Ph.D., and Danella M. Hafeman, M.D., Ph.D., of the University of Pittsburgh School of Medicine in an accompanying editorial. “Unfortunately, data suggest substantially lower rates of psychotherapy receipt (26%-50%) compared with medication management (46%-90%) among adults with [bipolar disorder].”

For related information, see the Psychiatric News article “Antipsychotics Increasingly Prescribed for Bipolar Disorder.”

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Overwhelming Second Wave of Psychiatric Disorders Expected Due to Pandemic

Even as public health experts warn of a new tide of COVID-19 cases and deaths, another “second wave” is building in the form of mental and substance use disorders associated with social isolation, economic insecurity, and loss of family and community supports, cautioned Naomi M. Simon, M.D., M.Sc., director of the Anxiety and Complicated Grief Program at the NYU Grossman School of Medicine, and colleagues in an article published Monday in JAMA.

They especially emphasized the risk of psychiatric disorders related to grief from the loss of loved ones. “This interpersonal loss at a massive scale is compounded by societal disruption,” they wrote. “The necessary social distancing and quarantine measures implemented as mitigation strategies have significantly amplified emotional turmoil by substantially changing the social fabric by which individuals, families, communities, and nations cope with tragedy.”

The piece accompanied another report in the journal on the number of excess deaths in the United States between February and August attributed to COVID-19.

Simon and colleagues wrote that in the wake of so much death related to the pandemic—and in the absence of normal social, cultural, and religious connections and rituals for coping with grief—survivors are at risk of prolonged grief disorder, major depressive disorder, and posttraumatic stress disorder. 

“This imminent mental health surge will bring further challenges for individuals, families, and communities including increased deaths from suicide and drug overdoses,” they wrote.

To cope with the coming tsunami of psychiatric disorders, Simon and colleagues called for a three-pronged public health strategy of screening, mental health risk assessment, and treatment for those at highest risk for prolonged grief and posttraumatic stress.

Crucial to prevention is rebuilding forms of social and community support. “Clinicians can help bereaved families find creative ways to safely honor traditions, memorialize the deceased, and improve social support,” they wrote. “Public health campaigns and public policy initiatives could be created to support the implementation of these preventive strategies.”

They concluded: “A second wave of devastation is imminent, attributable to mental health consequences of COVID-19. The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations.”

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

Suicidal Thoughts Elevated Among Depressed Patients Reporting Anger Attacks

People with major depressive disorder (MDD) who often experience sudden bouts of anger—also known as anger attacks—may have elevated levels of suicidal ideation compared with those who do not experience anger attacks, suggests a study in Depression & Anxiety.

“While patients with anger attacks typically experience improvement with antidepressants, previous reports have found new‐onset anger attacks in a small minority of patients,” wrote Manish Kumar Jha, M.D., of the Icahn School of Medicine at Mount Sinai and colleagues. “Thus, there is an urgent need to develop treatment strategies that specifically target anger attacks.”

Jha and colleagues analyzed data from the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study. EMBARC was a 16-week randomized, controlled trial that compared the responses of patients aged 18 to 65 with MDD who took sertraline and/or bupropion with those who took placebo.

The researchers specifically focused their analysis on 293 participants who completed the Massachusetts General Hospital Anger Attack Questionnaire (AAQ) at the start of the EMBARC trial. Through the AAQ, patients reported experiences with anger attacks, including how often the attacks occurred in the past month, physical symptoms that accompanied such attacks (for example, dizziness, shortness of breath, and trembling), and whether the attacks led to aggressive behavior (for example, physically or verbally attacking others). As part of the trial, the participants were also asked weekly whether or not they agreed with the following statements: “I have been having thoughts of killing myself,” “I have thoughts about how I might kill myself,” and “I have a plan to kill myself.”

At baseline, 37.2% of the participants reported anger attacks within the past six months. Aggressive behaviors were reported by 32.8%. Levels of suicidal ideation were found to be significantly higher in MDD participants with anger attacks than those with MDD with no anger attacks. Specifically, participants who reported experiencing nine or more anger attacks in the previous month reported significantly higher suicidal ideation at baseline than those who reported fewer anger attacks. Participants who reported anger attacks at baseline continued to report higher suicidal ideation while taking antidepressants, the authors reported.

“These associations between anger attacks and [suicidal ideation] were significant even after controlling for related constructs such as irritability and hostility or other features associated with [suicidal ideation] such as depression, anxiety, previous history of suicidal tendencies, pain, and hopelessness. Similar findings were noted for the presence of aggressive behaviors,” Jha and colleagues wrote. “Taken together, these findings suggest that the presence of anger attacks may identify a subgroup of depressed patients with persistently elevated [suicidal ideation].”

For related information, see the Psychiatric News article “The Role of C-L Psychiatrists in Assessing Suicide.”

(Image: iStock/Chinnapong)

Most Parents Support Depression Screening in Middle School

Most parents support school-based depression screening starting in middle school, a study in the Journal of Adolescent Health suggests.

Deepa L. Sekhar, M.D., M.Sc., of Penn State College of Medicine and colleagues analyzed the responses of 770 parents who participated in the University of Michigan’s C.S. Mott Children’s Hospital National Poll on Children’s Health, a cross-sectional Internet-based survey about child health topics. The parents all had children in either middle or high school.

When asked whether their children’s school should screen all students for depression, 70.5% said either “definitely yes” or “probably yes,” and the remaining 29.5% said “probably no” or “definitely no.” Nearly 47% said screenings should begin in sixth grade, and just over 15% said screenings should begin in seventh grade. The researchers wrote that these responses suggest a “desire for further support in recognizing adolescent depression and the need for additional services that begin in the middle school years.” They also noted that the majority preference for beginning screening in middle school is consistent with the U.S. Preventive Services Task Force recommendations for screening for depression in children and adolescents.

More than 93% of parents said that a child’s parents should be informed if the child has signs of depression, and about 3% felt the child should decide whether the parents are informed. However, more than 47% of parents did not know whether their children’s school currently provides mental health services for students.

“This suggests a lack in parent understanding of how schools will handle screening results and the availability of mental health resources, or perhaps highlights parent expectation to directly manage results,” the researchers wrote.

For related information, see the Psychiatric News article “New Primary Care Guidelines Recommend Routine Screening for Depression in Adolescents.”

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How Does Racism Impact Your Practice? APA Task Force Wants to Know

The APA Presidential Task Force on Structural Racism Throughout Psychiatry is fielding a new short survey on the impacts of racism on psychiatric practice. Help the Task Force inform its important work and share your thoughts by October 23. Learn more about the Task Force and view the results of its previous two surveys on the Task Force webpage.

TAKE SURVEY

New App Helps People With Serious Mental Illness Develop a Crisis Plan

APA on Wednesday announced the release of My Mental Health Crisis Plan, a mobile app that allows people with serious mental illness (SMI) to create a plan to inform their treatment should they experience a mental health crisis.

Through the app, users can easily create and share a psychiatric advance directive (PAD), a legal document that outlines one’s preferences around treatment during a crisis. Informational videos in the app explain to users what PADs are and how they work. The app also includes state-specific requirements, such as signatures or witnesses, for completing the PAD.

The app was developed by SMI Adviser, an APA initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). It is available in the Apple App Store and Google Play.

“A psychiatric advance directive is an important tool for individuals with serious mental illness to be able to plan ahead and have some control over their treatment at a time when they may not be able to make decisions,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a news release. “We are pleased to partner with SAMHSA in creating this important technological tool for people with serious mental illness.”

The app allows users to clearly state their preferences for care, as well as designate a person to make decisions on their behalf in the event of a crisis. They can also choose what hospitals, physicians, and medications they prefer. Additionally, they can note who should be notified about their admission into a psychiatric hospital, and who should care for their children if they are unable to do so.

“During a mental health crisis, you may not be able to think clearly, or you may be confused,” the app’s informational video explains. “A PAD is a way to plan ahead in case of a crisis. … In short, a PAD allows you to be an active part of your treatment even when you are not well...”

For related information, see the Psychiatric News article “SMI Adviser Smartphone App Delivers Expert Guidance With Just a Few Taps.”

Psychiatrists Can Now Apply for COVID-19 Provider Relief Funding

The Department of Health and Human Services (HHS) has announced $20 billion in new funding for an expanded group of behavioral health providers, including psychiatrists, in the third round of distributions from the CARES Act Provider Relief Fund. HHS is encouraging providers to apply as soon as possible for the funds.

Providers who have previously received a payment under phase 1 or phase 2 of the General Distribution are eligible to apply for a payment even if they have previously received a disbursement of 2% of annual revenue from patient care. Providers who have not previously received a General Distribution payment, such as psychiatrists whether or not they take insurance, may also apply for funds.

“Our behavioral health providers have shouldered the burden of responding and confronting this expanded challenge [of mental health needs] triggered by the pandemic,” stated an HHS press release announcing the Phase 3 General Distribution. “When traditional face-to-face counseling was restricted and new telehealth flexibilities were put in place in response to the pandemic, many behavioral health providers invested in and adopted telehealth technologies to continue providing patient care.”

According to the release, HHS has already issued over $100 billion in relief funding to providers through in prior distributions. The Phase 3 General Distribution will include funds for providers who previously received, rejected, or accepted a General Distribution Provider Relief Fund payment; as well as those who were previously ineligible, such as psychiatrists, whether or not they bill insurance, and providers who began practicing in 2020.

Funding for the Phase 3 General Distribution was made possible through the bipartisan Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act, which allocated $175 billion in relief funds to hospitals and other health care providers. Providers have until November 6 to apply for Phase 3 General Distribution funding.

Information about the Provider Relief Fund and how to apply is available on the APA website, which also includes a link to an Application and Attestation Portal for physicians who want to apply for funds.

Escalating Financial Incentives May Increase Antidepressant Adherence, Pilot Study Shows

Offering increasing financial incentives to patients recently prescribed antidepressants may increase the likelihood they take the medication as prescribed, suggests a report in JAMA Psychiatry. The pilot study also found patients who received the financial incentives over six weeks were more likely to report improvements in depression symptoms compared with those who received antidepressants only.

For the study, Steven C. Marcus, Ph.D., of the University of Pennsylvania School of Social Policy and Practice and colleagues enrolled 120 patients aged 21 to 64 with depression (Patient Health Questionnaire-9 [PHQ-9] score of 10 or above) who had received a prescription for an antidepressant from a primary care provider in the past 10 days. (Patients diagnosed with substance use disorder, schizophrenia, bipolar disorder, and/or who were pregnant were excluded from the study.) The researchers then randomly assigned the participants to one of three groups: (1) usual care, (2) usual care and escalating daily financial incentives ($2/day, increasing by $1/week up to $7/day), or (3) usual care and deescalating financial incentives ($7/day, decreasing to $2/day) for each antidepressant-adherent day.

Marcus and colleagues monitored the participants’ daily antidepressant adherence using smart pill bottles, and participants assigned to the two financial incentive groups received weekly credits to a debit card and text notifications. The participants’ depression symptoms were evaluated at the start of the study and again six weeks after they began taking antidepressants. Depression response was defined as a ≥50% decrease in PHQ-9 score from initial screening and depression remission was defined as a PHQ-9 score of <5.

At six weeks, participants in the group assigned to escalating financial incentives were more likely to be adherent than participants in the control group (mean adherence, 90.7% vs. 74.9%). Additionally, participants in the escalating group were significantly more likely than those in the control group to experience depression response (65% vs. 40%) and remission (35.0% vs. 8.6%). Participants in the group assigned to deescalating financial incentives were also more likely than controls to experience symptom response (63.2%) and remission (26.3%) than controls, but they did not have significantly greater adherence.

“Although antidepressant medications are efficacious for depression, nonadherence frequently undermines their effectiveness,” the authors wrote. “Future research should include evaluations of financial incentives powered to ascertain sustainability of antidepressant adherence and symptom improvement,” they concluded.

For related information, see the Psychiatric Services article “Use of Behavioral Economics to Improve Medication Adherence in Severe Mental Illness.”

(Image: iStock/Mladen Zivkovic)

History of Psychiatric Illness May Increase Risk of Death From COVID-19

Patients hospitalized for COVID-19 who have previously been diagnosed with a psychiatric disorder may be at higher risk of death than patients without a history of a psychiatric disorder, suggests an analysis in JAMA Network Open.

Luming Li, M.D., and colleagues at Yale University assessed the outcomes of 1,685 patients who were hospitalized with COVID-19 between February 15 and April 25 in Yale New Haven Health System hospitals. Based on electronic health record data, 28% of these patients had a history of psychiatric illness (this group included those with an active psychiatric condition, those in remission, and those who were in recovery at time of admission for COVID-19).

Overall, 144 of the 473 patients with a psychiatric diagnosis died from COVID-19, compared with 174 deaths among the 1,212 patients with no prior psychiatric diagnosis. Li and colleagues noted that the patients with a psychiatric history were more likely to be older and have a medical comorbidity such as cancer, heart failure, or diabetes. But even after factoring in these differences, patients with a prior psychiatric diagnosis hospitalized for COVID-19 had a 50% greater risk of death compared with patients with no psychiatric history.

“It is unclear why psychiatric illness predisposes to COVID-19–related mortality,” Li and colleagues wrote. “Psychiatric symptoms may arise as a marker of systemic pathophysiologic processes, such as inflammation, that may, in turn, predispose to mortality. Similarly, psychiatric disorders may augment systemic inflammation and compromise the function of the immune system, while psychotropic medications may also be associated with to mortality risk.”

To read more on this topic, see the Psychiatric News article “Psychological Stress May Not Be Only Route Of COVID-19’s Psychiatric Burden.”

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Cardiorespiratory Fitness May Cut Risk of Depressive Symptoms

Adults with good cardiorespiratory fitness—the ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity—have half the risk of developing symptoms of depression, suggests a study in the Journal of Affective Disorders.

Vincenza Gianfredi, M.D., and colleagues at Maastricht University in The Netherlands analyzed data from 1,730 adults aged 40 to 75 years in The Maastricht Study, a large population-based study that focuses on the development, progression, and complications of type 2 diabetes, although not all participants in the study have the condition. The study measured the participants’ cardiorespiratory fitness at baseline through an exercise test on stationary bicycles. The researchers divided the participants into three groups according to whether they had low, medium, or high cardiorespiratory fitness. Participants completed the Patient Health Questionnaire-9 (PHQ-9), which is used to screen for symptoms of depression, at baseline and during annual follow-ups over five years.

During five years of follow-up, 9.6% of the participants developed clinically relevant symptoms of depression (defined by authors as a score of at least 10 on the PHQ-9). When the researchers compared rates of depressive symptoms among the three groups of participants, they found that compared with participants who had low cardiorespiratory fitness, those with medium or high cardiorespiratory fitness had a 50% lower risk of developing depressive symptoms. This reduced risk was independent of the participants’ current exercise levels. Results remained similar when the researchers excluded participants who were taking antidepressants at baseline and participants who had a lifetime history of major depressive disorder.

“In other words, long-term [moderate to vigorous physical activity]-based interventions or other approaches that lead to increased [physical activity] may be effective in preventing depression so far as they also lead to an improvement in [cardiorespiratory fitness],” Gianfredi and colleagues wrote. “Short-term [moderate to vigorous physical activity] or low-intensity [physical activity] may not be sufficient to prevent clinically relevant depressive symptoms.”

For related information, see the Psychiatric News article “Exercise May Offset Genetic Risk for Depression.”

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Alcohol Use Increases During COVID-19 Pandemic, Especially Among Women, Study Suggests

U.S. adults appear to be drinking alcohol more frequently during the COVID-19 pandemic than they were during the same time last year, suggests a study published in JAMA Network Open.

“In addition to a range of negative physical health associations, excessive alcohol use may lead to or worsen existing mental health problems, such as anxiety or depression, which may themselves be increasing during COVID-19,” wrote Michael S. Pollard, Ph.D., of the RAND Corporation and colleagues.

Pollard and colleagues used data from 1,540 adults aged 30 to 80 who completed both waves of a RAND Corporation national survey. The baseline survey took place from April 29 to June 9, 2019, and the second wave of the survey was conducted from May 28 to June 16, 2020. 

The researchers compared the number of days that the participants reported any alcohol use and heavy alcohol use, as well as the average number of drinks consumed over the past 30 days before and during the pandemic. Heavy drinking was defined as five or more drinks for men and four or more drinks for women over a couple of hours. The researchers used the 15-item Short Inventory of Problems (SIP) scale to assess adverse consequences associated with alcohol use within the past three months, asking participants to respond to statements such as “I have taken foolish risks when I have been drinking.”

On average, past month alcohol use increased from 5.48 to 6.22 days among all respondents, a 14% increase from 2019 to 2020. Women’s alcohol consumption appeared to be particularly impacted by the pandemic, the authors noted: Past month alcohol use increased 17% among women, heavy drinking days increased by 41%, and scores on the SIP scale increased by 39%.

“[T]hese results suggest that examination of whether increases in alcohol use persist as the pandemic continues and whether psychological and physical well-being are subsequently affected may be warranted,” the authors wrote.

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

(Image: iStock/alvarez)