Medication Followed by Psychotherapy May Reduce Risk of Depression Relapse/Recurrence

A sequential approach to depression management that starts with medication and then transitions to psychotherapy can reduce the risk of relapse or recurrence, reports a meta-analysis in JAMA Psychiatry.

“A sequential strategy may include maintenance of antidepressant drug treatment or its discontinuation. Thus, the sequential model offers a unique opportunity for antidepressant drug tapering and discontinuation, with the advantage of yielding enduring results while limiting exposure to [antidepressant medications],” wrote Jenny Guidi, Ph.D., of the University of Bologna and Giovanni Fava, M.D., of the University of Buffalo.

Guidi and Fava compiled data from 17 studies (2,283 participants) that assessed the effects of sequential treatment on reducing depression relapse (a return of symptoms after a patient achieves remission) or recurrence (a return of symptoms after a patient achieves full recovery) in adults aged 18 to 65. For this analysis, the authors pooled relapse and recurrence into one category.

The authors focused specifically on studies in which patients were given antidepressant medication first to manage acute symptoms, followed by the addition of face-to-face psychotherapy. All the studies used some variation of cognitive therapy/cognitive-behavioral therapy as the sequential intervention, and most compared sequential psychotherapy with standard clinical care (for example, monitoring the patients and adjusting medications as necessary). The follow-up period ranged from 7 months to 10 years.

The authors found that the sequential model of care reduced the risk of depression relapse/recurrence by about 17% compared with control interventions. The risk of relapse/recurrence was similar for patients who continued antidepressants during psychotherapy or tapered and discontinued antidepressants during the psychotherapy.

For related information, see the Psychiatric News article “Combining CBT With Antidepressant Found to Be Effective Regardless of Order.”

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Older Adults May Be More Resilient During Pandemic Than Younger People

Older adults may be more resilient to the anxiety, depression, and stress-related mental disorders that are being reported by younger adults during the COVID-19 pandemic, according to an article in JAMA.

“[S]tudies from different countries have shown that at least some older adults are not experiencing disproportionately increased negative mental health consequences commensurate with the elevated risks they faced during the first few months of the COVID-19 pandemic,” wrote Ipsit Vahia, M.D., medical director of Geriatric Psychiatry Outpatient Services at McLean Hospital; past APA President Dilip Jeste, M.D., director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego; and Charles Reynolds III, M.D., a professor of psychiatry at the University of Pittsburgh Medical Center.

Vahia and colleagues cited a survey of 5,412 community-dwelling adults conducted by the Centers for Disease Control and Prevention from June 24 to 30. The survey found that compared with younger age groups, the percentage of participants aged 65 years or older with anxiety disorder (6.2%), depressive disorder (5.8%), or trauma- or stress-related disorder (9.2%) was lower. According to the report, of the 731 participants aged 18 through 24 years, 49.1% reported anxiety disorder; 52.3%, depressive disorder; and 46%, trauma- or stress-related disorder. The findings mirror those of other high-income countries, including Spain, Canada, and the Netherlands, they noted.

Vahia and colleagues cautioned that the results are from surveys conducted early in the pandemic, and the longer-term effects of COVID-19, “especially in countries like the U.S. with very high rates of disease, remain unclear.” Moreover, there are no similar data on subgroups of older adults such as those with dementia, those caring for persons with dementia, or those residing in assisted-living facilities or nursing homes. The effect of comorbid chronic medical or psychiatric conditions also remains unclear.

But they noted that older adults may have traits of resilience that have enabled them to withstand the stresses of COVID-19, especially wisdom and a tendency to value the quality of a few close relationships over having many more superficial relationships. The authors noted that several recent studies involving various groups of people across the adult lifespan have shown a significant inverse correlation between loneliness and wisdom; other data also suggest that compassion may reduce loneliness and promote greater well-being.

“Understanding the factors and mechanisms that drive [older people’s] resilience can guide intervention approaches for other older people and for other groups whose mental health may be more severely affected,” the authors concluded.

For related information, see the Psychiatric News article “Interventions That Promote Wisdom May Help Patients With Psychiatric Conditions.”

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Effects of Sertraline-Olanzapine on Weight, Cholesterol May Differ According to Patient Age

Older adults with psychotic depression may experience less weight gain and increases in total cholesterol than younger adults when taking a combination of sertraline and olanzapine over an extended period, suggests a study in the American Journal of Geriatric Psychiatry.

The findings are from the Study Pharmacotherapy of Psychotic Depression II (STOP-PD II). The original STOP-PD trial established that a combination therapy of the antidepressant sertraline plus the antipsychotic olanzapine was more likely to lead to remission of psychotic depression than olanzapine alone over 12 weeks of therapy. STOP-PD II examined the risks and benefits of patients continuing to take sertraline and olanzapine to prevent a relapse of the symptoms. (Eli Lilly provided olanzapine and matching placebo pills and Pfizer provided sertraline; neither company provided funding for this study.)

“Older adults are more likely to experience psychotic features during a major depressive episode than younger adults,” wrote Alastair J. Flint, M.B., of the Department of Psychiatry at the University of Toronto and colleagues. Metabolic disorders, such as diabetes and hyperlipidemia, also increase later in life. “It is therefore important to determine whether there are age-related differences in anthropometric and metabolic outcomes associated with the treatment of psychotic depression with antipsychotic medication,” Flint and colleagues wrote.

They analyzed data from 269 adults aged 18 to 85 years with psychotic depression who were treated with open-label sertraline plus olanzapine for up to 12 weeks (acute phase). A total of 126 participants who remained in remission for eight weeks (stabilization phase) on the sertraline-olanzapine combination were then randomly divided into two groups: one group continued taking the sertraline-olanzapine combination, and the other group was transitioned to a sertraline-placebo combination; the randomized phase was for 36 weeks. The researchers evaluated changes in participants’ weight, waist circumference, plasma lipids, glucose, hemoglobin A1c, and insulin over the course of the study, comparing participants aged 18 to 59 (younger) with those 60 to 85 (older).

While both younger and older participants experienced weight gain and an increase in total cholesterol levels when treated with sertraline-olanzapine versus sertraline-placebo, “the increase in these measures was less in the older group,” Flint and colleagues reported.

“At the acute-stabilization termination visit, mean weight in older participants remained below their mean premorbid weight, whereas it was approximately 18 lb. higher than premorbid weight in younger participants,” they continued. “These findings suggest that the weight gained during the acute and stabilization treatment of psychotic depression was partial restoration of lost weight in older patients [during depressive episodes] but clinically significant excess weight in younger patients.” There were no clinically significant differences between younger and older participants in glycemic measures.

For related information, see the Psychiatric News article “Maintenance Antipsychotic Lowers Risk of Psychotic Depression Relapse.”

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Prazosin Can Reduce Drinking in AUD Patients With Severe Withdrawal Symptoms

Prazosin is effective at reducing alcohol consumption in adults with alcohol use disorder (AUD) and severe withdrawal symptoms such as sweating, headache, and nausea, reports a study in AJP in Advance.

In a 12-week, randomized clinical trial of 112 treatment-seeking adults with AUD, those with severe withdrawal symptoms who took prazosin had half as many drinking days and only one-fifth the number of heavy drinking days as adults with severe withdrawal symptoms taking placebo. In contrast, there was no difference in drinking days between participants taking prazosin who were experiencing few or no symptoms of alcohol withdrawal and those taking placebo. 

“In parallel, we found that the higher the alcohol withdrawal symptom severity, the greater the benefit of prazosin in reducing anxiety, depressed mood, and alcohol craving over the course of the trial,” wrote Rajita Sinha, Ph.D., of Yale University School of Medicine and colleagues. “These findings support the speculation that prazosin’s benefits may be mediated by its effects on the high craving, negative mood, and anxiety that are clinically observed in those with greater alcohol withdrawal symptom severity.”

Sinha and colleagues randomized adults with AUD to receive either 16 mg/day prazosin or placebo along with weekly behavioral counseling sessions for 12 weeks. At baseline, the participants’ withdrawal symptoms were assessed using the Clinical Institute Withdrawal Assessment for Alcohol–Revised. The participants were then divided into low/no-withdrawal and high-withdrawal groups.

The participants reported their drinking each day using their smartphones or automated voice messaging. Additionally, the researchers evaluated the patients’ vital signs, medication adherence, and breath alcohol levels during biweekly outpatient visits.

At 12 weeks, adults in the high-withdrawal group taking prazosin reported drinking on 27.46% of total days and heavy drinking (four to five drinks per day) on 7.07% of days, while those on placebo reported drinking 58.47% of total days and heavy drinking on 35.58% of days. The researchers found no benefit of prazosin among adults with low or no withdrawal symptoms.

Prazosin was found to be safe and well tolerated, and there were no significant differences in medication adherence between the prazosin and placebo groups, the authors added.

To read more on this topic, see the Psychiatric News article “Gabapentin Found to Work Best for Those With Severe Alcohol Withdrawal Syndrome.” 

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Suicidality Among Childbearing Women Found to Increase Over 12-Year Period

From 2006 to 2017, the prevalence of suicidal ideation and intentional self-harm among women in the year before or after birth increased substantially, according to a study published this week in JAMA Psychiatry.

“Maternal health experts note that the lack of consistent, inclusive data on suicidality before and after birth is alarming,” wrote Lindsay Admon, M.D., M.Sc., of the University of Michigan and colleagues. “Further, … suicidal ideation and intentional self-harm remain excluded from standard measures of severe maternal morbidity.”

Admon and colleagues conducted the Maternal Behavioral Health Policy Evaluation study to evaluate suicidality trends from 2006 to 2017 among women aged 15 to 44. They used Optum Clinformatics Data Mart, which included medical claims data from a national, commercially insured population from all 50 states. The researchers compared women with or without a suicidality diagnosis (defined as a diagnosis of suicidal ideation and/or intentional self-harm in inpatient or outpatient settings) in the year before and after giving birth. The authors also identified whether the patients had clinical comorbidities, including depression, anxiety, bipolar disorder, psychosis, and substance use disorders.

The authors identified 698,239 deliveries among 595,237 commercially insured women during the study period. Of these women, 2,683 individuals were diagnosed with suicidal ideation or intentional self-harm one year before or after giving birth. Other findings, as described by the authors, include the following:

• Suicidality increased from 0.2% per 100 individuals in 2006 to 0.6% per 100 individuals in 2017.
• Suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017.
• Intentional self-harm increased from 0.1% per 100 individuals in 2006 to 0.2% per 100 individuals in 2017.
• Suicidality with comorbid depression or anxiety increased from 1.2% per 100 individuals in 2006 to 2.6% per 100 individuals in 2017.
• Suicidality with comorbid psychotic disorders increased from 7.1% per 100 individuals in 2006 to 47.6% per 100 individuals in 2017.

The authors noted that Black women, those with lower incomes, and younger women experienced the larger increases in suicidality. “Given the severe maternal mortality crisis among racial/ethnic minority individuals, especially Black women, it is imperative to include psychiatric risks in predictive models and practice guidelines,” they wrote.

“[P]olicymakers, health plans, and clinicians should ensure access to universal suicidality screening and appropriate treatment for pregnant and postpartum individuals and seek health system and policy avenues to mitigate this public health crisis, particularly for high-risk groups,” they concluded.

For related information, see the Psychiatric News article “Drugs, Suicide Among Leading Causes of Postpartum Death in California.”

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COVID-19 Patients With Delirium in Emergency Department May Experience Worse Outcomes

Nearly 30% of adults aged 65 and older who are diagnosed and treated for COVID-19 in U.S. emergency departments (EDs) may present with delirium, suggests a report published today in JAMA Network Open. These patients appear to have worse outcomes, including longer stays in the intensive care unit (ICU) and in-hospital death than those with COVID-19 who do not show signs of delirium.

“These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation,” wrote Maura Kennedy, M.D., M.P.H., of Massachusetts General Hospital and colleagues.

Kennedy and colleagues analyzed data from older adults who were seen in one of seven ED study sites across the United States and diagnosed with COVID-19 on or after March 13 (the date COVID-19 was declared a national emergency in the United States). They specifically focused on outcomes in patients whose medical records noted delirium symptoms at the time of arrival to the ED.

A total of 817 patients (mean age 77.7 years) were included in the analysis; 226 patients had delirium at presentation. Common symptoms of delirium noted in the medical record included impaired consciousness (122 patients), disorientation (96 patients), hypoactive delirium symptoms (45 patients), and agitation or hyperactive delirium symptoms (35 patients).

Of patients with delirium, 37 had delirium as a primary presenting complaint. Importantly, 84 of these patients had no fever or shortness of breath. The researchers found that delirium at presentation to the ED was significantly associated with increased risk for spending more than eight days in the ICU, discharge to a rehabilitation facility, and death.

“Our study demonstrates that clinicians must include COVID-19 in the differential diagnosis of delirium among older adults, regardless of whether they have other symptoms of COVID-19 infection. This is important to avoid missing diagnoses altogether and to better identify severe cases of COVID-19 at high risk for poor outcomes and death,” Kennedy and colleagues wrote.

“Furthermore, the data from this multicenter study strongly support an immediate revision in CDC guidance on symptom profiles for COVID-19 to include delirium as an important COVID-19–related symptom. Current CDC guidance lists new confusion as an emergency warning sign only, not as a presenting symptom in COVID-19. Many centers use the CDC guidance to prioritize screening, testing, and evaluation of presenting patients. By continuing to exclude delirium as a known presenting symptom of COVID-19, many cases will be missed or diagnoses delayed, as is already happening on a wide scale, particularly in older adults.”

For related information, see the Psychiatric News article “Do Not Forget Delirium During the COVID-19 Scramble.”

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Specific Symptoms of Borderline Personality Disorder Linked to Suicide Risk

Certain symptoms of borderline personality disorder—especially chronic feelings of emptiness, fear of abandonment, and disturbances in one’s sense of identity—appear to be significantly associated with suicide attempts, according to a report published today in JAMA Psychiatry.

“[T]he results of this study show the importance of assessing and targeting identity disturbance, abandonment, and emptiness in patients with BPD [borderline personality disorder] when considering suicide prevention, symptoms that may often be overshadowed by affective or behavioral features of BPD [borderline personality disorder],” wrote Shirley Yen, Ph.D., of Beth Israel Deaconess Medical Center in Boston and colleagues.

Yen and colleagues analyzed data from the Collaborative Longitudinal Study of Personality Disorders, a multisite, prospective study of adults with at least one of four personality disorders (schizotypal, borderline, avoidant, and obsessive compulsive) and a comparison group of adults with major depressive disorder. They looked at the occurrence of suicide attempts in both groups over a 10-year period and examined the associations between specific symptoms and suicide attempts.

Of all disorders, borderline personality disorder emerged as the most robust factor associated with suicide attempts, even after controlling for demographic and clinical factors (such as childhood sexual abuse, alcohol use disorder, substance use disorder, and posttraumatic stress disorder).

Among the specific borderline personality disorder criteria, identity disturbance, chronic feelings of emptiness, and “frantic efforts to avoid abandonment” were significantly associated with suicide attempts.

“These criteria may interfere with self-direction, development of meaningful and lasting interpersonal relationships, and engagement in goals and value-directed living, becoming increasingly problematic throughout the life span because these facets of life might otherwise buffer suicidal tendencies,” Yen and colleagues wrote.

For related information, see the Psychiatric News article “Data Mining May Help Identify Suicide Risk.”

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Impact of Racism Across Generations Discussed at APA Town Hall

The adverse effects of structural and interpersonal racism persist across generations, said panelists last night in the third online town hall meeting hosted by APA’s Presidential Task Force to Address Structural Racism Throughout Psychiatry.

“This is a period of turbulence in our country, and we are all being forced to confront the disparities in the treatment of Black, indigenous, and people of color,” said moderator, task force member, and APA Trustee-at-Large Michele Reid, M.D. She is a clinical assistant professor in the Department of Psychiatry and Behavioral Neurosciences at Wayne State University in Detroit and the chief medical officer of CNS Healthcare. “The COVID-19 pandemic has highlighted long-standing inequities caused by race, ethnicity, and income.”

Chuan-Mei Lee, M.D., an assistant clinical professor in psychiatry at the University of California, San Francisco (UCSF), and a child and adolescent psychiatrist at UCSF Benioff Children’s Hospital, spoke about the long-term, epigenetic effects of adverse childhood events (ACEs) that may occur as the result of structural and interpersonal racism.

“Experiences of discrimination produce the type of chronic stress that increases allostatic load, sets off cortisol production, shortens telomeres, and methlylates DNA,” Lee explained.

Ebony Dix, M.D., an assistant professor in the Department of Psychiatry at Yale University School of Medicine and an inpatient geriatric psychiatrist, discussed how structural racism affects Black adults on a daily basis. She cited differential treatment of patients in the emergency department due to their race, as an example.

“Take an African-American male who is 50 years old and a white female who is 50 years old presenting to the same ED with the same psychotic symptoms,” Dix said. “I’ve seen time and time again that the full … work-up will be given to the white woman, but for the Black man the first things at the top of the differential is substance abuse or schizophrenia.”

Peter Ureste, M.D., an assistant clinical professor in the UCSF Department of Psychiatry and Behavioral Sciences, discussed how structural racism affects Latinx and LGBTQ populations, including transgender people of color.

“Transgender and gender nonconforming individuals face extraordinarily high rates of social and health inequalities, including poverty and discrimination by employers. They are [more likely to be] victims of violence, and they face higher rates of family rejection and homelessness than their cisgender peers. I would say this is even more so for transgender people of color,” Ureste said.

At the end of the discussions, Reid gave an update on the task force’s work. Highlights include the following:

• A website resource, psychiatry.org/TaskForce, that offers a recommended reading list, educational content, and a glossary of terms approved by the APA Board of Trustees.
• Three mini-surveys issued to guide the task force’s work and engage APA’s membership.
• A report by the task force’s Assembly work group that outlined eight actions to improve diversity and inclusion and reduce structural racism in the Assembly, actions that have since been approved by the Board of Trustees.
• Feedback sessions with APA councils and committees.
• Presentations made at the Kentucky, Missouri, North Dakota, Ohio, Utah, and Virginia district branches.

The next town hall will take place on February 8, 2021, from 8 to 9:30 p.m. ET.

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Amisulpride Found More Effective Than Olanzapine or Aripiprazole

Patients with schizophrenia taking the antipsychotic amisulpride showed greater symptom improvements after one year compared with those taking aripiprazole or olanzapine, according to a study in Lancet Psychiatry. (Intravenous amisulpride was approved this past February to treat postoperative nausea/vomiting; it is not approved for schizophrenia in the United States but is approved in Europe and licensed in over 50 countries.)

Erik Johnsen, M.D., of Haukeland University Hospital in Bergen, Norway, and colleagues randomized 144 adults diagnosed with schizophrenia to receive oral amisulpride, aripiprazole, or olanzapine for 52 weeks. The trial was designed as semi-blinded; that is, the patients and their psychiatrists knew which medication the patients were taking, but the researchers who conducted periodic evaluations did not. The researchers assessed the participants’ symptoms using the Positive and Negative Syndrome Scale (PANSS) and side effects at baseline and weeks 1, 3, 6, 12, 26, 39, and 52 of the study.

After 52 weeks, the patients who were taking amisulpride had a PANSS total score reduction of 32.7 points, which was superior to improvements seen in patients taking aripiprazole (21.9 points) or olanzapine (23.3 points). Patients taking amisulpride saw greater improvements in positive symptoms (such as hallucinations and delusions) and general symptoms (such as anxiety and attention) than those taking aripiprazole or olanzapine. There were no differences between the groups when it came to improvements in negative symptoms (such as emotional or social withdrawal).

Twenty patients experienced at least one serious adverse event, such as readmission to a psychiatric hospital: four were taking amisulpride, 10 were taking aripiprazole, and six were taking olanzapine. There were no statistical differences among the study drugs with regard to risk of a serious adverse event or metabolic side effects such as weight gain.

“Results from clinical trials without a placebo control should be interpreted with caution,” Johnsen and colleagues wrote. “Nevertheless, it seems reasonable to surmise that in acutely psychotic patients starting treatment on a new oral antipsychotic, a substantial and clinically relevant improvement [with amisulpride] can be expected.”

“This study is interesting in that it used a pragmatic design. The result is that the treatments were administered in a manner that is similar to the way they are administered in the community," Stephen Marder, M.D., a professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, told Psychiatric News. Marder, who was not involved with the study, noted that the differences in PANSS scores between amisulpride and the other drugs corresponded to effect sizes of over 0.5—significant changes that a physician would notice quickly. “The advantages of amisulpride were substantial. I’m hopeful that studies like this may encourage industries to sponsor amisulpride studies in the United States.”

To read more on this topic, see the Psychiatric News article “Which Antipsychotics Are Best for Your Patients?”

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APA Urges You to Join in Tonight’s Town Hall on Racism

Join APA today, Monday, November 16, at 8 p.m. ET, as speakers examine how the persistent stress of experiencing racial discrimination has an impact across generations and the degree to which the health consequences of racism and bigotry can be passed down from one generation to the next. The Town Hall will include an update on the work of the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry.

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Patient’s Weight May Affect Response to Antidepressants

A patient’s body mass index (BMI) may play a role in the effectiveness of treatment with certain antidepressants for major depressive disorder, suggests a study published Thursday in the Journal of Affective Disorders.

Le Xiao, M.D., Ph.D., of Capital Medical University in Beijing and colleagues analyzed data collected in a clinical trial that included 202 adults with major depressive disorder at five hospitals from 2011 to 2016. Patients were 18 to 60 years and had scores of at least 20 on the 17-item Hamilton Rating Scale for Depression (HAMD-17) upon enrollment. All patients initially received paroxetine, and those whose symptoms did not begin to improve after two weeks were randomized to continue paroxetine, switch to mirtazapine, or take both paroxetine with mirtazapine for six weeks. BMI analysis revealed that 55% of patients had normal body weight, 35.1% were overweight or obese, and 9.9% were underweight.

The researchers found that patients who were normal weight or underweight were twice as likely to experience remission of their depression by the end of the eighth week, as defined by HAMD-17 scores of 7 or lower.

The researchers noted that one possible reason why people with a high BMI or excessive body fat may have a lower response to antidepressants compared with people with a lower BMI is that the drug must travel through more tissue and fluid in their bodies than in the bodies of people who are normal weight or underweight.

“The other potential mechanisms underlying the association between body weight and antidepressant response could be attributed to brain insulin resistance, inflammatory dysregulation, oxidative and nitrosative stress which is caused by obesity,” the researchers wrote. “Finally, decreased physical activity and obesity stigma can also contribute to poor response to antidepressants in patients with excess weight.”

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APA Urges You to Join in Next Town Hall on Racism

Join APA leaders Monday, November 16, at 8 p.m. ET, as they examine how the persistent stress of experiencing racial discrimination has an impact across generations and the degree to which the health consequences of racism and bigotry can be passed down from one generation to the next.

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FDA OKs App That Disrupts Nightmares Associated With PTSD

The Food and Drug Administration (FDA) has approved the marketing of NightWare—artificial intelligence software shown to reduce sleep disturbances in people experiencing nightmares related to posttraumatic stress disorder (PTSD) or nightmare disorder.

In May 2019 NightWare received the FDA’s breakthrough device status designation, a process designed to expedite the development and review of devices that may provide for more effective treatment or diagnosis of life-threatening or irreversibly debilitating diseases or conditions.

NightWare uses artificial intelligence software installed on an Apple Watch to monitor the user’s heart rate and movement while sleeping. When NightWare detects that the user is experiencing a nightmare based on its analysis of heart rate and body movement, the device emits a vibration through the Apple Watch before the nightmare reaches a severity that would awaken the user.

The device was evaluated in a 30-day randomized, sham-controlled trial of 70 patients, according to the FDA release. The researchers used two versions of the Pittsburgh Sleep Quality Index scale to compare outcomes among participants in the sham group (wore the device but received no stimulation during nightmares) with those in the active group (wore the device and received stimulation during nightmares). “Both the sham and active groups showed improvement on the sleep scales, with the active group showing greater improvement than sham,” the FDA reported.

According to a press release by NightWare Inc., a multisite randomized, sham-controlled trial remains ongoing with a planned enrollment of 240 patients. NightWare is available by prescription only and is intended for home use.

“NightWare is not a standalone therapy for PTSD. The device should be used in conjunction with prescribed medications for PTSD and other recommended therapies for PTSD-associated nightmares and nightmare disorder, according to relevant consensus guidelines,” the agency continued.

For related information, see the Psychiatric News article “Digital Nightmare Therapy Receives Breakthrough Designation.”

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Register for Webinar on ONC Rules on Sharing Patient Records: Nov. 19

APA, in concert with the College of Healthcare Information Management Executives, will host a webinar on Thursday, November 19, at noon ET, for members interested in learning more about the final rule and interim rule concerning the sharing of patient records issued by the Office of the National Coordinator for Health Information Technology (ONC). APA’s overview of the final rule can be accessed here, and more information about the interim rule can be accessed here.

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Implementing Suicide Screening in VHA Settings Can Help Identify Veterans at Risk

When incorporated into Veterans Health Administration (VHA) medical settings, a population-level, suicide-risk screening may help identify veterans at risk of suicide who may not be receiving mental health treatment, according to a study published in JAMA Network Open.

“Emerging evidence suggests that suicide risk screening in AC [ambulatory care] and ED [emergency department] or UCC [urgent care center] settings may provide critical opportunities to identify risk among patients who are not receiving or seeking mental health treatment,” wrote Nazanin Bahraini, Ph.D., of the Rocky Mountain Regional Veterans Affairs Medical Center in Aurora, Colo., and colleagues. “Although the feasibility and utility of screening in the ED or UCC setting and medical settings [have] been demonstrated in community hospitals, it has yet to be examined in the VHA, the country’s largest integrated health care system.”

The researchers analyzed data from the VA Suicide Risk Identification Strategy (Risk ID), a screening and evaluation process that includes three stages: the primary screen (Patient Health Questionnaire-9), the secondary screen (Columbia Suicide Severity Rating Scale Screener), and the VHA’s Comprehensive Suicide Risk Evaluation. Individuals who screen positive at one level move into the next level of screening or evaluation.

Risk ID was implemented throughout all VHA facilities from 2018 to 2019. Patients were screened in ambulatory care settings if they had at least one outpatient visit and they did not have an existing diagnosis of depression, bipolar disorder, or posttraumatic stress disorder. All patients visiting an emergency department or urgent care center were also screened.

During the first year of Risk ID’s implementation (from October 1, 2018, to September 30, 2019), 4.1 million veterans in ambulatory care and over 1 million veterans who visited emergency departments or urgent care centers received the primary screening. The prevalence of suicidal ideation was 3.5% for primary screenings and 0.4% for secondary screenings in ambulatory care, and 3.6% and 2.1%, respectively, in emergency departments or urgent care centers. Those screened in emergency departments or urgent care centers were more likely to endorse suicidal ideation with intent, specific plan, or recent suicidal behavior during the secondary screening, compared with those screened in ambulatory care.

“The higher acuity of risk among veterans presenting to ED or UCC compared with AC settings highlights the importance of scaling up implementation of brief evidence-based interventions designed for ED or UCC settings to promote treatment engagement and reduce suicidal behavior,” the authors wrote.

Earlier this year, President Donald Trump signed the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 (S 785), and the House passed the Veterans Comprehensive Prevention, Access to Care, and Treatment (COMPACT) Act of 2020 (HR 8247). The bills both focus on preventing veteran suicide and address a range of issues related to veterans’ mental health care, including ensuring veterans can access the care they need.

“APA was pleased to see Congress focusing on veterans’ suicide prevention and mental health, and we are encouraged that lawmakers have recognized the importance of addressing this urgent issue,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “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 VA and beyond.”

For related information, see the Psychiatric News article “Telephone Counseling May Offer Needed Boost to Veterans With Depression.”

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APA Town Hall to Examine Generational Trauma of Structural Racism: Nov. 16

Join APA leaders Monday, November 16, at 8 p.m. ET, as they examine how the persistent stress of experiencing racial discrimination has an impact across generations and the degree to which the health consequences of racism and bigotry can be passed down from one generation to the next.

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APA Congratulates President-Elect Joe Biden and Vice President-Elect Kamala Harris

APA this weekend issued a statement congratulating President-Elect Joe Biden and Vice President-Elect Kamala Harris on their victory in the 2020 election. The Associated Press and numerous other media outlets called the election for Biden and Harris over the weekend.

“[W]e welcome the opportunity to work with the Biden administration on concrete initiatives to increase access to high-quality mental health care for our patients,” APA President Jeffrey Geller, M.D., M.P.H., said in the statement. “APA has worked diligently this past year to expand the use of telehealth to address the COVID-19 pandemic, and we have pushed hard for enforcement of mental health parity and expanded funding for federal agencies tasked with addressing the mental health of the nation. Our work will continue as the impacts of COVID will be felt for years.”

In addition to expanded use of telehealth and mental health funding, APA will continue to advocate for the reversal of executive orders and regulations from the Trump administration that have prevented individuals from receiving mental health treatment, Geller said. APA will also continue to advocate for continuing the protections of the Affordable Care Act (ACA).

On November 10, the ACA faces another legal challenge before the U.S. Supreme Court as proceedings on California vs. Texas are set to begin. The justices will listen to arguments on whether the ACA is unconstitutional following the 2017 passage of the Tax Cuts and Jobs Act, which eliminated the tax penalty for individuals who failed to enroll for health insurance.

“Our members stand ready to work with the Biden administration and members of both parties to ensure through effective and sound policy that every American who needs high-quality mental health and substance use care will be able to access it,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.

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Psilocybin Paired With Psychotherapy May Help Patients With Major Depression

Psilocybin, also known as magic mushrooms, may be effective in treating major depressive disorder when paired with supportive psychotherapy, suggests a study in JAMA Psychiatry. The study also found that the beneficial effects of psilocybin may last longer than those of ketamine.

Alan K. Davis, Ph.D., of the Johns Hopkins School of Medicine and colleagues studied 24 adults aged 21 to 75 years with major depressive disorder who received gelcaps of psilocybin at two sessions roughly a week and a half apart. All patients had eight hours of in-person visits with session facilitators to prepare for their first psilocybin session, two to three hours of follow-up meetings after the psilocybin sessions, and 11 hours of supportive psychotherapy over the course of the study. None of the patients were taking antidepressants during the study. During the psilocybin sessions, which lasted approximately one day each time, treatment facilitators were present and available to respond to the patients’ physical and emotional needs.

The patients were divided into two groups: One group, the immediate-treatment group, had their preparatory sessions and treatment immediately after they enrolled in the study; the other group, the delayed-treatment group, received the same preparation and treatment sessions eight weeks after enrollment.

The researchers assessed the severity of the patients’ depression with the GRID-Hamilton Depression Rating Scale (GRID-HAMD) at baseline, at week 5, and at week 8. This means that at weeks 5 and 8, they were comparing GRID-HAMD scores of patients who had already had their psilocybin sessions with those of patients who were still waiting and had not yet received either preparatory visits or treatment.

At baseline, the mean GRID-HAMD score was 22.9 in the immediate-treatment group and 22.5 in the delayed-treatment group. At weeks 5 and 8, the median score in the immediate-treatment group dropped to 8.0 and 8.5, respectively, whereas the median score in the delayed-treatment group remained about the same at 23.8 and 23.5, respectively.

The researchers then followed up with the delayed-treatment group one week and four weeks after the patients received their preparation sessions and treatment. When the researchers looked at the results for all of the patients in the study together, they found that 67% experienced at least a 50% reduction in GRID-HAMD scores one week after receiving their second psilocybin session. Four weeks after their second psilocybin session, 71% had achieved at least a 50% reduction in their scores.

“Although the rapid antidepressant effects of psilocybin are similar to those reported with ketamine, the therapeutic effects are different: ketamine effects typically last for a few days to 2 weeks, whereas the current study showed that clinically significant antidepressant response to psilocybin therapy persisted for at least 4 weeks,” the researchers wrote. “Further studies are needed with active treatment or placebo controls and in larger and more diverse populations.”

For related information, see the Psychiatric News article “Psychedelics for Psychiatric Disorders: More Research Needed.”

(Image: iStock\Ryland Zweifel)

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Register for Webinar on 2021 Changes to Billing and Documentation for Outpatient E/M Services

Register to attend this webinar on Tuesday, November 17 at 8 p.m. ET 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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For Smokers With Schizophrenia, Varenicline Found Most Effective at Achieving Abstinence

Smokers with schizophrenia who received pharmacotherapeutic smoking cessation aids, especially the medication varenicline, had significantly higher abstinence rates compared with smokers with schizophrenia who received a placebo, according to a study published in Psychiatric Services.

“Despite evidence of the safety and efficacy of first-line pharmacotherapeutic cessation aids in this population, clinicians report negative attitudes toward providing smoking cessation treatment for smokers with schizophrenia, and pharmacotherapy—particularly non-nicotine pharmacotherapy—is particularly underutilized,” wrote A. Eden Evins, M.D., M.P.H., of Massachusetts General Hospital and colleagues.

Evins and colleagues analyzed data on abstinence rates and neuropsychiatric adverse events (NPSAEs) that were collected as part of the Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES). EAGLES was conducted from November 2011 to January 2015 with participants aged 18 to 75 who smoked 10 or more cigarettes a day. There were 390 participants with schizophrenia spectrum disorders (including schizophrenia and schizoaffective disorders) and 4,028 without a psychiatric illness (the control group).

Participants were randomly assigned to receive 1 mg varenicline twice daily, 150 mg buproprion sustained-release twice daily, 21 mg of a nicotine replacement therapy patch daily, or a placebo for 12 weeks. Participants set a quit date for one week after random assignment, and study visits occurred weekly for six weeks, biweekly for six weeks, and then at weeks 13, 16, 20, and 24. Participants also received 10 minutes of smoking cessation counseling at each visit.

During each study visit, smokers with schizophrenia who were assigned to varenicline had significantly higher rates of abstinence (defined as self-reported tobacco abstinence since the previous study visit) compared with the placebo group. Participants receiving buproprion and nicotine replacement therapy also had higher rates of abstinence than the participants in the placebo group, though the rates were not as high as those for the group receiving varenicline. The participants without a psychiatric disorder overall had higher rates of abstinence, with varenicline also associated with the highest rates.

Neuropsychiatric adverse events were not significantly higher for smokers with schizophrenia receiving any active treatment compared with the placebo group. The estimated rate of neuropsychiatric adverse events was 5% for participants with schizophrenia and 1% for participants without a psychiatric disorder.

“Tobacco smokers, particularly smokers with schizophrenia, need help to quit,” the authors concluded. “These data, together with strong evidence that smoking cessation does not exacerbate mental illness and strong consistent evidence for low abstinence rates among smokers with schizophrenia with behavioral treatment alone,” support greater use of smoking cessation aids for smokers with schizophrenia as a standard of care.

For related information, see the Psychiatric News article “Schizophrenia Patients Show Cognitive Improvements After Smoking Cessation.”

(Image: iStock\Sezeryadigar)

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Register for Webinar on 2021 Changes to Billing and Documentation for Outpatient E/M Services

Register to attend this webinar on Tuesday, November 17 at 8 p.m. ET 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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District Court Issues Injunction Against UBH for Failure to Cover Mental Health/Substance Use Disorders

A federal district court yesterday ruled that United Behavioral Health (UBH) must use medical necessity criteria and assessment tools developed by mental health and substance use disorder specialty organizations when making coverage-related determinations.

The ruling was part of a 10-year injunction against UBH issued by Judge Joseph Spero of the United States District Court for the Northern District of California in Wit v. United Behavioral Health. The injunction also includes a requirement that UBH personnel be trained in the use of the court-ordered medical necessity criteria and that UBH reprocess nearly 67,000 mental health and substance use disorder benefit claims over the next year. UBH is the country’s largest managed behavioral health care organization.

The injunction requires UBH to use the Level of Care Utilization System (LOCUS), Child and Adolescent Service Intensity Instrument (CASII), and Early Childhood Service Intensity Instrument (ECSII)—assessment tools developed by the American Association of Community Psychiatry (LOCUS) and the Academy of Child and Adolescent Psychiatry (CASII and ECSII)—as well as criteria developed by the American Society of Addiction Medicine.

Yesterday's ruling is the “remedy” phase of the case resulting from the court’s decision signed on February 28, 2019. The court held that UBH had illegally denied coverage for mental and substance use disorders based on flawed medical necessity criteria. Those denials impacted more than 50,000 UBH enrollees and involved 67,000 claims for coverage across four states: Connecticut, Illinois, Rhode Island, and Texas.

The ruling was the first time a major insurer was found to be relying on improper guidelines as a basis for denying health care services. In its 2019 decision, the court found that “[m]any mental health and substance use disorders are long term and chronic. While current symptoms are typically related to a patient’s chronic condition, it is generally accepted in the behavioral health community that effective treatment of individuals with mental health or substance use disorders is not limited to the alleviation of the current symptoms. Rather, effective treatment requires treatment of the chronic underlying condition as well.”

Reacting to the ruling, APA President Jeffrey Geller, M.D, M.P.H., said, “We applaud Judge Spero for holding this major insurer accountable for discriminating against patients with mental illness by denying them the care they need and are entitled to by law.”

He said APA will continue to be vigilant whenever insurers fail in their duty to abide by laws requiring parity between coverage of general medical care and coverage for mental illness and substance abuse disorders. “We hope insurers will take note of this ruling and stop the discriminatory practice of denying or limiting coverage of treatment for mental illness and substance use disorders.”

For further coverage of the Wit v. UBH decision, see upcoming editions of Psychiatric News. For background information, see the Psychiatric News article “UBH Internal Documents Show Focus on Short-Term Stabilization.”

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APA Town Hall to Examine Generational Trauma of Structural Racism

APA President Jeffrey Geller, M.D., M.P.H., invites you to participate in the next of his series of town halls on structural racism throughout psychiatry. It will be held Monday, November 16, at 8 p.m. ET. Presenters will examine how the persistent stress of experiencing racial discrimination has an impact across generations and the degree to which the health consequences of racism and bigotry can be passed down from one generation to the next.

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NEJM Special Report Examines Future of U.S. Health Policy Following 2020 Election

What might the results of the 2020 presidential election mean for the future of health policy in the United States? Robert J. Blendon, Sc.D., and John M. Benson, M.A., of the Harvard T.H. Chan School of Public Health examine this question in a special report in the New England Journal of Medicine.

Blendon is the Richard L. Menschel Professor of Public Health and Professor of Health Policy and Political Analysis, Emeritus. Benson is a senior research scientist and is managing director of the Harvard Opinion Research Program.

“Our analysis … is drawn from the results of 19 national public opinion polls [with sample sizes ranging from about 500 to over 5,000 people], some as recent as October 2020,” they wrote.

The authors noted that these polls have revealed health care to be an issue weighing heavily on voters’ minds. In particular, one poll found that high health care costs in general and high drug costs were the top issues among voters who said that health care was extremely important to their presidential vote. This included 60% of those who said they were likely to vote for Trump and 54% of those likely to vote for Biden.

“When asked their opinion of several potential policy options for health insurance reform, majorities of Americans favor more than one approach,” Blendon and Benson noted. The authors offered several scenarios for health insurance reform should Democrats or Republicans control the Senate, Congress, and the presidency: “If Democrats are in the majority in the House and Senate and win the presidency, they will move on some sort of plan to achieve universal health care coverage,” likely building on the Affordable Care Act (ACA). “Republicans would be likely to put forward plans that would give states more authority to manage the operation of the existing ACA and Medicaid. They also would encourage the sale and availability of plans that would have much more limited benefits but be far less expensive to purchase. If the presidency and the Congress are divided by party, there is likely to be no major health care legislation enacted in the next term.”

They continued, “[I]n the next few years, state and local governments will have substantial financial shortfalls due to the economic downturn, which has worsened the state revenue forecasts.” Blendon and Benson described the impact that the presence or absence of federal subsidies to state or local governments might have on Medicaid, state public health, and mental health department spending.

They also examined where voters likely stand on the role of the government regarding slowing the spread of COVID-19, abortion rights, and racial disparities in health care and health overall.

“The polling suggests that regardless of the desire for bipartisan health policies addressing the major issues, the cores of the two parties are very far apart on these issues and are growing even farther apart as time goes on. Thus, it is important to recognize that the health policy directions of the next president and Congress may not be the same as those of the following presidents and Congresses,” Blendon and Benson wrote. “Looking at health care, for instance, we are likely to see an instability in U.S. health policy as decision-making shifts from one political party to another.”

For related information, see the Psychiatric News Alert “Americans Report Increasing Rates of Anxiety, APA Poll Finds.”

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Number of Children Prescribed Multiple Psychiatric Medications Appears to Be Growing

The number of children and adolescents who take multiple types of psychiatric medications has risen significantly since 1999 in the United States, driven mainly by prescriptions to youth diagnosed with attention-deficit/hyperactivity disorder (ADHD). These findings were published today in JAMA Pediatrics.

“The use of medication from two or more psychotropic classes, i.e., polypharmacy, has increased among U.S. youth despite limited evidence of efficacy and mounting safety concerns,” wrote Chengchen Zhang, M.P.H., of the University of Maryland School of Pharmacy and colleagues.

Zhang and colleagues analyzed data from the Medical Expenditure Panel Surveys (MEPS) collected between 1990 and 2015. The MEPS is a national survey that tracks various trends in health care use and expenditures. 

The researchers examined the number of youth up to age 18 years who received prescriptions for at least three classes of psychiatric medications each year of the survey. The medication classes included in the analysis were stimulants, antidepressants, mood stabilizers, antipsychotics, anxiolytics, sedatives, and α-agonists. The data were grouped into three blocks: 1999-2004, 2005-2010, and 2011-2015.

Zhang and colleagues found that the number of youth prescribed three or more classes of psychiatric medications increased from 101,836 between 1999 and 2004 to 222,955 between 2005 and 2010 to 293,492 between 2011 and 2015. Stimulants were the most common medication prescribed to youth treated with polypharmacy across all three time periods. More than 80% of the youth had an ADHD diagnosis.

The use of antipsychotics by youth prescribed multiple psychiatric medications rose sharply during this period (from 38% of youth receiving polypharmacy between 1999 and 2004 to 75% of youth between 2011 and 2015). In contrast, there was a significant decline in mood stabilizer use (from 61% of youth between 1999 and 2004 to 38% of youth between 2011 and 2015). Between 2011 and 2015, the most common three-drug combination was stimulants, antipsychotics, and α-agonists, which were prescribed to nearly 22% of all youth in the analysis.

To read more on this topic, see the Psychiatric News article “Education Can Reduce Antipsychotic Polypharmacy.”

(Image: iStock\Brian)

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Candidates for APA Area 4 Trustee Announced

The APA Nominating Committee, chaired by Immediate Past President Bruce Schwartz, M.D., has announced the candidates for Area 4 Trustee for APA’s 2021 election. The candidates are Theadia LaRue Carey, M.D., of Southfield, Minn., and Cheryl D. Wills, M.D., of Cleveland. The candidates were approved by the Board of Trustees on October 30.

The names of the candidates for all other offices were announced earlier in October, and their names and additional election information are posted at psychiatry.org/election. All candidates and supporters are encouraged to review the Election Guidelines.