Friday, September 17, 2021

Residency Experience Treating Patients With Buprenorphine Boosts Prescribing Down the Road

The United States has a dearth of physicians who are trained to offer medication treatment with buprenorphine to patients with opioid use disorder (OUD). One community-based family medicine residency program in Massachusetts has shown that integrating patients treated with buprenorphine directly into resident training can help increase the number of graduates prescribing buprenorphine. Layla Cavitt, M.D., of the Tufts University School of Medicine Lawrence Family Medicine Residency and colleagues outlined the program’s steps and success in the Journal of Substance Abuse Treatment.

In 2011, the Lawrence residency program integrated mandatory Drug Enforcement Agency (DEA) X-waiver training into the second-year didactic curriculum. (The X-waiver is the special DEA license required by the Drug Addiction Treatment Act of 2000 that allows health care professionals to prescribe buprenorphine to outpatients for treatment of OUD.) Also, family medicine attending physicians began shadowing patients being treated for opioid use disorder in 2011. In 2014, the program integrated patients being treated with buprenorphine into resident continuity clinic patient panels, and residents managed two to five patients over the course of their residency, closely supervised by an attending physician experienced in buprenorphine treatment.

Cavitt and colleagues analyzed data from the 2016, 2017, 2018, and 2019 National Family Medicine Graduate Surveys, focusing on the respondents’ answers to questions about whether they believed that residency prepared them to prescribe buprenorphine and whether they currently prescribed buprenorphine.

Of those who responded to the national survey, more graduates of the Lawrence Family Medicine Residency reported they were adequately prepared to prescribe buprenorphine on graduation. For example, 75% of the graduating class of 2016 reported they were prepared to prescribe buprenorphine compared with 12% of respondents nationwide.

In addition, compared with respondents nationwide, more graduates of the Lawrence Family Medicine Residency reported prescribing buprenorphine in their practice three years after graduating. All of the graduating class of 2016 reported that they were prescribing buprenorphine three years after graduating compared with 12% of respondents nationwide.

“[Our residency] approach helps to build a rich repertoire of clinical skills invaluable to post-residency practice that go far beyond the skills acquired by simply obtaining a DEA-X waiver,” the researchers wrote. “We posit that our program has been successful because it produces physicians who treat opioid use disorder in practice, which is directly related to our program’s integration of patients receiving buprenorphine into residents’ continuity clinic panels. We recommend that this approach be considered an evidence-based approach to increasing the total number of graduates who go on to provide this life-saving medication in practice.”

For related information, see the Psychiatric News article “Resource Document Calls for Improved Residency Training on SUDs.”

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Thursday, September 16, 2021

Emergency Department Staff More Likely to Restrain Black Children Than White Children, Report Finds

Black children are almost twice as likely to be physically restrained in the emergency department compared with White children, according to a research letter published this week in JAMA Pediatrics. Use of physical restraints is an uncommon but serious intervention that has been found to increase the risk of injury, trauma, and death.

“Racial and ethnic disparities in restraint use likely reflect racism at multiple levels within and beyond the emergency care continuum,” wrote Katherine A. Nash, M.D., of Yale University School of Medicine and colleagues. “Potential drivers include interpersonal racism in the perception of threat or aggression, institutional racism leading to disparities in access to behavioral health care, and structural racism leading to disproportionate experiences with risk factors for mental illness, including poverty, trauma, and discrimination.”

The researchers examined the health records of nearly 552,000 emergency department visits by children from less than a year old to age 16 at 11 emergency departments within a New England health care system between 2013 and 2020. They found that physical restraints were ordered for 532 visits (0.1%). The majority of the children who were physically restrained were publicly insured, had a behavioral health problem, and were males above the age of 10. 

Results were adjusted for age, sex, language spoken, insurance, school month, behavioral health presenting problem, presence of an outpatient psychotropic medication, and history of behavioral health condition. They found that emergency department staff were 1.8 times more likely to use physical restraints on Black pediatric patients than White pediatric patients. They found no difference in the use of physical restraints on White versus Hispanic pediatric patients.

The researchers noted that previous research showed that Black adult patients are also more likely to be physically restrained in emergency rooms. Physical restraint should be used only after trying behavior de-escalation or chemical restraint, they added.

“Documenting racial and ethnic inequities is important but insufficient,” the authors concluded. “Physical restraint is a traumatic experience that can have lasting consequences for a child’s development and well-being. Further research should identify interventions that address inequities in physical restraint use and ensure a health care system that is a therapeutic rather than traumatic environment.”

For related information, see the Psychiatric Services article “The Role of the Psychiatrist in Seclusion and Restraint.”

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Wednesday, September 15, 2021

CMS Proposes Adding Payment for Telehealth Services by Mental Health Professionals

The federal government is proposing to permanently allow payment under the Medicare program for “audio-only” telehealth mental health services. These services have been temporarily reimbursed as part of the government’s response to the COVID-19 public health emergency. The government also would retain other temporarily reimbursed telehealth services through 2023 in order to evaluate whether those services should be permanently added to the list of covered Medicare services.

The recommended changes are part of the proposed 2022 Physician Fee Schedule by the Centers for Medicare and Medicaid Services (CMS). A final rule will be issued later this year; look for further reporting in Psychiatric News.

The proposed telehealth recommendations are a victory for psychiatrists and their patients for which APA has strongly advocated.

“Audio-only services have been a lifeline for patients for whom it is the only option when seeking mental health and substance use disorder treatment,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a letter to CMS Administrator Chiquita Brooks-LaSure. “Patients who cannot interact with their physician via a live, synchronous audio-video connection may need to rely on audio-only care for myriad reasons: they may lack access to sufficient broadband internet or access to the technology itself (e.g., they may not own a smartphone, tablet, or PC); their diagnosis may preclude using such technology; or they may not consent to being seen via video.”

He added, “We appreciate [that] CMS is proposing to make permanent—or otherwise continue to temporarily extend and evaluate—many of the telehealth provisions that clinicians and patients have relied on over the course of the public health emergency.”

Coverage of audio-only services would be restricted to clinicians who have the capability to furnish two-way audiovisual services and who have seen the patient in person at least once in the previous six months. In its comments to CMS, APA urged CMS to waive the six-month in-person requirement, emphasizing that the need for an in-person visit should be left to the psychiatrist’s clinical judgment.

The proposed rule also includes changes to the physician payment formula. Importantly, CMS is proposing a reduction to the “conversion factor” used in the formula that is likely to result in an overall reduction in physician payment. The change is partly the result of a budget neutrality adjustment that requires improvements in payment for Evaluation and Management Services last year to be offset in 2022 to maintain budget neutrality.

According to an AMA analysis of the impact of the proposed changes on different specialties, psychiatry would experience an overall reduction in payment of 3.1%; how individual practices will be affected would depend on practice and billing patterns.

In the letter to CMS, Levin urged CMS and the Department of Health and Human Services to work together with Congress to waive the budget neutrality adjustment set to go into place for 2022. “The reduction in the Medicare conversion factor will have a significant financial impact on psychiatrists who treat Medicare patients and comes at a time when practices have already experienced financial losses due to the COVID-19 public health emergency,” Levin wrote. “Payment cuts will only further compound the growing access problem for patients with mental health and/or substance use disorders.”

For more information, see the Psychiatric News article “CMS Proposes Permanent Payment for Telehealth Services Allowed During Pandemic.” A report on the final rule will appear in the December issue of Psychiatric News.

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Tuesday, September 14, 2021

ECT May Reduce Risk of Death in Older Patients Hospitalized for Psychiatric Disorders

Patients aged 65 or older who received electroconvulsive therapy (ECT) while hospitalized for a psychiatric disorder were found to have a lower rate of death in the year following discharge than similar patients who did not receive ECT while hospitalized, reports a study in AJP in Advance.

“This report adds to a growing body of research suggesting a positive effect of ECT from a population health perspective,” wrote Taeho Greg Rhee, Ph.D., of the University of Connecticut and colleagues. “Future efforts should focus on ways to ensure broader implementation of this treatment and to improve the maintenance therapy of severely ill patients who receive ECT.”

In this observational study, Rhee and colleagues used Medicare claims data to compare the mortality of Medicare beneficiaries 65 and up who received at least one ECT session during a psychiatric hospitalization between 2011 and 2015 with those who did not receive ECT during a psychiatric hospitalization. The final sample included 10,460 ECT patients and 31,160 control patients who were matched based on such characteristics as age, gender, and number of psychiatric hospitalizations in the previous year. The authors compared the mortality rates of patients due to various causes at one, two, three, six, and 12 months after their discharge from the hospital.

Patients who received at least one ECT session had a 39% lower rate of all-cause mortality 12 months after discharge compared with patients who did not receive ECT, while patients who received at least five sessions of ECT within a 30-day period had a 44% lower all-cause mortality rate.

In looking at different mortality categories, the authors found that ECT patients were less likely to die from smoking-related diseases, circulatory diseases, diabetes, and cancer. “While several mechanisms may be at play, one potential way in which ECT might lead to reduction in mortality risk is that improved functioning following ECT allows patients to maintain a healthier lifestyle and to better engage in treatment for whatever medical conditions they face,” they wrote.

Older patients who received any ECT or at least five sessions of ECT also had a 44% and 59% lower rate of suicide after three months, respectively, compared with patients who received no ECT, but by one year suicide rates of both groups were similar. “This is in line with the traditional understanding of the treatment course of ECT, where a large portion of ECT patients relapse after 6 months without a continuation treatment,” the authors wrote.

To read more on this topic, see the Psychiatric News article “When Is ECT Right for Your Patients With Depression?

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Today at 3 p.m. ET: Ask an App Advisor

Join APA’s App Advisor Expert Panel today, September 14, as they field your questions about APA’s App Evaluation Model. Registrants are encouraged to pre-submit their questions using the Zoom registration page.


Monday, September 13, 2021

APA Joins Other Health Organizations in Support of Collaborative Care Bill

APA has joined 17 other health organizations in supporting the Collaborate in an Orderly and Cohesive Manner (COCM) Act. The COCM Act was introduced by Reps. Lizzie Fletcher (D-Texas) and Jaime Herrera Beutler (R-Wash.) in the House of Representatives on Friday. If enacted, this legislation would improve access to evidence-based mental health care and substance use treatment by supporting and investing in the implementation of the Collaborative Care Model in primary care offices.

In the Collaborative Care Model, a primary care physician, a psychiatric consultant, and a care manager work as a team to identify and provide evidence-based treatment for patients with mental health conditions, measure their progress, and adjust care when appropriate. More than 90 research studies have demonstrated this model’s efficacy in improving patient outcomes. Furthermore, treatment provided through the Collaborative Care Model is covered by Medicare, most private insurers, and many states’ Medicaid programs.

However, the Collaborative Care Model has not been implemented on a wide scale yet in the United States. The COCM Act will provide primary care practices with startup funds and technical assistance as they adopt the model. The bill also provides funds for research to build the evidence base for other models of integrated behavioral health care.

“The Collaborative Care Model is a proven method of reaching more Americans with quality mental health care services,” said APA President Vivian Pender, M.D., in a news release issued by the supporting organizations. “The mental health impacts of COVID-19 and the way it uprooted our lives led to high levels of anxiety and depression and record overdoses in our country. We applaud Reps. Fletcher and Herrera Beutler for introducing this legislation, which promotes an innovative solution that will help more Americans get the high-quality treatment they need.”

For more information on the Collaborative Care Model and training provided by APA, see the APA webpage Learn About the Collaborative Care Model.

September 14, 3 p.m. ET: Ask an App Advisor

Join APA’s App Advisor Expert Panel on Tuesday, September 14, as they field your questions about APA’s App Evaluation Model. Registrants are encouraged to pre-submit their questions using the Zoom registration page.


Friday, September 10, 2021

APA Reflects on 20th Anniversary of 9/11

To mark the 20th anniversary of the terror attacks on September 11, 2001, APA released a statement today in honor of the thousands of men and woman who perished and the first responders who put their own lives on the line.

“We salute the first responders in New York, Washington, D.C., and Pennsylvania who bravely put themselves into harm’s way to rescue as many people as they could. We think of the efforts of psychiatrists and mental health clinicians in those regions, who from the very beginning treated many who suffered from trauma, from substance use disorders, and from other mental illness as a result of this tragedy. We remember the service members who deployed across the world in the resulting wars and the families they had to leave behind,” the APA statement read.

In the years since these attacks, there has been an enormous body of research on the effects of 9/11 on mental illness and substance use. In the September issue of Psychiatric News, psychiatrists reflect on how the attacks elevated disaster psychiatry and altered the way that psychiatrists understand psychological and behavioral responses to disasters.

“As we continue to face the aftermath of that day, whether in the form of quiet remembrances or the ongoing turmoil in Afghanistan, we urge everyone impacted to know that in times of tragedy and distress, we, as psychiatrists, are here to support you, and mental health help is available,” APA wrote.

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Thursday, September 9, 2021

Survey Finds Marijuana Use Soared Among College Students, While Alcohol Use Dropped

Drug use trends among young adults have shifted dramatically in recent years, with 44% of college students reporting past-year marijuana use in 2020, according to the 2020 Monitoring the Future (MTF) study issued yesterday. Marijuana use was similar among young adults not enrolled in college, with 43% reporting past-year use.

“The pandemic has caused fundamental changes in the daily lives of teens and adults,” John E. Schulenberg, Ph.D., of the University of Michigan Institute for Social Research and colleagues wrote. “This endemic disruption is likely to affect substance use, and MTF is uniquely designed to examine such potential period effects and quite likely lasting cohort effects.”

Since 1980, the MTF study has annually tracked substance use among college students and noncollege adults aged 19 to 22. Data for 2020 were collected between March 2020—when much of the nation began pandemic lockdowns and virtual school—and November 2020. The 2020 results are based on the online responses of 1,550 college-aged adults.

The study revealed that past-year use of hallucinogens—including LSD, psilocybin, mushrooms, and other psychedelic substances—had also significantly increased among college students, from 5% in 2019 to nearly 9% in 2020. Among noncollege adults, past-year hallucinogen use remained consistent at around 10% in 2020, compared with 8% the previous year.

College students reported significantly lower alcohol use on several key measures in 2020, compared with the prior year. For example, 56% of students reported using alcohol in the past 30 days (down from 62% in 2019), and 28% reported being drunk in the past 30 days (down from 35%). In addition, 24% of college students reported binge drinking (consuming five or more alcoholic drinks in a row at least once in the past two weeks) in 2020, down from 32% in 2019. Among young adults not in college, trends in alcohol use across all measures were stable over the past five years, with 49% of noncollege respondents reporting alcohol use in the past 30 days, 22% reporting being drunk in the past 30 days, and 24% reporting binge drinking at least once in the past two weeks.

“While binge drinking has been gradually declining among college students for the past few decades, this is a new historic low, which may reflect effects of the COVID-19 pandemic in terms of reduced time with college friends,” said Schulenberg in a media release.

Psychiatrist Encourages Informing Patients About Marijuana Risks

“The changes that we’re seeing now have been unfolding for the past 10 to 15 years,” Elie G. Aoun M.D., an assistant professor of clinical psychiatry at Columbia University, told Psychiatric News. Marijuana is easier to use without detection than alcohol, particularly the edible and vaped forms of the drug. It may also be easier for young adults to obtain, since many states now allow purchase by young adults at age 18, compared with age 21 for alcohol.

Aoun said patients may have the misconception that marijuana use is “healthy,” he said. “However, the vast majority of people are not using marijuana for its medical benefits. People use it as a drug because they want to achieve a state of feeling high and of feeling pleasure. That can be a personal choice. But it doesn’t come without costs.” He noted that marijuana use may cause sleep disturbances, cognitive distress, reduced motivation and energy, memory difficulties, poorer performance at work and school, and, for those with psychiatric disorders, deteriorating psychiatric symptoms.

What’s the bottom line? “We need to talk, talk, talk with our patients and have honest conversations about marijuana use. We shouldn’t shy away from this just because marijuana has become so available,” he said. “We can apply the same model with our patients that we use with alcohol: Recognize that it’s not necessarily a bad thing [for people] to have a drink, but that it can be problematic when they’re having consequences, when they have an addiction, or when they’re using it because they’re too depressed or anxious.”

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Wednesday, September 8, 2021

Study Reveals Patterns of Youth Emergency Visits for Suicide During the Pandemic

Youth aged 5 to 17 were more likely to present to an emergency department (ED) for suicidal thoughts and behaviors in the second half of 2020 compared with the same period in 2019, a study in JAMA Psychiatry has found.

Specifically, suicide-related ED visits among female youth from June 1 to December 15, 2020, were significantly higher than in the corresponding months in 2019. Youth with no history of outpatient mental health or suicide visits and those with comorbid psychiatric conditions documented at the ED visit also had a higher risk of presenting with suicide-related problems from September to December 2020 compared with the same period in 2019.

“As suicide-related encounters have made up more ED volume during the pandemic, increasing ED-based interventions, staff trained in addressing emergency mental health needs, and aftercare resources may also be valuable in addressing the needs of this population,” wrote Kathryn K. Ridout, M.D., Ph.D., of The Kaiser Permanente Medical Group and colleagues.

Ridout and colleagues analyzed electronic health record data for patients aged 5 to 17 years seeking emergency care for suicidal thoughts or behaviors at Kaiser Permanente Northern California from January 1, 2020, to December 15, 2020, and for the same dates in 2019. The researchers focused on four time frames: pre–COVID-19 pandemic period (January 1 to March 9), the period during which shelter-in-place orders were in effect in the Bay Area and California (March 10 to May 31), the summer (June 1 to August 31), and the fall (September 1 to December 15).

There were 2,123 youth with suicide-related ED encounters in 2020 compared with 2,339 in 2019. The following patterns were found:

  • The incidence rates of suicide-related ED encounters were significantly lower in March through May 2020 compared with this period in 2019—likely because of shelter-in-place orders at the beginning of the pandemic—before returning to prepandemic levels in June through December 2020.
  • Female youth had an 11.4% higher risk of presenting with suicidal thoughts or behaviors during the fall compared with the same period in 2019, while male youth had a 21.3% lower risk of presenting with suicidal thoughts or behaviors during this period.
  • Relative to all youth ED encounters, youth with no history of outpatient mental health encounters during the previous two years had a 129.4% higher risk of a suicide-related ED encounter during the fall of 2020 compared with fall of 2019.
  • There was a 6.7% higher risk of having a comorbid psychiatric nonsubstance diagnosis at the time of the suicide-related ED encounter during the fall of 2020 compared with 2019.

“Preventive efforts, including mental health screening, psychoeducation, and support in connecting to care, may be particularly valuable for these youth and their families,” the researchers wrote. “Innovative and immediately accessible tools for mental health care, such as technology-based care, may address the needs of this population as well.”

For related information, see the Psychiatric Services article “Universal Suicide Risk Screening for Youth in the Emergency Department: A Systematic Review.”

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Tuesday, September 7, 2021

Irritability at Age 3 May Predict Psychiatric Disorders in Adolescence

Irritability in preschool-aged children may point to youth at risk of developing psychiatric disorders in adolescence, according to a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

“[O]ur findings underscore the clinical significance and predictive validity of early childhood irritability,” wrote Leah K. Sorcher and Lea Dougherty, Ph.D., of the University of Maryland and colleagues. “Preschool irritability predicted internalizing and externalizing disorders in adolescence, parent-reported anxiety and depressive symptoms [in the youth], and greater functional impairment, even after controlling for baseline psychiatric disorders.”

The findings were based on information collected as part of the Stony Brook Temperament Study—a longitudinal study investigating the role of early child temperament on the development of internalizing disorders. At the start of the study, parents were asked questions about their 3-year-olds’ irritability, other psychiatric symptoms, and functional impairment. When these children reached age 12 and/or 15, both parents and youth were asked questions about any psychiatric symptoms the youth were experiencing, including symptoms of anxiety and depression as well as suicidal thoughts. Additionally, they answered questions about the youth’s physical health and overall functioning.

“[I]rritability at age 3 predicted adolescent anxiety disorders, including specific phobia, social phobia, and [generalized anxiety disorder]; and ADHD and [disruptive behavioral disorders],” Sorcher, Dougherty, and colleagues wrote. Preschool irritability also predicted greater functional impairment in adolescence, including poorer peer functioning and physical health, and greater likelihood of nonsuicidal self-injury and use of psychiatric treatment, psychotropic medications, and educational services.

“These findings strongly support the need for early identification of irritability in young children and the importance of intervening as early as possible,” the authors concluded.

For related information, see the Psychiatric News article “Irritability in Childhood May Point to Teens at High Risk for Suicide.”

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Annual Meeting Submission Deadline Extended to September 30

The deadline to submit abstracts of general sessions, courses, and posters for the 2022 APA Annual Meeting has been extended to Thursday, September 30, at 5 p.m. ET. All proposals must be submitted through the abstract submission portal.


Friday, September 3, 2021

APA, Five Other Physicians Groups Condemn Texas Law Restricting Access to Abortion

Yesterday APA joined five other leading physician groups in opposing a Texas state law that took effect Wednesday banning abortions, medical counseling, and support related to abortion after six weeks of pregnancy.

“Our organizations, which represent nearly 600,000 physicians and medical students, strongly oppose any laws and regulations that interfere in the confidential relationship between a patient and their physician. This new law will endanger patients and clinicians, putting physicians who provide necessary medical care, or even offer evidence-based information, at risk, by allowing private citizens to interfere in women’s reproductive health decision making,” wrote APA, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Osteopathic Association in a statement. “Moreover, this law virtually eliminates women’s access to evidence-based, comprehensive care and information, and denies women their right to make decisions about their own health.”

The organizations stated that they are firmly against any policies that limit the evidence-based practice of medicine; threaten the patient-physician relationship; and inhibit the delivery of safe, timely, and necessary comprehensive care, including reproductive health services and information.

“To that end, we fundamentally oppose the unprecedented ability for private citizens to take legal action against individuals who help a woman obtain an abortion, including physicians providing necessary, evidence-based care for their patients,” they wrote. “Physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of punishment, harassment, or retribution.”

“Restrictive abortion and contraception policies have been shown to be related to an increased risk for a variety of mental health problems and may have a negative impact on the overall health of women, including physical, emotional, and social well-being. APA opposes interference in the doctor-patient relationship and laws that threaten the health and well-being of women,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.

For related information, see APA’s position statement on abortion and women’s reproductive health care rights.

Annual Meeting Submission Deadline Extended to September 30

The deadline to submit abstracts of general sessions, courses, and posters for the 2022 APA Annual Meeting has been extended to Thursday, September 30, at 5 p.m. ET. All proposals must be submitted through the abstract submission portal.


Thursday, September 2, 2021

Telepsychiatry-Based Collaborative Care Approach as Effective as Traditional Referrals

A telepsychiatry-based collaborative care model (CoCM) for managing patients with posttraumatic stress disorder (PTSD) or bipolar disorder was as effective as telepsychiatry-enhanced referral at improving patient outcomes over one year, according to a study in JAMA Psychiatry.

“This study expands the evidence base for CoCM in two ways: First, it demonstrates that the CoCM can effectively manage more complex [psychiatric] disorders just as well as referring to a specialist,” lead author John C. Fortney, Ph.D., the director of the Division of Population Health and professor of psychiatry and behavioral sciences at University of Washington’s School of Medicine, told Psychiatric News. “Second, it adds to the small evidence base that CoCM can be delivered through a virtual care team using video visits. In other words, members of the CoCM team do not need to be physically located together.”

The study took place in 24 primary care clinics that had no psychiatrist or psychologist on site in rural Arkansas, Michigan, and Washington. All 1,004 participants were adults who screened positive PTSD and/or bipolar disorder during an annual wellness visit. Most were already receiving psychotropic medications prescribed by a primary care physician, but none were seeing a mental health specialist. The patients were randomized to one of the following groups:

  • Telepsychiatry collaborative care: Following a diagnostic assessment from a consulting telepsychiatrist, patients were prescribed all psychotropic medications by the primary care clinician, who was supported by behavioral health care managers (for example, social workers or nurses) and off-site telepsychiatrist consultants. Behavioral health care managers, who checked in with telepsychiatrists weekly, monitored patient symptoms and provided psychoeducation, psychotherapy, and treatment engagement activities.
  • Telepsychiatry/telepsychology–enhanced referral: Patients were referred for a telepsychiatry visit to confirm a diagnosis and develop a treatment plan. Afterwards, the telepsychiatrist ordered lab tests, prescribed medications, and/or referred for psychotherapy. Telepsychiatrists and telepsychologists monitored patient symptoms.

The patients were given phone or online surveys at baseline, six months, and 12 months to assess their mental health functioning using the Veterans RAND 12-item Health Survey Mental Component Summary (MCS).

The researchers found that patients in both groups experienced large, clinically meaningful improvements in MCS scores from baseline to 12 months (9-point to 10-point increase on average). Both groups also had greater perceived access to and engagement in care and experienced fewer adverse effects from psychotropic medications. However, the telepsychiatry/telepsychology–enhanced referral group had three times more encounters with telepsychiatrists (4.3 visits on average for referral group vs. 1.4 visits for collaborative care group).

“From a health care system perspective, [the] results suggest that clinical leadership should implement whichever evidence-based practice [collaborative care or referral] is most sustainable,” Fortney and colleagues wrote. “From a societal perspective, [telepsychiatry collaborative care] should be incentivized by policy makers because it leverages scarce telepsychiatrist capacity through consultation and case-review.”

For related information, see the Psychiatric News article “Collaborative Care Fits COVID-19 Workflows.”

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Wednesday, September 1, 2021

Study Points to Soldiers Most Likely to Attempt Suicide Within 30 Days of Suicidal Thoughts

About 3.5% of U.S. Army soldiers who were diagnosed with suicidal thoughts attempted suicide within 30 days of reporting these thoughts, according to a report in AJP in Advance. Those most likely to attempt suicide within 30 days of reporting suicidal thoughts were women, combat medics, individuals with a pre-existing anxiety disorder, and those with a sleep disorder.

“Although the majority of soldiers who attempt suicide have no history of administratively documented ideation, there is a significant minority whose suicidal thoughts are diagnosed prior to their attempt,” wrote Holly B. Herberman Mash, Ph.D., and Robert J. Ursano, M.D., of the Uniformed Services University of the Health Sciences, Bethesda, Md., and colleagues. “This paper importantly speaks to psychiatrists and other mental health care providers who have to make difficult treatment and management decisions for those specifically struggling with suicide ideation,” Ursano noted in a media release.

The researchers analyzed data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) collected between 2006 and 2009. The authors identified 11,178 active-duty soldiers with medically documented suicidal ideation and no prior medically documented suicide attempts. They examined risk factors for suicide attempt within 30 days of first suicidal ideation including sociodemographic characteristics, psychiatric diagnoses, injuries, history of family violence, and criminal history or history of being victim of crime.

Among soldiers with documented suicidal ideation, 830 (7.4%) attempted suicide and 387 (46.3%) of these did so within 30 days of their ideation. Women with suicidal ideation were 1.3 times more likely than males to attempt suicide in the first 30 days, and combat medics were 1.6 times more likely to attempt suicide than other service members with suicidal ideation.

Additionally, soldiers diagnosed with a sleep disorder on the same day that they were diagnosed with suicidal ideation were more than twice as likely to attempt suicide than those without a sleep disorder. Those with a pre-existing anxiety disorder were 1.3 times as likely to attempt suicide as soldiers who did not have that diagnosis.

“Developing screening tools specifically for suicidal ideation may help identify individuals at imminent risk,” the researchers wrote. “Future research should include examination of attempt methods as predictors of imminent attempt risk and the contribution of treatment and treatment-related factors in the transition of ideation to attempt.”

APA President Vivian Pender, M.D., noted that September is Suicide Prevention Month, and said the AJP study will help identify individuals most at risk for suicide. “It is also a reminder that we can all play a role in preventing suicide by learning to recognize signs of distress and reaching out to connect anyone at risk with help,” she said.

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

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Tuesday, August 31, 2021

People With Disabilities at Elevated Risk of Suicidal Behavior, Study Suggests

People with disabilities appear to be significantly more likely to think about, plan, and/or attempt suicide than people without disabilities, according to a report in the American Journal of Preventive Medicine. Individuals with multiple disabilities were found to be at a particularly heightened risk of suicidal behavior.

The findings highlight the need to consider functional disability when implementing suicide prevention strategies, “particularly the presence of complex activity limitations or multiple disabilities,” wrote Nicole M. Marlow, Ph.D., M.S.P.H., of the University of Florida and colleagues.

Marlow and colleagues analyzed data collected as part of the National Survey on Drug Use and Health between 2015 and 2019. The final sample included 198,640 U.S. adults who had answered survey questions regarding the presence or absence of any suicidal thoughts, plans, and attempts during the 12 months prior to the survey. These respondents also answered six questions about the presence or absence of functional disabilities.

The researchers categorized the respondents into seven groups based on their reported functional disability type; these groups included those with no functional disability, hearing limitation only, vision limitation only, cognitive limitation only, mobility limitation only, complex activity limitation only, and ≥2 limitations. The researchers also categorized respondents into six groups based on the number of disabilities they reported (0, 1, 2, 3, 4, or ≥5 limitations)

Overall, 19.8% of respondents reported any disability. People with any disability were found to be more than twice as likely to report suicidal ideation, suicide planning without attempt, and suicide attempt compared with people without disabilities. Among disability categories, individuals with a cognitive limitation or complex activity limitation had the highest rates of suicidal behaviors. Additional analysis revealed that those with ≥5 limitations were nearly four times as likely to report suicidal ideation, more than six times as likely to report suicide planning without attempt, and more than eight times as likely to report a suicide attempt compared with people without a disability.

“Because many disability types tend to be associated with an increase in prevalence as well as severity with aging, the results of this study may underestimate the extent to which suicide-related outcomes reduce quality of life over time,” Marlow and colleagues wrote. “Future research should examine how functional disability is associated with suicide-related outcomes over time.”

For related information, see the Psychiatric Services article “Predictors of Mental Health Crises Among Individuals With Intellectual and Developmental Disabilities Enrolled in the START Program.”

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Monday, August 30, 2021

Integrative Oncology Care May Reduce Emotional Distress in Cancer Patients

Cancer patients undergoing chemotherapy who regularly attended a weekly integrative oncology program had lower levels of depression, anxiety, and sleep problems than patients who did not regularly attend the program, according to a report in Psycho-Oncology.

“Emotional distress is one of the leading challenges facing supportive and palliative oncology care,” wrote Eran Ben‐Arye, M.D., of Technion‐Israel Institute of Technology in Haifa, Israel, and colleagues. Several studies have suggested that integrative oncology care—which combines complementary therapies with conventional cancer treatments—may reduce some symptoms in patients with cancer. Ben-Arye and colleagues specifically focused on the impact of such programs on emotional distress in cancer patients.

They examined data from 439 adults who received personalized integrative oncology care while undergoing chemotherapy for localized cancer (stages 1-3). After an initial hour-long consultation, patients were invited to attend weekly 30- to 45-minute integrative oncology sessions tailored to their needs. These sessions included guidance on herbal supplements, acupuncture, reflexology, music therapy, and more.

The researchers evaluated patients’ depression, anxiety, and sleep quality using the Edmonton Symptom Assessment Scale (ESAS) and quality of life was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC) at baseline and six weeks later. They compared outcomes in 260 patients who attended at least four integrative oncology sessions over a six-week period with 179 patients who attended fewer sessions.

After six weeks, the patients who attended four or more integrative oncology sessions showed significantly greater improvements in both ESAS and EORTC scores compared with patients who attended fewer sessions. The benefits of attending the integrative oncology sessions were most pronounced in patients with moderate or high anxiety levels (ESAS anxiety scores of 4 to 10) at baseline.

“Patients with baseline mild ESAS anxiety showed no improvement for any of the study outcomes, with some in the high- and low‐[adherence to integrative oncology] groups reporting worsening ESAS anxiety scores at six weeks,” the researchers noted. “The reduced beneficial effect of the [integrative oncology] program on emotional distress in patients with low baseline ESAS anxiety scores presents an opportunity to explore this unique subgroup of patients. It is possible that what appears to be a worsening of ESAS anxiety scores in this group at six weeks was not due to symptom progression but rather an increased willingness to open up with time to the [integrative physicians and integrative oncology] practitioners.”

To read more on this topic, see the Psychiatric News article “Understanding the Breadth and Depth of the Subspecialty: Psycho-Oncology.”

Friday, August 27, 2021

People Experiencing Mental Crisis Less Likely to Face Arrest When Police Pair With MH Professionals

Individuals experiencing a mental health crisis were less likely to be arrested following a 911 call if a police officer and mental health professional responded to the call together compared with if the police responded alone, according to a report published Thursday in Psychiatric Services in Advance.

Katie Bailey, M.P.A., and Bradley Ray, Ph.D., of Wayne State University in Michigan and colleagues analyzed data collected as part of a co-response team (CRT) pilot in an Indianapolis Metropolitan Police Department from August 1 through December 31, 2017. The team—involving a police officer trained in crisis intervention, a master’s-level mental health professional, and a local EMS paramedic—responded when 911 calls involved a person with suspected mental health or substance use issues, including suicidal ideation; indicated a need for an officer trained in crisis intervention; and/or involved a person who frequently used emergency services.

The researchers compared the outcomes of people who received CRT responses to 911 calls with people who received treatment-as-usual responses to 911 calls (calls received by separate Indianapolis police districts). The authors examined two immediate outcomes following the CRT or treatment-as-usual response: jail booking (within 24 hours of the 911 call) and emergency detention (involuntary admittance to a hospital). They also compared the groups’ subsequent EMS contacts and jail bookings six months and 12 months after the 911 call.

Individuals in the CRT group were 52% less likely than those in the treatment-as-usual group to be booked into jail within 24 hours of the call. However, those in the CRT group were 71% to 85% more likely to have had subsequent encounters with EMS at 6- and 12-month follow-up.

“[T]he mechanism through which Indianapolis’s CRT response resulted in higher rates of subsequent EMS contact … is difficult to identify,” the researchers wrote. “Perhaps EMS involvement in the Indianapolis CRT resulted in individuals’ perceiving EMS as an effective means of managing a crisis and thus increased utilization of subsequent services.”

Both groups had a similar likelihood of emergency detention at the time of the call and a similar likelihood of being booked into jail at six and 12 months.

“Our findings suggest CRTs may reduce short-term incarceration risk but may not have a positive impact on long-term outcomes,” the researchers added. “Future research should consider the extent to which CRT and follow-up services improve engagement with stabilizing treatment services, which may reduce the likelihood of future crises.”

For related information, see the Psychiatric News article “Psychiatrists Can Help Train Police in Crisis Response.”

(Image: iStock/Chalabala)

Thursday, August 26, 2021

Stanford Initiative Aims to Educate Media About Responsible Suicide Reporting

In 2017, the popular Netflix drama “13 Reasons Why” became one of the most controversial series of the year because of its depiction of the fictional suicide of a 17-year-old girl. After its release, Google searches for “how to commit suicide” and “how to kill yourself” increased dramatically, and a 2020 study reported that the suicide rate among youth spiked 29% above historical trends in the month after the release of “13 Reasons Why.”

It is not surprising: An enormous body of research from American and international researchers—some of it dating back to the 1980s—has firmly established that certain kinds of media reporting on suicide deaths, and depictions of suicide in movies and television dramas, can influence suicide contagion, especially among young people.

To address that problem, the Media and Mental Health Initiative in the Department of Psychiatry at Stanford University aims to promote public education about mental health and suicide through proactive, sustained engagement with content producers in the news media, entertainment media, and social media.

“This collaborative project will systematically embed evidence-informed guidelines across all media platforms to advance narratives that promote hope, help seeking, and awareness about mental health and suicide while mitigating harmful ones,” said Steven Adelsheim, M.D., director of the Stanford Center for Youth Mental Health and Wellbeing and a member of the APA Council on Children, Adolescents, and Their Families.

The initiative is an outgrowth of a 2018 meeting of concerned psychiatrists and representatives from media outlets at the APA Annual Meeting in New York.

The World Health Organization, in collaboration with the International Association for Suicide Prevention, has formulated guidelines to promote responsible reporting about suicide. Some of those recommendations include avoiding prominent placement of stories about suicide and undue repetition of stories about suicide and never describing the method used or providing details about the site or location.

Victor Schwartz, M.D., a clinical associate professor of psychiatry at New York University School of Medicine who has partnered with Adelsheim in developing the new initiative, urges psychiatrists to visit the website of the Media and Mental Health Initiative and become involved. “It is an opportunity for psychiatrists to help educate journalists and the public about suicide risks and suicide contagion and about mental health and mental illness generally,” he said.

For more information about the initiative and a list of the media guidelines, see the Psychiatric News article “Psychiatrists Create Initiative to Educate Media About Suicide Contagion.”

(Image: iStock/svetikd)

Wednesday, August 25, 2021

APA Urges Attention to Veteran and Refugee Mental Health During Evacuation From Afghanistan

The news and images coming out of Afghanistan over the last several days have been difficult to watch. APA extends sympathy to the people of Afghanistan and to the U.S. and allied service members who worked to establish peace in the country over the past 20 years.

“The needs of returning soldiers, Americans and allies stationed in Afghanistan, and Afghan refugees are liable to be profound," said APA President Vivian Pender, M.D. "We know that the effects of trauma are long-lasting and take many forms. The APA wants to extend its knowledge and resources around trauma-based care, grounded in years of research, to assist all those coming from Afghanistan.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., agreed. “It is critical that we provide mental health access and support to service members, those in the foreign service and their families, and their Afghan co-workers and families who were evacuated,” he said. “The many refugees and U.S. asylum seekers are at higher risk of developing mental disorders such as depression or posttraumatic stress disorder due to the trauma of fleeing their country.”

Levin said APA and its members stand ready to support those affected in the weeks and months ahead. “We should ensure that our country provides the needed mental health resources to address this traumatic situation for all who need them.”

He added that these recent events are liable to trigger a range of emotions from anger to concern for the people left behind. APA recommends that anyone impacted by these recent events connect with friends and support systems and seek professional help if needed. Talking about a traumatic experience can be very beneficial to mental health. When complex feelings are left unaddressed, they can manifest as stress, anxiety or more serious mental disorders.

The following resources are available for those in need:

For related information, see the American Journal of Psychiatry, “Trauma and Resiliency: A Tale of A Syrian Refugee.”

Tuesday, August 24, 2021

Rawle Andrews Jr. Esq. Named Executive Director of APA Foundation

Rawle Andrews Jr., Esq., has been named executive director of the American Psychiatric Association Foundation (APAF) and will assume his new post on September 27.

Andrews comes to APAF from AARP (American Association of Retired Persons), where he served for 15 years, most recently as vice president. He was a member of the national leadership team overseeing the organization’s field operations in the seven largest and most diverse states in the country, including California, Florida, New York, and Texas.

The APAF is APA’s charitable foundation. As executive director, Andrews will oversee APAF’s efforts to raise awareness about mental health, overcome barriers to access, invest in the future leaders of psychiatry, support research and training to improve care, and lead partnerships to address public challenges in mental health.

“Rawle Andrews’ record of results and action, coupled with his passion for health equity, will make him an excellent leader for the APA Foundation,” said APA CEO and Medical Director and APAF Board Chair Saul Levin, M.D., M.P.A. “He joins a strong organization that does so much to improve our nation’s mental health, and I’m excited to see what the Foundation will achieve with him at the helm.”

During his 15-year tenure at AARP, after joining as Managing Attorney, Legal Counsel for the Elderly, Andrews led business, financial and external affairs for the Maryland state office. He then was named a vice president in 2011, and moved into his current role in 2015, where he launched a new strategic business unit that represents nearly half of AARP’s membership.

Andrews expressed gratitude to Amy Porfiri, M.B.A., who has been serving as the organization’s interim executive director during the pandemic. She will return to her position as the foundation’s managing director.

“I am honored and humbled to be joining the APA Foundation at such a dynamic time in this country and beyond,” Andrews said. “Mental health awareness and the need for medical help are growing exponentially. Working together, our Board, staff, fellows, and community partners will continue to meet this moment with focus, determination, and consistency while introducing the APAF to new communities where our neighbors in need live, learn, work, worship, and play.”

Andrews was a psychology major at Texas Southern University and graduated with honors from the Howard University School of Law. He spent 16 years practicing law before joining the AARP management team. He was honored with the D.C. Bar’s Pro Bono Lawyer of the Year Award in 2006 and the Distinguished Healthcare Leadership Award by the National Association of Healthcare Services Executives in 2018. Andrews serves as president-elect of the Bar Association of D.C., an adjunct professor at Howard Law, a member of the Board of Directors of the Thurgood Marshall Center Trust, and national chair of the public policy committee for Kappa Alpha Psi Fraternity Inc.

Monday, August 23, 2021

Lower Antipsychotic Doses May Still Prevent Schizophrenia Relapse, Study Suggests

Patients on maintenance antipsychotic treatment may not require more than 5 mg of risperidone daily (or equivalent) to keep their risk of schizophrenia relapse low, according to a meta-analysis published in JAMA Psychiatry. Doses higher than this amount may provide a little additional protection but also cause more adverse events.

“Because patients often need to use antipsychotics for many years, adverse events, such as movement disorders and weight gain, can accumulate and result in even more severe problems, such as tardive dyskinesia or cardiovascular problems,” wrote Stefan Leucht, M.D., of the Technical University of Munich and colleagues. “Therefore, psychiatrists need to know which doses are sufficient for maintenance treatment. If lower doses than needed for short-term treatment were sufficient, the adverse-event burden could be substantially reduced.”

Leucht and colleagues combined data from 26 placebo-controlled studies that assessed relapse prevention of antipsychotics. The collected sample encompassed 4,776 patients and the following medications: oral and LAI aripiprazole, fluphenazine LAI, oral and LAI haloperidol, oral lurasidone, oral and LAI olanzapine, paliperidone LAI, oral quetiapine, risperidone LAI, oral ziprasidone, and oral zotepine. To maintain consistency, all antipsychotic doses were converted to their equivalent dose of oral risperidone.

Overall, the effectiveness of antipsychotics increased sharply at lower doses but then began to plateau. Sixty-seven percent of patients who took placebo relapsed, compared with 42% of patients taking 2.5 mg risperidone equivalents daily, 29% of patients at 5 mg daily, 25% at 7.5 mg daily, and 22% at 10 mg daily. Meanwhile, the risk of adverse side effects rose linearly with dose. For example, the dropout rate due to side effects was 4% with placebo, 4.7% at 2.5 mg risperidone equivalent daily, 5.5% at 5 mg daily, 6.5% at 7.5 mg daily, and 7.7% at 10 mg daily.

Based on this risk-benefit data, Leucht and colleagues calculated that a maintenance dose equivalent to 5 mg risperidone daily was optimal. Among patients taking potent first-generation antipsychotics such as haloperidol or fluphenazine, the optimal level was 3 mg daily, while for patients who had achieved full remission of symptoms, the optimal level was 2.5 mg daily. For comparison, risperidone is typically dosed between 4 mg to 16 mg daily for management of acute symptoms.

“The results of our meta-analysis may provide some guidance based on average patients with chronic disease. The dose-response associations in specific populations are likely to be different,” Leucht and colleagues noted. “For example, doses might be lower for patients with a first episode of schizophrenia and higher for treatment-resistant patients. Moreover, the substantial interindividual variability in all these outcomes is important to consider. Individual dosing decisions should be guided by patient wishes. For many patients, adverse events may be a priority, and for many others, avoidance of relapse may be more important.”

For related information, see the Psychiatric News article “What Antipsychotic Dose Is Most Effective?

(Image: iStock/Olivier Le Moal)

Friday, August 20, 2021

Telehealth Finds Favor Among Patients With Substance Use Disorders

Patients with substance use disorders (SUDs) who have used telehealth services during the COVID-19 pandemic are largely satisfied with the quality of care they receive, suggests a small study in the American Journal on Addictions.

Dawn E. Sugarman, Ph.D., of McLean Hospital in Belmont, Mass., and colleagues analyzed data from a 23-item online survey taken by 58 adult patients with SUDs who used telehealth through the hospital’s outpatient Alcohol, Drug, and Addiction Treatment Program during the pandemic. The survey assessed the frequency and type of services the patients received via telehealth, as well as the patients’ satisfaction with telehealth for each treatment service, preference for service delivery type (for example, telehealth, in-person, a mix of both, no preference), factors they liked and disliked about telehealth, and technical issues accessing telehealth.

The majority of patients—78%—were engaged in group therapy, 52% were receiving individual therapy, and 41% were receiving medication management services. Only 8.6% reported that they had ever received telehealth treatment services before the pandemic.

Overall, 86.2% of the patients reported that they were “very satisfied” or “satisfied” with the quality of telehealth care they received and 82% reported that telehealth visits met their needs “equally well” or “better” than in-person visits. Furthermore, 90% of those who received individual therapy and 75% of those who received medication management via telehealth reported feeling “very satisfied” with the services they received. However, only 58% of those who received group therapy reported feeling “very satisfied” with receiving this service via telehealth, and 36% of these patients reported that they did not connect as well with other group members as they did in person.

Despite their general satisfaction with telehealth, only 36% of participants preferred individual therapy via telehealth, while 43% and 48% preferred group therapy and medication management visits via telehealth, respectively. Another 19% to 25% of patients preferred a mix of telehealth and in-person treatment depending on the type of services they received.

“[T]he majority of participants preferred care that included telehealth—either as their sole mode of treatment or as some part of their care combined with in-person treatment,” Sugarman and colleagues wrote. “When the mode of treatment delivery is not dictated by COVID-19 safety guidelines, it will be important to understand how best to offer telehealth to patients (hybrid or sole mode of treatment), and which individual treatment characteristics to consider.”

For related information, see the Psychiatric News article “Telehealth Options for Treating Patients With SUD Expand.”

(Image: iStock/gpointstudio)

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Thursday, August 19, 2021

Most Adolescents Have Tried or Want to Quit Vaping, Study Reports

More than half of adolescents who vape said that they intend to quit and about two-thirds had tried to quit during the past year, according to a study of middle and high school students published online in Pediatrics. These numbers reflect a significant increase in the intention and number of attempts to quit compared with the results of a similar survey of adolescents in 2017. That survey found that 44% of the respondents had thought seriously about quitting and 25% had tried.

The study in Pediatrics also revealed that adolescents’ perceived harm from vaping is strongly associated with their intention to quit and attempts to quit in the past year.

“[I]t is alarming that 44.5% of current e-cigarette users still perceived e-cigarette use as no harm or little harm, which could dampen the motivation for vaping cessation,” wrote author Hongying Dai, Ph.D., of the University of Nebraska Medical Center College of Public Health.

Dai analyzed the responses from 1,660 students in grades 6 through 12 who participated in the National Youth Tobacco Survey in 2020 and had reported using e-cigarettes one or more times in the past month. That survey estimated that 20% of high school students and 5% of middle school students were current e-cigarette users. Dai was interested in what factors influenced students’ intentions to quit vaping and past-year quit attempts.

Dai found that more than half of students perceived e-cigarette use to be harmful (56%). These students were more than twice as likely to have intended to quit vaping within the year than those who did not perceive vaping as harmful. Among students who attempted to quit e-cigarettes in the past year, they averaged 5.3 attempts. The number of vaping quit attempts was lower in females than in males.

Other results include the following:

  • The type of e-cigarette device used by students had an impact on their intent to quit vaping. Adolescents using a “modifiable” system that allows users to add fruit or candy flavors and customize e-cigarettes for more efficient delivery of nicotine were 60% less likely to intend to quit, compared with those using cartridge-based or disposable e-cigarettes.
  • Four in 10 students reported using e-cigarettes as well other tobacco products. These students were 30% less likely to have attempted to quit vaping during the past year than those using solely e-cigarettes.
  • Students’ reasons for using e-cigarettes were also a factor in their intent to quit vaping. Students who reported using e-cigarettes due to curiosity or because a friend had used them were more likely to intend to quit, compared with those who used them to conceal their smoking at home or school.
  • Students who said they had seen or heard about the FDA’s campaign to educate youth about vaping risks, “The Real Cost,” had a higher intention to quit vaping (50% more likely) than those who hadn’t.

“These findings can inform the development of evidence-based vaping cessation interventions for clinicians and public health researchers,” Dai wrote in an email to Psychiatric News. “Clinicians should emphasize the adverse health outcomes of vaping and deliver the message that e-cigarettes, just like cigarettes, will increase the risks of nicotine addiction, respiratory injury, cardiovascular illnesses, and other tobacco-related diseases.”

For more information, see the Psychiatric News article “FDA Bans Some Flavored E-Cigarettes, but Advocates Say Policy Falls Short.”

(Image: iStock/Bulat Silvia)

Wednesday, August 18, 2021

Escitalopram Found to Reduce Anxiety in Patients With Coronary Heart Disease

Escitalopram appears to be more effective than exercise at reducing anxiety in patients with coronary heart disease, a study published today in JAMA Psychiatry has found.

“To our knowledge, [this study] is the first randomized clinical trial to evaluate the efficacy of a selective serotonin reuptake inhibitor or aerobic exercise in the treatment of anxiety in patients with [coronary heart disease] and high levels of anxiety,” wrote James A. Blumenthal, Ph.D., of Duke University Medical Center and colleagues. “Escitalopram produced clinically meaningful reductions in anxiety, as well as significant reductions in depression.”

Blumenthal and colleagues recruited men and women aged 40 years or older with coronary heart disease and anxiety symptoms (score of 8 or higher on the Hospital Anxiety and Depression-Anxiety Subscale, or HADS-A) and/or a DSM-5 primary diagnosis of an anxiety disorder for the trial. Patients were excluded if they had a primary psychiatric diagnosis other than an anxiety disorder, were currently receiving mental health treatment, and/or if they exercised regularly. A total of 128 participants were randomly assigned to aerobic exercise (three days a week), escitalopram (up to 20 mg a day), or a placebo pill for 12 weeks.

The researchers evaluated the patients using the Structured Clinical Interview for DSM-5 Disorders and the 14-item Hamilton Anxiety Rating Scale before and after the 12-week interventions. They also assessed the participants weekly using the Spielberger State-Trait Anxiety Inventory-State, which asks about the frequency of such feelings as “I am tense; I am worried.” Symptoms of depression (using the HADS depression subscale and Beck Depression Inventory-II) as well as heart rate variability, baroreflex sensitivity, and endothelial function—biomarkers for coronary heart disease—were also measured before and after the interventions.

Examination of HADS-A scores after 12 weeks revealed that all groups showed reduced levels of anxiety following treatment, with mean reductions of −4.0 in the exercise group, −5.7 in the escitalopram group, and −3.5 in the placebo group, Blumenthal and colleagues reported. Additional analysis revealed that participants in the escitalopram group had greater reductions in HADS-A scores compared with participants in the placebo group, while the exercise and placebo groups were not different.

“Although exercise achieved comparable reductions in state anxiety relative to escitalopram after 12 weeks and greater reductions compared with placebo controls, exercise did not result in lower anxiety scores compared with placebo on the HADS-A or on any of the supplemental trait anxiety measures,” the authors wrote. “There were no treatment-related differences in [coronary heart disease] biomarkers, so the clinical significance of these findings regarding potential cardiovascular benefits is unknown.”

For related information, see the chapter on heart disease in the book The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry.

(Image: iStock/bymuratdeniz)


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