Tuesday, April 13, 2021

Support for Women With Opioid Use Disorder May Be Key to Their Infants’ Survival

Infants who were exposed to opioids in utero but not diagnosed with neonatal opioid withdrawal syndrome shortly after birth appear to be at an increased risk of death compared with those who have been diagnosed with neonatal opioid withdrawal syndrome, suggests a study published Monday in JAMA Pediatrics.

“The findings of this study suggest that programs and policies to support women with opioid use disorder and their infants are warranted, regardless of perceived severity of neonatal opioid withdrawal,” wrote JoAnna K. Leyenaar, M.D., Ph.D., M.P.H., of Children’s Hospital at Dartmouth-Hitchcock Medical Center and colleagues.

Leyenaar and colleagues conducted a retrospective cohort study of mother-infant pairs using the Texas Neonatal Intensive Care Project dataset, which includes information on maternal health care claims/encounters during pregnancy and infant mortality. For mother-infant pairs to be included in the study, infants had to be born in Texas between 2010 and 2014 at a gestational age of 22 to 43 weeks to women aged 15 to 44 and insured by Texas Medicaid.

Among the 1,129,032 maternal-infant pairs included in the analysis, 7,207 had prenatal opioid exposure, including 4,238 infants who were diagnosed with neonatal opioid withdrawal syndrome and 2,969 who were not. The infant mortality rate was highest in opioid-exposed infants without neonatal opioid withdrawal syndrome (20 per 1,000 live births), compared with infants with a history of neonatal opioid withdrawal syndrome (11 per 1,000 live births) and infants with no prenatal opioid exposure (6 per 1,000 live births), the authors reported.

After adjusting for maternal and infant characteristics, Leyenaar and colleagues found that infants diagnosed with neonatal opioid withdrawal syndrome were no more likely to die during their first year of life than those with no history of prenatal opioid exposure. In contrast, the odds of death in opioid-exposed infants not diagnosed with neonatal opioid withdrawal syndrome was 72% greater than those infants with no history of opioid exposure.

“The postnatal period is one of substantial risk to women with OUD [opioid use disorder], including increased risks of treatment discontinuation, overdose, and postpartum depression,” Leyenaar and colleagues wrote.

“The findings of our study suggest that opioid-exposed infants are at increased risk of mortality during infancy, and the constellation of treatments and supports provided to infants diagnosed with [neonatal opioid withdrawal syndrome] may be protective. Clinical interventions, public health programs, and health policy to support women with OUD and their infants appear to be warranted, regardless of the perceived severity of neonatal opioid withdrawal,” they concluded.

For related information, see the American Journal of Psychiatry article “Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum During the COVID-19 Pandemic.”

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Members Invited to Apply for New Presidential Task Force on Social Determinants of MH

APA members are invited to apply for appointment to the new Task Force on the Social Determinants of Mental Health, which reflects the theme of incoming APA President Vivian Pender, M.D. There will also be eight work groups that will address major issues related to social determinants of mental health. The appointments begin on May 3 and conclude at the close of the 2022 Annual Meeting. Those interested should submit a CV, brief summary of expertise, and specific area of interest to TFSDOMH@psych.org by the deadline of by April 26.




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Monday, April 12, 2021

Hyperactive Delirium May Be Common Among Critically Ill COVID-19 Patients

Critically ill COVID-19 patients who develop delirium are likely to become hyperactive and agitated, suggests a small study published today in the Journal of Neuropsychiatry and Clinical Neurosciences. In general, patients with delirium tend to be hypoactive, or show quiet confusion.

The study by Juan D. Velásquez-Tirado, M.D., of Clinica Universitaria Bolivariana in Medellín and colleagues involved 20 adult inpatients with COVID-19 who had delirium diagnosed by the Liaison Psychiatry Service at a hospital in Medellín, Colombia. Eighteen of these patients were in the intensive care unit (ICU) at the start of the study. A liaison psychiatrist evaluated the COVID-19 patients using DSM-5, the Delirium Diagnostic Tool-Provisional (DDT-Pro), Delirium Etiology Checklist (DEC), and Delirium Motor Subtype Scale-4 (DMSS-4).

At baseline, all the patients had multiple problems known to contribute to delirium, with the most common being organ failure (present in all 20 patients), systemic infection (present in all 20 patients), and metabolic disturbances (present in 19 patients). Half of the patients had DDT-Pro scores of 2 or less (which indicates significant cognitive and circadian impairment), including six patients with a score of 0. Patients with more severe COVID-19 were more likely to have lower DDT-Pro scores. In contrast, preexisting medical problems did not correlate with DDT-Pro scores.

According to DMSS-4 assessments, 15 of the 20 patients presented with only hyperactive delirium, whereas only three patients developed the more common hypoactive delirium and one patient fluctuated between hyperactive/hypoactive states. All the patients received frontline therapy with haloperidol or quetiapine; two patients who did not respond to haloperidol were switched to quetiapine while a third was switched to levomepromazine. Eight patients received adjunct trazodone to help with sleep.

Five of the 20 patients died, and the analysis suggested that lower baseline DDT-Pro scores was related to increased mortality risk.

“Although studies in larger samples are needed, more severe delirium on admission to ICU for COVID-19 may be a harbinger of mortality even in patients who did not have much preexisting medical comorbidity,” the authors wrote.

To read more on this topic, see the Psychiatric News article “Do Not Forget Delirium During the COVID-19 Scramble.

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Friday, April 9, 2021

Study Identifies Risk Factors for Opioid Use Disorder, Overdose in Youth

Opioid use disorder (OUD) and overdose among young people who fill an initial opioid prescription are rare but more likely to occur in those who have other substance use disorders or who have mood or anxiety disorders, a study in Addiction has found.

Scott E. Hadland, M.D., M.P.H., M.S., of Boston University School of Medicine and colleagues analyzed data from the health insurance claims of more than 3.2 million youth aged 11 to 25 years who filled an initial opioid prescription between 2006 and 2016.

Within 12 months of first filling their opioid prescriptions, 0.3% of the patients either developed OUD or overdosed. Patients who had other substance use disorders were more than 20 times more likely to develop these complications than their peers who did not have a substance use disorder. Roughly 73% of those who developed OUD or overdosed had a comorbid substance use disorder. and of these, 33.4% used alcohol, 33% used cannabis, and 43.2% used nicotine.

Patients who had mood or anxiety disorders were 4.45 times more likely to develop either of these opioid-related complications than their peers who did not have the disorders.

“We do not advocate for withholding opioid prescriptions from youth with comorbid mental health conditions or substance use; however, clinicians might consider ensuring close follow-up … for youth identified as having comorbid mental health conditions or substance use to minimize the risk [of OUD or overdose],” the researchers wrote.

The researchers also found a link between formulations of opioids and increased risk of opioid-related complications. Taking long‐acting opioids more than doubled the risk of OUD or overdose compared with taking short-acting formulations. Similarly, taking opioids for 15 days or more doubled the risk compared with taking opioids for three or fewer days.

The researchers concluded that consistent with U.S. opioid prescribing guidelines for adults, opioid prescriptions for young people should be for short-acting formulations at the lowest dose and for a short duration.

For related information, see the Psychiatric News article “Polysubstance Use Common in SUD Patients.”

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Thursday, April 8, 2021

FDA Approves Once-Daily Nonstimulant for Treatment of ADHD

The Food and Drug Administration (FDA) has approved the selective norepinephrine reuptake inhibitor Qelbree (viloxazine extended-release) for the treatment of attention-deficit/hyperactivity disorder (ADHD) in youth 6 to 17 years of age. The nonstimulant drug, which is to be taken once a day, can be swallowed whole or opened and sprinkled into applesauce.

The efficacy of Qelbree was evaluated in three multicenter randomized, controlled trials. In the first trial, researchers randomly assigned 477 patients with ADHD aged 6 to 11 to receive Qelbree 100 mg, Qelbree 200 mg, or placebo once daily for six weeks. The patients were evaluated using the ADHD Rating Scale (ADHD-RS-5) and the Clinical Global Impression Improvement (CGI-I) scale at the start of the study and again at six weeks. Patients who received Qelbree 100 mg or Qelbree 200 mg experienced a greater reduction in ADHD-RS-5 total scores and improvements in CGI-I scores over the course of the trial compared with those who received placebo. The second trial involved 313 patients with ADHD aged 6 to 11 who were assigned to Qelbree 200 mg, Qelbree 400 mg, or placebo once daily for eight weeks. As seen in the first trial, patients who received Qelbree 200 mg or Qelbree 400 mg experienced greater reductions in ADHD-RS-5 total scores and improvements in CGI-I scores from baseline to the end of the study.

For the third trial, Qelbree was evaluated in patients aged 12 to 17 years: 310 youth with ADHD were randomly assigned to Qelbree 200 mg, Qelbree 400 mg, or placebo once daily for six weeks. As in the trials with the younger patients, these youth also experienced greater reductions in ADHD-RS-5 total scores and improvements in CGI-I scores from baseline to the end of the study.

“This approval offers a novel once-a-day sprinkleable nonstimulant that can be a great option for children and adolescents with ADHD,” Andrew J. Cutler, M.D., a clinical associate professor of psychiatry at SUNY Upstate Medical University, said in a press release from Supernus, maker of Qelbree. (Cutler has received consultant fees from Supernus.)

Qelbree’s label contains a boxed warning that the medication may increase the risk of suicidal thoughts and behaviors. Physicians are advised to monitor patients closely for “clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes.”

Data from the clinical trials suggest that the medication may induce manic or mixed episode in patients with bipolar disorder and/or increase blood pressure and heart rate. “Prior to initiating treatment with Qelbree, screen patients to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a personal or family history of suicide, bipolar disorder, and depression,” the label cautions. Assessing heart rate and blood pressure prior to initiating treatment as well as when increasing dosages is also advised.

According to the press release, the company plans to make Qelbree available in the United States later this year.




Webinars to Be Held Tonight on Impact of COVID-19 on MH of African Americans

Join APA for a two-part webinar series that will examine strategies and opportunities to improve the mental health of African Americans during the pandemic, while also raising awareness and building trust on the efficacy of the COVID-19 vaccine. The webinars begin at 7 p.m. ET.

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Wednesday, April 7, 2021

One-Third of COVID-19 Survivors May Develop a Neuropsychiatric Disorder Within Months of Infection

One-third of individuals diagnosed with COVID-19 developed a psychiatric or neurological problem within six months of their diagnosis, according to a study published Tuesday in The Lancet Psychiatry. The prevalence of a post-COVID neurologic or psychiatric diagnosis was even greater among individuals with severe illness who had required hospitalization.

“Given the size of the pandemic and the chronicity of many of the diagnoses and their consequences (for example, dementia, stroke, and intracranial hemorrhage), substantial effects on health and social care systems are likely to occur,” wrote Maxime Taque, Ph.D., of the University of Oxford and colleagues. “Our data provide important evidence indicating the scale and nature of services that might be required.”

Taque and colleagues used data from a multinational electronic health record (EHR) database to identify 236,379 patients diagnosed with COVID-19 on or after January 20, 2020, and who were still alive on December 13, 2020. This sample included 190,077 patients who did not require hospitalization and 46,302 who did (including 8,945 patients who required intensive care). For control groups, Taque and colleagues also examined the EHR records of patients diagnosed with influenza and patients diagnosed with any respiratory tract infection during the same period.

The researchers then investigated the occurrence of the following neuropsychiatric outcomes in the first 180 days after COVID-19 diagnosis: intracranial hemorrhage; ischemic stroke; Parkinson’s disease; Guillain-Barré syndrome; nerve, nerve root, and plexus disorders; neuromuscular disorders; encephalitis; dementia; psychotic disorders; mood disorders; anxiety disorders; substance use disorder; and insomnia.

Overall, 33.62% of COVID-19 patients received one of the above diagnoses within 180 days; this rate increased to 38.73% among patients who were hospitalized and 46.42% among patients admitted to intensive care. The rates of almost all these outcomes were higher in patients in the COVID-19 group compared with those in the influenza group or respiratory tract infection group. The exceptions were Parkinson’s disease and Guillain-Barré syndrome, which were similar in COVID-19 and influenza patients.

Anxiety disorders were the most common neuropsychiatric diagnoses among all patients, occurring in 17.39% of COVID-19 patients; they were followed by mood disorders in 13.66% of COVID-19 patients and substance use disorder at 6.58% of COVID-19 patients. Psychotic disorders were diagnosed in 1.40% of COVID-19 patients.

Compared with neurological disorders, the rates of mood and anxiety disorders did not significantly increase among hospitalized patients, Taque and colleagues noted. “This might indicate that their occurrence reflects, at least partly, the psychological and other implications of a COVID-19 diagnosis rather than being a direct manifestation of the illness,” they wrote.

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

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APA to Sponsor Webinars on Impact of COVID-19 on MH of African Americans

Join APA for a two-part webinar series that will examine strategies and opportunities to improve the mental health of African Americans during the pandemic, while also raising awareness and building trust on the efficacy of the COVID-19 vaccine. The webinars will be held on April 8 beginning at 7 p.m. ET.

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Tuesday, April 6, 2021

Bipolar II Disorder Associated With Higher Prevalence of Seasonal Affective Disorder

Patients with early-onset bipolar II disorder may be more likely to experience seasonal affective disorder (SAD) than those with other mood disorders, according to a study published in Depression and Anxiety.

“SAD can co-occur with several psychiatric disorders, including mood disorders,” wrote Heon-Jeong Lee, M.D., Ph.D., of the Korea University College of Medicine, and colleagues. They noted that although there have been debates on separating SAD as an independent diagnosis, DSM-5 recognizes seasonality as a specifier of major depressive disorder, bipolar I disorder, and bipolar II disorder.

The authors recruited 378 participants from the Mood Disorder Cohort Research Consortium study, a multicenter observational study of individuals with early-onset mood disorders including major depressive disorder, bipolar I disorder, and bipolar II disorder. The participants had to be either under 25 years old or under 35 years old and treated for a mood disorder for less than two years. Participants completed the Korean language version of the Seasonal Pattern Assessment Questionnaire to determine overall seasonal impairment and the Mood Disorder Questionnaire to identify bipolarity. The authors also recruited 235 health control subjects.

Of the participants, 138 were diagnosed with major depressive disorder, 101 were diagnosed with bipolar I disorder, and 139 were diagnosed with bipolar II disorder. Participants with mood disorders had higher overall seasonal impairment than the healthy controls. About 10% of participants with major depressive disorder and bipolar I disorder also had SAD, compared with 23% of those with bipolar II disorder and only 6% of the controls. Participants with bipolar I disorder had the highest proportion of winter-associated SAD, while those with major depressive disorder had the highest proportion of summer-associated SAD. Participants with bipolar II disorder were between two and three times more likely to experience SAD compared with those with major depressive disorder.

Additionally, the authors noted that previous studies have shown that SAD is more common in females than males. Their study, however, did not identify sex as a risk factor for SAD, which they hypothesized may be due to the younger age of the study sample and suggests that risk factors for seasonality in patients with early-onset mood disorder may differ between age groups.

“It remains unclear and needs further investigation to understand why [bipolar II disorder] has the highest seasonality among the mood disorders,” the authors wrote. “Considering the close relationship between [bipolar II disorder] and SAD, it may be helpful for clinicians to screen for seasonality in [bipolar II disorder] and bipolarity in those suspected to have SAD.”

For related information, see the Psychiatric News article “This Winter, Pandemic May Intensify Seasonal Depression.”

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APA to Sponsor Webinars on Impact of COVID-19 on MH of African Americans

Join APA for a two-part webinar series that will examine strategies and opportunities to improve the mental health of African Americans during the pandemic, while also raising awareness and building trust on the efficacy of the COVID-19 vaccine. The webinars will be held on April 8 beginning at 7 p.m. ET. 

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Monday, April 5, 2021

Psychotherapy Aimed at Social Engagement Reduces Depression Associated With Loneliness

A form of psychotherapy aimed at helping older adults feel more connected to other people reduced depression and improved quality of life for those who had reported they felt lonely and/or were a burden to people around them, according to a study in the American Journal of Geriatric Psychiatry.

“Social connection is essential for health and quality of life at all ages and may be an especially useful intervention target for promoting mental health in later life,” wrote Kimberly Van Orden, Ph.D., an associate professor of psychiatry at the University of Rochester, and colleagues.

The researchers adapted a manualized form of behavioral psychotherapy called Engage Psychotherapy to specifically target social connection among older adults at risk for suicide. Engage is designed to help patients reengage with the pleasant, physical, and/or social activities they may have stopped doing because of their depression. Participants create “action plans” that involve setting a goal, brainstorming ways to achieve the goal, and selecting specific actions to take before their next session. The form of Engage used in the study is called Social Engage, which includes psychoeducational materials to address the importance of social connection and instructions to therapists to focus action plans on social engagement.

Participating in the study were 62 adults aged 60 years or older who endorsed feeling lonely and/or feeling like a burden to others in the prior two weeks. Thirty-two individuals were randomly assigned to 10 sessions of Social Engage, and 30 were assigned to usual care. Follow-up assessments were at three weeks, six weeks, and 10 weeks.

Outcomes were measures of depression and suicidal ideation using the 16-Item Quick Inventory of Depressive Symptomatology (QIDS-C) clinician interview, the Geriatric Suicide Ideation Scale, and measures of social-emotional quality of life using the World Health Organization Quality of Life Scale.

Social Engage was associated with statistically significant improvements in depression at all timepoints and in social-emotional quality of life. It was not associated with a perceived sense of being a burden or belonging.

“[F]eedback from participants suggests that improvements may unfold over time, indicating a longer duration of intervention and follow-up may be needed to document improvement in subjective connection,” the researchers wrote. “[P]articipants reported increased insight and awareness of the importance of social connection, increased social engagement, and acquisition of skills to manage barriers to social engagement; however, it may take more time (and practice) to build/improve social connections that impact perceptions about social connection.”

For related information, see the Psychiatric News article “Loneliness Persists Even When Older Adults Live in Social Environments.

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APA to Sponsor Webinars on Impact of COVID-19 on MH of African Americans

Join APA for a two-part webinar series that will examine strategies and opportunities to improve the mental health of African Americans during the pandemic, while also raising awareness and building trust about the efficacy of the COVID-19 vaccine. The webinars will be held on April 8 beginning at 7 p.m. ET.

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Friday, April 2, 2021

Children of Parents With Bipolar Disorder at Risk of ADHD and Early Onset Bipolar, Study Suggests

Children who have a parent with bipolar disorder are more likely to develop attention-deficit/hyperactivity disorder (ADHD) during their preschool years than children with no family history of bipolar disorder, reports a study in Journal of the American Academy of Child and Adolescent Psychiatry. The study also found that these children were more likely to develop symptoms of bipolar disorder as they grew older.

“[Bipolar disorder] symptoms were scarce during the preschool years and increased throughout [early adolescence],” wrote Boris Birmaher, M.D., of the University of Pittsburgh School of Medicine and colleagues. “Developing early interventions to delay or, ideally, prevent [bipolar disorder] onset are warranted.”

Birmaher and colleagues recruited 116 children who had a parent with either bipolar I or II disorder (BD-I/II parents), 53 children of parents with a non-bipolar psychiatric disorder (non-BD parents), and 45 children of parents with no psychiatric disorder (healthy parents) for the study. All children were between the ages of 2 and 5 years at the start of the study and were periodically assessed for about 10 years using the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (KSADS-PL).

The researchers found that the children of BD-I/II parents were significantly more likely to have ADHD by age 5 (21.6% of children) than children of non-BD parents (3.8%) and children of healthy parents (2.2%). After age 5, children of BD-I/II parents and non-BD parents showed no statistical difference in rates of non-bipolar psychiatric disorders. However, compared with children of healthy parents, children of BD-I/II parents had elevated rates of anxiety, ADHD, and behavior problems after age 5.

During the study period, 17 of the children of parents with BD-I/II (about 15%) were diagnosed with bipolar disorder; four children developed BD-I/II and 13 developed BD-Not-Otherwise-Specified (BD-NOS), with an average age of onset of 11.4 and 7.4 years, respectively. (BD-NOS is typically diagnosed in people who show bipolar mood swings but the timing and/or intensity do not meet the full criteria of BD-I or BD-II.) None of the children in the other groups received a diagnosis of bipolar disorder during the study.

“Given that youth with BD-NOS exhibit as much psychosocial impairment, suicide risk, substance abuse, comorbid disorders, and family history of BD as youths with BD-I/II, and are at very high risk to transition into BD-I/II (particularly if they have family history of BD), the diagnosis of BD-NOS warrants significant clinical consideration,” Birmaher and colleagues wrote.

The researchers looked over the data to see which factors might help predict the youth who would develop bipolar disorder; the only significant risk factors they identified were an ADHD diagnosis before age 6 and having parents with early onset bipolar disorder.

To read more on this topic, see the Psychiatric News article “Study Sheds Light on Trajectory of Developing Bipolar Disorder.”

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APA Seeks Input on How Psychiatrists Can Address Racial Inequities

The APA Presidential Task Force to Address Structural Racism Throughout Psychiatry is fielding a new short survey. Help the task force inform its important work by responding to the survey by Wednesday, April 14. Learn more about the task force and view the results of its previous three surveys on the task force webpage.

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Thursday, April 1, 2021

Maternal Depression, Anxiety Worsened During Pandemic, Meta-Analysis Suggests

Postnatal depression and maternal anxiety appear to have increased worldwide during the COVID-19 pandemic, according to a meta-analysis published Wednesday in The Lancet Global Health.

“It is clear that pregnant individuals and babies have been subjected to harm during the pandemic, and the onus is on the academic community, health care providers, and policymakers to learn from it,” wrote Asma Khalil, M.D., of St. George’s University of London and colleagues.

Khalil and colleagues searched MEDLINE and Embase for studies published from January 1, 2020, to January 8, 2021, that compared maternal, fetal, and infant health outcomes before and during the pandemic. Studies that only included women infected with COVID-19 were excluded.

Of the 3,592 abstracts the authors screened, 40 studies from 17 countries were included in the analysis. Overall, the studies indicated increased maternal mortality, stillbirth, and maternal stress during the pandemic compared with before, with a particularly disproportionate impact on low- and middle-income countries.

Eleven studies compared maternal mental health outcomes before and during the pandemic, using such measurements as the Generalized Anxiety and Depression Scale, Inventory of Depression and Anxiety Symptoms, the Generalized Anxiety Disorder 7-item (GAD-7) Questionnaire, and the Edinburgh Postnatal Depression Scale, among others. Seven of these studies reported a statistically significant increase in postnatal depression, maternal anxiety, or both.

The authors hypothesized that the increase in adverse pregnancy outcomes could be attributed to reduced access to care. “Although maternal anxiety was consistently shown to [have] increased during the pandemic, health care providers around the world have reported reduced attendance for routine and unscheduled pregnancy care,” the authors wrote. “This reduction could be driven by concern about the risk of acquiring COVID-19 in health care settings, governmental advice to stay at home, or reduced public transport and childcare access during lockdowns.”

Other changes during the pandemic—including the reported increase in intimate partner violence, a rise in unemployment among women, and a greater burden of childcare responsibilities due to school closures—may also play a role in these adverse outcomes, the authors noted.

“Women’s health care is often adversely affected in humanitarian disasters and our findings highlight the central importance of planning for robust maternity services in any emergency response,” the authors concluded.

For related information, see the Psychiatric News articles “Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions” and “Pandemic Has Compromised Mental Health of New Moms.”

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Wednesday, March 31, 2021

Is Self-Censorship in Med School, Residency Applications Driving Burnout Among Physicians?

“From its earliest stages, a medical career unfolds within a culture of censorship of our vulnerabilities, a culture that contributes to burnout and depression.” So writes Michelle H. Silver, M.D., an internal medicine resident at the Hospital of the University of Pennsylvania, in an article in the New England Journal of Medicine describing the ways in which aspiring physicians are instructed early to censor their personal narratives in competing for medical school admission and residency slots.

In Silver’s case, this included censoring the story of her history of an eating disorder. “Like many of my pre-med colleagues, I agonized over what to write in my personal statement. … None of my ideas felt sufficiently personal—until I wrote the truth: I wanted to be a healer because of my past suffering from mental illness. The years I had spent coming to understand and recovering from my eating disorder had empowered me to apply those skills to my future patients. This experience, I believed, would make me an empathetic doctor, capable of taking a holistic approach to patients’ wellness.”

Silver quoted the disapproving advice of a physician who reviewed the statement: “While someone who knows you well can appreciate your openness. I don’t think it is a good idea to share this with an admissions committee. They won’t think you’re fit to enter into the medical field.”

“The irony was glaring: mental illness is even more prevalent among medical professionals and trainees than in the general population,” Silver wrote. “But it is so stigmatized that despite its disproportionate prevalence in the field I was about to enter, I had to pretend I’d never faced it.”

She found the same censoring voice when, in an application for residency, she described a challenging encounter with a critically ill patient and his family. Her mentor “explained that by describing an experience in which I had cried during routine medical practice, I was setting myself up to look unfit for the role—that I appeared ‘too emotional’ to handle the day-to-day work of a resident,” Silver wrote.

Silver argues that the censoring of personal stories is not only detrimental to individual doctors and to the field of medicine, but is also fueling the epidemic of burnout in American medicine.

“I hope that explicit criticism of the outdated tradition of devaluing life experiences deemed unpalatable by an admissions committee will inspire a cultural shift toward transparency,” she wrote. “In such a culture, our personal statements might in fact become personal—and could, collectively, become a celebration of diverse lived experiences, an opportunity for a more comprehensive appreciation of each person who aspires to become an empathetic and effective physician.”

For related information, see the Psychiatric News article “Symposium to Address Self-Disclosure of Mental Illness, Burnout Symptoms.”

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APA Seeks Input on How Psychiatrists Can Address Racial Inequities

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Tuesday, March 30, 2021

Psychiatrists Offer 5 Strategies for Integrating Videoconferencing Into OCD Treatment

People with obsessive-compulsive disorder (OCD) can benefit from medication and/or psychotherapy that teaches them to confront situations that trigger obsessive fears while refraining from performing compulsions. Yet, for many with OCD, these therapies may be out of reach due to therapists’ availability, cost, location, and more.

“Increasing evidence suggests that digital health technologies, including videoconferencing and other approaches (for example, online platforms, websites, and mobile applications) can circumvent these barriers,” wrote Reilly R. Kayser, M.D., of Columbia University’s Vagelos College of Physicians and Surgeons and colleagues in an article in Psychiatric Services in Advance.

One evidence-based treatment for OCD is exposure with response/ritual prevention (EX/RP)—a standardized treatment in which patients are encouraged to gradually approach feared stimuli through real-life and imagined exposures. Drawing from their experience at Columbia’s Center for OCD and Related Disorders, Kayser and colleagues describe five potential strategies for integrating videoconferencing into OCD treatment, including advantages and challenges of each approach:

Hybrid EX/RP: Beginning EX/RP treatment in person enables therapists to establish the therapeutic alliance with the patient, supervise patients’ successful completion of exposures before practicing them independently, and overall progress. Videoconferencing offers patients and therapists the ability to adapt when a patient moves, becomes ill, or other unexpected life events occur. When transitioning to remote treatment, it is important that therapists obtain informed consent and review with the patient the treatment model as well an overview of how the videoconferencing software works. “Licensure issues may occur with relocations, requiring clinicians to obtain limited permits or arrange local referrals,” they wrote.

Fully remote EX/RP: Patients who are homebound, live far from OCD treatment facilities, and/or feel significant shame about their symptoms may “find videoconferencing more tolerable than office-based care and may more readily seek remote treatment,” the authors continued. However, there are challenges to this approach: “A therapist might observe a patient’s engagement in safety behaviors onsite, but these may be less obvious over videoconferencing, limiting opportunities for corrective feedback. … Fully remote treatment may be inappropriate when patients struggle with adherence, have certain comorbid conditions (for example, psychosis, severe personality disorders), or face immediate safety concerns (for example, suicidality).”

Videoconferencing-assisted psychopharmacology: In some situations, medications may be the first-line therapy for patients with OCD, the authors noted. Videoconferencing can expand “expert pharmacological consultation and treatment beyond metropolitan centers (where most specialty programs are located).” Potential challenges to this approach include licensure and/or medication supply issues and the inability to perform a physical exam of the patient.

Virtual support groups: There is evidence to suggest that OCD support groups may reduce loneliness, isolation, and stigma while reinforcing cognitive-behavioral therapy techniques. Virtual support groups have the advantage of allowing patients to see each other without the logistical challenges of in-person meetings. “We recommend groups with trained moderators to ensure that treatment does not inadvertently reinforce accommodation of symptoms or avoidance,” they wrote.

Videoconferencing-assisted clinical supervision: Videoconferencing can also be used to facilitate and increase access to clinical supervision. “Similar to traditional supervision, online software allows supervisors to view trainees’ recorded treatment sessions and provide retrospective feedback. Supervisors can also passively view sessions with video or audio disabled, activating video or audio at key moments to provide real-time feedback.”

The authors concluded, “Although digital health technologies such as videoconferencing are unlikely to replace in-person OCD treatment, they are quickly becoming important tools to increase access and improve care for this debilitating, undertreated condition.”

For related information, see the Psychiatric News article “How Are OCD Patients Coping With COVID-19?


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Monday, March 29, 2021

Demand for Care for Depression, Suicidal Thoughts Among U.S. Youth Is Growing, Report Finds

Roughly 1 in 5 U.S. adolescents received mental health care between 2005 and 2018, with the greatest proportion receiving care for internalizing mental health conditions such as depression and suicidal ideation, a study in JAMA Psychiatry has found.

“Trends in types of problems for which adolescents received care correspond with recent national trends of adolescent psychopathology and appear to highlight the growing importance of recognizing and managing internalizing problems across the major treatment settings,” wrote Ramin Mojtabai, M.D., Ph.D., M.P.H., of Johns Hopkins Bloomberg School of Public Health and Mark Olfson, M.D., M.P.H., of Columbia University.

Mojtabai and Olfson examined data from 230,070 adolescents aged 12 to 17 years who were interviewed as part of the National Survey on Drug Use and Health from January 1, 2005, through December 31, 2018. The survey participants were asked whether they had received mental health treatment or counseling in the past 12 months, where they received this care, and the reasons for receiving care. Internalizing problems included thoughts of killing or harming themselves, depressive symptoms, feeling afraid or tense, or eating problems. Externalizing problems included breaking rules, trouble controlling anger, or getting into fights. Relationship problems included problems at home, in the participant’s family, or with the participant’s friends.

The researchers found that 47,090 adolescents, or 19.7% of the total sample, reported receiving mental health care during the past year. Of those who received care, 51.8% received care for internalizing problems, 29.7% for externalizing problems, 29.7% for relationship problems, and 18.4% for school-related problems, with some reporting care for more than one kind of problem.

The proportion who received care for internalizing problems increased from 48.3% in 2005-2006 to 57.8% in 2017-2018. This increase was notable for suicidal thoughts or suicide attempts, which rose from 15.0% of those who received mental health care in 2005-2006 to 24.5% in 2017-2018. The proportion of adolescents who received care for externalizing problems declined from 31.9% in 2005-2006 to 23.7% in 2017-2018. The proportion receiving care for relationship problems declined from 30.4% in 2005-2006 to 26.9% in 2017-2018.

The majority of adolescents (61.5%) received care in outpatient mental health settings, followed by counseling in schools (48.8%), general medical settings (14.5%), and inpatient mental health settings (12.3%).

“The observed trends in adolescent mental health care raise questions about the extent to which these problems are matched to appropriate services,” Mojtabai and Olfson wrote. “School counseling and general medical services may not be optimally equipped to manage more severe forms of internalizing problems that account for a large and increasing share of the adolescent mental health problems they encounter.”

For related information, see the Psychiatric Services article “Differences in Utilization of Mental Health Treatment Among Children and Adolescents With Medicaid or Private Insurance.”

 (Image: iStock/SDI Productions)




APA Seeks Input on How Psychiatrists Can Address Racial Inequities

The APA Presidential Task Force on Structural Racism Throughout Psychiatry is fielding a new short survey. Help the Task Force inform its important work and share your thoughts here by Wednesday, April 14. Learn more about the Task Force and view the results of its previous three surveys on the Task Force web page.

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Friday, March 26, 2021

Persistent Loneliness at Midlife Linked to Late-life Dementia, Alzheimer’s Disease

People aged 45 to 64 years who are persistently lonely have nearly twice the risk of developing dementia and Alzheimer’s disease later in life compared with their peers who do not experience persistent loneliness, a study in Alzheimer’s and Dementia suggests. However, transient loneliness was linked to lower risk of dementia and Alzheimer’s disease compared with those who reported no loneliness.

“[M]idlife loneliness may be an independent, modifiable risk factor for dementia and [Alzheimer’s disease],” wrote Wendy Qiu, M.D., Ph.D., of Boston University School of Medicine and colleagues.

The researchers analyzed data from a subset of 2,880 adults in the Framingham Heart Study, an ongoing, nationwide study begun in 1948 to determine cardiovascular risk factors. Participants in this subset were 45 to 64 years old between 1998 and 2001 and had no cognitive problems. These participants received health exams every four years and completed the Center for Epidemiologic Studies Depression Scale (CES-D) at least twice, approximately three years apart. Qiu and colleagues analyzed the participants’ responses to one item on the CES-D, “I felt lonely during the past week,” and defined loneliness as feeling lonely at least one to two days within the past week. They then separated the participants into subgroups as follows:

  • No loneliness, wherein participants did not report loneliness at either assessment
  • Transient loneliness, wherein participants reported loneliness at one assessment but not the next
  • Incident loneliness, wherein participants reported loneliness in the second of the two assessments but not the first
  • Persistent loneliness, wherein participants reported loneliness at both assessments

Participants who reported persistent loneliness had a 91% greater risk of developing dementia later in life compared with those who reported no loneliness. Those who reported transient loneliness had a 66% lower risk of developing dementia later in life compared with those who reported no loneliness. The results were similar for Alzheimer’s disease risk.

“Our results motivate further investigation of the factors that make individuals resilient against adverse life events and urge us to tailor interventions to the right person at the right time to avert persistency of loneliness, promote brain health, and prevent [Alzheimer’s disease],” Qiu and colleagues wrote.

For related information, see the Psychiatric News article “Loneliness: A Modern Epidemic Psychiatric Is Poised to Address.”

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Help APA Fight for Improved Reimbursement: Take Insurance Survey

APA advocates on behalf of psychiatrists to increase reimbursements from health plans, legislators, and regulatory agencies. To ensure APA is well equipped to fight for improved payment for clinical services, we need to know more about the nature of your outpatient practice and experience in the health plan networks in which you participate.

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Thursday, March 25, 2021

Recent Diagnosis of Cognitive Impairment, Dementia May Increase Suicide Risk

People diagnosed recently with mild cognitive impairment or dementia may be more likely to attempt suicide compared with those who have not received either diagnosis, according to a study published Wednesday in JAMA Psychiatry.

The findings point to the importance of offering supportive services to people at the time of or shortly after a diagnosis of mild cognitive impairment or dementia, wrote Mia Maria Günak, M.Sc., of Leiden University in the Netherlands, Kristine Yaffe, M.D., of the University of California, San Francisco, and colleagues.

The researchers conducted a longitudinal cohort study, with a baseline period from October 1, 2011 to September 30, 2013, and follow-up through the end of 2016. They used five national databases, including the VA’s National Patient Care Database, which contained inpatient and outpatient records; the Centers for Medicare & Medicaid Services data, which contained medical claims and diagnoses; the National Suicide Prevention Applications Network; the Mortality Data Repository; and the VA’s Pharmacy Managerial Cost Accounting National Data Extract.

Patients aged 50 years or older were split between those who had a mild cognitive impairment or dementia diagnoses during or before the baseline period and a comparison group of participants who had received neither diagnosis. Diagnoses were considered recent if patients received them during the baseline period.

The total study population of 147,595 (mean age: 75 years) included 21,085 patients with mild cognitive impairment and 63,255 with dementia. Of the patients with mild cognitive impairment, 0.7% attempted suicide during the follow-up period, compared with 0.6% of patients with dementia and 0.4% of patients with neither diagnosis. Altogether, the risk of suicide attempt was 73% higher in patients recently diagnosed with mild cognitive impairment and 44% higher in those recently diagnosed with dementia, compared with those who had received neither diagnosis. Psychiatric comorbidity did not appear to change the associations between mild cognitive impairment or dementia and the risk of suicide attempt, the authors reported.

Additional analysis revealed that patients with a prior diagnosis of mild cognitive impairment or dementia (that is, those diagnosed before the baseline period) were no more likely to attempt suicide than others without these diagnoses.

“The findings in this cohort study suggest that patients who have recently been diagnosed with [mild cognitive impairment] or dementia should be viewed as a high-risk group for suicide attempt,” the authors concluded. “Additional supportive services in the care of patients with [mild cognitive impairment] or dementia are imperative, especially around the time of initial diagnosis.”

For related information, see the Psychiatric News article “Disclosure of Alzheimer’s Risk May Not Result in Short-Term Increase in Depression, Anxiety.”

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Help APA Fight for Improved Reimbursement: Take Insurance Survey

APA advocates on behalf of psychiatrists to increase reimbursements from health plans, legislators, and regulatory agencies. To ensure APA is well equipped to fight for improved payment for clinical services, we need to know more about the nature of your outpatient practice and experience in the health plan networks in which you participate.

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Wednesday, March 24, 2021

Psychosocial Programs for Black Families May Mitigate Mental Health Effects of Racial Discrimination

Family-centered psychosocial interventions may protect young Black adolescents who experience frequent racial discrimination from subsequent mental health problems, according to a report in JAMA Open Network.

“[I]nterventions that focus on strengthening protective caregiving could help to forestall or attenuate some of the mental health problems that racial discrimination can produce,” wrote Gene H. Brody, Ph.D., director of the Center for Family Research at the University of Georgia, and colleagues.

They analyzed data from two community-based randomized clinical trials—the Strong African American–Teen (SAAF–T) program, which included 502 Black adolescents (56% girls) aged 14 to 16, and the Adults in the Making (AIM) program, which included 367 Black adolescents (59% girls and women) aged 17 to 18. These programs have been implemented in 12 rural Georgia counties. At baseline, adolescents in both trials completed the Schedule of Racist Events, which assessed the frequency that adolescents encountered discriminatory events, including racial slurs, physical threats, and false accusations.

SAAF–T consisted of five consecutive weekly, two-hour sessions in which parents or the adolescents’ primary caregivers were taught emotional and instrumental support, limit setting, methods for communicating about sex and alcohol use, and more. Youth learned the importance of abiding by household rules, setting goals for the future and making plans to attain them, and strategies for resisting substance use. Each meeting included one hour of separate training for youth and caregivers, followed by a one-hour caregiver-youth session during which participants practiced what they had learned in the separate sessions.

In the AIM program, youth and their primary caregivers attended six consecutive weekly, two-hour meetings, also with separate parent and youth skill-building curricula. Primary caregivers were taught protective emotional and instrumental support, occupational and educational mentoring, cooperative problem solving, and communication skills. Youth were taught how to make plans to meet their goals, to identify people in their communities who could help them with goal attainment, and to formulate self-care strategies.

In both trials, data were collected on depression, anxiety, and conduct disorders two months before the intervention, six months after baseline, and 18 months after baseline for SAAF–T and 27 months after baseline for AIM. Before and after participation, SAAF–T and AIM primary caregivers reported the frequency and quality of their protective caregiving practices using the Family Support Inventory and the Discussion Quality Scale.

Adolescents assigned to SAAF–T and AIM who had experienced frequent discrimination exhibited fewer conduct problems at follow-up than did youth assigned to the control group in both trials. Those in the AIM program who experienced frequent discrimination also exhibited less depression and anxiety symptoms than those in the control group.

“[M]ore supportive parents may be better able to establish strategies that enhance their children’s emotion regulation for coping with racial discrimination,” the researchers wrote. “This in turn may have reduced the physiological and psychological effects of racial discrimination that can influence mental health. To our knowledge, this is the first study to show that family-centered prevention was associated with buffering the effects of racial discrimination on adolescents’ mental health.”

For related information, see the Psychiatric News article “Trauma of Racism Has Long-Term Impact on Health.”

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Help APA Fight for Improved Reimbursement: Take Insurance Survey

APA advocates on behalf of psychiatrists to increase reimbursements from health plans, legislators, and regulatory agencies. To ensure APA is well equipped to fight for improved payment for clinical services, we need to know more about the nature of your outpatient practice and experience in the health plan networks in which you participate.

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Tuesday, March 23, 2021

Dystonia May Increase Risk of Suicide

Patients with dystonia—a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal movements and postures—may be at a higher risk of suicide compared with the general population, according to a recent report in Neurology.

“[I]n addition to debilitating motor symptoms, up to 90% of patients with dystonia have comorbid psychiatric disorders, most frequently including generalized or social anxiety, obsessive-compulsive disorder, and major depression,” wrote co-authors Alexis Worthley, B.A., and Kristina Simonyan, M.D., Ph.D., Dr. Med., of Harvard Medical School.

To examine the relationship between dystonia and suicidal behaviors, Worthley and Simonyan invited patients with dystonia to complete an online survey, which included questions about dystonia diagnosis and treatment as well as past and present psychiatric history. The participants were also specifically asked whether they had had thoughts of harming or killing themselves and whether they had ever made a suicide attempt.

A total of 542 participants (mean age: 57 years; 80% female), the majority of whom had been diagnosed with focal dystonia, completed the online survey. The most frequent psychiatric disorder reported by the participants was generalized anxiety (43.4%), followed by depression (40.4%), social anxiety (29.1%), and panic disorder (13.8%).

Overall, 32.3% of the participants reported a lifetime history of suicidal ideation—a percentage the authors noted is more than three times the prevalence rate of suicidal ideations in the general global population. The prevalence of suicidality was higher in patients with multifocal/segmental and generalized forms of dystonia compared with patients with focal dystonias, the authors noted.

Among the participants who reported a history of suicidal ideations, 16.6% reported having made a suicide attempt. Patients with generalized dystonia were found to have the highest incidence of a suicide attempt over their lifetime, with an ideation-to-attempt ratio of 4:1.

“[A]lthough it is necessary to consider depression and other psychiatric history as potential risk factors for suicidal ideations and attempt, it is also critical to evaluate their interplay with dystonia symptomatology, the individual’s propensity to suicide, and other potential social and biological stressors that may lead to suicidal behavior in patients with dystonia,” Worthley and Simonyan wrote.

“Given the devastating effects of suicide, our findings strongly support the incorporation of a suicidal risk screening into the routine clinical evaluations of patients with dystonia,” they added.

For related information, see the Psychiatric News article “Tardive Dyskinesia: Assessing and Treating a Debilitating Side Effect of Prolonged Antipsychotic Exposure.”

(Image: iStock/SeventyFour)



Resident-Fellow Members: Webinar With Task Force on Structural Racism is Tonight

Resident-fellow members are urged to register for the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry for a discussion on the task force’s work and opportunities to get involved as the work continues. The event will be held tonight at 7 p.m. ET.

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Monday, March 22, 2021

Hypertension During Pregnancy May Increase Risk of Neurodevelopmental Disorders in Children

Women experiencing hypertensive disorders during pregnancy may be at a higher risk of having children with autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) than those without hypertensive disorders, reports a study published today in JAMA Pediatrics.

Judith S. Brand, Ph.D., of Örebro University in Sweden and colleagues analyzed health registry data of over 1 million individuals born in Sweden between 1987 and 1996 to identify associations between maternal hypertensive disorders (chronic hypertension, gestational-onset hypertension, or preeclampsia) and neurodevelopmental disorders in children. They also used data from over 285,000 men born between 1982 and 1992 who underwent military medical assessments at age 18 to examine the association between maternal hypertensive disorders and future cognitive performance; the military assessments included a full battery of cognitive tests.

Overall, 4% of the mothers of the health registry cohort and 5% of the mothers of the military cohort had a hypertensive disorder during pregnancy. After adjusting for various health and demographic factors, Brand and colleagues found that a maternal hypertensive disorder was associated with a 22% increased risk of ASD, 10% increased risk of ADHD, and 39% increased risk of intellectual disability in offspring. In the military cohort, maternal hypertensive disorders were associated with lower scores on the cognitive performance tests.

Brand and colleagues next analyzed outcomes only among siblings who were born under different maternal conditions (for example, a mother had two children but only had a hypertensive disorder during one of the pregnancies). They found that ASD and ADHD risks remained the same as were seen in the larger sample, but there was no longer any increased risk of intellectual disability or lower cognitive function due to maternal hypertensive disorders.

“Together, these results suggest that, while modestly increased risks of ASDs, and possibly ADHD, may be explained by intrauterine effects of [hypertensive disorders in pregnancy], associations with ID [intellectual disability] and cognitive performance are likely confounded by unmeasured shared familial (environmental or genetic) factors,” the authors wrote.

To read more about this topic, see the Psychiatric News article “Anxiety Linked to Hypertensive Disorders in Pregnancy.”

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Resident-Fellow Members: Webinar With Task Force on Structural Racism Is Tomorrow

Resident-fellow members are urged to register for the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry for a discussion on the task force’s work and opportunities to get involved as the work continues. The event will be held tomorrow, Tuesday, March 23, at 7 p.m. ET.

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Friday, March 19, 2021

‘Zero Suicide’ Practices at Mental Health Clinics Reduce Suicide Among Patients, Study Finds

Patients who were seen at outpatient mental health clinics were significantly less likely to attempt suicide when clinics practiced “Zero Suicide” principles, including suicide screening, safety planning, and support during care transitions with follow-up after discharge from acute care settings. These findings were published Thursday in a report in Psychiatric Services in Advance.

Zero Suicide principles grew out of a 2012 partnership between the Office of the Surgeon General and the National Action Alliance for Suicide Prevention (NAASP). The NAASP Clinical Care and Intervention Taskforce developed a set of organizational best practices aimed at eliminating suicide and targeted specifically at health care settings. The Psychiatric Services study is the first to show that when mental health clinics abide by these principles, the risk of suicide among patients is significantly diminished.

Deborah M. Layman, M.A., of the New York State Office of Mental Health and colleagues surveyed 110 outpatient mental health clinics in New York state for their “fidelity” to 17 Zero Suicide’s organizational practices (meaning how closely they abided by the practices) using the Zero Suicide Organizational Self-Study questionnaire. Responses to the 17 items were averaged to compute a total Zero Suicide fidelity score for each clinic. Data on suicidal behaviors—specifically, suicide attempts and deaths—were extracted from the New York State Incident Management Reporting System.

The researchers found that the higher the fidelity to the Zero Suicide organizational practices, the less likely clinics were to have suicidal attempts or deaths among their patients. Moreover, there was a statistically significant difference in total fidelity scores between clinics with and without a suicide incident in the previous year.

Two practices had the highest effect on reducing the risk of suicide among patients:

  • Suicide-specific quality improvement activities, which the authors defined as “having suicide care embedded in the medical chart, written clinical workflows for suicide care, and data collection and review by clinical teams.”
  • Lethal means reduction, or working to ensure patients are safe from the means for suicide at home. The authors noted that lethal means reduction “requires documentation in safety plans as a standard practice” as well as “policies addressing clinician training, family inclusion in means reduction, and confirmation of means reduction.”

Five other practices were also found to be crucial: commitment of clinic leadership to suicide prevention, assessments of confidence in suicide care and of skills among staff, suicide risk assessments, engaging hard-to-reach and no-show patients, and following up with patients who were discharged from acute settings.

“Clinic engagement in suicide-specific quality improvement activities and in strategic development of effective policy- and protocol-based lethal means reduction may be particularly important for reducing suicide risk,” the researchers wrote.

For related information, see the Psychiatric News article “Upping Our Game to Prevent Suicide.”

(Image: iStock/robypangy)




Resident-Fellow Members: Webinar With Task Force on Structural Racism is Tuesday, March 23

Resident-fellow members are urged to register for the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry for a discussion on the task force’s work and opportunities to get involved as the work continues. The event will be held Tuesday, March 23, at 7 p.m. ET.

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