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“I hope that explicit criticism of the outdated tradition of devaluing life experiences deemed unpalatable by an admissions committee will inspire a cultural shift toward transparency,” she wrote.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

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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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.”

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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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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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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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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.”

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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.”

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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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Thursday, March 18, 2021

APA Condemns Violence Against Asian Americans in Georgia

In response to the shooting of eight people, including six women of Asian descent, at spas in Georgia on Tuesday, APA issued a statement condemning the act and expressing support for Asian American and Pacific Islander communities.

“This year has seen a significant increase in racism and xenophobia against Asian Americans, and it is unacceptable and harmful,” said APA President Jeffrey Geller, M.D., M.P.H., in a media release. “This unspeakable tragedy can cause further fear for the AAPI [Asian American and Pacific Islander] community, which has endured so much already. We send our condolences to the victims’ families and friends, and others who knew them.”

“The tragedy that occurred in Georgia is becoming far too familiar,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in the release. “We must be mindful that the mental health impacts of mass shootings are far reaching, touching families, communities, and the nation as a whole. If you are struggling to cope with these traumatic events, please reach out to family or friends for support. If you are overwhelmed, seek help from a psychiatrist or your primary care provider.”

There has been a well-documented uptick in hate crimes against Asian American and Pacific Islander communities since the start of the COVID-19 pandemic. Nearly 3,800 incidents of harassment, discrimination, or violence against these communities occurred between March 19, 2020, and Feb. 28, 2021, according to a report released by Stop AAPI Hate, a reporting center created in response to the escalation in xenophobia and bigotry that these communities have faced over the past year. The vast majority of the incidents reported to Stop AAPI Hate were experienced by women.

Stop AAPI Hate noted that its report includes only incidents that were reported to the organization, representing, “only a fraction of the number of hate incidents that actually occur.”

In a Psychiatric News special report, Dora Calott Wang, M.D., M.A., and Jesus Salvador Ligot, M.D., noted that, in addition to the increase in harassment and violence, “Asian Americans have long been underserved in terms of mental health care and have encountered cultural barriers to seeking care.

“We must heal from two epidemics: COVID-19 and anti-Asian activity,” Wang and Ligot continued. “Both are potentially long lasting, with lethal consequences. Yet the epidemic of anti-Asian activity is fully up to us to end, as an American nation. It must stop, for America to heal this season of epidemics.”

For related information, see the Psychiatric News article “Special Report: Asian American Hate Incidents—A Co-occurring Epidemic During COVID-19.”




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Wednesday, March 17, 2021

Tailored CBT Protocol May Help Patients With Body Dysmorphic Disorder

Cognitive-behavioral therapy (CBT) designed specifically to address body dysmorphic disorder may be more effective for treating patients with the condition than more generalized supportive psychotherapy, a study in Depression and Anxiety suggests.

Hilary Weingarden, Ph.D., of Massachusetts General Hospital and Harvard Medical School and colleagues analyzed data from 120 adults with body dysmorphic disorder who received 22 one-hour therapy sessions of either CBT or supportive psychotherapy over 24 weeks. CBT consisted of skills-based treatment that specifically addressed symptoms of body dysmorphic disorder, whereas supportive psychotherapy consisted of nonspecific, nondirected treatment intended to support patients’ expression of emotions and use of adaptive coping skills more broadly.

The researchers evaluated the study participants using several measures, including the Yale‐Brown Obsessive Compulsive Scale Modified for BDD (BDD‐YBOCS). Remission of body dysmorphic disorder was defined as a score of ≤16 on the BDD‐YBOCS. 

At the end of 24 weeks, 68% of patients in the CBT group experienced remission of symptoms of body dysmorphic disorder, compared with 42% in the supportive psychotherapy group. At six-month follow-up, 52% of patients in the CBT group had sustained remission, compared with 27% in the supportive psychotherapy group. Only 18% of those in the CBT group experienced no remission of their symptoms, compared with 45% of those in the supportive psychotherapy group.

“Remission rates following CBT are highly encouraging; these data fill a critical gap in the literature on efficacy outcomes for BDD [body dysmorphic disorder] psychotherapy,” the researchers wrote. “Clinicians may wish to inform prospective patients that following a 24-week course of CBT, they are likely to experience partial or full alleviation of BDD symptoms.”

For related information, see the Psychiatric News article “Brief Update and Review on Treating Eating Disorders.”

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Tuesday, March 16, 2021

Older Schizophrenia Patients Found More Likely to Be Diagnosed With Dementia

Older U.S. adults with schizophrenia may be more likely to be diagnosed with dementia than those who do not have a serious mental illness (SMI), according to a report in JAMA Psychiatry. The study also found that this population is more likely to receive a dementia diagnosis at an earlier age.

“Approximately 28% of the group with schizophrenia had received a diagnosis of dementia before 66 years of age, indicating early-onset dementia,” wrote T. Scott Stroup, M.D., M.P.H., of Columbia University Vagelos College of Physicians and Surgeons and colleagues. “The implications of this high rate of comorbidity are substantial for families and for the service system, which must provide high levels of care for individuals with a combination of disabling conditions and uncertain treatment pathways.”

Stroup and colleagues examined Medicare data from 2007 to 2017 to estimate dementia diagnoses among people aged 66 years or older. They compared those who had received a diagnosis of schizophrenia with those without a diagnosis of schizophrenia, bipolar disorder, or recurrent major depressive disorder (that is, without SMI). Dementia was defined by the diagnostic codes used by Centers for Medicare & Medicaid Services Chronic Conditions Warehouse algorithm for Alzheimer’s disease and related disorders or senile dementia.

The study population of more than 8 million adults 66 years or older included more than 74,000 individuals with schizophrenia and more than 7.9 million without SMI. The analysis by Stroup and colleagues revealed the following:

  • The prevalence of diagnosed dementia was 27.9% among individuals with schizophrenia compared with 1.3% in the group without SMI at 66 years of age. By 80 years of age, the prevalence of dementia diagnoses was 70.2% in the group with schizophrenia compared with 11.3% in the group without SMI.
  • The annual incidence of dementia diagnoses per 1,000 person-years at 66 years of age was 52.5 among individuals with schizophrenia and 4.5 among individuals without SMI and increased to 216.2 and 32.3, respectively, by 80 years of age.
  • The prevalence of Alzheimer’s disease diagnoses at 66 years of age was 8.2% in the group with schizophrenia and 0.4% in the group without SMI. By 80 years of age, the prevalence of Alzheimer’s diagnoses was 37.2% in the group with schizophrenia and 5.1% in the group without SMI.

The authors noted that much remains unknown about the onset, course, and management of schizophrenia in patients with dementia. “Identification of modifiable risk factors, possibly including anticholinergic medications, inadequately treated psychosis, and comorbid medical conditions such as hypertension and diabetes, may help focus prevention efforts,” they wrote.

“Further investigation is also needed of the clinical assessment of dementia in patients with schizophrenia, particularly broad neuropsychological assessment that covers the characteristic cognitive deficits of both schizophrenia and dementia and the evaluation of different medication classes for treatment and the course of illness in people with schizophrenia and dementia,” they added.

For related information, see the Psychiatric News article “Milestones in the History of Schizophrenia. A Comprehensive Chronology of Schizophrenia Research: What Do We Know and When Did We Know It.”

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Monday, March 15, 2021

More Than Half of COVID-19 Patients Report Depressive Symptoms Months Later, Study Finds

A significant number of adults who become infected with COVID-19 may report symptoms of depression months later, according to a report in JAMA Network Open.

Roy Perlis, M.D., M.Sc., of Massachusetts General Hospital and colleagues analyzed data collected from U.S. adults who participated in an internet-based survey conducted by Qualtrics. Of 82,319 respondents who completed the Patient Health Questionnaire-9 (PHQ-9) that was part of this survey, the researchers identified 3,904 adults who had previously been diagnosed with COVID-19. The respondents were asked to indicate their overall severity of illness (not at all severe, not too severe, somewhat severe, or very severe) as well as the presence or absence of specific COVID-19 symptoms.

The respondents completed the survey an average of four months after being diagnosed with COVID-19. Overall, 52.4% (2,046) met the criteria for moderate or greater symptoms of major depression (PHQ-9 score of 10 or more). The odds of reporting depressive symptoms following a diagnosis of COVID-19 were higher among men, younger people, and those who reported more severe COVID-19 symptoms.

Additional analysis revealed that headaches were the only COVID-19 symptom associated with an increased risk of future depression: People who experienced headaches from COVID-19 were 33% more likely to report symptoms of depression than those who had not experienced headaches.

“[W]e cannot attribute these symptoms to new onset of depression; individuals with acute infection could be less likely to recover from prior depressive episodes or those with preexisting depressive symptoms could have greater risk of contracting COVID-19,” Perlis and colleagues cautioned.

“Nevertheless, our results add to a growing body of evidence suggesting the importance of considering potential neuropsychiatric sequelae of COVID-19 infection. Our results also suggest the importance of considering strategies that might mitigate the elevated risk of depressive symptoms following acute infection,” they concluded.

For related information, see the Psychiatric News article “Patients With MH Disorders Found More Susceptible to COVID-19, Death.”

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Friday, March 12, 2021

Spiritual CBT Protocol May Help Patients Integrate Their Spirituality Into Treatment

Spiritual Psychotherapy for Inpatient, Residential, and Intensive Treatment (SPIRIT) may be useful for patients in psychiatric hospitals who wish to integrate spirituality into their treatment, a study in Psychiatric Services in Advance suggests. SPIRIT is based on cognitive-behavioral therapy (CBT) and includes a psychoeducation component and specific tools or skills drawn from spiritual concepts or beliefs and activities that patients can use to shape their emotional experience.

David H. Rosmarin, Ph.D., of Harvard Medical School, and colleagues analyzed data from a one-year trial at McLean Hospital, an independent academic psychiatric hospital in Belmont, Mass. During the trial, 22 clinicians in 10 different clinical units provided SPIRIT to 1,443 adults. The patients had a range of psychiatric diagnoses such as bipolar disorder, depressive disorder, eating disorders, psychotic disorders, trauma- or stress-related disorders, substance use disorder, or other disorders. Clinicians identified with a range of religious or spiritual affiliations: Buddhist, Catholic, Jewish, Muslim, Protestant, spiritual but not religious, and no affiliation. Clinicians included mental health specialists, social workers, expressive art therapists, psychologists, and others.

All patients completed one SPIRIT group session, after which they completed the Clinically Adaptive Multidemensional Outcome Survey, which assesses the importance of spirituality and religion to the patient and whether the patient believes in God. The survey also assesses indicators of spiritual distress such as loss of spiritual inspiration or direction and spiritual guilt. Patients were also asked how much they agreed or disagreed with the following statements following their participation in the SPIRIT group: “This group helped identify spiritual/religious resources that I can utilize to reduce my distress” and “This group helped identify spiritual/religious struggles that are contributing to my distress.”

Sixty-nine percent of patients reported that SPIRIT helped them to identify spiritual and religious resources to aid their recovery to at least a “fair” extent and 47% reported such benefits to at least a “moderate” extent. Among those with significant spiritual distress, 76% reported that SPIRIT helped them to identify spiritual and religious struggles that were contributing to their distress to at least a “fair” extent and 51% reported that SPIRIT did so to at least a “moderate” extent. The patients’ diagnoses did not appear to affect how likely they were to respond to SPIRIT. However, greater religious affiliation in the clinicians who provided SPIRIT was associated with worse treatment outcomes, regardless of the patients’ spiritual or religious affiliation.

“Our results … suggest that religious therapists may be less apt in providing spiritual psychotherapy, compared with their secular colleagues. It is possible that religious therapists struggle to maintain objectivity about the subject matter when delivering clinical interventions that include spiritual content,” the researchers wrote. “Moreover, secular clinicians might be better positioned to validate and convey the importance of patients’ spiritual needs because they have no personal or religious incentive.”

For related information, see the American Journal of Psychotherapy article “Spiritual Psychotherapy for Inpatient, Residential, and Intensive Treatment.”

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Thursday, March 11, 2021

Cardiovascular Problems May Worsen Cognition in People With Schizophrenia

Risk factors for cardiovascular disease (CVD), such as metabolic disorders, diabetes, or hypertension, are significantly associated with cognitive deficits in patients with schizophrenia, according to a study published in JAMA Psychiatry.

The findings point to the importance of efforts to address risk factors for cardiovascular disease in these patients to help prevent further deterioration in cognition and improve functioning, wrote Katsuhiko Hagi, Ph.D., of Sumitomo Dainippon Pharma in Tokyo, Japan, Jean Pierre Lindenmayer, M.D., of the New York University School of Medicine, and colleagues.

Hagi and colleagues searched databases including Embase, Scopus, MEDLINE, PubMed, and Cochrane for studies on cognitive functioning in patients with schizophrenia or schizoaffective disorder and the association of CVD risk factors (including metabolic syndrome, diabetes, obesity, hypertension, and others). The studies also compared cognitive performance between those with and without CVD risk factors.

In total, 27 studies were included in the analysis, representing 10,174 individuals with schizophrenia. The authors identified significantly greater cognitive deficits in patients who had metabolic disorders, diabetes, or hypertension compared with those who did not have those disorders. Further, these patients performed worse on reasoning/problem solving, speed of processing, and verbal learning compared with patients without these disorders. Cognitive impairment was not significantly associated with being overweight or obese.

The authors noted that pharmacological interventions and other lifestyle changes, such as diet, for cardiovascular risk factors are treatment options for individuals with schizophrenia. However, they added, implementing such interventions can be challenging since people with schizophrenia have such low rates of access to care.

“Routine physical health monitoring and interventions to improve physical health in people with schizophrenia are urgently needed to maintain or restore physical and mental health and improve functional outcomes,” Hagi and colleagues wrote. “Collaborative care models that integrate behavioral and medical care are likely to be particularly useful for addressing CVD risk in those with schizophrenia.”

For related information, see the Psychiatric News article “Cardioprotective Treatments After Heart Attack Can Help Patients With Schizophrenia Live Longer.”

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Wednesday, March 10, 2021

APA Hails Passage of COVID Relief Bill Including Funds for Mental Illness and Substance Use Disorders

APA leaders praised the inclusion of several provisions related to mental health in the American Rescue Plan Act of 2021 (HR 1319)—the $1.9 trillion coronavirus relief package, which the House of Representatives passed today by a vote of 220-211. The legislation, which is expected to be signed into law by President Biden later this week, includes approximately $4 billion in funding for programs that support the prevention of and treatment for mental and substance use disorders.

“It is essential and heartening that Congress and the administration included funding for our nation’s mental health system in this wave of COVID relief,” said APA President Jeffrey Geller, M.D., M.P.H. “We are particularly pleased to see support for our frontline physicians and other workers, many of whom have made great sacrifices during this time, and many of whom are hurting.”

Among the provisions APA supported are the following:

  • Funding for mental/substance use disorder services through programs like the Community Mental Health Services Block Grant and the Substance Abuse Prevention and Treatment Block Grant.
  • The Dr. Lorna Breen Health Care Provider Protection Act, which includes funding for training, educational programs, and other initiatives designed to promote mental and behavioral wellness of health care workers.
  • Funding for community behavioral health services, such as the National Child Traumatic Stress Network, Project AWARE (Advancing Wellness and Resiliency in Education), youth suicide prevention, and Certified Community Behavioral Health Clinics.
  • Expanded eligibility for premium assistance for individuals under the Affordable Care Act.
  • Increased Medicaid funding, including resources for mobile crisis services and other community-based behavioral health needs.
  • Funding for pediatric mental health care access grants to promote mental health integration with pediatric primary care.

In addition, mental health services and supports are eligible for a portion of the funding provided to reopen elementary and secondary schools.

“We will not recover sufficiently from this pandemic long term unless we address our mental health with the same urgency and attention as our physical health,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “This package is a huge step in the right direction, and we look forward to working with Congress and the administration to implement policies and services that will help all our patients.”

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Tuesday, March 9, 2021

Older Adults With Dementia at Risk From Taking Multiple Psychotropics, Study Suggests

Despite the known dangers of older adults’ being prescribed multiple medications for dementia, including death, nearly 14% of older adults with dementia in the United States were prescribed three or more psychotropic and/or opioid medications for more than 30 consecutive days in 2018, according to a study published today in JAMA.

“Although memory impairment is the cardinal feature of dementia, behavioral and psychological symptoms (for example, apathy, delusions, agitation) are common during all stages of illness and cause significant caregiver distress,” wrote Donovan T. Maust, M.D., M.S., of the University of Michigan and colleagues. “Despite limited high-quality evidence of efficacy for pharmacological treatment, clinicians regularly prescribe psychotropic medications to community-dwelling persons with dementia in rates that far exceed use in the general older adult population.”

Maust and colleagues analyzed data on Medicare beneficiaries with dementia who had Part D prescription drug coverage on January 1, 2018. (Those living in long-stay nursing homes were excluded from the analysis.) The study cohort was followed up until the death, loss of Medicare fee-for-service coverage, enrollment in Medicare Advantage, loss of Part D coverage, or December 31, 2018.

The authors analyzed the prescription fills by those in the study cohort that took place between October 1, 2017, and December 31, 2018 (the observation year plus the three preceding months). The authors defined the prevalence of CNS-active polypharmacy in 2018 as “as concurrent exposure to three or more medications for longer than 30 days consecutively from the following six classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (for example, z-drugs), and opioids.”

The final sample included 1,159,968 older adults with dementia (median age 83.0), of whom 13.9% met the criterion for CNS-active polypharmacy. Further analysis of those individuals exposed to CNS-active polypharmacy in 2018 revealed the following:

  • They were significantly younger with a higher level of comorbidity compared with those not exposed to polypharmacy.
  • 57.8% were exposed to polypharmacy for longer than 180 days and 6.8% for a full year.
  • 29.4% were exposed to five or more medications, and 5.2% were exposed to five or more medication classes.

Of the medication classes associated with CNS-active polypharmacy, antidepressants accounted for 92.0% of polypharmacy days, followed by antiepileptics (62.1%), antipsychotics (47.1%), benzodiazepines (40.7%), opioids (32.3%), and z-drugs (6.0%), Maust and colleagues reported. The most common CNS-polypharmacy class combination included at least one antidepressant, one antiepileptic, and one antipsychotic, accounting for 12.9% of polypharmacy days.

“[W]ithout knowing the indication for the medications or examining the range of prescribed dosages, it is not possible to assess the appropriateness of the particular combinations used,” Maust and colleagues wrote. They did caution, however, that there is evidence to suggest that CNS-active polypharmacy increases the risk of respiratory suppression and death, QT-interval prolongation, falls, impaired cognition, and more.

For related information, see the Psychiatric News article “Treating Symptoms of Dementia Requires Trial and Error, Judicious Use of Medication.”

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Monday, March 8, 2021

Ketamine Appears Safe and Effective for Adolescents With Treatment-Resistant Depression

A single dose of intravenous ketamine appears to reduce depressive symptoms within 24 hours in adolescents with treatment-resistant depression, suggests a small study in AJP in Advance. These improvements lasted for at least two weeks.

Jennifer Dwyer, M.D., of Yale University and colleagues enrolled 17 adolescents aged 13 to 17 years in a four-week trial. All the teens had a diagnosis of major depressive disorder, as determined by the Schedule for Affective Disorders and Schizophrenia for School-Age Children, and had failed to respond to at least one antidepressant treatment. The participants had failed an average of 3.24 prior treatments, and the average length of their current depressive episode was 21 months.

The study employed a crossover design. The participants randomly received a single infusion of either ketamine (0.5 mg/kg over 40 minutes) or midazolam (0.045 mg/kg over 40 minutes) and then received the other compound two weeks later. Midazolam was chosen as the placebo compound since like ketamine, it can produce dissociative symptoms but has no antidepressant effects. Depressive symptoms were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) 1, 2, 3, 5, 7, 10, and 14 days post-infusion.

The adolescents who received ketamine had significantly greater reductions in MADRS scores after 24 hours compared with those who received midazolam (average MADRS reduction of 18 points compared with 9 points). Overall, 76% of the adolescents who received ketamine achieved a treatment response (defined as a >50% reduction in their MADRS scores) within three days, compared with 35% of participants who received midazolam.

The adolescents who received ketamine experienced greater increases in blood pressure and more dissociative symptoms in the first hour after infusion than those who received midazolam. Both effects were transient, however, disappearing within a few hours. No serious adverse effects emerged in any of the participants.

“This trial provides promising initial data on the feasibility, preliminary efficacy, and safety of intravenous ketamine in adolescent depression,” Dwyer and colleagues wrote. “However, additional data on long-term safety and efficacy are needed before any recommendations regarding integration into care in non-research pediatric populations can be made.”

To read more on this topic, see the Psychiatric News article “Researchers Look to Extend Benefits of Ketamine.”

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