Childhood Exposure to Air Pollution Linked to Psychiatric Symptoms in Young Adulthood

Exposure to air pollution in childhood may be a risk factor for poorer mental health in young adulthood, a study in JAMA Network Open has found. The study suggests that exposure to outdoor nitrogen oxides (NOx) such as those emitted from vehicles and industry may increase the risk of symptoms of psychiatric illness as much as childhood exposure to lead.

“Given the ubiquity of this exposure, air pollution could represent a meaningful contributor to the global burden of psychiatric illness, particularly in poor air-quality regions,” wrote Aaron Reuben, M.E.M., of Duke University, Louise Arseneault, Ph.D., of Kings College London, and colleagues.

The researchers analyzed data from 2,039 young adults in the Environmental-Risk Longitudinal Twin Study, a population-based cohort study of children born from January 1, 1994, to December 4, 1995, in England and Wales. The study followed participants until they were 18 years old, at which time the participants were interviewed about past-year symptoms of mental disorder. Reuben and colleagues combined symptoms associated with 10 psychiatric disorders to create a single measure of mental health, the psychopathology factor (p-factor). They also assessed the young adults’ internalizing symptoms (depression, generalized anxiety, posttraumatic stress, and disordered eating), externalizing symptoms (substance use, oppositional behavior, and attention-deficit/hyperactivity), and symptoms of thought disorders (delusions, hallucinations, and unusual thoughts and feelings).

By using high-quality air dispersion models and data provided by the U.K. National Atmospheric Emissions Inventory and the Imperial College’s U.K. road-traffic emissions inventory, Reuben and colleagues were able to determine the levels of NOx around the participants’ homes when the participants were 10 and 18 years old.

The researchers found that those with the greater exposure to NOx as children had higher p-factors and were more likely to have internalizing symptoms, external symptoms, and symptoms of disordered thought at age 18 than those with lower exposure, even after adjusting for other mental health risk factors such as lower socioeconomic status and a family history of mental illness.

Reuben and colleagues noted that air pollution may affect central nervous system (CNS) development.

“Overall, robust but nonspecific elevations in psychopathology after air pollution exposure reflect the findings that air pollutants can effect diverse and diffuse CNS developmental impairments, depending on the pollutant mix, duration of exposure, age of exposure, and pathway to the brain,” they wrote.

For related information, see the Psychiatric Services article “Air Pollutants and Daily Hospital Admissions for Psychiatric Care: A Review.”

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Interested in Loan Repayment Program? NHSC Welcomes Applicants

The deadline to submit applications for the National Health Service Corps (NHSC) Loan Repayment Program has been extended until Thursday, May 27 at 7:30 p.m. ET. Learn more about your eligibility and the application process here.

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Co-prescribing Opioids, Z-Drugs May Increase Risk of Overdose

People who use prescription opioid painkillers along with the so-called Z-drugs (zolpidem, zopiclone, and zaleplon) for insomnia have a significantly higher risk of overdose than people who use opioids alone, according to a report in AJP in Advance.

“[T]he potential implications of these findings are substantial given the growing number of opioid-treated patients receiving Z-drugs, which we estimated to be about 1.2 million individuals in the United States, based on the 2013–2014 NHANES survey,” wrote Alejandro Szmulewicz, M.D., M.P.H., of the Harvard T.H. Chan School of Public Health and colleagues.

Using the IBM Marketscan Commercial and Medicare Supplemental Database, Szmulewicz and colleagues analyzed data on patients 15 to 85 years of age who had filled an opioid prescription between January 1, 2004, and December 31, 2017. The authors compared 510,529 patients within this group who also began taking Z-drugs with an equal number of patients who were taking opioids alone. The primary outcome of interest was any hospitalization or emergency department visit due to an overdose within 30 days.

There were 217 overdose events per 41,344 person-years among patients taking both Z-drugs and opioids, compared with 57 overdose events per 39,705 person-years among patients taking opioids alone. After controlling for all confounding factors, the researchers found that patients who had prescriptions for both Z-drugs and opioids were more than two times as likely to overdose as those taking only opioids.

“Although Z-drugs are widely perceived as safe, drug-induced respiratory depression has been reported in association with their use,” Szmulewicz and colleagues wrote. “Clinicians need to weigh this risk when considering whether to co-prescribe Z-drugs to patients taking prescription opioids.”

For related information, see the Psychiatric News article “Synthetic Opioid Overdose Deaths Soar.”

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It’s Not Too Late to Register for APA Annual Meeting!

APA’s Annual Meeting kicks off tomorrow, April 30, with a Pre-Conference Expo—a full day of exhibits with over 95 representatives, Product Theater presentations, and opportunities to meet with recruiters for employment opportunities. Then, from Saturday, May 1, through Monday, May 3, join thousands of psychiatrists from across the globe for 135+ scientific sessions with live Q&As, poster sessions, Virtual Exhibit Gallery, discounts on books from APA Publishing, opportunities for member engagement, and more.

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Suicide Prediction Models May Exacerbate Racial Health Disparities

Models that predict patients most at risk of suicide may be less accurate at predicting this risk in people who identify as Black or American Indian/Alaskan Native, suggests a study published today in JAMA Psychiatry.

Because clinical prediction models frequently rely on health records, they may be less accurate for patients who experience disparities in access to health care, wrote R. Yates Coley, Ph.D., of the Kaiser Permanente Washington Health Research Institute and colleagues. The authors noted that current suicide prediction models are accurate at the population level, but research is lacking on their accuracy for racial and ethnic subgroups.

Coley and colleagues gathered data on outpatient visits to a mental health specialist, including health record and insurance billing information, from seven health systems between January 1, 2009, and September 30, 2017. Suicide predictors used in the analysis included demographic characteristics (age, sex, race, ethnicity, and insurance type), comorbidities, mental and substance use diagnoses, dispensed psychiatric medications, prior suicide attempts, prior mental health encounters (including at emergency departments and hospitalizations), and Patient Health Questionnaire-9 (PHQ-9) responses. The researchers ran two prediction models for suicide deaths that occurred within 90 days after an outpatient visit. Because patients self-reported their race/ethnicity information during clinic visits, the information may not have been recorded if the patient had too few encounters during which it was collected, they did not identify with any of the categories offered, or clinic staff did not make inquiries about the information.

The analysis included nearly 14 million visits by 1.4 million patients, and 768 suicide deaths were observed within 90 days of 3,143 visits. Suicide rates were highest for patients who did not have a race or ethnicity recorded, followed by patients who were Asian or White. Overall the models predicted who would die by suicide with about 82% accuracy when including the entire data set at the population level. Within racial/ethnic subgroups, the model was most accurate at predicting suicide among for White, Hispanic, and Asian patients, and least accurate at predicting suicide in Black and American Indian/Alaskan Native patients, as well as those with unrecorded race or ethnicity.

“Health records data may poorly predict suicide death in some racial/ethnic groups for several reasons,” the authors wrote. These include barriers to affordable, culturally competent mental health care; practitioner bias and institutionalized discrimination that lower the likelihood that underrepresented populations will receive a mental health diagnosis or treatment; and the potential misclassification of suicide deaths as unintentional or accidental, or vice versa.

“[P]otential benefits and harms of using a prediction model within particular populations must be considered in the context of existing health inequities,” the authors concluded. “BIPOC [Black, Indigenous, and people of color] populations already face significant barriers to accessing mental health care and, as a result, have poorer outcomes. In this context, deploying a prediction model that provides less benefit to already underserved populations will widen this care gap.”

For related information, see the Psychiatric Services article “Reconciling Statistical and Clinicians’ Predictions of Suicide Risk.”

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‘Digital Divide’ May Further Worsen Mental Health Disparities in Youth

Although policy changes during the COVID-19 pandemic enabled physicians to deliver care via telehealth, people of all ages from across the country remain without access to such care due to a lack of reliable internet service and/or computers.

“While a large majority of youth in the United States have internet access, about 14% of youth ages 6 to 17 live in homes without internet and 17% of youth ages 3 to 18 live in homes without computers, numbers which translate to approximately 11 million youth without access to the internet,” wrote Marie Smith-East, Ph.D., D.N.P., and Shaquita Starks, Ph.D., A.P.R.N., in a Letter to the Editor in the Journal of the American Academy of Child & Adolescent Psychiatry. Failing to address the needs of youth without access to the internet and/or computers can serve to marginalize them and may widen pediatric mental health disparities, they continued.

Smith-East is director of the Psychiatric Mental Health Nurse Practitioner Program at Duquesne University School of Nursing. Starks is a family psychiatric mental health nurse practitioner at Emory University Nell Hodgson Woodruff School of Nursing.

Smith-East and Starks offered several recommendations for connecting youth without internet access and/or computers to remote mental health care, including the use of telephone consultations with psychiatrists; buses that go into local communities equipped with internet service and laptops, where patients can access telehealth appointments; and community internet hubs where youth can access the internet outside their home for telehealth appointments.

“For youth without internet but who have insurance, policies could be developed to mandate that insurance companies reimburse patients for internet service or have a mobile wi-fi device sent to them for use during their appointments with their psychiatric providers,” Smith-East and Starks continued. “For youth without insurance who typically use community mental health clinics, federal funding for grants should include the ability to apply for mobile hot spots or innovative approaches to reach patients without internet access.”

They concluded, “Until more disadvantaged youth, especially low-income minority youth, have internet access and either computers or smartphones, they will continue to be left out of the fast-paced technological changes occurring in U.S. health care settings, and this will undoubtedly result in deteriorating mental health outcomes,” they concluded. “The long-term effects of lack of access to reliable internet services for mental health care should thus be of critical concern, as negative mental health outcomes in adolescence typically continue into adulthood.”

For related information, see the Psychiatric News article “The COVID-19 Pandemic and Virtual Care: The Transformation of Psychiatry” by Jay Shore, M.D., M.P.H., and Peter Yellowlees, M.B.B.S., M.D.

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Interested in Loan Repayment Program? NHSC Welcomes Applicants

The deadline to submit applications for the National Health Service Corps (NHSC) Loan Repayment Program has been extended until Thursday, May 27 at 7:30 p.m. ET. Learn more about your eligibility and the application process here.

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Eye-Tracking App Found to Accurately Identify Toddlers With Autism

A phone/tablet-based app that tracks eye movements and visual attention can accurately distinguish toddlers with autism spectrum disorder (ASD) from typically developing toddlers, according to a study published today in JAMA Pediatrics.

“Current methods for measuring gaze require specialized expensive equipment, calibration, and trained personnel, limiting their use for universal ASD screening, especially in low-resource settings,” wrote Zhuoqing Chang, Ph.D., of Duke University and colleagues. “We demonstrated for the first time, to our knowledge, that an app deployed on relatively low-cost, widely available devices can reliably measure gaze and detect early ASD symptoms related to social attention.”

Chang and colleagues enrolled 993 toddlers aged 16 to 38 months along with their caregivers for this study. During a well-child primary care visit, all caregivers completed a 20-item questionnaire on the presence or absence of various ASD symptoms. Children whose scores on the questionnaire suggested a risk for ASD were referred for a diagnostic evaluation using DSM-5 criteria. The total sample included 40 toddlers diagnosed with ASD, 17 diagnosed with developmental and/or language delay, and 936 classified as typically developing.

During the well-child visit, the children viewed a series of brief videos (each 60 seconds or less) on an iPhone or iPad set on a tripod while sitting on the lap of their caregiver. The videos tested social preference and featured a person talking or doing an activity (blowing bubbles) on one side of the screen and a static toy on the other side. The children were also shown two movies without people or language (floating bubbles and a barking puppy) as a control. While the children were watching the movies, the researchers tracked the direction of their gaze.

Overall, Chang and colleagues noted that these videos “elicited distinctive patterns of gaze in toddlers with ASD, characterized by reduced preference for social stimuli, lower attentional focus on salient social segments of the movie, and previously unknown deficits in the ability to coordinate their gaze with the speech sounds of others.” There were no differences in gaze patterns among toddlers for any of the control movies, the authors noted.

Using the eye-tracking data from all the social preference videos, Chang and colleagues developed an algorithm that could distinguish toddlers with ASD from typically developing toddlers with about 90% accuracy; the predictive ability of any individual video ranged from 76% to 84%.

“We hope a digital screening tool can be complementary to other assessment approaches and ultimately increase the accuracy, exportability, accessibility, and scalability of ASD screening, allowing improved risk detection and earlier intervention,” Chang and colleagues concluded.

To read more on this topic, see the Psychiatric News article “Smart Glasses May Help Children With Autism Recognize Emotions.”

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Last Day 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 end 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 today, Monday, April 26.

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Psychotropic Polypharmacy Common Among Youths With Intellectual and Developmental Disabilities

More than half of youths with intellectual and developmental disabilities who take psychotropic medications take at least three of them, a study published Thursday in Psychiatric Services in Advance has found. Furthermore, a third take anticonvulsants even though they do not have a seizure disorder.

“Future research should assess strategies to further support youths with intellectual and developmental disabilities and to reduce these potentially harmful prescribing practices,” wrote Jennifer L. McLaren, M.D., of the Dartmouth-Hitchcock Medical Center and colleagues.

The researchers analyzed data from 1,333 youth aged 5 through 21 years who had enrolled in the Center for Systematic, Therapeutic, Assessment, Resources, Treatment (START) Services at the University of New Hampshire Institute on Disability between January 2013 and mid-July 2017. START programs provide crisis support, consultation, training, and outreach to individuals, families, and systems of care. All youths in the study had intellectual and developmental disabilities with co-occurring challenging behaviors or psychiatric diagnoses.

Most of the youths in the study “presented with aggression (e.g., physical, verbal, property destruction, and threats), and more than one-third had psychiatric hospitalizations or emergency department visits in the year before START intake,” the authors reported. Many had also been diagnosed with at least one psychiatric disorder, with the most common diagnoses being attention-deficit/hyperactivity disorder, autism spectrum disorder, and depression.

The researchers found the following:

• 86% of the youths received at least one psychotropic medication.
• 55% received three or more psychotropic medications.
• 65% received antipsychotic medications.
• 32% received anticonvulsants in the absence of a seizure disorder.

The older the youths were, the more likely they were to take more than one psychotropic medication and the more likely they were to receive anticonvulsants without having a seizure disorder. Having a psychiatric hospitalization in the past year was also associated with taking more than one psychotropic medication and receiving anticonvulsants without having a seizure disorder.

“To avoid polypharmacy, providers prescribing psychotropic medications to youths with intellectual and developmental disabilities should consider a slow, step-wise approach when initiating and titrating psychotropic medications and coordinating care with the child’s behaviorist or therapist to provide behavioral data or collateral information,” McLaren and colleagues wrote.

For related information, see the Psychiatric Services article “Psychotropic Polypharmacy Among Youths with Serious Emotional and Behavioral Disorders Receiving Coordinated Care Services.”

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Virtual MindGames This Saturday

MindGames, the popular residents’ competition typically held during the Annual Meeting, will take place virtually tomorrow, April 24, at 6 p.m. ET. Watch residency teams from Cooper Medical School of Rowan University, SUNY Upstate Medical University, and the University of Texas Health San Antonio have their knowledge tested on patient care, medicine, and psychiatric history while winning team earns bragging rights for their program. Art Walaszek, M.D., will host the event with special judges Michelle Riba, M.D., and Philip Muskin, M.D.

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‘Cultural Humility’ Key to Healing Racial Trauma, Psychiatrist Says

The widespread publicization of violent police encounters with Black people combined with the disproportionate burden of COVID-19 deaths on the Black community is “fuel for psychological trauma,” wrote psychiatrist Gowri Aragam, M.D., of Massachusetts General Hospital and Harvard Medical School and colleagues in an article published Wednesday in JAMA Psychiatry.

What can clinicians do to help people experiencing ethno-racial trauma—the individual and/or collective psychological distress and fear arising from experiencing or witnessing discrimination, threats of harm, violence, and intimidation directed at ethno-racial minority groups?

“Addressing this issue requires a systematic approach that involves recognizing and treating symptoms of racialized trauma while eliminating barriers to care at the clinician, organizational, and system levels,” Aragam and colleagues wrote.

As a starting point, the authors recommend that clinicians take steps to optimize their interactions with patients with values, backgrounds, and experiences different from their own. “The hallmark features of adopting a culturally humble lens (for example, critical self-reflection, openness, nonjudgment, and curiosity) have shown benefits in treatment, such as strengthening the therapeutic alliance and improving outcomes,” they wrote.

Such “cultural humility provides a framework for researchers and clinicians to (1) facilitate dialogue about the impact of race and racism on a person’s mental health; (2) examine their own biases, assumptions, and role in perpetuating racist behaviors and narratives; and (3) develop comprehensive case conceptualizations and needs assessments that more accurately reflect individual experiences and acknowledge the diversity within a community.”

Historically, there have been barriers to engaging in the practice of cultural humility, including “inadequate organizational support and training, avoidance of conversations about race and racism, and clinicians’ difficulty in identifying personal bias and racism (or refusal to do so).” They noted there are several coaching and assessment tools available to help clinicians overcome these barriers, including the 5Rs of Cultural Humility coaching tool and the University of Connecticut Racial/Ethnic Stress & Trauma Scale (UnRESTS).

“The Black community faces an acute and potentially long-lasting mental health crisis that necessitates a critical upscaling of mental health interventions. Further, the national reckoning on institutionalized racism sheds new light on long-standing disparities and the need to integrate cultural humility in direct interactions between patients and clinicians and in the development of health care innovations,” Aragam and colleagues concluded. “Adopting a culturally humble approach offers a potential path to reform, a key to healing racial trauma and advancing health equity.”

For related information, see the Psychiatric News article “Seeing the Chauvin Trial Through the Eyes of Another.”

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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 end 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 April 26.

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ABMS Releases New Draft Standards for Board Certification; Members Urged to Submit Comments

The American Board of Medical Specialties (ABMS) yesterday released new draft Standards for Board Continuing Certification. These standards will shape the maintenance of certification (MOC) programs for all ABMS boards, including the American Board of Psychiatry and Neurology, for years to come.

APA is conducting a thorough analysis regarding how the revised MOC standards will impact physicians’ ability to practice medicine and care for patients.

“APA members have sent a consistent message that they want a lifelong learning and continuing certification process that is less burdensome, less expensive, and more relevant to their clinical practice,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., told Psychiatric News. “The new standards have the potential to impact all parts of ABPN’s maintenance of certification program and will directly impact all psychiatrists who are currently board certified. Our Division of Education and our advocacy staff will review the standards closely for how they will affect members immediately and in the future.”

APA encourages all members to review the new standards and submit comments directly to the ABMS regarding how the revised MOC standards will impact physicians’ ability to practice medicine and care for patients. “It is imperative that we make our voices heard during the public comment period,” Levin said.

APA is also encouraging members to submit any comments you might have about the draft standards to APA. You can do so by emailing MOCfeedback@psych.org.

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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 end 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 April 26.

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New Network Aims to Transform Care of First-Episode Psychosis

The National Institute of Mental Health’s Early Psychosis Intervention Network (EPINET) aims to be a “learning health care network” continuously improving the care of patients with first episode psychosis (FEP).

EPINET consists of 101 community-based early psychosis programs and eight regional hubs that coordinate the programs across 17 states. The participating clinics use the EPINET Core Assessment Battery at baseline and follow-up for gathering a wide range of clinically relevant data on FEP. Those data are collected by the National Data Coordinating Center, operated by Westat.

EPINET is still young—the National Institute of Mental Health (NIMH) began funding the network in fall 2019—and its goal is to continuously generate new knowledge about FEP, the effectiveness of current interventions, and ways to improve care.

“Learning in real time is the goal,” said Robert Heinssen, Ph.D., director of the Division of Services and Intervention Research at NIMH, in an interview. “COVID slowed things down, but we now have the Core Assessment Battery that is used by all participating clinics. Now, the data coming in can be harmonized across settings and fed back to participating programs so that a program is able to see how its performance stacks up against national metrics in close to real time.”

The Core Assessment Battery collects information on symptoms, medication use, functioning, school participation, crisis service use, hospitalization, and other factors important to the treatment and outcome of patients with FEP. Susan Azrin, Ph.D., chief of the early psychosis prediction and prevention unit at NIMH, said the battery is posted on the EPINET website for clinicians who want to incorporate measurement-based care into their treatment of patients with FEP. Azrin also urged clinicians treating these patients to use the EPINET website to connect their patients to a participating FEP clinic.

EPINET is modeled on the Institute of Medicine’s vision for “learning health care” as a broad aspirational goal of the U.S. health care system. “That goal is to offer the best possible care, measure the impact of treatment at the point of delivery, and use data to continuously drive quality improvement,” Heinssen continued.

“This really has the potential to change the way we go about treating people with early serious mental illness and may be a harbinger for the way health care for larger populations can be organized,” he said.

For more information, see the Psychiatric News article, “New Network Collects Real-Time Data to Improve Treatment of Early Psychosis.”

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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 end 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 April 26.

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Study Finds Psilocybin as Effective as Escitalopram at Reducing Depression Over Six Weeks

The psychedelic psilocybin may have antidepressant effects comparable to escitalopram, according to a small clinical study published in the New England Journal of Medicine. In a six-week, randomized trial, adults with a long history of depression who took psilocybin experienced similar reductions in depressive symptoms and similar levels of side effects as those taking escitalopram.

Robin Carhart-Harris, Ph.D., of Imperial College London and colleagues recruited 59 adults aged 18 to 80 with moderate or severe depression (at least a score of 17 on the Hamilton Depression Rating Scale); many participants had chronic depression, and the average duration of illness was about 18 years. The participants were assigned to receive either 25 mg of psilocybin (taken one day after enrollment and again three weeks later) along with daily placebo capsules or 1 mg of psilocybin on the same schedule along with daily escitalopram (10 mg/day for the first three weeks and 20 mg/day for the next three weeks). All the participants received psychological counseling sessions one day after taking psilocybin.

The primary outcome measure was improvement in depression symptoms as assessed by the Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR-16).

After six weeks, participants in both groups reported statistically similar improvements in their depression symptoms; average QIDS-SR-16 scores decreased by 8 points in the psilocybin group and 6 points in the escitalopram group. A greater percentage of participants taking psilocybin experienced a clinical response (a drop in their QIDS-SR-16 scores of more than 50%) than those taking escitalopram (70% in the psilocybin group vs. 48% in the escitalopram group). In addition, more participants taking psilocybin achieved remission (QIDS-SR-16 score of ≤5) than those taking escitalopram (57% vs. 28%, respectively).

“A limitation of the trial is the brief duration of escitalopram treatment, because this drug has a delayed therapeutic action on depression,” Carhart-Harris and colleagues wrote. “Had the course of escitalopram been extended, it is possible that better efficacy would have been observed among the patients in the escitalopram group.” Carhart-Harris and colleagues also cautioned that most of the participants volunteered because of an interest in psychedelic medicine, which may limit how applicable the findings are to a broader population.

“Although this trial is an evidentiary milestone in the development of psychedelic drugs, it also reveals major knowledge gaps,” wrote Jeffrey A. Lieberman, M.D., of Columbia University Vagelos College of Physicians and Surgeons and New York State Psychiatric Institute, in an accompanying editorial.

Lieberman, a former president of APA and psychopharmacology expert, noted that researchers do not know how psychedelics produce their mind-altering effects or if a patient needs to have a mystical experience following psychedelic ingestion to get a therapeutic effect. “The Carhart-Harris study notwithstanding, we are still awaiting definitive proof of the therapeutic efficacy of psychedelics and their capacity to improve the human condition.”

To read more on this topic, see the Psychiatric News articles “The Return of Psychedelics: Still Time to Prevent Tragedy,” by Stanley Caroff, M.D., and “The Return of Psychedelics: A Measured Approach,” by Charles Grob, M.D. APA’s 2021 Annual Meeting will also feature a session on psychedelics; a preview can be found here.

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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 end 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 April 26.

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Hospital SUD Programs, Psychiatric Hospitals Lag in Electronic Health Record Use

Hospital-based substance use disorder (SUD) programs and psychiatric hospitals are less likely than acute care hospitals to use basic electronic health record (EHR) and electronic health information exchange (HIE) technology, a study in Psychiatric Services in Advance has found.

Morgan C. Shields, Ph.D., of the University of Pennsylvania and colleagues reviewed data from the 2017 National Survey on Substance Abuse Treatment Services to determine the extent to which basic EHR functionality has been adopted by hospital-based programs. Basic EHR functionality was defined as assessment, progress monitoring, discharge, labs, and prescription dispensing. They also analyzed the use of electronic HIE across hospital-based programs.

In 2017, 68% of hospital-based SUD programs reported basic EHR functionality compared with 84% of acute care hospitals, and 71% reported sending electronic HIE to outside health care professionals, compared with 88% of acute care hospitals. Hospital-based programs that provided medications for alcohol or opioid use disorders were nearly twice as likely to use basic EHR than those that did not provide such medications. Psychiatric hospitals were roughly half as likely as acute care hospitals to have adopted EHRs. Hospitals that used HIE to send information to outside health care professionals were nearly five times as likely to use basic EHR functionality.

The researchers noted several potential reasons for lower EHR adoption among hospital-based SUD programs and psychiatric hospitals, including the stringent privacy requirements of 42 CFR Part 2 and of various state laws.

“Given the importance of [health information technology] in the quality and safety of health care, important future policy efforts should not only encourage adoption in behavioral health treatment settings but also apply consistent definitions of adoption to behavioral health settings,” the researchers wrote.

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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 end 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 April 26.

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Psycho-oncology Services May Reduce Distress, Depression in Cancer Survivors

Outpatient psycho-oncology services, including pharmacotherapy and psychotherapy, significantly reduced distress in cancer survivors up to two years after their diagnosis, according to a study published in Psycho-Oncology.

“Studies which have assessed the effectiveness of psycho-oncology interventions most often did so early in the patient’s cancer treatment course and not in later phases of survivorship,” wrote Jessica Molinaro, M.D., of the Medical College of Wisconsin and colleagues. “As distress is prevalent throughout survivorship, it is imperative that ongoing assessment of psychosocial concerns, intervention on psychological distress, and coordination of care between providers occurs to ensure the needs of the patient are met.”

Molinaro and colleagues recruited 243 patients who had received a cancer diagnosis and were referred to psycho-oncology services. Participants were referred to treatment for a variety of reasons, including difficulty coping with psychosocial stressors or adjusting to cancer diagnoses. Participants had at least one psycho-oncology visit, and the majority were recommended to return for a second visit. They were seen by a physician, nurse practitioner, psychologist, or licensed clinical social worker, all of whom had expertise in psycho-oncology. Interventions included pharmacotherapy and/or psychotherapy. Patients completed the Distress Thermometer and Problem Checklist (DT + PL) and the nine-item Patient Health Questionnaire (PHQ-9), at the beginning of their first and second visits, and the Distress Thermometer again at the end of each visit.

In total, 174 patients had one psycho-oncology visit and 69 had two, with an average of 20 days between visits. The average time from the initial diagnosis of cancer to the first psycho-oncology visit was 2.5 years. While the patients’ average distress scores before their psycho-oncology visits were clinically significant (defined as a score of ≥4 on the DT), distress scores fell significantly after their sessions and were below the cut-off for clinical significance. Among patients who had two sessions of a psycho-oncology intervention, PHQ-9 scores were significantly reduced from the first to second visit.

“As distress and depression are prevalent throughout survivorship and associated with adverse outcomes and higher health care costs, identifying an effective outpatient psycho-oncology intervention is highly valuable in improving overall cancer care quality and outcomes,” the authors wrote.

For related information, see the Psychiatric News article “Understanding the Breadth and Depth of the Subspecialty: Psycho-Oncology.”

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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 end 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 April 26.

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Deaths by Suicide Drop in 2020 While Overall Deaths Soared During Pandemic

Deaths by suicide declined by almost 6% from 2019 to 2020, according to a report in JAMA based on statistics from the Centers for Disease Control and Prevention (CDC).

The decline is one hopeful finding in an otherwise grim report that revealed a 17.7% increase in overall deaths in 2020, with most of those directly attributable to COVID-19.

“The reported decrease in deaths by suicide makes us hopeful that protective mental health measures are having a positive impact amid a time of collective distress,” said Christine Moutier, M.D., chief medical officer for the American Foundation for Suicide Prevention (AFSP), in a statement. “While we don’t know the exact contributors to the reported decline in suicides, research does show us that prioritizing and having open, honest dialog about mental health on the individual and national levels, implementing practices that reduce suicide risk in clinical and community settings, and seeking help early and when indicated can reduce suicide deaths.”

In the JAMA report, Farida B. Ahmad, M.P.H., and Robert Anderson, Ph.D., of the CDC’s National Center for Health Statistics looked at deaths that occurred from January through December 2020, as reported in the National Vital Statistics System. A total of 44,834 deaths by suicide occurred in 2020, a decrease of 5.6% from the 47,511 suicides in 2019. In contrast, the overall number of deaths increased by 503,976 (17.7%) in 2020, with 345,323 of those attributable to COVID-19.

While the AFSP statement noted that the reported decline in suicide deaths is encouraging, it cautioned that much remains unknown about the impact of COVID-19 on suicides. “Suicide is complex, risk is dynamic, and an individual’s personal risk factors combined with precipitants such as evolving experiences with isolation, depression, anxiety, economic stress, and suicidal ideation and access to lethal means may lead to periods of increased risk,” the AFSP statement noted.

AFSP President Maria A. Oquendo, M.D., Ph.D., who also is a past APA president, said it is not entirely surprising that people are less likely to die by suicide in the wake of a collective, community trauma.

“Suicidologists have long observed that suicide rates tend to decline after a catastrophe,” she told Psychiatric News. “The reason is unknown, but some hypotheses include the possibility that individuals become more externally focused given the environmental threat, that the community cohesion that sometimes follows catastrophe has beneficent effects, or that community suffering makes personal suffering more tolerable.”

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

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Complete Survey on How Psychiatrists Can Address Racial Inequities Today

Today, April 14, is the last day to complete the most recent survey by the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry. Learn more about the task force and view the results of its previous three surveys on the task force webpage.

TAKE SURVEY

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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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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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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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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.

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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.

Register Now

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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.

Register Now

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