Popularity of Telehealth Services Has Been Rising Since Start of Pandemic, Survey Finds

Nearly 4 in 10 Americans—38%—have used telehealth services to meet with a medical or mental health professional, up from 31% in the fall of 2020, an APA-sponsored online survey has found. The survey was conducted between March 26 and April 5 and included 1,000 adults 18 years old and older.

Among survey respondents who reported using telehealth services, 82% used the services since the start of the COVID-19 pandemic; 69% used a video platform, and 38% used only phone calls.

Other key findings of the survey include the following:

• 45% of respondents said that telehealth services can offer the same quality of care as in-person services, up from 40% last year.
• 59% would use telehealth services for mental health care, up from 49% last year.
• 43% want to continue using telehealth services when the pandemic is over.
• 34% prefer using telehealth services rather than an in-person doctor’s office visit, up from 31% last year.

“The quick pivot to providing telehealth services at the start of the pandemic was vital to providing continued access to care, and this poll shows the important potential role for telehealth going forward,” said APA President Vivian Pender, M.D., in a statement. “Telepsychiatry especially helps those facing barriers such as lack of transportation, the inability to take time off work for appointments, or family responsibilities.”

“Continued access to telehealth during and after the pandemic is vital, and the poll indicates increasing public support for it,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “As we continue to face the long tail of the pandemic, we have an opportunity to innovate and continue to improve access through telehealth.”

For related information, see the Psychiatric News articles “CMS Lifts Restrictions on Telehealth for Psychiatry, Other Services to Meet COVID-19 Challenge” and “The COVID-19 Pandemic and Virtual Care: The Transformation of Psychiatry.”

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APA Members Invited to Apply for Council and Committee Appointments

APA President-elect Rebecca W. Brendel, M.D., J.D., invites APA voting members to indicate their interest in serving on an APA council or committee. Members who are willing to share their expertise and make a significant time commitment to serve APA, the field of psychiatry, and patients are asked to submit their names or nominate a colleague through the online nomination form. Members who represent the varied demographics of APA’s member and patient populations are highly encouraged to apply. The deadline for nominations is Wednesday, September 1.

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Patients With Social Anxiety Disorder Treated for Sleep Problems May Have Better Outcomes

For patients with social anxiety disorder who received exposure therapy, poor sleep quality was associated with slower symptom improvement over time, according to a study published in Depression & Anxiety.

“Social anxiety disorder, a prevalent psychiatric diagnosis, is often associated with sleep disturbance,” wrote Christina D. Dutcher, M.Ed., of the University of Texas at Austin; Sheila Dowd, Ph.D., of the Rush University Medical Center; and colleagues. “Sleep difficulties may prove an obstacle for optimizing therapeutic gains; thus, clinicians should consider assessing for sleep difficulties and incorporate sleep-relevant techniques into their treatment plans.”

Dutcher and colleagues analyzed data from a clinical trial involving 152 participants that tested the efficacy of D-cycloserine (DCS) augmentation of exposure therapy. All participants had a score of 60 or greater on the Liebowitz Social Anxiety Scale and underwent a five-week group exposure therapy protocol that included 90-minute treatment sessions per week. Symptom severity was assessed at baseline; across the course of the intervention; and during one-week, one-month, and three-month follow-up visits. The participants reported their baseline sleep quality using the Pittsburgh Sleep Quality Index, then completed sleep diaries assessing sleep duration and quality on the nights before and after treatment.

Participants’ scores on the Pittsburgh Sleep Quality Index indicated that 56% identified as poor sleepers. Poorer sleep quality at baseline was significantly associated with slower improvement of social anxiety symptoms over time and predicted worse outcomes at the three-month follow-up visit. Further, participants who slept more before the exposure therapy sessions showed improvement at the next session. There was, however, no significant association between the quality of sleep the night before or after a session with symptoms at the next session.

“Reduced sleep duration impairs the acquisition of new information and the ability to recall previously stored information; thus, it is possible new learning in the session was impaired for individuals with reduced sleep duration before treatment sessions,” the authors wrote. “[I]mplementing interventions that target poor sleep (e.g., stimulus control, relaxation, and cognitive restructuring of sleep-related beliefs) before and throughout the course of exposure-based therapy may assist in maximizing therapeutic outcomes for [social anxiety disorder].”

For related information, see the Psychiatric News article “Overlapping Symptoms Complicate Diagnosis, Treatment of Psychiatric and Sleep Disorders.”

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Cognitive Therapy While Tapering Antidepressants May Be Alternative to Maintenance Medication

Treating patients whose depression is in remission with preventive cognitive therapy (PCT) or mindfulness-based cognitive therapy (MBCT) as they taper an antidepressant medication appears to be a safe alternative to maintenance antidepressant therapy, suggests a report in JAMA Psychiatry.

“Current clinical guidelines recommend the continued use of antidepressant medication for patients at high risk for depressive relapse,” wrote Claudi L. Bockting, Ph.D., of Amsterdam University Medical Center and colleagues. “These results suggest that even for patients with a poor clinical prognosis, it may be possible to recommend offering PCT or MBCT during and after tapering of antidepressants as an alternative to continuing the use of antidepressants.”

Bockting and colleagues performed a literature search for studies that compared adults with depression fully or partially in remission who received preventive psychological intervention while being tapered off their antidepressant with those who continued antidepressant treatment only. Six studies met the researchers’ criteria; the researchers were able to obtain individual patient data for four of these studies (714 patients total), which made up the final sample. Three of the studies involved patients who received MBCT during the tapering period; the fourth involved patients who received PCT during and/or after the tapering period.

The researchers specifically compared whether the patients who received the psychological interventions while tapering antidepressants differed in time to depressive relapse compared with those who continued to take antidepressants. Relapse of depression was measured using the Structured Clinical Interview for DSM-IV Axis I disorders.

Bockting and colleagues found no significant difference in time to relapse between use of a psychological intervention during the tapering period versus antidepressant therapy alone. Younger age at onset, shorter duration of remission, and higher levels of residual depressive symptoms at baseline were associated with a higher overall risk of relapse.

“Although these findings suggest that psychological interventions may be an alternative for continued antidepressant medication use for all individuals, collaborative decision-making between patients and practitioners is crucial,” the authors concluded.

For related information, see the Psychiatric News article “AJP Board Member Responds to NYT Story on Antidepressant Withdrawal.”

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How to Incorporate Anti-Racism Into Psychiatric Practice

The murder of George Floyd by a police officer one year ago today “forced overdue conversations about the structural racism in the very roots of our nation. It also caused many to examine what was once considered business as usual,” APA wrote in a statement released today. “The American Psychiatric Association and psychiatry were forced to confront our own past [as well as] to examine how racism had entwined itself into our current operations and how racism was impacting our patients on a daily basis.”

“We recommit as an organization and a field to staying vigilant to injustices that impact our patients and taking action to achieve mental health equity for all,” the statement concluded.

What actions can individual psychiatrists take to achieve mental health equity for all?

In an article appearing in the June issue of Psychiatric News, psychiatrists shared suggestions on how to adopt anti-racist practices within and outside of clinical practice. “To eradicate racism, in all its forms, everyone must embrace the concept of anti-racism,” said Rahn Bailey, M.D., APA’s minority/underrepresented trustee and chief medical officer of the Kedren Community Health Systems in Los Angeles. “Anti-racism is proactive and assertive,” he said. “It is taking an active stance against racism in every facet of your life and career.”

Acknowledge that racism exists everywhere: The first step to centering racial equity is starting the process of self-reflection and self-education, Lucy Ogbu-Nwobodo, M.D., M.S., an APA/APAF SAMHSA Minority Fellow and PGY-3 psychiatry resident at the Harvard Massachusetts General Hospital/McLean Psychiatry Program, told Psychiatric News. “It’s being willing to take an honest inventory of yourself, your role, and who you are in society.” Jessica Isom, M.D., M.P.H., a psychiatrist at Codman Square Health Center and a voluntary faculty member at Yale School of Medicine, emphasized that building awareness of racism is a skill that individuals must hone over time by committing themselves to doing so. Acknowledging racism’s role both individually and within the field of psychiatry can lead to better outcomes for patients.

Incorporate anti-racist values into your practice: There are many ways to bring anti-racist values into psychiatric practice, said Michael Mensah, M.D., M.P.H., APA’s immediate past resident-fellow member trustee and a PGY-4 psychiatry resident and co-chief of the residency program at the Semel Institute of Neuroscience of the University of California, Los Angeles. “Ask yourself: What does it look like for you to center anti-racism? Does it mean introducing a sliding scale to help patients who can’t pay? Does it mean taking more Medicare and Medicaid patients than before? Does it mean taking a more active role in your local residency program to advocate for a more diverse residency class?” Ayala Danzig, M.D., M.S.W., a fourth-year resident in the Yale University Department of Psychiatry, chair of the Assembly Committee of Resident-Fellow Members, and the Assembly’s Area 1 resident-fellow member representative, described how she regularly audits her own panel of patients, for example, to see if she is disproportionally diagnosing her Black patients with psychotic illnesses or if she’s prescribing more controlled substances to her White patients.

Ask for guidance: Mensah noted there are multiple resources about how psychiatrists can incorporate anti-racism into clinical practice. APA staff can direct psychiatrists to anti-racism advocacy opportunities, and district branches may be able to help identify local anti-racism experts who can offer valuable insights. He encouraged psychiatrists to reach out to other experts to ask for guidance.

“In medicine, we sometimes think that racial equity is not in our lane or our issue to tackle,” Ogbu-Nwobodo said. “But unless we all think of it as our duty as physicians to address these issues, they’re never going to be tackled. We all need to roll up our sleeves and get into the discomfort of this work.”

For more information, see the Psychiatric Services article “Racism and Mental Health Equity: History Repeating Itself,” the APA resource document “How Psychiatrists Can Talk With Patients and Their Families About Race and Racism,” and APA’s structural racism task force hub.

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Serve Your Association and Make a Difference

Members of the Board of Trustees make the important decisions that ultimately steer the organization and have a real-life impact on patients. To reflect APA’s diversity, members of minority or underrepresented groups are especially encouraged to run for office. Nominate yourself or a colleague for the following national offices for 2022: president-elect, treasurer, trustee-at-large, Area 3 and 6 trustees, and resident-fellow member trustee-elect. The deadline for nominations is Wednesday, September 1.

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Off-Label Psychiatric Use of Gabapentin Found to Be Frequent, Risky

An analysis in Psychiatric Services in Advance reports that over 99% of prescriptions for the anticonvulsant gabapentin are off label, including many prescriptions for psychiatric disorders. In addition, nearly 60% of the patients prescribed gabapentin were also found to be taking central nervous system depressants (CNS-D) such as benzodiazepines, a combination that the Food and Drug Administration (FDA) recently warned against.

To better understand gabapentin prescribing for psychiatric disorders, Brianna Costales, B.S., and Amie J. Goodin, Ph.D., M.P.P., of the University of Florida analyzed data from the National Ambulatory Medical Care Survey (NAMCS)—an annual survey of office-based physicians that captures national practices in outpatient medicine.

The authors specifically focused on data gathered from 2011 to 2016, which included 205,417 office visits involving patients aged 18 and older. Of these visits, 5,732 involved a prescription for gabapentin. Compared with those who were not prescribed gabapentin, the patients who were prescribed gabapentin were older (average age of 59.8), about 87% were White, and more than 60% were female.

Only 0.6% of all gabapentin prescriptions were for an approved indication, namely, focal seizures or shingles-related neurological pain. In contrast, 5.3% of all gabapentin prescriptions were for a depressive disorder, 3.5% were for an anxiety disorder, 1.8% were for bipolar disorder, and 0.7% for alcohol use disorder.

Costales and Goodin also found that for 33.1% of the visits in which gabapentin was prescribed, the patient was also taking one CNS-D drug; 25.3% of gabapentin visits involved a patient taking two or more CNS-D drugs. Antidepressants were the most common CNS-D being taken, followed by opioids and benzodiazepines. In December 2019, the FDA issued a safety warning advising against concomitant use of gabapentin and CNS-D drugs due to risks such as sedation, breathing problems, and respiratory arrest.

“[T]he FDA also warned that elderly patients are at an increased risk when co-prescribed gabapentin and CNS-D drugs,” Costales and Goodin wrote. “Our sample had a large representation of older patients, which highlights the need for providers to be aware of this risk when considering whether to continue gabapentin when a patient is also prescribed a CNS-D medication.”

Costales and Goodin added that gabapentin has carried a warning for suicidal behavior and ideation in its package insert since 2008. “These added risks warrant a reevaluation of gabapentin’s risk-benefit profile in psychiatry, specifically to prevent unintended consequences of exacerbating a psychiatric disorder.”

To read more on this topic, see the Psychiatric News article “Suicide Attempts Involving Gabapentin, Baclofen Rising.”

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Serve Your Association and Make a Difference

Members of the Board of Trustees make the important decisions that ultimately steer the organization and have a real-life impact on patients. To reflect APA’s diversity in leadership positions, members of minority or underrepresented groups are especially encouraged to run for office. Nominate yourself or a colleague for the following national offices for 2022: president-elect, treasurer, trustee-at-large, Area 3 and 6 trustee, and resident-fellow member trustee-elect. The deadline for nominations is Wednesday, September 1.

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Youth Who Seek Hospital Care for Self-Harm May Be at Increased Risk of Psychotic, Bipolar Disorders

Adolescents and young adults who go to a hospital for treatment of self-harm may have an increased risk of developing a psychotic or bipolar disorder by the time they are 28 years old, a study in Schizophrenia Bulletin has found.

Koen Bolhuis, M.D., Ph.D., of the Royal College of Surgeons in Dublin, Ireland, and colleagues analyzed data from 59,476 people in the 1987 Finnish Birth Cohort study. The study comprises information from nationwide registers for all children who were born in Finland that year and includes data on inpatient care and outpatient visits at public hospitals. Bolhuis and colleagues followed individuals in the study from birth until the end of 2015, and the maximum age of people included in their study was 28 years.

Approximately 18% of people who visited a hospital for treatment of self-harm when they were between 11 and 28 years old went on to be diagnosed with a psychotic or bipolar disorder by the end of the study. People 21 years and younger had higher risk: 21% of those who were 18 to 21 years old and 29% of those who were younger than 18 years old at their first visit to the hospital for self-harm were diagnosed with a psychotic or bipolar disorder.

Overall, nearly 13% of the people who visited the hospital for treatment of self-harm went on to receive a diagnosis of psychosis, suggesting that they had more than six times the risk of developing psychosis compared with their peers who did not go to the hospital for self-harm. More than 9% visited the hospital for treatment of self-harm went on to receive a diagnosis of bipolar disorder, suggesting that they had nearly eight times the risk of developing bipolar disorder compared with their peers who did not go to the hospital for self-harm.

Bolhuis and colleagues noted that fewer than 1 in 10 adolescents who self-harm goes to the hospital because of their injuries. Therefore, the results of the study do not suggest that self-harm by itself increases the risk of psychotic or bipolar disorders. Rather, the findings suggest that going to the hospital for treatment of self-harm indicates a higher risk.

“[E]xisting health care systems (i.e., hospital registrations for self-harm) can be used as a strategy to identify individuals at elevated risk for psychosis and bipolar disorder,” the researchers wrote. “Our findings suggest that young people presenting to hospital emergency departments with self-harm should be carefully assessed for psychotic or bipolar disorders.”

For related information, see the Psychiatric Services article “Emergency Department Use and Inpatient Admissions and Costs Among Adolescents With Deliberate Self-Harm: A Five-Year Follow-Up Study.”

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Serve Your Association and Make a Difference

Members of the Board of Trustees make the important decisions that ultimately steer the organization and have a real-life impact on patients. To reflect APA’s diversity, members of minority or underrepresented groups are especially encouraged to run for office. Nominate yourself or a colleague for the following national offices for 2022: president-elect, treasurer, trustee-at-large, Area 3 and 6 trustees, and resident-fellow member trustee-elect. The deadline for nominations is Wednesday, September 1.

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Court Ruling in Wit v. UBH Should be Upheld, Urges APA

Managed care organizations must use medical necessity criteria and assessment tools developed by nonprofit mental health and substance use disorder specialty organizations when making coverage-related determinations.

That’s what APA and seven other medical organizations told the United States Court of Appeals for the Ninth Circuit in a friend-of-the-court brief filed yesterday in the case David Wit, et. al., v. United Behavioral Health (UBH). The brief is informed by a 2020 APA Position Statement on Level of Care Criteria for Acute Psychiatric Treatment.

UBH is appealing an October 2020 ruling by Judge Joseph Spero of the United States District Court for the Northern District of California ordering the company to re-process more than 67,000 claims for mental health and substance use disorder (MH/SUD) treatment, using level of care and clinical guidelines developed by nonprofit mental health and substance use disorder associations. Spero’s injunction followed a 2019 ruling by the same court that UBH had illegally denied those claims based on flawed medical necessity criteria.

The 2019 ruling and the 2020 injunction are groundbreaking because managed care companies have traditionally created their own guidelines for level of care and medical necessity, factoring costs into the coverage decisions. “Such guidelines may lead to denial of coverage for treatment that is recommended by a patient’s physician and even cut off coverage when treatment is already being delivered,” according to the APA brief.

In the brief, APA outlined eight requirements for coverage decisions derived from guidelines developed by APA, the American Society of Addiction Medicine, and other mental health specialty groups:

• Practitioners must undertake a multidimensional assessment prior to designing a treatment plan.
• Effective MH/SUD treatment requires addressing underlying conditions, not merely presenting symptoms.
• Proper treatment of MH/SUDs requires coordinated treatment of co-occurring conditions.
• Patients should be placed in the least-restrictive level of care that is both safe and effective.
• When the proper level of care is ambiguous, physicians should exercise caution and place the patient in the higher level of care.
• Effective MH/SUD treatment often requires providing continuing services to support recovery and prevent relapse or deterioration.
• Duration of care should be individualized and not subject to arbitrary limits.
• Treatment plans for children and adolescents must account for their unique needs.

“Standards of care should be based on the best treatment for patients, not the bottom line,” APA President Vivian Pender, M.D., said in an APA news release. “Some managed care organizations develop their own coverage guidelines that are overly focused on stabilizing acute symptoms of mental health and substance use disorders, rather than treating the underlying illness. When the injury is physical, insurers treat the underlying disease and not just the symptoms. Discrimination against patients with mental illness must end.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., noted that failure to provide appropriate levels of care for treatment of patients with mental illness and/or substance use disorders can lead to relapse, overdose, transmission of infectious diseases, and death. “APA calls upon courts, legislatures, and insurance commissioners to require insurance companies to deliver the care for which patients and employers have paid based upon evidence-based, objective, and patient-centered guidelines, rather than company profits.”

For related information, see the Psychiatric News article “UBH Ruling Called an Enormous Victory for Patients, Wake-Up Call to Insurers.”

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Serve Your Association and Make a Difference

Members of the Board of Trustees make the important decisions that ultimately steer the organization and have a real-life impact on patients. To reflect APA’s diversity, members of minority or underrepresented groups are especially encouraged to run for office. Nominate yourself or a colleague for the following national offices for 2022: president-elect, treasurer, trustee-at-large, Area 3 and 6 trustees, and resident-fellow member trustee-elect. The deadline for nominations is Wednesday, September 1.

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HHS to Establish Behavioral Health Coordinating Council, Distribute $3 Billion in MH, SUD Funding

The Department of Health and Human Services (HHS) on Tuesday announced plans to establish a Behavioral Health Coordinating Council focused on collaboration and strategic planning across the department. The council will “ensure that millions of Americans receive prevention, early intervention, treatment, and recovery services for mental illness and substance use disorders,” an APA news release stated.

APA applauded the Biden-Harris administration for creating the council, which will be composed of senior leadership from across HHS. It will be co-chaired by Assistant Secretary for Health Rachel Levine, M.D., and Acting Assistant Secretary for Mental Health and Substance Use Tom Coderre. In an HHS news release, HHS Secretary Xavier Becerra noted that he is convening the council because the COVID-19 pandemic “calls for department-wide coordination.”

“APA looks forward to continuing to work with the Assistant Secretary for Mental Health and Substance Use, the Assistant Secretary for Health, and other HHS leadership on innovative and action-oriented approaches,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the APA release. “This Council has great potential to ease the challenges we face as we begin to recover from the pandemic’s impact on our society, and APA looks forward to assisting in [these] efforts.”<

HHS also announced that the Substance Abuse and Mental Health Services Administration (SAMHSA) is distributing $3 billion in funding made available through the American Rescue Plan Act of 2021, which Congress passed earlier this year. The Community Mental Health Services Block Grant (MHBG) and the Substance Abuse Prevention and Treatment Block Grant (SABG) programs will each disperse $1.5 billion to states and territories.

During a virtual event announcing the plans, Coderre said the MHBG funds will be used for a variety of treatment and recovery services for children with serious emotional disturbances and adults with serious mental illness (SMI). The SABG will be used to plan, carry out, and evaluate prevention, intervention, treatment, and recovery services for communities impacted by substance use. “These supplements to the block grants triple the amount of money available to help people who are suffering from mental and substance use disorders,” Coderre said.

The MHBG requires states to set aside 10% of their total allocation for first-episode psychosis or early SMI programs, Coderre continued, and SAMHSA is recommending states set aside 5% for crisis services.

“In the wake of the pandemic an unprecedented, and as of yet untold, number of Americans are faced with mental health and substance use disorders, particularly in communities impacted by structural racism,” APA President Vivian Pender, M.D., said in APA’s news release. “With the creation of this Council and this investment in mental health, the administration is taking a huge step forward.”

For related information, see the Psychiatric News article “APA Applauds Passage of COVID-19 Relief Package.”

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Help APA Fight for Better Reimbursement for YOU – Take our Outpatient Insurance Survey by May 20

APA advocates on behalf of psychiatrists to increase reimbursement and decrease administrative burdens from public and private payers, legislators, and regulatory agencies. To ensure APA is well equipped to fight for better payment for clinical services, we need to know about our members’ experience with outpatient insurance participation. Your responses to questions regarding the nature of your outpatient practice and your experience with participating in health plan networks will help strengthen our arguments for appropriate reimbursement.

Will you please take 5 minutes today to complete this important survey?

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ABCD Study Asks Children About Experiences With Racism

There is ample evidence that racism has negative effects on the health of youth, but few studies have examined the numbers of children in the United States who experience racism and discrimination directly. Data from the Adolescent Brain Cognitive Development (ABCD) Study—a national NIH-funded study tracking the biological and behavioral development of nearly 12,000 U.S. children beginning at age 9 and 10 through adolescence into young adulthood—may point to those at greatest risk and suggest ways to mitigate the effects of racism.

“Identifying the prevalence of racism and discrimination among a crucial developmental age group is imperative to curtail poor outcomes, adjust public health measures, and improve medical and mental health assessments and treatments,” wrote Jason M. Nagata, M.D., M.Sc., of the University of California, San Francisco, and colleagues in a research letter published Monday in JAMA Pediatrics.

During a one-year follow-up assessment of ABCD Study participants, children aged 10 and 11 years completed the Perceived Discrimination Scale. This assessment asked the children about their experiences of being treated unfairly or feeling unaccepted due to race, ethnicity, or color. The analysis included 10,354 children (49% girls; 51% boys), more than 45% of whom were identified by their parents or other caregivers as members of racial/ethnic minorities (19.2% Latino/Hispanic, 16.0% Black, 5.5% Asian/Pacific Islander children, 3.0% Native American, and 1.3% Other).

About 5% of the children reported discrimination due to their race/ethnicity, with the prevalence of discrimination highest among Black children (10%). After adjusting for other demographic factors, Asian/Pacific Islander (adjusted odds ratio [AOR], 2.76); Black (AOR, 2.64); Native American (AOR, 1.86); and Latino/Hispanic (AOR, 1.84) children had higher odds of perceived racism compared with White children. Additional analysis revealed that annual household income modified the association between being Black and perceived racism. Black race was associated with 8.23 higher odds of perceived racism among children with household incomes of $75,000 or higher compared with 2.43 higher odds of perceived racism among children with household incomes less than $75,000. This association was not seen in other racial/ethnic groups.

Although the children indicated that their peers were mostly the perpetuators of racism, “teachers and other adults were often reported as the source of this unfair treatment, highlighting the critical need to ensure antiracism practice and address structural racism within educational communities, which are important social determinants of health,” Nagata and colleagues wrote. “Mitigating the effects of racism on health should start with interventions in childhood.”

For related information, see the Psychiatric News article “Psychiatrists Discuss Impact of Racism Across Generations.”

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Help APA Fight for Better Reimbursement for YOU – Take our Outpatient Insurance Survey by May 20

APA advocates on behalf of psychiatrists to increase reimbursement and decrease administrative burdens from public and private payers, legislators, and regulatory agencies. To ensure APA is well equipped to fight for better payment for clinical services, we need to know about our members’ experience with outpatient insurance participation. Your responses to questions regarding the nature of your outpatient practice and your experience with participating in health plan networks will help strengthen our arguments for appropriate reimbursement.

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Study Examines Cognitive Effects of Schizophrenia Medications

People with schizophrenia often experience problems with learning, memory, attention, and social cognition. A study published in AJP in Advance examines how the cumulative effects of medications with anticholinergic properties (decrease the activity of the neurotransmitter acetylcholine) may contribute to worse cognitive outcomes.

“Psychotropic medications, especially antipsychotics, are critically important therapeutics for schizophrenia, have substantially improved the lives and outcomes for countless patients living with schizophrenia, and represent an essential staple of comprehensive treatment,” wrote Yash Joshi, M.D., Ph.D., of the University of California, San Diego, and colleagues. However, “[e]fforts to limit or avoid excessive anticholinergic medication burden—regardless of source—may have a beneficial impact on cognitive outcomes in schizophrenia.”

Joshi and colleagues analyzed medication records of 1,120 adults with schizophrenia or schizoaffective disorder who were part of a study on the genetics of schizophrenia. The researchers assigned each medication that a patient was taking a score of 0 to 3 based on its anticholinergic strength (clozapine and olanzapine received 3s, for example, whereas risperidone received a 1). Most scores were available on an existing database known as the Anticholinergic Cognitive Burden (ACB) scale, and the researchers estimated scores for other medications based on their similarities to medications with ACB scores. The researchers added these scores together for total ACB score.

The average ACB score for the sample was 3.8, with individual scores ranging from 0 to 20. “For context, an ACB score of 3 in healthy older adults is associated with cognitive dysfunction and a 50% increase in risk for developing dementia,” Joshi and colleagues wrote. “In our data, the proportion of patients with an ACB score of at least 3 was 63%, with approximately 25% having an ACB score ≥6.”

Joshi and colleagues found that patients with higher ACB scores had on average lower scores on various cognitive assessments; deficits were seen across multiple cognitive domains including memory, attention, visual and spatial recognition, and motor skills. The connection between higher ACB score and worse cognitive function persisted even after adjusting for patients’ age, severity of illness, smoking status, and antipsychotic dose.

“The present results do not necessarily suggest that a specific psychotropic or combination of psychotropics is ‘better’ or ‘worse’ for cognition,” the authors wrote. However, physicians should be cognizant of a patient’s cumulative anticholinergic burden when prescribing both psychotropic as well as nonpsychotropic medications, they continued.

To learn more about this topic, see the Psychiatric News article “Anticholinergics Linked to Increased Risk of Dementia.”

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Overweight, Obesity in Early Adulthood Linked to Late-Life Dementia

People who are overweight or obese in early adulthood may have a higher risk of dementia later in life, a study in Alzheimer’s and Dementia suggests.

Adina Zeki Al Hazzouri, Ph.D., of Columbia University and colleagues analyzed data from 5,104 older adults from the Cardiovascular Health Study and the Health, Aging, and Body Composition study. The participants were between 69 and 78 years old at enrollment and were followed for roughly eight years on average. Hazzouri and colleagues estimated the participants’ BMIs in early adulthood (aged 20 to 49 years) based on trends among their peers in the Coronary Artery Risk Development in Young Adults study and the Multi Ethnic Study of Atherosclerosis. They defined overweight as a body mass index (BMI) between 25 and 30 and obesity as a BMI higher than 30.

Compared with women who had an early adulthood BMI of less than 25, women who were overweight or obese had 1.82 times the odds and 2.45 times the odds of developing dementia in late life (age 70 to 89), respectively. Compared with men who had an early adulthood BMI of less than 25, men who were overweight or obese had 1.35 times the odds and 2.47 times the odds of developing dementia in late life, respectively.

“In light of the growing obesity epidemic among U.S. adults, with recent figures suggesting about 40% of U.S. adults ages 20 years or older are obese, our findings suggest that interventions aimed at modifying trends in obesity early in the life course may reduce the risk of dementia by potentially modifying the course of its preclinical phase.”

For related information, see the Psychiatric News article “Drops in Blood Pressure, BMI Common Prior to Dementia Diagnosis.”

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APA advocates on behalf of psychiatrists to increase reimbursement and decrease administrative burdens from public and private payers, legislators, and regulatory agencies. To ensure APA is well equipped to fight for better payment for clinical services, we need to know about our members’ experience with outpatient insurance participation. Your responses to questions regarding the nature of your outpatient practice and your experience with participating in health plan networks will help strengthen our arguments for appropriate reimbursement.

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Patients Report Greater Satisfaction With Extended-Release Over Daily Buprenorphine

Patients with opioid dependence who received weekly or monthly buprenorphine injections reported greater satisfaction compared with patients who took oral buprenorphine daily, according to a study in JAMA Network Open. The results highlight the importance of using patient-reported outcomes when developing medication treatment for substance use disorders.

“Long-acting injectable depot buprenorphine formulations have been developed to mitigate some of the concerns of daily dosing,” but few studies have compared the patients’ experiences with the injectable versus oral form of the medication, wrote Nicholas Lintzeris, M.B.B.S., Ph.D., of the University of Sydney Discipline of Addiction Medicine in Australia and colleagues.

Lintzeris and colleagues conducted an open-label trial involving 119 participants aged 18 and older, recruited from six outpatient clinical sites in Australia. All participants met the criteria for opioid dependence according to ICD-10 and were receiving daily buprenorphine before the study began. They were randomized to receive either weekly or monthly injections of extended-release buprenorphine or daily oral buprenorphine as a film formulation. Those who received the extended-release buprenorphine were administered injections of the medication with a maximum weekly dose of 32 mg or a maximum monthly dose of 160 mg. Those who received daily buprenorphine were administered a maximum daily dose of 32 mg.

Participants completed the Treatment Satisfaction Questionnaire for Medication (TSQM) at baseline and at weeks four, eight, 12, 16, 20, and 24. Higher scores indicated greater satisfaction with treatment. By week 24, the depot buprenorphine group expressed significantly higher satisfaction compared with the group receiving daily buprenorphine. The mean TSQM scores at baseline were 71.2 in the depot buprenorphine group and 73.8 in the daily group, but at 24 weeks the mean scores were 82.5 and 74.3, respectively.

In an accompanying commentary, Nora Volkow, M.D., director of the National Institute on Drug Abuse (NIDA), and Wilson Compton, M.D., M.P.E., deputy director of NIDA, noted the importance of including the voice of the patient in medication development. “Patient preferences and apparently improved function may prove to be useful secondary outcomes in medication trials, and the measures used in this new study deserve consideration,” they wrote.

They continued: “[T]he greater treatment satisfaction by patients receiving [extended-release] buprenorphine suggests that [extended-release] formulations might help to improve long-term retention and, as such, be a valuable tool to help combat the current opioid epidemic and reduce its associated mortality,” Volkow and Compton wrote.

For related information, see the Psychiatric News article “Factors to Consider Before Prescribing Buprenorphine.”

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Studies Point to Promise of Digital Interventions for Patients With Depression, OCD

A pair of articles published this week in JAMA point to the potential promise of using digital interventions to help youth and adults who are experiencing symptoms of mental illness.

One article describes two separate trials involving adults aged 21 years and older who had clinically significant depressive symptoms (Patient Health Questionnaire-9 score of 10 or greater) and were being treated for hypertension and/or diabetes in São Paulo, Brazil, and Lima, Peru.

One group of participants received a smartphone with an app that regularly sent users automated behavioral activation sessions that could be completed in 10 minutes or less. The behavioral activation sessions focused on encouraging participation in activities pleasant or meaningful to the patient. Nurse assistants met with participants in the intervention group for an initial face-to-face meeting to go over the app and followed up by phone with participants who did not appear to be using the app. The second group received enhanced usual care, which included regular evaluations for depressive symptoms over the course of the trial and referral to specialists as needed. Participants in both groups received regular health services for depression, diabetes, or hypertension.

“[A] significantly greater proportion of participants who received the digital intervention compared with enhanced usual care experienced at least a 50% reduction in depressive symptoms at three months (40.7% vs. 28.6% in Brazil; 52.7% vs. 34.1% in Peru), although the differences were no longer statistically significant at six months,” reported Ricardo Araya, M.D., Ph.D., of King’s College London and colleagues. “In the intervention group, worsening of depressive symptoms occurred in 10% of patients and worsening of suicide ideation occurred in 6% of patients vs. worsening by 12% and 7% in the control group,” they added.

The second article describes a trial in Sweden comparing outcomes in children and adolescents aged 8 to 17 years with obsessive-compulsive disorder (OCD) who received either online cognitive-behavioral therapy (CBT) for 16 weeks followed by traditional in-person CBT if necessary (stepped-care group) versus in-person CBT alone (control group).

The online CBT program consisted of 14 modules, which included text, movies, and exercises centered on education, exposure with response prevention, and relapse prevention. The families of patients in the stepped-care group were assigned a therapist whom they could contact via an online platform. Participants in the control group received manualized in-person CBT with up to 14 sessions over 16 weeks. Youth in either group who were classified as nonresponders at three months were offered up to 12 sessions of in-person CBT between the three-month follow-up and six-month follow-up. Responder status was defined as those who experienced at least a 35% reduction on the Yale-Brown Obsessive-Compulsive Scale from baseline to follow-up.

“After six months, the mean Children’s Yale-Brown Obsessive-Compulsive Scale score was 11.57 in those treated with internet-delivered CBT vs. 10.57 in those treated with in-person CBT”—a difference that suggests the treatments are similarly effective, reported Kristina Aspvall, Ph.D., of the Karolinska Institutet and colleagues. “Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups.”

“Although these two studies featured different countries (high-income vs. low-/middle-income), different digital technology approaches (self-help app vs. computerized stepped care), different diseases (depression vs. OCD), and different ages (children and adolescents vs. adults), they shared underlying commonalities around the universal application of digital mental health, including the importance of human support, the need to monitor and assess digital interventions, and the need for assessment in the clinical population,” wrote psychiatrist John Torous, M.D., in an accompanying editorial. Torous is the director of the Digital Psychiatry Division in the Department of Psychiatry at Beth Israel Deaconess Medical Center and leads APA’s work group on the evaluation of smartphone apps. “Both studies also offer behavioral treatments that are low risk and thus may not be considered a high priority for clinician monitoring. … However, both studies show that low risk does not mean that there is no risk or need to follow and monitor patient progress.”

Torous concluded, “The two studies reported in this issue of JAMA are timely contributions that underscore how digital interventions can help patients today. They also highlight how high-quality research can advance digital health science and raise the next generation of questions to make digital approaches even more effective and clinically important.”

For related information, see the Psychiatric Services article “User Engagement in Mental Health Apps: A Review of Measurement, Reporting, and Validity.”

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People at High Risk for Psychosis Found to Have Thinner Cortex

Individuals who are at high risk for psychosis appear to have a thinner cortex as measured by structural magnetic resonance imaging (sMRI) than healthy individuals, according to a report in JAMA Psychiatry.

Moreover, lower brain volume measurements among at-risk individuals, especially between the ages of 12 and 16, appear to predict whether they will later become acutely psychotic. “Findings from this international effort suggest that conversion to psychosis among those at clinical high risk is associated with lower cortical thickness (CT) at baseline,” write Maria Jalbrzikowski, Ph.D., an assistant professor of psychiatry at the University of Pittsburgh, and colleagues.

The researchers analyzed sMRI images of the brains of 1,792 individuals at clinical high risk (CHR) for psychosis, including 253 individuals who later developed acute psychosis, and 1,377 healthy controls at 31 centers around the world participating in the ENIGMA Clinical High Risk for Psychosis Working Group. From the sMRI images, they formulated 155 measures of cortical thickness, surface area, and subcortical volume, as well as three global neuroimaging measures—total intracranial volume, average cortical thickness, and total surface area.

High-risk participants had smaller overall brain volume measurements compared with healthy controls, with the greatest difference in cortical thickness. (There was no difference in cortical surface area or subcortical volume.) Additionally, the 253 individuals who later developed psychosis had thinner cortexes than the high-risk individuals who did not develop psychosis and the healthy controls in three brain regions—the paracentral, superior temporal, and fusiform regions.

Finally, compared with the healthy control group, those aged 12 to 16 in the high-risk group—including those who did and did not later develop psychosis—had significantly thinner cortexes in the paracentral and fusiform region.

“In the largest study of brain abnormalities in individuals at CHR to date, we found robust evidence of a subtle, widespread pattern of CT differences, consistent with observations in psychosis,” the investigators write. “These findings also point to age ranges … when morphometric abnormalities in individuals at CHR might be greatest.”

For related information, see the Psychiatric News article “Imaging Advances Could Aid Outcome in High-Risk Patients.”

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Researchers Identify Childhood Behaviors That May Signal Future Self-Harm

Researchers have identified two distinct pathways by which adolescents develop self-harming behaviors: the first is associated with years of emotional difficulties and bullying: the second is associated with more willingness to take risks and experiencing less security with peers and family during adolescence. These findings were published in the Journal of the American Academy of Child and Adolescent Psychiatry.

“There is global consensus that self-harm is a prevalent concern in adolescence and a priority for public health efforts,” wrote Stepheni Uh, M.Phil., of the University of Cambridge and colleagues. “Establishing early risk factors and profiles that can be traced and tracked across development provides a crucial step towards the early identification of these young people … and ultimately prevention and treatment.”

Uh and colleagues analyzed data from the Millennium Cohort Study, a longitudinal assessment of about 19,000 young people throughout the United Kingdom. They focused on 1,580 participants (73% female) who had reported engaging in self-harm at age 14 and used computer modeling to identify any social or behavioral similarities in this group compared with peers who did not self-harm. Data were taken from the participants’ responses on the Strength and Difficulties Questionnaire and Mood and Feelings Questionnaire (MFQ) at ages 5, 7, 11, and 14; a positive answer on the MFQ question “In the past year have you hurt yourself on purpose?” was used as an indicator of self-harm.

The model found that most of the adolescents who harmed themselves fit into one of two behavioral clusters. The first group, which included 379 teens, was characterized by emotional and behavioral difficulties such as hyperactivity or conduct problems as early as age 5; these children also reported frequent bullying. The second and larger cluster (905 teens) did not exhibit any childhood psychopathology; rather, self-harm was associated with increased risk-taking behaviors and changes in their relationship with family and friends during adolescence. Uh and colleagues also found that adolescents in both clusters reported low self-esteem and difficulty sleeping at age 14.

“A key implication of our findings is that we have a decade-long window to intervene for some children who are at increased risk of self-harm as adolescents,” Uh and colleagues wrote. “Early targeted interventions, particularly those focused on emotion regulation, may be helpful for this [first] group.”

The larger group of self-harming adolescents without childhood psychopathology “represents the challenge we face to assist those in the general population,” the authors continued. “However, their indication of poorer mental health on the MFQ than the Comparison sample at age 14 as well as both risk-taking and peer-related factors suggest that access to universal programs and materials for self-help and problem-solving/conflict regulation … may be effective.”

For related information, see the Psychiatric News article “Bullying Found to Increase Risk for Adolescent Suicide Attempts Worldwide.”

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Contingency Management Programs May Help Patients With Cocaine Use Disorder

Contingency management interventions that reward patients for abstaining from cocaine use may be an effective treatment option for patients with cocaine use disorder, a meta-analysis published today in JAMA Network Open suggests.

Brandon S. Bentzley, M.D., Ph.D., of Stanford University and colleagues analyzed data from 157 clinical trials that included 402 treatment groups and 15,842 participants aged 18 years or older with cocaine use disorder. Participants enrolled in the trials on average used cocaine about three days week and had been using cocaine for several years.

The most common treatments were psychotherapy and contingency management programs. Other interventions included treatment with anticonvulsants, antidepressants, antipsychotics, dopamine agonists, opioids, psychostimulants, or placebo. The primary outcome was a negative urine test for cocaine metabolites at the end of treatment.

Overall, 26.9% of patients completed treatment and were cocaine-free at the end of treatment.

The researchers found that only contingency management programs were associated with an increased likelihood of having a negative urine test at the end of treatment. Patients who participated in contingency management programs were roughly twice as likely to have a negative urine test compared with those in placebo groups.

The researchers noted that contingency management programs have been helpful in treating substance use disorders at the U.S. Department of Veterans Affairs.

“Given the results of our study and the fact that the Department of Veterans Affairs is the largest integrated provider of addiction services in the U.S., consideration of the implementation of contingency management programs on a national level or within other major health care systems in the U.S. is warranted,” they wrote.

Psychotherapy did not appear to have a significant impact on cocaine use. However, the researchers noted that their analysis did not take into account the type or dose (session length and frequency) of psychotherapy. They added that their approach to analyzing the data cannot rule out the benefits associated with specific approaches or doses of psychotherapy.

For related information, see the American Journal of Psychiatry article “Searching for Treatments for Cocaine Use Disorder: The Quest Continues.”

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Sustained Model May Be Effective for Smoking Cessation in Psychiatric Patients

A hospital-based smoking cessation intervention that involves motivational counseling and post-discharge follow-up helps patients maintain abstinence longer than usual care, according to a study published Wednesday in JAMA Psychiatry.

“Individuals with serious mental illness (SMI) smoke cigarettes at disproportionately higher rates, are more likely to smoke heavily, and have lower cessation rates than the general population,” wrote Richard A. Brown, Ph.D., of the University of Texas at Austin; Nancy Rigotti, M.D., of Harvard Medical School; and colleagues. “These findings, if replicated, provide a scalable approach to achieving sustained smoking cessation in patients with SMI following a psychiatric hospital stay.”

Brown, Rigotti, and colleagues conducted a clinical trial involving 342 participants aged 18 and older receiving inpatient treatment for SMI who smoked at least five cigarettes per day when not hospitalized. Participants’ diagnoses included depressive, anxiety, bipolar, psychotic, and personality disorders, among others. The participants were randomly assigned to one of two interventions: usual care or sustained care.

Patients assigned to the usual care group received five to 10 minutes of smoking cessation information and advice from the admitting nurse, self-help materials, and an offer of nicotine replacement therapy to use after discharge. Those in the sustained care group received a single 40-minute motivational interview tailored for patients with SMI provided by a smoking cessation counselor; four weeks of free transdermal nicotine patches upon discharge; access to free telephone-, text-, or web-based cessation counseling after discharge provided by a counselor trained to work with callers with psychiatric diagnoses; and enrollment in an automated, interactive voice response telephone system that asked participants about their smoking and intentions to quit following discharge.

The participants in both groups were asked about their use of smoking cessation treatment (smoking counseling and/or pharmacological interventions) at one, three, and six months after hospital discharge. At the six-month follow-up, participants were also asked about smoking in the past seven days; smoking status was also biochemically verified. Participants reported smoking an average of 17 cigarettes per day prior to hospitalization. At the six-month follow-up, those in the sustained care group had significantly higher rates of seven-day abstinence compared with the participants who received usual care (8.9% vs. 3.5%). Participants in the sustained care group were also significantly more likely to report using smoking cessation treatment over the six months following their hospitalization compared with those in the usual care group (74.6% vs. 40.5%).

“These findings are notable, given that two-thirds of this sample could be considered economically disadvantaged (with household annual incomes less than $25,000), in addition to having SMI,” the authors wrote. “Both of these factors are associated with higher smoking rates and less success at quitting.

“Our findings suggest that combining this evidenced-based, client-centered counseling approach with automated, proactive resources, such as [interactive voice response], text messaging, and other technology-assisted interventions … increases the likelihood of successful attempts at quitting,” the authors continued.

For related information, see the Psychiatric News article “Psychiatrists Can Do More to Help Patients Quit Smoking.”

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Racism Said to Shape Social Determinants of Psychosis

Neighborhood disadvantage, trauma history, and pregnancy complications are all established risk factors for psychosis. These social determinants of health are also more likely to impact minority groups in the United States, in part because of the racial discrimination these groups experience. A comprehensive review published in AJP in Advance examines how structural racism helped lead to the disproportionate risk of psychosis facing minority groups.

“That racism has historically structured U.S. societal systems means that the neighborhood and social context may hold a significant portion of the relative contribution of risk for psychosis. This may occur through individual-level discrimination as well as through collective trauma at the community level (e.g., police and gun violence),” wrote Deidre M. Anglin, Ph.D., an associate professor of clinical psychology at the City College of New York, and colleagues. Anglin presented the review at a virtual press session at APA’s online 2021 Annual Meeting on Monday.

Anglin and colleagues summarized multiple studies that show that common characteristics of many minority neighborhoods (including more densely populated areas and inequitable access to health care, healthy foods, clean air and water, green spaces, and employment) and exposure to trauma (including gun violence and police victimization) are associated with cumulative stress and increased risk of psychosis.

The authors presented data showing that Black women in the United States are at substantially increased risk for many obstetric complications, as well as data showing that obstetric complications are often associated with psychotic disorders in offspring. For instance, studies show that Black women tend to have higher rates of preterm birth and infants born at low birth weights compared with other women in the United States. “Our review of obstetric complications suggests that discrimination among Black and Latina mothers may [also] contribute to … these complications because of heightened responses to stress (for example, inflammatory responses),” the authors wrote.

The review highlighted several studies demonstrating that discrimination is not just associated with psychological distress, but also adverse biological effects including advanced cellular aging and changes in neural connections.

“Overall, this research indicates that we need to acknowledge and treat structural racism as it is: A critical public health threat,” Anglin said during the virtual press session.

The authors offered several recommendations for addressing the ways that racism shapes social determinants of psychosis, such as establishing a federal program to provide reliable and up-to-date estimates of psychosis prevalence across different racial and ethnic groups and incorporating more discussion of discrimination and racial trauma in mental health training.

“To truly adopt an anti-racist framework, it is necessary to walk in the opposite direction on the path that seeks to maintain the status quo,” the AJP article concluded. “Building a critical consciousness about the ways behaviors and symptoms are connected to the contexts in which we live, including in our training programs, among providers, and in our patients, can enhance practice effectiveness.”

For related information, see the Psychiatric News article “We Must Speak to Patients and Their Families About Racism.”

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