Friday, July 30, 2021

House Passes Bills to Boost Funding for Mental Health, Substance Use Programs

Yesterday the U.S. House of Representatives approved significant funding increases for key mental health and substance use disorder (SUD) programs included in the FY 2022 Labor, Health and Human Services, Education, and Related Agencies and the Military Construction, Veterans Affairs, and Related Agencies appropriations bills.

The legislation increases funding for the Substance Abuse and Mental Health Services Administration (SAMHSA) by $3.16 billion, an increase of nearly 50% over FY 2021, to $9.16 billion. The SAMHSA increase includes the following:

  • An $825 million increase to the Mental Health Services Block Grant, including a 10% set-aside for crisis services and an additional $100 million for mobile crisis response and an $89.6 million increase for the Suicide Lifeline and implementation of the 988 phone number.
  • Additional substance use treatment resources of $1.6 billion, including a 33% increase in State Opioid Response Grants.
  • $20.3 million for the Minority Fellowship Program, a 20% increase.

The bill also includes the following funding:

  • An increase of $341 million for the Health Resources Services Administration (HRSA) to support health workforce development, including $28 million for HRSA’s loan repayment program for the substance use disorder treatment workforce.
  • $37.5 million for the Employee Benefits Security Administration, including a specific focus on improving compliance with the Mental Health Parity and Addiction Equity Act.
  • $330 million for the National Institutes of Health research on health disparities, including $250,000 through the National Institute on Minority Health and Health Disparities, as well as a 25% overall increase for the National Institute on Drug Abuse and a roughly 5% increase for the National Institute of Mental Health and the National Institute on Alcohol Abuse and Alcoholism.
  • $2.9 billion in additional funding for veterans mental health care, including a $286 million boost for suicide prevention outreach.

APA issued a statement thanking House Appropriations Committee Chair Rosa DeLauro (D-Conn.) and the committee for leading the effort to provide the funding in the legislation.

“This week’s action by the House is step one in an appropriations process that needs to go through the legislative process,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “But the best way to position funding for psychiatry and mental health, including substance use, for success is for the APA administration and our members to be aggressive advocates at every step in the process. So spread the word. Our advocacy matters and is making a difference.”

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Register Now for Mental Health Services Conference

The program for APA’s Mental Health Services Conference is now available. This virtual event will take place Thursday, October 14, and Friday, October 15. Under the theme “Sociopolitical Determinants: Practice, Policy, and Implementation,” the meeting will feature educational programs and innovations in clinical services designed to ensure equal access to high-quality mental health care for all patients regardless of race/ethnicity, age, religion, nationality, sexual orientation, gender identity, socioeconomic status, or geographical background. Lowest registration rates are now in effect.


Thursday, July 29, 2021

Lyme Disease Heightens Risk of Mental Disorders, Suicidality, Study Finds

People in Denmark diagnosed with Lyme disease in a hospital went on to have 28% higher rates of mental disorders and were twice as likely to have attempted suicide, compared with those without the diagnosis, according to a study published Wednesday in AJP in Advance. Having more than one episode of Lyme disease was associated with a higher rate of mental disorders, affective disorders, and suicide attempts.

According to the CDC, nearly half a million people a year in the United States are treated for Lyme disease (also known as Lyme borreliosis), the most common vector-borne disease, and the areas where Lyme disease is common are expanding. Several studies have pointed to a connection between Lyme disease and psychiatric manifestations in people with untreated infection as well as months to years after antibiotic therapy, wrote Brian A. Fallon, M.D., M.P.H., of Columbia University and New York State Psychiatric Institute and colleagues. The current study is believed to be the first large population-based study examining the relationship between Lyme disease and psychiatric outcomes.

The researchers analyzed patient medical records for the nearly 7 million people living in Denmark and compared individuals diagnosed with Lyme disease in a hospital setting (n=12,616) with those without this diagnosis. Specifically, they examined cases of various mental disorders and suicidality among all individuals and adjusted the results based on known risk factors for mental illness such as sex, age, education level, socioeconomic status, and comorbidities. Patients who had a history of mental disorder or suicidality prior to the Lyme disease diagnosis were excluded from the analysis.

The analysis revealed that in addition to patients with Lyme disease being at greater risk of mental disorders and suicide attempts compared with those without this disease, they also had a 42% higher rate of affective disorders and a 75% higher rate of death by suicide. “Notably, the rate for affective disorders was highest during the first year after diagnosis and highest for completed suicide during the first 3 years after diagnosis,” Fallon and colleagues wrote.

“Our study focused on those whose Lyme disease was severe enough to require hospital contact,” Fallon told Psychiatric News. “Our results are therefore not surprising, given that individuals with hospital-based diagnoses of serious infections are known to have an increased risk of subsequent affective disorders and suicide.” The study results may not be generalizable to potentially less severe cases of Lyme disease that were handled outside the hospital.

Despite the findings, hospital-diagnosed cases of Lyme disease were not a major contributor to the overall rate of mental disorders or suicide in the general population, the authors noted. For example, the absolute rate for suicide of patients who were diagnosed with Lyme disease in the hospital was low, accounting for 25 fatalities over a 22-year period, representing 0.2% of all suicides during that time.

“Although the absolute population risk is low, clinicians should be aware of the potential psychiatric sequelae of this global disease,” Fallon and colleagues concluded.

For more on this topic, see the chapter on infectious diseases in The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry from APA Publishing.

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Wednesday, July 28, 2021

People With Mental Illness at Greater Risk of Death From COVID-19, Meta-Analysis Finds

People with mental illness had a higher risk of dying from COVID-19 than people without mental illness, according to an international meta-analysis of studies conducted between December 2019 and July 2020. Patients with schizophrenia and/or bipolar disorders had the highest risk of COVID-19 mortality, according to the report. The findings were published Tuesday in JAMA Psychiatry.

“Patients with mental health disorders can have multiple comorbidities that have been identified as risk factors for severe COVID-19: diabetes, hypertension, chronic obstructive respiratory disease, and end-stage kidney disease,” wrote Guillaume Fond, M.D., Ph.D., of Aix-Marseille University in France and colleagues. “Mental health disorders are also associated with socioeconomic deprivation and reduced access to care, two important factors of poor COVID-19 outcomes.”

Fond and colleagues analyzed data from 16 population-based studies across seven countries (Denmark, France, Israel, South Korea, Spain, the United Kingdom, and the United States). These studies included 19,086 patients with a wide range of mental disorders, including mood disorders, alcohol use disorder, schizophrenia spectrum disorders, and bipolar disorders, among others.

The meta-analysis revealed that patients with any mental disorders had a 1.38 times greater risk of dying from COVID-19 than did people without mental disorders. Those with schizophrenia and/or bipolar disorders had a 1.67 times greater risk of COVID mortality; this may be related to genetic variations in patients with schizophrenia or bipolar disorder that compromise their immune function, Fond and colleagues wrote.

The findings point to the importance of “requiring enhanced preventive and disease management strategies for people with mental illness,” the authors concluded. “Future studies should evaluate the risk [of COVID-19] for each mental health disorder and confirm that patients with schizophrenia and bipolar disorders are at the highest risk of mortality.”

For related information, see the Psychiatric News article “COVID-19 Greatly Increases Mortality Risk for Schizophrenia Patients, Research Shows.”

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Tuesday, July 27, 2021

Children With ADHD May Benefit From Taking Micronutrients

Children with attention-deficit/hyperactivity disorder (ADHD) and irritable mood who are not taking psychotropic medications may benefit from supplemental micronutrients, suggests a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

Evaluations by clinicians revealed that a greater percentage of children who took micronutrient capsules for eight weeks experienced symptom improvements compared with children who took placebo pills, the study found. The children in the micronutrients group also grew taller on average over the eight-week trial.

“Although [the] findings did not demonstrate between-group differences on core symptoms of ADHD in this study, micronutrient supplementation was associated with global improvements that factored in a range of life domains including anxiety, anger, and sleep,” wrote Jeanette M. Johnstone, Ph.D., of Oregon Health & Science University and colleagues.

For the multisite trial, Johnstone and colleagues recruited children aged 6 to 12 who met DSM-5 criteria for ADHD and displayed at least one symptom of irritability or anger, according to parent reports. To be included in the trial, the participants had to be psychotropic medication free for at least two weeks and be willing to swallow 9 to 12 capsules a day with food.

The researchers randomly assigned 135 children to either the micronutrient or placebo groups. Children in the micronutrient group took capsules containing a blend of vitamins and essential minerals (including vitamins A and B12, folate, copper, potassium, and more), amino acids, and antioxidants. Children in the placebo group took the same number of placebo capsules from bottles with a mild vitamin/mineral scent. Parents completed the Child and Adolescent Symptom Inventory-5 (CASI-5), which assesses ADHD, oppositional defiant behavior, disruptive mood dysregulation, and peer conflict symptoms, at the start of the study as well as weeks 4 and 8. Clinicians completed the Clinical Global Impression-Improvement (CGI-I) subscale at week 8.

Of the 135 children randomized, 126 completed the trial. For the CGI-I, 54% of the micronutrient group and 18% of the placebo group were categorized as responders (defined by a CGI-I score of 1 or 2, “very much” or “much” improved). The parent-reported CASI-5 revealed significant improvements in both groups; however, there was no significant difference between these groups. Children in the micronutrient group on average grew six millimeters (about 0.24 inches) more than children in the placebo group. There were no differences in adverse events reported by children in either group.

“This fully-blinded RCT of micronutrients addresses several concerns related to existing ADHD treatment, including the possibility of counteracting height suppression and treating associated irritable mood, emotional dysregulation, and aggression,” the authors concluded. “Based on blood and urine tests and systematic adverse event reporting, micronutrients given at doses between the Recommended Dietary Allowance and Upper Tolerable Intake Level appear safe and may be developed into an alternative or complementary treatment for ADHD.”

For related information, see the Psychiatric News article “Irritable Symptoms in Youth With ADHD Don’t Necessarily Require Extra Medications.”

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Monday, July 26, 2021

Future Care Planning Can Help Patients With SMI, Aging Caregivers With Major Life Transitions

Future care planning can be difficult for aging parents and caregivers of people with serious mental illness (SMI). An article in Psychiatric Services in Advance describes the important role that mental health professionals can play in helping families to prepare for the future.

“Just as mental health professionals guide parent caregivers to facilitate medication adherence and prevent relapses for a child with serious mental illness, they should also routinely take the lead in discussing and cocreating a future care plan [when caregivers and patients are older],” wrote Thanapal Sivakumar, M.D., of the National Institute of Mental Health and Neuroscience in Bengaluru, India, and colleagues.

Sivakumar and colleagues offer recommendations for mental health professionals on when to begin planning for future care, who should participate in this planning, and what should be included in a future care plan for the plan to be successful. The recommendations include the following:

  • Begin working on a future care plan while parents are in good health. The authors noted that developing a future care plan will likely require multiple meetings between mental health professionals and families, and needs may change over time.
  • Facilitate conversations between parents, patients, and prospective caregivers so that everyone feels heard. The authors wrote that these conversations may help to identify life skills that patients may need to develop and help mental health professionals triage patients to appropriate services to support this development.
  • Consider patients’ needs related to food and housing, health services, social support, transportation, insurance, and finances, and work with families to identify how they might share the responsibilities related to these needs in the future.

The authors noted that mental health professionals should take the lead in collaborating with parents, patients, and others to facilitate future care planning. “This initiative will provide a sense of relief to parents that their son or daughter will be cared for after their lifetime while ensuring that the [patient] has the best chance to manage the transition successfully,” they wrote.

For related information, see the Psychiatric News article “Mobile App Helps People With SMI Create Crisis Plan.”

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Friday, July 23, 2021

Nonpartner Physical Violence Affects More Than Half of Men With Disabilities

More than half of men who have disabilities have experienced nonpartner physical violence, mostly by strangers, a study in the American Journal of Preventive Medicine has found. The findings highlight the need for violence prevention and intervention programs that are inclusive of and responsive to the needs of men and women with disabilities.

Zarintaj A. Malihi, Ph.D., of the University of Auckland in New Zealand and colleagues analyzed data from the 2019 New Zealand Family Violence Survey/He Koiora Matapopore, in which face-to-face interviews were conducted with 2,887 New Zealanders aged 16 years or older between 2017 and 2019. The study was designed to determine the prevalence rates of nonpartner physical and sexual violence reported by people with physical, intellectual, psychological, and multiple disabilities compared with the prevalence reported by people without disabilities. Questions about violence were drawn from the WHO Multi-Country Study on Violence Against Women questionnaire and adapted to include men.

Overall, more people with disabilities reported nonpartner physical and sexual violence experience than those without disabilities. Among men with disabilities, 56.2% experienced lifetime nonpartner physical violence and 5.6% experienced lifetime nonpartner sexual violence. In 59.3% of cases, this violence was perpetrated by strangers. Among women with disabilities, 15.4% experienced lifetime nonpartner physical violence and 11.1% experienced lifetime nonpartner sexual violence. In 59.7% of cases, this violence was perpetrated by parents and relatives.

People with psychological disabilities reported the highest prevalence rates of nonpartner physical and sexual violence. Women with psychological disabilities had 1.97 times the odds of experiencing nonpartner physical violence and 2.65 the odds of experiencing nonpartner sexual violence compared with women who had no psychological disabilities. Men with psychological disabilities had 2.5 the odds of experiencing nonpartner physical violence and 43.74 times the odds of experiencing nonpartner sexual violence compared with men who had no psychological disabilities.

“Policy and practice implications [of the findings] include the need for the development of prevention and intervention programs that meet the needs of people with different types of disabilities,” Malihi and colleagues wrote. “Programs need to be implemented in ways that are accessible and appropriate, considering physical needs and the needs of those with intellectual and psychological disabilities because these individuals may have difficulty in understanding danger or in communicating their experiences in ways that others believe.”

The vast majority of perpetrators of nonpartner physical and sexual violence upon people with disabilities were men. Men were the main perpetrators in 84.7% of nonpartner physical violence experienced by men with disabilities and 55.3% of nonpartner violence experienced by women with disabilities. Men were the perpetrators in 80% of cases of nonpartner sexual violence against men with disabilities and all cases of nonpartner sexual violence against women with disabilities.

“The findings also speak to the importance of addressing social norms about masculinity and power,” the researchers wrote. “The social norms that support men’s use of violence need to be addressed as part of national prevention campaigns.”

For related information, see the Psychiatric Services article “Victimization and Perpetration of Violence Involving Persons With Mood and Other Psychiatric Disorders and Their Relatives.”

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US Remains Under Public Health Emergency Due to COVID-19

The U.S. Secretary of Health and Human Services on Tuesday signed a renewal of determination that the public health emergency due to the COVID-19 pandemic remains in effect.


Thursday, July 22, 2021

More Than 1.5 Million Children Globally Lost Caregivers Due to COVID-19 Pandemic

An estimated 1.562 million children worldwide lost a caregiver from March 2020 to April 2021 due to the COVID-19 pandemic, according to a study published this week in The Lancet.

“Studies like this play a crucial role in illuminating the COVID-19 pandemic’s long-lasting consequences for families and the future mental health and well-being of children across the globe,” said National Institute on Drug Abuse (NIDA) Director Nora D. Volkow, M.D., in a news release. NIDA helped fund the study.

Susan Hillis, Ph.D., of the Centers for Disease Control and Prevention COVID-19 Response Team and colleagues noted that orphanhood (defined as the death of one or both parents) can have severe consequences for children. “Because COVID-19 can lead to death within weeks, families have little time to prepare children for the trauma they experience when a parent or caregiver dies,” they continued.

Hillis and colleagues used excess death and COVID-19 death data from 21 countries from March 1, 2020, to April 30, 2021. The countries accounted for 76% of global COVID-19 deaths. The deaths included those caused directly by the virus, as well as those caused indirectly by other causes, such as lockdowns or decreased access to health care. The authors also used fertility rates to calculate the average number of children that each adult would have during the study period, to estimate the number of children orphaned by these deaths. They extended the study to incorporate deaths of grandparents aged 60 to 84 who lived with their grandchildren. Primary caregivers were defined as parents and custodial grandparents, while secondary caregivers were defined as co-residing grandparents or other relatives.

The authors found that 862,365 children in the 21 countries had been orphaned or lost a custodial grandparent due to COVID-19, including 788,704 who lost a mother, father, or both parents. South Africa, Peru, the United States, India, Brazil, and Mexico had the highest numbers of children losing primary caregivers. In the United States, 136,692 children lost a primary or secondary caregiver. Based on their findings, the authors estimated that 1.134 million children around the world lost a mother, father, both parents, or a custodial grandparent during the study period. Further, the authors found that there were up to five times more children with deceased fathers than mothers.

“Though the trauma a child experiences after the loss of a parent or caregiver can be devastating, there are evidence-based interventions that can prevent further adverse consequences, such as substance use, and we must ensure that children have access to these interventions,” Volkow said in the news release.

“Now is the time to focus on a group that will continue to grow as the pandemic progresses: the more than 1 million children who have lost a parent and another half a million children who have lost a grandparent caregiver living in their own home,” the authors concluded. “These unnamed children are the tragic overlooked consequence of the millions of pandemic dead.”

For related information, see the Psychiatric News article “Long-Term Impact of COVID-19 on Children, Adolescents Constitutes Public Health Emergency.”

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US Remains Under Public Health Emergency Due to COVID-19

The U.S. Secretary of Health and Human Services on Tuesday signed a renewal of determination that the public health emergency due to the COVID-19 pandemic remains in effect.


Wednesday, July 21, 2021

Dementia at Younger Ages More Prevalent Than Previously Estimated, Meta-Analysis Suggests

The development of dementia in people between the ages of 30 and 64 years (known as young-onset dementia) is more common than previously estimated, according to a report published Monday in JAMA Neurology. The new report estimates young-onset dementia affects some 3.9 million people globally.

“Although this is higher than previously thought, it is probably an underestimation owing to lack of high-quality data,” wrote lead author Stevie Hendriks, M.Sc., of Maastricht University in the Netherlands and colleagues. Specifically, “more data are needed from low-income countries as well as studies that include younger age ranges,” they wrote.

Hendriks and colleagues searched the literature for population-based studies on the prevalence of young-onset dementia published between January 1, 1990, and March 31, 2020. A total of 74 studies with more than 2.7 million patients were included in an analysis that looked at the prevalence of dementia in adults grouped by five-year age blocks beginning at age 30 through age 64. (The authors noted that most of the studies included in the analysis were conducted in Europe and in older groups in Asia, North America, and Oceania.) Specific diagnoses analyzed included Alzheimer’s disease, frontotemporal dementia, and vascular dementia.

They found an overall global age-standardized prevalence of 119.0 per 100,000 population in the age range of 30 to 64 years, corresponding to 3.9 million people aged 30 to 64 years living with young-onset dementia in the world. The majority of cases occurred when people were between the ages of 45 and 64 years; the prevalence of dementia in people aged 30 to 34 years was found to be extremely rare at about 1.1 per 100,000 but rose to 77.4 per 100,000 among people aged 60 to 64 years.

The most common diagnosis was Alzheimer’s disease, followed by vascular dementia and frontotemporal dementia. However, in the lower age ranges, until 50 years of age, vascular dementia prevalence was the highest, followed by frontotemporal dementia and Alzheimer’s.

“Most dementia care is geared for older patients, and as a consequence, services are rarely available to address the needs of someone diagnosed with dementia in their 50s who has dependent children at home and a spouse who must continue working. Understanding the prevalence and incidence of [young-onset dementia] is a first step in addressing this challenge,” wrote David Knopman, M.D., of the Mayo Clinic, in an accompanying editorial. “[A] rationally derived estimate of dementia prevalence across the population aged 30 to 64 years provides a basis for initiating more efforts to improve methods for timely diagnosis and to address the unique needs of [these] patients.”

For related information, see the Psychiatric News article “Measurements of Brain Age May Help Target Therapy.”

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US Remains Under Public Health Emergency Due to COVID-19

The U.S. Secretary of Health and Human Services on Tuesday signed a renewal of determination that the public health emergency due to the COVID-19 pandemic remains in effect.


Tuesday, July 20, 2021

COVID-19 Has Numerous Neuropsychiatric Consequences, Report Finds

An article appearing today in the Journal of Neuropsychiatry and Clinical Neurosciences provides a comprehensive overview of the neurological and psychiatric impact of the COVID-19 pandemic.

“Although best known for its severe effects on respiratory function, SARS-CoV-2 produces a broad range of acute and chronic neurological and neuropsychiatric problems,” wrote Theodora Manolis, M.D., of Red Cross Hospital in Athens, Greece, and colleagues. “The COVID-19 pandemic has also had an important impact on the mental health of many individuals in the general population as a result of loss of loved ones, fear of calamity or death, financial hardships, social isolation resulting from government-mandated quarantine and social distancing requirements, and major disruptions of daily life and social connectedness.”

Manolis and colleagues compiled data from individual case reports, cohort studies, and meta-analyses on the neurological and psychiatric outcomes in patients with SARS-CoV-2 infection. Neurological problems in hospitalized COVID-19 patients are diverse and common, the authors noted, with one analysis finding that over 80% of these patients developed one neurologic condition over the course of the illness. While muscle pain, headache, and loss of taste/smell tend to be the most common neurologic symptoms in these patients, potentially fatal symptoms including stroke and encephalopathy were also reported among hospitalized patients.

“CNS infection combined with environmental stress caused by pandemic fear, social and financial restrictions, and ICU monitoring may result in the development of neuropsychiatric symptoms or syndromes, including depressive symptoms or episodes, manic or hypomanic symptoms or episodes, psychotic symptoms, obsessive-compulsive symptoms, and posttraumatic stress,” the authors added. They described several studies and case series that seem to suggest that patients hospitalized for COVID-19 may be at higher risk of depression and/or psychosis compared with those without COVID-19.

The range of acute and long-term neurological and psychiatric problems reflects the multipronged way the virus impacts the brain, the authors noted. This includes direct penetration of the nervous system through the nasal passage or circulatory system, indirect damage from the body’s immune response, and damage related to hypoxia or delirium.

Other topics explored in the article include the following:

  • Impact of COVID-19 on neurodegenerative disorders
  • Adverse neuropsychiatric effects of COVID-19 treatments
  • Psychiatric impact of the pandemic on health care workers
  • Maladaptive coping strategies and other psychosocial impacts of the pandemic

“There is an immediate need for interventions aimed at managing the psychosocial impact and mitigate the neuropsychiatric manifestations in addition to the other health and economic consequences of this unprecedented viral pandemic,” Manolis and colleagues concluded. “Protection of mental well-being can be accomplished by providing programs structured for psychosocial support to all those in need, such as health care workers, persons stricken by unemployment and financial hardship, families with COVID-19-affected members, older adults, and other vulnerable groups.”

To read more on this topic, see the Psychiatric News articles “Expect a ‘Long Tail’ of Mental Health Effects From COVID-19” and “Psychological Stress May Not Be Only Route Of COVID-19’s Psychiatric Burden.”

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Monday, July 19, 2021

VA Study Shows Patients With Schizophrenia Least Likely to Discontinue Clozapine, LAI Antipsychotics

Patients with schizophrenia may be less likely to stop treatment if prescribed clozapine or the long-acting injectable (LAI) formulations of aripiprazole and paliperidone compared with oral olanzapine, reports a study published today in AJP in Advance. The study made use of data from over 37,000 veterans

“Randomized controlled trials are the gold-standard design used to test the efficacy of antipsychotics but only reflect effectiveness in patients who volunteer for such trials,” wrote Marc Weiser, M.D., of the Stanley Medical Research Institute and colleagues.

Weiser and colleagues used the U.S. Department of Veterans Affairs (VA) pharmacy and health databases to compare two outcomes associated with antipsychotic treatment: treatment discontinuation rates and psychiatric hospitalization rate. The analysis included 15 categories: patients taking one of nine oral medications (aripiprazole, clozapine, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone, and oral first-generation antipsychotics), patients taking one of five LAI formulations (aripiprazole, fluphenazine, haloperidol, paliperidone, and risperidone LAIs), and patients receiving polypharmacy.

The researchers compared all other medications to olanzapine since it had the lowest discontinuation rate in the seminal Clinical Antipsychotic Trials of Intervention Effectiveness schizophrenia study in 2005.

After adjusting for other factors, Weiser and colleagues found that five groups had a lower risk of treatment discontinuation than the olanzapine group: clozapine (57% reduced risk), LAI aripiprazole (29% reduced risk), LAI paliperidone (24% reduced risk), antipsychotic polypharmacy (23% reduced risk), and LAI risperidone (9% reduced risk). Oral quetiapine, oral ziprasidone, oral aripiprazole, oral risperidone, and oral first-generation antipsychotics all had higher risks of discontinuation than olanzapine.

“The smaller risk of discontinuation for clozapine may be related to the use of this agent in people who are more likely to be adherent to the monitoring requirements or the increased frequency of visits required to monitor the use of this agent,” Weiser and colleagues wrote. “The smaller risk of clozapine discontinuation may also be related to the lack of alternative treatments for people who fail to demonstrate a robust response to clozapine.”

None of the medications were found to reduce the risk of psychiatric hospitalization compared with olanzapine. Several medications were associated with slightly higher hospitalization risk compared with olanzapine: oral first-generation antipsychotics (22% increased risk), LAI paliperidone (27% increased risk), oral lurasidone (33% increased risk), oral quetiapine (36% increased risk), LAI haloperidol (39% increased risk), LAI fluphenazine (40% increased risk), and oral ziprasidone (46% increased risk).

To read more on this topic, see the Psychiatric News article “Which Antipsychotics Are Best for Your Patients?

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Friday, July 16, 2021

Want to Present at APA's 2022 Annual Meeting? Abstract Submissions Are Now Being Accepted

APA is now accepting abstract submissions for its 2022 Annual Meeting, which will be held May 21 through 25 in New Orleans. The theme of the meeting is “Social Determinants of Mental Health.” Submissions must be made electronically through APA's online abstract submission system to be considered. The site will close on Thursday, September 9, at 5p.m. ET.

APA has made the following updates to the submission process:

  • All presenters/co-authors must attest to their participation in the proposal.
  • A single author cannot be listed on more than five submissions of any type, including a maximum of two posters.
  • A general session cannot have more than one chair and three presenters.
  • Proposals by residents and medical students must be reviewed by a faculty mentor prior to submission.

All presenters and co-authors must enter the abstract system using their username and password. All authors must have an account before submission. To obtain additional information about topics and format and to download sample abstracts, view the Submission Guidelines.

APA’s next major meeting is coming up this fall–the Mental Health Services Conference, whose theme is “Sociopolitical Determinants: Practice, Policy, and Implementation.” It will be held virtually on October 14 and 15. The conference, which is the successor to APA’s Institute on Psychiatric Services and has a new, more intensive format, will highlight educational programs and innovations in clinical services that are designed to ensure equal access to high-quality mental health care to all patients regardless of race, ethnicity, age, religion, nationality, sexual orientation, gender identity, socioeconomic status, or geographical background.

Experts will discuss the following topics:

  • The impact of social determinants of health in the care of those with serious mental illness
  • How systems of care can influence the use of the social determinants of mental health to improve diagnosis and treatment planning
  • The policy landscape and opportunities encouraging the use of evidence-based medicine and the role it plays in addressing care equity

Register by Monday, August 16, to take advantage of the meeting’s lowest registration rates.

For related information, see the Psychiatric News article “Addressing Social Determinants of Mental Health.”

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Thursday, July 15, 2021

In Canada, Black Patients More Likely to Receive Coercive Treatment, Study Finds

Black people of Caribbean or African descent with first-episode psychosis in Canada were more likely to be coercively referred for treatment and to receive coercive psychiatric services compared with patients of other races and ethnicities, according to a study published Tuesday in Psychiatric Services in Advance.

“Medical coercion refers to the use of force, threats, or other means to gain compliance from another person who is deemed an imminent danger to themselves or others,” wrote Sommer Knight, M.Sc., and G. Eric Jarvis, M.D., M.Sc., of McGill University in Montreal and colleagues. In Canada, the authors continued, “certain groups, particularly ethnic minority groups of African or Caribbean descent, are at greater risk for involuntary admission; this discriminatory treatment may be due to excessive application of the ‘danger’ criterion for psychiatric commitment among members of these groups.”

Knight, Jarvis, and colleagues analyzed data from 208 patients with first-episode psychosis who were referred to the First Episode Psychosis Program in the Institute of Community and Family Psychiatry of the Jewish General Hospital in Montreal. The participants were between the ages of 16 and 30; had been taking antipsychotic medications for less than 30 days; and had exhibited psychotic symptoms such as hallucinations, delusions, or paranoid ideation for more than three consecutive days. Participants’ ethnic and racial identifies were included in their charts, and when that information was unavailable, the authors conducted a search to determine that information based on categories from Statistics Canada, a census of the population, including the participants’ country of birth, languages spoken, immigration status, religion, and family name.

Participants who were brought to emergency services via the police, ambulance, or court order were considered to have been coercively referred to treatment. Whether a participant received a coercive intervention was determined from legal documents and physician notes. Coercive interventions included those required by a Canadian court, as well as those rendered by medical staff, including seclusion, physical restraints, or the administration of urgent intramuscular antipsychotic.

In total, 96 of the participants were White; 42 were Black; and 70 were of Arab, Asian, or Latinx descent (categorized as the non-Black visible minority groups). Half of Black participants in the study were coercively referred for treatment, compared with 24% of White participants and 36% of non-Black minority participants. Further, 81% of Black participants received a coercive intervention, compared with 56% of White participants and 54% of non-Black minority participants. Black participants were also significantly more likely to experience court-involved coercive interventions than White participants.

The findings, the authors concluded, suggest “that systemic racism may be an international problem embedded in medical and legal institutional frameworks of nations and health care systems. Racial discrimination and prejudice are important public health issues and must be addressed to ensure that medical, psychiatric, and legal interventions are implemented according to best practices for all.”

For related information, see the Psychiatric Services article “Coercion and the Inpatient Treatment Alliance.”

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APA Invites Submissions for 2022 Annual Meeting

The 2022 Annual Meeting submission site is now open for new submissions of general sessions, courses, and posters. The theme for the meeting is “Social Determinants of Mental Health.” The site will close on Thursday, September 9, at 5 p.m. ET.


Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Wednesday, July 14, 2021

Telehealth Services Increased During Pandemic, but Age and Regional Disparities Exist

Telehealth visits accounted for nearly two-thirds of all mental health visits by patients enrolled in private insurance plans in the early months of the COVID-19 pandemic, according to a report published Tuesday in Psychiatric Services in Advance.

However, telehealth use for mental health services from April to June 2020 was lower in rural areas compared with urban areas, and lower among those over 65 years of age compared with those 24 to 35 years of age.

“Telehealth-based mental health services increased overall, but future work might examine why uptake was lower in rural areas and among older individuals and how broadband infrastructure and digital literacy may affect telehealth use,” wrote lead author Jiani Yu, Ph.D., of Weill Cornell Medical and colleagues.

The researchers analyzed roughly 25 million separate mental health claims submitted between January and June 2020 in a national data set of commercial enrollees from FAIR Health, a nonprofit organization managing a database of more than 33 billion privately billed health insurance claims. They calculated telehealth use rates for different conditions as a percentage of all mental health services.

The researchers found that the telehealth use rate for all mental health services increased from 2.2% in January 2020 to 65.2% in April 2020, remaining stable at 65.6% in June 2020. By comparison, telehealth rates for acute respiratory diseases and infections (the service category with the next-highest telehealth use rate behind mental health) decreased from 44.3% to 28.1% from April to June 2020.

Services for generalized anxiety disorder made up the largest share of mental health telehealth services (28.4%), followed by major depressive disorder (23.6%), and adjustment disorder (18.6%).

The changes in the rates of telehealth use for mental health conditions early in the pandemic varied according to where the patients lived, the authors noted. In April 2020, telehealth use for mental health was similar in urban (65.6%) and rural (60.5%) areas, but by June 2020, telehealth use decreased to 49.6% in rural areas while urban use remained high at 66.8%.

“As mental health digital interventions continue to proliferate, new evidence on the cost-effectiveness of telehealth may determine whether mental health services will still primarily be delivered remotely,” the researchers wrote.

For related information, see the Psychiatric News article “Will Telehealth Rules Change After Pandemic? Prepare Now.”

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Tuesday, July 13, 2021

Benefits of ECT May Outweigh Risks for Patients Hospitalized for Depression

Electroconvulsive therapy (ECT) does not appear to significantly increase the risk of serious medical events in adults who are hospitalized for depression, according to a study published Monday in The Lancet Psychiatry. Additionally, the study found that ECT may reduce the risk of suicide in these patients.

Despite substantial evidence that ECT can help patients with treatment-resistant depression, ECT remains underused, due in part to patients’ concerns over potential side effects of the treatment, wrote Tyler S. Kaster, M.D., of the Centre for Addiction and Mental Health in Toronto and colleagues. “For patients to make fully informed decisions regarding electroconvulsive therapy, studies need to assess risk of serious medical events among those with depression who receive electroconvulsive therapy compared with those who receive standard care,” they wrote.

Kaster and colleagues compared more than 10,000 hospitalization records for adults with depression who received treatment at psychiatric inpatient facilities in Ontario, Canada, for more than three days between April 1, 2007, and February 28, 2017. The researchers examined the number of serious medical events (defined as hospitalization or death) experienced by patients who received ECT during their hospitalization compared with those who did not receive ECT. Specifically, the researchers were interested in serious medical events that occurred within 30 days of the first exposure to ECT or the corresponding index date (for those patients who did not receive ECT).

Patients in the ECT group received a mean number of eight ECT sessions. Of the 5,008 patients in the ECT group, 105 had a serious medical event within 30 days (an incidence of 0.25 per person-year); of the 5,008 patients who did not receive ECT, 135 had a serious medical event within 30 days (an incidence of 0.33 per person-year). The number of nonsuicide deaths was low in both groups, with 11 in the ECT group and 12 in the group that did not receive ECT. Similarly, deaths by suicide were rare in both groups, but significantly lower in the ECT group, the authors noted.

“Among individuals hospitalized with depression, we found no evidence for a clinically significant increased risk for serious medical events with exposure to electroconvulsive therapy, and the risk of suicide was found to be significantly reduced, suggesting the benefits of electroconvulsive therapy for depression outcomes might outweigh its risks in this population,” Kaster and colleagues concluded.

For related information, see the Psychiatric Services article “Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners.”

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Monday, July 12, 2021

ADHD May Develop in Children Following Severe TBI

Children who experience a severe traumatic brain injury (TBI) appear to be at greater risk of developing attention-deficit/hyperactivity disorder (ADHD) than children who experience less severe injuries, reports a meta-analysis published today in JAMA Pediatrics. Mild or moderate TBI was not associated with any subsequent risk of ADHD.

“Given the clinical significance of ADHD in pediatric practices and parental concerns about the serious effects of mild TBI/concussion stimulated by media reports, information about the risk for ADHD following TBI may be useful in managing children with TBI and counseling their parents,” wrote Robert F. Asarnow, Ph.D., of the University of California, Los Angeles, and colleagues.

The researchers compiled data from 24 studies that assessed the prevalence of ADHD before and after a TBI in children. The studies included 12,374 children aged 4 to 18 who experienced TBI of various severities and 43,491 controls with no TBI history. Sixteen percent of the children who experienced TBI of any severity had preexisting ADHD and were excluded from most post-injury analyses. TBI severity was measured with the Glascow Coma Scale (scores of 13-15 for mild, 9-12 for moderate, and 3-8 for severe TBI). The authors assessed the risk of post-injury ADHD in both the short (1 year or less) and long (>1 year) term.

They found that children who had had a severe TBI and no ADHD prior to their injury were more likely to be diagnosed with ADHD both in the short and long term compared with children without TBI, including children who had experienced other injuries (like broken limbs). Overall, 18.8% of children who had a severe TBI were diagnosed with ADHD within one year, compared with 4.9% of children with a mild TBI and 10.3% of children with moderate TBI; 35.5% of children with severe TBI had ADHD more than a year after their injury.

“When confronted with claims that a mild TBI causes persistent, severe ADHD symptoms, clinicians should carefully review how the child was functioning before the TBI before concluding that the child developed ADHD as a result of a TBI,” they wrote. “There may be psychosocial and medical issues that antedated the TBI that need to be addressed to adequately treat a child’s ADHD symptoms.”

To read more on this topic, see the Psychiatric News article “Experts Weigh Risks, Benefits of Sports for Youth With ADHD.”

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Friday, July 9, 2021

FDA Narrows Use of New Alzheimer’s Drug to Early Stage Patients

The Food and Drug Administration (FDA) has approved an updated label for the recently approved Alzheimer’s drug Aduhelm (aducanumab) to emphasize that the anti-amyloid monoclonal antibody should be used only in patients whose Alzheimer’s disease is in early stages.

The updated label states, “Treatment with Aduhelm should be initiated in patients with mild cognitive impairment or mild dementia stage of disease, the population in which treatment was initiated in clinical trials. There are no safety or effectiveness data on initiating treatment at earlier or later stages of the disease than were studied.” The original label stated only that Aduhelm was for the treatment of Alzheimer’s disease.

Just last month the FDA granted accelerated approval to the drug based on data from three clinical studies (including two phase 3 studies) that demonstrated a significantly greater reduction of amyloid beta plaques in patients with early stage Alzheimer’s disease who took aducanumab compared with those who took placebo. However, data from two phase 3 trials on the effects of aducanumab on cognition were inconclusive: One of the trials found that patients who received aducanumab had slightly slower cognitive decline than those who received placebo, but the other trial did not.

The FDA’s accelerated approval pathway is designed to speed up the approval of medications for a serious or life-threatening illness that provides a meaningful therapeutic advantage over existing treatments. The pathway enables drug companies to provide a surrogate biomarker that they believe can reasonably suggest future clinical benefit. Yet Aduhelm’s approval drew criticism because last November an FDA advisory panel voted nearly unanimously to reject the drug on the grounds that the clinical data supporting it were not sufficient to warrant approval. Since then, three of the advisory committee members who voted to reject the drug have resigned. The FDA is not obligated to follow the recommendations of its advisory committees, which are made up of outside experts.

Aduhelm is the first novel therapy approved for Alzheimer’s disease since 2003.

For related information, see the Psychiatric News article “Alzheimer’s Pipeline Edges Away From Amyloid.”

Show Your Support of Young People of Color Tomorrow by Participating in Moore Equity in Mental Health 5K

Join hundreds across the country virtually this Saturday, July 10, for the first Moore Equity in Mental Health 5K Run, Walk, and Roll. The virtual program begins at noon ET. The money raised by the 5K will support the APA Foundation’s Moore Equity in Mental Health Community Grants Initiative. The initiative will provide education about the mental health needs of young people of color and support individuals and organizations that develop and provide culturally sensitive mental health services.


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Thursday, July 8, 2021

Missing Emotional Development Milestones in Childhood Associated With Anorexia Risk

Children who struggle to regulate their emotions as they grow older may be at greater risk of exhibiting symptoms consistent with a diagnosis of anorexia nervosa at age 14, according to a study published in JAMA Psychiatry.

Though interventions in childhood could prevent anorexia nervosa, “targets for such interventions are elusive,” wrote Mariella Henderson, M.Sc., of the University College London, Helen Bould, Ph.D., of Bristol Medical School, and colleagues. Emotion regulation, however, “defined as the ability to both intrinsically and extrinsically monitor, appraise, and modify one’s emotional state, has been increasingly proposed as a potential target,” the authors continued.

Henderson, Bould, and colleagues used data from the Millennium Cohort Study, a longitudinal study in the United Kingdom of children born from 2000 to 2002. When the children were 3, 5, and 7 years of age, their mothers reported on their emotion regulation abilities over the previous six months using five questions from the Child Social Behavior Questionnaire (a modified version of the Adaptive Social Behavior Inventory). Scores ranged from zero to 10, with higher scores indicating greater difficulties regulating emotions.

When the children were age 14, the researchers used a set of questions broadly covering DSM-5 criteria for anorexia nervosa and atypical anorexia nervosa to identify participants who had behaviors and thoughts consistent with these two diagnoses (which the authors termed “broad anorexia nervosa”). Adolescents who were defined as having broad anorexia nervosa were those who met all of the following criteria: reported lifetime dieting and exercising for weight loss; were trying to lose weight; skipped breakfast every day; described themselves as overweight despite a body mass index in the underweight or normal weight range; and scored below the median sample score on a question about body image.

In the sample of 15,896 participants, emotion regulation largely improved between ages 3 and 5. Among the 9,912 participants with complete data during childhood and adolescence, 97 (89% of whom were girls) had symptoms consistent with a broad anorexia nervosa diagnosis at age 14.

There was no association between lower emotion regulation ability at age 3 and greater risk of later reporting symptoms of broad anorexia nervosa. However, children whose emotion regulation did not improve over childhood had higher odds of broad anorexia nervosa at 14 years. Those children exhibited the same emotion regulation scores at ages 3 and 7 (about 4.4), while most children in the study had improved scores, falling from 4.4 at 3 years to about 3.6 at age 7.

“If the associations we observed were causal, universal interventions fostering skills for emotion regulation in this age group, such as building tolerance for uncomfortable feelings and learning how to overcome frustration, could have a preventative role in the emergence of eating disorders and other mental health problems with an onset in adolescence,” the authors concluded.

For related information, see the Psychiatric News article “Eating Disorders: Current Knowledge and Treatment Update.”

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Wednesday, July 7, 2021

Non-White Patients May Be More Likely to Be Excluded From Alzheimer’s Disease Trials

Black, Asian, and Hispanic individuals may be less likely than Whites to be included in clinical trials for treatment of Alzheimer’s Disease (AD), according to a report in JAMA Network Open. Increasing the diversity of participants in AD trials is essential to developing treatments and ultimately minimizing disparities in disease burden.

Rema Raman, Ph.D., of the Alzheimer’s Therapeutic Research Institute at the University of Southern California and colleagues analyzed screening data from 5,945 candidates for the Anti-Amyloid in Asymptomatic AD (A4) trial. This study is an ongoing 240-week, placebo-controlled, randomized phase 3 trial of an anti-Aβ monoclonal antibody in older adults with preclinical AD. Specifically, the researchers looked at the recruiting and screening processes for 5,107 White candidates, 323 Black candidates, 261 Hispanic candidates, 112 Asian candidates, and 142 candidates who reported race or ethnicity as “other.”

While multiple strategies were used to recruit candidates for the trial (including community outreach, referrals by trial investigators, paid advertisements, and more), White candidates were more likely to report referrals from a variety of sources, while Black, Hispanic, and Asian candidates were more likely to report being recruited by the study sites.

The screening process for the AD4 trial included five visits completed within 90 days. A total of 1,683 participants were excluded based on their initial screening visit, which included cognitive testing and other assessments. Non-White participants were excluded more frequently at an initial screening than were White participants: 30.7% of Black participants, 26.8% of Asian participants, and 26.1% Hispanic participants were excluded from the trial during an initial screening compared with 16.2% of White participants. Non-Whites were also more likely to be excluded when amyloid was assessed.

“The current results suggest that, even among the relatively small number of Hispanic and non-White participants recruited to the A4 trial, participants differed in their recruitment sources, their demographic and clinical characteristics, the reasons that they were excluded from participation, and their overall likelihood of being eligible for randomization,” Raman and colleagues wrote. “To the extent that the A4 Study is an accurate model of recruitment results for future preclinical AD trials, addressing each of these elements may be necessary to conduct truly inclusive studies of representative and generalizable samples.”

In an accompanying editorial, Jennifer J. Manly, Ph.D., of the Taub Institute for Research on Alzheimer’s Disease and the Aging Brain at Columbia University Irving Medical Center and colleagues said the study reveals the need to change recruiting protocols. “[W]e need to consider the lasting implications of engaging underrepresented communities to recruit for a research trial and then deeming most willing people ineligible,” they wrote. “To learn from each other, narrow widespread disparities in AD, and accelerate toward our 2025 goal of reducing the impact of AD in the United States, harmonization and standardization of recruitment data are needed, but if the foundation of that standard continues to be Whiteness, AD research will continue to be dramatically less inclusive than the disease itself.”

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Tuesday, July 6, 2021

Mobile Intervention as Effective as Group Intervention for Promoting Weight Loss in Young People With SMI

Young adults with serious mental illness (SMI) who are overweight or obese experienced similar weight loss and cardiorespiratory fitness improvements after participating in a 12-month group intervention as those who received one-on-one mobile health (mHealth) coaching for 12 months, a report in Psychiatric Services in Advance has found.

The findings suggest that “mHealth coaching may be a more scalable approach for addressing modifiable cardiometabolic risk factors among young adults with serious mental illness,” wrote Stephen J. Bartels, M.D., M.S., of Massachusetts General Hospital and colleagues.

The study involved 150 adults with SMI aged 18 to 35 years with a body mass index ≥25 kg/m2 who were receiving services at four community mental health centers in the northeastern United States. The participants were randomly assigned to one of two groups:

  • PeerFIT: Participants in the PeerFIT group were invited to twice-weekly one-hour group meetings in person for six months followed by weekly exercise sessions for six months. They also received wearable activity trackers (Fitbits) and were encouraged to participate in a private Facebook group, where they could access information about healthy lifestyles and interact with others in the group. PeerFIT participants received weekly text messages (three to five texts per week) from the coach, encouraging healthy behaviors and monitoring of weight and physical activity.
  • BEAT: Participants in the BEAT mHealth group attended an in-person orientation during which they received a scale and Fitbit and were taught to weigh and track their daily step count regularly. A coach subsequently delivered five monthly 30-minute telephone calls, during which participants were reminded to monitor weight and daily step counts, detect changes in weight and physical activity, identify and reduce barriers to achieving healthy changes, and recognize and celebrate their success. BEAT participants received three to five text messages per week with reminders and encouragement about monitoring weight and physical activity.

All participants were assessed at the start of the study as well as six and 12 months later. (Participants received $50 for completing each assessment.) The primary outcome was the proportion of participants who achieved cardiovascular disease risk reduction—defined as either weight loss of 5% from baseline or an increase of >50 m on the six-minute walk test, an objective measure of functional exercise capacity—from baseline to 6 and 12 months.

“Participants in both groups achieved clinically significant weight loss, [cardiorespiratory fitness] improvements, and [cardiovascular disease] risk reduction from baseline to 6 and 12 months,” Bartels and colleagues wrote. “At 6 months, more than half of the participants in both groups were at or below their baseline weight: 52% of PeerFIT participants and 58% of BEAT participants. Similar rates of weight-gain prevention were found at the 12-month follow-up: 50% of PeerFIT participants compared with 54% of BEAT participants were at or below their baseline weight.”

For related information, see the Psychiatric Services article “Participant Experiences With a Peer-Led Healthy Lifestyle Intervention for People With Serious Mental Illness.”

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Friday, July 2, 2021

Study Reveals Extent of Unmet Need for Mental Health Counseling During Pandemic

More than 1 in 4 American adults who had symptoms of depression or anxiety reported an unmet need for mental health counseling at the end of 2020, a study in Psychiatric Services in Advance has found. Overall, more than 1 in 10 adults in the study reported this unmet need.

“COVID-19 has laid bare the unmet need for mental health counseling that varies across gender and racial lines throughout the adult population,” wrote Jason M. Nagata, M.D., M.Sc., of the University of California, San Francisco, and colleagues.

The researchers analyzed data from approximately 70,000 adults in the Household Pulse Survey, which was conducted by the U.S. Census Bureau and other federal agencies from December 9 to December 21, 2020. The survey aimed to provide data on the social and economic impacts of COVID-19 on adults in the United States. The study incorporated the Patient Health Questionnaire-2 to assess participants for symptoms of depression over the past seven days and an adapted version of the Generalized Anxiety Disorder Scale to assess participants for symptoms of anxiety over the past seven days. Participants then responded “yes” or “no” to the question, “At any time in the last 4 weeks, did you need counseling or therapy from a mental health professional but did not get it for any reason?”

More than 39% of participants had experienced symptoms of depression or anxiety in the past seven days. Of those, more than 25% reported an unmet need for mental health counseling in the past four weeks. Overall, nearly 13% of participants reported an unmet mental health need for counseling in the past four weeks.

Sociodemographic factors associated with higher odds of experiencing an unmet need for mental health counseling included female sex, income below the federal poverty line, higher education, and experiencing job loss during the pandemic. Older participants and participants who identified as Asian, Black, or Hispanic/Latino had lower odds of reporting an unmet need for mental health counseling.

“Despite the social upheaval and mobilization by Black Lives Matter after the murder of George Floyd and despite anti-Asian discrimination and violence, we found that Asian and Black races were negatively associated with unmet need for mental health counseling,” Nagata and colleagues wrote. “Although these findings were initially counterintuitive, it is possible that these populations may be less aware of an unmet mental health need and therefore less likely to self-report an unmet mental health need, even when they are experiencing a diagnosable mental condition.”

The researchers noted several ways of meeting the need for mental health counseling, including extending the use of telehealth past the emergency period; additional funding for mental health services; and expansion of mental health interventions at the individual, community, and national levels.

For related information, see the Psychiatric Services article “Social Determinants of Mental Health as Mediators and Moderators of the Mental Health Impacts of the COVID-19 Pandemic.”

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