People With Disabilities at Elevated Risk of Suicidal Behavior, Study Suggests

People with disabilities appear to be significantly more likely to think about, plan, and/or attempt suicide than people without disabilities, according to a report in the American Journal of Preventive Medicine. Individuals with multiple disabilities were found to be at a particularly heightened risk of suicidal behavior.

The findings highlight the need to consider functional disability when implementing suicide prevention strategies, “particularly the presence of complex activity limitations or multiple disabilities,” wrote Nicole M. Marlow, Ph.D., M.S.P.H., of the University of Florida and colleagues.

Marlow and colleagues analyzed data collected as part of the National Survey on Drug Use and Health between 2015 and 2019. The final sample included 198,640 U.S. adults who had answered survey questions regarding the presence or absence of any suicidal thoughts, plans, and attempts during the 12 months prior to the survey. These respondents also answered six questions about the presence or absence of functional disabilities.

The researchers categorized the respondents into seven groups based on their reported functional disability type; these groups included those with no functional disability, hearing limitation only, vision limitation only, cognitive limitation only, mobility limitation only, complex activity limitation only, and ≥2 limitations. The researchers also categorized respondents into six groups based on the number of disabilities they reported (0, 1, 2, 3, 4, or ≥5 limitations)

Overall, 19.8% of respondents reported any disability. People with any disability were found to be more than twice as likely to report suicidal ideation, suicide planning without attempt, and suicide attempt compared with people without disabilities. Among disability categories, individuals with a cognitive limitation or complex activity limitation had the highest rates of suicidal behaviors. Additional analysis revealed that those with ≥5 limitations were nearly four times as likely to report suicidal ideation, more than six times as likely to report suicide planning without attempt, and more than eight times as likely to report a suicide attempt compared with people without a disability.

“Because many disability types tend to be associated with an increase in prevalence as well as severity with aging, the results of this study may underestimate the extent to which suicide-related outcomes reduce quality of life over time,” Marlow and colleagues wrote. “Future research should examine how functional disability is associated with suicide-related outcomes over time.”

For related information, see the Psychiatric Services article “Predictors of Mental Health Crises Among Individuals With Intellectual and Developmental Disabilities Enrolled in the START Program.”

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Integrative Oncology Care May Reduce Emotional Distress in Cancer Patients

Cancer patients undergoing chemotherapy who regularly attended a weekly integrative oncology program had lower levels of depression, anxiety, and sleep problems than patients who did not regularly attend the program, according to a report in Psycho-Oncology.

“Emotional distress is one of the leading challenges facing supportive and palliative oncology care,” wrote Eran Ben‐Arye, M.D., of Technion‐Israel Institute of Technology in Haifa, Israel, and colleagues. Several studies have suggested that integrative oncology care—which combines complementary therapies with conventional cancer treatments—may reduce some symptoms in patients with cancer. Ben-Arye and colleagues specifically focused on the impact of such programs on emotional distress in cancer patients.

They examined data from 439 adults who received personalized integrative oncology care while undergoing chemotherapy for localized cancer (stages 1-3). After an initial hour-long consultation, patients were invited to attend weekly 30- to 45-minute integrative oncology sessions tailored to their needs. These sessions included guidance on herbal supplements, acupuncture, reflexology, music therapy, and more.

The researchers evaluated patients’ depression, anxiety, and sleep quality using the Edmonton Symptom Assessment Scale (ESAS) and quality of life was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC) at baseline and six weeks later. They compared outcomes in 260 patients who attended at least four integrative oncology sessions over a six-week period with 179 patients who attended fewer sessions.

After six weeks, the patients who attended four or more integrative oncology sessions showed significantly greater improvements in both ESAS and EORTC scores compared with patients who attended fewer sessions. The benefits of attending the integrative oncology sessions were most pronounced in patients with moderate or high anxiety levels (ESAS anxiety scores of 4 to 10) at baseline.

“Patients with baseline mild ESAS anxiety showed no improvement for any of the study outcomes, with some in the high- and low‐[adherence to integrative oncology] groups reporting worsening ESAS anxiety scores at six weeks,” the researchers noted. “The reduced beneficial effect of the [integrative oncology] program on emotional distress in patients with low baseline ESAS anxiety scores presents an opportunity to explore this unique subgroup of patients. It is possible that what appears to be a worsening of ESAS anxiety scores in this group at six weeks was not due to symptom progression but rather an increased willingness to open up with time to the [integrative physicians and integrative oncology] practitioners.”

To read more on this topic, see the Psychiatric News article “Understanding the Breadth and Depth of the Subspecialty: Psycho-Oncology.”

People Experiencing Mental Crisis Less Likely to Face Arrest When Police Pair With MH Professionals

Individuals experiencing a mental health crisis were less likely to be arrested following a 911 call if a police officer and mental health professional responded to the call together compared with if the police responded alone, according to a report published Thursday in Psychiatric Services in Advance.

Katie Bailey, M.P.A., and Bradley Ray, Ph.D., of Wayne State University in Michigan and colleagues analyzed data collected as part of a co-response team (CRT) pilot in an Indianapolis Metropolitan Police Department from August 1 through December 31, 2017. The team—involving a police officer trained in crisis intervention, a master’s-level mental health professional, and a local EMS paramedic—responded when 911 calls involved a person with suspected mental health or substance use issues, including suicidal ideation; indicated a need for an officer trained in crisis intervention; and/or involved a person who frequently used emergency services.

The researchers compared the outcomes of people who received CRT responses to 911 calls with people who received treatment-as-usual responses to 911 calls (calls received by separate Indianapolis police districts). The authors examined two immediate outcomes following the CRT or treatment-as-usual response: jail booking (within 24 hours of the 911 call) and emergency detention (involuntary admittance to a hospital). They also compared the groups’ subsequent EMS contacts and jail bookings six months and 12 months after the 911 call.

Individuals in the CRT group were 52% less likely than those in the treatment-as-usual group to be booked into jail within 24 hours of the call. However, those in the CRT group were 71% to 85% more likely to have had subsequent encounters with EMS at 6- and 12-month follow-up.

“[T]he mechanism through which Indianapolis’s CRT response resulted in higher rates of subsequent EMS contact … is difficult to identify,” the researchers wrote. “Perhaps EMS involvement in the Indianapolis CRT resulted in individuals’ perceiving EMS as an effective means of managing a crisis and thus increased utilization of subsequent services.”

Both groups had a similar likelihood of emergency detention at the time of the call and a similar likelihood of being booked into jail at six and 12 months.

“Our findings suggest CRTs may reduce short-term incarceration risk but may not have a positive impact on long-term outcomes,” the researchers added. “Future research should consider the extent to which CRT and follow-up services improve engagement with stabilizing treatment services, which may reduce the likelihood of future crises.”

For related information, see the Psychiatric News article “Psychiatrists Can Help Train Police in Crisis Response.”

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Stanford Initiative Aims to Educate Media About Responsible Suicide Reporting

In 2017, the popular Netflix drama “13 Reasons Why” became one of the most controversial series of the year because of its depiction of the fictional suicide of a 17-year-old girl. After its release, Google searches for “how to commit suicide” and “how to kill yourself” increased dramatically, and a 2020 study reported that the suicide rate among youth spiked 29% above historical trends in the month after the release of “13 Reasons Why.”

It is not surprising: An enormous body of research from American and international researchers—some of it dating back to the 1980s—has firmly established that certain kinds of media reporting on suicide deaths, and depictions of suicide in movies and television dramas, can influence suicide contagion, especially among young people.

To address that problem, the Media and Mental Health Initiative in the Department of Psychiatry at Stanford University aims to promote public education about mental health and suicide through proactive, sustained engagement with content producers in the news media, entertainment media, and social media.

“This collaborative project will systematically embed evidence-informed guidelines across all media platforms to advance narratives that promote hope, help seeking, and awareness about mental health and suicide while mitigating harmful ones,” said Steven Adelsheim, M.D., director of the Stanford Center for Youth Mental Health and Wellbeing and a member of the APA Council on Children, Adolescents, and Their Families.

The initiative is an outgrowth of a 2018 meeting of concerned psychiatrists and representatives from media outlets at the APA Annual Meeting in New York.

The World Health Organization, in collaboration with the International Association for Suicide Prevention, has formulated guidelines to promote responsible reporting about suicide. Some of those recommendations include avoiding prominent placement of stories about suicide and undue repetition of stories about suicide and never describing the method used or providing details about the site or location.

Victor Schwartz, M.D., a clinical associate professor of psychiatry at New York University School of Medicine who has partnered with Adelsheim in developing the new initiative, urges psychiatrists to visit the website of the Media and Mental Health Initiative and become involved. “It is an opportunity for psychiatrists to help educate journalists and the public about suicide risks and suicide contagion and about mental health and mental illness generally,” he said.

For more information about the initiative and a list of the media guidelines, see the Psychiatric News article “Psychiatrists Create Initiative to Educate Media About Suicide Contagion.”

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APA Urges Attention to Veteran and Refugee Mental Health During Evacuation From Afghanistan

The news and images coming out of Afghanistan over the last several days have been difficult to watch. APA extends sympathy to the people of Afghanistan and to the U.S. and allied service members who worked to establish peace in the country over the past 20 years.

“The needs of returning soldiers, Americans and allies stationed in Afghanistan, and Afghan refugees are liable to be profound," said APA President Vivian Pender, M.D. "We know that the effects of trauma are long-lasting and take many forms. The APA wants to extend its knowledge and resources around trauma-based care, grounded in years of research, to assist all those coming from Afghanistan.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., agreed. “It is critical that we provide mental health access and support to service members, those in the foreign service and their families, and their Afghan co-workers and families who were evacuated,” he said. “The many refugees and U.S. asylum seekers are at higher risk of developing mental disorders such as depression or posttraumatic stress disorder due to the trauma of fleeing their country.”

Levin said APA and its members stand ready to support those affected in the weeks and months ahead. “We should ensure that our country provides the needed mental health resources to address this traumatic situation for all who need them.”

He added that these recent events are liable to trigger a range of emotions from anger to concern for the people left behind. APA recommends that anyone impacted by these recent events connect with friends and support systems and seek professional help if needed. Talking about a traumatic experience can be very beneficial to mental health. When complex feelings are left unaddressed, they can manifest as stress, anxiety or more serious mental disorders.

The following resources are available for those in need:

• The Veterans Crisis Line connects veterans, service members and their families and friends with caring Veterans Administration responders through a confidential hotline at 1-800-273- 8255.
• The National Suicide Lifeline (800-273-8255) provides free, around-the-clock confidential support for people in distress and prevention and crisis resources.
• APA has developed resources for psychiatrists including a Stress & Trauma Toolkit for Treating Undocumented Immigrants in a Changing Political and Social Environment and a video on Immigrant and Refugee Mental Health.
• APA’s Find a Psychiatrist database is freely available and is searchable by geographic region.

For related information, see the American Journal of Psychiatry, “Trauma and Resiliency: A Tale of A Syrian Refugee.”

Rawle Andrews Jr. Esq. Named Executive Director of APA Foundation

Rawle Andrews Jr., Esq., has been named executive director of the American Psychiatric Association Foundation (APAF) and will assume his new post on September 27.

Andrews comes to APAF from AARP (American Association of Retired Persons), where he served for 15 years, most recently as vice president. He was a member of the national leadership team overseeing the organization’s field operations in the seven largest and most diverse states in the country, including California, Florida, New York, and Texas.

The APAF is APA’s charitable foundation. As executive director, Andrews will oversee APAF’s efforts to raise awareness about mental health, overcome barriers to access, invest in the future leaders of psychiatry, support research and training to improve care, and lead partnerships to address public challenges in mental health.

“Rawle Andrews’ record of results and action, coupled with his passion for health equity, will make him an excellent leader for the APA Foundation,” said APA CEO and Medical Director and APAF Board Chair Saul Levin, M.D., M.P.A. “He joins a strong organization that does so much to improve our nation’s mental health, and I’m excited to see what the Foundation will achieve with him at the helm.”

During his 15-year tenure at AARP, after joining as Managing Attorney, Legal Counsel for the Elderly, Andrews led business, financial and external affairs for the Maryland state office. He then was named a vice president in 2011, and moved into his current role in 2015, where he launched a new strategic business unit that represents nearly half of AARP’s membership.

Andrews expressed gratitude to Amy Porfiri, M.B.A., who has been serving as the organization’s interim executive director during the pandemic. She will return to her position as the foundation’s managing director.

“I am honored and humbled to be joining the APA Foundation at such a dynamic time in this country and beyond,” Andrews said. “Mental health awareness and the need for medical help are growing exponentially. Working together, our Board, staff, fellows, and community partners will continue to meet this moment with focus, determination, and consistency while introducing the APAF to new communities where our neighbors in need live, learn, work, worship, and play.”

Andrews was a psychology major at Texas Southern University and graduated with honors from the Howard University School of Law. He spent 16 years practicing law before joining the AARP management team. He was honored with the D.C. Bar’s Pro Bono Lawyer of the Year Award in 2006 and the Distinguished Healthcare Leadership Award by the National Association of Healthcare Services Executives in 2018. Andrews serves as president-elect of the Bar Association of D.C., an adjunct professor at Howard Law, a member of the Board of Directors of the Thurgood Marshall Center Trust, and national chair of the public policy committee for Kappa Alpha Psi Fraternity Inc.

Lower Antipsychotic Doses May Still Prevent Schizophrenia Relapse, Study Suggests

Patients on maintenance antipsychotic treatment may not require more than 5 mg of risperidone daily (or equivalent) to keep their risk of schizophrenia relapse low, according to a meta-analysis published in JAMA Psychiatry. Doses higher than this amount may provide a little additional protection but also cause more adverse events.

“Because patients often need to use antipsychotics for many years, adverse events, such as movement disorders and weight gain, can accumulate and result in even more severe problems, such as tardive dyskinesia or cardiovascular problems,” wrote Stefan Leucht, M.D., of the Technical University of Munich and colleagues. “Therefore, psychiatrists need to know which doses are sufficient for maintenance treatment. If lower doses than needed for short-term treatment were sufficient, the adverse-event burden could be substantially reduced.”

Leucht and colleagues combined data from 26 placebo-controlled studies that assessed relapse prevention of antipsychotics. The collected sample encompassed 4,776 patients and the following medications: oral and LAI aripiprazole, fluphenazine LAI, oral and LAI haloperidol, oral lurasidone, oral and LAI olanzapine, paliperidone LAI, oral quetiapine, risperidone LAI, oral ziprasidone, and oral zotepine. To maintain consistency, all antipsychotic doses were converted to their equivalent dose of oral risperidone.

Overall, the effectiveness of antipsychotics increased sharply at lower doses but then began to plateau. Sixty-seven percent of patients who took placebo relapsed, compared with 42% of patients taking 2.5 mg risperidone equivalents daily, 29% of patients at 5 mg daily, 25% at 7.5 mg daily, and 22% at 10 mg daily. Meanwhile, the risk of adverse side effects rose linearly with dose. For example, the dropout rate due to side effects was 4% with placebo, 4.7% at 2.5 mg risperidone equivalent daily, 5.5% at 5 mg daily, 6.5% at 7.5 mg daily, and 7.7% at 10 mg daily.

Based on this risk-benefit data, Leucht and colleagues calculated that a maintenance dose equivalent to 5 mg risperidone daily was optimal. Among patients taking potent first-generation antipsychotics such as haloperidol or fluphenazine, the optimal level was 3 mg daily, while for patients who had achieved full remission of symptoms, the optimal level was 2.5 mg daily. For comparison, risperidone is typically dosed between 4 mg to 16 mg daily for management of acute symptoms.

“The results of our meta-analysis may provide some guidance based on average patients with chronic disease. The dose-response associations in specific populations are likely to be different,” Leucht and colleagues noted. “For example, doses might be lower for patients with a first episode of schizophrenia and higher for treatment-resistant patients. Moreover, the substantial interindividual variability in all these outcomes is important to consider. Individual dosing decisions should be guided by patient wishes. For many patients, adverse events may be a priority, and for many others, avoidance of relapse may be more important.”

For related information, see the Psychiatric News article “What Antipsychotic Dose Is Most Effective?”

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Telehealth Finds Favor Among Patients With Substance Use Disorders

Patients with substance use disorders (SUDs) who have used telehealth services during the COVID-19 pandemic are largely satisfied with the quality of care they receive, suggests a small study in the American Journal on Addictions.

Dawn E. Sugarman, Ph.D., of McLean Hospital in Belmont, Mass., and colleagues analyzed data from a 23-item online survey taken by 58 adult patients with SUDs who used telehealth through the hospital’s outpatient Alcohol, Drug, and Addiction Treatment Program during the pandemic. The survey assessed the frequency and type of services the patients received via telehealth, as well as the patients’ satisfaction with telehealth for each treatment service, preference for service delivery type (for example, telehealth, in-person, a mix of both, no preference), factors they liked and disliked about telehealth, and technical issues accessing telehealth.

The majority of patients—78%—were engaged in group therapy, 52% were receiving individual therapy, and 41% were receiving medication management services. Only 8.6% reported that they had ever received telehealth treatment services before the pandemic.

Overall, 86.2% of the patients reported that they were “very satisfied” or “satisfied” with the quality of telehealth care they received and 82% reported that telehealth visits met their needs “equally well” or “better” than in-person visits. Furthermore, 90% of those who received individual therapy and 75% of those who received medication management via telehealth reported feeling “very satisfied” with the services they received. However, only 58% of those who received group therapy reported feeling “very satisfied” with receiving this service via telehealth, and 36% of these patients reported that they did not connect as well with other group members as they did in person.

Despite their general satisfaction with telehealth, only 36% of participants preferred individual therapy via telehealth, while 43% and 48% preferred group therapy and medication management visits via telehealth, respectively. Another 19% to 25% of patients preferred a mix of telehealth and in-person treatment depending on the type of services they received.

“[T]he majority of participants preferred care that included telehealth—either as their sole mode of treatment or as some part of their care combined with in-person treatment,” Sugarman and colleagues wrote. “When the mode of treatment delivery is not dictated by COVID-19 safety guidelines, it will be important to understand how best to offer telehealth to patients (hybrid or sole mode of treatment), and which individual treatment characteristics to consider.”

For related information, see the Psychiatric News article “Telehealth Options for Treating Patients With SUD Expand.”

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Most Adolescents Have Tried or Want to Quit Vaping, Study Reports

More than half of adolescents who vape said that they intend to quit and about two-thirds had tried to quit during the past year, according to a study of middle and high school students published online in Pediatrics. These numbers reflect a significant increase in the intention and number of attempts to quit compared with the results of a similar survey of adolescents in 2017. That survey found that 44% of the respondents had thought seriously about quitting and 25% had tried.

The study in Pediatrics also revealed that adolescents’ perceived harm from vaping is strongly associated with their intention to quit and attempts to quit in the past year.

“[I]t is alarming that 44.5% of current e-cigarette users still perceived e-cigarette use as no harm or little harm, which could dampen the motivation for vaping cessation,” wrote author Hongying Dai, Ph.D., of the University of Nebraska Medical Center College of Public Health.

Dai analyzed the responses from 1,660 students in grades 6 through 12 who participated in the National Youth Tobacco Survey in 2020 and had reported using e-cigarettes one or more times in the past month. That survey estimated that 20% of high school students and 5% of middle school students were current e-cigarette users. Dai was interested in what factors influenced students’ intentions to quit vaping and past-year quit attempts.

Dai found that more than half of students perceived e-cigarette use to be harmful (56%). These students were more than twice as likely to have intended to quit vaping within the year than those who did not perceive vaping as harmful. Among students who attempted to quit e-cigarettes in the past year, they averaged 5.3 attempts. The number of vaping quit attempts was lower in females than in males.

Other results include the following:

• The type of e-cigarette device used by students had an impact on their intent to quit vaping. Adolescents using a “modifiable” system that allows users to add fruit or candy flavors and customize e-cigarettes for more efficient delivery of nicotine were 60% less likely to intend to quit, compared with those using cartridge-based or disposable e-cigarettes.
• Four in 10 students reported using e-cigarettes as well other tobacco products. These students were 30% less likely to have attempted to quit vaping during the past year than those using solely e-cigarettes.
• Students’ reasons for using e-cigarettes were also a factor in their intent to quit vaping. Students who reported using e-cigarettes due to curiosity or because a friend had used them were more likely to intend to quit, compared with those who used them to conceal their smoking at home or school.
• Students who said they had seen or heard about the FDA’s campaign to educate youth about vaping risks, “The Real Cost,” had a higher intention to quit vaping (50% more likely) than those who hadn’t.

“These findings can inform the development of evidence-based vaping cessation interventions for clinicians and public health researchers,” Dai wrote in an email to Psychiatric News. “Clinicians should emphasize the adverse health outcomes of vaping and deliver the message that e-cigarettes, just like cigarettes, will increase the risks of nicotine addiction, respiratory injury, cardiovascular illnesses, and other tobacco-related diseases.”

For more information, see the Psychiatric News article “FDA Bans Some Flavored E-Cigarettes, but Advocates Say Policy Falls Short.”

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Escitalopram Found to Reduce Anxiety in Patients With Coronary Heart Disease

Escitalopram appears to be more effective than exercise at reducing anxiety in patients with coronary heart disease, a study published today in JAMA Psychiatry has found.

“To our knowledge, [this study] is the first randomized clinical trial to evaluate the efficacy of a selective serotonin reuptake inhibitor or aerobic exercise in the treatment of anxiety in patients with [coronary heart disease] and high levels of anxiety,” wrote James A. Blumenthal, Ph.D., of Duke University Medical Center and colleagues. “Escitalopram produced clinically meaningful reductions in anxiety, as well as significant reductions in depression.”

Blumenthal and colleagues recruited men and women aged 40 years or older with coronary heart disease and anxiety symptoms (score of 8 or higher on the Hospital Anxiety and Depression-Anxiety Subscale, or HADS-A) and/or a DSM-5 primary diagnosis of an anxiety disorder for the trial. Patients were excluded if they had a primary psychiatric diagnosis other than an anxiety disorder, were currently receiving mental health treatment, and/or if they exercised regularly. A total of 128 participants were randomly assigned to aerobic exercise (three days a week), escitalopram (up to 20 mg a day), or a placebo pill for 12 weeks.

The researchers evaluated the patients using the Structured Clinical Interview for DSM-5 Disorders and the 14-item Hamilton Anxiety Rating Scale before and after the 12-week interventions. They also assessed the participants weekly using the Spielberger State-Trait Anxiety Inventory-State, which asks about the frequency of such feelings as “I am tense; I am worried.” Symptoms of depression (using the HADS depression subscale and Beck Depression Inventory-II) as well as heart rate variability, baroreflex sensitivity, and endothelial function—biomarkers for coronary heart disease—were also measured before and after the interventions.

Examination of HADS-A scores after 12 weeks revealed that all groups showed reduced levels of anxiety following treatment, with mean reductions of −4.0 in the exercise group, −5.7 in the escitalopram group, and −3.5 in the placebo group, Blumenthal and colleagues reported. Additional analysis revealed that participants in the escitalopram group had greater reductions in HADS-A scores compared with participants in the placebo group, while the exercise and placebo groups were not different.

“Although exercise achieved comparable reductions in state anxiety relative to escitalopram after 12 weeks and greater reductions compared with placebo controls, exercise did not result in lower anxiety scores compared with placebo on the HADS-A or on any of the supplemental trait anxiety measures,” the authors wrote. “There were no treatment-related differences in [coronary heart disease] biomarkers, so the clinical significance of these findings regarding potential cardiovascular benefits is unknown.”

For related information, see the chapter on heart disease in the book The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry.

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MH Professionals in Correctional Systems Urged to Treat Sleep Issues, Advocate for Solutions

Disrupted and deprived sleep—known to increase the risk of psychiatric symptoms such as depression and anxiety and other health problems—is a common experience lived by inmates in U.S. jails and prisons. A paper in Psychiatric Services in Advance describes lawsuits by inmates that have attempted to address this problem and discusses clinicians’ responsibility to evaluate and treat inmates for sleep-related problems.

APA past President Renée L. Binder, M.D., Nathaniel Morris, M.D., and Jessica Holliday, M.D., M.P.H., of the University of California, San Francisco, outlined five conditions that have commonly led incarcerated individuals to file lawsuits alleging sleep deprivation:

Noise. A man who was placed in a federal prison cell with five other men for approximately 28 months filed a civil rights lawsuit over the constant noise as well as unsanitary environment, poor ventilation, extreme temperatures, and other conditions. In 2020, a jury awarded $20,000 to the plaintiff; as of October 2020, the case was pending appeal.

Inadequate Bedding. An incarcerated man in Connecticut filed a lawsuit alleging that his mattress had a large slit down its center and smelled of mildew. The plaintiff reported experiencing pain and sleep loss because of the mattress while at least one prison official allegedly disregarded requests for new bedding. In 2014, a jury awarded $12,000 in damages to the plaintiff.

Constant Illumination. A man filed a lawsuit against Oregon state prison officials claiming that “large [fluorescent] lights . . . shone into his cell 24 hours a day.” He alleged that the constant light prevented him from differentiating day from night, disrupted his sleep, and caused mental health problems.

Medication Restrictions. Incarcerated individuals may face considerable legal hurdles when suing for access to sleep-related medications. Several court decisions have cast doubt on whether insomnia alone constitutes a “serious medical need.”

Irregular Wake-Up Times. Incarcerated individuals filed a class action complaint over sleep deprivation, given a jail’s policy to keep lights on until at least 11 p.m., administer medications at 2:30 a.m., and turn lights back on at 4 a.m. for breakfast.

Despite jail and prison conditions that may be difficult to change, the authors emphasized that clinicians have a responsibility to evaluate and treat incarcerated patients with sleep-related concerns. Nonpharmacologic strategies, such as relaxation techniques or brief cognitive-behavioral therapy, may help mitigate the effects of prison and jail practices on sleep. Careful review of prescribing patterns of insomnia-related medication, analysis of patient outcomes, and use of evidence-based formulary restrictions are also key for supporting patients’ well-being.

“We wanted to alert psychiatrists to the fact that sleep deprivation is a pervasive problem in our nation’s jails and prisons that causes serious health and mental health consequences for individuals who are incarcerated,” Binder told Psychiatric News. “As psychiatrists, we can advocate for standards and policies that mitigate the kinds of conditions that result in sleep deprivation. Forensic psychiatrists and other mental health professionals who work in the correctional system can also adopt clinical practices that can help incarcerated individuals.”

For related information, see the Psychiatric Services article “Grave Disability in U.S. Jails and Prisons,” also by Binder and Morris.

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Exposure to Antipsychotics in Womb Not Found to Increase Risk of ADHD, Autism in Offspring

Children whose mothers took antipsychotics during pregnancy do not appear to be at a heightened risk of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), or low birth weight, reports a study published today in JAMA Internal Medicine. While there was a small increased risk of preterm birth of children exposed to prenatal antipsychotics, additional analysis suggested this may be due to maternal psychiatric illness and not the medication.

“Our study results suggest that if pregnant women have a clinical need for antipsychotics (including first-generation and second-generation antipsychotics), clinicians should not stop administering regular treatment because of a fear of birth outcomes with ADHD, ASD, preterm birth, and small for gestational age,” wrote Zixuan Wang, M.Sc., of University College London and colleagues.

Wang and colleagues used electronic health record data available from all public hospitals and ambulatory clinics in Hong Kong to compare neurodevelopment outcomes in children whose mothers took antipsychotics during pregnancy with those who did not. The sample included 411,251 mother-child pairs of children born between 2001 and 2015; 411,251 were evaluated for ASD, preterm birth, or small gestational age while 333,749 children born between 2001 and 2013 were evaluated for ADHD (ADHD outcomes were tracked for at least six years and ASD outcomes were tracked for at least three years).

In total, 706 children in the study cohort were prenatally exposed to antipsychotics. The analysis suggested there was no association between antipsychotic exposure in pregnancy and subsequent development of ADHD, ASD, or low birth weight.

Children exposed to antipsychotics in utero were at a 40% increased risk of preterm birth (<37 weeks) compared with those children who were not. A follow-up analysis comparing women who took antipsychotics during pregnancy versus those who took antipsychotics prior to pregnancy only identified no increased risk of preterm birth due to antipsychotic exposure. Likewise, an analysis of siblings in which one child was exposed to antipsychotics while the other was not found no differences in the rate of preterm birth or other adverse outcomes.

“These results suggest that maternal psychiatric disorders are associated with a higher risk of neurodevelopmental disorders rather than gestational exposure to antipsychotic drugs,” the authors wrote. “Moreover, gestational exposure to antipsychotic drugs is unlikely to pose a significant risk of preterm birth and small for gestational age in children.”

“This effort to distinguish medication effects from maternal illness, along with the large sample size and length of follow-up, are strengths of this study,” wrote Amanda Yeaton-Massey, M.D., of the University of California, San Francisco, and colleagues in an accompanying commentary. “These findings should provide some reassurance to patients and clinicians who are fearful of antipsychotic medications causing harm to the future child.”

For related information, see the Psychiatric News article “Taking Some Antipsychotics During Pregnancy May Raise Risk of Gestational Diabetes.”

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Lock in Lowest Registration Rates for APA’s Mental Health Services Conference

Register by today, Monday, August 16, to lock in the lowest registration rates for APA’s Mental Health Services Conference, to be held virtually on Thursday, October 14, and Friday, October 15. 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.

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Nine in Ten Children With ADHD May Experience Symptoms Into Young Adulthood

Up to 90% of children who have attention-deficit/hyperactivity disorder (ADHD) may continue to experience residual symptoms of the disorder into young adulthood even though many have periods of remission along the way, a study published online today in AJP in Advance suggests.

“The study findings emphasize that childhood-onset ADHD is a chronic but waxing and waning disorder with periods of full remission that are more often temporary than sustained,” wrote Margaret H. Sibley, Ph.D., of the University of Washington School of Medicine and Children’s Research Institute in Seattle and colleagues. “[Health professionals] should expect recurrence of clinically elevated ADHD symptoms and impairments in most patients who experience remission; continued periodic screening for recurrent symptoms and impairments should therefore be standard practice after successful treatment.”

Sibley and colleagues examined data from 558 participants with ADHD who had participated in the Multimodal Treatment Study of ADHD (MTA) and had at least one follow-up assessment over a 16-year period after initial assessment in the MTA. Follow-up assessments were offered to participants and parents at 2, 3, 6, 8, 10, 12, 14, and 16 years after baseline, and participants completed an average of 6.2 of the eight possible follow-up assessments. The average age of the participants who completed the follow-up assessments two years after baseline was 10.44 years, and the average age of participants who completed the assessments 16 years after baseline was 25.12 years.

Overall, 31.4% of the participants experienced full remission of their symptoms at a minimum of one time point. Among those, 59.4% then went on to have either a full or partial recurrence of ADHD after their initial period of full remission. Only 9.1% of participants experienced a full recovery from ADHD by the end of the follow-up period. In addition, 10.8% of participants consistently had symptoms of ADHD throughout the study, 15.6% experienced partial remission that was maintained through the study endpoint, and 63.8% had a pattern of fluctuating ADHD.

“[T]he results suggest that over 90% of individuals with childhood ADHD will continue to struggle with residual, although sometimes fluctuating, symptoms and impairments through at least young adulthood,” the researchers wrote.

The researchers noted that these results run counter to that of prior research that suggested that ADHD remits by adulthood in 50% of cases. The prior research considered ADHD symptoms at only a single point in time, however.

“The MTA’s longitudinal perspective highlights that full remission at a single time point should not be conflated with recovery from ADHD,” Sibley and colleagues wrote.

For related information, see the American Journal of Psychiatry article “Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25,” also by Sibley and colleagues.

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Register by Monday, August 16, to lock in the lowest registration rates for APA’s Mental Health Services Conference, to be held virtually on Thursday, October 14, and Friday, October 15. 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.

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Physical Activity Linked to Slower Cognitive Decline in Adults With Elevated Tau Levels

Older adults who were physically active reported significantly slower cognitive decline compared with sedentary adults, reports a study published Wednesday in JAMA Network Open. The association between physical activity and cognitive function was most dramatic among adults who had elevated levels of the Alzheimer’s-associated tau protein in their blood.

“Although we know that physical activity can positively impact cognitive function, much less is understood about the role of sedentary behavior and its association with the same,” wrote Pankaja Desai, Ph.D., of Rush University Medical Center in Chicago and colleagues. “Our results … demonstrat[e] the clear difference in cognitive decline among participants with little activity, compared with those who reported low or high activity in a large, population-based sample without disease.”

Desai and colleagues looked at data from 1,159 participants (63% women and 60% African American) in the Chicago Health and Aging Project, a population-based cohort study that followed adults over 65 years of age from four Chicago communities between 1993 and 2012. The study protocol included periodic cognitive tests, blood draws, and reports by participants on their physical activity. All participants had a baseline blood sample collected and at least two global cognitive function outcome measurements over the course of the study.

The participants were divided into three physical activity groups: little (no participation in any physical activity like jogging, swimming, golf, yard work, etc.), medium (average of 71 minutes of physical activity a week), or high (average of 422 minutes of physical activity a week). Each of the three groups was then subdivided into adults with low (≤0.40 pg/mL) or high (>0.40 pg/mL) concentrations of tau in their blood.

Among adults with high concentrations of tau, those who reported medium or high physical activity had 58% and 41% slower rate of cognitive decline, respectively, compared with adults who engaged in little physical activity over the course of the study. Among adults with low tau, those with medium or high physical activity had a 2% and 27% slower rate of decline, respectively, compared with adults who engaged in little physical activity.

“Future work should focus on examining the associations between physical activity and additional biomarkers … associated with [Alzheimer’s] diagnosis both pathologically as well as clinically,” the authors wrote. “Additional research should evaluate the associations of other health behaviors and particular types of physical activity (such as aerobic or strengthening activities) and blood biomarkers with outcomes such as cognitive function and magnetic resonance imaging results. Findings may inform the development of prevention trials or interventions that are tailored to individuals with at-risk characteristics … .”

To read more on the benefits of exercise, see the Psychiatric News article “Physical Activity May Lower, Prevent Depression.”

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Lock in Lowest Registration Rates for APA’s Mental Health Services Conference

Register by Monday, August 16, to lock in the lowest registration rates for APA’s Mental Health Services Conference, to be held virtually on Thursday, October 14, and Friday, October 15. 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.

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Criteria for Identifying Youth at High Risk for Psychosis Called Into Question

Sixteen percent of youth under age 18 identified at risk for schizophrenia based on criteria for “at-risk mental state” (ARMS) converted to psychosis within five years, according to a meta-analysis in the Journal of the American Academy of Child and Adolescent Psychiatry. This rate is considerably lower than the rate reported for individuals over 18.

“Our findings indicate a need for caution in applying ARMS methodology to children and adolescents and highlight the need for developmentally sensitive approaches when considering psychosis risk,” wrote senior author Ian Kelleher, M.D., Ph.D., of the Royal College of Surgeons in Ireland and colleagues.

In the past two decades, there has been increasing emphasis on early identification and treatment of young people at risk for schizophrenia and the development of instruments to assess this risk.

Kelleher and colleagues analyzed data from 16 articles based on nine studies reporting psychosis transition rates for 436 youth with ARMS aged 9 to 18 years. Youth were classified as high risk using the Comprehensive Assessment of At Risk Mental States, the Structured Interview for Psychosis Risk Syndromes, the Schizophrenia Proneness Instrument—Child and Youth version, and/or the Bonn Scale for the Assessment of Basic Symptoms.

The authors focused on the proportion of youth who went on to develop psychosis after one, two, and five or more years after designation as high risk. They found the pooled transition rate to psychosis at one year was 9.5%; at two years, 12.1%; and at five years, 16.1%. Those rates are lower than the conversion-to-psychosis rate—29% in three years—reported for adults who had been diagnosed with ARMS, according to the researchers.

Moreover, of 338 young people who experienced a first episode of psychosis, just two had received an ARMS diagnosis before the age of 18 in the only study in the analysis that looked at that association. “This finding suggests that even if highly effective preventive treatments existed, the capacity for psychosis prevention arising from services focusing on children and adolescents with ARMS diagnoses would be very low,” Kelleher and colleagues wrote.

In comments to Psychiatric News, Kelleher said the criteria for identifying at-risk individuals have been developed from research on at-risk adults. “While well intentioned, our findings show that this approach is not appropriate for children and adolescents—we need investment in specialist psychosis risk research and services specifically designed for children and adolescents, where a developmental focus is key,” he said.

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

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Older Adults Less Likely Than Younger to Report Psychiatric Symptoms After Suicide Attempt

Adults aged 65 years and older who are suicidal appear to report higher levels of intent compared with younger adults who are suicidal, but they are less likely to meet the criteria for major depression and several other mental disorders. These findings were published Monday in the American Journal of Geriatric Psychiatry.

Older adults’ lower scores on ratings of psychiatric symptoms “may cloud the clinician’s assessment of the serious nature of suicide attempts in older patients,” wrote Stefan Wiktorsson, Ph.D., of the University of Gothenburg in Sweden and colleagues. “If this is the case, safety issues and treatment needs may be underestimated.”

Wiktorsson and colleagues recruited patients aged 18 and older who had sought or been referred to emergency psychiatric services for self-harm at three hospitals in Sweden. Mental health staff conducted face-to-face interviews with the study participants, during which they collected information about the participants’ physical and mental health, as well as their contact with health care professionals. The researchers used the Columbia-Suicide Severity Rating Scale to help them separate participants who had made a suicide attempt from those who did not; participants whose self-injury was determined to be nonsuicidal were excluded from the study.

The researchers used the Suicide Intent Scale (SIS) to evaluate the circumstances surrounding the suicide attempt (for example, active preparation) and the Mini International Neuropsychiatric Interview (MINI) to determine other psychiatric diagnoses (including depression, anxiety, and substance use disorders). A total of 683 participants were selected for the study, and they were divided into three age groups: younger (18 to 44), middle-aged (45 to 64), and older (65 and older) adults.

Older adults scored higher on the SIS total score as well as the SIS subjective subscale compared with the younger adults, Wiktorsson and colleagues reported. No age group differences were detected for the objective subscale of the SIS. Half of the older adults met the criteria for major depression according to the MINI, as compared with three-fourths of the participants in each of the other two age groups. Anxiety disorders and substance use disorders were also less common in older adults. In contrast, a greater proportion of older adults reported living alone and/or having a serious physical condition/disability compared with younger and middle-aged adults.

“[T]hese findings point to a need for increased availability of services for older adults with suicidal issues, as well as treatment augmentation for those who already have mental health care contacts. Considering the finding that two-thirds of the older group had serious physical illness, multidisciplinary interventions are likely to be indicated,” the authors wrote. “Attention must be paid to medical morbidity and living situation, as well as other sources of vulnerability not examined in this study, that may be relevant for individualized preventive approaches.”

For related information, see the Psychiatric Services article “Suicide Mortality Among Veterans Health Administration Care Recipients With Suicide Risk Record Flags.”

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Mental Health Patients Found Willing to Answer Routine Question on Firearm Access

When patients receiving mental health care were asked to complete a standardized questionnaire that asked whether they had access to guns, most provided a response, reports a study in JAMA Health Forum. A positive response can help clinicians identify and provide appropriate follow-up care for patients at risk of suicide.

“Firearms are the most common method of suicide, one of the ‘diseases of despair’ driving increased mortality in the U.S. over the past decade,” wrote Julie E. Richards, Ph.D., M.P.H., of Kaiser Permanente Washington in Seattle and colleagues. “However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians.”

In August 2015, Kaiser Permanente clinics in Washington state began incorporating a question about firearm access—“Do you have access to guns?”—to the standard mental health monitoring questionnaire. Richards and colleagues compiled data on 128,802 patients who completed these questionnaires at either a primary care or mental health clinic between 2016 and 2019.

Overall, 83.4% of patients in primary care clinics and 91.8% of those in mental health clinics answered the question on access; in both settings those who did not respond were more likely to be older, male, live in a rural setting, and/or have a recent substance use disorder diagnosis. Richards and colleagues noted the rates for nonresponse were much higher than rates for other sensitive questions like alcohol or drug use (between 2% and 3%).

In terms of access, 20.9% of patients in primary care clinics and 15.3% in mental health clinics reported having access to firearms. Those with access were more likely to be male and live in a rural or suburban setting. Patients who reported a previous suicide attempt were far less likely to report firearm access than those without a suicide attempt history.

“This novel study demonstrates that standard assessment of access to firearms is feasible in the context of [mental health] monitoring in [primary care] and outpatient [mental health] specialty settings,” Richards and colleagues wrote. “Asking patients to routinely self-report firearm access can help clinicians identify and engage patients at risk of suicide in dialogue regarding storage of firearms and/or ammunition (i.e., increasing time and/or distance required to access firearms), which is a recommended component of evidence-based safety planning interventions for suicide prevention.”

To read more on this topic, see the Psychiatric Services “What Will Happen If I Say Yes?” Perspectives on a Standardized Firearm Access Question Among Adults With Depressive Symptoms.”

APA Foundation Offers Advice to Employers to Help Workers Ease Transition Back to Workplace

Returning to a workplace after telecommuting for more than a year can be stressful for employees. They may need to establish new routines for commuting and family caregiving, they may have concerns about COVID-19 variants, and some may still be processing grief from losing loved ones to the pandemic. To help employers assist their employees with the transition, the Center for Workplace Mental Health, a program of the APA Foundation, has developed a guide for returning to the workplace.

The guide offers insight into the concerns employees may have and tips on communicating with employees throughout the transition. The key recommendations, among others, include the following:

Understand concerns: Consider conducting a survey or hosting a town hall discussion to better understand how this historic time has impacted employees and their concerns related to returning.

Communicate often and be transparent: Keep employees informed about plans and changes in policies and procedures and encourage open discussion about experiences and concerns with transitioning back.

Make employees’ mental health a visible priority: Make sure employees are aware of the mental health services and resources available to them and create an environment where people are comfortable talking about mental health and accessing services when needed.

Stay flexible: Anticipate the need to be flexible as people transition to new schedules, new commutes, and new routines.

Promote resiliency: Offer opportunities for mindfulness practices and create a healthy work environment, prioritizing reasonable limits on work hours and promoting physical health.

“Everyone’s situation and experience will be different, but for those of us who spent the last 16 months at home, we’re not just going back to ‘normal,’” said APA President Vivian Pender, M.D., in a statement released by APA. “We’ll all be dealing with new logistical and emotional challenges, and different people will have different burdens.”

The new guide “is essential reading for managers who are seeking actionable steps to support employees returning to the workplace,” said Saul Levin, M.D., M.P.A., APA CEO and medical director and chair of the APA Foundation. “Everyone is dealing with new life circumstances, and some of it will involve trauma, and not all will be evident. It’s important that we check in on and take care of each other.”

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

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Assistant Secretary for Mental Health and Substance Use to Speak at Mental Health Services Conference

Miriam Delphin-Rittmon, Ph.D., the newly appointed assistant secretary for mental health and substance use and administrator of the Substance Abuse and Mental Health Services Administration, will deliver the opening keynote address on Thursday, October 14, at APA’s virtual Mental Health Services Conference. Register today to hear Delphin-Ritton speak about how to increase access to care and how federal funds might be used in innovative ways to provide sustainable services that help our society’s most vulnerable populations to receive evidence-based care.

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Rewards Improve Abstinence, Adherence in Medication Treatment for Opioid Use Disorder

Patients with opioid use disorder (OUD) who receive monetary rewards for completing goals within a medication-assisted treatment program have better outcomes than those who do not, according to a systematic review and meta-analysis published Wednesday in JAMA Psychiatry.

“This systematic review and meta-analysis provides support for the efficacy of contingency management for addressing a wide range of substantive clinical problems common among people receiving [medication-assisted treatment for OUD], including the current crisis of comorbid stimulant use disorder,” wrote Hypatia A. Bolivar, Ph.D., of the University of Vermont and colleagues.

Contingency management involves giving patients tangible rewards, such as vouchers exchangeable for retail items, when they show evidence of meeting therapeutic targets (for instance, abstinence from illicit drug use). “Incentives work because they stimulate the same brain areas as the medications used in treatment,” co-author Stephen T. Higgins, Ph.D., director of the Vermont Center on Behavior and Health and a professor of psychiatry and psychological science at the University of Vermont, told Psychiatric News by email.

The researchers examined the impact of contingency management on patients who received medication-assisted treatment for OUD, including abstinence from psychomotor stimulants, illicit opioids, and/or cigarettes; medication adherence; and therapy attendance. They reviewed the results of 74 studies involving more than 10,000 adults who received medication-assisted therapy for OUD; 60 of these studies were included in the meta-analysis. (The average amount participants could earn in the contingency management programs studied ranged from about $10 to $15 a day.)

Key results included the following:

• When researchers combined data from all the trials examining abstinence, they found that contingency management was associated with significant improvements compared with other treatments. Higgins reported that 72% of the patients who participated in the programs had better end-of-treatment abstinence, compared with those who did not.
• Contingency management also resulted in significant improvements in therapy attendance and medication adherence. Higgins said that 73% of the patients had a better treatment outcome for attending therapy or adhering to the medication than those who did not participate in these programs.
• Eighteen of 22 studies reviewed reported significant increases in end-of-treatment abstinence from stimulants. Higgins noted that 76% of the patients had better abstinence from stimulants than those who did not participate in these programs.
• Four out of five studies found that contingency management was associated with increased abstinence from cigarette smoking.

“Contingency management is a highly effective intervention for what is coming to be known as the twin epidemics—use of opioids and psychomotor stimulants. Yet it is not currently used in most community clinics due to lack of reimbursement by the government,” Higgins said. “Advocate your state leaders, the health department, and medical directors at the Centers for Medicare and Medicaid Services on the need to use these evidence-based interventions.”

For related information, see the Psychiatric Services article “Implementation of Contingency Management at a Large VA Addiction Treatment Center.”

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Assistant Secretary for Mental Health and Substance Use to Speak at Mental Health Services Conference

Miriam Delphin-Rittmon, Ph.D., the newly appointed assistant secretary for mental health and substance use and administrator of the Substance Abuse and Mental Health Services Administration, will deliver the opening keynote address on Thursday, October 14, at APA’s virtual Mental Health Services Conference. Register today to hear Delphin-Ritton speak about how to increase access to care and how federal funds might be used in innovative ways to provide sustainable services that help our society’s most vulnerable populations to receive evidence-based care.

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Oregon’s Death With Dignity Act Impacts Older Women, Men Differently, Study Suggests

Between 1998 and 2018, medical aid in dying (MAID) under Oregon state’s Death With Dignity Act was the most common form (52.7%) of self-initiated death among women over 65, according to an analysis in the American Journal of Geriatric Psychiatry. In contrast, firearm suicides were the most common form (65.7%) of self-initiated death among men in the state, followed by deaths caused by lethal medication under the Death With Dignity Act.

“[O]lder adult women’s likelihood of self-initiated death has grown substantially since [medical aid in dying legalization],” wrote Silvia Sara Canetto, Ph.D., of Colorado State University and John L. McIntosh, Ph.D., of Indian University. “Older adult women’s substantial representation among assisted-suicide/MAID [medical aid in dying] decedents, relative to suicide, may be a clue of their empowerment to determine the time of their death, when hastened-death assistance is permitted; or of their vulnerability to seeking a medicalized self-initiated death, when in need of care.”

The Oregon Death With Dignity Act became law in 1997. Canetto and McIntosh analyzed data from the Public Health Division of the Oregon Health Authority on deaths attributed to the Death With Dignity Act and from the CDC on unassisted suicide by sex and age for the 1998−2018 period.

Some key findings of the analysis included the following:

• There were 492 deaths by lethal medication under the Death With Dignity Act by women aged 65 and older and 578 deaths by men aged 65 and older—or 7.8 per 100,000 for women and 11.5 per 100,000 for men in this age group.
• There were 441 unassisted suicides by women (7.0 per 100,000) and 2,268 by men (45.2 per 100,000).
• For women over 65, deaths caused by lethal medication under the Death With Dignity Act (n=492) exceeded the number of unassisted suicides by all other methods combined (n=441).
• Among women aged 65 to 74 the rates of death by lethal medication (6.1 per 100,000) and suicide (7.4 per 100,000) were not significantly different from each other, but among women aged 75 and older, the rate of death by lethal medication (9.6 per 100,000) was significantly higher than the rate of death by suicide (6.6 per 100,000). In contrast, the rate of death by lethal medication was significantly lower than the rate of suicide among men aged 65 to 74 and among men 75 and older.

Canetto and McIntosh emphasized that men and women may make decisions about medical aid in dying and suicide for different reasons based on societal expectations and culturally ingrained beliefs. They noted, for instance, that women are less likely than men to express a preference for life-sustaining or life-prolonging care. “The reasons for this preference include concerns about being a burden—consistent with women’s socialized tendency to think of themselves as less deserving,” they wrote.

They also cautioned against making interpretations—either for or against medical aid in dying—on the basis of the analysis. “[Medical aid in dying] is a decision everyone makes under conditions of vulnerability; and a choice that ends all choices. At a minimum, significantly more information on the [medical aid in dying] process is needed.”

For related information, see the Psychiatric News article “How Should Organized Medicine Respond to Physician-Assisted Death?”

Opioid Tapering Associated With Increased Risks of Overdose, Mental Health Crises

Tapering patients’ opioid dose may increase their risk of overdose, withdrawal, and/or mental health crises, suggests a report published today in JAMA.

“The risks of long-term opioids are well documented, particularly at higher doses and in the presence of other risk factors for opioid toxicity, and clinicians and patients must carefully weigh risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy,” wrote Alicia Agnoli, M.D., M.P.H., of the University of California, Davis, and colleagues. “In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering.”

Agnoli and colleagues analyzed administrative claims data from 113,618 patients aged 18 years or older who had been taking opioids (mean daily dose of at least 50 morphine mg equivalents) for at least 12 months. Beginning the first day after the end of the baseline year of stable dosing, patients were followed for up to one year. The authors compared emergency or hospital encounters for drug overdose or withdrawal and/or mental health crisis (depression, anxiety, suicide attempt) by patients who underwent opioid tapering with those who did not. They defined tapering as at least 15% relative reduction in mean daily dose during any of six overlapping 60-day windows.

A total of 18.2% of baseline periods were followed by tapering (37,170 tapering events). Patients who underwent tapering had significantly higher baseline opioid doses; were more likely to be co-prescribed benzodiazepines; and had significantly higher baseline rates of overdose, drug use disorder, depression, and anxiety.

The analysis revealed that post-tapering periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods. Additionally, tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years in nontapered periods. Patients undergoing a taper from higher baseline opioid doses and/or more rapid tapering were at a greater risk of these outcomes compared with those undergoing a taper from a lower baseline dose and/or a slower taper, the authors noted.

The authors described several limitations to the study, including that the analyses could not assess tapering circumstances or control for all factors that may have contributed to increased risk for adverse outcomes in the study population. “The risks associated with opioid tapering warrant further exploration to inform clinical guidelines regarding patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition.”

“With caution in making any causal interpretations in mind, how should the findings reported by Agnoli et al influence the care of individuals receiving long-term opioid therapy?” asked Marc Larochelle, M.D., of Boston University School of Medicine and colleagues, in an accompanying editorial. “It is increasingly clear that opioid tapering needs to be approached with caution. In almost all cases, rapid or abrupt discontinuation should be avoided. Achieving the goals of minimizing risk yet also improving pain and function will require individualizing care and evidence-based approaches with more nuanced strategies that embrace the clinical complexity of the population of patients with chronic pain.”

For related information, see the Psychiatric News article “New HHS Guide on Opioid Tapering Encourages Collaboration.”

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