Stopping Antidepressants Doubles Relapse Risk, Study Finds

Patients with depression treated in primary care practices in the United Kingdom who felt well enough to consider stopping their antidepressants were twice as likely to relapse within 52 weeks if they discontinued their medication as those who continued to take it, according to a study published today in The New England Journal of Medicine.

The study, led by Gemma Lewis, Ph.D., of University College London and colleagues, involved 478 patients aged 18 to 74 years who had at least two prior episodes of depression or had been taking antidepressants for more than two years. “All the patients had been receiving and adhering to a daily regimen of 20 mg of citalopram, 100 mg of sertraline, 20 mg of fluoxetine, or 30 mg of mirtazapine for at least 9 months, had recovered from their most recent depressive episode, and felt well enough to consider stopping antidepressants,” Lewis and colleagues wrote.

The participants were randomly assigned to continue their current antidepressant therapy (maintenance group) or taper off their therapy over two months (discontinuation group). They did not know what group they had been assigned to until the end of the study. The study participants completed a battery of questionnaires at follow-ups (by mail at six weeks and face-to-face interviews at 12, 26, 39, and 52 weeks) that assessed mood, depressive symptoms, anxiety symptoms, physical side effects, withdrawal symptoms, and quality of life.

At 52 weeks, relapse had occurred in 39% of the participants in the maintenance group and 56% of the participants in the discontinuation group. Furthermore, 48% of the patients in the discontinuation group stopped taking the placebo during the trial and 39% of them returned to the use of an antidepressant.

Patients who discontinued antidepressants were nearly three times more likely than the maintenance group to report feeling worse at 12 weeks than they had at 6 weeks. Quality-of-life measures and symptoms of depression, anxiety, and medication withdrawal were generally worse in patients who discontinued their antidepressant therapy.

“These findings represent important but disappointing news. However, there are limitations to the application of the trial results to practice,” wrote Jeffrey L. Jackson, M.D., M.P.H., of the Zablocki VA Medical Center and the Medical College of Wisconsin in an accompanying editorial. For instance, it is unclear whether the trial results are generalizable to primary care patients with a first episode of depression, and it is unclear how long participants had been in remission prior to taking part in the trial, he noted.

“How do these results affect practice?” Jackson continued. “They confirm what most primary care physicians already knew or intuited. The frequency of relapse after the discontinuation of treatment is high, particularly among patients with several previous depressive episodes. … It is useful to educate patients to monitor their depressive symptoms and alert their provider if they sense they are having a relapse.”

For related information, see the Psychiatric News article “Treating Family Members Can Break Depression Cycle, Says Expert.”

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How Can You Help Latina/o Patients During and After Pandemic?

In celebration of National Heritage Hispanic Month, APA’s Division of Diversity and Health Equity is sponsoring a fireside chat on “The Impact of the COVID-19 Pandemic on the Mental Health of Latinas/os” on Monday, October 4, from 4 p.m. to 5 p.m. ET. Panelists will examine strategies to improve the mental health of Latinas/os during and after the pandemic and will raise awareness of pandemic stressors such as unemployment, insurance benefits inequities, and social isolation.

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History of Anger Attacks May Point to Soldiers at Greatest Risk of Anxiety Disorder, Suicidal Ideation

New Army soldiers with a history of impairing anger attacks were twice as likely to later develop major depressive disorder, generalized anxiety disorder, panic disorder, or suicidal ideation, according to a study published this week in JAMA Network Open.

When anger attacks, or sudden outbursts of verbal or physical aggression, cause substantial life impairment, they are a hallmark of intermittent explosive disorder (IED). IED is estimated to effect 4% to 7% of the U.S. population.

Diana M. Smith, A.B., and Murray B. Stein, M.D., M.P.H., of the University of California, San Diego, and colleagues analyzed data collected as part of Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) New Soldier Study. This included about 39,000 Army soldiers who were entering basic training (average age 21) and were screened for a history of psychiatric diagnoses with an adaptation of the Composite International Diagnostic Interview, a PTSD checklist, and an inventory of suicidal behavior. The soldiers also completed a survey evaluating their history of anger attacks—described in the survey as “when all of a sudden you lost control and either broke or smashed something worth more than a few dollars, hit or tried to hurt someone, or threatened someone.” The episodes were counted as anger attacks only if respondents reported (1) that they had difficulty controlling the aggressive impulse, experienced attacks in situations where most people would not get angry, or had high frequency of attacks (defined as 10 or more lifetime attacks) and (2) that attacks had occurred when they were not using alcohol or drugs.

At the start of the study, about 9% of the soldiers reported a history of nonimpairing anger attacks (those that did not interfere with work or personal life), and about 6% reported a history of impairing anger attacks (those that did interfere with work or personal life). Soldiers with a history of impairing anger attacks in particular tended to report more frequent incidents, with more than one-quarter of them reporting more than 50 lifetime anger attacks.

Four to seven years after enlistment, the soldiers completed additional screenings via phone or web. After adjusting for such variables as sex, race and ethnicity, site of basic combat training, deployment history at follow-up, and military status at follow-up, the researchers found that soldiers who had impairing anger attacks before enlistment were about twice as likely to develop new onset of major depressive disorder, generalized anxiety disorder (GAD), panic disorder, or suicidal ideation than those who had not had anger attacks. The authors also found that soldiers with nonimpairing anger attacks at baseline were more than twice as likely to attempt suicide compared with those who did not have anger attacks.

When baseline psychiatric comorbidity was controlled for, impairing attacks remained associated only with new onset of GAD and suicidal ideation.

“It is unknown why impairing anger attacks would contribute uniquely to GAD and suicidal ideation, but not other emotional disorders,” wrote Smith, Stein, and colleagues. “However, the occurrence of anger attacks seems to imply serious deficits in emotion regulation and social problem-solving.”

They added, “These findings suggest that detection of impairing anger attacks could aid in assessing elevated risk of developing anxiety disorders, depression, and suicidality after enlistment.” Interventions to reduce the incidence of anger attacks or to improve emotional regulation and problem-solving deficits might help to prevent GAD and suicidal ideation in soldiers.

For related information, see the Psychiatric News article “STARRS Findings Shed More Light On Army Suicides.”

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How Can You Help Latina/o Patients During and After Pandemic?

In celebration of National Heritage Hispanic Month, APA’s Division of Diversity and Health Equity is sponsoring a fireside chat on “The Impact of the COVID-19 Pandemic on the Mental Health of Latinas/os” on Monday, October 4, from 4 p.m. to 5 p.m. ET. Panelists will examine strategies to improve the mental health of Latinas/os during and after the pandemic and will raise awareness of pandemic stressors such as unemployment, insurance benefits inequities, and social isolation.

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Methylphenidate May Reduce Symptoms of Apathy in Patients With Alzheimer’s Disease

Methylphenidate may be able to help reduce symptoms of apathy in people with Alzheimer’s disease, according to a report published Monday in JAMA Neurology.

“Apathy, characterized by diminished will or initiative and one of the most prevalent neuropsychiatric symptoms in individuals with Alzheimer disease, is associated with significant caregiver burden, excess disability, increased medical costs, and mortality,” wrote Jacobo Mintzer, M.D., M.B.A., of the Medical University of South Carolina and colleagues. “Methylphenidate offers a treatment approach providing a modest but potentially clinically significant benefit for patients and caregivers.”

For the study, the researchers recruited individuals with possible or probable Alzheimer’s disease (AD), mild to moderate cognitive impairment, and frequent and/or severe apathy from clinical centers specializing in dementia care. Two hundred participants (aged 71 to 81 years) were randomly divided into either the methylphenidate or placebo group. The participants took identical-appearing capsules (capsules contained either 5 mg of generic methylphenidate or placebo), starting with one capsule two times a day, then two capsules twice daily for six months. The researchers followed up with the participants by telephone at days 15, 45, and 75 after the start of the study and in person monthly for six months. Participants and their caregivers received a standardized psychosocial intervention, including a 20- to 30-minute counseling session at each visit, educational materials, and 24-hour availability of study staff for crisis management, Mintzer and colleagues noted.

The researchers conducted monthly structured interviews with the participants’ caregivers, using the Neuropsychiatric Inventory (NPI) to assess the presence and severity of 12 neuropsychiatric symptoms, including apathy. The Alzheimer’s Disease Cooperative Study Clinical Global Impression of Change (ADCS-CGIC) scale, administered by an independent clinician, was also used to assess clinically meaningful change in the participants’ apathy at six months.

Mintzer and colleagues noted that a larger decrease was found from baseline to six months in the NPI apathy score in those receiving methylphenidate compared with placebo (mean between-group difference, −1.25), with the largest decrease in the NPI apathy score observed in the first 100 days. At six months, the odds ratio of having an improved rating on the ADCS-CGIC for methylphenidate compared with placebo was 1.90. “[I]t is important to note that there were no group differences in any of the cognitive measures, suggesting that the effect of the treatment is specific to the treatment of apathy and not a secondary effect of improvement in cognition,” the researchers added.

“While methylphenidate will not be an option for those individuals with medical or psychiatric contraindications to stimulants, the present study demonstrates that it is generally safe and well tolerated for the target population,” wrote Carolyn Fredericks, M.D., of Yale University in an accompanying editorial. “Despite its near ubiquity, apathy is far from a benign neuropsychiatric symptom, and its impact on the clinical course of AD is devastating. Clinicians who have struggled to treat apathy in their patients with AD should take heart at this evidence that methylphenidate may be a safe and efficacious option.”

For related information, see the American Journal of Psychiatry article “Methylphenidate for Apathy in Community-Dwelling Older Veterans With Mild Alzheimer’s Disease: A Double-Blind, Randomized, Placebo-Controlled Trial.”

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Learn About Changes to Clozapine REMS Requirements

The FDA recently approved modifications to the Clozapine Risk Evaluation and Mitigation Strategy (REMS). All prescribers and pharmacies must be re-certified by Monday, November 15, to be able continue prescribing/dispensing clozapine. SMI Adviser will host a webinar on how to navigate this process on Wednesday, September 29, at 3 p.m. ET.

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Lumateperone Found to Be Effective in Treating Bipolar Depression

Patients with bipolar disorder who are experiencing a major depressive episode may benefit from taking the antipsychotic lumateperone, suggests a study in AJP in Advance. The phase 3 trial, which was funded by Intra-Cellular Therapies (maker of lumateperone), revealed that adults taking lumateperone daily reported significantly greater improvements in their depressive symptoms and overall functioning after six weeks than those taking placebo. Lumateperone was also well tolerated, and participants experienced minimal changes in weight or other metabolic parameters.

“Approved antipsychotics for bipolar depression are associated with a range of undesirable side effects, including cardiometabolic disturbances, motor impairments, and hyperprolactinemia,” wrote Joseph R. Calabrese, M.D., of Case Western Reserve School of Medicine and colleagues. “Thus, a new treatment option that is effective for depressive episodes in both bipolar I and bipolar II disorders and has a more benign and favorable safety profile could improve patient outcomes, with lower morbidity and a higher quality of life.” The authors added that effective medications for treating depressive episodes associated with bipolar II disorder are particularly needed, as only quetiapine is approved as a monotherapy for treating these symptoms.

In this multinational trial, the investigators randomized 381 adults with bipolar I or II disorder who were experiencing a major depressive episode to receive 42 mg lumateperone or placebo daily for six weeks. Safety and efficacy assessments were conducted weekly during the six-week treatment period, as well as during a follow-up two weeks after each participant’s last dose of medication. The main outcomes of interest were the changes in participants’ Montgomery-Åsberg Depression Rating Scale (MADRS) and Clinical Global Impressions Scale–Bipolar Version severity (CGI-BP-S) scores.

After six weeks, average MADRS scores were 4.6 points lower among participants taking lumateperone compared with those taking placebo; 51.1% of adults taking lumateperone responded to the treatment (defined as a drop in MADRS scores from baseline of at least 50%) compared with 36.7% of adults in the placebo group. Statistical differences in symptom improvement between the two groups were evident by the end of the first week. CGI-BP-S scores were also significantly lower among adults taking lumateperone compared with placebo after six weeks.

The rate of side effects in participants taking lumateperone was similar to that of the placebo groups; drowsiness and nausea were the only common side effects more prominent in the lumateperone group. Only 1% of participants in either treatment group reported clinically significant weight gain (≥7% increase from start of study), and no participants exhibited any significant changes in glucose, insulin, triglyceride, or insulin levels. Lumateperone use was also not associated with movement-related extrapyramidal symptoms, outside of one participant who developed mild dyskinesia after six weeks.

To read more on this topic, see the Psychiatric News article “Patients With Refractory Bipolar Depression May Benefit From ECT.”

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You Have Just Days to Submit Annual Meeting Abstracts

The deadline to submit abstracts of general sessions, courses, and posters for the 2022 APA Annual Meeting is Thursday, September 30, at 5 p.m. ET. Speakers may indicate if they are willing to present in person, present in-person and virtually at a later date, present remotely with a prerecorded lecture and live Q&A, and/or record the session with no live Q&A.

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Methamphetamine Use, Overdose Deaths From Psychostimulants Soar

Methamphetamine use in adults aged 18 to 64 years increased 43% between 2015 and 2019, a study in JAMA Psychiatry has found. The study also found that overdose deaths involving psychostimulants other than cocaine, mostly methamphetamine, increased 180% during the same period.

Beth Han, M.D., Ph.D., M.P.H., of the National Institute on Drug Abuse (NIDA) and colleagues examined data from 195,711 people who responded to the annual National Survey on Drug Use and Health (NSDUH) between 2015 and 2019. The NSDUH, published by the Substance Abuse and Mental Health Services Administration, is a comprehensive survey of approximately 67,500 civilian, noninstitutionalized people aged 12 years or older. Han and colleagues also examined data from the 2015 to 2019 National Vital Statistics System Multiple Cause of Death files.

Between 2015 and 2019, frequent methamphetamine use, defined as 100 days or more of use in the past 12 months, increased 66%. Methamphetamine use with cocaine increased 60%.

The study also found that methamphetamine use disorder (MUD) without injection increased 105%. It more than tripled among women and doubled among men, nearly tripled among White people, more than doubled among Latinx people, and increased more than 10-fold among Black people. Risk factors for methamphetamine use, MUD, injection, and frequent methamphetamine use included lower education, lower annual household income, lack of insurance, housing instability, criminal justice involvement, comorbidities (for example, HIV/AIDS, hepatitis B or C virus, depression), suicidal ideation, and polysubstance use.

In a press release, NIDA Director Nora D. Volkow, M.D., one of the authors of the study, said, “Public health approaches must be tailored to address methamphetamine use across the diverse communities at risk, and particularly for American Indian and Alaska Native communities, who have the highest risk for methamphetamine misuse and are too often underserved.”

The data revealed sharp increases in overdose deaths involving psychostimulants, notably a 379% increase in overdose deaths that also involved cocaine and a 266% increase in overdose deaths that also involved opioids.

“A major challenge in addressing the high rates of methamphetamine-associated morbidity and mortality is the lack of U.S. Food and Drug Administration–approved medications for MUD treatment, highlighting the urgency for further research and investments in MUD medication development,” Han and colleagues wrote. “Studies on implementation of evidence-based prevention interventions and on public policies are needed to inform the response to the surge in methamphetamine use and associated adverse outcomes.”

For related information, see the Psychiatric News article, “Rise in Stimulant Misuse Poses Treatment Conundrum.”

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You Have Just Days to Submit Annual Meeting Abstracts

The deadline to submit abstracts of general sessions, courses, and posters for the 2022 APA Annual Meeting is Thursday, September 30, at 5 p.m. ET. Speakers may indicate if they are willing to present in person, present in-person and virtually at a later date, present remotely with a prerecorded lecture and live Q&A, and/or record the session with no live Q&A.

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Insulin Resistance Linked to Major Depressive Disorder, Dutch Study Finds

Insulin resistance predicted the development of major depressive disorder in adults over the course of nine years, according to a study published today in AJP in Advance.

“Several studies have shown an association between insulin resistance and depression, including our previous work,” Katie Watson, Ph.D., a postdoctoral scholar in the Department of Psychiatry and Behavioral Health at Stanford School of Medicine, told Psychiatric News. “We did not know whether being insulin resistant first could lead to new cases of depression in the future. Here we see that insulin resistance, a highly prevalent condition that often precedes type 2 diabetes, is also associated with an increased rate of depression.”

At baseline, researchers examined three surrogate measures of participants’ insulin resistance: the ratio of triglycerides to high-density lipoprotein (HDL); prediabetes, as measured by fasting plasma glucose level; and waist circumference. Participants included 601 adults in the Netherlands with no history of depression, anxiety, or other psychiatric disorders. Researchers conducted additional physical and psychiatric interviews and screenings at 2, 4, 6, and 9 years, and results were adjusted for behavioral and sociodemographic variables.

Researchers reported that higher triglyceride-HDL ratio at baseline increased risk for major depression by 89% in the nine-year follow-up. Similarly, higher fasting blood glucose levels increased major depression risk by 37% during the course of the study. A 2-inch increase in waist circumference at baseline corresponded to an 11% increased rate of major depression on average.

In addition, researchers found that the development of prediabetes within two years of study enrollment was associated with a nearly threefold risk of developing major depressive disorder during the seven years of the study. According to the National Institutes of Health, about 1 of 3 adults in the United States is prediabetic, and some antipsychotics increase the risk of prediabetes.

“[The] ability to predict an increased risk in major depressive disorder incidence using standard clinical tests of metabolic status can be deployed as an important tool for treatment and prevention. Indeed, our own work suggests that certain treatments that decrease insulin resistance can aid in the treatment of major depression in a subset of patients,” wrote Kathleen Rasgon, M.D., Ph.D., and colleagues. “It will be especially important to ascertain in future studies whether reversing insulin resistance is able to decrease the risk of future clinical depression.”

For related information, see the Psychiatric News article “Insulin Levels, BMI in Youth May Be Linked to Psychosis, Depression Risk in Adulthood.”

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Clozapine REMS Requirements Will Change November 15

The FDA recently approved modifications to the Clozapine Risk Evaluation and Mitigation Strategy (REMS). All prescribers and pharmacies must be re-certified by Monday, November 15, to be able continue prescribing/dispensing clozapine. SMI Adviser will host a webinar on how to navigate this process on Wednesday, September 29, at 3 p.m. ET.

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Report Finds No Link Between Antipsychotics, COVID-19 Deaths in SMI Patients

Several months into the COVID-19 pandemic data suggested that individuals with schizophrenia spectrum disorders are more likely to die from illnesses related to COVID-19 than those without schizophrenia. More than a year later, why this population appears to be at increased risk of death from COVID-19 continues to remain unclear. A research letter appearing today in JAMA Psychiatry found no association between antipsychotic use and mortality in adults with a serious mental illness (SMI) who were diagnosed with COVID-19.

“An association between antipsychotic medication and increased risk of COVID-19 mortality has been reported in population-based studies, but these studies did not take psychiatric diagnosis into account,” wrote Katlyn Nemani, M.D., of the New York University (NYU) Langone Medical Center and colleagues.

To examine the relationship between antipsychotic use and COVID-19 outcomes in patients with SMI, the researchers used data contained in the NYU Langone Health electronic health record system. The researchers included in their analysis adults who were diagnosed with COVID-19 infection between March 3, 2020, and February 17, 2021, and who had a preexisting diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder.

A total of 464 patients (mean age, 53 years) were included, of which 196 (42.2%) were treated with antipsychotic medication. Forty-one patients (8.8%) died within 60 days of being diagnosed with COVID-19. “The 60-day case fatality rate among patients with a schizophrenia spectrum disorder (n = 182) was 13.7%, and the case fatality rate among patients with bipolar disorder (n = 282) was 5.7%,” Nemani and colleagues noted.

After controlling for age, body mass index, insurance type, and psychiatric diagnosis, the researchers found that antipsychotic treatment was not significantly associated with mortality. However, patients who had a preexisting diagnosis of schizophrenia spectrum disorder were nearly three times as likely to die from COVID-19 than those with a preexisting diagnosis of bipolar disorder.

“Further research is needed to understand what underlies increased mortality risk in this population to address worsening health disparities,” Nemani and colleagues concluded.

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

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Clozapine REMS Requirements Will Change November 15

The FDA recently approved modifications to the Clozapine Risk Evaluation and Mitigation Strategy (REMS). All prescribers and pharmacies must be re-certified by Monday, November 15, to be able continue prescribing/dispensing clozapine. SMI Adviser will host a webinar on how to navigate this process on Wednesday, September 29, at 3 p.m. ET.

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Youth’s Online Activity May Point to Subsequent Suicidal Behaviors

The types of online content that youth explore and the messages they share with others may help identify those most likely to be at high risk of a suicide attempt or self-harm, a study in JAMA Network Open suggests. The greatest risk was found among youth who engaged in multiple types of online risk factors, such as expressing feelings of prolonged hopelessness and participating in cyberbullying.

“The findings of this study suggest that many discrete types of risk factors are identifiable from online data and associated with subsequent youth suicide-related behavior,” wrote Steven A. Sumner, M.D., M.Sc., of the Centers for Disease Control and Prevention and colleagues.

Sumner and colleagues analyzed data drawn from more than 2,600 U.S. schools participating in online safety monitoring using a program called Bark. This software monitors and sends alerts to school administrators and parents about content “threatening to the health and well-being of students, such as messages about self-harm, suicidal ideation, online predators, bullying, or threats of violence,” they wrote.

Between July 27, 2019, and May 26, 2020, the Bark online safety tool sent a severe suicide/self-harm alert requiring notification of school administrators for 227 youth. The researchers compared the online behaviors of these youth with those of five controls each (youth enrolled in the same school who participated in a similar volume of online activity) to examine whether there were differences between the two groups that preceded the notifications about the severe suicide/self-harm alert. The mean age of the youth in the analysis was 13.3 years.

The researchers focused on youth’s engagement in the following eight online behaviors: cyberbullying, drug-related content, sexual content, violence, hate speech, profanity, depression, and low-severity suicide/self-harm alerts (defined as third-party content viewed but not sent by the user that is related to suicide or self-harm). Although engagement in each of these eight online behaviors was associated with increased risk of a severe suicide/self-harm alert, viewing depression-related content had the highest association with subsequent severe suicide/self-harm alerts (adjusted odds ratio, 1.82), the authors noted. Youth with five or more of the eight risk factors present in their online activity had a more than 70-fold increased odds of subsequently having a severe suicide/self-harm alert.

“The findings support the importance of understanding and preventing exposure to harmful online activities among youths as a component of youth suicide prevention strategies,” Sumner and colleagues wrote. “Although there are important ethical and privacy considerations when using online, digital, or linked data, efforts to improve mental health using passive digital information or other administrative data are being researched, tested, and used. Conducted carefully and ethically, such approaches have the potential to help prevent devastating outcomes for families, such as youth suicide.”

For related information, see the Psychiatric News article “Rise in Youth Suicide Rates Confounds Experts.”

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HHS Announces $25.5 Billion in New COVID-19 Provider Relief Funding

The Department of Health and Human Services (HHS) has announced $25.5 billion in new COVID-19 provider funding. The funding includes $8.5 billion in American Rescue Plan resources for providers who serve rural Medicaid, Children's Health Insurance Program, or Medicare patients, and an additional $17 billion for Provider Relief Fund (PRF) Phase 4 for a broad range of providers who can document revenue loss and expenses associated with the pandemic. Providers are strongly encouraged to complete their report in the PRF Reporting Portal by September 30 but those who cannot meet the deadline will be granted a 60-day grace period, which will end on November 30.

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Intervening Before 18 Months May Reduce Odds of Autism Diagnosis in Babies Identified at High Risk

A program that teaches parents how to engage with babies identified to be at high risk of autism spectrum disorder (ASD) may reduce the likelihood of the children’s developing the disorder. This finding comes from a study published today in JAMA Pediatrics.

“Autism spectrum disorder is emergent in early development but is not typically diagnosed until age 3 years,” wrote Andrew J. O. Whitehouse, Ph.D., of the University of Western Australia in Nedlands and colleagues. “[I]nterventions beginning during the first 2 years of life, when the first signs of atypical development are observed and the brain is rapidly developing, may lead to an even greater impact on developmental outcomes in later childhood.”

The intervention tested was called iBASIS–Video Interaction to Promote Positive Parenting (iBASIS-VIPP); this approach uses video of family interactions to help caregivers build up their babies’ social engagement and interaction abilities. The intervention is delivered in family homes by a trained therapist in 10 sessions over five months.

Whitehouse and colleagues recruited families of babies aged 9 to 15 months old showing behaviors associated with ASD, as measured by the Social Attention and Communication Surveillance–Revised (SACS-R) 12-month checklist. Babies were considered at risk of ASD if they displayed atypical behaviors in three of five domains: spontaneous eye contact, protodeclarative pointing (pointing to indicate item of interest), social gestures, imitation, and response to name.;

A total of 103 families were randomized to receive either usual community care (whatever services were recommended by health professionals within the family’s local community) or usual care plus iBASIS-VIPP. The researchers assessed the ASD symptoms of infants in both groups at 12 and 24 months after the study started.

Whitehouse and colleagues found that the babies whose families had participated in the iBASIS-VIPP sessions had lower ASD symptom scores (assessed with the Autism Diagnostic Observation Schedule, second edition) than the babies in the usual care group at both time points. At the 24-month assessment, only 6.7% of iBASIS-VIPP toddlers met the DSM-5 criteria for ASD, compared with 20.5% of toddlers in the usual care group.

The authors noted that the relatively low intensity of the intervention—an average of two sessions a month conducted in a family’s own home—and the absence of any observed side effects point to the viability of using iBASIS-VIPP at a broad level. “A cost-effectiveness analysis of the entire treatment pathway (incorporating screening and service delivery) and modeling of longer-term childhood and adulthood outcomes is an important next step to determine the feasibility and value of this clinical model.”

To read more about this topic, see the Psychiatric News article “Assessment and Treatment of Autism Spectrum Disorder.”

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Residency Experience Treating Patients With Buprenorphine Boosts Prescribing Down the Road

The United States has a dearth of physicians who are trained to offer medication treatment with buprenorphine to patients with opioid use disorder (OUD). One community-based family medicine residency program in Massachusetts has shown that integrating patients treated with buprenorphine directly into resident training can help increase the number of graduates prescribing buprenorphine. Layla Cavitt, M.D., of the Tufts University School of Medicine Lawrence Family Medicine Residency and colleagues outlined the program’s steps and success in the Journal of Substance Abuse Treatment.

In 2011, the Lawrence residency program integrated mandatory Drug Enforcement Agency (DEA) X-waiver training into the second-year didactic curriculum. (The X-waiver is the special DEA license required by the Drug Addiction Treatment Act of 2000 that allows health care professionals to prescribe buprenorphine to outpatients for treatment of OUD.) Also, family medicine attending physicians began shadowing patients being treated for opioid use disorder in 2011. In 2014, the program integrated patients being treated with buprenorphine into resident continuity clinic patient panels, and residents managed two to five patients over the course of their residency, closely supervised by an attending physician experienced in buprenorphine treatment.

Cavitt and colleagues analyzed data from the 2016, 2017, 2018, and 2019 National Family Medicine Graduate Surveys, focusing on the respondents’ answers to questions about whether they believed that residency prepared them to prescribe buprenorphine and whether they currently prescribed buprenorphine.

Of those who responded to the national survey, more graduates of the Lawrence Family Medicine Residency reported they were adequately prepared to prescribe buprenorphine on graduation. For example, 75% of the graduating class of 2016 reported they were prepared to prescribe buprenorphine compared with 12% of respondents nationwide.

In addition, compared with respondents nationwide, more graduates of the Lawrence Family Medicine Residency reported prescribing buprenorphine in their practice three years after graduating. All of the graduating class of 2016 reported that they were prescribing buprenorphine three years after graduating compared with 12% of respondents nationwide.

“[Our residency] approach helps to build a rich repertoire of clinical skills invaluable to post-residency practice that go far beyond the skills acquired by simply obtaining a DEA-X waiver,” the researchers wrote. “We posit that our program has been successful because it produces physicians who treat opioid use disorder in practice, which is directly related to our program’s integration of patients receiving buprenorphine into residents’ continuity clinic panels. We recommend that this approach be considered an evidence-based approach to increasing the total number of graduates who go on to provide this life-saving medication in practice.”

For related information, see the Psychiatric News article “Resource Document Calls for Improved Residency Training on SUDs.”

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Emergency Department Staff More Likely to Restrain Black Children Than White Children, Report Finds

Black children are almost twice as likely to be physically restrained in the emergency department compared with White children, according to a research letter published this week in JAMA Pediatrics. Use of physical restraints is an uncommon but serious intervention that has been found to increase the risk of injury, trauma, and death.

“Racial and ethnic disparities in restraint use likely reflect racism at multiple levels within and beyond the emergency care continuum,” wrote Katherine A. Nash, M.D., of Yale University School of Medicine and colleagues. “Potential drivers include interpersonal racism in the perception of threat or aggression, institutional racism leading to disparities in access to behavioral health care, and structural racism leading to disproportionate experiences with risk factors for mental illness, including poverty, trauma, and discrimination.”

The researchers examined the health records of nearly 552,000 emergency department visits by children from less than a year old to age 16 at 11 emergency departments within a New England health care system between 2013 and 2020. They found that physical restraints were ordered for 532 visits (0.1%). The majority of the children who were physically restrained were publicly insured, had a behavioral health problem, and were males above the age of 10. 

Results were adjusted for age, sex, language spoken, insurance, school month, behavioral health presenting problem, presence of an outpatient psychotropic medication, and history of behavioral health condition. They found that emergency department staff were 1.8 times more likely to use physical restraints on Black pediatric patients than White pediatric patients. They found no difference in the use of physical restraints on White versus Hispanic pediatric patients.

The researchers noted that previous research showed that Black adult patients are also more likely to be physically restrained in emergency rooms. Physical restraint should be used only after trying behavior de-escalation or chemical restraint, they added.

“Documenting racial and ethnic inequities is important but insufficient,” the authors concluded. “Physical restraint is a traumatic experience that can have lasting consequences for a child’s development and well-being. Further research should identify interventions that address inequities in physical restraint use and ensure a health care system that is a therapeutic rather than traumatic environment.”

For related information, see the Psychiatric Services article “The Role of the Psychiatrist in Seclusion and Restraint.”

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CMS Proposes Adding Payment for Telehealth Services by Mental Health Professionals

The federal government is proposing to permanently allow payment under the Medicare program for “audio-only” telehealth mental health services. These services have been temporarily reimbursed as part of the government’s response to the COVID-19 public health emergency. The government also would retain other temporarily reimbursed telehealth services through 2023 in order to evaluate whether those services should be permanently added to the list of covered Medicare services.

The recommended changes are part of the proposed 2022 Physician Fee Schedule by the Centers for Medicare and Medicaid Services (CMS). A final rule will be issued later this year; look for further reporting in Psychiatric News.

The proposed telehealth recommendations are a victory for psychiatrists and their patients for which APA has strongly advocated.

“Audio-only services have been a lifeline for patients for whom it is the only option when seeking mental health and substance use disorder treatment,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a letter to CMS Administrator Chiquita Brooks-LaSure. “Patients who cannot interact with their physician via a live, synchronous audio-video connection may need to rely on audio-only care for myriad reasons: they may lack access to sufficient broadband internet or access to the technology itself (e.g., they may not own a smartphone, tablet, or PC); their diagnosis may preclude using such technology; or they may not consent to being seen via video.”

He added, “We appreciate [that] CMS is proposing to make permanent—or otherwise continue to temporarily extend and evaluate—many of the telehealth provisions that clinicians and patients have relied on over the course of the public health emergency.”

Coverage of audio-only services would be restricted to clinicians who have the capability to furnish two-way audiovisual services and who have seen the patient in person at least once in the previous six months. In its comments to CMS, APA urged CMS to waive the six-month in-person requirement, emphasizing that the need for an in-person visit should be left to the psychiatrist’s clinical judgment.

The proposed rule also includes changes to the physician payment formula. Importantly, CMS is proposing a reduction to the “conversion factor” used in the formula that is likely to result in an overall reduction in physician payment. The change is partly the result of a budget neutrality adjustment that requires improvements in payment for Evaluation and Management Services last year to be offset in 2022 to maintain budget neutrality.

According to an AMA analysis of the impact of the proposed changes on different specialties, psychiatry would experience an overall reduction in payment of 3.1%; how individual practices will be affected would depend on practice and billing patterns.

In the letter to CMS, Levin urged CMS and the Department of Health and Human Services to work together with Congress to waive the budget neutrality adjustment set to go into place for 2022. “The reduction in the Medicare conversion factor will have a significant financial impact on psychiatrists who treat Medicare patients and comes at a time when practices have already experienced financial losses due to the COVID-19 public health emergency,” Levin wrote. “Payment cuts will only further compound the growing access problem for patients with mental health and/or substance use disorders.”

For more information, see the Psychiatric News article “CMS Proposes Permanent Payment for Telehealth Services Allowed During Pandemic.” A report on the final rule will appear in the December issue of Psychiatric News.

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ECT May Reduce Risk of Death in Older Patients Hospitalized for Psychiatric Disorders

Patients aged 65 or older who received electroconvulsive therapy (ECT) while hospitalized for a psychiatric disorder were found to have a lower rate of death in the year following discharge than similar patients who did not receive ECT while hospitalized, reports a study in AJP in Advance.

“This report adds to a growing body of research suggesting a positive effect of ECT from a population health perspective,” wrote Taeho Greg Rhee, Ph.D., of the University of Connecticut and colleagues. “Future efforts should focus on ways to ensure broader implementation of this treatment and to improve the maintenance therapy of severely ill patients who receive ECT.”

In this observational study, Rhee and colleagues used Medicare claims data to compare the mortality of Medicare beneficiaries 65 and up who received at least one ECT session during a psychiatric hospitalization between 2011 and 2015 with those who did not receive ECT during a psychiatric hospitalization. The final sample included 10,460 ECT patients and 31,160 control patients who were matched based on such characteristics as age, gender, and number of psychiatric hospitalizations in the previous year. The authors compared the mortality rates of patients due to various causes at one, two, three, six, and 12 months after their discharge from the hospital.

Patients who received at least one ECT session had a 39% lower rate of all-cause mortality 12 months after discharge compared with patients who did not receive ECT, while patients who received at least five sessions of ECT within a 30-day period had a 44% lower all-cause mortality rate.

In looking at different mortality categories, the authors found that ECT patients were less likely to die from smoking-related diseases, circulatory diseases, diabetes, and cancer. “While several mechanisms may be at play, one potential way in which ECT might lead to reduction in mortality risk is that improved functioning following ECT allows patients to maintain a healthier lifestyle and to better engage in treatment for whatever medical conditions they face,” they wrote.

Older patients who received any ECT or at least five sessions of ECT also had a 44% and 59% lower rate of suicide after three months, respectively, compared with patients who received no ECT, but by one year suicide rates of both groups were similar. “This is in line with the traditional understanding of the treatment course of ECT, where a large portion of ECT patients relapse after 6 months without a continuation treatment,” the authors wrote.

To read more on this topic, see the Psychiatric News article “When Is ECT Right for Your Patients With Depression?”

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APA Joins Other Health Organizations in Support of Collaborative Care Bill

APA has joined 17 other health organizations in supporting the Collaborate in an Orderly and Cohesive Manner (COCM) Act. The COCM Act was introduced by Reps. Lizzie Fletcher (D-Texas) and Jaime Herrera Beutler (R-Wash.) in the House of Representatives on Friday. If enacted, this legislation would improve access to evidence-based mental health care and substance use treatment by supporting and investing in the implementation of the Collaborative Care Model in primary care offices.

In the Collaborative Care Model, a primary care physician, a psychiatric consultant, and a care manager work as a team to identify and provide evidence-based treatment for patients with mental health conditions, measure their progress, and adjust care when appropriate. More than 90 research studies have demonstrated this model’s efficacy in improving patient outcomes. Furthermore, treatment provided through the Collaborative Care Model is covered by Medicare, most private insurers, and many states’ Medicaid programs.

However, the Collaborative Care Model has not been implemented on a wide scale yet in the United States. The COCM Act will provide primary care practices with startup funds and technical assistance as they adopt the model. The bill also provides funds for research to build the evidence base for other models of integrated behavioral health care.

“The Collaborative Care Model is a proven method of reaching more Americans with quality mental health care services,” said APA President Vivian Pender, M.D., in a news release issued by the supporting organizations. “The mental health impacts of COVID-19 and the way it uprooted our lives led to high levels of anxiety and depression and record overdoses in our country. We applaud Reps. Fletcher and Herrera Beutler for introducing this legislation, which promotes an innovative solution that will help more Americans get the high-quality treatment they need.”

For more information on the Collaborative Care Model and training provided by APA, see the APA webpage Learn About the Collaborative Care Model.

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APA Reflects on 20th Anniversary of 9/11

To mark the 20th anniversary of the terror attacks on September 11, 2001, APA released a statement today in honor of the thousands of men and woman who perished and the first responders who put their own lives on the line.

“We salute the first responders in New York, Washington, D.C., and Pennsylvania who bravely put themselves into harm’s way to rescue as many people as they could. We think of the efforts of psychiatrists and mental health clinicians in those regions, who from the very beginning treated many who suffered from trauma, from substance use disorders, and from other mental illness as a result of this tragedy. We remember the service members who deployed across the world in the resulting wars and the families they had to leave behind,” the APA statement read.

In the years since these attacks, there has been an enormous body of research on the effects of 9/11 on mental illness and substance use. In the September issue of Psychiatric News, psychiatrists reflect on how the attacks elevated disaster psychiatry and altered the way that psychiatrists understand psychological and behavioral responses to disasters.

“As we continue to face the aftermath of that day, whether in the form of quiet remembrances or the ongoing turmoil in Afghanistan, we urge everyone impacted to know that in times of tragedy and distress, we, as psychiatrists, are here to support you, and mental health help is available,” APA wrote.

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Survey Finds Marijuana Use Soared Among College Students, While Alcohol Use Dropped

Drug use trends among young adults have shifted dramatically in recent years, with 44% of college students reporting past-year marijuana use in 2020, according to the 2020 Monitoring the Future (MTF) study issued yesterday. Marijuana use was similar among young adults not enrolled in college, with 43% reporting past-year use.

“The pandemic has caused fundamental changes in the daily lives of teens and adults,” John E. Schulenberg, Ph.D., of the University of Michigan Institute for Social Research and colleagues wrote. “This endemic disruption is likely to affect substance use, and MTF is uniquely designed to examine such potential period effects and quite likely lasting cohort effects.”

Since 1980, the MTF study has annually tracked substance use among college students and noncollege adults aged 19 to 22. Data for 2020 were collected between March 2020—when much of the nation began pandemic lockdowns and virtual school—and November 2020. The 2020 results are based on the online responses of 1,550 college-aged adults.

The study revealed that past-year use of hallucinogens—including LSD, psilocybin, mushrooms, and other psychedelic substances—had also significantly increased among college students, from 5% in 2019 to nearly 9% in 2020. Among noncollege adults, past-year hallucinogen use remained consistent at around 10% in 2020, compared with 8% the previous year.

College students reported significantly lower alcohol use on several key measures in 2020, compared with the prior year. For example, 56% of students reported using alcohol in the past 30 days (down from 62% in 2019), and 28% reported being drunk in the past 30 days (down from 35%). In addition, 24% of college students reported binge drinking (consuming five or more alcoholic drinks in a row at least once in the past two weeks) in 2020, down from 32% in 2019. Among young adults not in college, trends in alcohol use across all measures were stable over the past five years, with 49% of noncollege respondents reporting alcohol use in the past 30 days, 22% reporting being drunk in the past 30 days, and 24% reporting binge drinking at least once in the past two weeks.

“While binge drinking has been gradually declining among college students for the past few decades, this is a new historic low, which may reflect effects of the COVID-19 pandemic in terms of reduced time with college friends,” said Schulenberg in a media release.

Psychiatrist Encourages Informing Patients About Marijuana Risks

“The changes that we’re seeing now have been unfolding for the past 10 to 15 years,” Elie G. Aoun M.D., an assistant professor of clinical psychiatry at Columbia University, told Psychiatric News. Marijuana is easier to use without detection than alcohol, particularly the edible and vaped forms of the drug. It may also be easier for young adults to obtain, since many states now allow purchase by young adults at age 18, compared with age 21 for alcohol.

Aoun said patients may have the misconception that marijuana use is “healthy,” he said. “However, the vast majority of people are not using marijuana for its medical benefits. People use it as a drug because they want to achieve a state of feeling high and of feeling pleasure. That can be a personal choice. But it doesn’t come without costs.” He noted that marijuana use may cause sleep disturbances, cognitive distress, reduced motivation and energy, memory difficulties, poorer performance at work and school, and, for those with psychiatric disorders, deteriorating psychiatric symptoms.

What’s the bottom line? “We need to talk, talk, talk with our patients and have honest conversations about marijuana use. We shouldn’t shy away from this just because marijuana has become so available,” he said. “We can apply the same model with our patients that we use with alcohol: Recognize that it’s not necessarily a bad thing [for people] to have a drink, but that it can be problematic when they’re having consequences, when they have an addiction, or when they’re using it because they’re too depressed or anxious.”

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Study Reveals Patterns of Youth Emergency Visits for Suicide During the Pandemic

Youth aged 5 to 17 were more likely to present to an emergency department (ED) for suicidal thoughts and behaviors in the second half of 2020 compared with the same period in 2019, a study in JAMA Psychiatry has found.

Specifically, suicide-related ED visits among female youth from June 1 to December 15, 2020, were significantly higher than in the corresponding months in 2019. Youth with no history of outpatient mental health or suicide visits and those with comorbid psychiatric conditions documented at the ED visit also had a higher risk of presenting with suicide-related problems from September to December 2020 compared with the same period in 2019.

“As suicide-related encounters have made up more ED volume during the pandemic, increasing ED-based interventions, staff trained in addressing emergency mental health needs, and aftercare resources may also be valuable in addressing the needs of this population,” wrote Kathryn K. Ridout, M.D., Ph.D., of The Kaiser Permanente Medical Group and colleagues.

Ridout and colleagues analyzed electronic health record data for patients aged 5 to 17 years seeking emergency care for suicidal thoughts or behaviors at Kaiser Permanente Northern California from January 1, 2020, to December 15, 2020, and for the same dates in 2019. The researchers focused on four time frames: pre–COVID-19 pandemic period (January 1 to March 9), the period during which shelter-in-place orders were in effect in the Bay Area and California (March 10 to May 31), the summer (June 1 to August 31), and the fall (September 1 to December 15).

There were 2,123 youth with suicide-related ED encounters in 2020 compared with 2,339 in 2019. The following patterns were found:

• The incidence rates of suicide-related ED encounters were significantly lower in March through May 2020 compared with this period in 2019—likely because of shelter-in-place orders at the beginning of the pandemic—before returning to prepandemic levels in June through December 2020.
• Female youth had an 11.4% higher risk of presenting with suicidal thoughts or behaviors during the fall compared with the same period in 2019, while male youth had a 21.3% lower risk of presenting with suicidal thoughts or behaviors during this period.
• Relative to all youth ED encounters, youth with no history of outpatient mental health encounters during the previous two years had a 129.4% higher risk of a suicide-related ED encounter during the fall of 2020 compared with fall of 2019.
• There was a 6.7% higher risk of having a comorbid psychiatric nonsubstance diagnosis at the time of the suicide-related ED encounter during the fall of 2020 compared with 2019.

“Preventive efforts, including mental health screening, psychoeducation, and support in connecting to care, may be particularly valuable for these youth and their families,” the researchers wrote. “Innovative and immediately accessible tools for mental health care, such as technology-based care, may address the needs of this population as well.”

For related information, see the Psychiatric Services article “Universal Suicide Risk Screening for Youth in the Emergency Department: A Systematic Review.”

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Irritability at Age 3 May Predict Psychiatric Disorders in Adolescence

Irritability in preschool-aged children may point to youth at risk of developing psychiatric disorders in adolescence, according to a study in the Journal of the American Academy of Child & Adolescent Psychiatry.

“[O]ur findings underscore the clinical significance and predictive validity of early childhood irritability,” wrote Leah K. Sorcher and Lea Dougherty, Ph.D., of the University of Maryland and colleagues. “Preschool irritability predicted internalizing and externalizing disorders in adolescence, parent-reported anxiety and depressive symptoms [in the youth], and greater functional impairment, even after controlling for baseline psychiatric disorders.”

The findings were based on information collected as part of the Stony Brook Temperament Study—a longitudinal study investigating the role of early child temperament on the development of internalizing disorders. At the start of the study, parents were asked questions about their 3-year-olds’ irritability, other psychiatric symptoms, and functional impairment. When these children reached age 12 and/or 15, both parents and youth were asked questions about any psychiatric symptoms the youth were experiencing, including symptoms of anxiety and depression as well as suicidal thoughts. Additionally, they answered questions about the youth’s physical health and overall functioning.

“[I]rritability at age 3 predicted adolescent anxiety disorders, including specific phobia, social phobia, and [generalized anxiety disorder]; and ADHD and [disruptive behavioral disorders],” Sorcher, Dougherty, and colleagues wrote. Preschool irritability also predicted greater functional impairment in adolescence, including poorer peer functioning and physical health, and greater likelihood of nonsuicidal self-injury and use of psychiatric treatment, psychotropic medications, and educational services.

“These findings strongly support the need for early identification of irritability in young children and the importance of intervening as early as possible,” the authors concluded.

For related information, see the Psychiatric News article “Irritability in Childhood May Point to Teens at High Risk for Suicide.”

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Annual Meeting Submission Deadline Extended to September 30

The deadline to submit abstracts of general sessions, courses, and posters for the 2022 APA Annual Meeting has been extended to Thursday, September 30, at 5 p.m. ET. All proposals must be submitted through the abstract submission portal.

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APA, Five Other Physicians Groups Condemn Texas Law Restricting Access to Abortion

Yesterday APA joined five other leading physician groups in opposing a Texas state law that took effect Wednesday banning abortions, medical counseling, and support related to abortion after six weeks of pregnancy.

“Our organizations, which represent nearly 600,000 physicians and medical students, strongly oppose any laws and regulations that interfere in the confidential relationship between a patient and their physician. This new law will endanger patients and clinicians, putting physicians who provide necessary medical care, or even offer evidence-based information, at risk, by allowing private citizens to interfere in women’s reproductive health decision making,” wrote APA, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Osteopathic Association in a statement. “Moreover, this law virtually eliminates women’s access to evidence-based, comprehensive care and information, and denies women their right to make decisions about their own health.”

The organizations stated that they are firmly against any policies that limit the evidence-based practice of medicine; threaten the patient-physician relationship; and inhibit the delivery of safe, timely, and necessary comprehensive care, including reproductive health services and information.

“To that end, we fundamentally oppose the unprecedented ability for private citizens to take legal action against individuals who help a woman obtain an abortion, including physicians providing necessary, evidence-based care for their patients,” they wrote. “Physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of punishment, harassment, or retribution.”

“Restrictive abortion and contraception policies have been shown to be related to an increased risk for a variety of mental health problems and may have a negative impact on the overall health of women, including physical, emotional, and social well-being. APA opposes interference in the doctor-patient relationship and laws that threaten the health and well-being of women,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.

For related information, see APA’s position statement on abortion and women’s reproductive health care rights.

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Annual Meeting Submission Deadline Extended to September 30

The deadline to submit abstracts of general sessions, courses, and posters for the 2022 APA Annual Meeting has been extended to Thursday, September 30, at 5 p.m. ET. All proposals must be submitted through the abstract submission portal.

LEARN MORE