Young Cancer Survivors May Experience Cognitive Problems, Suicidal Thoughts

Child and adolescent survivors of cancer—particularly those experiencing cognitive problems—may be at higher risk of suicidal thoughts than other youth their age, suggests a report in Psycho-Oncology.

“Survivors of pediatric cancer are at elevated risk for both neurocognitive and psychological difficulties following cancer treatment,” wrote Christina M. Sharkey, Ph.D., of Children’s National Hospital in Washington, D.C., and colleagues. Studies of adult cancer survivors suggest there may be a link between neurocognitive deficits and suicidal ideation, but little is known of whether such deficits are also linked to suicidal ideation in younger cancer survivors, the authors wrote.

To examine the prevalence of suicidal ideation in young survivors of cancer, Sharkey and colleagues recruited youth who had been diagnosed with cancer between the ages of 6 and 19 and were receiving care at a pediatric neuropsychology clinic. Patients included in the study were medically stable at the time of the evaluation; had completed multiple behavioral and cognitive assessments; and had parents and teachers who had filled out assessments of the youth’s suicidal ideation, executive function, symptoms of attention-deficit/hyperactivity disorder, and more. Patients were an average age of 11.5 years old and had been diagnosed with cancer more than five years ago.

Of the 166 pediatric cancer patients in the analysis, 17.5% had experienced suicidal ideation. Those with suicidal ideation had significantly more parent-reported inattention symptoms compared with those without suicidal ideation, the authors reported. Additionally, those with suicidal ideation had significantly greater impairments in global executive functioning and behavioral regulation compared with youth without suicidal ideation according to both parent and teacher reports. Youth with suicidal ideation did not significantly differ on measures of IQ, working memory, and processing speed from those without suicidal ideation.

The researchers concluded, “Although replication of these findings is needed and a clearer understanding of the relationship between [executive function] impairments and suicidal ideation is essential, the present study underscores the importance of screening and examining suicidality among youth treated for pediatric cancer.”

For related information, see the Psychiatric News article “Pediatric Consultation-Liaison Psychiatry—Yesterday, Today, and Tomorrow.”

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Participate in Upcoming Virtual Events

Don’t miss your chance to participate in two APA virtual events this week:

• Tonight (November 30) at 8 p.m. ET: Fireside chat on COVID-19 and the mental health of Indigenous people.
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• Tomorrow (December 1) at 6 p.m. ET: Town hall on social determinants of mental health in psychiatry in the context of policy and public health.
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PCPs Sought Advice More Often on Youth Mental Illness First Year of Pandemic

Pediatric primary care providers (PCPs) made more calls to two state programs seeking advice on how to treat youth with mental illness, especially those with comorbid conditions, during the COVID-19 pandemic than before the pandemic. These findings were published today in Psychiatric Services in Advance.

The research is based on data from Pediatric Mental Health Care Access (PMHCA) programs in Maryland and Mississippi, which provide PCPs with free services to help bolster their knowledge and skills in managing common mental health problems in children and adolescents. Services include mental health care education, consultation, and referrals; some PMHCA programs also provide direct-to-patient consultation and treatment services.

“These programs, now operating in >30 states, have shown positive effects on mental health outcomes; these benefits include decreases in antipsychotic prescriptions, increased provider capacity for addressing mental health concerns, and increased identification and connection to mental health supports,” wrote Amie Bettencourt, Ph.D., of the Johns Hopkins School of Medicine and colleagues.

Bettencourt and colleagues examined the trends in the types of calls received by the PMHCAs that support PCPs in Maryland and Mississippi between January (Maryland) or September (Mississippi) 2019 and March 2021. They found that both programs experienced an uptick in call volume starting in April 2020, when the pandemic took hold in the United States, especially calls involving depression and anxiety.

The proportion of calls involving patients with comorbid diagnoses also increased sharply in both states. In Maryland, 37% of all PMHCA calls were for patients with multiple diagnoses during the pandemic, compared with 20% before the pandemic; in Mississippi, 11% of PMHCA calls were related to patients with multiple diagnoses during the pandemic compared with 0% before the pandemic. In contrast, the proportion of calls involving patients with severe mental health concerns (a patient with a score of >4 on the seven-point Clinical Global Impressions scale) dropped in both states during the pandemic, going from 11% pre-COVID-19 to 7% during COVID-19 in Maryland, and from 29% to 9% in Mississippi.

“[T]his highly similar pattern was observed in two PMHCA programs in operation for different durations; moreover, these programs had very different racial-ethnic and geographic features, health systems, and state responses to COVID-19,” the authors wrote. “Taken together, the increased utilization of PMHCA programs in these two states underscores the growing mental health needs during COVID-19 and how PMHCA programs are well situated to respond to this increased demand.”

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

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Cognitive-Behavioral Therapy for Insomnia May Prevent Depression in Older Adults

Cognitive-behavioral therapy for insomnia (CBT-I) may help to prevent depression in older adults with insomnia disorder, according to a report published today in JAMA Psychiatry.

“Insomnia, occurring in nearly 50% of persons 60 years or older, contributes to a 2-fold greater risk of major depression,” wrote Michael R. Irwin, M.D., of the David Geffen School of Medicine at UCLA and colleagues. “In this trial of older adults without depression but with insomnia disorder, delivery of CBT-I prevented incident and recurrent major depressive disorder by more than 50% compared with [sleep education therapy], an active comparator.”

CBT-I—a first-line treatment for insomnia disorder—combines cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. Sleep education therapy (SET) teaches about the day-to-day behavioral and environmental factors that contribute to poor sleep.

For the study, Irwin and colleagues enrolled 291 adults 60 years or older who lived within 15 miles of UCLA and met DSM-IV criteria for insomnia disorder. Individuals with a history of depression could participate in the study, but those who had experienced depression within the past year were excluded.

The 291 participants (including 123 with a history of depression) were randomized to receive either CBT-I or SET in weekly two-hour group sessions for two months. The participants were evaluated monthly using the Patient Health Questionnaire (PHQ-9) and every six months using the Structured Clinical Interview of the DSM-5 for 36 months.

Incident or recurrent major depression occurred in 19 participants in the CBT-I group (4.1 events per 100 person-years) and 35 participants in the SET group (8.6 events per 100 person-years). The proportion of participants who achieved remission of insomnia disorder after treatment was greater in the CBT-I group (50.7%) compared with the SET group (37.7%). Similarly, a greater proportion of participants in the CBT-I group achieved sustained remission of insomnia (defined as the absence of insomnia disorder at each follow-up assessment) compared with those in the SET group: 26.3% vs. 19.3%.

“This study indicates that an intervention aimed at insomnia can effectively reduce the incidence of major depression in those without a depressive disorder at the start of the intervention, meaning that depression can be prevented effectively without even using the word depression and thus avoid the associated stigma,” Pim Cuijpers, Ph.D., of Vrije Universiteit Amsterdam and Charles F. Reynolds III, M.D., of the University of Pittsburgh School of Medicine wrote in an accompanying editorial. “If prevention of major depression can be realized by focusing on insomnia, would it be possible to prevent depressive disorder by focusing on other problems that are associated with depression?”

Cuijpers and Reynolds added, “This major finding offers exciting new opportunities for the prevention field and opens a new field of research into indirect preventive interventions for avoiding the stigma of mental disorders.”

For related information, see the American Journal of Psychiatry article “The Evolving Nexus of Sleep and Depression.”

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Lithium Does Not Appear to Lower Risk of Suicidal Behavior in Veterans With Mood Disorders

Adding lithium to the treatment plan of veterans with depression or bipolar and recent suicidal behavior does not appear to reduce the risk of subsequent suicidal behavior, according to a report in JAMA Psychiatry.

“The present double-blind, placebo-controlled study found no benefit of lithium over placebo for preventing or delaying suicide-related events (suicide attempts, interrupted attempts, hospitalizations to prevent attempts, or deaths from suicide) when it was added to usual VA mental health management,” wrote Ira R. Katz, M.D., Ph.D., emeritus professor of psychiatry at the University of Pennsylvania Perelman School of Medicine, and colleagues. “However, lithium still has a role in the management of mood disorders, especially bipolar disorder.”

Veterans at 29 VA medical centers who had an episode of suicidal behavior or an inpatient admission to prevent suicide within the past six months were randomized to receive lithium or placebo in addition to their existing medications and treatment. Individuals were included in the study if they had a DSM-IV-TR diagnosis of major depression or bipolar disorder; they were excluded if they had schizophrenia, six or more lifetime suicide attempts, or had used lithium within the past six months.

Katz and colleagues tracked the occurrence of any suicide-related events in the participants for one year.

The trial was halted for futility after 519 participants had been randomized (255 with lithium and 264 with placebo), as the data indicated no difference in suicide-related events between the participants who received lithium and those who received placebo. A total of 127 participants (24.5%) had suicide-related outcomes: 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and three in the placebo group.

The authors cautioned that their data had some notable limitations, including that only half of participants assigned to lithium achieved clinically adequate blood levels of the medication (0.5 mEq/L or higher).

“Our findings are not necessarily generalizable to other health care settings or to other patient populations with differing proportions of individuals with bipolar disorder, lower rates of comorbidities, or higher treatment adherence,” Katz and colleagues wrote.

In an accompanying editorial, Ross J. Baldessarini, M.D., and Leonardo Tondo, M.D., M.S., of Harvard Medical School suggest that the report should be read with the study limitations in mind. “In our opinion, this rigorously designed and conducted trial has much to teach but cannot be taken as evidence that lithium treatment is ineffective regarding suicidal risk.”

They added, “The new trial did not find evidence of an antisuicidal effect of adding lithium to complex treatment regimens in relatively small numbers of mostly male veterans with complex, although realistic, psychopathological conditions, given relatively brief treatment with low circulating levels of lithium. Thus, its findings cannot be taken as evidence that lithium lacks antisuicidal effects.”

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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FDA Temporarily Suspends Some Clozapine REMS Program Requirements

The Food and Drug Administration (FDA) has temporarily suspended certain requirements of the recently modified Clozapine Risk Evaluation and Mitigation Strategy (REMS) Program after the agency received reports of challenges with the program. The Clozapine REMS is a safety program required by the FDA to manage patients’ risk of neutropenia associated with clozapine treatment.

“Health care professionals continue to alert FDA about ongoing difficulties with the Clozapine REMS program, including a high call volume and long call wait times for stakeholders since launch of the program on November 15,” the FDA wrote in a statement. “We understand that this has caused frustration and has led to patient access issues for clozapine. … Continuity of care, patient access to clozapine, and patient safety are our highest priorities. We are working closely with the Clozapine REMS program administrators to address these challenges and avoid interruptions in patient care.”

The temporary changes mean that pharmacists may dispense clozapine without REMS dispense authorization and wholesalers may continue to ship clozapine to pharmacies and health care settings without confirming REMS enrollment.

Patients who abruptly stop using clozapine can experience significant physical and behavioral symptoms, including the potential re-emergence of psychosis.

If you are having problems with the Clozapine REMS, please contact the APA Practice Helpline or SMI Adviser.

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House Passes Build Back Better Act to Invest in Mental Health, Substance Use Disorder Care

Today the U.S. House of Representatives passed the Build Back Better Act, a $2 trillion spending package that includes significant investments in mental health and substance use disorder (SUD) care.

APA applauds the inclusion of these provisions in the legislation:

• Enforcement of mental health parity laws: The 2008 federal parity law requires that insurance coverage for mental health and SUD services be no more restrictive than coverage for other medical care, but there has yet to be full compliance with this law. The legislation would levy civil monetary penalties for violating parity law requirements.
• Expansion of the behavioral health workforce: The legislation would fund 4,000 new, Medicare-supported graduate medical education slots in 2025 and 2026, the largest increase in more than 25 years, and it would allocate 15% of the new residency slots to psychiatry and other behavioral health training programs. Furthermore, it would provide $75 million in funding to award grants to establish or expand programs to enlarge and diversify the maternal mental health and SUD treatment workforce. It would also provide an additional $50 million for the SAMHSA Minority Fellowship Program in which APA participates.
• Enhancement of crisis services: The legislation would make permanent an increase in Medicaid funding for mobile crisis response. It would also include $75 million in funding for the National Suicide Prevention Lifeline to help expand programs as the Lifeline transitions to the new 988 number next summer.
• Increased access to care: The legislation would provide 12 months of continuous eligibility to children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) and permanently extends the state option. It would also invest in Medicaid by extending coverage to women 12 months after giving birth, permanently enhancing federal funding for the territories, and covering people 30 days prior to leaving jail or prison. In addition, the legislation would boost access to care through Certified Community Behavioral Health Care Clinics and would expand tax credits for purchasing insurance through the Affordable Care Act marketplaces.

APA urges the Senate to ensure that these provisions are retained in the final reconciliation package.

For more information, see the Psychiatric Services article “Supporting the Mental Health Workforce During and After COVID-19.”

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Drug Overdose Deaths Reach Record High During Pandemic

Drug overdoses killed more than 100,000 people in the United States during the one-year period ending in April 2021, according to provisional data issued yesterday by the Centers for Disease Control and Prevention (CDC). This marks the first time that drug overdose deaths reached six figures in one year and represents a 29% increase in overdose deaths from the prior year.

Synthetic opioids (that mimic the effects of natural opioids like heroin but are far more potent), primarily fentanyl, were responsible for 64% of the total deaths, a rise of nearly 50% from the year before, according to the CDC’s National Center for Health Statistics. Psychostimulants, such as methamphetamine, were responsible for 28% of the total deaths.

APA, responding to this news, renewed its call for the following actions:

• Improved access to mental health and substance use services through early identification, utilizing evidence-based models that integrate behavioral health treatment into primary care services.
• Effective substance use disorder treatment for all patients, through the development of science-based policies that are based on a thorough review and discussion with Congress, federal policymakers, and experts in the field of addiction treatment.
• Policies and programs to support accredited medical schools and residency programs to provide training for the treatment of individuals with substance use disorders and incentivize more educators, consultants, and physician leaders to take on roles to develop an addiction workforce.

White House Response

The White House Office of Drug Control Policy also yesterday issued a model law states may adopt to expand access to the emergency opioid agonist naloxone, which can reverse opioid overdoses. At present, naloxone access is largely dependent on where one lives, according to Rahul Gupta, M.D., director of National Drug Control Policy.

“This model law provides states with a framework to make naloxone accessible to those who need it—an evidence-based solution that, according to research, would have a significant effect on reducing opioid-related overdose deaths,” Gupta said in a media release.

The model law aims to be a template for state legislatures. It would require health insurers to cover naloxone, encourage citizens to obtain it, protect individuals from unjust prosecution for administering it, and increase access in educational and correctional settings.

Last month, the Department of Health and Human Services released an overview of the Biden administration’s plan to combat drug overdoses. It includes measures designed to remove barriers to prescribing medication for opioid use disorder; reduce stigma; and provide new funding for prevention, evidence-based treatment and recovery support, and harm reduction. President Biden’s proposed fiscal year 2022 budget for drug-related programs and initiatives totals $11.2 billion, a 54% increase over this year’s budget.

For related information, see the Psychiatric News article “Drug Overdoses Surge Due to Pandemic, Early Reports Show.”

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Low-Dose, Off-Label Exposure to Some Antipsychotics May Increase Risk of Cardiometabolic Death

People taking off-label, low doses of the antipsychotics olanzapine or quetiapine for more than six months may be at higher risk of death due to cardiometabolic complications than people not taking these medications, according to a report in the Journal of Psychiatric Research.

“Off-label” use of antipsychotics (meaning prescribing an FDA-approved drug for an unapproved use) has become extremely common, despite limited evidence of effectiveness, wrote Jonas Berge, M.D., of Lund University in Sweden and colleagues. Additionally, studies have shown that olanzapine and quetiapine are associated with cardiometabolic complications—obesity, dyslipidemia, hyperglycemia, hypertension—that can lead to death.

Using Swedish national registries, the researchers identified adults 18 years and older who had at least one psychiatric visit (inpatient or outpatient) between July 2006 and December 2016. People who had previous diagnoses of bipolar, psychotic, or cardiometabolic disorders and/or who were prescribed antipsychotics or drugs indicated for cardiometabolic-related reasons prior to the study period were excluded from the analysis. A total of 428,525 individuals (average age: 37 years) were followed for 10.5 years; of these, 18,317 were treated with low-dose olanzapine or quetiapine, defined as 5 mg/day or less. By the end of the study, 13,358 of the cohort died during the observation time.

Berge and colleagues compared cardiometabolic death outcomes in those taking low-dose olanzapine or quetiapine for six months or less, six to 12 months, and more than 12 months.

In total, 2,606 cardiometabolic-related deaths occurred. Compared with no treatment, treatment for less than six months was associated with a significantly lower risk of cardiometabolic death. However, people treated for six to 12 months had a 1.89 times higher risk of cardiometabolic death than those not treated. (There was a slightly higher risk of death for those treated more than 12 months, but it was not statistically significant.)

Among those treated, each year of exposure to an average dosage of 5 mg/day was associated with a 1.45 times higher risk of death, according to the report.

“Clinicians ought to be aware of potential cardiometabolic consequences [of off-label exposure to low-dose olanzapine or quetiapine],” the researchers wrote. “Before prescribing, a thorough risk-benefit analysis should be performed, with screening and follow-up being well employed regardless of prescribed dose or length of treatment.”

For related information, see the Psychiatric News article “Special Report: Guidance on Managing Side-Effects of Psychotropics.”

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REIMAGINE: A Week of Action to Reimagine National Response to People in Crisis

APA is pleased to be a partner in REIMAGINE: A Week of Action to Reimagine Our National Response to People in Crisis, which kicked off Monday and continues through Friday, November 19. Each day features different speakers and topics, with the goal of exploring the impact of our current inadequate response to people in crisis and how to advocate to change things for the better. Please participate and invite others in your district branch to participate as well.

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COVID-19 Survivors With Depression Respond to SSRIs Within 4 Weeks, Small Study Suggests

People who develop major depression following a COVID-19 infection appear to respond to treatment with selective serotonin reuptake inhibitors (SSRIs) within four weeks, according to a small study reported in European Neuropsychopharmacology.

“After COVID-19, depression was reported in 40% of patients at one-, three-, and six-months’ follow-up,” wrote Mario Gennaro Mazza, M.D., of Vita-Salute San Raffaele University in Milan, Italy, and colleagues. “The host immune response to SARS-CoV-2 infection and the related severe systemic inflammation seems to be the main mechanism contributing to the development of post-COVID depression.”

The study included 60 adults (average age: 55 years) who developed a major depressive episode within six months following recovery from COVID-19 and were starting a new SSRI treatment; 26 were treated with sertraline, 18 with citalopram, 10 with paroxetine, four with fluvoxamine, and two with fluoxetine. The researchers evaluated the patients using the Hamilton Depression Rating Scale (HDRS) at the beginning of the study and after four weeks of SSRI treatment.

After four weeks, average HDRS among the patients dropped from 23.37 to 6.71, with similar improvements seen in men and women as well as people with or without a history of psychiatric illness. Fifty-five of the 60 patients (92%) achieved a clinical response to antidepressant treatment, defined as ≥50% reduction in HDRS score. For comparison, studies in the general population have shown that depressed patients tend to respond to an antidepressant about 40% to 60% of the time, the authors wrote.

“SSRI treatment could contribute to the rapid antidepressant response by directly targeting the neuroinflammation triggered by SARS-CoV-2,” they wrote.

While the authors acknowledged the limitations of the study (including the lack of a control group and the small sample size), they suggested that the findings point to the importance of routinely screening COVID-19 survivors for depression so they can be promptly treated.

For related information, see the Psychiatric News article “Antidepressants May Reduce Severity of COVID-19.”

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REIMAGINE: A Week of Action to Reimagine National Response to People in Crisis

APA is pleased to be a partner in REIMAGINE: A Week of Action to Reimagine Our National Response to People in Crisis, which kicked off yesterday and continues through November 19. Each day features different speakers and topics, with the goal of exploring the impact of our current inadequate response to people in crisis and how to advocate to change things for the better. Please participate and invite others in your district branch to participate as well.

LEARN MORE

Today Is Deadline to Recertify in Modified Clozapine REMS, Re-enroll Patients

Today—Monday, November 15—is the last day for physicians and pharmacies to recertify in the updated Clozapine Risk Evaluation and Mitigation Strategy (REMS), a safety program required by the Food and Drug Administration (FDA) to manage patients’ risk of neutropenia associated with clozapine treatment. Physicians must also re-enroll all their clozapine patients in the REMS program by today’s deadline. After today, noncertified prescribers and pharmacies will no longer be able to receive or dispense clozapine.

Clozapine is an effective medication for treating patients with refractory schizophrenia, but in rare instances the medication can lead to a rapid and severe loss of neutrophils (a type of white blood cell). This loss of neutrophils can potentially lead to fatal infections; thus, patients taking clozapine must undergo regular blood testing. The FDA’s REMS program ensures that physicians/pharmacies that dispense clozapine understand and can manage these risks.

In July the FDA approved modifications to the Clozapine REMS, which necessitated the recertification and reenrollment process. Among the important changes:

• Physicians must use a new patient status form to document neutrophil monitoring for all patients prescribed clozapine and submit the form to REMS monthly. The new form also requires physicians to submit neutrophil results for patients who have recently discontinued clozapine.
• Pharmacies will no longer be permitted to use telecommunication to verify a patient can use clozapine safely. Instead, they must obtain authorization to dispense either through the Clozapine Call Center (888-586-0758) or online at www.clozapineREMS.com.

To recertify and re-enroll patients in the Clozapine REMS, visit https://www.newclozapinerems.com. More information on the changes for prescribers is posted at cpmg-prchanged-whats changed prescriber v00_04 clean.pdf.

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Help Push the 988 Crisis Hotline Over the Finish Line

A dedicated phone number for individuals in crisis or experiencing suicidal thoughts—988—goes into effect July 16, 2022, but many states are not prepared for its implementation, putting people’s lives at stake. Join APA and other coalition organizations for “REIMAGINE: A Week of Action to Reimagine Our National Response to People in Crisis” this week to learn about what needs to be done to ensure that the 988 crisis hotline is implemented across the nation. Free, virtual events are being held throughout the week; they will highlight personal stories and how to coordinate federal and state advocacy efforts to establish and fully fund a more effective crisis response. Register today and join in the effort to build a better, more equitable crisis system for all people in this country.

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CMS Approves Permanent Coverage of Audio-Only Telehealth Services for Mental Illness/SUDs

The Centers for Medicare and Medicaid Services (CMS) has expanded the definition of telehealth services that will be permanently eligible for reimbursement under the Medicare program to include audio-only services for established patients with mental illness/substance use disorders (SUDs) who are unable or unwilling to use video technology.

The final rule on telehealth services for mental illness/SUDs is part of the 2022 Medicare Physician Fee Schedule, which covers updates to physician payment and other regulations regarding Medicare’s Merit-Based Incentive Payment System (MIPS) each year.

The expansion of telehealth to include audio-only services applies only to mental health/substance use disorders. These services had been temporarily reimbursed as part of the government’s response to the COVID-19 public health emergency, beginning with the presidential emergency declaration in March 2020. The rule will be published in the Federal Register on November 19 and goes into effect in January 2022.

The rule is an enormous victory for patients and psychiatrists for which APA had advocated unceasingly for months.

In July 2021 CMS proposed that in-person visits take place every six months after the initial telehealth encounter; in the final rule, the administration extended it to every 12 months, with exceptions at the discretion of the treating psychiatrist. Moreover, under the new rule, CMS expanded the definition of the patient’s home residence to include locations beyond the home, such as a homeless shelter or places a patient may need to go to have privacy.

“This is a real win for our patients,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “The expansion of telehealth services under the public health emergency has transformed the medical landscape and dramatically expanded access to mental health services during an extremely difficult period. APA advocated for permanent payment for audio-only telehealth services and argued successfully that the treating psychiatrist, together with the patient, should decide whether an in-person visit is required.

“We are grateful to CMS for this rule, which will prove invaluable to our patients well beyond the public health emergency,” Levin said.

CMS approved a reduction to the conversion factor (the dollar figure used in the physician payment formula to determine overall payment) of $1.30. The change is partly the result of a decision made last year that requires improvements in payment for Evaluation and Management Services to be offset in 2022 to maintain budget neutrality.

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

For complete coverage of how the changes might impact psychiatrists, see an upcoming edition of Psychiatric News. For related information, see the Psychiatric News article “CMS Proposes Permanent Payment for Telehealth Services Allowed During Pandemic.”

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Help Push the 988 Crisis Hotline Over the Finish Line

A dedicated phone number for individuals in crisis or experiencing suicidal thoughts—988—goes into effect July 16, 2022, but many states are not prepared for its implementation, putting people’s lives at stake. Join APA and other coalition organizations for “REIMAGINE: A Week of Action to Reimagine Our National Response to People in Crisis” during the week of November 15 to learn about what needs to be done to ensure that the 988 crisis hotline is implemented across the nation. Free, virtual events will be held throughout the week; they will highlight personal stories and how to coordinate federal and state advocacy efforts to establish and fully fund a more effective crisis response. Register today and join in the effort to build a better, more equitable crisis system for all people in this country.

REGISTER

Subthreshold PTSD Affects More Than 8% of Older Veterans

More than 8% of older veterans have subthreshold posttraumatic stress disorder (clinically significant PTSD symptoms below the threshold for a diagnosis), a study in the American Journal of Geriatric Psychiatry suggests.

Jennifer Moye, Ph.D., of the VA New England Geriatric Research Education and Clinical Center and colleagues analyzed data from 3,001 U.S. veterans aged 60 years or older who participated in the National Health and Resilience in Veterans Study between November 2019 and March 2020. The veterans were assessed using the PTSD Checklist for DSM-5, the Life Events Checklist for DSM-5 (for trauma exposure), and other measures. The researchers collected demographic information from the participants (including age, gender, race/ethnicity, and education), as well as their history of trauma exposures; suicidal behaviors; psychiatric and substance use disorders; and mental, cognitive, and physical functioning.

Overall, 8.5% of veterans screened positive for subthreshold PTSD, and 1.7% screened positive for full PTSD. Furthermore, 92.7% of all veterans in the study reported exposure to one or more potentially traumatic events, and among those, 9.6% screened positive for subthreshold PTSD and 1.9% screened positive for full PTSD. The prevalence of both subthreshold and full PTSD was higher in women and those who used the VA as their main source of health care. Veterans with subthreshold PTSD were equally as likely as those with full PTSD to have psychiatric, cognitive, and physical comorbidities, including a history of suicide attempts and current suicidal ideation.

“Given that older veterans aged 55 to 74 are at the highest risk for dying by suicide, better recognition of both subthreshold and full PTSD may be an important component of suicide prevention efforts,” Moye and colleagues wrote.

“Subthreshold PTSD is associated with a comparable clinical and functional burden as full PTSD, thus underscoring the importance of assessing, monitoring, and treating both of these manifestations of PTSD symptoms in clinical settings,” the researchers concluded.

For related information, see the APA blog post to commemorate Veterans Day, “Technology Playing Role in Veterans’ Access to Mental Health Services.”

(Image: iStock/Im Yeongsik)

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Help Push the 988 Crisis Hotline Over the Finish Line

A dedicated phone number for individuals in crisis or experiencing suicidal thoughts—988—goes into effect July 16, 2022, but many states are not prepared for its implementation, putting people’s lives at stake. Join APA and other coalition organizations for “REIMAGINE: A Week of Action to Reimagine Our National Response to People in Crisis” during the week of November 15 to learn about what needs to be done to ensure that the 988 crisis hotline is implemented across the nation. Free, virtual events will be held throughout the week; they will highlight personal stories and how to coordinate federal and state advocacy efforts to establish and fully fund a more effective crisis response. Register today and join in the effort to build a better, more equitable crisis system for all people in this country.

REGISTER

Report Examines Suicide Risk Among Adults Who Identify as Sexual Minorities

Adults who identify as lesbian, gay, or bisexual are more likely to report suicidal thoughts, plans, and attempts than those who identify as heterosexual, regardless of their age, gender, and race/ethnicity, suggests a report published today in the American Journal of Preventive Medicine.

“This study demonstrates the importance of asking about sexual identity in national data-collection efforts, and it highlights the pressing need for suicide prevention services that address the specific experiences and needs of lesbian, gay, and bisexual adults of different genders, ages, and race and ethnic groups,” lead author Rajeev Ramchand, Ph.D., senior advisor on epidemiology and suicide prevention at the National Institute of Mental Health, said in a media release.

The report was based on analysis of data collected as part of the National Survey of Drug Use and Health, an annual survey of adults in the United States. As part of this survey, participants were asked about their sexual identity (responses included heterosexual, lesbian or gay, bisexual, and don’t know) and if they had experienced suicidal thoughts over the past 12 months; those who answered yes were asked about suicidal plans and attempts. The participants also reported their age, race, and ethnicity. The researchers then grouped the participants into four race/ethnicity categories: non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic other race/multiracial.

The researchers focused their analysis on data from 2015 (when the survey first introduced questions about sexual identity) through 2019. The total sample size was 191,954 adults, of whom 14,693 identified as lesbian, gay, or bisexual.

Among gay and bisexual men, 12% and 17%, respectively, had thought about taking their lives in the past year; 5% had made a suicide plan; and about 2% had made a suicide attempt. Among lesbian or gay women and bisexual women, 11% and 20%, respectively, had thoughts of suicide; 7% had made a suicide plan; and about 3% had made a suicide attempt.

“When adjusting for demographics, [lesbian, gay, and bisexual adults] had 3- to 6-times greater risk than heterosexual adults across every age group and race/ethnicity category examined,” Ramchand and colleagues wrote.

The researchers compared past-year thoughts of suicide between those who identified as bisexual and lesbian/gay. They found that there were no differences in past-year thoughts of suicide between gay and bisexual men for any race/ethnicity or age group; however, among both White and Black women, bisexual women had significantly elevated odds of suicidal thoughts compared with lesbian/gay women.

“Examining disparities across groups is critical for stemming the threat that self-harm poses to the country’s health and well-being,” Ramchand and colleagues wrote. “This study provides foundational data that can inform future work examining how social inequalities (e.g., sexism, racism, heterosexism) influence suicide thoughts, plans, and attempts among individuals with multiple social identities.”

For related information, see the Psychiatric Services article “Predicting the Transition From Suicidal Ideation to Suicide Attempt Among Sexual and Gender Minority Youths.”

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Help Push the 988 Crisis Hotline Over the Finish Line

A dedicated phone number for individuals in crisis or experiencing suicidal thoughts—988—goes into effect July 16, 2022, but many states are not prepared for its implementation, putting people’s lives at stake. Join APA and other coalition organizations for “REIMAGINE: A Week of Action to Reimagine Our National Response to People in Crisis” during the week of November 15 to learn about what needs to be done to ensure that the 988 crisis hotline is implemented across the nation. Free, virtual events will be held throughout the week; they will highlight personal stories and how to coordinate federal and state advocacy efforts to establish and fully fund a more effective crisis response. Register today and join in the effort to build a better, more equitable crisis system for all people in this country.

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Shared Genetic Risk Does Not Explain Association Between Schizophrenia and Heart Disease

People with schizophrenia are known to have a lower life expectancy than people without this disorder, largely driven by an increased risk of cardiovascular disease. Some studies have suggested that the relationship between schizophrenia and cardiovascular disease may be due to shared etiology—that is, people who are genetically at risk of schizophrenia are also genetically at risk for cardiovascular disease. A study published in Schizophrenia Bulletin now suggests shared genetics likely does not explain this schizophrenia-cardiovascular association.

“The lack of evidence for genetic correlation between schizophrenia and [cardiovascular disease] is striking, given … the fact that a considerable amount of the risk variants for schizophrenia are located in genes relevant for cardiological functioning,” wrote Rada Veeneman and Jorien L. Treur, Ph.D., of the University of Amsterdam and colleagues. “This implies that effective treatment and intervention in early psychosis is important to decrease excess cardiovascular mortality.”

Veeneman and colleagues used data from seven genome-wide analyses (involving more than 1 million people) that identified genetic variants associated with coronary artery disease and heart failure, as well as other adverse cardiovascular outcomes including high systolic and diastolic blood pressure, highly variable heart rate, prolonged QT interval, early repolarization, and dilated cardiomyopathy. Another genome-wide analysis involving more than 130,000 people with schizophrenia and controls to identify genetic variants for schizophrenia risk was also included in the study. The researchers examined whether the people who had high genetic risk for one of these cardiovascular disease traits were more likely to develop schizophrenia and vice-versa (whether people who had high genetic risk for schizophrenia were more likely to have an adverse cardiovascular outcome).

The researchers found almost no evidence that an increased genetic risk of cardiovascular disease was associated with a similarly increased risk of developing schizophrenia, except for a weak association between high systolic blood pressure and schizophrenia risk. In contrast, people at an increased genetic risk of schizophrenia had higher odds of heart failure or early repolarization (an ECG pattern that resembles a heart attack and is considered a risk factor for cardiac arrest).

“Our findings are in line with the notion that schizophrenia is characterized by a systemic dysregulation of the body, including inflammation and oxidative stress, which promotes cardiac alterations and ultimately heart failure,” the authors wrote. “More thorough screening throughout psychiatric treatment must become a priority, in order to decrease the stark mortality gap between schizophrenia patients and individuals from the general population.”

To read more on this topic, see the Psychiatric News article “Cardioprotective Treatments After Heart Attack Can Help Patients With Schizophrenia Live Longer.”

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Universal School-Based Depression Screening May Connect More Students to Care

Universal school-based screening for major depressive disorder (MDD) in high school increases the likelihood that students with MDD will begin treatment, a study published today in JAMA Network Open suggests.

Deepa L. Sekhar, M.D., M.Sc., of Pennsylvania State College School of Medicine and colleagues analyzed data from 12,909 students in 14 Pennsylvania high schools who were randomized to either targeted screening or universal screening for MDD between November 2018 and November 2020. Targeted screening followed current school practice; if a student exhibited behaviors suggestive of MDD, a referral was made to the Student Assistance Program—a team of school staff and liaisons from mental health agencies. Universal screening involved students completing the nine-item Patient Health Questionnaire (PHQ-9). Students with a PHQ-9 score above 10; 1 or greater on Question 9 of the PHQ-9 (suicidal thoughts or self-harm); and/or displaying MDD behaviors were referred to the Student Assistance Program.

Compared with students in the targeted screening group, students in the universal screening group had 5.92 times higher odds of being identified with MDD symptoms, 3.30 times higher odds of their Student Assistant Program confirming that they had symptoms and needed treatment, and 2.07 times higher odds of beginning treatment. Overall, 9.5% of students had MDD symptoms. Of those, 15.9% in the universal screening group had MDD symptoms, compared with 3.1% in the targeted screening group.

“The results of this [study] support that universal adolescent MDD screening conducted in a school system can successfully identify students who would not otherwise be detected, with increased odds of treatment initiation among identified students,” Sekhar and colleagues wrote. “Future work should identify the barriers to school participation in universal screening and the means to overcome them, including an economic and resource analysis in partnership with policymakers, schools, and parents to consider the most effective means for implementation nationally.”

For related information, see the Psychiatric Services article “Schools As a Vital Component of the Child and Adolescent Mental Health System.”

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Biden Unveils Gun Safety Program to Reduce Suicides Nationwide Including Among Military Members

A new suicide prevention initiative announced earlier this week by the Biden administration will promote safer firearms storage; best practices for firearms dealers; and for veterans and military members, a focus on lethal means safety (or reducing access to lethal means of self-harm).

More than 45,000 people were killed by firearms in the United States in 2020, according to provisional data from the Centers for Disease Control and Prevention; about half of annual suicides result from firearms. Suicidal crises are often brief and sudden, so strategies that create time and space between a person in crisis and their access to a firearm can be lifesaving, according to a release from the White House. The number of suicides among current military rose by 15% in 2020 from 2019, according to data from the Pentagon.

In what the administration is calling “an unprecedented federal focus on improving lethal means safety as a tool to save lives” of military members and veterans, federal agencies will come together to create a plan addressing lethal means safety awareness, education, training, and program evaluation. The agencies will also launch a public education campaign to encourage safer storage of firearms as well as lethal means safety training for crisis responders, health care professionals, family members, and other gatekeepers. The agencies involved include the departments of Defense, Health and Human Services, Homeland Security, Justice, and Veterans Affairs and the Department of Transportation’s Office of Emergency Medical Services.

The administration will also make it easier for customers to obtain secure gun storage and safety devices by finalizing a rule proposed in 2016 requiring that firearms dealers offer these items for sale.

Finally, the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) will promote “best practices” for federal firearms dealers by issuing a guide reminding them of their responsibilities regarding background checks, safety and security, and distributing educational materials to customers.

The effort could go a long way toward solving a very complicated public health problem that claims the lives of 18 veterans every day in our country, Jeffrey Swanson, Ph.D., M.A., told Psychiatric News. He is a professor of psychiatry and behavioral sciences at Duke University School of Medicine who studies firearm-related violence and suicide. “Suicide has many causes—from social and economic strains to psychological distress and substance use to lethal means access—which is why we need a comprehensive approach that addresses all of those contributing factors. I think the White House strategy tries to do that. I applaud the focus on firearm safety, since guns play such a prominent role in veteran suicide.”

At the same time, Swanson expressed concern about the initiative’s lack of reach to veterans who are not enrolled in or receiving care from the VA’s health care system. These veterans have a very high rate of suicide and make up more than half of the veteran population, he said.

For related information, see the Psychiatric Services article “Preventing Suicide Through Better Firearm Safety Policy in the United States.”

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Combined Therapy May Improve Cognition, Reduce Negative Symptoms of Schizophrenia

The combination of two interventions that focus on building social skills, challenging defeatist beliefs, and improving cognitive function may be more effective at reducing negative symptoms of schizophrenia—such as low motivation and lack of interest in life—than an intervention that focused on individual recovery goals, according to a report in Schizophrenia Bulletin.

Eric Granholm, Ph.D., of the University of California, San Diego, and colleagues conducted a small study of adults with moderate-to-severe negative symptoms of schizophrenia or schizoaffective disorder. Fifty-five adults were randomly assigned to either 25 twice-weekly, one-hour manualized group sessions of combined Cognitive-Behavioral Social Skills Training (CBSST) and Compensatory Cognitive Training (CCT) or goal-focused Supportive Contact (SC) for about 13 weeks.

“The [cognitive-behavioral therapy] component of CBSST addresses defeatist beliefs, which have been associated with negative symptoms, … whereas [social skills training] promotes social engagement and behavioral rehearsal,” Granholm and colleagues wrote. “CCT teaches strategies to implement skills, which promotes self-reliance and compensation for cognitive deficits.” The SC intervention focused on individual recovery goals.

The researchers evaluated the severity of participants’ negative symptoms using the Clinical Assessment Interview for Negative Symptoms and the Scale for the Assessment of Negative Symptoms at the beginning of the study, midway through treatment, immediately after treatment, and at a six-month follow-up. Also, the study participants completed cognitive tests and answered questions about daily functioning, defeatist beliefs, and motivation.

The researchers found a greater reduction in negative symptom severity in the CBSST-CCT group compared with the SC group. The CBSST-CCT group also showed greater improvement in verbal learning.

“[P]reliminary findings from the current pilot randomized, controlled trial suggest that CBSST-CCT has the potential to improve negative symptoms and cognitive functioning in individuals with schizophrenia,” they wrote. “A larger investigation of CBSST-CCT is warranted to further examine its efficacy in treating negative symptoms, along with potential mediators and moderators of treatment effects.”

For related information, see the Psychiatric Services article “Confirmatory Efficacy of Cognitive Enhancement Therapy for Early Schizophrenia: Results From a Multisite Randomized Trial.”

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Join APA leaders for two town halls featuring presentations on the importance of the social determinants of mental health (SDoMH) in psychiatry, the efforts of the APA Presidential Task Force on SDoMH, and the opportunity to engage with task force members. The first town hall, scheduled for Wednesday, November 3, will explore SDoMH in the context of clinical practice, research, and education.

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Black Nursing Home Residents With Dementia More Likely to Be Diagnosed With Schizophrenia

The frequency of schizophrenia diagnoses in U.S. nursing home residents with Alzheimer’s disease and related dementias rose between 2011 and 2017, a report in the American Journal of Geriatric Psychiatry has found. During the study period, Black nursing home residents experienced a greater increase in the likelihood of being diagnosed with schizophrenia than White nursing home residents, even if they received care in the same nursing home.

“Future research is need[ed] to examine the root cause for this increase and to re-examine policies that may incentivize inaccurate diagnosis and exacerbate racial disparities in [nursing home] care,” wrote Shubing Cai, Ph.D., of the University of Rochester School of Medicine and Dentistry and colleagues.

Although antipsychotics can reduce behavioral problems in older adults with dementia, multiple studies have shown that the use of such medications can increase the risk of falls, cognitive worsening, and death. To reduce antipsychotic prescribing to older adults with dementia, the Centers for Medicare and Medicaid Services (CMS) in 2012 began requiring nursing homes to report antipsychotic prescribing to residents. However, as Cai and colleagues noted, nursing homes “are not penalized for using antipsychotics” if a resident is coded as having a schizophrenia diagnosis.

To examine whether diagnoses of schizophrenia among nursing home residents with Alzheimer’s and related dementias varied as a function of race, Cai and colleagues analyzed information collected in two databases: the Minimum Data Set (captures information about diagnoses of psychiatric disorders and other conditions) and the Master Beneficiary Summary File (captures demographic information for residents in Medicare- and/or Medicaid-certified nursing homes). The authors specifically focused on Black and White nursing home residents with Alzheimer’s and related dementias who were 55 years or older and who were long-stay residents (a stay of at least 90 days) between 2011 and 2017. (CMS started to publicly report antipsychotic use on July 1, 2012.)

The sample included over 7.7 million person-years (nearly 3 million individuals) over the 2011-2017 period. Among the long-stay nursing home residents with Alzheimer’s and related dementias, about 14% were Black and 86% were White. The overall frequency of schizophrenia diagnosis codes in this cohort was 10.62% for Blacks and 5.75% for Whites, the authors reported. From 2011 to 2017, the proportion of residents with schizophrenia diagnosis codes increased from 4.98% to 7.21% among Whites, and from 9.16% to 12.78% among Blacks

“[Nursing homes] with a higher proportion of Blacks appeared to have a higher proportion of residents with schizophrenia diagnosis and greater increase over time: from 2.59% to 3.34% in [nursing homes] with the lowest percent of Blacks and from 9.59% to 13.19% in [nursing homes] with the highest percent of Blacks,” the authors wrote. “Additionally, among residents of the same [nursing home], increase in schizophrenia diagnosis was greater over time for Blacks than for their White counterparts.”

The authors concluded, “The increase in the diagnosis of schizophrenia … may result in residents being exposed to treatment with significant risks of adverse effects and poor health outcomes that further exacerbate the long-standing racial disparities in care quality among [nursing home] residents with [Alzheimer’s and related dementias].”

For related information, see the Psychiatric News article “Special Report: Racism and Inequities in Health Care for Black Americans.”

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People With Parents With Alcohol Use Disorder Have Higher Rate of Somatic Diseases

People with at least one parent with alcohol use disorder (AUD) have a higher rate of alcohol-related and other diseases compared with people whose parents did not have AUD, a study in Addiction suggests.

Charlotte Holst, Ph.D., of the National Institute of Public Health and University of Southern Denmark in Copenhagen and colleagues analyzed data from 14,008 people born in Denmark between 1962 and 2003 who had at least one parent with AUD and matched them with 139,087 people born to parents without AUD. They followed the individuals in the sample from their 15th birthday onward, through 2018. The researchers obtained information on somatic diseases and emergency department contacts from the Danish National Patient Registry. They examined data about the individuals’ history of alcohol-related, blood, cancer, circulatory, digestive, endocrine and metabolic, genitourinary, infectious, musculoskeletal, nervous, respiratory, and skin diseases. They also obtained data on overall mortality and alcohol-related mortality from the Danish Cause of Death Registry.

Compared with people born to parents without AUD, people born to parents with AUD had nearly three times the rate of alcohol-related diseases. This group also had 30% greater rate of infectious diseases, 28% greater rate of blood diseases, 26% greater rate of respiratory diseases, and 21% greater rate of digestive diseases. People born to parents with AUD had nearly twice the rate of dying of any cause and more than three times the rate of alcohol-related deaths compared with children born to parents without AUD.

One explanation for the higher rates of disease and death among people born to parents with AUD may be “that children who grow up with parental AUD are more likely than their peers to experience adverse childhood experiences (ACEs), such as physical and sexual abuse or parental separation or divorce,” the authors wrote. “Also, families affected by AUD may be characterised by lack of parenting, less parental resources, and parental mental health problems.”

The researchers wrote that these circumstances may affect a person’s way of coping with life in general such that people who have experienced ACEs turn to high-risk behaviors to deal with stress and adverse life events later in life.

For more information, see the American Journal of Psychiatry article “A Contagion Model for Within-Family Transmission of Drug Abuse.”

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Register Now: First Town Hall on Social Determinants of Mental Health to Be Held Wednesday, November 3

Join APA leaders for two town halls featuring presentations on the importance of the social determinants of mental health (SDoMH) in psychiatry, the efforts of the APA Presidential Task Force on SDoMH, and the opportunity to engage with task force members. The first town hall, scheduled for Wednesday, November 3, will explore SDoMH in the context of clinical practice, research, and education.

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