Tuesday, October 26, 2021

Hospitalizations of Youth With Eating Disorders Rose During Pandemic, Report Shows

More than 18 months since COVID-19 first led to lockdowns across the United States, data are beginning to emerge that reveal the harmful effects of the pandemic on some people with eating disorders. A report appearing in the October issue of Pediatrics describes how the number of children and adolescents admitted for eating disorders at a children’s hospital in Michigan rose steadily during the first 12 months of the pandemic.

“An increase in severely ill adolescents with [eating disorders] during COVID-19 is likely to present challenges for patients, their families, and their providers because demand for treatment (access to which is already limited by pandemic precautions, as well as a lack of providers predating the pandemic) is likely to increase, perhaps dramatically,” wrote Alana K. Otto, M.D., M.P.H., of the University of Michigan and colleagues.

Otto and colleagues performed a chart review of youth aged 10 to 23 years admitted to C.S. Mott Children’s Hospital in Ann Arbor, Mich., between March 1, 2017, and March 31, 2021, for medical complications of restrictive eating disorders, including anorexia nervosa, atypical anorexia nervosa, and avoidant or restrictive food intake disorder.

The researchers compared data on youth admitted to the hospital from March 2017 through March 2020 (before the COVID-19 pandemic) with data on youth admitted to the hospital from April 2020 through March 2021 (during the COVID-19 pandemic).

There were 297 admissions of youth for medical complications related to eating disorders among 248 patients during the study period. The researchers found that while the number of admissions decreased in April 2020, the number of admissions per month increased significantly over time. The total number of admissions during the first 12 months of the COVID-19 pandemic (April 1, 2020, through March 31, 2021) was more than double the mean number of admissions per year for the same time frame (April 1 through March 31) for the previous three years, the authors noted. The highest counts were observed near the end of the study period, nine to 12 months after the pandemic began.

“[A]lthough anecdotal, our recent clinical experience suggests adolescents with new [eating disorders] frequently report their [eating disorder] behaviors began when pandemic precautions were implemented because, for example, they found themselves with nothing else to do or with more time to engage in diet and/or exercise behaviors they had previously considered but not acted on,” they wrote. Also, because of the interruption of social relationships, the youth may have turned to social media, which has been suggested to contribute to the development of eating disorders, according to the authors.

“Although our findings reflect the experience of a single institution, they are in keeping with emerging reports suggesting a developing epidemic within the pandemic, one with the potential to have profound negative effects on the mental and physical health of adolescents around the globe,” they continued. “It is unclear how long these effects may last.”

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

(Image: iStock/fizkes)

Register Now: First Town Hall on Social Determinants of Mental Health to Be Held 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.


Monday, October 25, 2021

Stimulants May Pose Short-Term Cardiovascular Risks in Older Adults

Older adults prescribed stimulant medications appear to be at an elevated risk of cardiovascular problems in the first 30 days after beginning the treatment, according to a study published today in JAMA Network Open. However, these risks decrease over time, with no evidence of increased cardiovascular risk at six months and one year after initiating treatment.

“Although stimulants are most commonly used among children and youth for the treatment of attention-deficit/hyperactivity disorder (ADHD), an increase in stimulant use among older adults in recent years has been observed,” wrote Mina Tadrous, PharmD., Ph.D., of the University of Toronto and colleagues. Doctors may prescribe stimulants off label to older adults for the treatment of depression, poststroke recovery, motor function, and fatigue, they noted. There is evidence that stimulants can increase resting heart rate and systolic blood pressure, but few studies have examined the cardiovascular impact of stimulants in older adults.

Tadrous and colleagues used hospital and prescription databases to assess the cardiovascular outcomes of 6,457 Ontario residents aged 66 years and older who received a new prescription for a stimulant (for example, amphetamine, methylphenidate, lisdexamfetamine, or dextroamphetamine) between January 1, 2002, and March 31, 2015. These adults were matched with a control group of 24,853 similarly aged adults who did not take any stimulants during this time. Adults in both groups were followed for up to 365 days or until they experienced a cardiovascular event (myocardial infarction, stroke, transient ischemic attack, or ventricular arrhythmia), died, or stopped taking stimulants.

Compared with the control group, older adults who took stimulants had a 40% increased risk of any cardiovascular event 30 days after starting their prescription. Among individual outcomes, stimulant use was not associated with any heart attack risk but was associated with a 60% increased risk of stroke/transient ischemic attack and a 300% increased risk of ventricular arrhythmia. Adults who took stimulants did not experience any increased cardiovascular risk compared with controls at 180 or 365 days after starting medication, except for continued arrhythmia risk at 180 days.

“These findings suggest that safety considerations should be included when stimulants are prescribed to older adults,” the authors concluded.

To read more on this topic, see the Psychiatric News article “To Improve Safety in Older Patients, Consider Deprescribing.”

(Image: iStock/fizkes)

Register Now: First Town Hall on Social Determinants of Mental Health to Be Held 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.


Friday, October 22, 2021

TMS May Help Reduce Symptoms of Depression, PTSD in Veterans

Transcranial magnetic stimulation (TMS), a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain, may help relieve symptoms of depression and posttraumatic stress disorder (PTSD) in veterans, a study in the Journal of Affective Disorders has found.

Michelle R. Madore, Ph.D., of Stanford University School of Medicine and colleagues analyzed data from 770 patients who had major depressive disorder and received at least one TMS session at any of 27 Veterans Administration sites from October 2017 to March 2020. Of these patients, 68.4% also met the criteria for a diagnosis of PTSD. The researchers defined an adequate dose of TMS as 30 sessions over the course of six to eight weeks. Among all patients, 340 received an adequate dose of TMS.

The researchers used the nine-item Patient Health Questionnaire (PHQ-9) and the PTSD symptom checklist from DSM-5 (PCL-5) to assess the patients’ mental health before and after the study period.

Among the 340 patients who received all 30 TMS sessions, scores on the PHQ-9 dropped from a mean of 18.34 before treatment to a mean of 11.29 after treatment, suggesting an improvement in their major depressive disorder. In this group, 245 had also met the criteria for PTSD at baseline with a mean PCL-5 score of 52.67, indicating moderate PTSD severity. After TMS, the mean PCL-5 score in this subset was 33.74. Furthermore, 113 (46.1%) of these patients no longer met PTSD criteria.

“These data demonstrate the importance of delivering an entire TMS treatment series,” Madore and colleagues wrote. “Future studies will need to evaluate the relationship between the number of sessions required for optimal outcomes; however, since remission is the goal of antidepressant treatment, patients can be empirically recommended to receive six weeks of TMS.”

For related information, see the American Journal of Psychiatry article “Whither TMS: A One-Trick Pony or the Beginning of a Neuroscientific Revolution?

(Image: iStock/Im Yeongsik)

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Thursday, October 21, 2021

Inflammation May Be Linked to Specific Depression Symptoms, Study Suggests

Systemic inflammation appears to be associated with some but not all symptoms of depression, according to a report in AJP in Advance.

The pooled cohort study by Philipp Frank, M.Sc., of University College London and colleagues found that in individuals with depression, inflammation was associated with such physical symptoms as changes in appetite, loss of energy and motivation, and sleep problems. “In contrast, we found strong evidence against an association with a number of exclusively emotional symptoms, including fearfulness, feeling bothered by things, hopelessness about the future, and feeling life had been a failure,” the researchers wrote.

The findings point to the importance of “a more targeted, symptom-focused approach to exploring the link between systemic inflammation and depression, particularly in anti-inflammatory drug trials,” they added.

The report was based on data from 15 independent population-based cohort studies from multiple countries that examined the relationship between inflammation and depressive symptoms in adults. The analysis included more than 56,000 people 18 years and older who had blood samples collected at the start of their respective studies and answered questions about 24 individual depressive symptoms across five domains: physical, emotional, cognitive, perception of self, and self-harm. The concentration of C-reactive protein (CRP) in the blood samples was assessed in all 15 studies, and three studies also measured interleukin-6 (IL-6).

The pooled analysis revealed that the prevalence of depressive symptoms in the sample ranged from 1.1% (suicidal ideation) to 21.5% (sleep problems). Higher concentrations of CRP were associated with an increased risk of experiencing four physical symptoms (changes in appetite, felt everything was an effort, loss of energy, and sleep problems) and one cognitive symptom (little interest in doing things), Frank and colleagues reported. The association between CRP and these physical and cognitive symptoms remained after controlling for a variety of factors that also contribute to inflammation, including age, chronic illness, and adverse child events. Higher levels of IL-6 were also associated with an increased risk of experiencing these physical and cognitive symptoms.

“Our results lend support to the sickness behavior theory, which posits that peripherally localized inflammatory activity can initiate a cascade of initially adaptive depressive-like symptoms in a subset of people,” Franks and colleagues wrote. “These include a lack of energy (lethargy), changes in appetite, sleepiness, reduced social exploration, and, at times, confusion.”

For related information, see the American Journal of Psychiatry editorial “Using the Power of a Giant Wisely: Confirming Inflammation in Depression.”

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Wednesday, October 20, 2021

Children’s Medical Groups Declare National Emergency on Child and Adolescent Mental Health

Three children’s advocacy organizations, including the American Academy of Child and Adolescent Psychiatry (AACAP), on Tuesday declared a national state of emergency in child and adolescent mental health requiring urgent government action.

AACAP, along with the American Academy of Pediatrics and the Children’s Hospital Association, said that social isolation and other effects of the COVID-19 pandemic—including uncertainty, fear, and grief—have exacerbated longstanding problems affecting youth’s mental health. A report in Pediatrics this month showed that more than 140,000 U.S. children have experienced the death of a primary or secondary caregiver during the COVID-19 pandemic, with children of color disproportionately impacted.

“We were concerned about children’s emotional and behavioral health even before the pandemic. The ongoing public health emergency has made a bad situation worse,” said AACAP President Gabrielle A. Carlson, M.D., in a news release. “We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and suicidality that will have lasting impacts on them, their families, their communities, and all of our futures. We cannot sit idly by. This is a national emergency, and the time for swift and deliberate action is now.”

According to a report by the Centers for Disease Control and Prevention (CDC), emergency department visits for mental health emergencies rose by 24% for children aged 5 to 11 years and 31% for youth aged 12 to 17 years between March and October 2020. More recently, the CDC reported that emergency department visits for suspected suicide attempts increased nearly 51% among girls aged 12 to 17 years in early 2021 compared with the same period in 2019.

Among other actions, the organizations are urging policymakers to take the following steps to support youth and their families:

  • Make funding available so all families can access mental health services.
  • Increase access to telehealth.
  • Support effective models of school-based mental health care.
  • Accelerate integration of mental health care in primary care pediatrics.
  • Address ongoing challenges of the acute care needs of children and adolescents.
  • Promote and pay for trauma-informed care services.

The organizations stated in the declaration: “We must identify strategies to meet these challenges through innovation and action using state, local, and national approaches to improve the access to and quality of care across the continuum of mental health promotion, prevention, and treatment.”

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

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Tuesday, October 19, 2021

Survey Highlights Strengths and Challenges of Telehealth for Addiction

Telehealth may help to engage more patients in addiction treatment by improving access and convenience, but there is limited evidence that patients with substance use disorder benefit more from services delivered via telehealth than in-person care, concluded a report in Psychiatric Services in Advance.

“The COVID-19 public health crisis forced the addiction treatment system to pivot from delivering most addiction treatment in person to delivering treatment via telehealth,” wrote Tami L. Mark, Ph.D., M.B.A. of RTI International in Rockville, Md., and colleagues. They noted that federal and state agencies temporarily eased many telehealth restrictions to enable this transition. “Of special relevance to addiction treatment are requirements for in-person visits to prescribe buprenorphine and for in-person intake and physical exam to initiate methadone treatment. Policymakers and payers are now considering which of these flexibilities should be maintained.”

Mark and colleagues first conducted a literature review comparing the effectiveness of in-person addiction treatment with telehealth (telephone or videoconferencing for assessment, diagnosis, and/or treatment). Of the eight studies identified, seven found no significant differences between these two modalities for outcomes such as treatment retention, treatment satisfaction, substance use rates, or the strength of the therapeutic alliance. However, one observational study reported that telehealth facilitated methadone prescribing and improved treatment retention among patients with opioid use disorder.

The researchers next conducted an online survey of leaders at addiction treatment organizations throughout California and received 100 responses. The results indicated that addiction professionals were evenly split with regard to the effectiveness of telehealth versus in-person individual counseling; 46% said that telehealth was equal to or more effective than in-person care, and 45% said that telehealth was less effective than in-person care. However, there was less support for telehealth in group counseling; 62% said it was less effective than in-person group therapy while only 25% said telehealth group therapy was equal to or more effective than in-person care. More than half of the respondents said that they believed telehealth was less effective than in-person care for providing intensive outpatient treatment or medication management.

“Telehealth may allow patients to more easily begin and stay in addiction treatment, which has been a longstanding challenge,” said Mark in a news release. “However, research is needed to confirm this benefit. As providers pivot to hybrid telehealth models—offering both telehealth and in-person treatment—they need information to help target telehealth to the most appropriate services and patients.”

To read more on this topic, see the Psychiatric News article “Telehealth Options for Treating Patients With SUD Expand.”

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Monday, October 18, 2021

Plenary Speakers at APA’s Fall Conference Focus on Social Determinants of Mental Health

APA’s two-day virtual Mental Health Services Conference was held Thursday and Friday, October 14 and 15. Summaries of the plenary addresses appear below. 

SAMHSA Partners With States to Target Social Determinants of Mental Health

In collaboration with states and communities, the federal government is committed to addressing social determinants of health (SDOH) and mental health, said Miriam E. Delphin-Rittmon, Ph.D., assistant secretary for mental health and substance use and administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA). She made her remarks last Thursday at the opening plenary session of APA’s virtual 2021 Mental Health Services Conference.

“We know that having access to high-quality mental health care isn’t enough if people lack access to education, housing, and transportation,” she said. 
Delphin-Rittmon outlined SAMHSA’s initiatives and priorities specifically targeting SDOH. Among these is the Resiliency in Communities After Stress and Trauma, which assists high-risk youth and families in communities impacted by civil unrest. This program offers violence prevention and community youth engagement programs, as well as linkages to trauma-informed behavioral health services. She also described the Food and Mood Project, which aims to promote emotional wellness and reduce the impact of mental health and substance use issues in the Midwest and mountain states through strategies—such as school gardens—that address the link between behavioral health and food or food insecurity, and/or cultural food diversity. 

Delphin-Rittmon was joined by Sonja Gaines, M.B.A., deputy executive commissioner for Intellectual and Developmental Disability and Behavioral Health Services at the Texas Health and Human Services Commission, and Keri L. Waterland, Ph.D., director of the Division of Behavioral Health and Recovery at Washington State Health Care Authority. Gaines and Waterland shared examples of several innovative projects in their states that are aimed at addressing social determinants of mental health. These efforts are funded by SAMHSA. 

Delphin-Rittmon said, “We are here to be partners with APA and look forward to our ongoing collaboration addressing social determinants of health.”

Economist Encourages Framing of Mental Health as a Form of Capital

Taking an economics framework and applying it to the delivery of mental health can help psychiatrists better connect with decision-makers to help drive key policies, an economics scholar said during last Friday’s plenary session.

“It’s important to conceptualize mental health as a form of capital because without it, people cannot do the work they need to do; they cannot be productive,” explained Peter Q. Blair, Ph.D., M.Sc., an assistant professor at the Harvard Graduate School of Education and principal investigator of the Blair Economics Lab. “We want to think specifically and concretely about how to help and best serve those who are marginalized and experiencing severe symptoms. But we also want to think preemptively about mental health as a form of capital—that we need to invest in proactively or it will depreciate over time.” 

Blair said that mental health is not merely the absence of psychiatric symptoms, it also includes the ability to realize one’s capacity for agency and contribute to the larger society with dignity, Blair said. He discussed the role of educational opportunity, occupational skill attainment, and meaningful employment as instrumental components to mental health. Blair pointed out that even among those with the most serious mental illness, most want to work.

Blair also talked about the importance of psychiatrists investing in their mental health in the same way they invest in their physical health (through regular checkups and exercise) and education (through continuing coursework). 

Session moderator and psychiatrist Sarah Y. Vinson, M.D., founder of the Lorio Psych Group, said that shifting one of the profession’s focuses to prevention would require reimagining. “In medicine as a whole, and in psychiatry too, there’s more of a focus on pathology, on diagnoses, on illness.  People don’t [seek mental health services] until there’s a problem. ... Part of our challenge is we’re dealing with a system where we don’t have the resources to do the task we have.”

Blair pointed out that that mental illness can disproportionately affect marginalized populations. He delved into the social determinants of health and how racism has held back minority populations. He is working to channel the public outrage over the murder of George Floyd by police officers last May into action. For example, he is urging Fortune 500 companies to recognize the systemic racism inherent in today’s national employment market. One major barrier to economic mobility for Black people is the requirement for a college degree as a condition of employment, and so Blair is promoting the hiring of rising STARS, or individuals who have acquired Skills Through Alternative Routes.

Further coverage of the conference will appear in a future issue of Psychiatric News.

Friday, October 15, 2021

Brain Activity Patterns After Trauma May Predict Long-Term Mental Health, Likelihood of Stress Disorders

How people’s brains respond to stress following a traumatic event may help to predict their long-term mental health outcomes, suggests a study published Thursday in AJP in Advance.

Jennifer Stevens, Ph.D., of Emory University and colleagues analyzed data from 69 participants in the AURORA study, a large-scale, multisite study funded by the National Institute of Mental Health that follows patients for a full year after exposure to trauma. The 69 patients in the current study received treatment in an emergency department following a car accident.

Two weeks after their accidents, the participants had their brain activity measured via functional MRI while they completed a series of standard computer-based tasks. The tasks assessed their brain activity in response to social threat cues, reward cues, and situations that required them to inhibit a response. Over the next six months, the participants also completed digital surveys in which they reported their mental health symptoms, including symptoms of posttraumatic stress disorder (PTSD), depression, dissociation, anxiety, and impulsivity.

Analyses of the participants’ brain activity data revealed the following four distinct profiles:

  • Reactive/disinhibited: High reactivity related to both threat and reward, little activity related to response inhibition
  • Low reward/high threat: High reactivity related to threat, low reactivity related to reward
  • High reward: No reactivity related to threat, little activity related to response inhibition, and high reactivity related to reward
  • Inhibited: Deactivation related to threat, some activity related to inhibition, and low reactivity related to reward

The researchers then performed the same analyses with another group of 77 AURORA participants who had received treatment following exposure to a range of traumatic events, including interpersonal trauma. In this group, they found evidence for three of the four profiles: reactive/disinhibited, low reward/high threat, and inhibited.

Looking at participants’ brain activity profiles in relation to their mental health outcomes, the researchers found that participants with the reactive/disinhibited profile—those who showed high reactivity to both threat and reward—reported higher levels of symptoms of both PTSD and anxiety over time compared with participants with the other profiles. However, the researchers found no association between any of the brain activity profiles and other mental health outcomes, such as symptoms of depression, dissociation, or impulsivity.

“Heightened reward reactivity in the early aftermath of a major stressor may be an underexplored risk mechanism for the development of stress-related disorders,” the researchers wrote. “The biotypes identified here … may provide important information about targeted interventions to address different forms of future stress-related psychopathology.”

For related information, see the American Journal of Psychiatry article “Individual Patterns of Abnormality in Resting-State Functional Connectivity Reveal Two Data-Driven PTSD Subgroups.”

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Thursday, October 14, 2021

Candidates for APA's 2022 Election Announced

The APA Nominating Committee, chaired by Immediate Past President Jeffrey Geller, M.D., M.P.H., has reported the following slate of candidates (in alphabetical order) for APA’s 2022 election. This slate has been approved by the Board of Trustees and is considered official.

The deadline for candidates who wish to run by petition is November 10. APA voting members may cast their ballots from January 3, 2022, to January 31, 2022.

APA’s election guidelines have been changed as part of a pilot test for the 2022 and 2023 elections. All campaigning is prohibited except through APA-managed activities and other activities as the APA Elections Committee may permit. The changes are meant to level the playing field for all candidates and ensure that APA’s leadership reflects the diversity of the APA membership and thus includes candidates who are from minority and underrepresented groups. APA activities include a special APA election newsletter that includes candidates’ platforms, which will be emailed to all voting members about December 1, and a series of town halls with the candidates for which members may submit questions for candidates and RSVP to attend.

For more election details, please visit the Election section of the APA website.

Petros Levounis, M.D., M.A.
James B. Potash, M.D., M.P.H.

C. Freeman, M.D., M.B.A.
Richard F. Summers, M.D.

Samuel O. Okpaku, M.D., Ph.D.
Michele Reid, M.D.

Area 3 Trustee
Kenneth M. Certa, M.D.
Geetha Jayaram, M.B.B.S., M.B.A., 
Mark S. Komrad, M.D.

Area 6 Trustee
Mary Ann Schaepper, M.D., M.Ed.
Shannon Suo, M.D.
Barbara Yates Weissman, M.D.

Resident-Fellow Member Trustee-Elect
Faiz Kidwai, D.O., M.P.H.
Mary-Anne Hennen, M.D.
Seth L. Daly Stennis, M.D.

Wednesday, October 13, 2021

APA Joins Amicus Brief Against Texas Abortion Law

A Texas law to prohibit abortions after six weeks’ gestation threatens the health of pregnant women, runs counter to settled constitutional law, and offends core principles of medical ethics. So said APA and 18 other medical organizations in an amicus brief submitted to the United States Court of Appeals for the Fifth Circuit.

The brief, written by the American College of Obstetricians and Gynecologists, urges the court to uphold a lower court’s temporary restraining order against the law. The Texas law (SB 8) prohibits abortions after a fetal heartbeat is detected, usually around six weeks’ gestation—before many women know they are pregnant. Moreover, the law allows private individuals to take steps to enforce the ban against anyone who provides abortion care or helps a patient access abortion care after fetal cardiac tones can be detected.

“The Act threatens the health and well-being of pregnant patients by barring their access to a safe and essential component of reproductive health care,” according to the amicus brief. “In so doing, it disproportionately harms the most marginalized people in Texas—communities of color, people with low incomes, and those living in rural areas. SB 8 undermines longstanding principles of medical ethics. It forces clinicians into an untenable position of facing potentially unlimited personal and professional liability if they provide care consistent with their best medical judgment, scientific evidence, and moral and ethical duty.”

The brief adds: “SB 8 impermissibly intrudes into the patient-clinician relationship by deputizing community members and citizens to file suit and seek a civil reward of ‘not less than $10,000’ based on allegations that a physician or other health care professional facilitated a banned abortion. The Act creates an open-ended class of potential plaintiffs who might file harassing lawsuits, heavily favoring those plaintiffs in court, and extending liability to anyone in a woman’s support network who plays a role in facilitating a prohibited abortion.”

For related information, see the Psychiatric News article “Abortion-Specific State Conscience Laws Reflect Need to Balance M.D., Patient Rights.”

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Tuesday, October 12, 2021

Symptoms of Avoidant/Restrictive Food Intake Disorder Vary by Sex, Age

Children and adolescents with avoidant/restrictive food intake disorder (ARFID) are likely to present with a variety of symptoms depending on their age and sex, according to a report published Monday in JAMA Pediatrics. For example, older youth with ARFID were more likely to report not eating enough and a loss of appetite, whereas younger children were more likely to report a lack of interest in food, avoidance of certain foods, and refusal based on sensory characteristics. Similarly, the study revealed that boys were more likely to refuse food based on sensory characteristics while girls were more likely to eat but not enough.

Avoidant/restrictive food intake disorder is characterized by a lack of interest in or avoidance of food that leads to significant weight loss, nutritional deficiency, dependence on nutritional supplements, and/or marked interference with psychosocial functioning.

“A better understanding of children and adolescents with ARFID could aid in its earlier recognition, development of effective treatment strategies, and reduction of lifelong medical and psychological complications,” wrote Debra K. Katzman, M.D., of the University of Toronto and colleagues.

Katzman and colleagues surveyed Canadian pediatricians in community settings monthly for 24 months to identify youth aged 5 to 18 years who met the DSM-5 diagnostic criteria for avoidant/restrictive food intake disorder. They then mailed questionnaires to these youth/their families to establish the presence of avoidant/restrictive food intake disorder criteria; associated eating behaviors; medical, psychiatric, family, and social history; and more. In total, 207 children and adolescents were included in this analysis.

The incidence of ARFID in the sample was 2.02 per 100,000 patients; the incidence was the highest among girls and boys aged 10 to 14 years (3.43 per 100,000 patients). In general, the researchers found that older patients were more likely to have weight and growth issues (such as significant weight loss and faltering growth) compared with younger patients. Although girls were more likely than boys to meet the criteria for weight and growth issues, older boys had greater mean weight loss than girls, the researchers reported.

Nearly 49% of the children and adolescents with ARFID had comorbid anxiety, and just over 10% had comorbid depression. The rate of depression and anxiety was higher in the older patients compared with the younger patients, the researchers noted.

“These findings affirm the heterogeneity of the clinical presentations noted in this pediatric population. This study also illustrates substantial medical and psychological complications associated with ARFID, underscoring the need for pediatric health care professionals to be familiar with the identification and clinical management of this disorder,” Katzman and colleagues concluded.

“In this issue, Katzman et al offer one of the largest, most comprehensive, and nuanced community-based prospective studies on ARFID demographic characteristics,” wrote Laura K. Grubb, M.D., M.P.H., of Tufts Children’s Hospital in Boston in an accompanying editorial. “The study … provides crucial information to allow better early disease recognition and intervention, which may improve outcomes for patients with ARFID.”

For related information, see the Psychiatric News article “Eating Disorders: Current Knowledge and Treatment Update,” by B. Timothy Walsh, M.D.

(Image: iStock/KatarzynaBialasiewicz)

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Friday, October 8, 2021

APA Foundation Launches ‘Mentally Healthy Nation’ Podcast to Educate Public

On Sunday, October 10, World Mental Health Day, the American Psychiatric Association Foundation (APAF) will launch a monthly podcast to engage the public in conversations about the current mental health crisis. Each episode of “Mentally Healthy Nation” will focus on an aspect of mental health that affects people in their communities, where they live, learn, work, and worship.

“One of the most important things we can do to help ease the stigma of mental illness and to reach a more mentally healthy nation is to turn up the volume on the issue,” said APAF Executive Director Rawle Andrews Jr., Esq. “This is a time in our country when everyone is feeling the impacts of stress, and many are dealing with depression, anxiety, substance use disorders, or other mental health issues. We want to keep the conversation going and meet people where they are, and these podcasts are the logical next step in our education and outreach efforts.”

“APAF stands at the center of many important conversations on mental health, because it’s informed by APA’s psychiatrist members,” said APAF Board Chair and APA CEO and Medical Director Saul Levin, M.D., M.P.A. “The ‘Mentally Healthy Nation’ podcast is going to give many of our best and brightest the chance to talk about psychiatric issues in a way that will engage and educate the public.”

The first episode will be “Trauma’s Impact and What Communities Can Do.” It will feature a candid conversation between Anish Dube, M.D., M.P.H., a child and adolescent psychiatrist in the juvenile justice system in Orange County, Calif., and Theresa Dellick, a judge presiding over the Mahoning County Juvenile Court in Ohio. They will discuss ways to keep young people who have experienced trauma from being caught up in the criminal justice system.

On Monday, October 11, National Coming Out Day, the podcast will feature a discussion of “CURED,” an award-winning documentary that tells the story of how homosexuality was removed from the DSM after activists and psychiatrists challenged the classification of homosexuality as a mental disorder. The discussion will include Levin; Deena Gorland, APAF archivist and librarian; Jacki Lyden, writer, journalist, and recipient of APA’s 2021 Patient Advocacy Award; Patrick Sammon, the film’s co-director; and Jack Turban, M.D., M.H.S., medical journalist and psychiatry fellow at Stanford University School of Medicine. (The national PBS broadcast of “CURED” is scheduled for 10 p.m. ET/9 p.m. CT [check local listings] on Monday. More information about the documentary and a preview are posted on the PBS website.)

All episodes of “Mentally Healthy Nation” will be available on the APAF website and on the top podcast platforms. To learn more about the APAF, visit apafdn.org.

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Thursday, October 7, 2021

Eating Problems Common in Youth, Young Adults With Intracranial Hypertension

Young people with idiopathic intracranial hypertension (a condition that occurs when pressure inside the skull increases for no obvious reason) were more than four times more likely to report disordered eating behaviors and more than five times as likely to report depression, anxiety, and stress than those without the condition, according to a study in Pediatric Neurology.

“[Medical] caregivers should have increased awareness and implement active screening of [disordered eating behaviors] both at the time of the initial management and as part of the ongoing follow-up. This is of paramount importance to potentially prevent the consequential evolution into full-blown [eating disorders],” wrote Itay Tokatly Latzer, M.D., of the Pediatric Neurology Institute at Dana-Dwek Children’s Hospital at Tel Aviv Sourasky Medical Center and colleagues.

Disordered eating behaviors encompass a broad spectrum of eating pathologies—including strict or disinhibited eating, emotional eating, and weight or shape concerns—that do not meet the criteria for an eating disorder diagnosis, the researchers wrote. About 40% of individuals with disordered eating behaviors go on to develop an eating disorder.

The study included 53 patients aged 8 to 25 years who had been diagnosed with intracranial hypertension and received treatment at a medical center in Tel Aviv, Israel. They were compared with 106 age- and sex-matched healthy volunteers (control group). Latzer and colleagues reviewed the participants’ medical charts as well as their responses to two online self-rating questionnaires: the Eating Attitude Test-26 (EAT), which was adapted for participants younger than 18, and the Depression, Anxiety, and Stress Scale-21. Individuals with intracranial hypertension were treated with medication and surgery; those who were obese or overweight were also referred to a nutrition and lifestyle clinic and received a comprehensive nutritional assessment and diet plan. Participants with intracranial hypertension were assessed at different points in their treatment, with some in active treatment and others several years after recovery.

Participants with intracranial hypertension had a significantly higher body mass index (BMI), with significantly higher incidence of overweight/obesity than the control group (70% vs. 15%). Scores indicating disordered eating behaviors were found significantly more often in participants with intracranial hypertension than in the controls (26% vs. 6%), as was a near-threshold score for an eating disorder (19% vs. 1%), the researchers noted. Scores indicating a severe or extremely severe state of depression, anxiety, and stress were significantly more common among those with intracranial hypertension than those without this condition (15% vs. 3%).

In individuals with intracranial hypertension, disordered eating behaviors were associated with weight gain before disease presentation, a relatively long duration of treatment, and loss of significant weight during the course of treatment. Additionally, depression and anxiety were found to coexist in individuals with intracranial hypertension and disordered eating behaviors. The authors noted that they were unsure whether disordered eating behaviors were the cause of intracranial hypertension or a bidirectional association between the behaviors and disorder exists.

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

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Wednesday, October 6, 2021

Patients With SUDs Have Higher Risk of Breakthrough COVID-19 Infection

People who are fully vaccinated against COVID-19 and have a substance use disorder (SUD) appear to be at higher risk for breakthrough infections than people without an SUD, according to a report in World Psychiatry.

The risk of breakthrough infection for people with SUDs ranged from 6.8% for tobacco use disorder to 7.8% for cannabis use disorder. The risk of breakthrough infections in vaccinated people without an SUD was 3.6%.

“[T]he overall risk of COVID-19 among vaccinated people with substance use disorders is very low,” NIDA Director Nora D. Volkow, M.D., one of the study authors, said in a news release. “We must continue to encourage and facilitate COVID-19 vaccination among people with substance use disorders, while also acknowledging that even after vaccination, this group is at an increased risk and should continue to take protective measures against COVID-19.”

The researchers analyzed de-identified data from electronic health records for 30,183 fully vaccinated patients with history of SUD and 549,189 patients without SUD between December 2020 and August 2021—a period that included the Delta variant outbreak. Among the fully vaccinated population with an SUD, 7,802 patients had a diagnosis of alcohol use disorder, 2,058 of cannabis use disorder, 1,011 of cocaine use disorder, 2,379 of opioid use disorder, and 21,941 of tobacco use disorder.

The risk of breakthrough infection for all five SUDs was significantly higher than for vaccinated individuals without an SUD: alcohol use disorder (7.2%), cannabis use disorder (7.8%), cocaine use disorder (7.7%), opioid use disorder (7.1%), and tobacco use disorder (6.8%). Additionally, the rates of hospitalization and death for SUD patients with a breakthrough infection were 22.5% and 1.7%, respectively, compared with 17.5% and 1.1%, respectively, in patients without an SUD who had a breakthrough infection.

When the researchers matched individuals with and without an SUD for lifetime comorbidities and adverse socioeconomic determinants of health, they found there was no difference in the risk of breakthrough infections between these populations, except for patients with cannabis use disorder, who remained at increased risk.

“These data suggest that fully vaccinated SUD individuals are at higher risk for breakthrough COVID-19 infection, and this is largely due to their higher prevalence of comorbidities and adverse socioeconomic determinants of health compared with non-SUD individuals,” the study authors wrote. “The high frequency of comorbidities in SUD patients is also likely to contribute to their high rates of hospitalization and death following breakthrough infection.”

For related information, see the Psychiatric News article “SUD Patients More Susceptible to COVID-19, Adverse Outcomes.”

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Tuesday, October 5, 2021

More Adults Reporting Elevated Depressive Symptoms More Than Year Into Pandemic

The percentage of U.S. adults reporting symptoms of depression has not stopped rising since the pandemic began, according to survey data published Monday in The Lancet Regional Health – Americas. Those most likely to report elevated depressive symptoms tended to have less income and a greater number of COVID-related stressors, including the death of someone close to COVID-19, loss of employment, and/or challenges securing childcare.

“Typically, we would expect depression to peak following the traumatic event and then lower over time,” senior author Sandro Galea M.D., M.P.H., Dr.P.H., of Boston University School of Public Health said in a news release. “Instead, we found that 12 months into the pandemic, levels of depression remained high.”

Lead author Catherine Ettman, a doctoral candidate at Brown University, Galea, and colleagues analyzed data from two waves of the COVID-19 and Life Stressors Impact on Mental Health and Well-being study. The first survey included 1,441 respondents (aged 18 and older) and was conducted from March 31 to April 13, 2020, when much of the United States was under stay-at-home advisories. The second survey was conducted with the same group one year later, from March 23 to April 19, 2021, and included 1,161 respondents.

At both time points, the participants filled out the Patient Health Questionnaire-9 (PHQ-9) and answered questions about their stressful experiences. The authors defined elevated depressive symptoms as a PHQ-9 score of ≥10 and high stressor counts as the presence of 4 or more of 13 COVID-related stressors (including death of a loved one to COVID-19, job loss, financial problems, and more).

Although fewer respondents reported high stressor counts in 2021 compared with 2020 (37.1% vs 47.5%, respectively), the association between stress and depressive symptoms grew stronger, the authors reported. In 2020, people who experienced four or more stressors were about twice as likely to have elevated depressive symptoms as those who experienced one COVID-related stressor or less; in 2021 people who experienced four or more stressors were 5.4 times as likely to have elevated depressive symptoms. Similarly, adults with $19,999 or less in household income in 2020 were 2.3 times as likely to have elevated depressive symptoms as those with $75,000 income or more; by 2021, low-income adults were 7 times as likely to have elevated depressive symptoms.

Overall, the percentage of participants reporting elevated depressive symptoms rose from 27.8% in 2020 to 32.8% in 2021, the authors reported.

“The sustained and increasing prevalence of elevated depressive symptoms suggests that the burden of the pandemic on mental health has been ongoing—and that it has been unequal,” Ettman said in the news release. “Addressing stressors such as job loss, challenges accessing childcare, and difficulties paying rent will help to improve population mental health and reduce inequities that have deepened during the pandemic.”

For related information, see the Psychiatric News article “Why We Must Address Poverty,” by APA President Vivian B. Pender, M.D.

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Monday, October 4, 2021

Wide Racial and Geographic Disparities Found in Clozapine and LAI Prescriptions

Regional and racial variations in the prescribing of psychotropic medications to patients with schizophrenia may underlie some of the health inequities associated with these disorders, reports a study in Psychiatric Services in Advance.

“The most dramatic interstate differences were in prescription of clozapine and LAIs [long-acting injectable antipsychotics], which have distinctive roles in medication management,” wrote Natalie Bareis, L.M.S.W., Ph.D., of Columbia University and colleagues. “[C]lozapine has efficacy in managing treatment-resistant schizophrenia and reducing suicidal behaviors and has low rates of prescription by clinicians, and LAI medications address nonadherence, but they require clinician administration and pose risks for coercion.”

Specifically, non-Hispanic Blacks and people of other race-ethnic groups were more likely than non-Hispanic Whites to fill prescriptions for LAIs, whereas non-Hispanic Whites were more likely than all other groups to fill prescriptions for clozapine.

Bareis and colleagues used the national Medicaid Analytic eXtract databases to compile data on adults aged 18 to 64 who had been diagnosed with schizophrenia or schizoaffective disorder in 2011 and filled at least one 15-day prescription for an oral antipsychotic, antidepressant, benzodiazepine, or mood stabilizer or one prescription for an injectable LAI in 2012. Their sample included 357,914 adults from 47 states plus the District of Columbia (Hawaii, Idaho, and Maine had missing data and were not included).

The analysis showed wide ranges in psychotropic prescriptions across states. For example, the percentage of patients receiving LAIs ranged from 4% in Colorado to 22% in Rhode Island, while the percentage of patients receiving clozapine ranged from 1% in Nevada to 11% in South Dakota. Prescriptions for other psychotropics also varied geographically.

There were also significant variations at the patient level:

  • Non-Hispanic Blacks were 39% more likely to be given an LAI compared with non-Hispanic Whites and 60% less likely to be given clozapine.
  • Hispanics were 26% more likely to be given an LAI compared with non-Hispanic Whites and 37% less likely to be given clozapine.
  • Native Hawaiians/Pacific Islanders were 26% more likely to be given an LAI compared with non-Hispanic Whites and 20% less likely to be given clozapine.
  • Asians had similar rates of LAI prescriptions as non-Hispanic Whites, but 17% less likely to be given clozapine.
  • Non-Hispanic Whites were more likely to receive prescriptions for non-antipsychotic medications than all other ethnic groups.

“Psychiatric training that is culturally sensitive and seeks to minimize disparities by race or ethnicity and that requires competency in the prescription of clozapine and LAI antipsychotic medications may reduce variation,” Bareis and colleagues wrote. “A better understanding of the causes of wide variation in LAI and clozapine prescriptions is needed to improve access to these important treatment options.”

To read more on this topic, see the Psychiatric News article, “More Minority Patients May Be Able to Safely Use Clozapine.”

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Friday, October 1, 2021

Genetic Risk of Some Mental Illnesses Tied to Increased Hospitalizations in Bipolar Disorder

Patients with bipolar disorder who have a high genetic risk for the condition or for schizophrenia may have a higher risk of hospitalization compared with those who have a lower genetic risk for either of these conditions, a study in the Journal of Affective Disorders has found.

Janos L. Kalman, M.D., of the Ludwig Maximillian University of Munich and colleagues analyzed the polygenic risk scores of 954 patients who had bipolar disorder for at least five years to determine if the patients’ genetic risk of bipolar disorder, major depressive disorder, or schizophrenia was associated with severe bipolar disorder. (The polygenic risk score is the sum of the effects of genetic variations that may contribute to a trait or condition.) The researchers determined the severity of the patients’ bipolar disorder by the number of hospitalizations in a mental health facility. The researchers also looked at the patients’ scores on item 90 of the OPCRIT, which assesses the course of the disorder. They grouped the patients into two categories, according to the course of the disorder indicated in the OPCRIT: those with good recovery and those with chronic illness with residual symptoms.

The researchers found that higher polygenic risk scores for bipolar disorder and schizophrenia were associated with an increased number of hospitalizations. However, higher polygenic risk scores for major depressive disorder were not associated with hospitalizations.

Polygenic risk score did not appear to be associated with the severity of bipolar disorder as measured by item 90 of the OPCRIT. However, patients with chronic illness with residual symptoms had more hospitalizations than those with good recovery.

“[O]ur findings indicate … that common variants, as represented by [polygenic risk score], influence the disease course of psychiatric disorders in combination and interaction with additional genetic and environmental factors,” Kalman and colleagues wrote. “Therefore, prediction models that combine [polygenic risk score] with other genetic … and nongenetic risk factors may become helpful for stratifying patients and predicting disease courses.”

For related information, see the American Journal of Psychiatry article “Polygenic Risk and Progression to Bipolar or Psychotic Disorders Among Individuals Diagnosed With Unipolar Depression in Early Life.”

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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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Thursday, September 30, 2021

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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Wednesday, September 29, 2021

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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Tuesday, September 28, 2021

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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