Mindfulness-Based Intervention Found to Reduce Chronic Pain and Opioid Misuse

A mindfulness-based intervention known as Mindfulness-Oriented Recovery Enhancement (MORE) appears to be more effective than psychotherapy at reducing opioid misuse, pain, and emotional distress in adults with chronic pain, according to a study published today in JAMA Internal Medicine. The benefits of the eight-week MORE therapy over supportive psychotherapy remained nine months after the therapy sessions ended.

“The MORE intervention’s broad-spectrum effects were noteworthy given that many participants in the sample presented with multiple chronic pain conditions, were taking high opioid doses, and had co-occurring psychiatric disorders,” wrote Eric Garland, Ph.D., of the University of Utah and colleagues.

Garland and colleagues enrolled 250 adults with chronic pain who reported misusing opioids (defined as a score of 9 or more on the Current Opioid Misuse Measure). The participants were randomly assigned to receive eight weekly two-hour sessions of MORE or supportive psychotherapy; both interventions were delivered in a group format by the same set of clinical social workers. Participants in the MORE group received sequential training on mindfulness (for example, meditation and breathing skills), reappraisal (reframing maladaptive thoughts to decrease negative emotions), and savoring (focusing on pleasurable events and sensations to amplify positive emotions). Those assigned to the supportive psychotherapy group participated in discussions about coping with pain, the adverse effects of opioids, and the use of opioids to alleviate negative emotions.

The participants’ pain levels, opioid use, and emotional distress (depression, anxiety, and/or stress) were assessed at baseline; after the eight sessions; and at three-, six-, and nine-month follow-ups. Participants were prompted to assess their levels of opioid cravings three times a day throughout the eight-week intervention and for one month following the intervention. At nine months, 38.0% in the MORE group and 35.5% in the supportive psychotherapy group were unavailable for follow-up—discontinuation rates that are similar to those observed in clinical trials of psychosocial treatments for opioid use disorder, the authors noted.

At the nine-month follow up, 45.0% of the participants who received MORE group therapy were no longer misusing opioids compared with 24.4% of those who received supportive psychotherapy. In addition, 35.5% of participants in the MORE group decreased their opioid dose by at least 50% compared with 15.9% of those in the supportive psychotherapy group. Participants in the MORE group also reported less severe pain symptoms, less pain interference, fewer opioid cravings, and less emotional distress than those in the supportive psychotherapy group.

“Unlike many interventions with effects that are greatest immediately after treatment but gradually diminish, MORE’s effect was sustained, likely a function of the intervention’s unique mechanisms of action,” Garland and colleagues wrote. The researchers noted that additional clinical trials are needed to compare MORE with other evidence-based interventions, such as cognitive-behavioral therapy and mindfulness-based stress reduction.

To read more on this topic, see the Psychiatric News article “Meditation, CBT May Ease Opioid-Treated Pain.”

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APA Board Releases Statement on Lieberman Tweet

In light of this week’s news from Columbia University involving APA Past President (2013-2014), Jeffrey A. Lieberman, M.D., APA’s Board of Trustees on Thursday issued this statement to the APA membership and the public:

“In the aftermath of a racist and hurtful Twitter post by a past president of the APA from earlier this week, the APA Board of Trustees reiterates its position that both racism and sexism harm the APA as an organization, the field of psychiatry, and the people and communities we serve. Past APA presidents do not speak for, or on behalf of, the APA.

As we articulated within our apology a year ago, racism should not have a place in the APA or within psychiatry. To be a truly anti-racist organization, we must be accountable to our commitment and to each other and call out racism when we see it.

The APA embarked on implementing anti-racism measures approved by the Board of Trustees and will continue to hold firm to that promise. Systemic changes to racism and oppression are a journey and we must continue to have honest reflection and do the necessary work that will challenge us to create lasting change in the way that we see and value each other.

The APA remains steadfast and committed to its anti-racist agenda that promotes equity in mental health for all and will continue to educate our leaders, our members, and our patients in understanding and identifying racism and bias (conscious and unconscious) with the goal of achieving the social equality, health equity, and fairness that all human beings deserve.”   

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APA Praises Passage of Legislation to Address MH Problems, Burnout Among Health Care Professionals

APA joined five leading physician groups yesterday in commending the passage of the Dr. Lorna Breen Health Care Provider Protection Act (HR 1667). The legislation establishes grants to prevent and reduce suicide, burnout, and mental and behavioral health conditions among health care professionals. Having passed both the House and Senate, the bill now heads to President Joe Biden’s desk for signature.

The Dr. Lorna Breen Health Care Provider Protection Act is named in honor of Lorna Breen, M.D., an emergency room physician who was working on the front lines when COVID-19 first emerged in New York. Breen died by suicide in April 2020.

“Research shows that physicians in the U.S. face higher incidence of suicide than almost any other profession, and the COVID-19 pandemic has exacerbated personal hardships as physicians continue caring for patients, themselves, and their families,” wrote APA, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Osteopathic Association in a statement. “The passage of the Dr. Lorna Breen Health Care Provider Protection Act is timely and critical to ensuring our nation’s ability to respond to the mental health needs of physicians and other health care professionals.”

Sen. Tim Kaine (D-Va.) introduced the bill in July 2020. Co-sponsoring the legislation were Sens. Todd Young (R-Ind.), Jack Reed (D-R.I.), and Bill Cassidy, M.D. (R-La.) and Reps. Susan Wild (D-Pa.) and David McKinley (R-W.Va.).

According to a news release, the Dr. Lorna Breen Health Care Provider Protection Act will

• Establish grants for health profession schools, academic health centers, hospitals, and other institutions to help them train health workers in strategies to prevent suicide, burnout, and mental health conditions, including substance use disorders, among health care professionals.
• Seek to identify and disseminate evidence-informed best practices for reducing and preventing suicide and burnout among health care professionals and training health care professionals in appropriate strategies to promote their mental health.
• Establish a national evidence-based education and awareness campaign targeting health care professionals to encourage them to seek support and treatment for mental health and substance use disorders and stigma associated with seeking care for these conditions.
• Establish grants for health care professionals and professional associations for employee education, peer-support programming, and mental health treatment.
• Establish a comprehensive study on the impact of the COVID-19 pandemic on the mental health of health care professionals.

The legislation also directs the Department of Health and Human Services (HHS) to study and develop policy recommendations to remove barriers to accessing care and treatment and identify strategies to promote resilience, according a congressional summary of the bill.

“We’re … pleased that this bipartisan, bicameral legislation supports research on health care professionals’ mental and behavioral health, including how best to heal from the pandemic’s detrimental impact on the health care community,” APA and the five physician groups wrote. “Amid a public health emergency, this is more important than ever.”

For related information, see the Psychiatric News article “APA Applauds Passage of COVID-19 Relief Package.”

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Join DDHE for ‘Looking Beyond Series’ Tonight

The Division of Diversity and Health Equity (DDHE) invites you to join tonight's webinar titled “123 Years Since W. E. B. Du Bois’ Case Study … Social Determinants of Health Inequities Continue.” Du Bois’ famous case study, based in an 1890s Philadelphia neighborhood, is considered the first study of an urban population of African Americans. Du Bois tied the relatively poor health status of the residents, even those with higher income or social status, to discriminatory practices and health inequities that continue to this day. What can we do to create a country in which discrimination and health inequities no longer exist? The webinar will begin tonight at 7 p.m. ET.

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Combining Antidepressants Found Superior to Monotherapy in Treatment of Depression

Patients with depression treated with a combination of antidepressants appear to experience greater improvement than those treated with just one medication, according to a meta-analysis in JAMA Psychiatry.

Especially effective are the combination of “reuptake inhibitors” and α2-autoreceptor antagonists. Reuptake inhibitors include selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine or sertraline; serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine or duloxetine; or tricyclic antidepressants, such as desipramine or nortriptyline. The medications mianserin and mirtazapine are two examples of α2-autoreceptor antagonists.

Jonathan Henssler, M.D., of Cologne Medical School, Germany, and colleagues analyzed 39 randomized, controlled trials comparing combinations of antidepressant medication with treatment with just one medication. The studies, which included 6,751 patients, were published between 1977 and 2020. The primary outcome was the difference in treatment efficacy (symptom improvement) between combination therapy and monotherapy. Most studies measured depression symptoms using the Montgomery-Asberg Depression Rating Scale or the Hamilton Depression Scale. Secondary outcomes included remission from depression (symptoms below clinical threshold), response to treatment (50% or better symptom improvement) and tolerability (number of patients who dropped out of studies).

The researchers found that combination treatment was significantly superior to monotherapy in treatment efficacy, response to treatment, and depression remission. There was no difference between combination or monotherapy in terms of patient tolerability.

Henssler and colleagues also analyzed specific drug combinations and found that combining a reuptake inhibitor with an α2-autoreceptor antagonist was superior to other combinations of medications, both for patients new to medication and those who did not respond to another medication. In contrast, combinations involving bupropion were not superior to monotherapy as a first-line treatment but were slightly more effective when given to patients who did not respond to another medication.

“Physicians should be aware that combinations of reuptake inhibitors … with α2-autoreceptor antagonists are a potent treatment option, associated with superior outcomes relative to monotherapy,” the researchers concluded. “Clinicians can inform patients that on average this advantage does not come at the cost of lower tolerability… .”

For more information, see the Psychiatric News special report “Management of Major Depression: Yesterday, Today and Tomorrow.”

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Text Messaging Intervention May Reduce Suicidal Thoughts Among At-Risk Youth

Among youth at risk for suicide, a text messaging intervention may help reduce suicidal thoughts and behaviors after discharge from an emergency department, according to a report published in Psychiatric Services.

“Delivering caring contacts via text-messaging platforms is especially valuable in pediatric populations where most patients are comfortable with this mode of communication,” wrote Taylor Ryan, M.S., of Johns Hopkins University Bloomberg School of Public Health, Shawn Chambers, M.D., of Johns Hopkins University, and colleagues. “As the COVID-19 pandemic continues, the value and importance of using technology to deliver sustainable health care have become paramount.”

Ryan, Chambers, and colleagues recruited patients aged 12 to 17 who were seen in the Johns Hopkins Pediatric Emergency Department (PED) for suicidal thoughts or behaviors, or who screened positive for acute suicide risk on the Ask Suicide-Screening Questions tool to participate in a program evaluating the effectiveness of a text message intervention. The participants were required to have their own cell phones and were excluded if they were currently experiencing symptoms of psychosis or had a history of such symptoms.

The participants received one automated text message on days one, seven, 14, and 30 following their discharge from the emergency department. The four text messages were customized to address each patient by name, included a brief caring message (such as, “We are thinking about you and are wishing you the best.”), and encouraged patients to contact their community mental health provider or the Maryland crisis line if they were in crisis. Participants were told that the messages were automated and that they could not communicate directly with the sender, but they could reply “help” for a reminder to contact their provider if they were in distress.

After receiving all four messages, participants completed a phone survey, during which they reported their thoughts on the automated caring text messages and whether they believed the intervention helped reduce their suicidal thoughts and behaviors. Ryan, Chamber, and colleagues also examined electronic health record data to assess how many participants had a repeat pediatric emergency department visit within six months of enrolling in the study.

Thirty-seven youth consented to participate in the study, of whom 27 completed the follow-up survey. In total, 78% of survey respondents reported that the text messages had a positive impact on their mental health, 67% reported reduced suicidal ideation, and 74% reported that the messages helped prevent them from engaging in suicidal behavior. Nine of the 37 total participants had a repeat pediatric emergency department visit for psychiatric reasons during the follow-up period, with six participants returning within one month, one within three months, and two within six months.

“[A] text-messaging intervention may enable providers to maintain contact with patients and may even allow for providers to intervene if a patient experiences suicidal thoughts or behaviors,” the authors wrote. They noted that, during the study, a coordinator who was monitoring the system noticed that a participant messaged the platform saying, “I’m dying.” The coordinator and the project principal investigator reached the participant’s guardian at work, who “found that her child was in an acute suicidal crisis and was able to bring her child to our PED to initiate mental health care,” the authors wrote.

For related information, see the Psychiatric News article “Three-Day Intensive Crisis Intervention Found to Help Suicidal Youth.”

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Gender-Based Pay Gaps Persist in Academic Medicine, Study Finds

Women in academic medicine have lower starting salaries than men in the vast majority of medical specialties, including psychiatry, a study in JAMA Network Open has found. The study also found that starting at a lower salary has repercussions on earning potential that extend nearly 10 years down the road.

Eva Catenaccio, M.D., of the Children’s Hospital of Philadelphia and colleagues used publicly available mean debt and compensation data from 54,479 full-time physicians in academic medicine from 2019 to 2020. The researchers examined the physicians’ starting salary, salary in the 10th year of employment, annual salary growth rate, and overall earning potential in the first 10 years of employment. The study included 45 subspecialties, including psychiatry.

Compared with men, women in academic medicine had lower starting salaries in 42 of 45 subspecialties and lower salaries at year 10 in 43 of 45 subspecialties. Furthermore, women had slower mean annual salary growth rates in 22 of the 45 subspecialties and lower earning potential in 43 of 45 subspecialties. Psychiatry is one of the medical specialties in which these pay gaps exist.

Among all physicians in the study, just a one-year delay in promotion from assistant to associate professor reduced women’s earning potential by a median of $26,042 over 10 years, and failure to be promoted at all reduced earning potential by a median of $218,724. By analyzing the data, the researchers predicted that equalizing starting salaries between men and women could increase women’s earning potential by a median of $250,075 over 10 years in the subspecialties for which starting salaries of women were lower than those of men. Similarly, equalizing annual salary growth rates could increase women’s earning potential by a median of $53,661 over 10 years in the specialties for which mean annual salary growth rates were lower for women than for men.

Catenaccio and colleagues noted research that suggests that starting salaries may differ between men and women because women do not negotiate as frequently or as successfully as men and that women who do try to negotiate often are penalized disproportionately.

“Medical school curricula and postgraduate training should better address negotiation skills and financial literacy,” they wrote. “However, the onus for ensuring salary equity should not fall on the individual candidate alone; rather, departmental and hospital leadership should take responsibility to ensure uniform starting salaries and prevent gender-based inequalities.”

For related information, see the Psychiatric News article “Gender Bias, Discrimination Common in Academic Psychiatry.”

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Two Low-Intensity Outreach Programs Fail to Reduce Self-Harm Risk, Study Finds

Regular outreach to patients who have frequent suicidal thoughts through a patient portal and referral for additional services may not be enough to reduce their risk of self-harm, suggests a report published this week in JAMA. The study also found that patients who were offered online brief dialectical therapy (DBT) skills training in additional to usual care had an increased risk for self-harm compared with those who received usual care only.

“These findings do not argue against systematic efforts to identify and address suicide risk in health care settings,” wrote Gregory Simon, M.D., M.P.H., of the Kaiser Permanente Washington Health Research Institute and colleagues. “Instead, they indicate that the low-intensity adaptations of care management and DBT skills training tested in this trial have no benefit over usual care in these health systems, especially when offered to the broad population reporting frequent suicidal ideation.”

Simon and colleagues used electronic health record (EHR) data from four health systems that provide insurance coverage, as well as mental and medical health care. The systems routinely administer the 9-item Patient Health Questionnaire (PHQ-9) at all mental health visits or primary care visits for depression treatment. The authors identified 18,882 patients aged 45 years or older who reported thoughts of death or self-harm for the majority of days during the past two weeks. Participants were excluded if they were not insured by the health systems, if they did not previously use the systems’ patient portals, if they had dementia or a developmental disability, or if they needed an interpreter.

Patients were randomly assigned to continue their usual care (access to mental health or general medical services) or to have their usual care supplemented with a care management intervention or an online DBT skills training. The interventions were offered for up to 12 months, and the primary outcome was the time to a nonfatal or fatal self-harm event.

Both interventions began with invitation messages from a study clinician through the EHR portal. The care management intervention included regular outreach for assessment of suicide risk using the Columbia Suicide Severity Rating Scale, followed by recommendations and encouragement regarding outpatient follow-up. The skills training included an interactive online program with videos demonstrating four skills based off DBT: mindfulness, mindfulness of current emotion, opposite action, and paced breathing. Skills coaches sent EHR portal messages to reinforce visits to the online program and encourage practicing specific skills.

Thirty-one percent of participants offered care management and 39% offered skills training accepted the invitations to the interventions. During the 18-month follow-up period, 540 participants experienced a self-harm event (45 fatal and 495 nonfatal events), including 172 (3.27%) offered care management, 206 (3.92%) offered skills training, and 162 (3.10%) in the control group. The risk of self-harm did not differ significantly between the care management and usual care groups but the risk of self-harm among those offered skills training was approximately 30% higher than in usual care.

In an accompanying editorial, Barbara Stanley, Ph.D., and Lisa Dixon, M.D., M.P.H., of the Columbia University Vagelos College of Physicians and Surgeons wrote, “[T]he study raises as many questions as it answers, underlining the importance of looking more deeply to understand what the findings of this trial may reveal.”

They continued, “Although the findings from this study do not support implementation of the programs as tested, it may be that the implementation strategy failed, rather than the therapeutic approaches from which their interventions were derived. … This study provides an important lesson for investigators, health care network administrators, and policy makers addressing the critical challenge of scalability in implementing and advancing efforts to identify patients with suicide risk and prevent self-harm.”

For related information, see the Psychiatric News article “Preventing Suicide Begins With Regular Assessments.”

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Collaborative Care Successful in Urban Setting but Many Patients Choose Not to Participate

Despite a high rate of screening minority patients for anxiety and depression in seven primary care centers that used the Collaborative Care Model (CoCM), only 56% of eligible patients engaged in care, and 25% did not return for at least one follow-up appointment, a report in Psychiatric Services has found. Nevertheless, 58% who received care under the model had significant clinical improvement.

“These findings are sobering and indicate that even with the CoCM, considered a gold-standard behavioral health integration model in primary care, more work is needed to identify and overcome barriers to engaging vulnerable patients and advance the model’s impact,” wrote Michelle Blackmore, Ph.D., of the Montefiore Medical Center in New York and colleagues.

CoCM has an extensive evidence base, and care provided under the model is reimbursed by the Centers for Medicare and Medicaid Services. Beginning in 2015, CoCM was implemented in seven primary care practices serving patients from racial-ethnic minority groups in the Bronx and lower Westchester counties of New York state. Many of the patients were predominantly Medicaid beneficiaries.

In total, 88,236 of patients (87%) were administered the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7) in a primary care visit. Of these, 11,886 (13%) screened positive for clinically significant depressive or anxiety symptoms, and 6,849 (8%) had clinically significant comorbid anxiety and depression.

In total, 5,247 patients (56%) engaged in CoCM—defined as completing an initial assessment with a preliminary diagnosis and agreeing to start treatment—during the three-year study; 3,957 had one or more follow-ups after 10 to 14 weeks, during which the PHQ-9 or GAD-7 was again administered. For patients with at least one follow-up by 10 to 14 weeks, 58% had improved scores on the PHQ-9, GAD-7, or both; 19% of patients with depression and 20% of patients with anxiety were in remission (defined as scores of less than 5 on the PHQ-9 and GAD-7).

Twenty-five percent of patients who were eligible for collaborative care did not return for at least one follow-up appointment after agreeing to start treatment. Perceived stigma about mental illness, transportation problems, and family and work responsibilities may have impeded engagement, the researchers wrote.

“Improving the engagement of vulnerable patients in integrated models such as the CoCM can enhance receptivity and access to behavioral health treatment, representing key steps toward addressing health care inequity and increasing population impact,” the researchers wrote. “However, our findings also highlighted a significant need for targeted CoCM modifications to improve initial and ongoing patient engagement for this patient population.”

For more information, see the Psychiatric News article “Three Health Systems Find Success With Collaborative Care.”

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APA Announces Results of 2022 Election

At its meeting on February 14, APA’s Committee of Tellers approved the following results for the 2022 APA National Election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting on March 12 and 13.

President-Elect
Petros Levounis, M.D., M.A.

Treasurer
Richard F. Summers, M.D.

Trustee-at-Large
Michele Reid, M.D.

Area 3 Trustee
Geetha Jayaram, M.B.B.S., M.B.A.

Area 6 Trustee
Barbara Yates Weissman, M.D.

Resident-Fellow Member Trustee-Elect
Seth L. Daly Stennis, M.D.

“I am honored and grateful to have been elected by my fellow members to help lead the APA,” Levounis said in a media release. “I look forward to helping build APA’s leadership role in mental health both within American medicine and in collaboration with our colleagues across the world.”

“Congratulations to Dr. Levounis and the other candidates on their election,” said APA President Vivian Pender, M.D. “I look forward to working with these enthusiastic and dedicated newly elected APA leaders in the coming years to advance the important efforts of the APA and its members.”

“Dr. Levounis’ leadership and commitment will greatly benefit the APA,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “APA members and the profession of psychiatry will be well served by his guidance and leadership. I also want to personally congratulate all the winners and to salute the other candidates.”

Levounis’ term as president-elect of APA will begin in May at the conclusion of the APA Annual Meeting, when current President-Elect Rebecca Brendel, M.D., J.D., begins her one-year term as president. The other winners will also take office at that time.

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Mental Health Effects of Pandemic on Older Adults Vary, Psychiatrist Says

Many studies have sought to quantify the mental health impact of the COVID-19 pandemic on various groups of people. While early reports suggested that older adults were reporting less depression and anxiety in response to the pandemic than those in younger age groups, long-term studies have since revealed factors that increase the likelihood that older adults will face negative mental health outcomes related to the pandemic, wrote psychiatrist Ipsit V. Vahia, M.D., and research associate Hailey V. Cray, M.P.H., in an editorial published today in the American Journal of Geriatric Psychiatry. Vahia and Cray are both on the staff of McLean Hospital.

“Longitudinal data are sharpening our understanding of the long-term effects of COVID among recoverees, [those with] long COVID, … [and] people with dementia and especially their caregivers,” Vahia and Cray wrote.

The authors described several studies that point to worsening mental health reported by older adults who survived COVID-19, including higher rates of anxiety and posttraumatic stress disorder, than those who did not contract COVID-19 and persistent psychiatric symptoms reported by people with so-called “long COVID.” They also highlighted research that found behavioral and psychological symptoms in people with dementia worsened during the pandemic and the toll this has had on the mental health of the caregivers of people with dementia.

“While older adults, as a whole, may have withstood the stresses better than other groups, care at the individual level requires nuance,” Vahia and Cray wrote. “For clinicians, this will mean an additional layer of clinical assessment.” They offer several steps to consider when evaluating an older patient:

• Determine whether the patient was infected and, if so, the extent and nature of the initial COVID-19 symptoms, including neuropsychiatric symptoms.
• Establish whether the patient is experiencing any persistent symptoms and whether the cognitive status of the patient may have changed since recovery.
• Assess what caregiving responsibilities the patient may have and what support system the patient relies on; quantify the extent of the patient’s loneliness.

“It is also critical to acknowledge that the story of COVID-19 and its impact on geriatric mental health is still being written,” Vahia and Cray wrote. “As with any chronic stressor, it may be years before the true scope of mental health fallout may be evident. In the here-and-now, however, clinicians must assume the onus of adapting their approach to older adults to maximize their resilience and anticipate and mitigate COVID-induced challenges.”

For related information, see the Psychiatric News article “Are Older Adults More Resilient to Pandemic Stresses Than Assumed?”

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Driving Under the Influence Common Among People Who Use Both Alcohol and Cannabis

More than 2 in 5 drivers who use alcohol and cannabis have driven under the influence of one or both substances in the past year, a study in the American Journal of Preventive Medicine has found.

Priscila D. Gonçalves, Ph.D., of Columbia University and colleagues examined data from drivers aged 16 years or older who participated in the National Survey on Drug Use and Health between 2016 and 2019. The researchers specifically focused on 34,514 survey participants who reported using alcohol and cannabis, albeit not necessarily at the same time, in the previous year.

Overall, 42% of participants in the sample reported driving under the influence of alcohol, cannabis, or both in the past year. Eight percent reported driving under the influence of only alcohol, 20% reported driving under the influence of only cannabis, and 14% reported driving under the influence of both alcohol and cannabis.

Furthermore, 27.5% of those in the sample reported simultaneous alcohol and cannabis use, defined as using the two substances at the same time or within a couple of hours of one another. These participants had 2.88 times the odds of driving under the influence of only cannabis and 3.51 times the odds of driving under the influence of both alcohol and cannabis compared with participants who did not drive under the influence. Daily alcohol and cannabis use increased the likelihood of driving under the influence of alcohol and cannabis, respectively, and daily simultaneous use was associated with driving under the influence of both substances.

“From a harm reduction perspective, identifying which population subgroups are at high risk for DUIs could assist the development of more focused prevention strategies, considering risk patterns of substance intake,” the researchers wrote. “Prevention strategies targeting specific behaviors, such as simultaneous alcohol/cannabis use, should be tested to reduce DUI burden.”

For more information, see the American Journal of Psychiatry article “Alcohol and Cannabis Use Disorders.”

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Study Identifies Factors Associated With Negative COVID-19 Experiences

Family structure, socioeconomic status, and the experience of racism were primarily associated with negative impacts of COVID-19 across family generations in minority communities, more so than preexisting medical or psychiatric conditions, reports a study published yesterday in JAMA Psychiatry.

“[T]hese data raise the possibility that interventions aimed at the community level (e.g., provision of childcare, increased access to school meals, universal basic income to cover fundamental needs, continued COVID-19 unemployment assistance) might be effective in either preventing or combatting negative COVID-19 experiences across multiple generations within a single family,” wrote Sarah Yip, Ph.D., of the Yale School of Medicine and colleagues.

Yip and colleagues used data from the Adolescent Brain and Cognitive Development (ABCD) Study, a long-term study of brain development and child health in the United States. “The availability of baseline, pre–COVID-19 data from this cohort … provides an unprecedented opportunity to quantify transgenerational predictors of COVID-19 experiences,” the authors wrote.

Upon enrollment in the ABCD Study, children and their parents answered questions about their socioeconomic status, the child’s mental and physical health, and family psychiatric history, among others. In total, the baseline assessments—collected between 2016 and 2018—included more than 17,000 characteristics. Participants then completed COVID-19-related questionnaires between May and August 2020, covering topics such as school attendance, family stressors, access to needs, social distancing, screen time, mental health, change in routine, sleep, and physical activity.

Among the 9,267 youth and their caregivers, the authors found that social determinants of inequity, including lower socioeconomic status, living in single-parent households, and experiencing racism, were primarily associated with negative COVID-19 experiences, such as food insecurity and financial worry. During the pandemic, non-White families and Spanish-speaking families had fewer resources and increased financial worry and experienced food insecurity. In contrast, White families and families who had higher incomes before the pandemic or a parent with a postgraduate degree experienced less impact associated with the pandemic, as indicated by factors such as less food insecurity and financial worry. Children from these families reported sleeping longer, less difficulties with remote learning, and decreased worry about the impact of COVID-19 on their family’s financial stability.

The analysis also revealed that parents from non-White families and Spanish-speaking families were more likely to have discussions with their children regarding COVID-19 health and prevention, such as handwashing, conserving food, protecting elderly relatives, and isolating from others than those parents in families experiencing fewer negative impacts from COVID-19.

“Our results underscore that families most affected by inequity during COVID-19 were more likely to abide by safe practices such as social distancing and handwashing, despite a popular narrative that individuals from these communities are less likely to engage in such behavior,” the authors wrote.

“[O]ur investigation is consistent with the interpretation that individual behavior alone cannot singly affect or mitigate health outcomes. Rather, psychosocial factors such as built environment, access to education, racism, and parental and community support all play pivotal roles in promoting health equity.”

For related information, see the Psychiatric Services article “COVID-19, Structural Racism, and Mental Health Inequities: Policy Implications for an Emerging Syndemic.”

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Overuse of Digital Technology May Indicate Addiction, Expert Says

Addiction to digital technology is bound to become an increasing focus of psychiatrists, wrote addiction psychiatrist Petros Levounis, M.D., M.A., in a recent Psychiatric News special report. Levounis is a professor and chair of the Department of Psychiatry and associate dean at Rutgers New Jersey Medical School.

“Just as happens with substances like alcohol or opioids, some people become so caught up in their virtual world that their real world—jobs, finances, relationships, physical health—begins to suffer,” Levounis wrote. “As smartphones and other modern devices become more and more integrated into all facets of life, understanding, identifying, and treating these technological addictions will become a significant aspect of psychiatric care.”

Diagnosing technological addictions accurately requires more research. “Only one technological addiction has been semi-officially recognized by APA as of DSM-5: internet gaming disorder is in Section III of our manual as a condition for further study,” he wrote. However, Levounis said that the framework used to define internet gaming disorder could be extended to other online behaviors that addiction specialists agree may be of concern: online gambling, online shopping, cybersex, internet surfing, texting/emailing, and social media.

Under the current DSM-5 entry, internet gaming disorder is likely present if someone meets five of the following nine symptom criteria over a 12-month period:

• Being preoccupied with video games.
• Experiencing withdrawal symptoms when video games are inaccessible.
• Requiring more and more playing time to gain the same level of satisfaction.
• Being unable to cut down on game playing despite efforts to do so.
• Giving up other activities to play more frequently.
• Deceiving family members about how much time is spent gaming.
• Using video games to alleviate negative moods.
• Jeopardizing jobs or relationships due to gaming.
• Continuing to play video games despite knowledge of adverse consequences.

Just as psychiatrists’ ability to diagnose technological addictions requires further research, guidance on how to treat patients will as well. “The best advice currently is to rely on what works well across the broad addiction sphere: providing patients an integrated treatment that incorporates addiction psychotherapy, pharmacological treatment of other psychiatric disorders, and possibly mutual-help (otherwise known as 12-step) facilitation,” he wrote.

No medications are approved for any behavioral addiction, technology based or otherwise. “The optimal use of medications for most patients is in the management of common psychiatric comorbidities like depression or anxiety, which have been shown to worsen the problematic behavior,” Levounis wrote.

Recognizing, diagnosing, and treating people with technological addiction is a field just being born. “Research on the phenomenology and nosology of these illnesses will help us further elucidate the distinction between problematic and nonproblematic use of technology, especially in children and young adults,” he wrote. “[W]e will need to be ready to guide our patients, our colleagues, and the general public on how to best handle technology with an eye on maximizing its enormous potential for fulfillment, gratification, and happiness while minimizing its significant risks for dissatisfaction, misery, and despair.”

For related information, see the Psychiatric News article “CBT Intervention May Reduce Addictive Internet Use.”

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Initiation of Prescription Opioids May Slightly Increase Risk of Suicide in Some Youth

Youth and young adults who start taking prescription opioids appear to have double the risk of suicidal behaviors compared with those who do not start taking prescription opioids, a report published Monday in Pediatrics suggests. However, when comparing suicidal behaviors in youth initiating prescription opioids with those initiating prescription nonsteroidal anti-inflammatory drugs (NSAIDs), there appeared to only be a modest association between opioid initiation and suicidal behavior.

“These results are consistent with the hypothesis that confounding from preexisting factors associated with pain indications, rather than opioid initiation itself, drives much of the observed risk of suicidal behavior among opioid initiators,” wrote Kimberly L. Fine, Ph.D., of Indiana University and colleagues.

For the study, Fine and colleagues analyzed Swedish population-register data on nearly 1.9 million individuals aged 9 to 29 years for whom there was no record of prior opioid prescriptions. They tracked prescriptions dispensed to these youth and young adults beginning in January 2007 and diagnosed self-injurious behavior and death by suicide through December 2013. Of these individuals, 201,433 individuals (10.6%) began taking an opioid prescription during the study period. (Prescriptions for codeine and tramadol comprised more than 75% of these prescriptions.)

Youth and young adults who initiated prescription opioids had more than double the risk of suicidal behavior relative to young people who did not initiate prescription opioids: 2.9% of initiators experienced at least some suicidal behavior within five years, compared with 1.2% of those who did not begin taking these medications.

The researchers next compared suicidal behavior in 86,635 young people who initiated prescription opioids with 255,096 young people who initiated prescription NSAIDs. The incidence of suicidal behavior within five years was 2.2% for opioid initiators and 1.9% for NSAID initiators. “[O]pioid initiators had 19% relatively greater adjusted risk of suicidal behavior than did prescription NSAID initiators. Although this association was statistically significant, it was small, corresponding to 3 additional opioid initiators per 1,000 experiencing suicidal behavior within five years.”

While “the results cannot definitively establish the magnitude of a potential influence of opioid initiation, they suggest that any increase in risk of suicidal behavior is unlikely to be large, and decisions to initiate opioid prescription should consider the full range of potential benefits as well as harms,” the authors concluded.

For related information, see the Psychiatric News article “Psychiatrists Need to Be Prepared to Support Patients in Pain.”

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Writing Skills May Improve Odds of Restoring Cognition Following Mild Cognitive Impairment

Population studies have shown that some people who develop mild cognitive impairment (MCI) can subsequently revert to normal cognitive levels. A study in Neurology has now found that women with strong writing skills might be more likely to experience cognitive improvements following MCI than women without these skills.

“Cognition is fluid, and cognitive states can improve or decline over time,” wrote Maryam Iraniparast, Ph.D., of the University of Waterloo in Ontario, Canada, and colleagues. “[I]dentifying predictors associated with these transitions [are] important to inform the clinical prognosis of individuals with MCI and the design and interpretation of MCI clinical trials, and to develop public health strategies to prevent or delay dementia.”

Iraniparast and colleagues examined data from 619 participants in the Nun Study, a study that tracked the cognitive function of nuns (aged 75 years or older at enrollment) annually until their death or through the completion of 12 cognitive assessments. The researchers also evaluated autobiographies written by the participants decades earlier to assess their written language skills

Overall, 472 of the 619 participants developed MCI at some point during the follow-up period, which averaged 8.5 years. Of this group, 143 reverted at least once from MCI to normal cognition, 142 progressed to dementia, 16 remained in the MCI state at the end of follow-up period, and 171 died before any further cognitive changes were apparent. Most of the women who reverted from MCI to normal cognition subsequently developed MCI again, though 34 participants who reverted remained cognitively healthy for the rest of the study.

After adjusting for numerous factors, the researchers found that participants with a bachelor’s degree or higher level of educational attainment were more likely to revert from MCI to normal cognition than those with a high school degree or lower. In addition, participants who received As in high school English were nearly twice as likely to revert as those with lower grades. Participants who demonstrated complex writing skills (based on their autobiographies) were nearly six times as likely to revert as those with less complex writing skills.

“While our results show the importance of academic performance and written language skills as predictors of reversion, they also support the importance of education, a more widely available measure,” Iraniparast and colleagues wrote.

For related information, see the American Journal of Psychiatry article “Development and Validation of a Dementia Risk Prediction Model in the General Population: An Analysis of Three Longitudinal Studies.”

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Preeclampsia, Perinatal Complications Linked to Developmental, Psychiatric Disorders in Children

Preeclampsia and perinatal complications such as preterm birth and low birth weight may raise the risk of neurodevelopmental and psychiatric disorders in children and adolescents, a study in JAMA Network Open has found.

Linghua Kong, Ph.D., of the Karolinska Institutet in Stockholm and colleagues analyzed data from more than 1 million people born in Finland between January 1, 1996, and December 31, 2014. The researchers followed the children until December 31, 2018, when the oldest in the study were 22 years old. There were no twins, triplets, or other children born in multiple births in the study. The researchers used Finnish health registries to determine how many of the children’s mothers had preeclampsia while pregnant. They also determined how many children were born earlier than 34 weeks’ gestation or had low birth weight, defined together as perinatal complications.

Compared with children who were not exposed to preeclampsia or perinatal complications, children who were exposed only to perinatal complications had 1.77 times the risk of developing any neurodevelopmental or psychiatric disorder, and children who were exposed to both conditions had 2.11 times the risk. Children who were exposed only to preeclampsia did not appear to have increased risk when the researchers adjusted the results to account for shared familial risk factors.

Children who were exposed to both preeclampsia or perinatal complications also had 3.24 times the risk of intellectual disabilities, 3.56 times the risk of developmental disorders, 2.42 times the risk of attention-deficit/hyperactivity disorder and conduct disorders, and 2.45 times the risk of other behavioral and emotional disorders compared with children who were exposed to neither condition.

The researchers noted several limitations to the study, including a lack of data on paternal factors.

“[E]xploration of factors moderating and mediating the association of exposure to both preeclampsia and perinatal complications with neurodevelopmental and psychiatric disorders in offspring is warranted,” Kong and colleagues wrote.

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New Criteria Can Help Clinicians Diagnose, Treat Prolonged Grief Disorder

The addition of the diagnostic category prolonged grief disorder to DSM-5-TR is timely and important given the COVID-19 pandemic’s enormous death toll, wrote Holly Prigerson, Ph.D., of Weill Cornell Medicine and colleagues in a Viewpoint article published yesterday in JAMA Psychiatry. It is vital clinicians know how to identify pathological manifestations of grief and connect patients with proven treatments, notes Prigerson and her co-authors, psychiatrists Katherine Shear, M.D., of Columbia University and Charles F. Reynolds III, M.D., of the University of Pittsburgh Medical Center.

“[Prolonged grief disorder] is a serious mental disorder that puts the patient at risk for intense distress, poor physical health, shortened life expectancy, and suicide,” the authors wrote.

“The DSM-5-TR criteria for [prolonged grief disorder] require that distressing symptoms of grief continue for at least 12 months following the loss of a close attachment and that the grief response is characterized by intense longing/yearning for the deceased person and/or preoccupation with thoughts and memories of the lost person to a clinically significant (i.e., impairing) degree, nearly every day for at least the past month,” the authors continued. Patients must also experience symptoms such as feeling as though a part of oneself has died, intense emotional pain, emotional numbness, or feeling that life is meaningless because of the death.

The PG-13 Revised scale—a 13-item questionnaire that asks patients about the length of time since their loved one’s death and their symptoms of grief—can help to determine the severity of grief. A score of 30 or higher on the PG-13 Revised scale is consistent with a prolonged grief disorder diagnosis and may indicate treatment is needed.

Several studies suggest that patients with prolonged grief disorder may respond better to targeted therapy than to other therapies used to treat major depression (including citalopram and interpersonal therapy). Among 641 participants experiencing complicated grief, 71% of those treated with prolonged grief disorder therapy reported improvement on the Clinical Global Impression Scale compared with 44% of those who received either interpersonal psychotherapy or citalopram, the authors wrote.

Prolonged grief disorder therapy works under the central premise that, for patients with prolonged grief disorder, the coping responses typical of early grief—such as self-blame, avoidance, and anger—derail the naturally adaptive process of transforming and integrating grief, according to the authors. Prolonged grief disorder therapy helps the patient learn to accept his or her new reality and restore a sense of autonomy and competence. It includes seven themes, “or healing milestones,” the authors wrote, that are introduced sequentially:

1. Understanding and accepting grief
2. Managing grief emotions
3. Seeing a promising future
4. Strengthening relationships
5. Narrating the story of death
6. Living with reminders
7. Connecting with memories

“Because of the pandemic, the absolute number of [prolonged grief disorder] cases is likely to increase and the 7% to 10% prevalence rate among … bereaved people may rise,” they wrote. “[C]linicians should learn how to accurately assess, to accurately and differentially diagnose, and to offer or refer patients for treatment.”

For related information, see the Psychiatric News article “Pandemic Takes Toll on Those Who Grieve.”

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Americans Have Mixed Feelings About Social Media, APA Poll Finds

A third of Americans reported that social media does more harm than good to their mental health and more than 40% said that social media has hurt society at large and that it has damaged political discourse, according to the results of an APA poll released today.

At the same time, most respondents reported feeling positive about their own use of social media. Eighty percent of social media users said they felt interested while using social media, 72% felt connected, and 72% said they felt happy. In contrast, 26% said social media made them feel helpless, and 22% said it made them feel jealous.

The findings are from APA’s Healthy Minds Monthly, a poll conducted by Morning Consult. The poll—which asked respondents about their mental health and social media use—was fielded online from January 19 to 20, among a nationally representative sample of 2,210 adults. Data were weighted to approximate a target sample of adults based on gender, educational attainment, age, race, and region.

The results reflect ambivalence about a now ubiquitous phenomenon. “Twenty-five years into what almost feels like a giant psychological experiment, most Americans are interacting with social media daily, and many are concerned about its effects on mental health and society,” APA President Vivian Pender, M.D., said in a media release.

Additional findings from the poll include the following:

• Most adults rated their mental health as excellent (27%) or good (46%).
• Moms were more than twice as likely as dads to rate their mental health as fair or poor (31% vs. 15%), while dads are far more likely than moms to rate their mental health as excellent (40% vs. 18%).
• 31% of adults said social media has helped their relationships with family and friends, but 44% said it has hurt society at large, 38% said it has damaged civil discourse, and 42% said it has harmed political discourse. Adults who do not use social media were more likely than social media users to say social media has harmed society at large (59%), political discourse (56%), and civil discourse (57%).
• 80% of adults used social media during the COVID-19 pandemic to connect with family and friends, and 76% used social media for entertainment.
• 23% of adults used social media to find mental health resources during the pandemic.
• Although 67% of adults said they were confident in their knowledge of how to help a loved one who indicated mental health struggles on social media, only 22% of adults were very confident they would know what to do.

“We know that social media can be very harmful for some individuals,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “It has the effect of turning up the volume on conversations and connecting people in ways that can have a negative impact. That said, these poll results seem to indicate that many Americans are finding an ability to use social media in a way that feels harmless if not helpful to their lives.”

For more information, see the Psychiatric News special report “Be Prepared to Address Technological Addictions in Psychiatric Practice.”

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Should Short-Acting Opioids Be Used to Manage Hospitalized Patients With OUD?

Untreated pain, withdrawal, and opioid craving are known to drive people with opioid use disorder (OUD) to delay care despite serious illness, use illicit opioids while hospitalized, and/or leave the hospital early. Such actions can have life-threatening consequences, writes Ashish P. Thakrar, M.D., of the University of Pennsylvania in a Viewpoint article published yesterday in JAMA Internal Medicine.

“[A]s we enter the third decade of a worsening overdose crisis and face an increasingly contaminated supply of illicit opioids, it may be time to consider that adequate doses of short-acting opioids can serve as one component of compassionate, effective care of hospitalized patients with OUD,” Thakrar proposes. “Given their addictive risk, this is not a call to be cavalier with opioids in general. But for patients who already have active OUD, the risk of developing addiction is no longer germane.”

Thakrar cites American Society of Addiction Medicine guidelines that recommend hospitalized patients with OUD be treated with nonopioid medications, buprenorphine, or methadone but notes that these medications may be insufficient to initially manage some patients’ symptoms. For instance, he writes that methadone can take four hours to reach a peak effect and more than a week of daily dosing to achieve a steady state that is therapeutic for withdrawal and craving.

Thakrar describes several scenarios in which short-acting opioids might be used to treat acute pain and withdrawal in hospitalized patients with OUD, including those patients who choose to initiate or decline treatment with methadone or buprenorphine. “This last scenario, admittedly the most controversial, acknowledges that some patients are unable or unwilling to stop using short-acting opioids, even when offered treatment. We can accept this, offer a safer alternative to illicit opioids, and still treat the conditions that require hospitalization,” Thakrar writes.

“Although it may seem radical to some, this approach could quickly and effectively alleviate pain, withdrawal, and opioid craving, thereby facilitating treatment of the medical and surgical complications of addiction and of OUD itself,” he continues.

In an accompanying editorial, Nathaniel P. Morris, M.D., an assistant professor of clinical psychiatry at the University of California, San Francisco, acknowledges the profound impacts that undertreated pain can have on hospitalized patients with OUD.

“Health professionals must do more to provide humane and evidence-based care in these situations, and short-acting opioids may be one tool in the clinician’s comprehensive pain management toolbox, which should include nonpharmacologic strategies and nonopioid medications as well,” he writes. “More data collection surrounding these practices and development of evidence-based protocols can assist inpatient clinicians who are working to address the overwhelming morbidity and mortality associated with OUD. In developing these protocols, researchers and clinicians must also consider the ways in which social determinants of health, such as poverty, homelessness, criminal legal involvement, racism, and unemployment, shape the care of inpatients with OUD and associated health-related outcomes.”

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