Lithium Associated With Lower Osteoporosis in Patients With Bipolar Disorder

Patients with bipolar disorder may be at a greater risk for osteoporosis, but treatment with lithium could reduce that risk, according to a study published yesterday in JAMA Psychiatry.

“These findings suggest that bone health should be a priority in the clinical management of bipolar disorder and that the potential bone-protective properties of lithium should be subjected to further study, both in the context of bipolar disorder and in osteoporosis,” wrote Ole Köhler-Forsberg, M.D., Ph.D., D.M.Sc., of Aarhus University Hospital in Denmark and colleagues.

The authors used data from nationwide Danish registries, including the Danish Psychiatric Central Research Register and the Danish National Patient Register, which contain information on inpatient, outpatient, and emergency visits, including diagnoses. They identified 22,912 patients who were diagnosed with bipolar disorder between 1996 and 2019, but only patients aged 40 and older were included in the analysis to focus on what the authors noted is a period when the risk of osteoporosis increases. Each patient was matched with five individuals from the general Danish population who did not have bipolar disorder, schizoaffective disorder, or osteoporosis (the control group).

The authors identified all patients who were prescribed lithium, valproate, lamotrigine, and/or any antipsychotic. Patients were considered to have osteoporosis if they had received a formal diagnosis or filled a prescription for medication to treat osteoporosis.

The incidence rate of osteoporosis among patients with bipolar disorder was 8.70 per 1,000 person-years compared with 7.90 per 1,000 person-years in the control group. The association between bipolar disorder and osteoporosis was more pronounced among men than women.

Among patients with bipolar disorder, 38.2% received lithium, 73.6% received an antipsychotic, 16.8% received valproate, and 33.1% received lamotrigine, with some patients receiving multiple drugs. Lithium treatment was associated with a substantial and statistically significant decrease in the risk of osteoporosis compared with no lithium treatment. No such association was found for any of the other treatments.

The researchers also examined the relationship between cumulative dose of the medications and osteoporosis. Only lithium treatment corresponding to more than two years was associated with a statistically significant decrease in risk of osteoporosis, they wrote. The higher the cumulative lithium dose, the greater the decrease in risk of osteoporosis.

“[B]one health should be a priority in the clinical management of bipolar disorder,” the authors wrote. They noted that patients should be guided toward lifestyles that support bone health, such as by not smoking, reducing alcohol intake, maintaining a healthy diet, and exercising. Monitoring bone density via scans, they added, may also be warranted.

For related information, see the Psychiatric News article “Patients Taking Psychotropic Medications Found to Be at Elevated Risk of Fractures.”

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Therapy Challenging Cognitive Biases Reduces Symptoms of Psychosis, Meta-Analysis Suggests

Metacognitive training (MCT) for psychosis—which helps patients learn to question unfounded assumptions known as cognitive biases that contribute to their symptoms—was associated with reduced delusions and hallucinations and improved self-esteem and functioning, according to a report in JAMA Psychiatry. Common cognitive biases in people with psychosis include jumping to conclusions, inflexibility about one’s beliefs, and overconfidence in one’s judgments.

“[T]he benefits of MCT were maintained up to one year after the intervention,” said lead author Danielle Penney, a Ph.D. candidate at Douglas Research Center of McGill University, in a press release. “More generally, these findings support the utility of MCT as an effective tool that can be offered by mental health care workers across health care settings … .”

The researchers analyzed 43 studies of MCT involving 1,816 participants. Of the 43 studies, 30 were randomized, controlled trials (RCTs); 11 were non-RCTs; and two were quantitative descriptive studies. The researchers examined the effect of MCT on global symptoms, delusions, hallucinations, and cognitive biases. They also looked at the effect of MCT on self-esteem, negative symptoms, quality of life, well-being, and functioning.

MCT reduced all symptoms examined, with effect sizes that ranged from small (0.16 for cognitive biases, 0.17 for self-esteem, 0.23 for negative symptoms, and 0.26 for hallucinations) to medium (0.41 for functioning and 0.50 for positive symptoms) and large (0.69 for delusions). Moreover, analysis of RCTs found that both treatment and control groups maintained the therapeutic level reached at the end of treatment for all outcomes at the one-year follow-up.

The effects of MCT on symptoms in people with psychosis were similar to the effects reported in studies of cognitive-behavioral therapy for psychosis and cognitive remediation. Previous analyses of cognitive-behavioral therapy for psychosis found small to moderate effects on delusions and small effects on hallucinations, negative symptoms, and functioning. Similarly, prior meta-analyses of cognitive remediation have reported small to moderate effects for negative symptoms, global symptoms, and functioning.

The researchers concluded: “These findings provide some evidence to consider MCT in international treatment guidelines, and the focus may now shift toward implementation and cost-effectiveness trials in real-world clinical settings.”

For related information, see the Psychiatric News article “Therapy Targeting Cognitive Biases Reduces Delusions in Psychosis.”

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Long-Term Clozapine Use May Slightly Increase Risk of Some Blood Cancers

People who take the antipsychotic clozapine for more than five years may be at a slightly increased risk of developing blood cancers such as leukemia or lymphoma compared with people who take other antipsychotics, a report in The Lancet Psychiatry has found.

“To ensure a wider access to clozapine therapy, which is the most effective antipsychotic drug, our results suggest that patients and caregivers should be informed about early signs of hematological malignancies, just as they are currently encouraged to monitor early signs of agranulocytosis,” wrote Jari Tiihonen, M.D., of the Karolinska Institutet and colleagues. (Agranulocytosis is a rare but serious condition that occurs when there is an extremely low number of white blood cells called granulocytes.)

The findings were based on data from a national register collected from 61,889 people treated for schizophrenia in inpatient settings in Finland between 1972 and 2014. From this group, Tiihonen and colleagues identified 375 patients aged 18 to 85 years with a first-time diagnosis of lymphoid and hematopoietic tissue malignancy between 2000 and 2017 following their schizophrenia diagnosis; these patients were matched with 3,734 patients with schizophrenia who did not have a cancer diagnosis.

The researchers found that patients who used clozapine for less than one year or for one to four years did not have any increased risk of a hematological malignancy; however, patients who used clozapine for five years or more were about three times as likely as patients who had never used clozapine to be diagnosed with a hematological malignancy. The researchers also found that the risk of malignancy increased in a dose-response manner: a patient who took clozapine daily for a total number of doses between 1,000 and 2,999 had 1.79 increased odds of a hematological malignancy, whereas a patient who took clozapine daily for a total number of doses of 5,000 or more had 3.35 increased odds of a hematological malignancy (there was no increased risk of hematological malignancy among people who took clozapine daily for a total number of doses of 999 or fewer). Exposure to other antipsychotics was not associated with increased odds of these malignancies.

During the 17-year follow-up, 37 deaths were due to hematological malignancy among patients exposed to clozapine versus three deaths from agranulocytosis, the authors noted.

“Long-term clozapine use has a higher effect on mortality due to lymphoma and leukemia than due to agranulocytosis,” Tiihonen and colleagues wrote. “However, acknowledging that the absolute risk is small compared with the previously observed absolute risk reduction in all-cause mortality is important. … [M]ental health clinicians should be vigilant for signs and symptoms of hematological malignancy in patients treated with clozapine.”

In a commentary accompanying the article, Dan Siskind, M.B.B.S., M.P.H., of the University of Queensland and colleagues wrote, “[T]he findings by Tiihonen and colleagues are a signal of an uncommon but important adverse outcome. … They merit further investigation but should not be interpreted as a reason to deny a marginalized group access to potentially transformative and lifesaving treatment, to which there are few alternatives.”

For related information, see the American Journal of Psychiatry article “Clozapine, Long-Acting Injectables (and Polypharmacy?) Superior in U.S. and International Registries.”

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Antipsychotic Use During Pregnancy Generally Not Associated With Neurodevelopmental Risks

Exposure to most antipsychotics in the womb does not appear to increase the risk of neurodevelopmental disorders in children after controlling for other factors, such as the mother’s illness and lifestyle behaviors, according to a report published today in JAMA Internal Medicine.

“These findings provide much needed clarity regarding NDD [neurodevelopmental disorders] risk and may help to inform treatment decision-making in pregnancy, which is a sophisticated trade-off between benefits and risks,” wrote Loreen Straub, M.D., M.S., of Harvard Medical School and colleagues. “Although the observed 2-fold increase in risk of [neurodevelopmental disorders] is not causally related with in utero exposure to antipsychotic drugs, it does highlight the importance of closely monitoring the neurodevelopment of the offspring of women with mental illness to ensure that early intervention and support can be instituted when needed.”

Straub and colleagues made use of national health insurance databases, both public and private, to compile information on mothers who filled a prescription for any antipsychotic medication during the second half of pregnancy and their children. (The researchers focused on antipsychotic use in the second half of pregnancy because it marks a period of significant brain development for a fetus.) They compared the rates of the following neurodevelopmental disorders in the children exposed to antipsychotics in the womb with those who were not exposed: autism spectrum disorder, attention-deficit/hyperactivity disorder, learning disability, speech or language disorder, developmental coordination disorder, intellectual disability, and behavioral disorder.

By age 8, 37.3% of publicly insured children and 24.5% of privately insured children whose mothers took antipsychotics during the second half of pregnancy had been diagnosed with at least one neurodevelopmental disorder; in comparison, 23.7% of publicly insured children and 11.0% of privately insured children with no antipsychotic exposure were diagnosed with a neurodevelopmental disorder.

The researchers calculated that antipsychotic exposure during pregnancy was associated with a 1.9-fold increased risk of any neurodevelopmental disorders, with similar risks seen for first-generation antipsychotics, such as haloperidol, or second-generation antipsychotics, such as olanzapine. After adjusting for such variables as the mother’s underlying illness and comorbidities, sociodemographic factors, and lifestyle behaviors (such as smoking or drinking), most antipsychotics were no longer associated with any increased risk of neurodevelopmental disorders. The one exception was in children whose mothers who took aripiprazole in the second half of pregnancy; this population had a 1.36-fold increased risk of neurodevelopmental disorders.

Straub and colleagues noted that aripiprazole is a newer antipsychotic that exerts slightly different effects on dopamine receptors. “This action can result in lactation problems owing to prolactin reduction. Therefore, a potential hypothesis is that aripiprazole’s association with [neurodevelopmental disorders] may be mediated through a reduction in breastfeeding. Our data did not include information on breastfeeding, which may be an important avenue to explore in future studies,” they wrote.

Straub and colleagues also noted that the potential risks identified for aripiprazole require replication in other data sources before causality can be assumed.

To read more on this topic, see the Psychiatric News article “Taking Some Antipsychotics During Pregnancy May Raise Risk of Gestational Diabetes.”

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More Research Needed on Appropriateness of MIPS Measures for Psychiatrists, Study Shows

Psychiatrists score lower than other physicians on Medicare’s Merit-Based Incentive Payment System (MIPS) and are more likely to incur negative payment adjustments than other physicians who participate in the system, a study published today in JAMA Health Forum has found. The findings suggest more research is needed to evaluate the appropriateness of MIPS measures for psychiatrists.

MIPS—a mandatory, outpatient value-based payment program that ties reimbursement to performance on cost and quality measures—was “designed to assess performance for a broad range of outpatient clinicians, although different clinicians practice in widely disparate settings and elect to report different quality measures,” wrote Andrew C. Qi, M.D., of Washington University School of Medicine in St. Louis and colleagues. “Psychiatrists represent one group for whom MIPS may be particularly poorly suited to adequately assess care quality.”

The researchers analyzed data from 9,356 psychiatrists and 196,306 other outpatient physicians who participated in the 2020 MIPS, which covered performance in 2018. The mean final MIPS performance score for psychiatrists was 84.0 compared with 89.7 for other physicians. Furthermore, 6.1% of psychiatrists received a penalty compared with 2.9% of other physicians, 92.6% of psychiatrists received a positive payment adjustment compared with 96.3% of other physicians, and 82.0% of psychiatrists received a bonus payment adjustment compared with 88.7% of other physicians.

MIPS adjusts Medicare Part B payments based on performance in four performance categories: quality, cost, promoting interoperability, and improvement activities. Most of the performance disparities were driven by lower scores in the quality and interoperability domains. For example, psychiatrists performed more poorly on measures such as participation in health information exchanges; documentation of patient medications in medical records; and preventive measures that are not related to psychiatry, such as cancer screening. Regarding the measures that appear most relevant to the practice of psychiatry, psychiatrists had higher reporting rates and better performance, including for depression screening and follow-up, and screening for future fall risk, the authors noted.

“Ideally, each specialty would be judged on measures of greatest relevance to the patients treated by that specialty,” Qi and colleagues wrote. “The fact that just as many psychiatrists in our exploratory analysis reported on quality measures for cancer screening and flu shots as for depression care suggests that MIPS performance reflects multispecialty group performance as opposed to quality of psychiatric care.” They added that most measures included in the mental/behavioral health specialty set were almost entirely unreported, which points to a need to develop and encourage the use of measures relevant to psychiatric care in MIPS.

“The increased administrative and financial burdens introduced by MIPS may further disincentivize psychiatrists from treating Medicare patients, resulting in an even greater number of psychiatrists who require patients to pay out of pocket for services,” they wrote. “This factor has concerning implications for access to mental health care for Medicare beneficiaries.”

They concluded, “[Medicare] may want to reconsider the use of many current MIPS measures for assessing the performance of psychiatrists,” the researchers concluded.

For related information, see the Psychiatric News article “PsychPRO Reaping Benefits for Clinicians Reporting MIPS Data.”

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Rising Number of Older Americans Admitted for Treatment for Heroin Use

The number of adults over 55 admitted for substance use treatment for the first time nearly doubled between 2008 and 2018, according to a report in The Journal of Geriatric Psychiatry.

“The decade since 2008 has resulted in a marked escalation of heroin and methamphetamine use among older adults seeking treatment for the first time, driving illicit substances overall to be more common than alcohol as the reason older adults seek treatment,” wrote Andrea Weber, M.D., of the University of Iowa’s Carver College of Medicine and colleagues.

Using the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Treatment Episode Data Sets (TEDS), which include information about patients admitted for substance use treatment, the researchers compared the rate of first-time admissions for publicly funded substance use treatment by 453,598 adults 55 years or older with those by more than 3 million adults aged 30 to 54 years.

TEDS include demographic data and substance use characteristics regarding patients admitted to substance use treatment facilities in the United States that receive any public funding. Treatment agency staff interview individuals, recording their primary, secondary, and tertiary problem substances. Individuals report the following demographic information: age, race, ethnicity, age at which substance was first used, frequency of substance use, and the source of referral for treatment.

Weber and colleagues found that the percentage of older adults admitted for substance use treatment increased every year between 2008 and 2018. In 2008, 9.04% of all admissions were for adults 55 years or older; in 2018, the percentage rose to 15.64%. The number of older adults’ admissions increased 190%, from 35,787 to 67,872 over the 10-year period.

Older adults’ admissions for illicit drug use also increased every year by 1.91 percentage points, while admissions for alcohol use decreased 1.61 percentage points, and alcohol and drug admissions remained relatively stable (-0.28 percentage point change per year). First-time admissions for older adults with heroin as the primary substance rose from 10% in 2008 to 22% in 2018. Methamphetamine use also increased 0.61 percentage points per year in the older group.

“[T]he increase in heroin use among older adults seeking first-time substance use treatment increases the need for geriatricians, geriatric psychiatrists, and other primary care providers to offer evidence-based medications for opioid use disorder (MOUD) and other forms of risk mitigation, such as naloxone prescribing,” the researchers wrote. “In addition to ongoing access to MOUD throughout the age spectrum, this increasing use of heroin and methamphetamine among older adults seeking treatment increases the need to include older adults in studies evaluating the safety, tolerability, and effectiveness of any and all treatments for [substance use disorder].”

For related information, see the Psychiatric News article “Methamphetamine Involved in Rising Number of Heroin Treatment Admissions.”

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APA’s American Journal of Psychotherapy Publishes Edition Devoted to Mentalization-Based Therapy

The American Journal of Psychotherapy today published a special issue devoted to mentalization-based therapy, a form of psychotherapy that has proven highly effective, especially for personality disorders.

Originally developed 30 years ago by Anthony Bateman, M.A., and Peter Fonagy, Ph.D., for patients with borderline personality disorder, mentalization-based therapy combines elements of psychodynamic and cognitive-behavioral therapy to help patients with “mentalization”—the ability to observe their own emotions and those of other people and to appreciate how their behavior may affect others.

Guest edited by Lois W. Choi-Kain, M.D., M.Ed., director of the Gunderson Personality Disorders Institute at McLean Hospital, the special issue marks three decades of progress in the conceptual definition, scientific elaboration, and translation of mentalizing into clinical practice.

“Without adequate mentalizing, we are unable to contain our reactions to stress,” wrote Choi-Kain in an editorial in the issue. “Poor mentalizing is socially destructive. It impairs our ability to cope, communicate, and collaborate with others. As much as mentalizing can promote mental health and rewarding interactions, its instability can equally result in vulnerability for mental illness and social isolation. Herein lies the potential for psychotherapy to heal and revive psychological development. Psychotherapy can foster mentalization as a common mechanism of change and growth, across approaches and diagnoses.”

The issue includes articles by international experts in mentalization-based therapy. Bateman, who is the consultant psychiatrist and coordinator of mentalization-based therapy at the Anna Freud National Centre for Children and Families, wrote an article describing how mentalization can be used in group psychotherapy for patients with antisocial personality disorder. Fonagy, who is the CEO of Anna Freud National Centre for Children and Families and head of the Division of Psychology and Language Sciences at University College of London, teamed with Roslyn Law, D. Clin. Psychol., also of the Anna Freud National Centre for Children and Families and colleagues to describe how mentalizing and interpersonal psychotherapy work together to promote problem-solving, recovery, and resilience.

Additionally, Choi-Kain wrote an article on how the components of mentalization-based therapy can be applied in the treatment of individuals with narcissistic personality disorder. Jana Volkert, Ph.D., a research fellow in the Department of Psychosocial Prevention at the University of Heidelberg, described how mentalization can be used in family therapy to reduce psychological risk and promote a more rewarding environment for both parents and children. Robert P. Drozek, L.I.C.S.W., and Brandon T. Unruh, M.D., both of McLean Hospital, present a clinical case illustration of how mentalization-based therapy works to reduce symptoms in a physician with borderline personality disorder.

This issue marks the 75th year of nearly continuous publication of the American Journal of Psychotherapy, wrote Editor Holly A. Swartz, M.D., in an editor’s note. “We plan to commemorate this landmark year in the journal’s history with special pieces, including reflections from previous editors in chief and a look back at our seminal articles,” she wrote. “Watch the website and upcoming issues for these exciting features. We hope you will join the American Journal of Psychotherapy community in celebrating 75 years of excellence in psychotherapy scholarship!”

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Parent Questionnaire May Identify High-Risk Youth at Greatest Risk of Bipolar Disorder

Youth who are at high risk for developing bipolar disorder often experience mood swings or depression well before they develop the full disorder. A report in the Journal of the Academy of Child and Adolescent Psychiatry suggests that a questionnaire completed by parents about their children can help to track their mood instability, providing important clues about the youth’s symptoms over time.

“Interventions that are successful in reducing mood instability may enhance long-term outcomes among high-risk youth,” wrote David J. Miklowitz, Ph.D., of the University of California, Los Angeles, and colleagues.

Miklowitz and colleagues analyzed data collected during a trial of youth aged 9 to 17 at high risk for bipolar disorder who were randomly assigned to four months of a family-focused therapy or enhanced usual care. As part of this trial, the parents were asked to regularly complete the Children’s Affective Lability Scale (CALS), scoring their child on how often he or she demonstrated a range of behaviors (for example, suddenly becoming tense or anxious, crying, or having bursts of silliness). Parents also filled out the Conflict Behavior Questionnaire—20 true/false items assessing the level of argumentativeness, frustration in communication, and relational distress between parents and children. Independent evaluators also regularly assessed the youth’s depression, mania, hypomania, and psychosocial functioning. The youth were followed for an average of two years.

Of the 114 participants included in the analysis, 57% met DSM-IV-TR and DSM-5 criteria for major depressive disorder, and 43% met DSM-5 criteria for other specified bipolar disorder. The researchers found that participants who were younger and had an earlier onset of symptoms, a diagnosis of other specified bipolar disorder, more severe mood symptoms, and lower psychosocial functioning were more likely to have higher parent-rated mood instability over time. Although the mood instability scores decreased over the follow-up period, there was no difference in the mood instability scores of the youth who received the family-focused therapy compared with those who received enhanced usual care. Youth with higher mood instability scores in one assessment had higher parent/child conflict reported during the follow-up assessment, the researchers noted.

“The parent-rated CALS scale is not a diagnostic instrument but is an efficient way of tracking symptom trajectories and psychosocial impairment in high-risk youth,” Miklowitz and colleagues wrote. “Because it only takes five minutes for parents to complete and is easily hand scored, it will be considerably easier for clinicians to administer than Adolescent Longitudinal Interval Follow-up Evaluations or Young Mania Rating Scale interviews, which are lengthier and require extensive training.”

They concluded, “The present study has implications for treatment planning for youth at high risk for [bipolar disorder]. … Future clinical trials should examine whether intervening specifically on mood instability in high-risk youth helps delay or prevent the onset of syndromal [bipolar disorder] and enhances psychosocial functioning in adulthood.”

For related information, see the American Journal of Psychiatry article “Early Intervention in Bipolar Disorder.”

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Longer, More Frequent Daytime Naps Linked to Worse Cognition, Alzheimer’s Disease

Numerous studies have identified a connection between excess sleepiness and Alzheimer’s disease. A study appearing in Alzheimer’s and Dementia now reports that adults who napped excessively were more likely to experience worse cognition in the future, and conversely, adults with poor cognition were more likely to nap excessively in the future.

“To the best of our knowledge, this is the first cohort study demonstrating a bidirectional link between objectively measured, excessive daytime napping and Alzheimer’s dementia or cognitive impairment,” wrote Peng Li, Ph.D., of Brigham and Women’s Hospital in Boston and colleagues.

Li and colleagues examined data from 1,401 adults with a mean age of 81.4 years who were part of the Rush Memory and Aging Project between 2005 and 2020. All the participants were given a special watch that measured their movement and sleep activity; the participants were also given comprehensive cognitive tests annually.

Overall, the participants took more daytime naps and longer daytime naps as they aged, but the yearly increase in the frequency and duration of their daytime naps varied with cognitive status. Adults with no cognitive impairment increased their napping by around 11 minutes a year, whereas adults with mild cognitive impairment increased their napping by 25 minutes a year, and adults with Alzheimer’s increased their napping by 68 minutes a year.

Longer naps were also linked with Alzheimer’s risk. For example, participants who napped more than one hour a day on average had a 1.4-fold increased risk of developing Alzheimer’s during the follow-up period compared with those who napped less than one hour a day. This association between excess daytime napping and incident Alzheimer’s dementia remained even after adjusting for differences in nighttime sleep quality and quantity.

“We further note that we did not observe direct associations between these nighttime sleep measures and incident Alzheimer’s dementia,” Li and colleagues wrote. “Therefore, it is unlikely that the increased duration and frequency of daytime napping were simply to compensate nighttime sleep loss.”

To read more on this topic, see the Psychiatric News article “Sleep Loss Found to Exacerbate Spread of Toxic Protein Associated With Alzheimer’s Disease.”

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APA Releases DSM-5-TR—Fully Revised Version of DSM

Today APA released the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). The manual, which the APA has published and updated since 1952, defines and classifies mental disorders in order to improve diagnosis, treatment, and research.

Developed with the help of more than 200 subject matter experts, DSM-5-TR includes the fully revised text and references of DSM-5, all of the updates that have been made to DSM-5 since 2013, and updated diagnostic criteria and ICD-10-CM insurance codes. It features a new disorder, prolonged grief disorder, as well as codes for suicidal behavior and nonsuicidal self-injury. The category “Unspecified Mood Disorder” was restored in DSM-5-TR for mixed mood presentations that do not meet criteria for a bipolar or depressive disorder.

Diagnostic criteria have been revised for several disorders, primarily for clarification. These include changes in the criteria sets for the following diagnoses:

• Autism spectrum disorder
• Manic episode
• Bipolar I and bipolar II disorder
• Cyclothymic disorder
• Major depressive disorder
• Persistent depressive disorder
• PTSD in children
• Avoidant-restrictive food intake disorder
• Delirium
• Substance/medication-induced mental disorders
• Attenuated psychosis syndrome (in the chapter “Conditions for Further Study”)

For the first time in the history of DSM, two groups—the Ethnoracial Equity and Inclusion Work Group and the Cross-Cutting Culture Review Group, composed of more than 40 experts—provide a comprehensive review and update of the impact of culture, race, and racism on diagnosis.

“This text revision reflects the most recent updates in the literature with the added lens of ethno-cultural and racial constructs in diagnosis as well as sex and gender constructions,” said APA President Vivian Pender, M.D., in a statement. “It will be a powerful tool in the hands of psychiatrists and other mental health clinicians as we work to diagnose and treat our patients. In producing this volume, APA continues to advance the science of the mind.”

“Two hundred expert researchers and practitioners put in countless hours to ensure that the DSM-5-TR is an indispensable contribution to our understanding of mental illness,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We are grateful to all who contributed to its production and look forward to seeing it used by researchers, clinicians, and students worldwide.”

For related information, see the Psychiatric News articles “Updated DSM-5 Text Revisions to Be Released in March,” “Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR,” and “Facts About DSM-5-TR.”

APA members may purchase the manual at a discount on APA Publishing’s website.

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Severe COVID-19 May Increase Risk of Mental Health Problems Months After Diagnosis

Adults who experience severe illness after contracting COVID-19 appear more likely to develop symptoms of depression, anxiety, and/or poor sleep in the months following their illness than adults without a COVID-19 diagnosis, reports a study published this week in The Lancet Public Health. The study—based on analysis of data from people living in six European countries and tracked for up to 16 months—also suggests that adults who experience mild COVID-19 symptoms may have a slightly lower risk of subsequent mental health problems compared with adults without a COVID-19 diagnosis.

The findings highlight the importance of continuing to closely monitor patients and conducting “follow-up studies beyond the first year among individuals with the most severe symptomology after COVID-19 infections,” wrote Ingibjörg Magnúsdóttir, M.Sc., of the University of Iceland; Anikó Lovik, Ph.D., of the Karolinska Institute in Sweden; and colleagues.

The study investigators compiled data from patient cohorts in Denmark, Estonia, Iceland, Norway, Sweden, and the United Kingdom. The data were collected between March 27, 2020, and August 13, 2021, and the study sample included 247,249 patients, including 9,979 with a COVID-19 diagnosis. Of the patients who had COVID-19, 31.6% had a mild illness (defined as never bedridden), 24.6% had a moderate illness (bedridden at home or in the hospital for one to six days), and 16.2% had severe illness (bedridden for seven or more days at home or in the hospital). There were no data on the severity of COVID-19 in 27.6% of the patients.

Overall, people diagnosed with COVID-19 of any severity had an 18% higher prevalence of depression symptoms and 13% higher prevalence of poor sleep within 16 months of diagnosis compared with individuals without a COVID-19 diagnosis; rates of anxiety symptoms were similar between the groups.

When focusing on the severity of illness, the investigators found that people with severe COVID-19 had a 61% higher prevalence of depression symptoms, 43% higher prevalence of anxiety symptoms, and 41% higher prevalence of poor sleep compared with people without a COVID-19 diagnosis. In contrast, people with mild COVID-19 had a 17% lower prevalence of depression symptoms and 23% lower prevalence of anxiety symptoms than those without a COVID-19 diagnosis.

“Several factors might contribute to this pattern,” Magnúsdóttir, Lovik, and colleagues wrote. “For example, individuals with a mild COVID-19 infection were able to return to somewhat more normal lives after the benign infection as compared with their more severely impacted counterparts who still could be restrained by fear of ongoing symptoms. Also, the extended duration of official gathering restrictions might have had less impact on the mental health of recovered asymptomatic COVID-19 patients than the general population. … It is also possible that individuals with a low risk of mental morbidities before the pandemic had a less severe disease course after being infected.”

To read more on this topic, see the Psychiatric News article “Expect a ‘Long Tail’ of Mental Health Effects From COVID-19.”

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People Who Die by Suicide Using Firearms Less Likely to Have Ever Sought Mental Health Treatment

People who die by suicide using firearms appear to be less likely to have received treatment for mental illness compared with people who died by suicide using other means, according to a report in JAMA Network Open. They are also less likely to have a history of suicidal ideation or suicide attempt than people who die by suicide by other means.

People who die by suicide using firearms were slightly more likely to disclose suicide plans to someone within the previous month—although less than a quarter of all decedents disclosed suicide plans. “Those who die by firearm are not doing so without any notable risk indicator; rather, they are providing very important information to those around them,” wrote Allison Bond, M.A., of the New Jersey Gun Violence Research Center,  Michael D. Anestis, Ph.D., of Rutgers University, and colleagues.

Bond, Anestis, and colleagues examined data on 234,652 suicide deaths from 2003 to 2018 reported in the National Violent Death Reporting System. The average age at death was 46.3 years; 77.8% were male, and 87.8% were White. The researchers compared treatment seeking, history of suicidal ideation or plans, history of suicide attempts, and disclosure of suicidal ideation by people who died by the three most common methods of suicide (49.9% by firearm; 26.7% by hanging, strangulation, or suffocation; and 15.3% by poisoning).

They found that nearly three-quarters (73.2%) of all decedents were not receiving treatment for a mental health or substance abuse disorder at the time of their death, and two-thirds (66.4%) had never sought treatment for a mental or substance abuse disorder. Decedents whose highest level of education was a high school degree represented the largest percentage of deaths across all methods.

Of those who died by suicide using firearm, here are other important findings:

• 20.7% were receiving treatment at the time of death compared with 33% of those who died by other means; 26.6% had ever sought treatment for mental illness compared with 40.7% of those who died by suicide by other means.
• 10.7% had attempted suicide in the past, and 18.1% reported a history of suicidal ideation or plans; of those who died by other means, 25.4% had a past suicide attempt, and 21.3% had reported a history of suicidal ideation or plans.
• 23.4% disclosed thoughts or plans of suicide to someone in the month prior to death compared with 23.2% who died by other means. Those with a recent disclosure of suicidal plans within the last month had higher odds of using firearms (odds ratio, 1.16).

The findings that those who died by firearm were more likely to disclose plans “highlights the importance of increasing population-level understanding of means safety and possible mechanisms to limit access to lethal means,” the authors stated. “By increasing such knowledge, we can empower people to intervene and help friends and loved ones decrease the likelihood of suicide.”

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

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Registration for MindGames Closes March 16

MindGames, APA’s national residency team competition, is a fun way for residents to test their knowledge on patient care, medical knowledge, and psychiatric history while earning bragging rights for their program. Teams are composed of three residents and must complete the qualifying exam in one, 60-minute setting. Only one team per institution may compete. 2022 MindGames will be held virtually during APA’s Annual Meeting Online Experience. Registration closes Wednesday, March 16, at 11:59 p.m. ET.

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High-Income Households Overrepresented in U.S. Medical Student Body, Report Finds

Students at U.S. medical schools disproportionately hail from high-income households, a report appearing today in JAMA Network Open has found.

“The underrepresentation of low-income groups was nearly ubiquitous across race and ethnicity groups,” wrote Arman A. Shahriar, B.S., of the University of Minnesota Medical School, Jonathan M. Miller, Ph.D., M.P.H., of Hennepin Healthcare Research Institute in Minneapolis, and colleagues.

The researchers examined data collected through the Association of American Medical Colleges Matriculating Student Questionnaire (AAMC-MSQ) between 2017 and 2019. As part of this survey, matriculating medical students were asked to estimate their parents’ combined income for the last year. This income data were compared with data reported by households who responded to the Census Bureau’s Current Population Survey Annual Social and Economic Supplement between 2016 and 2018.

A total of 30,373 AAMC-MSQ respondents reported parental income; of these, 21.3% were non-Hispanic Asian students, 6.4% were non-Hispanic Black students, 10.9% were Hispanic students of any race, and 54.0% were non-Hispanic White students. More than half of the respondents belonged to households in the top 20% income bracket, including 24.0% in the top 5%. In comparison, only about 6% of students reported belonging to households in the bottom 20% income bracket.

The researchers next calculated the representation index (RI) for each subgroup of students by dividing the percentage of the population in each household income bracket represented in the medical student body by those in the general population. (For example, 9.1% of Black medical students came from households in the top 5%, compared with just 1.7% of Black individuals in the United States overall, which results in a RI of 5.3.) RI values above and below 1.0 indicate overrepresentation and underrepresentation in the medical student body, respectively, the authors noted.

The researchers found that the top 5% of households were consistently overrepresented in medical schools compared with the general population across all four racial and ethnic groups (all medical students: RI, 4.8; Asian: RI, 2.3; Black: RI, 5.3; Hispanic: RI, 6.6; White: RI, 4.8).

“Achieving demographic representation among physicians is a widely accepted ideal, but recent studies have shed light on the absence of progress with respect to race and ethnicity,” Shahriar, Miller, and colleagues wrote. “Long-term solutions will require upstream engagement, including community partnerships and targeted investments in pipeline programs.”

They continued, “Matriculants who come from low-income households should be monitored for financial health and the accumulation of unexpected expenses, given that they do not have the family support of their peers from high-income households.”

For related information, see the Psychiatric News article “Minority Students Lead Surge in Medical School Applicants.”

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Registration for MindGames Closes March 16

MindGames, APA’s national residency team competition, is a fun way for residents to test their knowledge on patient care, medical knowledge, and psychiatric history while earning bragging rights for their program. Teams are composed of three residents and must complete the qualifying exam in one, 60-minute setting. Only one team per institution may compete. 2022 MindGames will be held virtually during APA’s Annual Meeting Online Experience. Registration closes Wednesday, March 16, at 11:59 p.m. ET.

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APA Highlights Mental Health Investments in $1.5 Trillion Spending Package

Late last week, Congress passed a $1.5 trillion omnibus spending package that will fund the government through the end of the fiscal year and provide aid to Ukraine. APA expressed support for several mental health and telehealth investments included in the package and urged additional funding to address the mental health and substance use crises in this country.

“Congress’s continued investment in mental health remains essential as we navigate our emergence from COVID,” APA President Vivian Pender, M.D., said in a media release. “This summer, as we implement the national 988 hotline for mental health, these funds will be a critical piece of a larger puzzle.”

The Omnibus Appropriations for fiscal year 2022 (HR 2471) package includes critical funding for mental health programs and extends telehealth flexibilities implemented during the pandemic. Those flexibilities include waiving geographic site-of-service requirements, allowing audio-only telehealth services for Medicare beneficiaries, and delaying the requirement that Medicare patients have an in-person evaluation within six months of their first mental telehealth visit.

“Telehealth access to mental health services during the pandemic has been a lifeline that made it easier for patients to keep appointments and get the psychiatric care they need,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the release. “That experience shows how important it is to continue telehealth access for patients not only this year, but permanently.”

Additional APA-supported provisions in the package include the following:

• $45 billion to the National Institutes of Health (NIH)—an increase of $2.25 billion over last fiscal year.
• $6.5 billion to the Substance Abuse and Mental Health Services Administration (SAMHSA)—a $530 million increase over last fiscal year; $2 billion of these funds will be directed to mental health programs—an increase of $288 million over last year.
• $17 million to the SAMHSA Minority Fellowship Program to promote and train behavioral health care professionals on how to provide culturally competent care.
• $24 million to the Loan Repayment Program for Substance Use Disorder (SUD) Treatment Workforce to provide as much as $250,000 in loan repayments to psychiatrists and other SUD professionals who agree to work full-time in a health professional shortage area or county with high overdose rates for up to six years.
• $25 million to the Centers for Disease Control and Prevention and NIH to support research to identify the most effective ways to prevent firearm-related injuries and deaths and to broaden firearm injury data collection.
• $5 million to the Employee Benefits Security Administration, which is responsible for enforcing compliance with the Mental Health Parity and Addiction Equity Act for 2.2 million employer-sponsored health plans.
• Enhanced Medicaid funding for Puerto Rico and other U.S. territories extended through December 13, 2022.

The final funding package, however, resulted in far fewer resources for mental health services and programs than were initially included in the House’s original proposal, APA noted. “Those initial proposals were more in keeping with the gravity of the mental health and substance use crisis our nation is experiencing,” the APA release stated. “We look forward to working with the Appropriations Committees and others in Congress to devote more significant resources to the mental health and substance use needs in fiscal year 2023 and beyond.”

For related information, see the Psychiatric News article “Congress Passes Parity, Increases Some MH Funding.”

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Registration for MindGames Closes March 16

MindGames, APA’s national residency team competition, is a fun way for residents to test their knowledge on patient care, medical knowledge, and psychiatric history while earning bragging rights for their program. Teams are composed of three residents and must complete the qualifying exam in one, 60-minute setting. Only one team per institution may compete. 2022 MindGames will be held virtually during APA’s Annual Meeting Online Experience. Registration closes Wednesday, March 16, at 11:59 p.m. ET.

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COVID-19 Raises Risk of Cognitive Decline in Older Patients, Study Finds

Older patients who survive severe COVID-19 have a much higher risk of cognitive decline compared with their peers who do not get COVID-19, a study in JAMA Neurology has found. Overall, 21% of patients in the study who survived severe COVID-19 experienced progressive cognitive decline, which suggests that the virus may cause long-lasting damage to cognition.

“These findings imply that the pandemic may substantially contribute to the world dementia burden in the future,” wrote Yu-Hui Liu, M.D., Ph.D., of Daping Hospital in Chongqing, China, and colleagues.

The researchers analyzed data from 1,438 COVID-19 survivors older than 60 years who were discharged from three COVID-19–designated hospitals in Wuhan, China, from February 10 to April 10, 2020, including 260 who had severe illness and 1,178 who had nonsevere illness. The researchers also recruited 438 uninfected spouses of infected patients for a control group for the study. The main outcome was change in cognition one year after patient discharge. The researchers assessed all study participants for cognitive changes during the first and second six-month follow-up periods via the Informant Questionnaire on Cognitive Decline in the Elderly and the Telephone Interview of Cognitive Status-40, respectively.

The incidence of cognitive impairment in survivors 12 months after discharge was 12.45%. The researchers categorized participants as having early onset cognitive decline if the changes occurred in the first six months only; late-onset cognitive decline, if they occurred in the second six months.

Patients who had severe COVID-19 had lower Telephone Interview of Cognitive Status-40 scores than patients who had nonsevere cases and the control group at 12 months. Compared with the control group, patients who had severe COVID-19 had 4.87 times the odds of early onset cognitive decline, 7.58 times the odds of late-onset cognitive decline, and 19.00 times the odds of progressive cognitive decline. Patients who had nonsevere COVID-19 had 1.71 times the odds of early onset cognitive decline compared with the control group.

The researchers noted several potential explanations for the increased risk, including long-lasting infection-related hypoxia (inadequate oxygen delivery to tissue) and lingering inflammation, both of which can damage neurons. They added that it is possible that the virus can directly invade the brain and damage neurons.

For related information, see the Psychiatric News article “Cognitive Impact of COVID-19 Lasts Months.”

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Registration for MindGames Closes March 16

MindGames, APA’s national residency team competition, is a fun way for residents to test their knowledge on patient care, medical knowledge, and psychiatric history while earning bragging rights for their program. Teams are composed of three residents and must complete the qualifying exam in one, 60-minute setting. Only one team per institution may compete. 2022 MindGames will be held virtually during APA’s Annual Meeting Online Experience. Registration closes Wednesday, March 16, at 11:59 p.m. ET.

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Long-Term Cannabis Use Associated With Cognitive Deficits in Midlife

At age 45, people who reported using cannabis weekly or more frequently over the past year showed greater cognitive decline than those who never used cannabis, according to a report published this week in AJP in Advance.

“[C]annabis use is increasing among baby boomers (born 1946–1964), a group who used cannabis at historically high rates as young adults and who now use cannabis at historically high rates as midlife and older adults,” wrote Madeline Meier, Ph.D., of Arizona State University and colleagues.

Meier and colleagues analyzed data from the Dunedin Longitudinal Study, a birth cohort of participants (93% White) born between April 1972 and March 1973 in Dunedin, New Zealand. All participants were assessed regularly starting at age 3 until age 45. Starting at age 18, the participants were interviewed every three to six years about their substance use and past-year substance use dependencies, including their use of cannabis, tobacco, and alcohol. Long-term cannabis users were defined as those who were dependent on cannabis or used cannabis weekly or more frequently in the past year at age 45, and also reported using weekly or more frequently at one or more previous assessments. Long-term tobacco users were defined as those who smoked daily at age 45 and reported smoking daily at one or more previous assessments. Long-term alcohol users were defined as those who drank weekly at age 45 and had a diagnosis of alcohol dependence at two or more assessments.

Cognitive tests were conducted at ages 7, 9, and 11 using the Wechsler Intelligence Scale for Children-Revised and again at age 45 using the Wechsler Adult Intelligence Scale-IV. Additional neuropsychological tests were administered to measure the participants’ verbal learning, attention, memory, processing speed, and more. The participants also nominated people “who knew them well” at age 45 to be informants for the study. Informants completed questionnaires, indicating whether they believed the participants had problems with memory and attention over the past year.

Of 938 participants who were assessed at age 45, 86 were considered long-term cannabis users. Relative to the normative IQ of 100, long-term cannabis users had average IQs as children (99.3) but below-average IQs as adults (93.8). Participants who never used cannabis had an increase in IQ of 0.7 points between childhood and adulthood. Long-term users, however, had a mean childhood-to-adulthood IQ decline of 5.5 points, which was significantly larger than the IQ decline of 1.5 points and 0.5 points among, respectively, long-term tobacco users and long-term alcohol users. Long-term cannabis users were described as having more memory and attention problems by informants than less persistent users. Further, long-term cannabis users had poorer learning, memory, and processing speed than long-term tobacco or alcohol users.

“[R]esearch is needed to ascertain whether long-term cannabis users show elevated rates of dementia in later life,” the authors concluded. “This is important given the huge burden of dementia, and it is timely given the confluence of two trends: the growth of the aging population and the record high rates of cannabis use among today’s older adults.”

For related information, see the Psychiatric News article “Cannabis Withdrawal Syndrome Affects Nearly Half of Those Who Quit.”

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Registration for MindGames Closes March 16

MindGames, APA’s national residency team competition, is a fun way for residents to test their knowledge on patient care, medical knowledge, and psychiatric history while earning bragging rights for their program. Teams are composed of three residents and must complete the qualifying exam in one, 60-minute setting. Only one team per institution may compete. 2022 MindGames will be held virtually during APA’s Annual Meeting Online Experience. Registration closes Wednesday, March 16, at 11:59 p.m. ET.

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Combining Individual, Group Schema Therapy Found Superior for Treating Borderline Personality Disorder

A combination of group and individual “schema” psychotherapy for patients with borderline personality disorder (BPD) was found to be more effective in reducing BPD symptoms than group schema therapy alone or other forms of psychotherapy, according to a report in JAMA Psychiatry.

Schema therapy is a structured therapy that integrates elements of cognitive-behavior therapy and psychoanalysis to explore repetitive life patterns and core life themes, called “schemas.” Schema therapists use an inventory to assess the schemas that cause persistent problems in a patient’s life.

Arnaud Arntz, Ph.D., of the University of Amsterdam and colleagues recruited patients aged 18 to 65 years with BPD from 15 sites in five countries (Australia, Germany, Greece, the Netherlands, and the United Kingdom) for the study. They randomly assigned the participants to one of three groups for two years: 125 patients with BPD were assigned to predominantly group schema therapy, 124 patients were assigned to a combination of individual and group schema therapy, and 246 patients received treatment as usual.

Patients assigned to predominantly group schema therapy participated in two group sessions a week for one year and a maximum of 12 individual sessions if requested by patients. The frequency of group therapy sessions diminished progressively during the second year (from once weekly to biweekly to once monthly); patients could request a maximum of five individual sessions.

Patients assigned to individual and group therapy participated in two sessions (one individual and one group) a week for the first year, with the frequency of both diminishing progressively in the second year (from biweekly to once monthly). Patients assigned to treatment as usual were given the optimal psychological treatment available at the site; the most frequently offered treatment was dialectical behavior therapy.

The primary outcome was change in BPD severity as assessed at baseline, six months, 12 months, 18 months, 24 months, and 36 months with the Borderline Personality Disorder Severity Index-IV. Secondary measures included treatment retention and suicidality.

Patients receiving individual and group therapy had a greater reduction in symptoms and were more likely to remain in treatment than those receiving either predominantly group therapy or treatment as usual. Individual and group therapy was significantly superior to treatment as usual in reducing suicide attempts; there was no significant difference in suicide attempts when comparing patients who received individual and group therapy with those who received predominantly group therapy.

“Core emotional needs such as safe attachment and positive attention are often not adequately met during childhood in patients with BPD in both individual and group relationships,” Arntz and colleagues wrote. “The combined [schema therapy] format aimed to meet needs in both contexts, whereas [predominantly group schema therapy] provided less individual attention. Moreover, addressing severe problems and childhood trauma might be easier for therapists in individual treatment than in group treatment.”

For more information, see the Psychiatric News article “Psychotherapy Found Generally Effective for Borderline Personality Disorder.”

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Risk of Self-Harm Found Higher in Rural Areas Than Urban Areas

People living in rural areas in the United States appear to be at a greater risk of nonfatal self-harm than those living in urban areas, according to a report in the American Journal of Preventive Medicine.

The study findings may help “to generate a more complete picture of the rural−urban gap in the morbidity and mortality of suicidal behavior to guide prevention strategies in improving rural health,” wrote Jing Wang, M.D., M.P.H., of the National Center for Injury Prevention and Control and colleagues. The findings parallel what’s known of the rural-urban disparity in U.S. suicide rates.

The researchers used data from the Nationwide Emergency Department Sample (NEDS) to identify people 10 years or older who were seen in an emergency department for self-harm in 2018. The NEDS data included information on patients’ method of self-harm as well as the rural-urban designation for the patients’ counties of residence.

Among a weighted total of 488,000 emergency department visits for self-harm in the United States in 2018, 80.5% were by urban residents and 18.3% were by rural residents.

Overall, the age-adjusted emergency department visit rate for self-harm was 252.3 per 100,000 for rural residents, which was 1.5 times the rate for urban residents (170.8 per 100,000 residents), Wang and colleagues reported. Compared with urban residents, rural residents had higher risk for self-harm by all methods and across all age groups under 65.

The authors noted that females who lived in rural areas visited the emergency department more often for self-harm than male residents (313.1 per 100,000 for female residents vs. 195.1 per 100,000 for male residents); similar differences were seen when comparing females and males who lived in urban areas.

“Previous studies suggest unique risk factors among rural residents that may contribute to their increased risk for suicidal behavior, such as social isolation, lack of access to health care services, economic hardship, stigma around help seeking for mental health problems, and cultural and social beliefs encouraging self-sufficiency,” Wang and colleagues wrote. “The findings on the rural−urban gaps in self-harm by all mechanisms shown in this study underscore the importance of comprehensive primary suicide prevention strategies to address upstream risk factors in reducing the rural−urban disparity.”

For related information, see the SMI Adviser report “Improving Behavioral Health Services for Individuals With SMI in Rural and Remote Communities” and the Psychiatric News article “Patients Found Willing to Answer Routine Question on Firearm Access.”

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Some Pregnant Women Taking SSRIs Experience Symptoms of Depression, Breakthrough Anxiety

The majority of pregnant women who continue to take selective serotonin reuptake inhibitors (SSRIs) for depression show few or no depressive symptoms during pregnancy and the postpartum period. However, about 1 in 3 of these women still experiences depressive symptoms despite taking medication, and about 1 in 5 experiences worsening anxiety over the course of pregnancy. These were the findings of a study in Psychiatric Research & Clinical Practice.

“Our findings demonstrate that the treatment goal to achieve full resolution of maternal depression symptoms remains a clinical challenge,” wrote Gabrielle A. Mesches, M.S., and Jody D. Ciolino, Ph.D., of Northwestern University Feinberg School of Medicine and colleagues. “Our findings support the implementation of measures of both anxiety and depression to obtain a more complete clinical assessment of residual symptoms during SSRI maintenance treatment of maternal [depression].”

The study findings come from the Optimizing Medication Management for Mothers with Depression (OPTI‐MOM) study, which enrolled 88 pregnant women (18 weeks’ pregnant or less) who had at least one prior episode of major depressive disorder; were not in a current episode; and were treated with sertraline, fluoxetine, citalopram, or escitalopram. The women were assessed for depression and anxiety every four weeks until delivery and again at six and 14 weeks postpartum using such scales as the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder Scale, 7‐item (GAD-7). The authors noted that the women chose to continue SSRI therapy during pregnancy prior to study enrollment.

A score of 15 or more is the validated EPDS screening cutoff for probable antenatal major depressive disorder. The longitudinal assessments revealed three trajectories of depressive symptoms among the women that were relatively stable throughout pregnancy: 18% of women experienced minimal symptoms (EPDS scores below 5), 50% experienced mild symptoms (EPDS scores at 5), and 32% experienced subthreshold symptoms (EPDS scores from 8 to 11).

The authors also identified four anxiety trajectories, three of which were stable throughout pregnancy: 7% of women had asymptomatic anxiety (GAD-7 scores of 0), 53% had minimal anxiety (GAD-7 scores around 2), and 23% had mild anxiety (GAD-7 scores from 6 to 8). However, 18% of the women experienced breakthrough anxiety, in which their GAD-7 scores were low at the start of pregnancy but then rose almost to 10 (considered the clinical cutoff for anxiety disorder) at the end of pregnancy.

“This group of SSRI‐treated women may represent a subgroup who, despite their low anxiety scores in early pregnancy, are sensitive to stress across pregnancy and require additional intervention to mitigate escalating symptoms as they prepare for birth,” the authors wrote.

To read more on this topic, see the Psychiatric News article “How to Manage Meds Before, During, and After Pregnancy.”

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