Worsening Memory, Slowing Gait Associated With Increased Risk of Dementia

Older adults who experience worsening memory and slowed walking may be at greater risk of dementia than those experiencing one or none of these changes, suggests a report published today in JAMA Network Open.

“Our findings provide further evidence for the importance of adding serial gait speed measures to dementia risk screening assessments, providing the opportunity for further comprehensive assessment and early preventative treatments,” wrote Taya A. Collyer, Ph.D., of Monash University in Victoria, Australia, and colleagues.

The researchers analyzed data collected during the ASPirin in Reducing Events in the Elderly (ASPREE) trial—a randomized, controlled trial of more than 19,000 community-dwelling older adults in Australia and the United States that took place between 2010 and 2017. The trial included adults aged 70 years or older (or aged 65 or older for U.S. participants belonging to a minority group) who did not have cardiovascular disease, dementia, or physical disability at the time of enrollment.

As part of the ASPREE trial, researchers measured the gait speed (in meters/second) of the participants at the beginning of the trial; years 2, 4, and 6; and at the end of the trial in 2017. The researchers also administered a series of cognitive tests at the beginning of the trial; years 1, 3, and 5; and in 2017. The cognitive tests included the Modified Mini-Mental State examination for global cognition, Hopkins Verbal Learning Test-Revised for memory, Symbol Digit Modalities for processing speed, and Controlled Oral Word Association Test for verbal fluency. Participants with cognitive concerns over the course of the trial were flagged for additional cognitive testing, and an expert committee determined whether participants met the criteria for dementia (according to DSM-IV).

Participants whose gait slowed 0.05 meters/second or more per year were considered to have gait decline. Participants who scored in the lowest third of the annual change on the cognitive tests were considered to have cognitive decline.

Compared with the adults who did not experience any declines, adults who had gait decline along with either memory decline or global cognition decline were more than 20 times likely to develop dementia, Collyer and colleagues found. Those experiencing slowing gait along with processing speed or verbal fluency decline were about 4 to 5 times more likely to develop dementia, although this risk was about the same as for adults experiencing gait decline alone.

“These results highlight the importance of gait in dementia risk assessment and suggest that dual decline in gait speed and a memory measure may be the best combination associated with accurate assessment of future dementia risk,” the researchers wrote.

“Despite the established predictive validity of gait assessments for geriatric syndromes, an implementation barrier for routine gait assessment in clinics exists that needs to be addressed to improve care of older patients,” wrote Joe Verghese, M.D., of Albert Einstein College of Medicine in an accompanying editorial. “Routine annual assessments of gait speed and cognition will need to be established in clinical settings to identify dual decliners.”

For related information, see the Psychiatric News article “Dual-Task Gait Testing Identifies MCI Patients Likely to Develop Dementia.”

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Deadline for Mental Health Services Conference Abstracts Is Thursday

The Mental Health Services Conference will empower all mental health service providers with practical tools and innovations to shape the future of community collaboration. Held in person in Washington, D.C., at the Capital Hilton Hotel on October 13-14, the conference will provide up to 18 continuing education credits for physicians, psychologists, social workers, and nurses. The deadline for abstracts is Thursday, June 2, at 5 p.m. ET.

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Rheumatoid Arthritis, Depression Raise Risk of One Another, Meta-Analysis Finds

Rheumatoid arthritis and depression have a bidirectional association in which having one condition raises the risk of developing the other, a meta-analysis in the Journal of Affective Disorders has found.

Cyrus S.H. Ho, M.B.B.S., M.Sc., of the National University of Singapore and colleagues conducted a meta-analysis of 11 studies that included a total of 39,130 patients with rheumatoid arthritis, 550,782 patients with depression, and 7,802,230 patients who had neither condition when they enrolled (controls). The studies were conducted in six different countries and had a mean or median follow-up period ranging from 3.4 to 15.8 years.

Compared with controls, patients with rheumatoid arthritis had a 47% greater risk of developing depression.

“The mechanisms mediating the development of depression among [rheumatoid arthritis] patients are overlapping and multifactorial. Pain and functional disability form the hallmark features of [rheumatoid arthritis,] leading to impaired quality of life,” the researchers wrote. They added that fatigue is also highly prevalent in patients who have rheumatoid arthritis and that they often experience stress at the onset of disease.

Patients with depression had a 34% greater risk of developing rheumatoid arthritis compared with controls.

“There is a growing body of evidence supporting the molecular role of inflammation in the pathogenesis of depression,” the researchers wrote. They added that depression has also been associated with myriad autoimmune conditions such as systemic lupus erythematosus, psoriasis vulgaris, and Crohn's disease, all of which involve inflammation.

“Clinicians should systematically screen patients with [rheumatoid arthritis] for depression and be vigilant for the possibility of comorbid [rheumatoid arthritis] in persons, especially elderly, with depression,” the researchers wrote. “The use of anti-cytokine therapies in depression also represents a potential alternative for the treatment of depression that is not responsive to conventional therapy.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Biomarkers of Autoimmunity in Acute Psychiatric Disorders.”

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Deadline for Mental Health Services Conference Abstracts Is Next Thursday

The Mental Health Services Conference will empower all mental health service providers with practical tools and innovations to shape the future of community collaboration. Held in person in Washington, D.C., at the Capital Hilton Hotel on October 13-14, the conference will provide up to 18 continuing education credits for physicians, psychologists, social workers, and nurses. The deadline for abstracts is Thursday, June 2, at 5 p.m. ET.

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Multiple Barriers Inhibit Civilian Use of Extreme Risk Protection Orders

In many states, civilians can file extreme risk protection orders (ERPOs) to temporarily restrict access to firearms for people who present a risk of harm to themselves or others. Yet multiple barriers hinder civilians from taking this step, according to a report published yesterday in Psychiatric Services.

Interviews with civilians from Washington state who filed ERPOs “highlighted that ERPOs can be a useful tool for people seeking a way to limit access to firearms for people who display dangerous behavior,” wrote Laura Prater, M.P.H., Ph.D., of the Firearm Injury and Policy Research Program at the University of Washington and colleagues. “Although the [participants] noted that the ERPO met its major function of removing the firearm,” many noted the unmet need for linkage to mental health resources when the subjects of the ERPOs are particularly vulnerable, especially when they have expressed suicidal ideation, the authors continued.

As of October 2021, 19 states and the District of Columbia allowed ERPOs, which are commonly filed by law enforcement. In California, Colorado, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, Nevada, New Jersey, New York, Oregon, and Washington, civilians, such as partners or family members, are eligible to file an ERPO.

Prater and colleagues interviewed 15 participants who had filed an ERPO in Washington state between December 8, 2016, and September 30, 2020. The researchers asked open-ended questions about the participants’ perceived barriers or facilitators during the ERPO process; their understanding of the process and implications of the ERPO; their perceptions on the effectiveness of the ERPO; and their thoughts on how the process could be improved.

The participants filed ERPOs for their spouses, ex-spouses, siblings, children, and parents. Eight of the subjects of the ERPOs had expressed intentions to harm themselves, seven had represented a potential threat to others, and three represented a threat to harm both themselves and others. The participants identified numerous barriers to filing the ERPO, including the following:

• A perceived lack of help connecting with social services. Participants reported that the primary motivation for pursuing an ERPO was to protect their family members and others from harm, as well as to connect their family members with mental health services. Yet they expressed a sense of disappointment with the lack of connection to services.
• Ambiguities with the administrative and legal processes. Participants expressed a lack of clarity on the function of the ERPO, the proper steps to take to file, and how the ERPO would prevent a firearm sale. Additionally, some courthouse workers incorrectly told participants they could not file for an ERPO as a civilian.
• Feelings of distress. Participants were hindered by the distress they felt, usually related to the initial circumstances that led to the ERPO filing. They also reported that the process felt like a conflict with the family member for whom they were filing the ERPO, and they also perceived that the officials involved in the process had a personal bias against ERPOs.

Participants were facilitated in the ERPO process by their own previous legal experience and informal advocates who helped them, the authors wrote.

“Although continued research may be needed to gain insight into the views of civilian petitioners in other states, we believe that the observations from this study can be applied to make the ERPO filing process more efficient, easier to navigate, and a continued resource for civilians concerned about a loved one’s firearm access,” the authors concluded.

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

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One Week Left to Submit Abstracts for Mental Health Services Conference

The Mental Health Services Conference will empower all mental health service providers with practical tools and innovations to shape the future of community collaboration. Held in person in Washington, D.C., at the Capital Hilton Hotel on October 13-14, the conference will provide up to 18 continuing education credits for physicians, psychologists, social workers, and nurses. The deadline for abstracts is Thursday, June 2, at 5 p.m. ET.

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Dextromethorphan-Bupropion Significantly Improves Depression Symptoms, Study Finds

Patients with major depressive disorder (MDD) who take a combination of dextromethorphan and bupropion may experience greater symptom improvements than those taking bupropion alone, suggests a small study published Wednesday in the American Journal of Psychiatry. The study was funded by Axsome Therapeutics, which is developing an oral formulation of dextromethorphan and bupropion.

“This study is the first controlled trial of dextromethorphan-bupropion in patients with depression,” wrote Herriot Tabuteau, M.D., of Axsome Therapeutics Inc. and colleagues. “[T]reatment with dextromethorphan-bupropion resulted in clinically meaningful and statistically significant improvements in depressive symptoms compared with the active comparator bupropion, and was well tolerated.”

Tabuteau and colleagues analyzed data from a six-week, randomized, double-blind phase 2 trial including 80 participants aged 18 to 65 years. All participants had a confirmed MDD diagnosis and were experiencing a major depressive episode of moderate or greater severity. They were randomly assigned to receive either dextromethorphan-bupropion (45 mg/105 mg tablet) or bupropion (105 mg tablet) once daily for the first three days of the trial, and twice daily for the remainder of the six-week trial.

Depression severity was defined as participants’ ratings on the Montgomery-Åsberg Depression Rating Scale (MADRS), with higher scores representing more severe depression. MADRS was completed at baseline and at weeks one, two, three, four, and six. Clinical response was defined as a reduction of at least 50% from baseline in MADRS score, while remission was defined as a MADRS score of 10 or less.

Participants treated with dextromethorphan-bupropion were significantly more likely to experience a reduction in their MADRS scores between baseline and six weeks compared with those who received bupropion. By the end of the trial, participants in the dextromethorphan-bupropion group had an average reduction of 17.3 points on the MADRS scale, compared with 12.1 points for those in the bupropion group. Further, 46.5% of participants in the dextromethorphan-bupropion group entered remission by the end of the study, compared with 16.2% in the bupropion group. Finally, 60.5% of those in the dextromethorphan-bupropion group achieved a clinical response by the end of the study, compared with 40.5% in the bupropion group.

In the dextromethorphan-bupropion group, 72.9% of participants reported adverse events, such as dizziness, nausea, and anxiety, compared with 64.6% in the bupropion group. The majority of adverse events were mild or moderate, and no serious adverse events, such as hospitalizations, occurred.

“Dextromethorphan-bupropion rapidly reduced depressive symptoms, as measured by the MADRS total score, as early as week 1, with statistically significant differences over bupropion observed by week 2 and at every time point thereafter,” the authors wrote.

For related information, see the Psychiatric News article “Bupropion May Be Best for Overweight Patients With Depression.”

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APA Annual Meeting Kicks Off Tomorrow

After a two-year hiatus, it’s time to reconnect with your friends and colleagues in person at APA’s 2022 Annual Meeting, which gets underway this Saturday, May 21, in New Orleans. To make the most of your meeting experience, download the APA Meetings App, which can be searched by the scientific program by day, format, topic, or speaker. You can also use the app to browse some of the 190 exhibitors who will be showcasing technology and services at the Exhibit Hall.

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Poor Sleep Habits Linked to Binge Drinking Among Adolescents

Adolescents who prefer going to sleep later in the evening, are sleepy during the day, and sleep for shorter periods of time are more likely to participate in severe binge drinking the following year, according to a study published Tuesday in Alcoholism.

“Growing longitudinal evidence indicates that late childhood and adolescent sleep characteristics predict alcohol and cannabis use and related problems in later adolescence and young adulthood,” wrote Brant Hasler, Ph.D., of the University of Pittsburgh and colleagues. “These findings extend a growing literature supporting the relevance of sleep/circadian characteristics to risk for alcohol and cannabis use.”

Hasler and colleagues used data from six annual assessments from 801 participants enrolled in the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) study. Participants, aged 12 to 21 years at baseline, were interviewed to determine past-year alcohol use, cannabis use, and severity of binge drinking. The authors defined binge drinking based on a scale determined by age, ranging from three or more drinks for participants 13 and younger, up to five or more drink for male participants 18 and older, and four or more drinks for female participants 18 and older. Participants were considered to have engaged in heavy binge drinking if they reported consuming double the initial age-based binge levels and extreme binge drinking if they consumed triple the initial levels.

As part of the NCANDA study, the participants were also asked about their sleep habits, including circadian preference (meaning what time participants prefer to wake up and go to bed), past-month sleep quality, daytime sleepiness, and what time participants typically went to bed and woke on both weekdays and weekends.

Adolescents who reported a preference for going to bed later and waking later, greater daytime sleepiness, and shorter sleep duration on both weekdays and weekends were more likely to binge drink the next year, the researchers found. Further, shorter sleep duration on weekends was the predominant predictor of future binge drinking severity when compared with all the sleep measures, with one hour less sleep on weekends resulting in 19% increased risk for severe binging the following year. Preferring a later bedtime and wake time was also associated with a higher risk of cannabis use the next year.

“Sleep is a modifiable behavior in adolescents … and, consequently, adolescent sleep may be a viable target for reducing substance use risk through, for example, policy-level changes delaying school start times,” the authors concluded.

For related information, see the Psychiatric News article “Short Sleep Duration Increases Adolescent Suicide Risk.”

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Just a Few Weeks Left to Submit Abstracts for Mental Health Services Conference

The 2022 Mental Health Services Conference will empower all mental health service providers with practical tools and innovations to shape the future of community collaboration. Held in person in Washington, D.C., at the Capital Hilton Hotel on October 13-14, the conference will provide up to 18 continuing education credits for physicians, psychologists, social workers, and nurses. The deadline for abstracts is Thursday, June 2, at 5 p.m. ET.

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COVID-19–Related Trauma Reported by 40% of People With Mental Illness

About 40% of people with a history of psychiatric disorder reported having found some aspect of the COVID‐19 pandemic to be traumatic, according to a report in Depression and Anxiety. However, only about 5% of these people reported a traumatic event that met criteria for diagnosing posttraumatic stress disorder (PTSD), such as exposure to actual or threatened death or a threatening series of events.

Younger people, those with low income and lower social support, financial worries, and/or lived experience of PTSD were most likely to report traumatic stress symptoms.

“It is important to note that in the context of such a widespread event, even a very small percentage of people with PTSD amounts to a significant mental health burden,” wrote Catrin Lewis, Ph.D., of the National Centre for Mental Health at Cardiff University School of Medicine in the United Kingdom and colleagues.

The researchers surveyed 1,571 individuals with lived experience of psychiatric disorder who were participants in a longitudinal study of mental health during the COVID‐19 pandemic by the Welsh National Centre for Mental Health. Participants included those with lived experience with bipolar disorder, schizophrenia, depression, anxiety, eating disorders, personality disorder, PTSD, and autism spectrum disorders.

The participants were asked if they found any aspect of the COVID‐19 pandemic traumatic (yes/no); if they answered “yes,” they were prompted to share their most troubling experience. The researchers then judged whether that description met the traumatic stressor criterion of ICD‐11 (defined as “exposure to an extremely threatening or horrific event or series of events”) and/or DSM‐5 (defined as “exposure to actual or threatened death, serious injury, or sexual violence”). Additionally, participants who reported a traumatic experience completed the PTSD subscale of the International Trauma Questionnaire.

A total of 630 participants (40.10%) found some aspect of the pandemic traumatic, with generalized worry about the pandemic (12.22%) and lockdown/social distancing restrictions (8.47%) being the “most troubling” experiences reported most frequently. However, 5.28% reported a traumatic exposure that met the traumatic stressor criterion according to ICD‐11 and 3.06% according to DSM‐5. Traumas that met criteria according to both ICD‐11 and DSM‐5 included experiencing severe symptoms of COVID‐19 and witnessing another person being critically unwell or dying.

“Given the often‐chronic nature of PTSD, identifying risk factors for its development is vital, whilst being cautious not to unnecessarily pathologize transient reactions,” the researchers wrote. “Clinical services would benefit from being trauma‐informed and equipped to deal with PTSD on its own or in combination with other conditions.”

For related information, see the Psychiatric News article “40% of Adults Reported Worsening Mental Health During Pandemic.”

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Policies That Criminalize Perinatal Substance Use Linked to Poor Outcomes in Mothers

State policies that criminalize or punish pregnant women and adolescent girls for prenatal substance abuse may have a negative impact on outcomes such as opioid overdose and seeking treatment for opioid use disorder (OUD), a study in the Journal of Substance Abuse Treatment has found. The study also found that state policies that support treatment and early intervention may result in better outcomes for pregnant women and adolescent girls.

Angélica Meinhofer, Ph.D., of Weill Cornell Medicine and colleagues analyzed data from 164,538 females between the ages of 15 and 45 years who had a diagnosis of OUD between 2006 and 2019, of which 13% were pregnant at least once during that time. The researchers compared changes in outcomes in pregnant women and adolescent girls in states with and without a prenatal substance use policies, before and after the implementation of the policies. They defined punitive policies as those that criminalize prenatal substance use (that is, defining prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights) or use other punitive approaches. They defined supportive prenatal substance use policies as those policies that create or fund targeted substance use disorder (SUD) treatment programs specifically for pregnant females or make SUD treatment for pregnant females a priority.

The researchers found that after states implemented punitive policies, the proportion of pregnant females receiving psychosocial services for SUD and methadone services decreased. Furthermore, opioid overdoses increased 45% in states that implemented policies that criminalize pregnant females for using substances. In contrast, following the implementation of supportive policies that fund targeted SUD programs for pregnant females, the proportion of opioid overdoses decreased 45% and the proportion of pregnant females taking any medication for the treatment of OUD increased 11%. However, the researchers found that policies that made SUD treatment for pregnant females a priority were not associated with statistically significant changes in outcomes such as use of medications for OUD.

“[O]ur findings highlight the nation’s trend toward more punitive [policies] as a cause of concern, as our findings suggest that some punitive policies may negatively impact perinatal health outcomes,” the researchers wrote. “Our findings support the recommendations made by leading medical organizations who oppose punitive policies and emphasize efforts that focus on rehabilitation and treatment to minimize adverse health outcomes associated with substance use disorder.”

For related information, see the Psychiatric News article “Statutes Prosecuting Pregnant Women with OUD May Backfire.”

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Study Compares Efficacy of Ketamine vs. Esketamine in Clinical Setting

Intravenous ketamine may improve patients’ depressive symptoms more rapidly than intranasal esketamine, according to a report in JAMA Psychiatry.

Sina Nikayin, M.D., of Yale University and colleagues reviewed medical data from adults with major depressive disorder who received ketamine or esketamine therapy at the Interventional Psychiatry Service at Yale New Haven Psychiatric Hospital between September 2016 and April 2021. The sample included 129 individuals who received ketamine (0.5 mg/kg over 40 minutes per session) and 81 who received esketamine (56 mg or 84 mg spray per session). The demographic characteristics of the two groups were similar: Patients were predominantly non-Hispanic White with private insurance.

After six treatments administered at least weekly, patients who received ketamine had lower average scores on both the clinician-administered Montgomery Åsberg Depression Rating Scale (MADRS) and Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR) compared with patients in the esketamine group. After a full course of treatment (up to eight treatments), QIDS-SR scores remained lower in the ketamine group; there was no statistical difference in MADRS scores between the two groups after eight treatments.

Patients in both groups also had statistically similar rates of treatment response (defined as 50% or greater improvement in MADRS scores), depression remission (MADRS scores of 10 or less), and suicidal ideation (score on MADRS question 10 or QIDS-SR question 12). Overall remission rates were 29.6% for patients taking ketamine and 24.0% for patients taking esketamine. Nikayin and colleagues noted these rates are lower than those reported in other studies, likely because the Yale Interventional Psychiatry Service is a tertiary referral center that treats the most severely ill patients.

“Although both treatments reduce symptoms, these findings signal a potential difference [for ketamine] that could be attributable to many factors, including dosing, delivery mechanism, role of arketamine [chemical mirror image of esketamine], or patient expectations,” the researchers wrote. “A randomized trial is needed to determine the comparative efficacy of these treatments.”

To read more on this topic, see the American Journal of Psychiatry article “Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation.”

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Driving Under the Influence Common Among People Who Use Methamphetamine, Cocaine

Nearly half of adults who have used methamphetamine during the last year have driven while under the influence, a study in Addictive Behaviors has found. The study also revealed that more than one-fifth of adults who have used cocaine in the last year have driven under the influence.

Trenette C. Goings, Ph.D., of the University of North Carolina at Chapel Hill and colleagues examined data from 170,944 adults aged 18 years and older who participated in the annual National Survey on Drug Use and Health between 2016 and 2019. As part of this survey, participants were asked if they had used cocaine or methamphetamine in the previous 12 months or driven under the influence of either of these substances in the previous 12 months.

Among those who reported using these substances in the previous 12 months, 47.2% who used methamphetamine and 21.6% who used cocaine reported driving under the influence in the same time frame, respectively.

“This is noteworthy given evidence suggesting cocaine-influenced driving … is considered to be more dangerous than [driving under the influence] of cannabis and comparable to driving with relatively low blood alcohol concentration,” the researchers wrote. “Moreover, methamphetamine-influenced driving … is understood as comparable to or more dangerous than driving beyond legal [blood alcohol content] limits.”

Among adults who reported past-year use of cocaine or methamphetamine, those who drove while under the influence were more than twice as likely to have also experienced a depressive episode or psychological distress in the past year compared with those who used the substances but did not drive under the influence.

“[T]his greater likelihood of depressive symptoms might relate to psychological distress as a potential driver of increased substance use, which in turn, places individuals at greater risk of [driving under the influence of stimulants],” Goings and colleagues wrote. “Alternatively, or as a complement, we know depression is not only a primary symptom of cocaine/methamphetamine withdrawal, but also increased risk for depression is a long-term consequence of stimulant use.”

For related information, see the chapter “Substance-Related and Addictive Disorders” in The American Psychiatric Association Publishing Textbook of Psychiatry, Seventh Edition.

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Youth Who Transition to Another Gender Not Likely to Transition Back, Study Finds

Youth who socially transition to a gender other than the sex they were assigned at birth are likely to continue identifying as that gender five years later, according to a study published in Pediatrics.

“These results suggest that retransitions are infrequent. More commonly, transgender youth who socially transitioned at early ages continued to identify that way,” wrote Kristina Olson, Ph.D., of Princeton University and colleagues. “Nonetheless, understanding retransitions is crucial for clinicians and families to help make them as smooth as possible for youth.”

Olson and colleagues used data from the Trans Youth Project, a longitudinal study involving 317 youth aged 3 to 12 years old. All participants were recruited between July 2013 and December 2017. Prior to joining the study, the youth had to have socially transitioned to a gender other than their sex assigned at birth—a process that typically involves changing their pronouns, first names, hairstyles, and clothing.

The authors used reports from youth and their parents to determine whether the youth retransitioned (meaning they transitioned again after their initial transitions) or if they continued to identify as their transitioned gender several years later. Participants were classified into three categories based on the pronouns they used: binary transgender (the child identified as the transitioned gender), nonbinary (the child used they/them pronouns), or cisgender (the child again identified as the sex they were assigned at birth).

An average of 5.37 years after their initial transitions, 94% of participants were living as binary transgender, 2.5% identified as cisgender, and 3.5% identified as nonbinary. The rate of retransitions among the participants was 7.3%, and four participants (1.3%) had retransitioned twice, to a nonbinary then back to transgender. Most retransitions occurred before the youth reached age 10. Youth who initially socially transitioned before age 6 were more likely to be living as cisgender five years later compared with youth who transitioned at age 6 or later.

Concerns that youth will experience regret after transitioning, particularly after starting hormone therapy, has led some physicians and even legislatures to question the ability of minors to consent to gender-affirming treatment, wrote Christina Roberts, M.D., M.P.H., of Children’s Mercy in Kansas City in an accompanying editorial. The “stability of transgender identity” five years after the initial transition, as evidenced in Olson’s study, should reassure physicians when recommending gender-affirming treatment, Roberts wrote.

She continued: “The low risk of regret should also inform the actions of legislators attempting to substitute their judgment for the judgment of patients, parents, and providers by denying transgender adolescents access to this evidence-based and potentially life-saving treatment.”

For related information, see the Psychiatric News articles “Record Number of Anti-Trans Bills Filed in States This Year” and “Psychiatrists Need to Prepare to Care for Gender-Variant Patients.”

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Alzheimer’s and Dementia Linked to Eight Modifiable Risk Factors

More than a third of all individuals with Alzheimer’s disease and related dementias living in the United States had one or more of eight modifiable risk factors, according to a report in JAMA Neurology.

The eight risk factors—midlife obesity, physical inactivity, low education, smoking, depression, diabetes, midlife hypertension, and hearing loss—were associated with 36.9% of Alzheimer’s and related dementia cases. The proportion of Alzheimer’s disease and related dementias associated with these risk factors was higher among men compared with women and among Black, American Indian and Alaska Native, and Hispanic individuals compared with White and Asian individuals.

“Policymakers and clinicians should … consider increasing efforts to prevent [Alzheimer’s disease and related dementias] by focusing on midlife obesity, physical inactivity, and low education, especially in higher-risk groups,” wrote Roch Nianogo, M.D., Ph.D., of the Fielding School of Public Health at the University of California, Los Angeles, and colleagues.

Nianogo and colleagues used the U.S. Behavioral Risk Factor Surveillance Survey (BRFSS) to look at the prevalence of the eight modifiable risk factors among 378,615 non-institutionalized individuals with Alzheimer’s and related dementias between January 2018 and December 2018. The BRFSS is a system of health-related telephone surveys that collect state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services.

The researchers calculated population-attributable risk between the eight risk factors and Alzheimer’s disease and related dementias. Such “estimates take into account the strength of the association between the risk factor and the outcome as well as the prevalence of the risk factor,” they noted.

The most prominent risk factors among all participants were midlife obesity (17.7%), physical inactivity (11.8%), and low educational attainment (11.7%). The combined population-attributable risk was higher among men (35.9%) than women (30.1%); it was also higher among Black individuals (39.8%), American Indian and Alaska Native individuals (39.2%), and Hispanic individuals (34.2%) compared with White individuals (28.5%) and Asian individuals (15.8%).

“Understanding the sex-specific and race and ethnicity–specific associations with [Alzheimer’s disease and related dementias] burden may guide public health strategies,” Nianogo and colleagues concluded.

For related information, see the Psychiatric News article “Racial Disparities in Dementia Rate Linger.”

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COVID-19 Infection Less Likely in Hospitalized SMI Patients Prescribed Antipsychotics

Adults who are hospitalized with serious mental illness (SMI) and taking second-generation antipsychotics may be at lower risk of COVID-19 infection than those who do not take these medications, suggests a report in JAMA Network Open. In contrast, mood stabilizers may increase the risk of infection in this population.

“[T]o our knowledge, this is the largest study to systematically assess associations between the use of individual medications and the risk of COVID-19 infection among inpatients with serious mental illness,” wrote Katlyn Nemani, M.D., of the Nathan S. Kline Institute for Psychiatric Research in New York and colleagues.

Nemani and colleagues analyzed electronic health record data of adults aged 18 or older with serious mental illness who were treated at 18 psychiatric hospitals operated by the New York State Office of Mental Health. Beginning in March 2020, these hospitals started testing patients for COVID-19 and tracking their clinical status (for example, transfers to other facilities for COVID-19 treatment and COVID-19–related deaths).

The researchers focused specifically on 1,958 adults (average age 51.4 years) with schizophrenia, schizoaffective disorder, bipolar I disorder, or depression with psychotic features who were tested for COVID-19 and were continuously hospitalized from March 8, 2020, until medical discharge for COVID-19 or July 1, 2020. Patients were considered to have been exposed to a medication if it was prescribed before their COVID-19 test, used for at least seven days, and was administered on a schedule (as-needed medications were not considered for the analysis).

A total of 969 patients (49.5%) had laboratory-confirmed COVID-19 infection that occurred while they were hospitalized; of those, 38 (3.9%) died, the authors noted. The patients prescribed second-generation antipsychotics (for example, olanzapine, clozapine, risperidone, aripiprazole, quetiapine, or paliperidone) were 38% less likely to test positive for COVID-19 than those not prescribed second-generation antipsychotics. In contrast, patients prescribed mood stabilizers (for example, valproic acid, lithium, or lamotrigine) were 23% more likely to test positive for COVID-19 than those who were not prescribed these medications.

After controlling for such characteristics as age, sex, medical risk factors, and exposure to other medications, the researchers found that the use of paliperidone remained significantly associated with decreased risk of infection (41% less likely) whereas use of valproic acid remained significantly associated with increased risk of infection (39% more likely). Clozapine was the only medication associated with decreased odds of mortality; however, this association did not remain statistically significant after adjusting for age, sex, and medical risk factors.

“Considering that antipsychotic drug classes notably differ in terms of adverse effect profiles and drug-drug interactions, this finding suggests that clinical surveillance may identify a major factor associated with the minimization of the potential adverse effects or drug-drug interactions,” wrote Benedetta Vai, Ph.D., and Mario Gennaro Mazza, M.D., both of IRCCS San Raffaele Scientific Institute, Milan, Italy, in an accompanying commentary. “Future studies considering outpatient clinical settings, as well as prospective cohort designs, are needed to confirm the potential protective role played by antipsychotics with regard to the risk of COVID-19 infection or the association of the use of antipsychotics with the risk of mortality, as well as the detrimental effect of valproic acid use.”

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

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FDA Clears Cerebrospinal Fluid Test to Help Diagnose Alzheimer’s Disease

Last week, the Food and Drug Administration (FDA) cleared for marketing the first biomarker-based diagnostic test for Alzheimer’s disease.

The Lumipulse G β-Amyloid Ratio (1-42/1-40) test, manufactured by Fugirebio Diagnostics Inc., measures two variants of the amyloid beta protein in cerebrospinal fluid. A positive result suggests that a patient may have amyloid plaques in the brain associated with Alzheimer’s disease. The cerebrospinal fluid is obtained through a spinal tap, which can usually be performed on an outpatient basis. Currently, amyloid plaques can be identified only with positron emission tomography (PET) brain scans, a process that can be time consuming and expensive.

“With the Lumipulse test, there is a new option that can typically be completed the same day and can give doctors the same information regarding brain amyloid status, without the radiation risk, to help determine if a patient’s cognitive impairment is due to Alzheimer’s disease,” commented Jeff Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health, in a media release.

The Lumipulse test is intended for use in adults aged 55 years and older with cognitive impairment who are being evaluated for Alzheimer’s disease and other causes of cognitive decline. According to the FDA, the Lumipulse test should not be used by itself to diagnose Alzheimer’s and should instead be used as part of a comprehensive evaluation. As noted by the FDA, amyloid plaques may be present in other neurological conditions as well as in some older patients who are cognitively healthy.

The FDA approved the Lumipulse test following a study of cerebrospinal fluid samples from 292 older adults participating in the Alzheimer’s Disease Neuroimaging Initiative. In this clinical study, 97% of adults with a positive Lumipulse test had amyloid plaques in their brains as confirmed by PET scan, while only 16% of adults with a negative Lumipulse test had confirmed amyloid plaques.

For related information, see the Psychiatric News article “Alzheimer’s Blood Test Shows Clinical Potential.”

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Nearly One-Fourth of Physicians in Large Academic Medical Center Experience Mistreatment

Nearly one-fourth of physicians who work at a large academic medical center have experienced mistreatment such as sexual harassment or abuse; verbal mistreatment or abuse; or physical intimidation, violence, or abuse on the job in the past 12 months, a study published today in JAMA Network Open has found. Patients and visitors were the most common source of mistreatment, followed by other physicians.

Susannah G. Rowe, M.D., M.P.H. of Boston Medical Center and colleagues analyzed data from 1,505 physicians at Stanford University School of Medicine who responded to a survey on workplace mistreatment and occupational well-being in September and October 2020. The survey included questions from the Professional Fulfillment Index, which measures employees’ intent to leave, and the Mistreatment, Protection, and Respect Measure, which measures respondents’ perceptions of protective factors in the workplace such as institutional systems that ensure employees are treated with respect and the presence of bystanders who speak up or intervene when they witness mistreatment or abuse.

Of 1,397 physicians who answered questions about mistreatment, 23.4% reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, accounting for 70.9% of all mistreatment events as reported by 16.6% of physicians. Other physicians were the second most common source of mistreatment, reported by 7.1% of respondents.

Verbal mistreatment was the most frequent form of mistreatment, reported by 21.5% of physicians, followed by sexual harassment and physical intimidation, reported by 5.4% and 5.2% of respondents, respectively. Women were more than twice as likely as men to experience mistreatment, and multiracial and Black physicians were more likely than White and Asian physicians to report experiencing mistreatment.

Examples of mistreatment included complaints or criticisms related to professionalism, such as appearance or behavior; quality of work; sexual comments or jokes, inappropriate sexual attention, unwelcome advances, and requests for sexual favors; use of slurs, insulting jokes or humor, name-calling, swearing, yelling, intimidation, verbal attacks, nonphysical threats, warnings about retaliation; and pushing, shoving, and sexual or racial assault.

“Reducing mistreatment and enhancing protective systems has inherent ethical value, particularly considering that mistreatment is experienced inequitably based on race and gender,” Rowe and colleagues wrote. “Initiatives that prioritize reducing mistreatment of women and physicians of color can help reduce gender- and race-based workplace inequities, and thereby support greater racial and gender diversity among physicians.”

Physicians who perceived that there were no systems in place to protect against mistreatment had 711% higher odds of intending to leave, scored higher on measures of burnout, and scored lower on measures of professional fulfillment compared with those who believed such systems were in place. The researchers wrote that initiatives targeting mistreatment may result in benefits to patients, physicians, and health care organizations through reduction of burnout and its associated effects on care.

“These findings highlight the urgent need for organizations to put systems in place to reduce the incidence of mistreatment and for more research to determine which systems will be most effective,” the researchers concluded.

For related information, see the Psychiatric News article “Patient Characteristics Should Determine Response to Threatening Behavior.”

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Risk of Chronic Conditions Found Higher Among Certain Groups With Depression, Anxiety

Women aged 20 to 60 with depression or anxiety were more likely to develop multiple chronic conditions over time compared with similarly aged women without depression or anxiety, according to a report published this week in JAMA Network Open. Women with comorbid anxiety and depression had an even greater risk of developing chronic conditions.

Similarly, men with depression and/or anxiety at age 20 were more likely than those without depression or anxiety to develop chronic conditions.

“Our findings support the need for managing comorbid depression and anxiety, which may help lower the risk of premature mortality associated with [having multiple chronic medical conditions],” wrote William V. Bobo, M.D., M.P.H., of the Mayo Clinic in Florida and colleagues.

The researchers used data from the Rochester Epidemiology Project to identify a cohort of 40,360 residents of Olmsted County, Minn. (including 21,516 women), who celebrated their 20th, 40th, or 60th birthdays between 2005 and 2014. They were followed until death, last medical contact, or December 31, 2017.

They compared incidence rates of 15 chronic conditions of people diagnosed with depression or anxiety, comorbid depression and anxiety, and no depression or anxiety. Chronic conditions included hypertension, coronary artery disease, diabetes, stroke, asthma, and cancer.

Among women aged 20, those with comorbid depression and anxiety had a 1.60 times greater risk of developing chronic conditions than women in the same cohort who did not have depression or anxiety. The risk was 1.41 times greater for women aged 40 with comorbid depression and anxiety, and 1.29 times greater for women aged 60. Women in all three age groups who had depression or anxiety alone also had a higher risk of developing chronic conditions.

Men aged 20 with comorbid depression and anxiety had a 1.77 times greater risk of developing chronic conditions than men without depression or anxiety, but the increased risk was not statistically significant at age 40 and age 60.

The researchers noted that extensive research has documented associations of depression, anxiety, or depressive and anxious symptoms with the later onset of cardiovascular diseases, metabolic diseases, certain types of cancer, and chronic or recurring pain syndromes.

“Our findings suggest that common mechanisms may underlie depression and anxiety as well as aging and that these mechanisms may be magnified when depression and anxiety co-occur,” they wrote.

For related information, see the Psychiatric News article “Collaborative Care Improves Quality of Life in Patients With Heart Failure.”

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Black Parents’ Experiences of Racial Discrimination Associated With Children’s Depression

Black parents’ experiences of racial discrimination may be linked to greater conflict with their children, which could in turn be associated with higher levels of depression and anxiety among children, according to a study published in the Journal of the American Academy of Child & Adolescent Psychiatry.

Previous studies of Black adults have found that overt forms of racial discrimination, including being treated with less respect or unfairly stopped or threatened by police, contribute to heightened depression, anxiety, and traumatic stress, wrote Chardée Galán, Ph.D., of the University of South California and colleagues. “[S]tudies find that parents’ exposure to race-based discrimination is negatively linked not only to their own well-being but also to their parenting practices and parent-child relationship quality.”

Galán and colleagues recruited families who self-identified as Black from the Safe Keeping Youth study—a randomized, controlled trial of youth and caregivers receiving services at a clinic serving low-income youth in Pittsburgh. Families were recruited based on their sociodemographic risk, such as if they received Medicaid or their income was at or below 150% of the federal poverty level and if their children were between the ages of 9.75 and 13 years old and exhibited problem behaviors (such as impulsivity).

Families participated in 2.5-hour assessments in their homes when the parents and children entered the study, one year later, and two years later. The assessments consisted of questionnaires that both the parent and child completed, as well as video-recorded discussions between them. At the start of the study, parents completed the Microaggression Scale, a nine-item measure of parents’ experiences of discrimination related to race/ethnicity. During the one-year follow-up, parents were asked about their experience with 20 depressive symptoms and the frequency of these symptoms over the past week; youth completed an interview to assess behavioral and emotional problems and parent-child conflict. During the two-year follow-up, parents reported behavioral and emotional problems observed in the youth over the past six months, and youth were asked about their experiences with depressive symptoms, anxiety symptoms, and frequency of such activities as property damage or theft in the past year.

In total, 199 families completed all three assessments, and over 96% of parents who completed the initial assessment were mothers. Parents’ experiences of racial discrimination at the start of the study were not associated with parental depression a year later, but they were associated with parent-child conflict. Further, there was a significant association between parent-child conflict at the one-year follow-up and youth depression, anxiety, and conduct problems at the two-year follow-up, as reported by both children and parents. The authors did not identify a significant association between parental depression and parent-child conflict.

“Findings from this study suggest that efforts to promote youth well-being and resilience in the context of pervasive racism must consider the effects that racial discrimination has on the entire family unit and the quality of parent-child relationship,” the authors concluded. “[O]ur results can be used to further inform the development of key treatment targets for future clinical interventions.”

For related information, see the Psychiatric News article “We Must Speak to Patients and Their Families About Racism.”

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Study Reveals Drop in Spanish-Language Services at U.S. Mental Health Treatment Facilities

Even as the number of people who identify as Hispanic in the United States grew by an estimated 5.2 million people (or about 4.5%) between 2014 and 2019, the proportion of U.S. mental health treatment facilities offering services in Spanish fell by nearly 18%, a report published today in Psychiatric Services has found. The study also revealed that among states with the fastest Hispanic population growth, several also experienced the greatest reduction in Spanish-language services.

“A treatment provider’s competency in the patient’s primary language improves communication and allows for a more nuanced and personal discussion,” wrote George Pro, Ph.D., M.P.H., of the University of Arkansas for Medical Sciences and colleagues. “With the growing Hispanic population in the United States, a lack of providers who speak Spanish is a major barrier to health-seeking behavior.”

Pro and colleagues analyzed data from the National Mental Health Services Survey (N-MHSS), a survey completed annually by administrators from public and private mental health treatment facilities in the United States. Specifically, they focused on data collected from 13,015 facilities in 2014 and 12,345 facilities in 2019. Administrators of the facilities were asked to reply yes or no to the following question: “Do staff provide mental health treatment services in Spanish at this facility?” The authors also used data collected as part of the American Community Survey to estimate the proportion of states’ Hispanic residents in 2014 and 2019.

Between 2014 and 2019, the proportion of facilities that offered treatment in Spanish declined from 40.5% to 33.3%—a total loss of 1,163 Spanish-speaking facilities in the United States, Pro and colleagues reported. During the same period, Hispanics’ share of state populations increased from 17.6% to 18.4%—an increase of 5.2 million individuals, they wrote. Six states reported an increase in the percentage of facilities offering Spanish-language services during the study period: Delaware, Hawaii, Maryland, Montana, Nebraska, and New Mexico; all other states experienced a decline in the availability of these services.

“[T]he ratio of the number of facilities providing Spanish-speaking services (per 100,000 Hispanic state residents) varied more than 22-fold across the country, from 2.1 facilities in Texas to 47.2 facilities in Vermont,” Pro and colleagues wrote.

They concluded, “To promote equity in mental health outcomes across populations, efforts should be made to strengthen access to services, improve the quality of care, and promote culturally responsive services for large and growing Hispanic populations in the United States.”

For related information, see the American Journal of Psychotherapy article “Psychotherapy, Spanish, and Hispanic Patients With Limited English Proficiency.”

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ECT During Hospitalization for Depression Reduces Risk of Suicide by Nearly Half

Treating patients hospitalized for depression with electroconvulsive therapy (ECT) appears to reduce their risk of suicide by nearly 50% for at least one year, according to a study in Lancet Psychiatry. These findings came from a detailed analysis of nearly 70,000 hospital records from patients seen in psychiatric inpatient units in Ontario, Canada.

“We also found that this reduction in risk of death by suicide led to a significant reduction in all-cause mortality and that electroconvulsive therapy did not increase the risk of non-suicide deaths,” wrote Tyler Kaster, Ph.D., of the University of Toronto and colleagues. “Taken together, these findings support the view that electroconvulsive therapy can be a lifesaving treatment in patients with severe depression.”

Kaster and colleagues used Canadian registries to examine the mortality outcomes of all adults aged 18 and older with a primary diagnosis of major depressive disorder or bipolar disorder who were discharged from a psychiatric bed in Ontario between April 1, 2007, and December 31, 2017. Individuals were included in the analysis multiple times if their hospitalizations occurred more than 12 months apart. The final sample included 67,327 hospital discharges, of which 4,982 received ECT.

A total of 450 people included in the analysis died by suicide within 12 months of discharge from the psychiatric hospital; this included the deaths of 27 people in the group who had ECT (5.84 per 1,000 person-years) and 423 in the group who had not had to ECT (7.26 per 1,000 person-years).

After adjusting for potential variables that might influence receipt of ECT (such as age and medical comorbidities), the researchers found that patients who had received ECT in the hospital had a 47% reduced risk of suicide death and a 25% reduced risk of any death over 12 months compared with those who did not receive ECT. With regards to absolute risk reduction, ECT was found to be about as effective at reducing death by suicide as lithium, Kaster and colleagues added.

“This study reinforces the importance of electroconvulsive therapy, particularly for people with severe depression,” they wrote.

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

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