Suicide, Relapse Risk Lower When Schizophrenia Patients Take Long-Acting Injectables

People with schizophrenia who take long-acting injectable antipsychotics (LAIs) have a lower risk of disease relapse, health care use, and adverse events such as suicide attempts compared with those who take oral antipsychotics, a study in JAMA Network Open has found.

Yue Wei, M.P.H., of the University of Hong Kong and colleagues examined data from the electronic health records of 70,396 adults with schizophrenia who were prescribed at least one LAI and at least one oral antipsychotic between 2004 and 2019. They then compared the rates of different health outcomes during periods when patients were taking only LAIs with the periods when patients were taking only oral antipsychotics.

Compared with treatment with oral antipsychotics, treatment with LAIs was associated with 44% fewer suicide attempts, 37% fewer all-cause hospitalizations, and 48% fewer psychiatric hospitalizations for psychiatric disorders. LAIs were also associated with a 12% reduction in hospitalizations for cardiovascular diseases and a 14% reduction in extrapyramidal symptoms (such as an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements), suggesting LAIs were not associated with more adverse side effects than oral medications. There were no significant differences between LAIs and oral antipsychotics with respect to emergency department visits.

Wei and colleagues wrote that their results build upon those found in other studies.

“Our study adds further insights, as we investigated hospitalizations for different causes and safety outcomes, with findings that [LAIs] were associated with not only fewer disease relapses and less health care use, but also fewer adverse events,” they wrote. “It is worth investigating the medication preference and clinical outcomes of people treated with [LAIs] by performing multinational studies.”

For more information, see the American Journal of Psychiatry article “Maintenance Treatment With Long-Acting Injectable Antipsychotics for People With Nonaffective Psychoses: A Network Meta-Analysis.”

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Be Careful When Entering Arrangements With Purported Telemedicine Companies, HHS Warns

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has issued a special alert warning physicians and other health care professionals of the fraud and abuse risks associated with arrangements with telemedicine companies.

“OIG has conducted dozens of investigations of fraud schemes involving companies that purported to provide telehealth, telemedicine, or telemarketing services,” according to the alert. In some cases, telemedicine companies paid kickbacks to physicians sometimes described as payment per review, audit, consult, or assessment of medical charts,” OIG wrote. “OIG is aware that many practitioners have appropriately used telehealth services during the current public health emergency to provide medically necessary care to their patients,” the alert continued. However, OIG encourages physicians and other health care professionals to use heighten scrutiny before entering into arrangements with telemedicine companies. The alert outlines seven “suspect characteristics” that could suggest an arrangement that presents a heightened risk of fraud and abuse.

The full alert from OIG is available here. For more information about telepsychiatry, check out APA’s Telepsychiatry Toolkit.

People With Severe Mental Illness Have Elevated Risk for Multiple Physical Illnesses

People with severe mental illness (SMI)—including schizophrenia, bipolar disorder, and other psychotic disorders—have a significantly greater risk of developing multiple physical illnesses in the first few years after their SMI diagnoses compared with people without SMI, according to a report published in Lancet Psychiatry.

“If we are to positively affect the incidence and disability burden of chronic physical health problems in people with severe mental illness, interventions need to start early,” wrote Naomi Launders, M.Sc., David P. J. Osborn, Ph.D., and colleagues at the University College London.

Launders, Osborn, and colleagues used electronic health records from the UK Clinical Practice Research Datalink (a database containing records of patients seen in U.K. primary care practices) to identify patients aged 18 to 100 years who were diagnosed with an SMI between 2000 and 2018. The study included 68,789 patients with SMI who were matched with 274,827 patients without SMI. The authors examined if participants in the SMI group were diagnosed with up to 24 chronic physical health conditions five, three, and one years before and after they were diagnosed with SMI, as well as at the time of their SMI diagnoses; physical conditions in the matched group were tracked over the same period. The physical conditions include cancer, diabetes, asthma, hypertension, and HIV/AIDS.

At the time of their first SMI diagnoses, 43% of patients with SMI had at least one chronic physical health problem, compared with 38% of the matched group. The most prevalent conditions among SMI patients were asthma, hypertension, diabetes, neurological disease, and hypothyroidism. Five years later, 57% of patients with SMI had one or more physical health condition, compared with 47% of patients without SMI.

Patients with schizophrenia were at higher risk of five of the physical health conditions compared with the matched group at the time of diagnosis. Five years later, these patients had a greater risk of 13 of the physical health conditions, including nearly three times the risk of neurological disease and twice the risk of diabetes. Patients with bipolar disorder or other psychotic disorders had a higher risk of 15 of the physical health conditions compared with the matched group at the time of diagnosis. Five years later, patients with bipolar had a higher risk of 19 conditions, including nearly three times the risk of hypothyroidism and neurological disease, and patients with other psychotic disorders had a higher risk of 16 physical conditions, including nearly four times the risk of neurological disease.

“Chronic physical health problems should not be viewed as the inevitable result of psychotropic medication’s adverse effects and long-term health risk factors such as poor diet, smoking, or drug or alcohol misuse, because many of these conditions are present at the point of severe mental illness diagnosis first being recorded,” the authors concluded. “Potentially, interventions targeted at improving the physical health of people with severe mental illness have been initiated too late relative to disease progression, and we need to consider early intervention for physical health as well as mental health in this population.”

For related information, see the Psychiatric Services article “Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector.”

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APA Releases Positions on Psychedelics, Police Interactions With Minors in Crisis, and More

APA’s Board of Trustees has approved six position statements on issues including the need for continued research into the use of psychedelics to treat psychiatric disorders, the role of psychiatry in care of patients with HIV, and the mental health needs of immigrants and people affected by forced displacement.

Position statements approved by the Board of Trustees are official policy of APA on issues that are critical to the practice of psychiatry and to public health. The following are summaries of the statements approved by the Board:

Position Statement on the Use of Psychedelic and Empathogenic Agents for Mental Health Conditions

There is inadequate scientific evidence for endorsing the use of psychedelics to treat any psychiatric disorder except within the context of approved investigational studies. Clinical treatments should be determined by scientific evidence in accordance with applicable regulatory standards and not by ballot initiatives or popular opinion.

Position Statement on Police Interactions With Children and Adolescents in Mental Health Crisis

APA calls for national standards that protect children and adolescents against violence by law enforcement responding to youth in mental health crisis. This includes support for health care and mental health workers as first responders to noncriminal calls such as mental health crises; limits on the use of force against children; and mandatory training for law enforcement personnel who respond to youth in mental health crisis.

Position Statement on the Impact of Structural Racism on Substance Use and Substance Use Disorders

APA supports legislation and policies that promote equity and improve the social and structural determinants of substance use and substance use disorders (SUD) and opposes legislation and policies that perpetuate racial inequities. Additionally, APA supports multidisciplinary education on historical and current racial inequities around substance use and SUDs as well as culturally informed research on substance use and SUDs.

Position Statement on the Mental Health Needs of Immigrants and People Affected by Forced Displacement

Immigrants, asylum seekers, refugees, persons in the temporary protected status program, and persons in immigration custody should be treated with dignity and respect during all phases of migration. Government and health care agencies as well as community groups should work together to ensure this population has access to timely, affordable, trauma-informed, culturally accessible quality health care, encompassing mental health care and substance use treatment.

Position Statement on Level of Care Determinations for Acute Psychiatric Treatment

Utilization review (UR) is a process conducted by public and private insurers to evaluate a patient’s treatment plan to determine what level of care is necessary. APA supports focusing UR on hospitalized patients with high clinical need, psychosocial complexity, histories of repeat admissions, frequent emergency department visits, prolonged inpatient stays, and homelessness or other issues based on social determinants of health. APA supports education and training for UR agents and clinicians to ensure consistent and transparent utilization review and level of care determinations.

Position Statement on the Role of Psychiatry in HIV

The care of individuals with HIV requires comprehensive treatment, both physical and mental health attention, including collaboration between primary care physicians, psychiatrists, and other specialists, and continued research into the neurocognitive sequelae of HIV in the brain.

The full text of all of APA position statements are posted at https://www.psychiatry.org/about-apa/policy-finder. A report on the July APA Board of Trustees meeting will be featured in a future edition of Psychiatric News.

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School MH Professionals Found to Be Biased Against Black, Latinx Students

Mental health professionals working in U.S. schools—the setting where youth are most likely to access mental health services—associate distinct negative traits with Black and Latinx students, suggests a report in Psychiatric Services. School mental health professionals also showed pro-White, anti-Black, and anti-Latinx biases toward school-age youth on implicit bias tests. 

“Clinician bias includes prejudice (both positive and negative evaluations) and stereotyping (traits associated with a given social group),” wrote Freda F. Liu, Ph.D., of the University of Washington School of Medicine and colleagues. To understand the role of stereotypes and bias by mental health professionals in U.S. schools, Liu and colleagues conducted two separate studies.

The first study involved an online survey of 42 U.S. school-based clinicians. According to the authors, the participants were “geographically diverse,” predominantly White (81%), and female (95%). The participants were asked to reflect on conversations they have had or overheard of their colleagues and identify “behaviors or characteristics [they] think school mental health professionals most commonly associate with” Black youth. They were given the same prompt and asked to identify the behaviors and characteristics that school mental health professionals commonly associated with Latinx youth. For each group, the participants were encouraged to fill in their own responses and then to select the top three from a list of 14 characteristics.

Most (81%) of the school-based clinicians surveyed identified academic failure as the characteristic most frequently associated with Black and Latinx youth; 76% identified anger and aggression as a stereotype for Black youth and 29% identified this stereotype for Latinx youth; 62% described Latinx youth as unmotivated and 45% described Black youth this way.

Liu and colleagues next developed four distinct Implicit Association Tests (IATs) to assess school-based mental health clinicians’ implicit prejudice and stereotyping of Black and Latinx youth relative to non-Hispanic White youth. The IAT is a computer categorization task that measures the relative strength of associations by examining the speed with which people assign images and words to categories (for example, people who have stronger pro-White or anti-Black biases would be faster at pairing White people with positive words and Black people with negative words than the reverse), the authors noted. 

A new sample of 58 U.S. school-based mental health clinicians (74% White and 90% female) completed the IATs, as well as the Bias Awareness Scale, a four-item questionnaire that measures awareness of and concern for one’s own implicit bias. 

All four IATs generated average IAT difference scores that indicated implicit prejudice or stereotypes favoring White over Black and Latinx youths, the authors reported. The IATs negatively correlated with participants’ self-reported awareness of their own implicit bias (for example, those who demonstrated greater implicit bias reported less personal awareness and concern for implicit bias).

“The small samples in both studies limit the generalizability of findings, such that replication is needed before firm conclusions can be drawn,” Liu and colleagues wrote. However, the studies “provide important foundational knowledge and research tools (new IATs) to better understand how clinician bias contributes to biased care and disparate outcomes in youth mental health.”

For related information, see the Psychiatric News article “Psychiatrists Unveil Anti-Racism Tool.”

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Hypothyroidism in Dementia Patients Often Overtreated, Study Suggests

Dementia screenings often include thyroid evaluations, as there is some evidence that hypothyroidism—characterized by elevated thyroid-stimulating hormone (TSH) and reduced thyroid hormone levels—may contribute to cognitive problems. A study in Journal of the American Geriatrics Society now reports that older adults with hypothyroidism and dementia are more likely to receive too high a dose of thyroid hormone supplements or not enough compared with older adults with hypothyroidism who do not have dementia.

“With millions of individuals older than 70 years of age living with various forms of dementia, understanding the impact of clinical practice patterns can help clinicians start to individualize their approach to TSH elevation in older adults with dementia, which is critical to optimizing care,” wrote Enoch J. Abbey M.D., M.P.H., of Johns Hopkins University and colleagues.

Abbey and colleagues looked at data from HealthABC, a longitudinal study that began tracking the health outcomes of 3,075 adults aged 70 to 79 living independently in Memphis or Pittsburgh in 1997-1998. At the start of the study, none of the participants had dementia. In the second year of the study, 2,798 participants who were not taking anti-thyroid drugs for hyperthyroidism received TSH and cognitive testing. TSH levels between 0.45 and 4.5 mIU/L were considered normal.

During the second year of the study, 2.3% of the participants developed dementia. Compared with adults without dementia, those with a dementia diagnosis were slightly more likely to be taking thyroid hormone supplements (12.9% vs. 9.8%), the authors wrote. Older adults without dementia were much more likely to have elevated TSH that was not being treated with thyroid hormone supplements (10.7% vs. 1.9%). Abbey and colleagues said this discrepancy likely results from an aggressive attempt to treat hypothyroidism in dementia patients.

Further calculations showed that older adults with dementia who received thyroid supplements were 2.4 times as likely to not be receiving a high enough dose of thyroid hormone supplements (still had TSH levels above 4.5 mIU/L) and 10 times as likely to receive too high a dose of thyroid hormone supplements (TSH levels below 0.45 mIU/L) than older adults without a dementia diagnosis taking thyroid hormone supplements.

“If low TSH … levels are risk factors for dementia progression, and this status often results from thyroid hormone use, prescribing supplementation for emerging cognitive dysfunction has the potential to exacerbate cognitive decline,” Abbey and colleagues noted.

To read more on this topic, see the Psychiatric News article “Worse Outcomes in Patients With Depression Linked to Low Thyroid Hormones.”

Anger Issues as Veterans Leave Military May Point to Future Mental Health Problems, Study Finds

American service members whose anger causes them significant distress and decreased function (problematic anger) during their transition to civilian life may have a higher risk of mental health conditions such as depression and posttraumatic stress disorder (PTSD), a study in JAMA Network Open has found. The results also suggest that service members who have problematic anger during the transition are more likely to have difficulty in their relationships and experience financial instability.

“Given problematic anger is often underrecognized and undertreated, organizations could … leverage these results by ensuring that service members are trained in healthy emotion regulation,” wrote Amy B. Adler, Ph.D., of the Walter Reed Army Institute of Research and colleagues. “Training could also target individuals at high risk for problematic anger, and screening for problematic anger could be considered prior to [accepting people into the military].”

Adler and colleagues analyzed data from 3,448 participants in two waves of the Millennium Cohort Study, which investigates health effects associated with military service. The two waves were administered approximately five years apart. Participants were U.S. active-duty service members within 24 months of separating from the military at the first wave, and they were followed for up to 24 months after separation.

Participants were considered to have problematic anger if they scored at least 12 points on the 5-item Dimensions of Anger Reactions scale (DAR-5) at the first wave. The DAR-5 measures anger frequency, intensity, duration, aggression, and interference with social functioning. Participants’ behavioral and functional health was measured with standardized assessments such as the 8-item Patient Health Questionnaire and the PTSD Checklist-Civilian Version, as well as questions about their relationships and financial health.

Overall, 24% of participants screened positive for problematic anger during the first wave. The prevalence of problematic anger was lowest at 20 to 24 months prior to separation, with 15.9% screening positive, and highest at 20 to 24 months following separation, with 31.2% screening positive.

Programs designed to promote successful military-to-civilian transition should target the period before and immediately after separation, the authors wrote. Such programs are likely also needed “even years later, given there was no observed levelling off of [problematic anger] prevalence 2 years after separation,” they added.

After adjusting for mental health, problem drinking, and physical health at the first wave, the researchers found that participants who had problematic anger had 1.77 times the odds of screening positive for depression and 1.55 times the odds of screening positive for PTSD compared with participants who did not have problematic anger. Those with problematic anger were also more likely to report lower relationship quality, difficulties with parental coping, lower social support, lower financial security, unemployment, and job seeking.

“Individuals may benefit from knowing that problematic anger may pose a risk to their well-being, important relationships, and fiscal health,” Adler and colleagues wrote. “Much like public health messaging regarding diet and exercise can encourage individuals to follow a healthier lifestyle, warning about the association of problematic anger on well-being may be similarly helpful.”

For related information, see the Psychiatric Services article “Mental Health Care Use Among U.S. Military Veterans: Results From the 2019–2020 National Health and Resilience in Veterans Study.”

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Efforts to Reduce Use of Seclusion, Restraint at Pennsylvania State Hospitals Found Successful

The frequency and duration of mechanical restraint, physical restraint, and seclusion on patients committed to six Pennsylvania state hospitals and two forensic centers significantly declined between 2011 and 2020, according to a report published yesterday in Psychiatric Services. During the same period, incidents of assault, aggression, and self-injurious behavior also declined. 

“Uses of seclusion and restraints can be reduced or eliminated in both civil and forensic populations, with benefits to both the persons being served and their support staff,” wrote Gregory M. Smith, M.S., of Allentown State Hospital, Aidan Altenor, Ph.D., of Wernersville State Hospital, and colleagues. 

The Pennsylvania Department of Human Services, Office of Mental Health and Substance Abuse Services, was an early pioneer in reducing the use of seclusion and restraints in its state hospitals and forensic centers, according to Smith, Altenor, and colleagues. “This renaissance in the care of people with mental illness has spread worldwide, with seclusion and restraint no longer viewed as treatments, but rather as treatment failures,” they wrote.

The authors analyzed data on 3,989 adults committed to the Clarks Summit, Danville, Norristown, Torrance, Wernersville, and Warren State Hospitals in Pennsylvania and 3,548 adults committed to the Regional Forensic Centers at Norristown and Torrance State Hospitals between January 1, 2011, and December 30, 2020.

During the study period, seclusion was used at the civil hospitals three times for a total of 189 minutes and was last used in July 2013; mechanical restraint was applied 118 times for a total of 16,611 minutes and was last used in September 2015; and physical restraint was used 6,972 times for a total of 31,916 minutes. Physical restraint use decreased from a high of 2.62 uses per 1,000 days in 2013 to 1.9 per 1,000 days in 2020, the authors noted. Additionally, the average length of time a person was held in physical restraint declined from 6.6 minutes per episode in 2012 to 2.4 minutes or less from 2018 to 2020.

At forensic hospitals, containment procedures also declined over the study period. Seclusion was used once, in 2012, for 345 minutes; mechanical restraint was used 10 times for a total of 432 minutes and was last used in 2014; physical restraint was used 2,546 times for a total of 8,606 minutes. Physical restraint use also significantly declined in forensic hospitals—from a high of 3.8 episodes per 1,000 days in 2012 to 2.5 in 2020. The duration of physical restraint episodes significantly declined from 6.8 minutes in 2011 to 2.5 minutes or less from 2017 to 2020.

Incidents of aggression, defined as a verbal or physical threat of injury, were reported 12,167 times during the study period and were the leading reason for physical restraint use, accounting for 32.8% of use of the procedure. The number of patient-to-staff assaults, incidents of self-injurious behavior, and patient-to-patient assaults all declined during the study period.

“Pennsylvania’s ongoing emphasis on staff training, de-escalation techniques, [and] psychiatric emergency response teams … contribute to a person-centered approach to care and treatment with significant benefits to staff and patients,” the authors wrote. “Marked reduction in aggression, patient-to-patient and patient-to-staff assaults, and instances of self-injurious behaviors in the civil hospitals and forensic centers during this period all reinforce the utility of this approach.”

For related information, see the Psychiatric News article “Ensuring Patient, Staff Safety Begins With Supportive Management, Staff Training.”

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Black Youth Experienced Increased Racial Discrimination Online in 2020, Study Finds

Between March and November 2020, Black youth experienced increased online racial discrimination and reported poorer mental health immediately after, according to a study published this week in the Journal of the American Academy of Child & Adolescent Psychiatry.

“In 2020, the killings of Breonna Taylor, George Floyd, and other Black Americans at the hands of White civilians and law enforcement sparked an uprising against racial injustice that was met with fierce opposition from white nationalists and domestic terror groups in the United States,” wrote Juan Del Toro, Ph.D., and Ming-Te Wang, Ed.D., of the University of Pittsburgh. Those groups became more prominent in online spaces as youth simultaneously relied on those online spaces to connect with peers during the COVID-19 pandemic.

Del Toro and Wang recruited 602 self-identified Black and White adolescents (58% Black, 42% White) between the ages of 12 and 18. For two weeks in March, April, May, and October 2020, the participants completed daily surveys to determine if they had experienced online racial discrimination and to assess their mental health symptoms. Rates of participation varied from month to month, with 44% participating in the March surveys and 57% participating in the October surveys. The researchers collected a total of 18,454 daily assessments.

The authors included a single item from the Online Victimization Scale in the surveys to determine if the participants experienced online racial discrimination (Participants were asked: “Over the past 24 hours, did anyone say or post mean or rude things about you because of your race or ethnic group online?”). Participants were also asked about symptoms of their depression, anxiety, stress, and exhaustion/tiredness through the Profile of Mood States Questionnaire and a single item from the Daily Stress Scale.

Across all four survey periods, 45% of Black youth reported at least one instance of online racial discrimination. On average, Black youth experienced two incidents of online racial discrimination during the study period. The percentage of participants experiencing online racial discrimination increased from 8% during the first survey period to 22% during the final survey period, and the authors noted that this increase was not solely explained by increased time spent online. In contrast, reporting of online racial discrimination was low in White youth, ranging from 8% in the first survey to 11% in the last.

Black adolescents who experienced online racial discrimination also reported increased depressive symptoms, anxiety, and stress both on the day they experienced the discrimination and the next day, relative to days when they did not experience discrimination. No discernible effect of online racial discrimination emerged for White youth, the authors noted.

“[C]hronic exposure to online settings may exacerbate the impact of racial discrimination on youth’s mental health. Importantly, these daily effects may accrue and over time contribute to clinically significant levels of impairment,” Del Toro and Wang wrote. “To prepare racially minoritized youth and their families to cope with these adverse experiences, psychiatrists and clinicians should recognize online spaces as developmental contexts with immediate consequences for youth’s mental health.”

Health care professionals should be trained on culturally sensitive assessments and effective communication skills to use when patients’ racial trauma arises in clinical settings, the authors added. “[C]onversations about racial discrimination would be incomplete without discussing practical approaches to cope with race-related stressors in daily life.”

For related information, see the Psychiatric News article “Psychiatrists Demand Action on Racism.”

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Study Points to Benefit of Removing Barriers to Treatment for Opioid Use Disorder

A policy shift early in the pandemic from requiring people with opioid use disorder to report daily to clinics for methadone to sending stable patients home with a 28-day supply of the medication did not appear to lead to increased overdose deaths involving methadone relative to overdose deaths involving other substances, suggests a report published in JAMA Psychiatry. Rather, the percentage of overdose deaths involving methadone fell after March 2020, while overdose deaths that did not involve methadone continued to rise.

“Treatment is an essential tool to stop the addiction and overdose crises, but it is vastly underused,” said National Institute on Drug Abuse Director Nora Volkow, M.D., senior author of the study, in a news release. “This evidence adds significant weight to the argument that effective treatment for substance use disorders should be offered in an accessible and practical way that works for people who need it.”

Historically, people being treated with methadone for opioid use disorder in the United States could access this treatment only at federally certified opioid treatment programs (OTP), where most are required to make daily visits to receive the medication—a barrier for people trying to balance work, child care, and other needs, the release noted. On March 16, 2020, in an effort “to provide increased flexibility,” the Substance Abuse and Mental Health Services Administration (SAMHSA) alerted states that they could “request blanket exceptions for all stable patients in an OTP to receive 28 days of take-home doses of the patient’s medication for opioid use disorder.” The guidance also allowed patients identified by the OTP as “less stable” to receive up to 14 days of take-home medication.

For the current study, Volkow, Christopher M. Jones, Pharm.D., Dr.P.H., of the Centers for Disease Control and Prevention (CDC), and colleagues analyzed monthly drug overdose deaths that took place from January 2019 to August 2021, as recorded in the CDC’s National Vital Statistics System.

“After March 2020, overdose deaths not involving methadone continued to increase [by] approximately 69 deaths per month, whereas methadone-involved overdose deaths remained stable,” the authors wrote. The percentage of overall overdose deaths involving methadone fell from 4.5% of overdose deaths in January 2019 to 3.2% by August 2021, they added.

“Coupled with research demonstrating improved patient satisfaction, treatment access, and engagement from these policies, these findings can inform decisions about permanently expanding take-home methadone,” the authors concluded.

For related information, see the Psychiatric News articles “Pandemic Creates Challenges, New Opportunities for Treating Patients With Substance Use Disorder” and “Discrimination Persistent Barrier to Care for OUD Patients.”

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Child Care Stress Among Health Care Workers Associated With Burnout, Intent to Reduce Hours

Health care workers who reported experiencing high levels of stress about child care during the first months of the COVID-19 pandemic were more likely to report anxiety, depression, and burnout compared with those without child care stress, according to a report published today in JAMA Network Open. Health care workers experiencing such stress were also more likely to report an intent to reduce their hours or leave their position than those without child care stress.

“Since the start of the pandemic, 1 in 5 [health care workers] has quit their job according to a poll conducted in September 2021,” wrote Elizabeth M. Harry, M.D., of the University of Colorado School of Medicine and colleagues. “[P]rograms to reduce [child care stress] may be beneficial for workers and health systems.”

The findings were based on the results of the 14-item Coping with COVID survey of 58,408 health care workers (including 15,766 physicians and 11,409 nurses), conducted between April and December 2020. Survey participants were asked about their experiences with anxiety or depression; concerns about such factors as child care, work overload, and exposure of self and family members to COVID; and the likelihood they might reduce clinical care hours over the next year or leave practice within two years.

About 21% of all health care workers surveyed reported experiencing child care stress. “Racial and ethnic minority individuals had 40% to 50% greater odds of reporting [child care stress] than white respondents, and women had 22% greater odds of reporting [child care stress] than men,” Harry and colleagues reported. Those experiencing child care stress had 115% greater odds of anxiety or depression and 80% greater odds of burnout than those without child care stress, the authors continued. Additionally, participants who reported high child care stress were more likely to endorse an intent to reduce their clinical hours or leave their practice compared with those without child care stress.

“The COVID-19 pandemic has had … myriad … effects on [health care workers] that put our workforce at risk,” Harry and colleagues wrote. “Workplaces that can accommodate change on short notice, provide on-site care for ill children or on-site schools, and are aware of worker concerns about their children will be better positioned to show workers they are a caring environment, one that, we hope, workers would be more likely to remain with rather than leaving for shift work in other settings, a scenario that is currently occurring in large numbers.”

For related information, see the Psychiatric Services article “Health Care Workers’ Mental Health and Quality of Life During COVID-19: Results From a Mid-Pandemic, National Survey.”

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COVID-19 Public Health Emergency Extended Through Mid-October

The Department of Health and Human Services has renewed the public health emergency until October 13 due to the continued consequences of COVID-19. States will be given 60 days’ notice before termination of the public health emergency. The public health emergency was initially declared in January 2020, when the coronavirus pandemic began.

988 Suicide Prevention, MH Crisis Hotline Launched but Many States Unprepared

The nationwide 988 suicide prevention and mental health crisis line launched on July 16, although many states have not yet enacted legislation that would ensure there are crisis services available so 988 callers actually receive the kind of help they need.

The Federal Communications Commission approved 988 in July 2020. As of the launch date, all phone service providers were required to direct all 988 calls to the existing National Suicide Prevention Lifeline (1-800-273-TALK). This includes all telecommunications carriers and interconnected and one-way Voice over Internet Protocol (VoIP) service providers. The current Lifeline phone number is still in operation.

So far only four states—Colorado, Nevada, Virginia, and Washington—have passed comprehensive 988 legislation that includes funding to help 988 function as intended. This legislation allows them to build their local call center infrastructure, manage the increases in call volume that are expected when 988 goes live, and create new local crisis services to serve those in need. These states also included in their legislation an ongoing means of funding the new crisis services by tacking a small user fee onto each phone line, residential and commercial, as has been done for 911 for decades. Several other states have passed infrastructure laws but do not include user fees or appropriations to support mental health infrastructure.

Yet 37 states have not passed 988 legislation at all. People in those states will be able to call 988, but beyond that, little will change.

The number for crisis services switched to 988 in July, "but that’s the only thing that we can take for granted here,” Eric Rafla-Yuan, M.D., APA’s 2021 Jeanne Spurlock Congressional Fellow, told Psychiatric News. “Everything else that happens when someone calls that number is still up in the air in these states. This is why advocates are needed at the state and federal levels to obtain the resources and support to make sure the needed changes happen.”

Last month a report by the RAND Corporation revealed that many state, regional, and county behavioral health program directors felt unprepared for the transition. In a survey of 180 such directors, more than half (51%) reported that they had not been involved in the development of a strategic plan related to the launch of 988. Similarly, only 16% of respondents reported that they had helped develop a budget to support 988 operations.

APA is working with its district branches to advocate for legislation supporting 988 implementation in states that have not yet done so. In March, APA joined a coalition to drive awareness and support among state and municipal officials for the nationwide transition to the new 988 hotline.

APA urges members in states that have not passed legislation to implement 988 to contact their district branch and get involved in advocacy on this issue. For more information, contact Erin Berry Philp of APA’s Division of Government Relations. To track what your state is doing to enact legislation that will support 988, visit https://reimaginecrisis.org/map/.

For related information, see the Psychiatric News articles “988 is Coming, But Most Localities Still Not Prepared” and “AMA House Approves Publicity for 988 Awareness, Other Mental Health Measures.”

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Transmission of Anxiety Disorders More Common Among Parents and Children of Same Sex

A child may have a greater risk of developing an anxiety disorder if his or her parent of the same sex has an anxiety disorder, according to a study published this week in JAMA Network Open.

“One of the strongest known risk factors for developing an anxiety disorder is having a parent with an anxiety disorder, an effect that increases with [two] parents being affected,” wrote Barbara Pavlova, Ph.D., of Dalhousie University in Nova Scotia and colleagues. “[I]f the contribution of the same-sex parent with a disorder is greater, it may suggest that modeling and vicarious learning from the same-sex parent play a role in the transmission.”

Pavlova and colleagues interviewed families participating in the Families Overcoming Risks and Building Opportunities for Well-Being study, a cohort study that recruited families with at least one parent with a mood disorder. All families had one or more offspring between the ages of 5 and 21. The authors assessed parents for psychiatric disorders using the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM-5 Disorders (SCID-5). The offspring were assessed for psychiatric disorders using the Kiddie Schedule for Affective Disorders and Schizophrenia, as well as the SCID-5.

In total, 398 offspring of 221 mothers and 237 fathers participated, and both biological parents of 231 offspring completed the interviews. Diagnoses among the parents included major depressive disorder, bipolar disorder, schizophrenia, and anxiety disorders. Anxiety disorders in the parents of the same sex as the offspring, but not in opposite-sex parents, was significantly associated with a lifetime diagnosis of anxiety disorders in the offspring. Additionally, sharing the household with a same-sex parent without anxiety, but not with an opposite-sex parent without anxiety, was associated with a decreased risk of anxiety disorders in the offspring.

Because mood and anxiety disorders in parents were often comorbid and associated with anxiety disorders in offspring, Pavlova and colleagues completed an analysis to determine the unique contributions of parent mood and anxiety disorders. When the researchers analyzed the data using major mood disorders and anxiety disorders as independent variables, they found that anxiety disorders in parents were significantly associated with increased rates of lifetime diagnoses of anxiety disorders in offspring, but mood disorders in parents were not.

“Based on our findings, compared with parental mood disorders, anxiety in parents appears to be more closely associated with anxiety in offspring,” the authors wrote. “Treating parents with anxiety disorders may protect their offspring, especially their same-sex offspring, from developing an anxiety disorder regardless of parental mood disorder.”

For related information, see the Psychiatric News article “Treating Family Members Can Break Depression Cycle, Says Expert.”

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Improved Screening and Treatments for Sleep Problems Could Reduce Risk of Alzheimer’s Disease

Improved screening and treatments for sleep problems could help reduce the risk of Alzheimer’s disease (AD) in coming years when the number of cases of AD worldwide is expected to increase dramatically, wrote Erik S. Musiek, M.D., Ph.D., and Yo-El S. Ju, M.D., M.S.C.I., both of Washington University School of Medicine in a Viewpoint article in JAMA Neurology.

Accumulating data support a bidirectional association between AD pathology and sleep and circadian function. (The circadian rhythm, which is disrupted in sleep disorders, is the natural cycle of sleep and wakefulness.) “Despite the clear clinical need for therapeutic strategies to address sleep and circadian dysfunction, at the bedside we are stymied by lack of screening tools, prognostic markers, and most importantly, treatments to offer patients,” they wrote.

The authors noted that decreased sleep quality and fragmented circadian rhythms are associated with the development of AD as much as 15 years before symptoms begin to show. Moreover, large longitudinal studies show that obstructive sleep apnea and insufficient sleep increase risk of cognitive impairment.

The authors offered the following recommendations for advancing and translating sleep and circadian science into new strategies for AD prevention and treatment:

Basic Research

• Identify mechanisms linking sleep to the production and clearance in the brain of amyloid beta and tau, proteins that are associated with AD.
• Conduct studies to determine which aspects of sleep—sleep duration, specific sleep stages, or other variables—are most critical in AD pathogenesis.
• Examine the effects of different sleep- and circadian-promoting drugs or interventions on tau aggregation, inflammation, and other degenerative processes.

Clinical Research

• Conduct longitudinal studies beginning 20 years prior to the onset of cognitive symptoms that include sleep and circadian measures.
• Update existing longitudinal studies of aging and dementia to include the collection of sleep and circadian measures and enroll diverse cohorts to assess whether race and ethnicity may be associated with sleep and AD outcomes.
• Test the effect of existing treatments on cognitive outcomes, with specific attention to safety and tolerability.
• Identify and test new nonsedating therapies for sleep and circadian disruption in dementia patients.

“Greater implementation efforts are required to translate the emerging science on associations between sleep and circadian function and AD to benefit at the societal level,” Musiek and Ju wrote. For instance, evidence-based guidelines for sleep and circadian health behaviors, screening, treatment, and monitoring are needed and these guidelines need to be communicated to the public.

“A tsunami of AD looms in the coming 20 to 30 years, and sleep and circadian therapies that reduce AD risk would benefit societal health,” they continued. “To achieve such a goal, researchers in this area must intentionally adopt strategies to translate science efficiently and collaboratively into clinical trials and public implementation.”

For related information, see the Psychiatric News article “Sleep Loss Found to Exacerbate Spread of Toxic Protein Associated With Alzheimer’s Disease.”

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Experts Debate Benefits, Drawbacks of Universal Suicide Screening

While most experts agree that suicide represents a worsening national epidemic in need of increased attention, there is less agreement on whether universal screening across health care settings is the best approach for identifying those at greatest risk. In a column published yesterday in Psychiatric Services, researchers offer two differing perspectives on the benefits and drawbacks of universal screening for suicide.

“Behavioral health providers across the country are both motivated to respond to the suicide epidemic in the United States and acutely aware of the unintended consequences of new requirements and regulations,” wrote editor Patrick Runnels, M.D., M.B.A., in a summary introducing the two columns in the journal’s “Controversies in Psychiatric Services” series.

Research shows that many people who die by suicide are seen in a primary care setting in the months leading up to their deaths. This has led some to advocate for expanding universal suicide risk screening in primary care.

Unlike indicated or selective suicide risk screening—which takes place after patients are identified through a positive depression screen or present with other mental health symptoms warranting further evaluation—universal screening involves all patients in both medical and mental health settings, regardless of the reason for their visit.

“Our position is that, relative to the known benefits of indicated or selected screening, the assumed benefits of universal screening in primary care are overestimated while it’s possible risks are underestimated,” explained Craig J. Bryan, Psy.D., of Ohio State University College of Medicine; Michael H. Allen, M.D., of the University of Colorado School of Medicine; and Charles W. Hoge, M.D., of Walter Reed Army Institute of Research, in the first of the two columns.

One such risk is an increase in false positives, the authors noted. “Some of these positive screening results would be perceived as medical emergencies in settings where further evaluation is not readily available, leading to problematic transfers to [emergency departments]. Such transfers will often be involuntary on the part of the patient, and some will result in unnecessary psychiatric hospitalization.”

They concluded, “Until confirmation of the hypothesis that universal screening can incrementally improve outcomes among primary care patients relative to indicated or selected screening, we believe it is best to follow existing evidence supporting the latter screening approach.”

In contrast, Julie Goldstein Grumet, Ph.D., of Zero Suicide Institute and Edwin D. Boudreaux, Ph.D., of the University of Massachusetts Medical School argued in the second of the two columns that targeted screening among only those with known behavioral health disorders “will miss many if not most adults and children at risk.” Another benefit of universal suicide risk screening might be improved training of health care professionals, according to the authors.

“Although adoption of universal screening is inherently associated with increased burdens in clinical settings, these burdens can be overcome,” Goldstein Grumet and Boudreaux wrote, pointing to the importance of involving leadership, frontline staff, information technology specialists, and others to design the protocol, workflow, and training and to oversee implementation of the screening.

They concluded, “The data are clear: Application of universal screening for suicide risk is feasible in health care, improves identification of risk, makes identification more equitable across racial groups, and, when combined with an intervention, reduces the probability of future suicidal behavior.”

For related information, see the Psychiatric News article “Half of Patients With Suicidal Thoughts Deny It.”

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Planning Around Patient Strengths Can Reduce Emergency Department Stays for Psychiatric Problems

A safety planning framework that focuses on one’s strengths can improve the outcomes of patients admitted to an emergency department (ED) with psychiatric distress, reports a study in Psychiatric Services in Advance.

“Previously, the approach to risk management was restrictive and focused on patient deficits,” wrote Manaan Kar Ray, M.R.C.Psych., of Princess Alexandra Hospital in Brisbane, Australia, and colleagues. An innovative approach called PROTECT, however, draws on the patient’s strengths and means of personal support to create the self-belief that suicidal urges can be overcome.

The PROTECT framework has hospital staff engage in semistructured conversations with psychiatric patients to help them prepare for three time points after discharge:

• One hour: Staff and patients discuss practical issues related to leaving the hospital, such as how the patients will get to where they will be staying, what might await the patients in such settings, and whether they have what they need for this transition (charged cell phone, wallet, follow-up appointments, and/or medications or prescriptions).
• Two days: Staff and patients discuss the patients’ short-term needs and goals, such as access to food, shelter, and money; with whom the patient will spend time; and what activities they have planned.
• Seven days: Staff and patients explore potential risk factors for distress that patients may face and how these risks might be mitigated.

PROTECT was implemented in Princess Alexandra Hospital (PAH) in December 2019. Kar Ray and colleagues compared the pre- and post-implementation ED data of PAH with a comparable hospital in Queensland that did not use PROTECT.

They found that 13 months after implementing PROTECT, the average length of stay for patients with psychiatric distress dropped from 17.3 to 8.6 hours, while the number of patients who stayed in the ED for more than 24 hours dropped from 24% to 6%. In addition, the number of patients who were transferred directly to inpatient care dropped from 23% to 18%. None of these statistics changed significantly at the comparator hospital over the 13-month period.

This intervention “can unlock patients’ potential to manage their safety and help them reconnect with hope at a time when hope is dwindling,” the authors wrote. “This outcome mitigates clinical risk and reduces [average length of stays] and may enhance patients’ experiences, which could improve future treatment engagement and early help seeking.”

For related information, see the Psychiatric Services article “Feasibility of Peer-Delivered Suicide Safety Planning in the Emergency Department: Results From a Pilot Trial.”

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Electroacupuncture May Lessen Insomnia, Improve Mental Health in People With Depression

Electroacupuncture may improve sleep quality and mental health in patients who have insomnia and depression, a study in JAMA Network Open has found. Electroacupuncture is a form of acupuncture that involves passing a small electric current between pairs of acupuncture needles.

Xuan Yin, M.D., of the Shanghai University of Traditional Chinese Medicine and colleagues studied data from 247 adults aged 18 to 70 years who had depression and insomnia. All patients received standard care, which included recommendations by psychiatrists to get regular exercise; eat a healthy diet; manage their stress; and continue taking their prescription medications, such as antidepressants, sedatives, or hypnotics. The patients were divided into three groups. One group received only standard care (the control group), one group received three electroacupuncture sessions per week for eight weeks, and one group received three sham acupuncture treatments per week for eight weeks. The researchers measured the patients’ sleep quality via the Pittsburgh Sleep Quality Index (PSQI) and the patients’ mental well-being using the 17-item Hamilton Depression Rating Scale (HDRS-17) at baseline and at 4, 8, 12, 20, and 32 weeks.

At the fourth week, PSQI scores dropped a mean of 3.4 points from baseline in the electroacupuncture group, 1.5 points in in the sham acupuncture group, and 0.6 points in the control group. At the eighth week, PSQI dropped a mean of 6.2 points from baseline in the electroacupuncture group, 2.5 points in the sham acupuncture group, and 1.1 points in the control group. The electroacupuncture group maintained a significantly greater decrease in PSQI than the other two groups through the study’s end.

At the fourth week, HDRS-17 scores dropped a mean of 7.0 points from baseline in the electroacupuncture group, 3.7 points in in the sham acupuncture group, and 1.3 points in the control group. At the eighth week, PSQI scores dropped a mean of 10.7 points from baseline in the electroacupuncture group, 5.0 points in the sham acupuncture group, and 1.9 points in the control group. The electroacupuncture group maintained a significantly greater decrease in HDRS-17 than the other two groups through the study’s end.

“In the present trial, [electroacupuncture] treatment with standard care was clinically beneficial and superior to [sham acupuncture] and/or standard care for treating insomnia and helped patients to improve their mental health status,” Yin and colleagues wrote.

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

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Concept of 'Preaddiction' Could Lead to Early Intervention for Possible Substance Use Disorder

About 20 years ago, diabetes care changed when an organized effort was made to identify patients at risk of diabetes earlier and connect them with treatment. A similar strategy could be used within the substance use disorder (SUD) field by using the term “preaddiction,” advised A. Thomas McLellan, Ph.D., George F. Koob, Ph.D., and Nora D. Volkow, M.D., in a Viewpoint piece published yesterday in JAMA Psychiatry.

“Addiction is the most severe form of a full spectrum of substance use disorders,” the authors wrote. “It has been the almost exclusive focus of U.S. clinical and policy efforts. However, serious addiction only results after years of unhealthy substance misuse that could be identified and managed much earlier.”

McLellan is the co-founder of the Treatment Research Institute, Koob is the director of the National Institute on Alcohol Abuse and Alcoholism, and Volkow is the director of the National Institute on Drug Abuse.

The transition from using a substance to developing a substance use disorder is usually slow and variable, the authors wrote. “[T]he DSM-5 uses 11 equally weighted symptoms of impaired control to define SUDs along a three-stage severity continuum,” they continued. Severe SUDs, commonly referred to as addiction, are defined by six or more symptoms and found in only 4% to 5% of adults, while mild to moderate SUDs are defined by two to five symptoms and found in about 13% of adults. “However, treatment efforts and public health policies have focused almost exclusively on those with serious, usually chronic addictions, virtually ignoring the much larger population with early stage SUDs,” the authors wrote.

When faced with a similar problem, the American Diabetes Association suggested the term prediabetes in 2001, defined by elevated scores on two laboratory tests (impaired glucose tolerance and impaired fasting glucose). Advertising campaigns that followed to raise public awareness and partnerships with insurers led to the creation of new medications, testing, and interventions. If a similar approach were taken in the SUD field using the term preaddiction, McLellan, Koob, and Volkow wrote, it would require a similarly integrated effort in three areas, including the following:

• Establish measures to define and detect preaddiction: DSM-5 diagnoses are reliable and could be implemented in clinical settings to define preaddiction.
• Identify effective interventions: Screening, brief interventions, referrals to treatment, and a computerized version of cognitive-behavioral therapy could potentially be used as preaddiction interventions. However, the authors also pointed out the need for a broader range of medication treatments and social support.
• Advocate and educate: Few in the public or even in medical practice know how to recognize or what to do when an individual begins to transition to an SUD, and procedures for screening and tracking early stage SUDs must be taught in medical or nursing schools and properly reimbursed.

The authors acknowledged that some may be concerned that the term preaddiction could intensify stigma, yet they contend that it is exactly the right term to use for two reasons. First, preaddiction refers to the disease, not the individual. “Second, the term addiction is well understood by clinicians and patients as a serious condition to be avoided,” the authors wrote. “Thus, preaddiction has inherent motivational properties that convey the need for clinical action and patient change—just as prediabetes and precancerous currently do.”

For more information, see the Psychiatric News article “The Perils of a Pandemic: Challenges Faced by Addiction Services.”

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APA Online Systems Upgrade July 8-10, Password Reset Required

APA is upgrading its member portal (my.psychiatry.org), which is used to log into many connected APA websites. Information about this transition is available on this web page. Several APA systems will be unavailable during maintenance on July 8 through July 10. All members and APA website users will need to activate their accounts and set a new password. Going forward, the username you use to log into the system will always be the same as your primary email address on file. If you do not see an email by July 12, you may proceed to my.psychiatry.org and click “Forgot Password?” If you have forgotten your username, contact apa@psych.org or call APA Customer Service at 202-559-3900.

Patients With SMI More Likely to Die After Acute Cardiac Event

Individuals with serious mental illness (SMI)—including schizophrenia, bipolar disorder, and other nonaffective psychoses—were more likely to die following acute cardiac syndrome than those without the disorders, according to a meta-analysis in Schizophrenia Bulletin. Acute cardiac syndrome is characterized by a sudden reduction or blockage of blood flow to the heart.

Those with SMI were also found to be less likely to receive revascularization procedures (such as stent implants) to restore blood flow to the heart and medications that protect the heart (such as ACE inhibitors, beta-blockers, statins, and aspirin) following acute cardiac syndrome.

“Our findings underscore an urgent need to adequately address physical health disparities experienced by this vulnerable population,” wrote lead author Joe Kwun Nam Chan, a Ph.D. student, and Wing Chung Chang, M.D., both of the University of Hong Kong and colleagues.

The researchers analyzed data from 22 studies comparing mortality from acute cardiac syndrome, revascularization, and receipt of cardioprotective medications among 12 million patients, of whom 503,686 had SMI. Studies included in the analysis were from Australia, Canada, Denmark, Hong Kong, Sweden, Taiwan, United Kingdom, and the United States.

Overall, the meta-analysis revealed that SMI patients exhibited an increased risk of death following acute cardiac syndrome, with significantly elevated overall, 30-day, and one-year death rates (40%, 26%, and 68% higher rates, respectively) compared with those without SMI. Patients with SMI were 46% less likely to receive coronary revascularization and 11% less likely to receive cardioprotective medications after acute cardiac syndrome.

The “association between SMI and inferior medical care could be explained by an array of patient, physician, and system factors,” the authors wrote. For example, psychosis symptoms, diminished motivation, and cognitive dysfunction may compromise a patient’s ability to manage other diseases, leading to poorer outcomes. They added that stigmatizing attitudes of health care professionals toward people with SMI and a lack of coordinated care for psychiatric and physical disorders may also lead to delays in care.

“Effective multipronged interventions are urgently needed to reduce these physical health disparities,” the authors wrote. Such strategies include educating patients about the importance of regular exercise, smoking cessation, and maintaining a healthy weight; prescribing antipsychotics judiciously to minimize the risk of metabolic syndrome and cardiotoxicity; and teaching patients how to manage their physical conditions. Further, physicians and health systems can develop treatment algorithms that are specific to people with SMI to help identify those at high risk of cardiac disease, the authors wrote.

For related information, see the Psychiatric News article “Cardioprotective Treatments After Heart Attack Can Help Patients With Schizophrenia Live Longer.”

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