Major Depressive Disorder Common in Patients With Hoarding Disorder, Study Finds

Major depressive disorder is the most common comorbid mental illness in people with hoarding disorder, a study in the Journal of Psychiatric Research has found.

Luis Sordo Vieira, Ph.D., of the University of Florida and colleagues examined data from adults who participated in the Brain Health Registry (BHR), a large online research registry that asks participants questions about their medical, psychiatric, and neurological histories and to complete questionnaires about a variety of conditions.

The researchers first focused on 252 BHR participants (average age: 61 years) who received a thorough clinical assessment for psychiatric disorders; of this group 135 participants had hoarding disorder and 117 participants did not. Among participants with hoarding disorder, 61.5% had major depressive disorder, 31.9% had generalized anxiety disorder, and 22.2% had panic disorder, compared with 28.2%, 10.3%, and 9.4%, respectively, of those who did not have hoarding disorder. Furthermore, 34.8% of those with hoarding disorder had both major depressive disorder and an anxiety disorder (including but not limited to generalized anxiety disorder), compared with 12.8% of participants without hoarding disorder. Among those who had hoarding disorder and generalized anxiety disorder specifically, 72% also had major depressive disorder.

The researchers then analyzed the questionnaire responses from the larger BHR sample (15,978 adults; average age: 62 years). As with the 252 participants who received clinical assessments, major depressive disorder and generalized anxiety disorder were the most common comorbid mental health conditions in people with hoarding disorder.

When the researchers analyzed the data further, they found that generalized anxiety disorder did not have a direct relationship with hoarding disorder. Rather, the relationship between generalized anxiety disorder and hoarding disorder was mediated by major depressive disorder.

These findings “may provide hints to the underlying shared biological underpinnings of these disorders,” the researchers wrote.

For related information, see the Psychiatric News article “Hoarding: Ownership Gone Awry.”

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Folic Acid Taken by Prescription May Lower Risk of Suicide

People taking prescription folate may be at a lower risk of suicidal event, suggests a study published in JAMA Psychiatry. Specifically, the researchers found that each month of being prescribed folic acid was associated with an additional 5% decrease in risk of suicide attempt during the 24-month follow-up period.

“The role of folate in depression and cognition has been recognized for more than a decade, leading to recommendations for folate augmentation in patients with low or normal levels at the start of any depression treatment,” wrote Robert Gibbons, Ph.D., of the University of Chicago and colleagues.

Gibbons and colleagues used data from the MarketScan Commercial Claims and Encounters databases, which include inpatient, outpatient, and prescription claims from more than 100 insurers. The authors identified participants aged 18 and older who filled a folic acid prescription from 2012 to 2017. (Forty-eight percent of folic acid prescriptions were for 1 mg/d). They then used the database to identify if participants attempted suicide or intentionally harmed themselves or had any diagnoses relevant to suicide risk or folate deficiency between 2010 and 2018. They repeated a similar analysis of participants who had filled prescriptions of cyanocabalamin, or vitamin B12. (Folic acid is vitamin B9.)

The authors collected data on 866,586 participants, 81.3% of whom were female. During the period when participants were taking folic acid, there were 261 suicidal events, for a rate of 4.73 per 100,000 person-months, and 895 suicidal events during the months when participants were not taking folic acid, for a rate of 10.61 per 100,000 person-months. In the adjusted analysis, there was a 44% reduction in suicidal events among participants taking folic acid.

The authors noted a similar association in women of childbearing age, and age and sex did not moderate the association. They found no association between vitamin B12 and suicidal events.

“The results warrant the conduct of a randomized clinical trial with suicidal ideation and behavior as outcomes of interest,” the authors concluded. “If confirmed, folic acid may be a safe, inexpensive, and widely available treatment for suicidal ideation and behavior.”

For related information, see the Psychiatric News article “Prenatal Folic Acid Associated With Lower Psychosis Risk.”

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Feeling Strong Sense of Purpose May Protect Older Veterans From Mental Illness

Older veterans who say they have a strong sense of purpose in life may be less likely to experience a range of mental disorders compared with those with those lacking such a sense of purpose, according to a report in The American Journal of Geriatric Psychiatry.

Perceived purpose in life refers to the extent to which a person believes that his or her life is motivated by goals and aims that they care about, Ian C. Fischer, Ph.D., of Indiana University-Purdue University at Indianapolis and colleagues wrote. The “[r]esults of this study suggest that existing interventions that have been shown to increase [purpose in life] may have the potential to help mitigate risk for, and alleviate symptoms of, various mental disorders,” they added.

Data were drawn from the National Health and Resilience in Veterans Study (NHRVS), a survey of 4,069 U.S. veterans, the majority of whom were 60 years and older, White, and male. The NHRVS was administered between November 18, 2019, and March 8, 2020, and all participants completed an anonymous, 50-minute, web-based survey. As part of this survey, veterans completed the four-item Purpose in Life Test Short Form and were screened for mental disorders and suicidality.

The researchers broke the participants into three groups: those who endorsed a high purpose in life, average purpose in life, or low purpose in life.

Most participants (71.7%) endorsed average levels of perceived purpose in life; 16% endorsed low purpose in life and 12.4% endorsed high purpose in life. High purpose in life was associated with 42% to 94% reduced odds of screening positive for major depressive, generalized anxiety, posttraumatic stress, and substance use disorders, as well as suicidality, Fischer and colleagues wrote.

“Given the ‘dose-response’ relationship found between purpose in life and a broad range of mental health outcomes, purpose in life may be an important transdiagnostic prevention and treatment target,” they concluded.

For related information, see the Psychiatric News article “Interventions That Promote Wisdom May Help Patients With Psychiatric Conditions.”

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Black Children Less Likely to Report Suicidal Thoughts in Emergency Room, Study Suggests

Black children brought to an emergency department for behavioral issues appear less likely to report suicidal thoughts than children of other races, suggests a report published today in Psychiatric Services. Additionally, Black children were more likely to be brought to the emergency department by police and to be discharged rather than hospitalized for psychiatric care.

Carol Vidal, M.D., Ph.D., of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins and colleagues analyzed electronic medical record data from 504 patients aged 8 to 12 years visiting a pediatric emergency department (ED) with a psychiatric issue in 2019. This “urban pediatric ED, … located in the Mid-Atlantic region, has an estimated annual census of 35,000 patient visits (60% Black, 21% White, 10% Latino/Latina or Hispanic; approximately 60% had public insurance),” Vidal and colleagues wrote.

The researchers examined youth’s responses to the Ask Suicide-Screening Questions tool (ASQ)—a four-item suicide risk screening instrument completed in the ED. They also compared the youth’s demographic data, mode of arrival to the ED, primary ED clinical impression (for instance, suicidal ideations, oppositional defiant disorder or related problems, or depression and anxiety), and more. A total of 398 youth completed the ASQ; of these, 42% reported wishing they were dead, 32% reported feeling they would be better off dead, and 37% reported thinking of killing themselves in the past week. A previous suicide attempt was reported by 28% of the youth.

When the researchers examined the responses by the race of the youth, they found that there was little difference in the percentage of youth who reported a previous suicide attempt (27% of White youth, 28% of Black youth, and 29% of other/multiracial youth). However, Black youth were less likely to report wishing they were dead (35% vs. 57% in White youth and 50% of other/multiracial youth), feeling that they would be better off dead (27% vs. 38% and 50%), and thinking about killing themselves in the past week (33% vs. 47% and 43%) in the past couple weeks. Further analysis revealed that 35% of Black youth were transported to the ED by police compared with 12% of White youth and 15% of other/multiracial youth.

“[N]on-Black preadolescents were three times as likely as Black children to be admitted to inpatient psychiatric care,” Vidal and colleagues continued. “Although racial differences in admission to inpatient psychiatric care could be related to the lower frequency of self-reported suicidal thoughts among Black preadolescents, other patient, parent, and provider factors likely contribute to this disparity, given that Black preadolescents in our sample who reported thoughts of suicide were still less likely to be hospitalized than were non-Black peers with thoughts of suicide.”

While the authors noted several limitations of the study—including its small sample and focus on a single ED—they wrote that the findings point to the need for more research: “Research to better understand racial disparities in suicide risk among preadolescents can inform prevention efforts.”

For related information, see the Psychiatric News article “Study Investigates Link Between Discrimination, ADHD, Suicide.”

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Adults With Child Trauma History Respond to Depression Treatment Similar to Other Adults

Adults with depression and a history of childhood trauma respond as well to medications and psychotherapy as those without childhood trauma, according to a meta-analysis published in Lancet Psychiatry.

“Several individual and meta-analytic studies indicate that a history of childhood trauma is associated with poorer response to first-line depression treatments, suggesting the need for new personalised treatments for patients with major depressive disorder and childhood trauma,” wrote Erika Kuzminskaite, M.S., of Vrije University in the Netherlands and colleagues with the Childhood Trauma Meta-Analysis Study Group. “However, the evidence on poorer treatment outcomes in adults with depression and childhood trauma has not been definitive.”

Kuzminskaite and colleagues collected data from 29 randomized clinical trials testing a medication, psychotherapy, or combination treatment for adults with major depression; all trials included assessments for childhood trauma. The combined samples included 6,830 adults, of whom 62% had reported a history of childhood trauma. Although adults with a history of childhood trauma on average had more severe depressive symptoms at baseline, they had similar symptom improvement following treatment as adults with no trauma history. The findings were consistent regardless of depression type (depression or treatment-resistant depression), treatment type (medication or psychotherapy), or trauma type (emotional, physical, or sexual abuse or neglect).

Kuzminskaite and colleagues noted that previous studies in this area typically looked at treatment response or depression remission as the outcomes. “Subsequently, greater improvement could be required for patients with childhood trauma to meet the definition of remission,” they wrote. “By contrast, we examined depression severity change from baseline to after treatment consistently taking baseline symptoms into account and using depression severity correlations from before and after treatment.”

“This meta-analysis delivers a hopeful message to patients with childhood trauma that evidence-based psychotherapy and pharmacotherapy could improve depressive symptoms,” wrote Antoine Yrondi, M.D., Ph.D., of the University of Toulouse, France, in an accompanying editorial. “However, physicians should keep in mind that childhood trauma could be associated with clinical features which might make it more difficult to reach complete symptomatic remission of major depressive disorder and, therefore, have an effect on daily functioning.”

For related information, see Prospective Study Delves Deeper Into Mental Health Effects of Childhood Trauma.

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High Rates of Depression, PTSD Persist Five Years After Water Crisis in Flint, Mich.

Five years after the water crisis in Flint, Mich., residents of the community had higher rates of past-year depression and posttraumatic stress disorder (PTSD) compared with the rest of the nation, a study in JAMA Network Open has found. During the crisis, which occurred from 2014 to 2017, many residents were exposed to drinking water with unsafe levels of bacteria, disinfection byproducts, and lead after the city switched its drinking water supply from Detroit’s system to the Flint River.

Aaron Reuben, Ph.D., of Duke University and colleagues analyzed data from a survey of 1,970 adults who lived in Flint during the crisis. The survey was conducted from August 13, 2019, through April 20, 2020. It asked participants about their crisis experiences, their mental health symptoms five years later, and their access to and use of mental health services in the intervening years. Among respondents, 53.5% identified as Black or African American, 42.5% identified as White, and 97.4% identified as non-Hispanic; 56.8% reported earning less than $25,000 a year.

Overall, 22.1% of participants had symptoms of past-year depression, 24.4% had symptoms of past-year PTSD, and 14.0% had symptoms of both conditions. Participants who believed that their or their family’s health was moderately or greatly harmed by the water crisis were 123% more likely than their peers to have symptoms of depression, 66% more likely to have symptoms of PTSD, and 106% more likely to have symptoms of both conditions. Participants who had a history of potentially traumatic events such as a life-threatening illness, serious accident, or previous disaster were 173% more likely than their peers to have symptoms of depression and 355% more likely to have symptoms of PTSD.

“These findings suggest that the water crisis could have exacerbated existing mental health disparities in Flint—a possibility that should be investigated in future studies,” Reuben and colleagues wrote.

Only 34.8% of participants reported ever being offered mental health services to help address their concerns or problems associated with the crisis. About 79% of those who were offered mental health services used them.

The researchers concluded “that (1) there is a large, unmet mental health need in the Flint community 5 years after the onset of the water crisis and (2) this need for mental health services is unlikely to remit without a comprehensive, systematic, and coordinated response from the local, state, and federal governments and public health communities,” the researchers wrote. “These findings suggest that community-level public works environmental disasters have large-scale and lasting psychological sequelae.”

For related information, see the Psychiatric News article “Preparing for Disasters at the Community Level: Prevention and Social Cohesion.”

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APA Invites You to Partner on Perinatal Initiative Funded by CDC Foundation

To address training and knowledge gaps regarding untreated perinatal mental illness, it is important to understand providers’ perspectives about pregnant persons with mental health issues during and after pregnancy. APA has been awarded a grant from the CDC Foundation to conduct a needs assessment of these gaps. APA is seeking 400 providers to take a 30-minute survey and 16 providers to participate in two-hour focus groups. Survey respondents will receive a $30 Amazon gift card, and focus group participants will receive a $450 honorarium. Those interested in participating can register at redcap.link/panpbhp_register.

Telephone Intervention May Reduce Risky Alcohol Consumption

Participating in at least two sessions of a telephone-delivered intervention may help reduce total alcohol consumption, alcohol problem severity, and risky drinking patterns among patients with alcohol use problems, according to a study published yesterday in JAMA Psychiatry.

“Alcohol use disorders are estimated to affect 5.1% of the adult population worldwide,” wrote Dan Lubman, Ph.D., of Monash Addiction Research Centre in Victoria, Australia, and colleagues. “Yet, the magnitude of alcohol consumption and attributable harms remains in sharp contrast to the low rates of treatment use.”

Lubman and colleagues recruited participants aged 18 and older with problem alcohol use from across Australia via social media and clinician referrals. Problem alcohol use was defined as a score of more than 6 for females and more than 7 for males on the Alcohol Use Disorders Identification Test (AUDIT). Possible scores on the AUDIT range from zero to 40. AUDIT also measures hazardous use, harmful use, and dependence symptoms. Participants’ AUDIT scores were assessed at baseline and again three months later.

Participants were randomly assigned to either the intervention group or the active control group. Those in the intervention group received four to six 30- to 50-minute sessions of a telephone-delivered cognitive and behavioral intervention called Ready2Change. After receiving a clinical assessment in the first session, trained counselors introduced the participants in the intervention group to the following practices in session two: keeping a daily alcohol diary; identifying participants’ triggers; assistance managing urges with SOBER breathing (a mindfulness-based practice that includes five steps: stop, observe, breathe, expand, and respond); and establishing a helpful routine. The counselors tailored the remainder of the sessions (offered weekly) to individual participants, based on their reasons for engaging in treatment and challenges they faced. The active control group received alcohol consumption guidelines, stress management pamphlets, and four telephone check-ins that were five minutes or less.

Among 344 participants, two-thirds had AUDIT scores corresponding to the highest category of probable dependence, and only one-third had previously sought treatment for their alcohol use. Sixty-five percent of participants randomized to the intervention group completed the program (defined as participating in at least four sessions), and 80% of participants in the control group completed the program.

The AUDIT scores decreased significantly from baseline to three months in both groups, falling from 21 to 12.8 in the intervention group, and from 22.1 to 14.9 in the active control group. The intervention group showed a significantly greater reduction in hazardous use. When adjusting for exposure to two or more sessions, the researchers found that the intervention group had a greater reduction in their total AUDIT scores compared with the control group.

“The results of this clinical trial support [the] benefits of a telephone-delivered intervention in a general population sample of individuals who do not typically seek treatment for alcohol use problems, despite experiencing high problem severity,” the authors concluded. The “[f]indings demonstrate the potential benefits of this highly scalable telehealth model of alcohol treatment, with potential to reduce the treatment gap for problem alcohol use.”

For related information, see the Psychiatric News article “Pandemic May Be Accelerating Problematic Trends in Alcohol Use.”

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APA Invites You to Partner on Perinatal Initiative Funded by CDC Foundation

To address training and knowledge gaps regarding untreated perinatal mental illness, it is important to understand providers’ perspectives about pregnant persons with mental health issues during and after pregnancy. APA has been awarded a grant from CDC Foundation to conduct a needs assessment of these gaps. APA is seeking 400 providers to take a 30-minute survey and 16 providers to participate in two-hour focus groups. Survey respondents will receive a $30 Amazon gift card, and focus group participants will receive a $450 honorarium. Those interested in participating can register at redcap.link/panpbhp_register.

Computer Program That Boosts Self-Esteem May Prolong Effects of Single Ketamine Infusion

Completing a brief computer program that encourages positive thoughts about oneself appears to maintain the antidepressant effects of ketamine for at least 30 days in people with treatment-resistant depression, according to a report published today in the American Journal of Psychiatry.

While previous studies have shown that intravenous ketamine can rapidly reduce symptoms of depression within a couple of hours, these effects tend to wear off within weeks. The findings suggest that a low-cost, automated behavioral intervention might help to extend the effects of a single infusion of ketamine for patients who do not respond to other treatments.

“Training the brain to link perceptions of yourself with positive ideas during this ketamine-primed plasticity window exceeded my expectations,” said lead author Rebecca Price, Ph.D., an associate professor of psychiatry at the University of Pittsburgh School of Medicine, in a press release. “I was surprised and amazed to get such clear findings from an intervention that was so minimal.”

For the study, 154 adults (aged 18 to 60) with treatment-resistant depression were assigned to one of three groups: one received a ketamine infusion (0.5 mg/kg over 40 minutes) plus automated self-association training (ASAT); the second received a saline infusion plus ASAT; and the third received a ketamine infusion plus sham ASAT.

ASAT consisted of eight 15- to 20-minute sessions delivered twice daily for four consecutive days that were initiated one day after infusion. For the ASAT sessions, participants viewed words associated with positive feelings (such as “lovable” and “worthy”) and images of themselves and other people. Participants performed simple computer tasks, such as indicating whether targets were real words or random letter strings, to enhance engagement and reinforce the positive associations. Sham ASAT consisted of the same computer tasks, but with predominantly neutral rather than positive images and words, and no images of the participant.

The primary outcome was score on the Montgomery-Åsberg Depression Rating Scale (MADRS), and the participants were followed for 30 days.

Price and colleagues found that ketamine rapidly and significantly reduced MADRS total depression scores 24 hours after infusion.

Depression scores in the ketamine plus ASAT group remained significantly and stably low over the 30-day study period compared with those in the saline plus ASAT group. In contrast, depression scores in the ketamine plus sham ASAT group increased over the 30 days, approaching the levels observed in the saline plus ASAT group.

“If the present results can be replicated, this novel, integrative treatment may provide a method to urgently bring relief and to efficiently extend this relief via safe, low-cost, portable techniques,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “Single, Repeated, and Maintenance Ketamine Infusions for Treatment-Resistant Depression: A Randomized Controlled Trial.”

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Neurological Effects of Monkeypox Largely Unknown, Review Finds

Much remains unknown about the long-term neurologic effects of monkeypox. In an article published today in JAMA Neurology, researchers from the National Institute of Neurological Disorders and Stroke (NINDS) and colleagues described how reports of complications from other orthopoxviruses, such as smallpox, may offer clues about the neurologic consequences of monkeypox.

“Although the COVID-19 pandemic is the worst pandemic in a century, the recent past has seen several major pandemics, including Zika, Ebola, dengue, West Nile, and AIDS,” wrote B. Jeanne Billioux, M.D., of NINDS and colleagues. “A common thread to these pandemics is the long-term neurologic complications such as post–COVID-19 conditions, congenital Zika syndrome, post-Ebola syndrome, West Nile encephalitis, and HIV-associated neurocognitive disorders. … Yet often these manifestations go unrecognized, initially masked by the acute systemic involvement by the infection and later attributed to end-organ damage or to pandemic-related psychosocial stresses.”

Billioux and colleagues provided an overview of orthopoxviruses known to infect humans before describing the clinical features of smallpox and monkeypox. They described reports of headaches, febrile seizures/encephalopathy, and transverse myelitis among patients with smallpox as well as other symptoms. They noted that while “very few neurologic complications of monkeypox have been described,” existing reports highlight headache; neuropathic pain; and mood disturbance, including depression and anxiety as the most common symptoms in patients with monkeypox. Additionally, there have been several reports of patients with monkeypox experiencing encephalitis with seizures.

The authors offered several considerations for diagnosis, treatment, and prevention of monkeypox before concluding, “[B]ased on known neurologic complications of orthopoxviruses, we must be prepared for the possibility of viral encephalitis, myelitis, ADEM [acute disseminated encephalomyelitis], Guillain-Barré syndrome, neuropathic pain, and others, and treat them accordingly. Particular attention should be paid to patients with immunocompromised conditions… .”

In addition, health care professionals should be on the lookout for neurological adverse reactions to vaccines that protect against orthopoxviruses, they noted.

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Neuropsychiatry’s Role in the Postacute Sequelae of COVID-19: Report From the American Neuropsychiatric Association Committee on Research.”

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COVID-19 Infection Associated With Increased Risk of Alzheimer’s

Older adults infected with COVID-19 are at increased risk of Alzheimer’s disease over the following year, according to a study published in the Journal of Alzheimer’s Disease. The greatest risk of Alzheimer’s following infection was in women and adults 85 and up.

“An infectious etiology of Alzheimer’s disease has been postulated for decades, and despite supportive evidence, it is still controversial,” wrote Lindsey Wang of Case Western Reserve University, Nora Volkow, M.D., of the National Institute on Drug Abuse, and colleagues. The researchers noted that COVID-19 infection is associated with long-term neurological effects including memory problems in some people, so the virus may trigger or accelerate Alzheimer’s pathology.

The researchers used the TriNetX platform to analyze de-identified electronic health record data from over 95 million patients across 68 health care organizations. Their study included 6,245,282 adults aged 65 and up who were Alzheimer’s free and had health care visits between February 2, 2020, and May 30, 2021. Of this group, 410,748 adults contracted COVID-19 during this period. The researchers examined risks in both groups for a new diagnosis of Alzheimer’s in all older adults, as well as subgroups based on sex, age (65–74, 75–84, ≥85), and race/ethnicity (Black, White, and Hispanic).

After adjusting for many variables, the researchers found that older adults who contracted COVID-19 had a 69% increased risk of an Alzheimer’s diagnosis within 360 days of their infection. A statistically increased risk of Alzheimer’s was seen in all age groups, both sexes, Black adults, and White adults; no association was found for Hispanic adults. The highest risk of Alzheimer’s was found in adults aged 85 and older (89% increased risk) and women (82% increased risk).

“Our findings call for research to understand the underlying mechanisms and for continuous surveillance of long-term impacts of COVID-19 on Alzheimer’s disease,” the researchers wrote.

To read more on this topic, see the Psychiatric News article “Cognitive Impact of COVID-19 Lasts Months.”

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Daily Multivitamins Linked to Improved Cognition in Older People

Taking a daily multivitamin may improve cognitive function in older people, a study in Alzheimer’s & Dementia has found. Taking a cocoa supplement, however, does not appear to slow cognitive decline.

“There is an urgent need to identify effective strategies to preserve cognitive function to mitigate the heavy societal burden associated with Alzheimer’s disease and related dementia, which affect more than 46 million people worldwide,” wrote Laura D. Baker, Ph.D., of Wake Forest University School of Medicine and colleagues. Cocoa extract is rich in compounds called flavanols, and previous small studies suggest that these compounds may positively impact cognition.

Baker and colleagues analyzed data from 2,262 people aged 65 years or older who enrolled in the COcoa Supplement and Multivitamin Outcomes Study for the Mind (COSMOS-Mind) between August 2016 and August 2017. COSMOS-Mind is an ancillary study to a larger trial that investigated whether taking a daily cocoa extract supplement or a daily multivitamin-mineral supplement reduces the risk of developing heart disease, stroke, cancer, and other health outcomes. In the parent study, participants were randomized to one of four groups: Cocoa extract and placebo, multivitamin and placebo, cocoa extract and multivitamin, or placebo and placebo.

Participants in the COSMOS-Mind study (60% women, 89% non-Hispanic White), completed a baseline cognitive assessment over the phone and were scored on their verbal fluency, ability to recall stories, ability to put numbers in order, and other skills. The researchers then followed the participants with yearly cognitive assessments over the phone for three years. Of the enrolled participants, 92% completed the cognitive assessment at Year 1, 84% at Year 2, 79% at year three, and 77% in all three years.

Cognitive decline slowed 60%, or by 1.8 years, in participants who took the multivitamin compared with those who did not, the researchers estimated. Furthermore, the benefits of taking the multivitamin were more pronounced in people who had significant cardiovascular disease (CVD), a population that already has an above-average risk for cognitive decline, compared with people who did not have CVD.

“One account for this finding relates to the potential treatment-related improvement in micronutrient levels in CVD-compromised individuals, which could, in turn, have beneficial consequences for brain health,” Baker and colleagues wrote. They noted that people with CVD often have deficiencies in vitamin D, which predicts the severity of CVD, and vitamin K, which is linked to coronary artery calcification and increased risk of CVD-related death.

“COSMOS-Mind provides the first evidence from a large-scale, long-term, pragmatic [randomized, controlled trial] to suggest that daily use of a safe, readily accessible, and relatively low-cost [multivitamin] supplement has the potential to improve or protect cognitive function for older women and men,” the researchers wrote. “An additional trial is needed to confirm these findings in a more representative cohort and to explore potential mechanisms for cognitive benefit.”

For related information, see The American Journal of Psychiatry article “Dementia Is More Than Memory Loss: Neuropsychiatric Symptoms of Dementia and Their Nonpharmacological and Pharmacological Management.”

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American Indian Youth Reported Relationship Problems but Remained Resilient During Pandemic

During the COVID-19 pandemic, many American Indian youth reported feeling less connected to friends and less engaged in schoolwork. Nonetheless, many students also showed resilience at this difficult time, according to a study published yesterday in JAMA Network Open.

American Indian youth are at particularly high risk for COVID-19–related consequences, wrote Linda Stanley, Ph.D., of Colorado State University and colleagues. The study’s findings “indicate that the perceived impacts of the COVID-19 pandemic among this population were complex.”

Stanley and colleagues used data from the annual Our Youth, Our Future study, which collects nationally representative substance use data among middle and high school students who live on or near reservations. During spring 2021, measures related to the COVID-19 pandemic were added to the survey. Twenty schools participated in the survey, and the percentage of American Indian students enrolled in these schools varied between 20% and 100%.

The survey included measures from the COVID-19 OBSSR (Office of Behavioral and Social Sciences Research) Research Tools. Participants were asked to report COVID-19 illness outcomes for themselves, their family members, and close friends; perceived changes in family and friend relationships, school engagement, social isolation, and psychological factors (such as depression, sadness, and anxiety); and worry over COVID-19–related health outcomes.

A total of 2,559 American Indian students were included, among whom 46.9% were male, 50.2% were female, and 2.7% were another gender. Among the findings were the following:

• 14% of students reported having received a positive COVID-19 test. The authors noted that this rate is higher than the national rate, which was 9.6% in April 2021, and higher than the rate of cases among children nationally, which was 4.8% in April 2021.
• 27.9% of students reported that at least one family member or close friend died of COVID-19.
• 29.4% of students reported more family conflict, while half reported spending more time with family, and 41% reported that their family became closer.
• Half of students reported having a harder time focusing on schoolwork, falling behind on schoolwork, worrying about school, and missing participation in school events.
• Half of students reported spending more time alone, and 62.2% reported feeling less socially connected.
• 71.3% of students expressed worry about a family member getting COVID-19 or dying from COVID-19.
• More than 60% of students reported feeling no change or a decrease in negative emotions such as sadness or anxiety, though the results varied by gender: 43.5% of males and 28.8% of females reporting that they felt less depressed, and 24.4% of males and 40.2% of females reporting that they felt more depressed.

“Given major gaps in reporting of COVID-19 pandemic impacts among Indigenous communities globally, these findings, although descriptive, lay a foundation for better understanding through further research the COVID-19–related issues facing American Indian youth,” the authors concluded.

For related information, see the Psychiatric News article “COVID-19 and Native Americans, Alaska Natives, Native Hawaiians, Pacific Islanders: A Historical Perspective.”

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Health Care Workers More Open to Therapy After Watching Short Video About Its Benefits

Despite being at higher risk of anxiety and depression than the public, health care workers are often reluctant to seek mental health care. A report published Tuesday in Psychiatric Services suggests that watching a short video about the benefits of therapy for COVID-19–related anxiety and depression may reduce treatment-related stigma and encourage more health care workers to seek help.

“Educators, employers, and employee assistance programs should consider using such easily administered interventions to proactively encourage health care workers to seek help and should provide mental health treatment resources to those who need them,” wrote Doron Amsalem, M.D., of the New York State Psychiatric Institute and colleagues.

For the study, Amsalem and colleagues recruited English-speaking, U.S. health care workers (including nurses, physicians, health administrators, and mental health professionals) between the ages of 18 and 80 years using a crowdsourcing tool called Prolific. After completing a baseline assessment, which included questions about intention to seek treatment and stigma related to treatment, 1,402 participants were randomly assigned to one of two intervention groups or the control group:

• Participants in the intervention group watched a three-minute video during which a young female nurse (presented by either a White or Black actress using an identical script) described her struggles with the COVID-19 pandemic and how therapy helped her to cope with COVID-19–related stress and anxiety.
• Participants in the control group watched a three-minute nature video.

After watching the video, all participants completed treatment-seeking and stigma-related assessments, which asked them to rank how much they agreed with such statements as “I might want to have psychological counseling in the future” and “It would make me feel inferior to ask a therapist for help.” Fourteen days after first watching their assigned video, half of the participants in each intervention group were assigned to rewatch the same video. Whether assigned to rewatch a video or not, all participants completed treatment-seeking and stigma-related assessments again at the 14-day follow-up as well as at day 30. Participants were also asked if they had ever sought psychological counseling.

Both intervention videos elicited an immediate increase in treatment-seeking intention in the intervention groups, the authors reported, with larger effects among those who had never sought treatment. The increased effects were not sustained 14 days after the initial video or at 30-day follow-up, and there was no significant difference between those participants who had watched the intervention video once versus those who had watched it twice.

The “three-minute online video effectively increased immediate treatment-seeking intention and reduced treatment-related stigma, albeit without lasting effects, especially among health care workers who had never sought treatment,” Amsalem and colleagues concluded. “Future studies should examine whether these brief interventions, when linked to referrals, can foster immediate behavioral change.”

For related information, see the Psychiatric News Alert “Residency Directors Should Encourage, Support Personal Psychotherapy as Part of Training.”

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Exposure to Cannabis in Womb Associated With Behavioral Issues in Tweens, Study Finds

Children who were exposed to cannabis in the womb appear to be at a heightened risk of behavioral problems into at least early adolescence, suggests a report published Monday in JAMA Pediatrics. The findings—which are based on data collected as part of the Adolescent Brain and Cognitive Development Study (ABCD Study)—add to a growing body of evidence about the risks of cannabis use during pregnancy.

According to a media release from the National Institute on Drug Abuse, cannabis use among pregnant women increased from 3% in 2002 to 7% in 2017. In 2018, 4.7% of pregnant women reported cannabis use; 5.4% reported cannabis use in 2019.

A 2020 study by Ryan Bogdan, Ph.D., of Washington University in St Louis and colleagues found that children whose mothers used cannabis after learning they were pregnant were slightly more likely to have sleep, attention, and social problems at ages 9 and 10, among other issues. To determine if these associations remained as the children grew older, David A.A. Baranger, Ph.D., Bogdan, and colleagues followed up with these youth one and two years later. (As was done in the 2020 study, children and caregivers provided feedback on the Child Behavior Checklist and the Prodromal Questionnaire–Brief Child Version.)

The analysis included 10,631 individuals and 30,091 longitudinal assessments (baseline: n = 10,624; mean age, 9.9 years; one-year follow-up: n = 10,094; mean age, 10.9 years; two-year follow-up: n = 9,373; mean age, 12.0 years). The analysis revealed no significant changes in the rate of psychiatric conditions as the children aged.

“[Prenatal cannabis exposure] is associated with persisting vulnerability to broad-spectrum psychopathology as children progress through early adolescence,” Baranger and colleagues wrote. “Increased psychopathology may lead to greater risk for psychiatric disorders and problematic substance use as children enter peak periods of vulnerability in later adolescence.”

For related information, see the Psychiatric News article “Exposure to Alcohol, Cannabis in Womb Can Have Long-Term Consequences.”

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Socioeconomic Status of Neighborhood Matters for Mental Health of Refugee Children, Adolescents

Refugee children and adolescents are known to be at heightened risk of psychiatric disorders. A study published today in JAMA Pediatrics suggests that the more limited the resources of the neighborhood into which young refugees are settled, the more likely they are to go on to be diagnosed with a psychiatric disorder.

“At a time when high numbers of refugee children are seeking asylum in high-income countries, our findings suggest that targeted placement of families in less disadvantaged areas and investments to improve disadvantaged neighborhoods may have a positive long-term impact on mental health among refugee children and adolescents,” wrote Else Foverskov, Ph.D., of Aarhus University in Denmark and colleagues.

Foverskov and colleagues used multiple Danish health and census registers to monitor the outcomes of 18,709 child and adolescent refugees (ages 0-16) who resettled in Denmark between 1986 and 1998. (The researchers limited the study group to refugees from Afghanistan, Iran, Iraq, Lebanon, Somalia, Sri Lanka, Vietnam, and the former Yugoslavia.) During this time, refugees were “dispersed in neighborhoods across the country in a quasi-random (in other words, arbitrary) fashion,” the researchers wrote. “This dispersal policy led to assignment of refugee families to neighborhoods with different levels of socioeconomic disadvantage… .”

Overall, 7.7% of the youth were diagnosed with a psychiatric disorder by the age of 30, Foverskov and colleagues reported. The greater a neighborhood’s calculated disadvantage (the authors based this on the median family income, educational attainment, unemployment rate, and welfare benefits of the neighborhood), the greater the risk of the youth receiving a psychiatric disorder diagnosis. This association between neighborhood status and psychiatric disorder risk did not differ based on the refugees’ sex, age at arrival, or family structure (single vs. two parents). The risk was similar whether the authors used an International Classification of Diseases diagnostic code or the prescription of a psychotropic drug as the marker for a psychiatric disorder.

“Neighborhood disadvantage is likely associated with multiple potential mediating risk factors underlying psychiatric disorders. The neighborhood context may be associated with socioeconomic opportunities, health behaviors, social support, and collective efficacy, which can affect psychiatric morbidity in susceptible children and adolescents either directly or through processes within the family, peer group, and local institutions,” the authors wrote. “Future studies are needed to clarify the underlying processes.”

To read more about this topic, see the Psychiatric News article “Children Separated From Families at Border Need Trauma-Informed Care, Says APA President.”

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Walking Daily Linked to Lower Dementia Risk, but How Many Steps Does It Take?

Walking roughly 9,800 steps a day may lower the risk of developing dementia within seven years by 50%, a study in JAMA Neurology has found. However, the study also suggests that adults need not walk that far to derive protective benefits: Walking approximately 3,800 steps a day may lower the risk of dementia by 25%. Furthermore, the study found a link between higher-intensity walking and lower risk, and that steps taken at peak intensity need not be taken all at once to help lower risk.

Borja del Pozo Cruz, Ph.D., of the University of Southern Denmark and colleagues examined data from 78,430 adults aged 40 to 79 years who were part of the UK Biobank study, which contains in-depth genetic and health information from 500,000 participants in the United Kingdom. Participants wore an accelerometer on their wrists for at least three consecutive days between February 2013 and December 2015 to track their physical activity, including their daily number of steps. The researchers categorized step intensity three ways: They defined incidental steps as less than 40 steps a minute, such as indoor walking from one room to another; purposeful steps as 40 or more steps a minute, such as steps taken while exercising; and peak 30-minute cadence as the average number of steps a minute recorded for the 30 highest, but not necessarily consecutive, minutes in a day. The researchers then tracked the participants until October 2021 to determine the rate of dementia.

During the follow-up period of about seven years, 866 participants developed dementia, the researchers reported. Del Pozo Cruz and colleagues found that the optimal number of incidental steps a day was 3,677, which lowered risk by 42%. The optimal number of purposeful steps was 6,315, which lowered risk by 57%. For peak 30-minute cadence, the optimal dose was 112 steps a minute, which lowered risk 62%.

“Step count–based recommendations have the advantage of being easy to communicate, interpret, and measure, and may be particularly relevant for people who accumulate their physical activity in an unstructured manner,” the researchers wrote. “Future guidelines for dementia prevention may capitalize on the results of this study to promote step-based recommendations.”

For related information, see the Psychiatric News Alert “Worsening Memory, Slowing Gait Associated With Increased Risk of Dementia.”

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Psychological Distress Before Infection May Increase Risk of Long COVID Symptoms

Patients who report depression, anxiety, stress, and loneliness before contracting COVID-19 may be at increased risk of experiencing persistent signs and symptoms of COVID-19 (also known as long COVID), according to a study published yesterday in JAMA Psychiatry.

“Post–COVID-19 conditions remain poorly understood, with no definitive etiology, prevention, or treatment,” wrote Siwen Wang, M.D., of the Harvard T.H. Chan School of Public Health and colleagues.

To examine the relationship between psychological distress and post–COVID-19 conditions, Wang and colleagues used data from three ongoing studies: the Nurses’ Health Study II, Nurses’ Health Study 3, and the Growing Up Today Study. Participants in these studies included active health care workers and other adults; those who reported past COVID-19 infections at baseline were excluded from the study. Participants were invited to complete an online COVID-19 questionnaire from April to September 2020, after which participants completed additional surveys every three months until November 3, 2021.

The authors measured participants’ depression, anxiety, perceived stress, loneliness, and worry about COVID-19 at baseline. Depressive and anxiety symptoms in the past two weeks were assessed with the four-item Patient Health Questionnaire. Worry about COVID-19 was assessed with the question, “How worried are you about COVID-19?” The authors also measured perceived stress and loneliness among participants who were not active health care workers using the four-item Perceived Stress Scale and the three-item UCLA Loneliness Scale.

Participants reported COVID-19 test results on all questionnaires. Post-COVID-19 conditions (defined as signs and symptoms consistent with COVID-19 that extend beyond four weeks from the onset of infection) were assessed on the final questionnaire. Participants were asked whether they were experiencing persistent symptoms such as fatigue, confusion or brain fog, shortness of breath, or difficulty breathing.

Most of the 54,960 participants included in the analysis (mean age 57 years) were White (96.5%) and female (96.6%); 38% of them were active health care workers. In total, 3,193 participants reported positive COVID-19 tests during the study period, 43.9% of whom reported post-COVID-19 symptoms. The most common symptoms were fatigue, smell or taste problems, shortness of breath, confusion or brain fog, and memory issues.

All types of distress prior to the participants’ COVID-19 infections were significantly associated with increased risk of post-COVID-19 symptoms. The greatest risk was among participants who experienced anxiety or had the highest rates of perceived stress. These participants had a 1.5-fold increased risk of post-COVID-19 symptoms. Participants with high levels of two or more types of distress were at an even greater risk of post-COVID-19 symptoms compared with those who did not experience high levels of distress. The authors noted that these increased risks remained significant after adjusting for other health-related factors.

“Further research should investigate whether interventions that reduce distress help prevent or treat post–COVID-19 conditions,” the authors concluded. “Identification and treatment of biological pathways linking distress with long-term COVID-19 symptoms may benefit individuals with post–COVID-19 conditions or other chronic postinfection syndromes.”

For related information, see the Psychiatric News article “Psychiatry Patients With Long COVID-19 Need Team-Based, Coordinated Care.”

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FDA Clears Novel, Rapid-Acting TMS System for Treatment-Resistant Depression

The Food and Drug Administration (FDA) has cleared the SAINT Neuromodulation System for the treatment of refractory depression in adults, Magnus Medical Inc. (the manufacturer of the product) announced Tuesday. SAINT is a modified form of transcranial magnetic stimulation (TMS) that compresses weeks of conventional TMS therapy into just five days.

“I am excited and humbled by the FDA’s decision and ready for the next part of SAINT’s journey,” Nolan Williams, M.D., who guided the development of SAINT, told Psychiatric News. Williams is an assistant professor of psychiatry and behavioral sciences at Stanford University, director of the Stanford Brain Stimulation Lab, and advisor for Magnus Medical. “SAINT is now the first commercially available rapid-acting neuromodulation treatment, which means it can be used in emergency and inpatient settings.”

While most current TMS protocols involve delivering stimulation to patients for between 20 minutes and 30 minutes on a single day, SAINT can deliver therapeutic doses of magnetic energy in as little as three minutes. After receiving an MRI to best target the SAINT stimulation, patients receive 10 daily sessions, spaced 50 minutes apart.

As demonstrated in a clinical trial published in The American Journal of Psychiatry, Montgomery-Åsberg Depression Rating Scale (MADRS) scores dropped by 62% among participants following five days of SAINT stimulation compared with a 14% drop among participants receiving sham stimulation. These improvements were sustained over a four-week follow-up.

“We expect the commercial launch of our SAINT Neuromodulation System to begin later in 2023 on a limited basis, for which we are building a waitlist and engaging with an overwhelming number of teaching institutions, hospitals, clinics, interested clinicians, and medical professionals,” said Brett Wingeier, Ph.D., co-founder and CEO of Magnus, in a company press release.

To read more on this topic, see The American Journal of Psychiatry article “Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial” and the Psychiatric News article “New Stanford Protocol for TMS Found to Achieve Fast Remission.”

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AJP Editors Outline Ongoing Efforts to Address Racism, Publication Biases

Prioritizing papers that examine the impacts of systemic racism and health care inequities and creating a program for residents of diverse backgrounds to learn about the publishing process are just two of several changes made in the past two years by the American Journal of Psychiatry (AJP) to address structural racism and social injustice. So wrote AJP Editor-in-Chief Ned H. Kalin, M.D., and the Journal’s deputy and executive editors in an editorial appearing in the September issue.

“This editorial update is meant to show that we have endeavored to incorporate diversity and inclusion efforts into all aspects of our editorial processes,” Kalin and colleagues wrote. “[W]e are committed to continuing these efforts in order to attain substantial progress in the coming years.”

The editors outlined several changes to AJP’s submissions process meant to ensure that research reports on human subjects include complete sociodemographic data related to race, ethnicity, sex, and gender identity.

When authors submit manuscripts to AJP, they will now be required to answer the following yes/no questions (a comment box will allow the authors to elaborate on any of their responses):

• Does your submission indicate how participant race and participant ethnicity were ascertained?
• Does your submission distinguish between assigned sex at birth and gender identity?
• Does your submission indicate how sex and gender were ascertained?
• Is your sample representative of the population from which it was drawn?

Reviewers of AJP manuscripts will be encouraged to “take note of the authors’ responses to participant recruitment data and to engage in a dialogue among authors, reviewers, and editors about adequacy of efforts,” Kalin and colleagues wrote.

“We announce these initiatives as merely the initial steps in an ongoing process of improvement, and we will provide regular reports on this process,” the authors concluded. “By improving how we review submitted research papers, our intent is to have an effect further upstream by influencing how studies are designed, conducted, analyzed, and reported so that ultimately all individuals will be represented in papers published in the American Journal of Psychiatry.”

For related information, see the Psychiatric News articles “On Structural Racism and Mental Illness” and “Article on Dismantling Racism in Psychiatry Among 2021 AJP Editor’s Picks.”

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Experts Offer Tips on Talking About Firearms With Adolescents at Risk of Suicide

Mental health professionals who work with adolescents should ask about access to lethal means, including firearms, when assessing their patients who are at risk of suicide, according to the authors of a clinical perspectives piece in the Journal of the American Academy of Child & Adolescent Psychiatry.

“Many adolescent suicide attempts are impulsive; completed suicides may be prevented if access to firearms is limited during periods of crisis,” wrote Apurva Bhatt, M.D., of the University of California, Davis, and colleagues. “However, many clinicians do not talk about firearms with patients even when clinically relevant. This may be due to assumptions that adolescents do not have access to firearms, or to lack of comfort with this topic.”

The authors offered several tips to help child and adolescent mental health professionals approach the topic of firearms with their patients:

Be informed and respectful. Conversations about reducing the risk of firearm suicide are more effective if they are approached with knowledge and respect for the various reasons for ownership.

Establish context, assess risk, and ask about firearms. This should be a nonjudgmental conversation wherein the mental health professional asks about whether the adolescent has access to firearms not only at home, but at the homes of friends or family members where the adolescent spends time.

Provide tailored recommendations. Once an adolescent has been identified as at risk for suicide, mental health professionals should discuss their concerns with the adolescent’s caregiver and work collaboratively to reduce the youth’s access to firearms. They can use a harm reduction approach with shared decision-making and emphasize that the goal is to keep the person at risk as safe as possible.

Follow up with continued discussions. Follow-up discussions can foster a trusting relationship about the health and safety of all family members.

“By being informed and respectful, establishing context, and providing tailored recommendations for each clinical situation, clinicians can provide this important suicide prevention intervention in their clinical practice,” the authors concluded.

For related information, see the Psychiatric Services article “Promoting Firearm Safety as a Suicide Prevention Strategy Within Health Care Systems: Challenges and Recommendations.”

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