Naltrexone May Reduce Binge Drinking in Sexual and Gender Minority Men

Naltrexone may significantly reduce binge drinking among sexual and gender minority men (men who have sex with men) with mild or moderate alcohol use disorder, according to a study in AJP in Advance.

“Expanding naltrexone treatment access to these individuals can help address the public health consequences associated with binge drinking, especially among communities with high binge-drinking prevalence rates, such as [sexual and gender minority men],” wrote Glenn-Milo Santos, Ph.D., M.P.H., of the University of California, San Francisco, and colleagues.

The 12-week study involved 120 sexual and gender minority men (one transgender male and 119 cisgender males) who reported at least one binge-drinking episode (five or more drinks on a single occasion) per week in the past three months, but who did not meet DSM-IV criteria for alcohol dependence. The participants received a supply of either 50 mg oral naltrexone pills or matching placebo pills and were asked to take one pill whenever they craved alcohol and/or they anticipated they might drink heavily. All participants were asked to attend weekly sessions to report on drinking behaviors and receive medication management counseling; at periodic visits, the investigators also collected urine and/or blood spot samples to measure the alcohol biomarkers ethyl glucuronide and phosphatidylethanol.

Overall, 111 participants completed the study. On average, participants took about 31 doses of the study medication over 12 weeks; the results were similar between the treatment groups, the authors reported.

After 12 weeks, the sexual and gender minority men who received naltrexone reported 26% fewer binge-drinking days, 17% fewer weeks with any binge drinking, and 31% fewer drinks per month compared with the placebo group. The effects were sustained six months after treatment, they noted.

When comparing the groups overall, there was no significance difference in the alcohol biomarker levels. Among participants who took medication on average at least 2.5 times a week, those who took naltrexone had lower levels of the alcohol metabolite phosphatidylethanol.

“These findings suggest that while there were no differences in alcohol abstinence between groups, those who took naltrexone more frequently likely had reductions in alcohol consumption,” Santos and colleagues wrote.

They continued, “[T]his study supports the use of a targeted dosing approach for naltrexone in [sexual and gender minority men] who are interested in reducing their heavy alcohol consumption on an event-driven, as-needed basis.”

To read more on this topic, see the Psychiatric News article “Can Ketamine Curb Excess Drinking?”

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Study Highlights Children Most Likely to Be Taken to Psychiatric ER By Police After 911 Call

Compared with children taken to a psychiatric emergency room (ER) by family, those taken by police after a 911 call were more likely to be male, older, and Black, a report in Psychiatric Services has found.

“Clinical and sociodemographic differences in police arrivals highlight the need for a comprehensive systems approach for children, especially marginalized youths, who need psychiatric emergency care,” wrote Wilfred Farquharson IV, Ph.D., of Stony Brook University and colleagues.

The findings were based on data contained in the electronic medical records of children between the ages of 5 and 12.9 years who were brought to a psychiatric ER at a suburban university hospital between September 2017 and April 2018. Farquharson and colleagues specifically focused their analysis on such information as the children’s age, sex, and race/ethnicity; insurance status; living situation (for example, living with two parents versus not); referral source; occurrences of aggression and suicidality; and number of psychiatric ER visits.

The researchers compared children who were taken to the psychiatric ER by the police with those children taken to the psychiatric ER by their family. They noted, “The police brought children to the CPEP [comprehensive psychiatric emergency program] when someone [for example, caregiver or school personnel] called 911 and the responding officers felt that evaluation in the CPEP was warranted.”

During the study period, 339 children under age 13 were seen in the psychiatric ER a total of 435 times. Of these children, 30% were taken to the psychiatric ER by the police at least once through March 2020 (the end of the follow-up period); 7% were taken by the police multiple times; and 13% were taken multiple times by a combination of the police and family. Of the children taken to the psychiatric ER by family only, 70% had a single psychiatric ER visit, and 30% had multiple visits.

Although Black children and Latinx children were significantly more likely to be taken to the psychiatric ER by police compared with White and Asian or other children, Farquharson and colleagues reported that “only Black race, older age, male gender, not living in a two-parent family, and having Medicaid insurance were independently associated with a first police arrival.” They added, “Black children were brought to the ER for outbursts or aggression more often than their peers, whereas Asian or other children were more often brought for suicidality.”

The authors highlighted several limitations of the study, including that data were from one suburban, university-based psychiatric ER.

They concluded, “Our data are consistent with reports of serious behavioral health crises among children and adolescents that are often not adequately addressed by ERs, inpatient units, and outpatient treatment. These crises thus lead to law enforcement referrals that are used disproportionately for individuals who are marginalized and publicly insured.”

For related information, see the Psychiatric News article “Negative Language in Medical Records More Common for Black Patients” and the Psychiatric News Alert “Black Children Less Likely to Report Suicidal Thoughts in Emergency Room, Study Suggests.”

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Females With Autism More Likely Than Males to Develop Psychiatric Disorder, Study Finds

Females with autism are more likely than males to be diagnosed with a psychiatric disorder before their 25th birthday, according to a study published yesterday in JAMA Psychiatry.

“Around 70% of autistic children meet diagnostic criteria for at least [one] psychiatric disorder, and 54% to 79% of autistic adults receive at least [one] psychiatric diagnosis,” wrote Miriam Martini, M.Sc., and Ralf Kuja-Halkola, Ph.D., of the Karolinska Institutet in Stockholm, Sweden, and colleagues. “Mental health problems are reported even among autistic individuals showing good outcomes in other areas of functioning.”

Martini, Kuja-Halkola, and colleagues conducted a population-based cohort study including all individuals born in Sweden between 1985 and 1997. The authors used the National Patient Register to identify those participants who were diagnosed with autism from age 1 onward and to identify participants who were diagnosed with a psychiatric disorder between ages 16 and 24. They included 11 psychiatric disorders in their analyses, including anxiety, psychotic, and sleep disorders. They also analyzed psychiatric hospitalizations among the participants.

Of the 1.3 million individuals included in the study, 20,841 received an autism diagnosis, 34% of whom were female. Among females with autism, 77 of 100 received at least one psychiatric diagnosis, compared with 62 of 100 males. Both females and males with autism were about three times more likely to receive a psychiatric diagnosis compared with an individual of the same sex who did not have autism, but the risk was higher for females with autism. By age 25, 22.1% of females with autism and 10.9% of males with autism had been hospitalized due to a psychiatric disorder, compared with less than 4% among people without autism.

“The findings of this large, population-based sample … demonstrate a high level of psychiatric difficulties among young autistic female individuals, and thus clearly emphasize this group’s pressing mental health needs,” the authors wrote. “Nevertheless, we need to consider psychiatric disorders in both sexes as psychiatric diagnoses and hospitalizations were more likely in autistic female and male individuals compared with non-autistic individuals of the same sex.”

For related information, see the Psychiatric News article “Comorbidities Increase Suicide Risk in People With Autism.”

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Behavioral Therapy Plus Naltrexone-Bupropion Combination May Reduce Binge Eating

A combination of behavioral weight loss therapy and the medications naltrexone and bupropion appears to reduce symptoms of binge-eating disorder in people with comorbid obesity, according to a report in AJP in Advance.

“[T]he effectiveness of [behavioral weight loss therapy] for binge-eating disorder was observed across broad outcomes reflecting eating, psychological, and metabolic clinical domains,” wrote Carlos Grilo, Ph.D., a professor of psychiatry and psychology at of Yale University, and colleagues. Grilo is also director of the Program for Obesity, Weight and Eating Research at Yale.

Participants were recruited through advertisements and were included if they met DSM-5 criteria for binge-eating disorder, were age 18 to 70 years, and had a body mass index (BMI) between 30.0 and 50.0 (or at least a BMI of 27.0 with obesity-related comorbidity). The Eating Disorder Examination interview was used to assess binge-eating frequency and eating disorder psychopathology at baseline and following treatment. Weight and height were measured at baseline, and weight was measured at monthly and posttreatment assessments.

A total of 136 participants were randomized to one of four 16-week treatments: placebo (n=34), naltrexone-bupropion (n=32), behavioral weight loss therapy plus placebo (n=35), or behavioral weight loss therapy plus naltrexone-bupropion (n=35). Behavioral weight loss therapy was delivered in individual 45-minute sessions. Behavioral techniques included goal setting, monitoring food intake and physical activity, stimulus control to achieve and maintain the lifestyle changes, and problem-solving skills to overcome challenges.

A total of 57.1% of patients in the behavioral weight loss therapy plus naltrexone-bupropion group achieved remission (defined as no episodes of binge eating during the previous 28 days). Remission rates were 17.7% in the placebo group, 31.3% in the naltrexone-bupropion group, and 37.1% in the behavioral weight loss therapy plus placebo group. The rates of participants who achieved at least 5% weight loss were 11.8% in the placebo group, 18.8% in the naltrexone-bupropion group, 31.4% in the behavioral weight loss therapy plus placebo group, and 38.2% in the behavioral weight loss therapy plus naltrexone-bupropion group.

“These findings are encouraging given the well-known difficulty in producing weight loss in patients with binge-eating disorder and comorbid obesity,” the authors concluded.

For related information, see the Psychiatric News article “Eating Disorders: Current Knowledge and Treatment Update.”

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Neurological Complications Associated With Worse Outcomes in Youth Hospitalized for COVID-19

About 1 in 15 children and adolescents hospitalized for COVID-19 experiences neurologic complications, suggests a study in Pediatrics. Among those complications are an increased risk of admission to the intensive care unit (ICU), hospital readmissions, and death.

For the study, James W. Antoon, M.D., Ph.D., M.P.H., of the Children’s Hospital at Vanderbilt and colleagues analyzed data on youth aged 2 months up to 18 years who were hospitalized for COVID-19 between March 2020 and March 2022. The researchers examined reports of neurologic complications (including encephalopathy, encephalitis, aseptic meningitis, seizures, cerebral infarction, and more) during the hospitalization of the youth.

A total of 15,137 children and adolescents hospitalized for COVID-19 were included in the analysis; 1,060 (7.0%) had at least one neurologic complication. The most common neurologic complication was febrile seizures (3.8%) followed by nonfebrile seizures (2.3%) and encephalopathy (2.2%). The least common neurologic complications were brain abscess or bacterial meningitis and cerebral infarction (0.13% and 0.05%, respectively).

Antoon and colleagues compared the hospital outcomes (such as length of stay, readmissions within 30 days of discharge, and costs associated with hospitalization) of children and adolescents with COVID-19 who experienced neurologic complications with those who did not have neurologic complications. They found that youth with neurologic complications had more ICU admissions (29.8% vs. 21.8%), longer ICU length of stay (3.2 days vs. 2.5 days), and more in-hospital deaths (1.8% vs 0.6%). Youth with neurologic complications also had more 30-day readmissions and higher hospital costs compared with those without neurologic complications.

The researchers noted that youth with chronic neurological conditions had greater odds of experiencing neurologic complications during hospitalization for COVID-19. In contrast, youth who were older, received remdesivir or dexamethasone treatment, and/or were infected by the SARS-CoV-2 delta variant had lower odds of neurologic complications.

“Our findings emphasize the importance of COVID-19 immunization in children, especially in high-risk populations, such as those with neurologic comorbidity,” Antoon and colleagues concluded.

For related information, see the Psychiatric Services article “Mental Health Conditions Among Children and Adolescents With a COVID-19 Diagnosis.”

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AACAP Publishes Practice Guidelines on Child and Adolescent Depression

Children and adolescents with moderate to severe major depression or persistent depression should be treated with cognitive-behavioral therapy (CBT), interpersonal therapy, and/or selective serotonin reuptake inhibitors (excluding paroxetine due to potential suicidal ideation), according to new practice guidelines released by the American Academy of Child & Adolescent Psychiatry (AACAP).

For youth with milder cases of depression, supportive interventions such as psychoeducation or counseling should be considered first, the guidelines panel noted.

These guidelines, which were published in the Journal of the American Academy of Child and Adolescent Psychiatry, are based on a comprehensive review of the evidence conducted by members of the AACAP Committee on Quality Issues. The members examined information from scientific articles, previously published practice guidelines, chapters in leading textbooks of child and adolescent psychiatry, DSM-5-TR, and prescription drug information websites. A first draft of the guidelines was sent to relevant members of the AACAP community for edits and suggestions.

The 55-page guideline is broken down into the following sections:

• Overview of the guideline development process, including the scientific review and peer review process.
• Assessment of depression, including structured interview guides and safety evaluation.
• Treatment of depression, including strength of the evidence, risk/benefits of various psychotherapies and SSRIs, and areas for additional research.
• Limitations of the guideline.

“In the context of a protracted severe shortage of child and adolescent-trained behavioral health specialists, research demonstrating convenient, efficient, cost-effective, and user-friendly delivery mechanisms (including telepsychiatry, web and telephone application-based adaptations of psychotherapy, trained mid-level practitioner- and lay-delivered treatments, collaborative care) for safe and effective treatment of child and adolescent depressive disorders is an urgent priority,” the guideline concluded.

For related information, see the Psychiatric News article “New Primary Care Guidelines Recommend Routine Screening for Depression in Adolescents.”

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Risk of Mental Illness, Pain Disorders Higher in Children of Parents With PTSD

Children of parents who have posttraumatic stress disorder (PTSD) may have a higher risk of developing mental illnesses and pain disorders, a study in General Hospital Psychiatry has found.

Dian-Jeng Li, M.D., of the Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, in Kaohsiung, Taiwan, and colleagues analyzed data from 12,529 patients in the Taiwan National Health Research Database. Among the patients, 1,139 had at least one parent who had PTSD and 11,390 had parents who did not have PTSD or any other major psychiatric disorder. The researchers followed the patients’ records from 1996 or time of birth to the end of 2011, and the average age of the patients in the study was 22.5 years.

After adjusting for the patients’ demographics, the researchers found that children of parents with PTSD had increased odds of developing psychiatric disorders compared with children whose parents did not have PTSD, as follows:

• 2.90 times the odds of depression
• 2.82 times the odds of bipolar disorder
• 2.26 times the odds of schizophrenia
• 2.05 times the odds of alcohol use disorder

After adjusting for the patients’ demographics, the researchers found that children of parents with PTSD also had increased odds of developing pain disorders compared with children whose parents did not have PTSD, as follows:

• 2.37 times the odds of migraine
• 1.87 times the odds of fibromyalgia
• 1.80 times the odds of peripheral neuropathy
• 1.63 times the odds of diseases of the spine and paravertebral tissues
• 1.58 times the odds of irritable bowel syndrome (IBS)
• 1.51 times the odds of dysmenorrhea

When further adjusting for family history of psychiatric disorders, the authors found the children of parents with PTSD had a significantly higher risk of depression, migraine, and IBS than those whose parents did not have PTSD.

The researchers noted that genetics, environment, and an inherited propensity for abnormal levels of the stress hormone cortisol may play a role in the increased risk among children of parents who have PTSD.

“The findings of the current study highlight the importance of timely assessment and intervention for parents with PTSD,” Li and colleagues wrote. They added that the results also emphasize the importance of early assessment and intervention of children whose parents have PTSD.

For related information, see the Psychiatric Services article “Interpersonal Psychotherapy of Posttraumatic Stress Disorder for Veterans and Family Members: An Open Trial.”

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ECT May Be Superior to Ketamine for Reducing Severity of Depression

Electroconvulsive therapy (ECT) may improve acute depression severity compared with ketamine, although treatment decisions should still be individualized and patient centered, according to a meta-analysis published yesterday in JAMA Psychiatry.

“[ECT] is considered the gold standard treatment for [treatment-resistant depression] because of its proven high efficacy,” wrote Taeho Greg Rhee, Ph.D., of Yale University School of Medicine and colleagues. However, several barriers—including few professionals trained in ECT delivery, stigma, and fears of side effects—have led to underuse of the technology.

Rhee and colleagues searched PubMed, MEDLINE, the Cochrane Library, and Embase for literature about clinical trials that included patients with a diagnosis of depression who were separated into groups receiving ECT or ketamine. The studies measured the severity of participants’ depressive symptoms using the Montgomery-Åsberg Depression Rating Scale, the Hamilton Depression Rating Scale, or the Beck Depression Inventory. The studies also evaluated safety-related events, including reports of headache, nausea, or dissociative symptoms.

Six studies were included with 340 participants, 162 of whom received ECT and 178 received ketamine. ECT was superior to ketamine across all three measures for depressive symptoms. Participants who received ketamine had lower risks for headaches compared with those who received ECT, though transient dissociative or depersonalization symptoms were more common among patients who received ketamine. ECT was associated with lower risks of blurred vision and vertigo compared with ketamine. The authors noted, however, that among some of the studies, ketamine appeared to have faster antidepressant effects for patients compared with ECT.

“Future research should assess long-term adverse events resulting from either ketamine or ECT and weigh the potential long-term benefits and risks of these treatment options,” the authors concluded.

For related information, see the Psychiatric News article “ECT for Depression May Cut Suicide Risk by Nearly 50%.”

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Experts Offer Six Steps for Increasing Universal Access to Medication for OUD

Universal access to medications for opioid use disorder (MOUD)—such as methadone, buprenorphine, and naltrexone—could save lives and reduce health care costs, but multiple barriers stand in the way. So wrote Rahul Gupta, M.D., M.P.H., director of the White House Office of National Drug Control Policy, and colleagues in a perspective article appearing in the New England Journal of Medicine (NEJM).

“We believe there are about 8 million above the age of 12 [with opioid use disorder], and less than 5% of those individuals are able to get treatment for opioid use disorder,” Gupta said in an interview with Stephen Morrissey, Ph.D., executive managing editor of the NEJM.

President Joe Biden’s 2022 National Drug Control Strategy (NDCS), which is spearheaded by the Office of National Drug Control Policy, calls for access to MOUD for any person with OUD by 2025. The authors recommended six steps that could assist in meeting this goal:

1. Bolster educational opportunities for health professionals: The federal government, along with medical education accreditation bodies, “could bolster addiction-treatment and education infrastructure” by “enhancing content related to MOUD in medical education curricula for all health-related professions and further building workforce capacity in addiction medicine by means of continuing education.”
2. Increase access to prescription MOUD in clinic- and community-based programs: One way to increase access to prescription MOUD may be through “low-threshold” buprenorphine treatment (an approach that embraces the harm-reduction philosophy of meeting patients where they are). “Low-threshold treatment programs have shown promise in enrolling people with OUD who may avoid conventional health care settings, where they often face stigma, and whose only point of contact with the health care system might be the emergency department.”
3. Ease restrictions on telemedicine: “On the basis of emerging evidence supporting the critical role of telemedicine in increasing access to buprenorphine, the NDCS calls for permanently extending pandemic-era telehealth waivers and flexibility that have permitted the initiation and maintenance of buprenorphine treatment.”
4. Increase access to treatment for people who are incarcerated: “Many people who use drugs have frequent interactions with the justice system, and overdose risk in the weeks after release from incarceration is extraordinarily high. … In addition to reducing mortality after release, offering MOUD during incarceration may reduce recidivism.”
5. Develop and support programs to address social determinants of health: “Food insecurity, income inequality, discrimination, housing instability, and homelessness have long been recognized as social drivers of population health and can affect retention in MOUD treatment.”
6. Take steps to reduce stigma in the health care system against people with OUD: Stigma can reduce the likelihood of initiating and continuing use of MOUD. By using patient-first language (for example, a “person with substance use disorder” rather than an “addict”) and publicizing the benefits of MOUD, clinicians and researchers may be able to help to reduce OUD-related stigma.

Gupta emphasized the role that health care professionals can play in ensuring their patients with OUD have access to MOUD. “The success of the national strategy will ultimately depend on the ability, willingness and the actions by individual providers in communities to act with urgency and make sure that we’re doing the most we can do save lives and get people into treatment,” he said.

For related information, see the Psychiatric News article “Most Youth With OUD Who Need Medication Treatment Do Not Receive It.”

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Trauma-Informed OB Care Can Help Pregnant Women, Their Children

A history of trauma in pregnant women can negatively impact the experience of pregnancy, postpartum, and parenting. Psychiatrists caring for women in the perinatal period are in an ideal position to screen for trauma and work with obstetrical (OB) clinical care teams to respond to the trauma-related challenges that can arise during obstetric care, according to the authors of a review article in the Journal of Consultation-Liaison Psychiatry.

“Women are specifically vulnerable to gender-related traumatic events such as unwanted pregnancy, reproductive loss, traumatic birth, childhood sexual abuse, sexual assault, rape, and intimate partner violence,” wrote Jyoti Sachdeva, M.D., an associate professor of psychiatry and obstetrics and gynecology at the University of Cincinnati, and colleagues. “Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause re-traumatization.”

The literature review by Sachdeva and colleagues summarizes research showing how a mother’s experience with trauma can impact everything from birth outcomes (such as preterm birth) to the way a mother bonds and interacts with her child.

The authors described several instruments (such as the Adverse Child Experiences Score and the Trauma Screening Questionnaire) that can be used to routinely screen women in the perinatal period for trauma history. They also outlined what the authors termed “physical, behavioral, and emotional warning signs” that suggest that a patient may have a history of trauma (including unexplained somatic symptoms; delayed or absence of prenatal care; and/or panic attacks, flashbacks, and dissociation triggered by pelvic exams). Lastly, they described how women who experienced trauma might benefit from psychotherapy and/or pharmacotherapy.

“Psychiatrists working in collaboration with obstetrical colleagues have the opportunity to positively impact systems of care by facilitating the implementation of trauma-informed, patient-centered care,” Sachdeva and colleagues concluded. “This opportunity requires expertise in recognizing the sequelae of trauma in perinatal populations and engaging our obstetrical colleagues to sensitively screen for trauma and involving patients in universal TIC [trauma-informed care]. By raising the awareness of obstetrical teams to the importance of gathering an accurate trauma history and providing TIC, patients will be empowered to communicate their choices and exert control through their perinatal course, decreasing the likelihood for re-traumatization and mitigating trauma-related symptoms.”

For related information, see the Psychiatric News special report “Women’s Reproductive Mental Health—A Clinical Framework.”

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APA Announces Candidates for 2023 Election

The APA Nominating Committee, chaired by Vivian Pender, M.D., reports the following slate of candidates for APA’s 2023 Election. This slate has been approved by the Board of Trustees and is considered official.

President-Elect
Robert L. Trestman, Ph.D., M.D.
Ramaswamy Viswanathan, M.D., Dr.Med.Sc.

Secretary
Jenny L. Boyer, M.D., Ph.D., J.D.
C. Freeman, M.D., M.B.A.
Gabrielle L. Shapiro, M.D.

Minority/Underrepresented Representative Trustee
Kamalika Roy, M.D.
Dora-Linda Wang, M.D.

Area 2 Trustee
Kenneth B. Ashley, M.D.
Glenn A. Martin, M.D.

Area 5 Trustee
Heather Hauck, M.D.
Sudhakar Madakasira, M.D.

Resident-Fellow Member Trustee-Elect
Sarah El Halabi, M.D., M.S.
Sarah A. Friedrich, D.O., M.B.A., M.S.
Sarin Pakhdikian, D.O.

The deadline for petition candidates is Thursday, November 10. All candidates and supporters should review the Election Guidelines, which were updated as part of a pilot test for the 2022 and 2023 elections. APA voting members may cast their ballots from January 3 to January 31, 2023. For more election information, please visit the election section on the APA website.

If you have any questions about the election, please contact Monique E.M. Morman, C.M.P., director of Association Governance, at mmorman@psych.org or Chiharu Tobita, also of Association Governance, at ctobita@psych.org.

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Adverse Childhood Experiences During Pandemic Take Toll on High Schoolers’ Mental Health

Nearly 3 out of 4 high school students were affected by at least one adverse childhood experience (ACE) such as sexual violence, physical abuse, emotional abuse, or family financial insecurity during the COVID-19 pandemic, a study in Morbidity and Mortality Weekly Report has found. These students were more likely to report poor mental health and suicidal behavior than students without ACEs, prompting researchers to call for greater efforts to prevent childhood harm.

“Comprehensive, cross-sector approaches, partnerships, and policies focused on primary ACE and suicide prevention and intervention, including those focusing on early identification, linkage to care, and access to trauma-informed services and supports, are necessary to improve adolescent mental and behavioral health,” wrote Kayla N. Anderson, Ph.D., of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention and colleagues.

The researchers analyzed data from 4,390 high school students younger than 18 years old who participated in the 2021 Adolescent Behaviors and Experiences Survey, a 110-question online survey designed to ascertain students’ health and mental behaviors and experiences with ACEs.

Overall, 73.1% of the students reported at least one ACE during the pandemic, 53.2% reported one to two ACEs, 12.0% reported three ACEs, and 7.8% reported four or more ACEs. Compared with students without ACEs, those with ACEs had higher rates of poor mental health and suicidal behaviors such as making a suicide plan or attempting suicide. Students who reported four or more ACEs had the highest risk: 57% reported seriously considering suicide, 48.6% reported making a suicide plan, and 38.7% attempted suicide, compared with 5.3%, 3.7%, and 0.9% of students, respectively, who did not report ACEs. Poor mental health was four times more common and past-year suicide attempts were 25 times more common among students who reported four or more ACEs compared with students who reported no ACEs.

Certain ACEs carried a higher risk of poor mental health. For example, 82.7% and 82.0% of students who experienced past-year sexual violence or physical teen dating violence, respectively, felt persistently sad or hopeless. Emotional abuse was most strongly associated with poor mental health.

“This analysis highlights the ongoing, urgent need to address adversity experienced before and during the pandemic to mitigate its impact on mental and behavioral health,” the researchers concluded.

For additional information, see the Psychiatric News article “Long-Term Impact of COVID-19 on Children, Adolescents Constitutes Public Health Emergency.”

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Follow-up Care of Youth After Psychiatric Emergencies Found Inadequate

Many privately insured youth and young adults seen in emergency rooms or hospitalized for psychiatric conditions are not receiving recommended follow-up care in the month following hospital discharge, suggests a report published yesterday in Psychiatric Services.

“Follow-ups with a mental health care provider within 7 and 30 days are national quality measures associated with improved medication adherence, decreased suicide risk, and increased long-term health care engagement,” wrote Julie Hugunin, B.S., and Maryann Davis, Ph.D., of the University of Massachusetts Chan Medical School and colleagues.

Hugunin, Davis, and colleagues used data collected between 2013 and 2018 in the IBM MarketScan commercial database to identify people aged 12 to 27 with a mental health hospitalization (n=95,153) or emergency room (ER) visit (n=108,576). Both samples included youth and young adults who had what the authors defined as an “acute event stemming from a mental health condition.” The authors then looked at whether the participants had received outpatient mental health care or primary care follow-ups within 7 and 30 days of discharge from the hospital. They also looked at whether having sought outpatient primary and/or mental health care in the six months prior to hospitalization impacted follow-up care.

The most common primary diagnosis for hospitalized patients was major depression (54%), followed by bipolar disorder (22%); self-harm, suicidal ideation, or suicide attempt was coded on 57% of hospitalizations. The most common primary diagnosis for ER patients were anxiety disorders/phobias (44%), followed by major depression (23%); self-harm, suicidal ideation, or suicide attempt was coded on 25% of these visits

The researchers found that nearly 43% of those in the hospitalized group received follow-up within 7 days and 68% within 30 days. In the ER group, nearly 29% received follow-up within 7 days and 46% within 30 days.

“The strongest predictor of mental health follow-up was established outpatient care,” wrote Hugunin, Davis, and colleagues. Compared with people with no established care, the likelihood of receiving follow-up within 7 days was highest among those with mental health care and primary care, followed by those with mental health care only and those with primary care only, they added. Similar trends were observed within 30 days of discharge.

The study by Hugunin, Davis, and colleagues was released ahead of APA’s Mental Health Services Conference, which kicks off today in Washington, D.C. See future issues of Psychiatric News for coverage of this meeting.

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Effectiveness of iTBS for Major Depression May Be Improved by Addition of D-Cycloserine

Individuals with major depressive disorder (MDD) who received intermittent theta burst stimulation (iTBS) augmented by the antibiotic D-cycloserine experienced greater improvement in depressive symptoms than those who received iTBS and a placebo, according to a report in JAMA Psychiatry.

iTBS is a new form of transcranial magnetic stimulation that can deliver therapeutic doses of magnetic energy in as little as three minutes. D-cycloserine is used to treat tuberculosis, but it has also been studied as an add-on treatment for trauma, anxiety-related disorders, and obsessive-compulsive disorder. This antibiotic targets the NDMA receptor in the brain, which is important in synaptic plasticity—the ability of neurons to adjust the connections with their neighbors. “[T]here are several lines of evidence to suggest that synaptic plasticity is not intact in MDD,” wrote lead author Alexander McGirr, M.D., Ph.D., of the University of Calgary and colleagues.

Fifty patients who had a primary diagnosis of moderate to severe MDD received 20 sessions of iTBS over four weeks supplemented with 100 mg of D-cycloserine or placebo for the first two weeks. All participants had a score of 18 or more on the Hamilton Depression Rating Scale.

The primary outcome was change in depressive symptoms as measured by the Montgomery-Åsberg Depression Rating Scale (MADRS) at the end of treatment. Secondary outcomes included clinical response (50% or more reduction in MADRS score), clinical remission (MADRS score ≤10), and Clinical Global Impression (CGI) scores.

Those receiving iTBS plus D-cycloserine had an average decrease in MADRS score of 16.16 compared with 10.20 for those receiving iTBS and placebo. Rates of clinical response were higher in the iTBS plus D-cycloserine group than in the iTBS plus placebo group (73.9% vs 29.3%), as were rates of clinical remission (39.1% vs 4.2%).

The authors concluded: “Replication [of these results] in a larger multisite study is required, as is additional investigation into intersectional approaches with other dosing regimens and precision medicine targeting approaches.”

For more information see the Psychiatric News article “New TMS Protocol Turns Six Weeks of Treatment Into One.”

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Patients With Mental Illness Found Less Likely to Undergo Recommended Colorectal Screening

People with mental illness may be less likely to participate in recommended colorectal cancer screenings than people without mental illness, suggests an article in the American Journal of Preventive Medicine.

“Colorectal cancer is one of the most frequent causes of cancer-related deaths in high-income countries,” wrote Benedicte Kirkøen, Ph.D., of the Cancer Registry of Norway, Oslo, Norway. The U.S. Preventive Services Task Force as well as the European Union recommend that adults receive regular screenings for colorectal cancer.

To examine the impact of different types and doses of psychotropic medications on participation in colorectal screenings, Kirkøen and colleagues analyzed data collected from nearly 117,000 adults aged 50 to 74 years who were participants in a large clinical trial in Norway. The data included 46,919 adults who were invited to receive a sigmoidoscopy screening, and 70,019 who were invited to receive fecal immunochemical testing. Data on psychotropic medication prescriptions from four years before the date of the screening invitation were obtained from the Norwegian Prescription Database. Kirkøen and colleagues specifically focused on participants who received at least two prescriptions of at least one of the following classes of psychotropic medications in the 12 months before the screening invitation: antipsychotics, anxiolytics, hypnotics and sedatives, and antidepressants.

Of the 116,938 participants invited to a colorectal screening, 55.7% received either a sigmoidoscopy screening or fecal immunochemical testing, the researchers found. In the 12 months preceding the screening invitation, 19.2% of the invitees (24.8% of women, 13.4% of men) were prescribed at least one class of psychotropic medication; 10.1% used hypnotics or sedatives, 8.5% used antidepressants, 6.3% used anxiolytics, and 2.6% used antipsychotics.

“The use of psychotropic medications, in particular anxiolytics and antipsychotics, was inversely associated with screening participation, independent of the screening method,” Kirkøen and colleagues wrote. The more psychotropic medications a participant was taking, the odds of participation in colorectal screening decreased, they noted.

“Together, these findings show significant disparities in [colorectal screening] participation for people with mental illness, differing according to type and dose of psychotropic medication,” Kirkøen and colleagues concluded. “Targeted interventions are warranted to ensure that people with mental illness are supported to access the benefits of colorectal cancer screening.”

For related information, see the Psychiatric Services article “Impact of Psychiatric Diagnoses and Treatment on Postoperative Outcomes Among Patients Undergoing Surgery for Colorectal Cancer.”

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Antipsychotics Found to Lower Risk of Work Disability Following First-Episode Psychosis

Patients with first-episode psychosis have a lower risk of work disability during periods when taking antipsychotics compared with periods not taking the medications, a report published Thursday in The American Journal of Psychiatry has found. The data—obtained from multiple Swedish databases on patients aged 16 to 45 who received a first nonaffective psychosis diagnosis—revealed that long-acting injectable (LAI) formulations may be particularly beneficial with regard to work disability.

“Reducing work disability can reduce indirect costs of schizophrenia and enable patients to be involved in gainful employment and to experience a sense of accomplishment, a structure for daily routine, and the possibility of belonging to a social group through interactions with coworkers,” wrote Marco Solmi, M.D., Ph.D., of the University of Ottawa and colleagues.

The study included 21,551 people (average age 29; 61% male) who received a first nonaffective psychosis diagnosis (including schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders). The researchers compared work disability outcomes (sickness absence or disability pension) during periods when these patients were taking antipsychotics with periods when they were not between 2006 and 2016.

Nearly 46% of first-episode patients had work disability during the average length of follow-up of 4.8 years, according to the researchers. The risk of work disability was 35% lower during antipsychotic use compared with no use by the same individuals.

“The lowest adjusted hazard ratios emerged for long-acting injectable antipsychotics (aHR=0.46), oral aripiprazole (aHR=0.68), and oral olanzapine (aHR=0.68),” Solmi and colleagues wrote. “Long-acting injectables were associated with lower risk than olanzapine, the most commonly used oral antipsychotic (aHR=0.68).”

The researchers noted, “The mechanism through which antipsychotics are associated with better work functioning is currently unknown. We hypothesize that antipsychotics exert their action at least partially via their effect on positive symptoms, enabling psychosocial rehabilitation and/or return to functionality in a sizable subgroup of patients.”

For related information, see the Psychiatric News articles “LAI Antipsychotics Beat Oral Meds for Preventing Relapse, Hospitalization” and “Study Calculates Disability Caused by Schizophrenia.”

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Majority of Americans Believe Mental Health Is Public Health Emergency

Almost 80% of U.S. adults agree that lawmakers need to give more attention to mental health, and 71% are more likely to vote for political candidates who prioritize investments in mental health, according to an APA poll released today.

“This poll sends a strong message that constituents want their lawmakers to promote policy solutions that advance mental health,” APA President Rebecca W. Brendel, M.D., J.D., said in a news release. “Those solutions exist and can be put into practice on the state or federal level. Our health and well-being are universal concerns that transcend political and party divides.”

The APA-commissioned poll was conducted by Morning Consult. It included a targeted sample of 2,210 adults who responded to the poll on September 21 and 22.

Though 79% of respondents said the state of mental health in the United States is a public health emergency, more women (56%) than men (47%) held this view. U.S. adults across all demographics said they were more likely to vote for a candidate who prioritizes investments in mental health, but it was young adults aged 18 to 34 who had the strongest response to this question (42% of these respondents replied they were definitely more likely to vote for a candidate who prioritizes investments in mental health).

Additional findings include the following:

• 80% of respondents said they thought children’s mental health constituted a public health emergency.
• 63% said they are worried about the outcomes of the 2022 midterm elections.
• 59% said they avoid having election-related conversations.
• 57% said they feel worried when they consume election-related news.
• 30% said they had disconnected with friends and/or family over their political differences.
• 25% said they believe Americans regularly find common ground on political views.

“With many crucial issues at stake, explored hourly on television and social media, it is no wonder that so many Americans are expressing anxiety over this coming election,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the release. “Some people will feel better if they vote or otherwise become involved, others will need time off from the news, and still others may find ways to talk with family or friends. No matter how we cope, one finding rings through: People are looking for even more government action on mental health.”

For related information, see the Psychiatric News Alerts “Majority of Adults Favor Mental Health Resources in Schools, Worry About Gun Violence” and “Americans Anxious Over Current Events, But Most Rate Their Overall Mental Health as Good.”

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APA Provides Information on New ICD Codes Impacting Psychiatry

Psychiatrists and other mental health professionals should now be using updated ICD-10-CM codes. The codes impacting psychiatry are outlined in APA’s 2022 DSM-5-TR Update: Supplement to the Diagnostic and Statistical Manual of Mental Disorders and DSM-5-TR Neurocognitive Disorders Supplement.

“Every October 1, the ICD-10-CM codes for all of medicine are updated, resulting in the addition of new codes and the revision or deletion of existing codes,” wrote Michael B. First, M.D., a professor of clinical psychiatry at Columbia University in the Division of Behavioral Health and Policy Research, in a Psychiatric News article. “[C]linicians and institutions need to keep on top of these coding changes, especially since the addition of new codes usually results in some existing codes becoming obsolete.”

This year’s coding changes represent the most consequential updates for DSM-5 disorders since the October 1, 2015, changeover from ICD-9-CM to ICD-10-CM, according to First, who is also the co-chair of the Revision Subcommittee and DSM-5-TR editor and a member of the DSM Steering Committee.

First offers several examples of the coding changes for neurocognitive disorders (NCD), including the addition of a fourth character code to indicate the severity of the major neurocognitive disorder and a combination of fifth and sixth characters to indicate the presence of an accompanying behavioral or psychological disturbance. He also describes the addition of two new mental disorder codes for mild NCD due to a medical condition with or without a behavioral disturbance.

The DSM-5-TR Update, produced by APA’s Division of Research, includes instructions on how to use the restructured NCD chapter in DSM-5-TR, information on conditions that have been added or removed from DSM-5-TR, and updated criteria for some disorders. Also, APA has updated psychiatry.org with information and documents describing the revisions in detail to make it easy to stay on top of these changes, including a list of DSM-5-TR diagnoses and prior (when applicable) and new ICD-10-CM codes.

The DSM-5-TR Neurocognitive Disorders Supplement, produced by APA Publishing, includes the DSM-5-TR classification, updated DSM-5-TR chapter on neurocognitive disorders (including revisions to the major and mild NCD coding table, coding notes for each NCD, and a newly added NCD disorder to enhance characterization of NCD symptom pattern and severity in cases where the precise etiology is unknown), and alphabetical and numerical listings in the Appendix that contain each of the more than 400 new NCD code listings.

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Recent Supreme Court Rulings Could Increase Risk of Intimate Partner Violence

Clinicians should be on the lookout for more people of childbearing age experiencing intimate partner violence following two recent U.S. Supreme Court decisions. So wrote Elizabeth Tobin-Tyler, J.D., an associate professor of health services, policy, and practice at Brown University, in a perspective article in the New England Journal of Medicine. Dobbs v. Jackson Women’s Health Organization allows states to ban or restrict access to abortion; New York State Rifle & Pistol Association v. Bruen struck down state limits on who may carry a firearm in public.

“[Intimate partner violence] encompasses physical and sexual violence and intimidation, as well as psychological abuse,” Tobin-Tyler wrote. Overall, 1 in 3 U.S. women experiences such violence, she noted.

She described several studies demonstrating the association between pregnancy, intimate partner violence, and homicide. “Most vulnerable in this new legal landscape will be people who have limited access to resources and services and inadequate protection against violence, especially those living in overburdened communities—primarily young, low-income women from historically marginalized racial or ethnic groups,” she continued. “Legal restrictions on reproductive health care and access to abortion will leave people more vulnerable to control by their abusers. Policies permitting easier access to firearms, including the ability to carry guns in public, will further jeopardize survivors’ safety.”

Clinicians have a vital role to play in supporting and helping to protect patients experiencing such abuse, Tobin-Tyler concluded. “Health care systems should provide training to all staff to help them understand the dynamics of [intimate partner violence], especially during pregnancy and the postpartum period, and to assess risk of homicide; should implement best practices for creating safe, supportive, and empowering environments for patients to disclose [intimate partner violence] and seek assistance; and should fund partnerships with domestic-violence experts and lawyers to facilitate protection, safety, and independence from abusive partners.”

For related information, see the Psychiatric News articles “Restricting Rights to Abortion Is Direct Assault on Women’s Mental Health” and “Congress Passes First Significant Gun Safety Bill in Decades.”

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Antidepressant Use During Pregnancy Not Associated With Neurodevelopmental Risk in Children

Children who were exposed to antidepressants in the womb do not appear to have an increased risk of neurodevelopmental disorders, according to a report published today in JAMA Internal Medicine.

Elizabeth Suarez, M.P.H., Ph.D., of Harvard Medical School and colleagues used national public and private health insurance databases to compile information on mothers who filled a prescription for an antidepressant medication during the second half of pregnancy (a period of marked fetal brain development). The total sample included over 145,000 women who took an antidepressant during the second half of pregnancy and over 3 million who did not. The children of these women were tracked from birth until they were diagnosed with a neurodevelopmental disorder, died, disenrolled, or reached age 14.

The researchers specifically focused on the rates of the following neurodevelopmental disorders in the children: autism spectrum disorder, attention-deficit/hyperactivity disorder, learning disorder, speech or language disorder, developmental coordination disorder, intellectual disability, and behavioral disorder.

Overall, children who were exposed to any antidepressants had a 1.76-fold increased risk of being diagnosed with any neurodevelopmental disorder; this risk was similar regardless of the class of antidepressants taken by the mother (selective serotonin reuptake inhibitors, serotonin norepinephrine uptake inhibitors, and tricyclics), Suarez and colleagues reported. The risk of neurodevelopmental disorders in the children was also similar when limiting the comparison to those whose mothers took sertraline, fluoxetine, bupropion, citalopram, or escitalopram.

However, when the researchers adjusted for multiple variables, including the maternal mental health diagnoses, sociodemographic factors, and lifestyle behaviors (such as smoking and drinking), they found that the neurodevelopmental risk associated with antidepressants dropped to 1.15-fold increased risk of any disorder. The risk was even lower when comparing women who took antidepressants during pregnancy with women who stopped taking antidepressants shortly before pregnancy.

Finally, Suarez and colleagues compared families in which some siblings had been exposed to antidepressants while others had not. There was no evidence of increased risk from antidepressant exposure for any neurodevelopmental disorder when comparing these groups, they reported.

“The results of this cohort study suggest that antidepressant use in pregnancy itself does not increase the risk of neurodevelopmental disorders in children,” Suarez and colleagues concluded. “However, given strong crude associations, antidepressant exposure in pregnancy may be an important marker for the need of early screening and intervention.”

To read more on this topic, see the Psychiatric News article “Special Report: Women’s Reproductive Mental Health—A Clinical Framework.”

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