Undergraduates Taking Online-Only Courses During Pandemic Reported Greater Psychological Distress

U.S. undergraduate college students who attended online-only classes during the COVID-19 pandemic experienced higher levels of psychological distress than those who took a mix of online and in-person classes, according to a report published today in JAMA Network Open.

“Although online classes may be simpler logistically and may minimize the risk of COVID-19 transmission, they also may increase the risk of negative mental health sequelae that should not be ignored,” wrote Abdelrahman ElTohamy, M.D., of Brigham and Women’s Hospital in Boston and colleagues. “These results are particularly relevant to mental health professionals within educational settings. Knowing that a student is attending classes fully online may provide insight that informs therapeutic approaches and suggestions for recovery.”

The researchers analyzed data from the 2021 American College Health Association–National College Health Assessment III, a biannual survey administered to students in higher educational institutions across the United States. The spring 2021 survey, administered from January to early June 2021, was entirely web-based and included demographic data, psychometric scales, and COVID-19–related questions.

As part of the survey, students were asked about the way they were participating in courses that term (response options were as follows: “entirely in-person,” “entirely online,” or “a mix of in-person and online classes”). The students also completed the Kessler Screening Scale for Psychological Distress, which asked them to report how often over the past 30 days they felt “nervous,” “hopeless,” “restless or fidgety,” “so sad nothing could cheer you up,” “that everything was an effort,” and “worthless.”

Of the 59,250 participants in the study sample, 3.5% attended fully in-person classes, 61.2% attended fully online classes, and 35.3% attended a mixed format of in-person and online classes. Compared with the students attending mixed-format classes, those who attended fully online classes were more likely to report psychological distress. This association remained significant regardless of geographic region, year in school, gender, race and ethnicity, food security, current anxiety and/or depressive disorders, COVID-19 concerns, whether students were living on or off campus, and time spent socializing with friends.

“Socializing with friends was likely more challenging for those who attended classes only online, as such engagement requires greater intentionality and effort,” the researchers wrote. “In contrast, a mixed format still afforded at least some in-person experiences that students were accustomed to, with informal opportunities for social interaction.”

For related information, see the Psychiatric News article “College Students Struggle Amid Pandemic’s Uncertainty.”

(Image: iStock/seb_ra)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Telepsychiatry Collaborative Care Found Effective for Treatment of Complex Disorders in Rural Areas

Telepsychiatry collaborative care (TCC) can help primary care clinicians working in rural or underserved areas to identify and treat patients with posttraumatic stress disorder (PTSD) and bipolar disorder with more confidence. These were the findings of a report published today in Psychiatric Services, which describes how care managers, primary care clinicians, and telepsychiatrists work together to support these patients.

Theresa J. Hoeft, Ph.D., of the University of Washington and colleagues analyzed data from the Study to Promote Innovation in Rural Integrated Telepsychiatry trial. The trial was conducted in 24 community health centers associated with 12 Federally Qualified Health Centers (FQHCs) in underserved areas of Arkansas, Michigan, and Washington between 2016 and 2020.

As part of this trial, patients with PTSD or bipolar disorder were randomly assigned to receive TCC or referral for direct treatment by a telepsychiatrist or telepsychologist for up to 12 months. Patients in the TCC group saw a telepsychiatrist over a videoconference for an initial visit. The consulting telepsychiatrist then communicated the diagnosis and treatment plan through the electronic health record or the care manager to the primary care clinician, who oversaw the patients’ care (including prescribing medications).

Hoeft and colleagues conducted 30- to 60-minute interviews with 22 primary care clinicians who had patients assigned to the TCC group. Clinicians were asked to describe their role on the TCC team, experiences communicating and working with team members, and the extent to which TCC changed how they managed patients’ mental health care. The authors highlighted several key takeaways from these interviews:

• Primary care clinicians—especially early career clinicians—appreciated support from the telepsychiatrist consultant both in medication management and in improving their ability to recognize, diagnose, and treat PTSD and bipolar disorder.
• Primary care clinicians identified the care manager (typically a social worker or registered nurse) as key to fostering communication between clinical care team members and with each patient. The authors noted that while the clinicians could access the telepsychiatrist’s notes via the electronic health record, they had minimal real-time interaction with the telepsychiatrist and relied on care managers for this information. Similarly, these managers “ensured that information on diagnosis, medication management, and side effects was clearly communicated to the clinician and patient while also relaying treatment progress to the telepsychiatrist consultant.”
• Primary care clinicians noted TCC increased patient engagement, and collaboration with the clinical manager reduced clinicians’ administrative burden.

“Primary care clinicians in underserved areas valued TCC and offered positive feedback about their experiences treating patients with PTSD or bipolar disorder,” Hoeft and colleagues wrote. “This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.”

For related information, see the Psychiatric News article “Collaborative Care as a Way to Stave Off Burnout.”

(Image: iStock/Anchiy)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Media Coverage, Placebo Response Linked to Pain Relief Seen in Cannabinoid Trials

A strong placebo response contributes significantly to the perception of pain reduction observed in clinical trials of cannabis-based therapies, according to a review and meta-analysis in JAMA Network Open. The study also suggests that media coverage of cannabis trials may promote high expectations of pain relief in clinical trial participants, thus increasing the placebo effect.

“In particular, we found that news articles and blogs had a strong positive bias toward the efficacy of cannabinoids in pain therapy,” wrote Filip Gedin, Ph.D., of Sweden’s Karolinska Institutet and colleagues. “The unusually high media attention surrounding cannabinoid trials, with positive reports irrespective of scientific results, may uphold high expectations and shape placebo responses in future trials. This influence may impact the outcome of clinical trials, regulatory decisions, clinical practice, and ultimately patient access to cannabinoids for pain relief.”

Gedin and colleagues identified 20 clinical trials that tested cannabis-based products for pain relief. The combined sample included 1,459 adults who had pain conditions such as neuropathic pain or multiple sclerosis. All participants were given placebo; tetrahydrocannabinol (THC) and/or cannabidiol (CBD) extracts; or synthetic cannabinoids like nabilone, in a variety of formats, such as pills, oils, sprays, and vapor.

Overall, participants who received an active cannabis product reported large reductions in pain intensity. However, the participants who took placebo also reported significant reduction in pain intensity, and there was no statistical difference in pain relief between the groups.

The treatment delivery method, duration of the study, or type of patient pain did not influence the size of the placebo effect. However, a larger placebo response was observed among well-controlled trials that reduced potential biases.

The authors wrote that it is possible that the trials with low risk of bias were successfully blinded so that patients could not tell whether they were receiving active cannabis. Thus, participants in the placebo group who had high expectations of pain relief were more likely to maintain positive treatment expectations through the trial and benefit more from the placebo treatment.

To read more on this topic, see the Psychiatric News article “Be Prepared to Discuss CBD Products With Patients.”

---

APA’s 2023 Election: Your Vote Matters

Get to know the candidates in APA’s 2023 election by attending four live, virtual meet-the-candidate town halls on December 5 through 8. The town halls will begin at noon ET and run 60 to 90 minutes. Make an informed choice to determine who will shape the future of APA and psychiatry.

Register

Submit questions for candidates

Rates of Smoking Among People With MH/SUD Fell From 2008 to 2019, Study Suggests

The rates of smoking by adults with mental and/or substance use disorders (MH/SUD) fell by about 10% between 2008 and 2019, a study in Addiction suggests. The decline in smoking and increase in smoking abstinence coincided with greater gains in insurance coverage for adults with MH/SUD, according to the authors.

“These findings, which hold after controlling for age, sex and race/ethnicity, are among the first to identify meaningful, population-level reductions in smoking and increases in abstinence among adults with MH/SUD, a group that has maintained significantly higher smoking rates in recent decades despite the implementation of numerous preventive public health measures and clinical interventions that have driven change in the general adult population,” wrote Timothy B. Creedon, Ph.D., of the U.S. Department of Health and Human Services and colleagues.

The researchers analyzed data collected between 2008 and 2019 as part of the National Survey on Drug Use and Health (NSDUH)—an annual survey of approximately 70,000 people living in the United States. One of the primary objectives of the NSDUH is to track trends in alcohol, tobacco, and other drug use.

Specifically, Creedon and colleagues examined trends in smoking among adults with and without MH/SUD before and after the health insurance expansions under the Affordable Care Act (ACA) took effect. Such expansions included coverage of young adult family members under age 26 in 2010 and Medicaid expansion and the launch of the private marketplaces in 2014.

The researchers examined three measures of cigarette use by 448,762 adults aged 18 to 64 who participated in the NSDUH during the study period:

• Any current smoking (defined as having smoked at least 100 cigarettes over lifetime and smoked all or part of at least one cigarette in the 30 days prior to completing the NSDUH survey).
• Daily smoking (smoked all or part of at least one cigarette during 25 or more of the 30 days).
• Recent smoking abstinence (smoked at least 100 cigarettes over lifetime but no cigarettes in last 30 days).

When comparing pooled data from 2008-2009 with 2018-2019, Creedon and colleagues found that current smoking rates of adults with MH/SUD decreased from about 38% to 28% while current smoking rates of adults without MH/SUD decreased from about 21% to 16%—a significant difference in decrease of about 5 percentage points for people with MH/SUD. Similarly, adults with MH/SUD experienced a greater drop in daily smoking. Recent smoking abstinence rates for adults with MH/SUD increased from about 7.5% to 11%, while recent smoking abstinence rates for adults without MH/SUD increased from about 9.5% to 12%—a difference in increase of 1 percentage point for people with MH/SUD.

In 2008-2009, the adjusted prevalence of any insurance coverage (defined as at least 10 of 12 months prior to NSDUH survey) was about 6 percentage points lower for adults with MH/SUD (72%) than for adults without MH/SUD (78%), Creedon and colleagues wrote. In 2018-2019, there was only a two-point difference in percentage points between the two groups (with 82% of people with MH/SUD with insurance coverage compared with 84% of people without MH/SUD with insurance coverage). Having any health insurance for at least 10 of the 12 months prior to being surveyed was strongly associated with a reduction in the likelihood of any current smoking and daily smoking and an increase in the likelihood of recent smoking abstinence, they added.

“[T]his study presents new evidence that smoking among adults living with MH/SUD has begun to decline substantially and that health insurance coverage expansions may play a supporting role in these important reductions,” Creedon and colleagues concluded.

For related information, see the Psychiatric Services article “Smoking Cessation Medication Prescribing for Smokers With and Without Mental Illness.”

(Image: iStock/eternalcreative)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

APA Denounces Anti-LGBTQI Rhetoric in Statement Following Colorado Springs Shooting

APA on Monday issued a statement expressing sympathy for the victims and survivors of the shooting that took place late Saturday at Club Q Nightclub in Colorado Springs, Colo.

Responding to the shooting that left five people dead and at least 18 injured at a nightclub that has served as a haven for gay and transgender people in the conservative Colorado Springs area, APA denounced anti-LGBTQI rhetoric as well as rhetoric linking violent acts of hate to mental illness.

“Hate has no place in America. Violence based in hate is abhorrent. Bias toward LGBTQI people, whatever form it takes, hurts mental health,” APA stated. “We stand opposed to laws and rhetoric that discriminate against this community, whether it is promoting dangerous conversion therapy or restricting provision of health care services to trans or gender-diverse individuals. We stand in solidarity with the LGBTQI community in the aftermath of this devastating event and in the ongoing discrimination its members face, with the hope that one day we will turn the page.”

As APA has responded to past acts of mass gun violence, the organization asserted that gun violence is a public health crisis. “APA has worked over the past years, often in concert with other physician and mental health organizations, … to promote legislation that strengthens background checks, research, and other methods to control access to firearms,” APA stated. “At the same time, APA strongly opposes rhetoric that would link violent acts of hate and mass shootings to mental illness. Mental illness is prevalent across the globe, but this level of firearm violence is unique to the United States.”

“We … mourn the lives of those who were lost and send support to those recovering from injuries,” APA stated. “Our hearts go out to the families and friends of the victims, and we urge whoever may need it to seek mental health support in the aftermath of this tragedy.”

The APA statement encouraged anyone feeling overwhelmed by the tragedy in Colorado Springs to call 988, the national mental health crisis hotline, or visit APA’s website for additional mental health resources on coping after a disaster and traumatic events.

For related information, see the Psychiatric News Alert “APA Implores Congress to Act to Prevent Firearm Violence.”

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Lisdexamphetamine May Help People With Amphetamine Use Disorder

Lisdexamphetamine may reduce hospitalization and death in people with amphetamine use disorder, a report in JAMA Psychiatry suggests. Lisdexamphetamine (brand name Vyvanse) is a stimulant approved to treat attention-deficit/hyperactivity disorder and binge eating disorder.

“Amphetamines are the second most used illicit drugs worldwide and amphetamine-related hospitalizations are increasing substantially,” wrote Milja Heikkinen, M.D., of the University of Eastern Finland and colleagues. Though deaths related to amphetamine or methamphetamine use have doubled over the past decade, there are no approved pharmacological interventions available for treating people with these disorders, they wrote.

Heikkinen and colleagues used national registers to identify all Swedish residents aged 16 to 64 who received a first diagnosis of a methamphetamine or amphetamine use disorder between July 2006 and December 2018. The study cohort included 13,965 people with methamphetamine or amphetamine use disorders (average age: 34 years) whose use of psychotropic medication as well as hospitalizations and/or death were tracked for an average of four years.

During the follow-up period, 74.0% of the cohort were hospitalized for a substance use disorder, 82.3% were hospitalized for any reason, and 9.5% died. The researchers found that individuals prescribed lisdexamphetamine had an 18% reduced risk of substance use hospitalization, 14% reduced risk of any hospitalization, and 57% reduced risk of death during periods when they were taking the medication compared with periods when they were not; it was the only medication that showed a benefit for all three of these outcomes. Methylphenidate, another stimulant, was also associated with decreased mortality risk but had no effect on hospitalizations.

In contrast, individuals with methamphetamine or amphetamine use disorders were at higher risk of any hospitalization during periods when they were taking benzodiazepines, antidepressants, or antipsychotics compared with periods when they were not taking these medications; benzodiazepine use was also associated with a higher risk of death.

Heikkinen and colleagues noted that the findings suggest that people with methamphetamine or amphetamine use disorder might benefit from replacement therapy to control stimulant intake—similar to how patients use nicotine patches to reduce smoking or buprenorphine to reduce opioid use.

To read more on this topic, see the Psychiatric News article “Naltrexone-Bupropion Combination May Reduce Methamphetamine Use.”

(Image: iStock/MJ_Prototype)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Cannabis Use in Pregnancy Linked to Preterm Birth

Using cannabis while pregnant may raise the risk of preterm birth, a study in Addiction has found.

“The findings further support the message provided by the American College of Obstetricians and Gynecologists that pregnant mothers should be encouraged to avoid cannabis use during [the] prenatal period,” wrote Bereket Duko, Ph.D., of Curtin University in Australia and colleagues.

The researchers analyzed data from 27 studies that measured cannabis use during pregnancy and were published between 1986 and 2022. Each study had between 304 and 4.83 million participants who had live births. Preterm birth was defined as a live birth before the pregnant person completed 37 weeks of gestation.

Participants who used cannabis during pregnancy were 35% more likely to have a preterm birth. The results were similar after the researchers adjusted for the participants’ use of tobacco, alcohol, and other drugs during pregnancy; gestational diabetes; hypertension; household income; and previous preterm birth.

Duko and colleagues offered several possible causes for the increased risk, noting that several compounds in cannabis can cross the placenta, including delta-9-tetrahydrocannabinol (THC) and cannabidiol.

“These chemicals can result in impaired placenta development and insufficient blood circulation,” they wrote. “Insufficient placental blood circulation may result in fetal growth restriction and development. This, in turn, has been associated with spontaneous preterm birth.”

The researchers added that the increased risk may be because of confounding by alcohol, tobacco, or other drug use during pregnancy.

They concluded that the findings warrant public health messages to avoid cannabis exposure, particularly during pregnancy.

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

(Image: iStock/Andrii Zorii)

---

Get to Know the Candidates in APA’s 2023 Election

APA will host four live, virtual meet-the-candidate town halls on December 5 through 8. The town halls will begin at noon ET and run 60 to 90 minutes.

Register

Submit questions for candidates

Adverse Social Determinants of Health Associated With Self-Harm Among Youth

Youth with a psychiatric illness who experience at least one adverse social determinant of health—such as child welfare placement, abuse, or neglect—have a significantly increased risk of self-harm, according to a study published this week in Psychiatric Services.

“Self-harm is a key risk factor for youth suicide and is a major public health concern,” wrote Elyse Llamocca, Ph.D., of Ohio State University College of Medicine and colleagues. “A better understanding of [social determinants of health] and suicide risk in pediatric primary care and other health care settings could inform targeted suicide prevention strategies to reduce youth suicide rates.”

Llamocca and colleagues analyzed Ohio Medicaid claims data to identify youth aged 10 to 17 who had at least one claim with a primary psychiatric diagnosis between April 2016 and December 2018. The authors used ICD-10 codes to identify adverse social determinants of health and incidents of self-harm (defined as both nonsuicidal self-injury and suicide attempts). Adverse social determinants of health were classified into 14 categories, including abuse and neglect; housing instability; death of a family member; family disruption by separation or divorce; or other family problems such as inadequate parent supervision, parental overprotection, or needing to care for a dependent relative.

The authors identified a total of 244,958 youth, with the most common psychiatric diagnoses including ADHD (40%), depression (26%), and anxiety disorders (24%). Twenty-one percent of the youth had a documented adverse social determinant of health, the most prevalent of which was abuse and neglect (13%).

Self-harm occurred among 1.3% of the youth. Abuse and neglect, child welfare placement, parent-child conflict, and other family problems significantly increased the risk of self-harm. In particular, the risk of self-harm among youth who experienced abuse and neglect was nearly two times greater than that of youth who had not.

“Our findings suggest that adverse [social determinants of health] provide vital information beyond demographic and clinical factors in understanding risk for self-harm,” the authors wrote. “Use of ICD-10 codes to identify clinical and social factors related to self-harm risk in medical records could help to identify youths for appropriate prevention efforts and may allow health care providers to bill for efforts to address adverse [social determinants of health] in general clinical settings.”

For related information, see the Psychiatric News article “Youth Online Behavior Offers Clues to Suicidality.”

(Image: iStock/xijian)

---

Get to Know the Candidates in APA’s 2023 Election

APA will host four live, virtual meet-the-candidate town halls on December 5 through 8. The town halls will begin at noon ET and run 60 to 90 minutes.

Register

Submit questions for candidates

Long-Term Use of Some Antipsychotics Increases Risk of Fractures, Study Shows

Individuals who take antipsychotics that increase the hormone prolactin for four years or more are at heightened risk of low-energy fractures (fractures resulting from falls from standing height or lower), according to a report in Schizophrenia Bulletin.

Most first-generation antipsychotics increase prolactin levels, as do the second-generation antipsychotics risperidone and paliperidone. Prolactin-sparing antipsychotics (known to slightly increase levels of prolactin) include aripiprazole, clozapine, and quetiapine, among others.

High levels of prolactin (hyperprolactinemia) can cause a decrease in bone mass density, wrote Marco Solmi, M.D., of the University of Ottawa, and colleagues. “In subjects treated with prolactin-increasing antipsychotics, prolactin levels should be monitored and hyperprolactinemia should be avoided when possible and treated when it occurs,” they wrote.

The researchers used Finnish national birth registries to look at the use of prolactin-increasing and prolactin-sparing antipsychotics among 4,960 people with schizophrenia who experienced a low-energy fracture and 24,451 people with schizophrenia who did not experience a low-energy fracture, matched for age, sex, and duration of illness. About 61.5% of all subjects were females, with a mean age of 62 years.

Those with schizophrenia who took prolactin-increasing antipsychotics for 4 to 7 years were 22% more likely to experience a low-energy fracture than those who took medications for less than one year. The longer participants took the prolactin-increasing antipsychotics, the greater the risk of a low-energy fracture: People who took the medications for 7 to 10 years had a 30% increase in low-energy fracture; exposure greater than 13 years carried a 38% increased risk low-energy fracture. All dosages of prolactin-increasing antipsychotics carried an increased risk of low-energy fracture, with the risk rising as the dosage increased.

For prolactin-sparing antipsychotics, only very high doses (greater than 6,000 defined daily doses) were associated with increased risk of low-energy fracture.

“Prevention of hyperprolactinemia can be successfully achieved by prescribing prolactin-sparing antipsychotics,” Solmi and colleagues wrote. Such medications include partial D2 agonists aripiprazole, brexpiprazole, cariprazine, and lumateperone; clozapine; and quetiapine.

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

(Image: iStock/stevecoleimages)

---

Erratum

In today’s Psychiatric News Update, the dates and time of the town halls to meet the candidates in APA’s 2023 election were wrong. We apologize for the error. Please note that the town halls will be held December 5 through 8 at noon ET each day.

Register

Submit questions for candidates

Most Youth Who Died by Suicide Sought Health Care in Year Prior to Death

Nearly 90% of young people who died by suicide were seen by a health care professional at least once in the year prior to their death, including more than 40% who were seen in the month prior to death, a report in Psychiatric Services has found.

“In this large, geographically diverse sample of young people seeking care in nine large U.S. health systems, mental and general medical disorders were common among suicide decedents,” wrote Jordan M. Braciszewski, Ph.D., of Henry Ford Health in Detroit and colleagues. “Depression, anxiety, ADHD, and substance use disorders were the most common among those with a behavioral health diagnosis, highlighting targets for suicide prevention.”

Braciszewski and colleagues analyzed data from nine health care systems across the country that participate in the Mental Health Research Network. The overall study population consisted of 4,895 young people aged 10 to 24 years, including 445 who died by suicide between January 2000 and September 2015. The mean age of the sample was about 17 years.

The researchers found that young people who died by suicide made on average 11.4 health care visits in the previous year, compared with 6.5 among the young people who did not die by suicide. Outpatient specialty visits were most common among both groups, followed by primary care visits.

Young people who died by suicide were more likely to have been diagnosed with at least one mental disorder (51% vs. 16%) and had higher rates of nearly all mental disorders, the researchers reported. Diagnoses associated with the greatest odds of death by suicide included suicidal ideation, psychotic disorders, alcohol use disorder, and any substance use disorder. Epilepsy and sleep disorders were also significantly associated with increased risk for suicide death.

“Patients living in census blocks with low education levels were significantly less likely to be suicide decedents,” the researchers noted. “Insurance type and living in a higher-poverty census block were not significantly associated with suicide death.”

They concluded, “High rates of health care utilization among suicide decedents indicate a need for improving identification of mental health conditions and suicide risk across the health care system.”

For related information, see the Psychiatric News articles “Youth Suicide Rate Increases by Nearly 60%” and “Youth Online Behavior Offers Clues to Suicidality.”

(Image: iStock/Prostock-Studio)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Attachment Anxiety Following Mild TBI Associated With Poor Outcomes

Adults with attachment anxiety are more likely to have severe and persistent symptoms following a mild traumatic brain injury (mTBI), according to a report in The Journal of Neuropsychiatry and Clinical Neurosciences. The presence of attachment anxiety following mTBI was also associated with increased depression, increased anxiety, and decreased quality of life.

“Interpersonal attachment influences the development and course of disease,” wrote Noah D. Silverberg, Ph.D., of the University of British Columbia and colleagues. “Overall, our findings suggest that attachment strategies in current relationships may buffer or exacerbate stress after mTBI. Greater consideration of the attachment system may improve understanding and management of persistent symptoms after mTBI.”

Silverberg and colleagues recruited 91 adults from two outpatient mTBI clinics in British Columbia who were experiencing persistent mTBI symptoms such as headache, fatigue, memory, and/or sleep problems. The participants completed two sets of questionnaires on TBI symptoms, depression, anxiety, and health-related quality of life at intake (about 18 weeks after their injury) and about three to four months later. They also completed the Relationship Scales Questionnaire (includes questions about attachment) at the follow-up session. Eighty-three adults who completed both assessments were included in the final analysis.

The researchers found significant associations between higher attachment anxiety and persistent symptoms, greater depression and anxiety symptoms, and less improvement in depression and quality of life at follow-up. In contrast, there was no association between higher attachment avoidance (being more emotionally and affectionately distant) and any clinical measures.

Silverberg and colleagues wrote that the mechanisms that connect attachment anxiety with slower mTBI recovery are unclear.

“Future research is needed to disentangle the directionality of the relationship between attachment strategies and clinical outcomes after mTBI,” they concluded. “Longitudinal assessment of attachment strategies and analyses of individual trajectories might reveal unique patterns (attachment strategies contributing to persistent symptoms, persistent symptoms influencing attachment strategies, or both) for different patients.”

To read more on this topic, see the Psychiatric News article “Healing After Moderate to Severe TBI Takes Time.”

(Image: iStock/KatarzynaBialasiewicz)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Most Smokers With SMI Don’t Get Treated for Smoking Cessation, Study Finds

From 2005 to 2019, nearly 98% of smokers—including those with and without serious mental illness (SMI)—were not prescribed treatments for tobacco use disorder, according to a study published yesterday in Psychiatric Services.

“Pharmacotherapy is safe and effective for smokers with mental illness, and evidence shows that these medications improve outcomes without worsening psychiatric symptoms,” wrote Sarah White, M.S.P.H., of Johns Hopkins Bloomberg School of Public Health, Karly Murphy, M.D., M.H.S., of Johns Hopkins School of Medicine, and colleagues. “However, estimates indicate that only 25% of specialty mental health treatment facilities offer [nicotine replacement therapy] and 21% offer non-nicotine cessation medications.”

White, Murphy, and colleagues analyzed Medical Expenditure Panel Survey (MEPS) data from 2005 to 2019 to examine how often individuals with and without any mental illness received smoking cessation medications, including varenicline, bupropion, and nicotine replacement therapy (NRT). The data included medical conditions, smoking status, prescribed medicines, inpatient and outpatient services, and office-based visits for individuals aged 18 and older. Participants were divided into groups based on their smoking status and presence of mental illness, including SMI (defined as a diagnosis of schizophrenia, bipolar disorder, or major depressive disorder).

The MEPS data included 55,662 smokers: 18,353 individuals had mental illness (7,421 of whom had SMI), and 37,309 did not have mental illness. From 2005 to 2019, the proportion of smokers with or without any mental illness who were prescribed any of the three cessation medications never exceeded 17%. There was a slight increase in smoking cessation prescriptions among smokers with SMI during the study period, rising from 0.3% in 2006 to 2.4% in 2019 for varenicline; 0.4% in 2005 to 1.6% in 2016 for NRT; and 8% in 2005 to 16.7% in 2019 for bupropion.

The authors also conducted interviews with 20 general internists and 20 psychiatrists in October and November 2017. Interviewees were asked about cessation treatment practices and barriers and facilitators to help people with mental illness stop smoking. Eighty-five percent reported routinely screening their patients’ smoking status, and 95% also reported offering smoking cessation medication, though only 58% offered counseling for smoking cessation. Three barriers to smoking cessation treatment were consistently cited: patients’ perception that tobacco is a helpful coping mechanism, patients’ unwillingness to engage in cessation practices, and an inability to use certain medications due to previous negative side effects or interactions with psychotropic medications.

“Low rates of delivery of guideline-concordant treatment for tobacco use disorder to people with serious mental illness are of particular concern given the high prevalence of tobacco smoking, adverse social determinants of health, and the 25- to 30-year mortality gap (vs. people without mental illness) among individuals in this population,” Eden Evins, M.D., M.P.H., and Corinne Cather, Ph.D., of Harvard Medical School wrote in an accompanying commentary. “System- and provider-level strategies to incorporate evidence-based smoking cessation treatment into standard workflows are needed to increase delivery of smoking cessation medication to people with and people without mental illness who are addicted to smoked nicotine.”

For related information, see the Psychiatric News article “Psychiatrists Can Do More to Help Patients Quit Smoking.”

(Image: iStock/Altayb)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Sleep Debt, Daytime Sleepiness Common Among American Adults

Nearly 30% of adults have trouble falling or staying asleep, a study in JAMA Network Open has found. The results also indicate that more than 30% of adults have at least 1 hour of sleep debt a week (get 1 hour less of sleep than their bodies need), and nearly 10% have at least 2 hours of sleep debt a week.

“Given that emerging evidence suggests that … sleep debt could be associated with obesity, diabetes, cardiovascular health, and mood disorders, more evidence is needed on the trend in sleep debt over time and the benefits of reducing its risk, even in those without substantive sleep deprivation,” wrote Hongkun Di, M.D., of the Huazhong University of Science and Technology in Wuhan, China, and colleagues.

The researchers analyzed data from 9,004 adults aged 20 years and older who participated in the National Health and Nutrition Examination Survey (NHANES) from 2017 to 2020. The participants had responded to questions that allowed researchers to investigate the sleep-wake timing on workdays and free days. For participants who were retired, unemployed, or students, weekdays were considered workdays and weekends were considered free days.

Participants slept a mean of 7.59 hours a day on workdays and 8.24 hours a day on free days. Many participants also reported experiencing sleep problems as follows:

• 30.5% had 1 hour or more of sleep debt a week.
• 9.75% had 2 hours or more of sleep debt a week.
• 29.8% had trouble sleeping.
• 27.2% had daytime sleepiness.

Furthermore 46.5% experienced 1 hour or more of social jet lag, which occurs when there is a discrepancy between a person’s biological time, which is determined by the person’s internal body clock, and social times, which are dictated by social obligations such as school or work.

On workdays, 23.1% of participants slept less than 7 hours and 25.4% went to sleep at midnight or later. On free days, 12.9% of participants slept less than 7 hours and 40.9% went to sleep at midnight or later.

“More research is needed to determine long-term trends and further elucidate the importance of instability in sleep timing for public health,” Di and colleagues wrote.

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

(Image: iStock/fizkes)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

What Prevents Indigenous People From Seeking Mental Health Treatment?

A lack of Indigenous mental health professionals and mistrust of the effectiveness of mental health treatment are two of multiple barriers that may keep Indigenous people from seeking and using mental health services, a review in Psychiatric Services suggests.

Christiana J. Goetz, M.A., Christopher J. Mushquash, Ph.D., and K. Amanda Maranzan, Ph.D., of Lakehead University in Ontario searched five databases—PsycINFO, PubMed, Web of Science, Social Services Abstracts, and Bibliography of Native North Americans—for original studies with data specific to Indigenous people about barriers to or facilitators of seeking professional help for mental disorders. Of the 1,010 records that the researchers identified, the final synthesis included 41 articles with information specific to Indigenous people in Canada, the United States, Australia, or the Pacific Islands.

The researchers identified six main themes associated with mental health service use among Indigenous populations:

Informal supports: Participants reported being more comfortable talking to family and friends than to a mental health professional.

Structural obstacles and supports: Participants reported a lack of mental health services and resources for Indigenous patients, including a lack of access to Indigenous service providers and long waitlists for care. Transportation assistance and referrals were identified as facilitators of help seeking and service use.

Stigma and shame: Participants’ feelings of shame and embarrassment about mental health concerns and perceived or experienced discrimination were associated with a decreased likelihood of seeking mental health treatment; anonymity encouraged seeking mental health treatment.

Self-reliance and uncertainty about services: Many participants expressed skepticism about the effectiveness of mental health treatment, and many expressed the desire to handle their problems on their own.

Cultural factors and mistrust of mainstream services: Participants emphasized culture in their preferences for mental health professionals and treatment; some participants did not trust non-Indigenous professionals. Allowing families access to traditional modes of health care, based on Indigenous values, facilitated care.

Need for outreach and information regarding mental illness and services: Participants’ lack of recognition of mental health problems was a significant barrier to seeking help; greater knowledge of mental illness was associated with more positive attitudes toward mental health treatment.

“Increased funding, increased availability of culturally sensitive services, and incentives for Indigenous people to be educated and trained in mental health services delivery would enhance help seeking among Indigenous people,” the authors wrote. “On a larger scale, policymakers have a responsibility to address the systemic barriers that inordinately affect access to proper mental health support for Indigenous populations.”

More information about this review can be found on APA blog post “Indigenous Populations Face Unique Barriers to Accessing Mental Health Help.”

For related information, see the Psychiatric News articles “Mindfulness Has Parallels to Indigenous Cultural Practices” and “Culture as Treatment: Some Indigenous People Wary of Evidence-Based Treatment.”

(Image: iStock/SDI Productions)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Use of Electronic Cigarettes Continues to Rise Among Teens

Though the overall prevalence of electronic cigarette (e-cigarette) use among teens has dropped since 2019, those who begin vaping appear to be starting at a younger age and vaping more frequently, according to a report published today in JAMA Network Open.

“These changes may reflect the increased addictive potential of [electronic] nicotine delivery products that make it easier to inhale nicotine than from cigarettes or other combustible tobacco products,” wrote Jonathan P. Winickoff, M.D., M.P.H., of Massachusetts General Hospital for Children and colleagues. “The fact that e-cigarette addiction trends are continuing to increase despite the 2019 federal legislation raising the tobacco sales age to 21 years suggests that tighter regulation, additional legislative action, or both may be necessary to protect adolescents.”

Winickoff and colleagues looked at data collected from middle and high school students who participated in the 2014 to 2021 National Youth Tobacco Surveys (NYTS). The final analysis included data from 151,573 respondents, who were on average 14.5 years.

The researchers found that among teens who currently use tobacco or nicotine products, those who first used e-cigarettes rose from 27.2% in 2014 to a peak of 78.3% in 2019 and remained high at 77.0% in 2021. During the same period, the age of first e-cigarette use dropped by about two months each calendar year. Additionally, the average frequency of vaping among users steadily rose from three to five days/month between 2014 and 2018 to six to nine days/month in 2019 to 2020 and 10 to 19 days/month in 2021. Similar patterns were not seen in the use of cigarettes, cigars, and smokeless tobacco, the authors noted.

The researchers also examined data on youth’s addiction to e-cigarettes, which they characterized as use of an e-cigarette within the first five minutes of waking. From 2014 to 2017, only 1% of youth who used only e-cigarettes reported doing so, but this rose to 4% in 2019, and over 10% in 2021. During this same time, addiction did not change for youth who smoked only cigarettes or used smokeless tobacco but increased among youth who used cigars only.

“Because tobacco addiction is a chronic disease, clinicians should be ready to address youth addiction to these new high-nicotine products during the course of many clinical encounters,” they concluded.

To read more on this topic, see the Psychiatric News article “FDA Bans Some Flavored E-Cigarettes, but Advocates Say Policy Falls Short.”

(Image: iStock/Hiraman)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Nearly 4 in 10 Americans Experience Declining Mood in Winter, APA Poll Finds

Declining mood affects 38% of Americans in the winter, APA’s November Healthy Minds Monthly Poll has found. The poll also found that 24% of Americans feel generally depressed in winter. APA’s Healthy Minds Monthly tracks timely mental health issues throughout the year.

The November Healthy Minds Monthly Poll, conducted online by Morning Consult from October 19 to October 21, asked 2,211 adults about the state of their mental health during the winter and found the following:

• 66% of participants noted behavioral changes during winter.
• 33% said they sleep more.
• 28% said they feel fatigued in the winter months.
• 21% said they become moody.
• 20% said they lose interest in the things they liked doing.
• 19% said they eat more sweets in the winter months.
• 17% said they had difficulty sleeping.

The poll also found that women and mothers were more likely than men and fathers to say their mood declined in the winter. Participants who lived in rural areas were more likely to report declining mood in winter compared with people who lived in suburban or urban areas. Furthermore, participants who lived in the Northeast and Midwest were more likely to say their mood worsened in the winter compared with those who lived in the South and West.

The survey also identified situations that improved participants’ mood during the winter; 44% of participants reported looking forward to spending time with friends and family during the holidays, and 49% said that enjoying good food improves their mood.

“Cold, dark weather can have a real impact on our mood,” APA President Rebecca W. Brendel, M.D., J.D., said in a statement. “Especially in northern areas of the country, where winter lasts for several months, it’s important to keep tabs on our mood and to seek help if sadness or other symptoms become overwhelming. It’s also a great time to remember that there are winter traditions and activities that can bring us joy and lift our moods.”

When asked about daylight savings time, 57% of participants said that the time change didn’t affect their mental health, 25% said it had a negative impact, and 18% said it had a positive impact. Parents were more likely to report a positive impact than nonparents.

The poll also examined awareness of seasonal affective disorder (SAD), a form of depression with symptoms that emerge in the fall or winter and typically resolve in the spring. Women were more likely to be familiar with it than men, and White and Latinx participants were more likely to be aware of it than Black participants. Among all participants, roughly half reported having heard or read about SAD. Slightly more than half gauged the symptoms of SAD as serious as depression, and just over a third said the symptoms are less serious. Men were more likely than women to consider the symptoms as less serious.

“Seasonal affective disorder is more than just the winter blues, and people need to be aware that if they’re having depression symptoms specifically during these months, it’s a medical disorder for which they can get help,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “It’s important to get the word out, especially in communities that have been historically underserved by medicine, that this disorder exists and that help is available.”

For related information, see the Psychiatric News article “CBT, Light Therapy Found Comparable for Seasonal Affective Disorder.”

(Image: iStock/VSFP)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Youth With Migraines Twice as Likely to Have Anxiety, Depression

Children and adolescents who get migraines may have a greater risk of experiencing anxiety and depressive symptoms and disorders compared with their peers who do not get migraines, according to a report published in JAMA Pediatrics.

“The association between migraine and anxiety and depressive symptoms and disorders is likely bidirectional and multifactorial,” wrote Katherine Falla, M.D., of the University of Calgary and colleagues. “The experience of pain and internalizing symptoms may result in mutually reinforcing behaviors, such as reduced sleep and withdrawal from activities, and mutually reinforcing cognitive patterns, such as negativity bias and attention bias.”

Falla and colleagues conducted a systematic review of case-control, cohort, and cross-sectional studies that assessed the association between internalizing symptoms and/or disorders and experiences of migraines in children and adolescents 18 years or younger. They searched MEDLINE, Embase, PsycINFO, and CINAHL databases for studies that assessed symptoms and disorders on the spectrum of anxiety disorders, depressive disorders, and trauma- and stressor-related disorders, as defined in DSM-5. The authors reviewed 80 studies, and 51 included data that were able to be pooled in a meta-analysis.

Anxiety and depressive symptoms were significantly higher in children and adolescents who had migraines compared with controls. Further, youth who experienced migraines were about twice as likely to have an anxiety or depressive disorder compared with those without migraines. In studies that compared children and adolescents who experienced migraines with those who had other headache disorders (tension-type headaches, new daily persistent headaches), no significant differences emerged for internalizing symptoms between the two groups.

Three studies assessed the longitudinal association between anxiety and depressive symptoms and migraine outcomes, and these found that higher anxiety and depressive symptoms were associated with higher headache frequencies at follow up, which ranged from one to four months.

This study “is one more piece of evidence supporting our need to address and improve mental health care for youth,” wrote Jessica Hauser Chatterjee, M.D., Ph.D., and Heidi Blume, M.D., M.P.H., of the Seattle Children’s Research Institute in an accompanying commentary. “It is likely that youth with migraine are particularly vulnerable to experiencing significant adverse effects and poor outcomes related to mental health disorders, but more work is needed to investigate these associations. There needs to be a radical evolution in how the medical and governmental systems support mental health of youth with migraine, other headache syndromes, neurological disorders, and other chronic health problems.”

For related information, see the Psychiatric News article “Psychiatrists Have a Role in Managing Pediatric Pain.”

(Image:iStock/kokouu)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Youth More Likely to Access Mental Health, Substance Use Treatment Following a Firearm Injury

Youth who survive a firearm injury are significantly more likely to access mental health services—including services for substance use disorders—within one year of the injury than are children who do not have a firearm injury, according to a report in JAMA Surgery.

The authors noted that health care professionals should be especially aware of the risk for substance use by children and adolescents following a firearm injury. “Adolescents are already vulnerable for developing addictions,” wrote Elizabeth Oddo, M.D., M.P.H., of the Medical University of South Carolina and colleagues. “Substance use in adolescence may worsen preexisting mental health disorders, such as anxiety and depression, and may have negative consequences for attention, learning, and memory.”

The researchers used commercial insurance and Medicaid claims databases to examine use of mental health and substance use treatment among 2,127 children and adolescents (average age 13.5 years) who sustained firearm injuries between January 2016 and the end of December 2017, and an equal number of age-matched youth who had not had a firearm injury. The primary outcome was any mental health care utilization (versus no mental health care utilization) in the 12 months after injury. Secondary outcomes included psychotherapy utilization, substance use–related utilization, and psychotropic medication prescription.

Among those who sustained a firearm injury, 504 youth (23.7%) received at least one mental health service in the 12 months after their injury compared with 351 controls (16.5%); 298 (14.0%) received psychotherapy at least once compared with 237 controls (11.1%); 268 (12.6%) received substance use services compared with 184 controls (8.7%); and 402 (18.9%) had a prescription claim for a psychotropic medication compared with 349 controls (16.4%).

After controlling for several potential confounders, the authors found that youth with a firearm injury had a 1.40 times greater risk of utilizing mental health services in the 12 months after their injury compared with those without a firearm injury. They also had a 1.23 times greater risk of utilizing psychotherapy and a 1.40 times greater risk of utilizing substance use treatment than those without firearm injury. Black youth who were injured by a firearm were 1.64 times more likely to use mental health services compared with White youth with a firearm injury.

“This study included only children and adolescents who had utilized the mental health care system; given what is known about poor access to mental health care in the US, it likely underestimates the burden of psychological distress experienced by this population,” the authors wrote. “Health care practitioners should be aware of this increased risk and ensure adequate mental health follow-up for these patients. Comprehensive solutions aimed at increasing mental health care access for at-risk populations are needed to prevent ongoing negative consequences.”

For related information see the Psychiatric News article “APA Joins New Organization to Address Public Health Crisis Involving Firearms.”

(Image: iStock/zodebala)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Oral, Transdermal Hormone Therapy for Menopause Before Age 50 May Increase Risk of Depression

Women who begin taking oral or transdermal estrogen or estrogen/progestin for menopause between the ages of 45 and 50 appear to be at greater risk of developing depression, suggests a report that was published today in JAMA Network Open. The study of more than 825,000 women in Denmark found that the risk was highest during the first years after starting hormone therapy.

“Our findings suggest that around menopause, women may be more sensitive to the influence of [hormone therapy] on mood than at later ages,” wrote Marie K. Wium-Andersen, M.D., Ph.D., D.M.Sc., of Bispebjerg and Frederiksberg Hospitals in Denmark.

The study included 825,238 women in Denmark who turned 45 years between 1995 and the end of 2017. Women with a prior oophorectomy, breast cancer, and cancer in reproductive organs were excluded from the trial, as were the women who received hormone therapy before age 45. The researchers used the Danish National Prescription Registry to examine participants’ use of hormone therapy between 1995 and 2017 and the Danish Psychiatric Central Research Register and the Danish National Patient Registry to examine participants’ depression diagnoses from 1995 through 2018.

During the follow-up of about 11 years, 189,821 women (23.0%) initiated systemically (oral or transdermal) or locally administered (intravaginal or intrauterine) hormone therapy and 13,069 (1.6%) were diagnosed with depression.

Compared with women who did not use hormone therapy, those who did experienced a higher risk of being diagnosed with depression. For systemically administered hormone therapy, there was a higher risk of depression among younger women (hazard ratio [HR] for 48 to 50 years of age, 1.50) and a lower risk of depression with greater age (HR for 51 to 53 years of age, 1.13). Locally administered hormone therapy was associated with lower risk of depression when initiated when the women were older than 54 years (HR, 0.80) and was not associated with depression risk in women younger than 54 years (HR, 0.98).

“These findings suggest that women undergoing menopause who initiate systemically administered [hormone therapy] should be aware of depression as a potential adverse effect, and locally administered [hormone therapy] should be recommended when needed,” Wium-Andersen and colleagues wrote.

For related information, see the Psychiatric News article “Older Age at Menopause May Reduce Risk of Depression.”

(Image: iStock/SDI Productions)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!