Friday, December 30, 2022

Abortion Restrictions May Increase Risk of Suicide Among Women

Restricted access to abortion care may be associated with increased risk of suicide among women of reproductive age, according to a study published this week in JAMA Psychiatry.

“Abortion and access to reproductive care represent divisive issues in the United States, with staggering health consequences for women,” wrote Jonathan Zandberg, Ph.D., of the Wharton School of the University of Pennsylvania and colleagues. “Since 1970, states have enacted more than 1,300 abortion restrictions, including efforts to prohibit abortion after [six] weeks of gestational age. The dynamic nature of this legislation and its extensive media coverage have implications for the mental health of reproductive-aged women.”

Zandberg and colleagues analyzed laws in U.S. states that targeted abortion providers between 1974 (the first full year in which abortions were legal) and 2016 (the last full year when the data were available). They looked at laws that subject clinicians who provide abortions to the same regulations as ambulatory surgical centers; require those clinicians to have admitting privileges at nearby hospitals; and require facilities to have a written agreement with a nearby hospital in case of emergencies. These are known as Targeted Regulation of Abortion Providers (TRAP) laws.

The researchers used the Centers for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiological Research (WONDER) database to determine state-level suicide rates. They specifically looked at how restrictions on reproductive care were related to suicide deaths among women of reproductive age (aged 20 to 34) compared with suicide deaths in women of post-reproductive age (aged 45 to 64). Further, to test the specificity of the findings on suicide, they also tested associations between restricted access to abortion and death rates due to motor vehicle crashes among women, another leading cause of death.

Twenty-one states enforced at least one TRAP law between 1974 and 2016. Enforcement of a TRAP law was associated with higher suicide rates among reproductive-aged women, but not among women of post-reproductive age. Specifically, enforcement of a TRAP law was associated with a 5.81% higher suicide rate among women of reproductive age compared with pre-enforcement years. Enforcement of TRAP laws were not associated with death rates due to motor vehicle crashes.

“[A]ccess to reproductive care may represent a potentially modifiable population-level suicide risk factor for reproductive-aged women,” the authors concluded. “The results may have important implications for clinicians and policymakers in the United States.”

For related information, see the Psychiatric News article “Experts Share Advice for Post-Roe World: ‘We Have to Be Proactive’.”

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Thursday, December 29, 2022

Performance Assessments in Graduate Medical Education May Be Biased Toward White Residents

Internal medicine residents who are Asian or belong to racial groups that are underrepresented in medicine often receive lower ratings on performance assessments than their White peers in the first and second years of postgraduate training, a study in JAMA Network Open has found. The findings suggest a racial and ethnic bias in trainee assessment that may have a far-reaching impact.

“This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder workforce diversity,” wrote Dowin Boatright, M.D., M.B.A., M.H.S., of the New York University Grossman School of Medicine and colleagues. For example, trainee assessments are often considered in decisions regarding promotion, chief resident selection, readiness for unsupervised practice, and entry into competitive subspecialty graduate medical education programs.

The researchers examined data from the performance assessments of 9,026 internal medicine residents from the graduating classes of 2016 and 2017 who were in internal medicine residency programs accredited by the Accreditation Council of Graduate Medical Education (ACGME). Among the residents, 50.4% were White, 36.1% were Asian, and 13.5% belonged to groups that are underrepresented in medicine, defined as Latinx only; non-Latinx Native American, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Latinx Black. The researchers focused on scoring for the midyear and year-end ACGME Milestones. These Milestones are used by residency programs’ Clinical Competency Committees to assess residents’ knowledge, skills, attitudes, and other attributes in clinical competency domains such as medical knowledge, patient care, professionalism, and others.

The researchers found no significant difference in the first postgraduate year (PGY) midyear total Milestone scores between White residents and residents from groups underrepresented in medicine. However, total Milestone scores were a median of 1.27 points higher for White residents compared with Asian residents.

From the midyear PGY1 assessment onward, White residents began to receive increasingly higher scores compared with Asian residents and residents from groups underrepresented in medicine. These disparities peaked in PGY2, when White residents’ total scores were a mean of 2.54 points higher than those of residents from groups underrepresented in medicine and 1.9 points higher than Asian residents. However, the gap in scores narrowed by the PGY3 year-end assessment, when the researchers found no racial and ethnic differences in the total Milestone scores.

The researchers also found differences in the ratings for individual clinical competency domains between White residents and Asian residents and residents from groups that are underrepresented in medicine, with White residents scoring higher than the other groups.

“Although differences in ratings … in competency domains were small, these inequalities could reflect substantive differences in how residents from minoritized racial and ethnic groups are perceived in summative assessments,” Boatright and colleagues wrote.

For related information, see the Psychiatric News article “Leadership, Centering Equity Vital to Future of Medical Education.”

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Wednesday, December 28, 2022

Research Urgently Needed on 988 Crisis Line Effectiveness, Caller Demographics, and More

It has been nearly six months since the launch of 988—the nationwide suicide prevention and mental health crisis line. While available evidence suggests that crisis lines may help to reduce immediate crisis, substantial gaps remain in understanding how crisis lines work, according to a report in the December issue of JAMA Psychiatry.

“While there is some initial research supporting 988, we implore researchers, crisis line organizations, and federal funding partners to work together to rigorously examine factors to increase the scientific rigor backing 988,” wrote Adam Bryant Miller, Ph.D., of the University of North Carolina at Chapel Hill and colleagues. Such factors include tracking how the demographics of the callers, the training of the crisis line counselors, and the relationship that forms during a call might influence the outcomes of crisis calls, they wrote.

Miller and colleagues noted that suicidal crises are often intense but transient and impulsive and that an active suicidal crisis may be the most impactful moment for preventing suicide death. They cited a 2001 study that found that 24% of survivors aged 13 to 24 years reported that less than 5 minutes passed between the time they decided to attempt suicide and when they actually attempted suicide. Another 24% reported 5 to 19 minutes between idea and attempt, and 23% reported 20 minutes to 1 hour. They also cited a 2013 study that found 8% of callers with suicidal ideation attempted suicide or harm to themselves while using crisis lines.

“The launch of 988 brings a renewed sense of urgency to examine what happens in these short, highly emotionally laden moments of crisis calls,” the authors wrote.

Because there is little information on what influences the outcomes of crisis conversations, Miller and colleagues offered the following recommendations for research on crisis lines:

  • Conduct observational and randomized, controlled trials that examine how crisis line training increases positive counselor behaviors and reduces negative counselor behaviors.
  • Conduct randomized, controlled trials to identify suicide risk assessment practices in crisis contexts that are most effective at reducing suicide risk in the moment and in the future.
  • Evaluate which components of evidence-based interventions, such as dialectical behavior therapy, may be feasibly adapted for crisis contexts.
  • Follow up with callers after the crisis conversation to investigate whether they were connected to services and the impact these services had on reducing suicide risk.
  • Gather information on the individuals who contact crisis lines.
  • Conduct studies with callers and counselors to assess how the quality of the therapeutic alliance between counselors and callers impacts the callers’ suicide risk at follow-up.
  • Conduct observational studies to examine how counselor qualifications and certifications are associated with crisis line effectiveness.

“This should not be viewed as a comprehensive list, but rather, initial examples within each domain,” they wrote. “Access to crisis lines can only be as effective as the strategies used once a counselor answers the call. Focused research on factors that influence outcomes of crisis conversations will begin to improve crisis care.”

For related information, see the Psychiatric News article “After 988’s Launch, Experts Emphasize More Work Needed.”

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Tuesday, December 27, 2022

Researchers Outline DSM-5-TR Changes, Rationale Behind Changes

When DSM-5-TR was released last March, it marked the first revised edition since the publication of DSM-5 in 2013. In an article in Psychiatric Services, Michael B. First, M.D., of Columbia University and colleagues provide an overview of notable changes in DSM-5-TR, the rationale for these changes, and the process by which these changes were made.

First is co-chair of the Revision Subcommittee and DSM-5-TR editor, a member of the DSM Steering Committee, and the chief technical and editorial consultant on the World Health Organization’s ICD-11 revision project. Other authors of the article include researchers from APA, Johns Hopkins, and the New York State Psychiatric Institute.

The authors first describe the process used to revise and update DSM, including the review of the 21 disorder chapters by content experts and vetting the entire text by the Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination. The authors then provide an overview of the significant changes in DSM-5-TR:

  1. Addition of diagnostic entities: Diagnostic entities that are new to DSM-5-TR include prolonged grief disorder, unspecified mood disorder, and stimulant-induced mild neurocognitive disorder, as well as a code for “no diagnosis or condition” and symptom codes to indicate suicidal behavior and nonsuicidal self-injury.
  2. Changes to criteria sets: Modifications and clarifications were made to the criteria sets for more than 70 disorders, primarily for clarification of ambiguous wording and inconsistencies. A comprehensive list of significant changes to the criteria sets can be found here.
  3. Updated terminology: Several disorders (for example, social anxiety disorder and persistent depressive disorder) were renamed. Terms used in the DSM-5 gender dysphoria text were updated (for example, the terms natal male, natal female, and natal gender have been replaced by, respectively, assigned male at birth, assigned female at birth, and assigned gender at birth; desired gender has been replaced by experienced gender; and the terms cross-sex medical procedure and cross-sex hormone treatment have been replaced by, respectively, gender-affirming medical procedure and gender-affirming hormone treatment.

“With continued advances in the field, the DSM will continue to be updated to provide clinicians and researchers with the most accurate information for diagnosing patients’ conditions and conducting research,” First and colleagues state. “Maintaining the utility of the DSM as the prime diagnostic reference for psychiatry remains the overriding goal.”

For related information, see the Psychiatric News articles “Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR” and “Updated DSM-5 Text Revisions to Be Released in March.”

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Friday, December 23, 2022

APA Applauds Mental Health Provisions in Federal End-of-Year Spending Package

APA today responded to the Congressional passage of the fiscal year 2023 Omnibus Appropriations bill (HR 2617 – Consolidated Appropriations Act, 2023). The bill includes funding for workforce equity, collaborative care, telehealth, and other measures that APA supports.

“As families around the nation continue to contend with the adverse impacts of the pandemic, a crisis in child and adolescent mental health, a high rate of suicide, and the opioid epidemic, it is heartening to see Congress forge a bipartisan agreement and invest in policies that that are proven to help,” APA said in a statement.

The fiscal year 2023 Omnibus Appropriations bill includes funding to support following:

Workforce Equity: The bill invests in 100 new graduate medical education slots specifically for psychiatry or psychiatry subspecialties.

Collaborative Care Model: The bill provides grants and technical assistance to primary care practices to implement the evidence-based Collaborative Care Model into their practices for prevention of mental health and substance use disorders (SUD) and early intervention for treatment.

Telehealth: The bill extends certain emergency measures related to Medicare telehealth payments for mental health services. It also delays implementation of the in-person requirement for such services until December 31, 2024.

Health Equity: The bill provides increased authorization and funding for programs to improve maternal health and for the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Minority Fellowship Program. APA participates in this program.

Mental Health/SUD Funding: The bill significantly increases funding for critical mental health and SUD programs under SAMHSA, the Centers for Disease Control and Prevention, and the National Institutes of Health, including the National Institute on Minority Health and Health Disparities.

Parity Compliance: The bill eliminates the ability of non-federal governmental health plans to opt out of parity and provides funding for state insurance departments to enforce and ensure compliance with mental health parity requirements.

APA also expressed concern that Congress had only adjusted and not completely eliminated a cut in Medicare payments to physicians. The cut, which will go into effect on January 1, was originally slated to be 4.5% but will now be 2%.

“This runs counter to the need to improve access to care for patients, and we urge Congress to revisit this continuing challenge as soon as possible in the new year,” APA said in the statement.

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Thursday, December 22, 2022

More Americans Rate Their Mental Health Worse Compared With a Year Ago, Poll Finds

Most American adults anticipate feeling the same level of stress or more stress at the start of 2023 than they felt at the start of 2022, according to the latest findings from APA’s Healthy Minds Poll.

“Americans are telling us that they are concerned about their mental health going into the New Year, and we must continue to prioritize our physical and mental wellness as a society,” said APA President Rebecca W. Brendel, M.D., J.D., in a news release. “It’s concerning any time we hear Americans say that they are more stressed out and that their mental health is worse, and we know that there are many contributing causes, including economic uncertainty and another season of respiratory illnesses.”

The Healthy Minds Monthly Poll was conducted by Morning Consult on December 7 and 8 with a sample of 2,212 adults. The margin of error was plus or minus two percentage points, and the interviews were conducted online.

In relation to current events, respondents have remained consistently anxious about inflation (82%) and a recession (75%) over the past polls taken in October, November, and December. In this poll, 46% of moms reported anxiety over the COVID-19 pandemic, compared with 36% in the poll conducted last month.

Thirty-seven percent of Americans rated their mental health as only fair or poor, up from 31% last year. Young adults aged 18 to 34 were especially likely to rate their mental health in 2022 as fair or poor (48%), as well as adults who made under $50,000 (41%).

When asked about the sources of their anxiety in the coming year, respondents indicated they were somewhat or very anxious about the following:

  • Personal finances (64%, up from 58% last year).
  • The uncertainty of 2023 (55%, up from 54% last year).
  • Their physical health (49%, up from 44% last year).
  • Their mental health (41%, up from 37% last year).
  • Relationships with friends and family (31%, up from 28% last year).

Twenty-nine percent of Americans say they plan to adopt New Year’s resolutions related to their mental health. Of those, most said their resolutions will be to exercise more (65%), meditate (45%), see a therapist (38%), focus on spirituality (37%), or take a break from social media (32%).

“Focusing on our mental health is so important in stressful times, and we are in stressful times,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the release. “Self-care is important, but it’s promising to see that nearly two in five people are considering therapy in 2023. The guidance and support of a mental health professional can be life changing.”

For related information, see the Psychiatric News AlertNearly 1 in 3 Americans Anticipates More Stress Over Holidays This Year.”

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Wednesday, December 21, 2022

Treatment-Resistant Depression Associated With High Mortality, Lost Work Days, Health Care Use

A report in JAMA Psychiatry has found that among patients with major depressive disorder (MDD), those with treatment-resistant depression (TRD) have higher risks of psychiatric comorbidities, health care use, death, and self-harm. The patients were considered to have TRD if they continued to have symptoms of depression after three different treatments.

“We show that having TRD was associated with a more than 20% increase in all-cause mortality, which is in alignment with previous studies,” wrote Johan Lundberg, M.D., Ph.D., of the Karolinska Institutet in Stockholm and colleagues. “Although causes of death were not investigated, we found that factors closely linked to risk of suicide, such as self-harm, were higher in patients with TRD, especially during the year following the index date [the start of their third treatment trial].”

The researchers identified all recorded MDD episodes that started between January 1, 2012, and December 31, 2017, among individuals aged 18 years or older who lived in the Stockholm region. These episodes were then categorized as either TRD (3 or more treatment trials of an antidepressant, an add-on medication, electroconvulsive therapy, or repetitive transcranial magnetic stimulation) or non-TRD. The start of each TRD episode was the date that the third treatment trial was initiated.

A total of 158,169 MDD episodes (145,577 patients) were identified. Of these, 12,793 episodes (12,765 patients) fulfilled TRD criteria. The authors found the following:

  • Patients with MDD experiencing a TRD episode were 1.23 times more likely to die of any cause than those with MDD who did not experience a TRD episode.
  • Patients with TRD had an average of 3.9 inpatient hospital days and 132.3 lost workdays in the year following their diagnosis compared with 1.3 inpatient hospital days and 58.7 lost workdays for non-TRD patients, respectively.
  • Intentional self-harm was more than 4 times more common in patients with TRD.

Using a secondary sample of all MDD episodes from January 2015 through December 2017, the researchers also examined variables that might predict TRD. The most important predictive factor was severity of depression, as rated on the Montgomery-Åsberg Depression Rating Scale (MADRS).

“Our finding that the risk of subsequent TRD can be assessed by severity could help clinicians identify at first MDD diagnosis the patients in need of closer follow-up,” the researchers stated.

For related information, see the Psychiatric News article “Effective Next Step Treatments Identified for Refractory Depression.”

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Tuesday, December 20, 2022

Antidepressants Do Not Appear to Increase Risk of Serotonin Syndrome in Patients Prescribed Linezolid

Serotonin syndrome is a serious drug reaction that can lead to agitation, high blood pressure, seizures, and death when left untreated. After several reports of serotonin syndrome by patients taking the antibiotic linezolid (a reversible monoamine oxidase inhibitor) and antidepressants, the Food and Drug Administration in 2011 warned against linezolid therapy for patients taking serotonergic psychiatric medications. A study published yesterday in JAMA Network Open now suggests that patients taking linezolid and antidepressants are not at a significantly increased risk of serotonin syndrome.

Despite being “ideal as first-line or step-down oral antibiotic therapy for bacteremia and pneumonia as well as skin and soft tissue infections,” linezolid use “has been limited because of concerns of drug interactions,” wrote Anthony D. Bai, M.D., of Queen’s University in Ontario, Canada, and colleagues. “However, data on the risk of serotonin syndrome associated with linezolid are scarce,” they added.

To assess the incidence of serotonin syndrome in patients receiving oral linezolid and antidepressants, Bai and colleagues analyzed data collected by ICES—an independent, nonprofit research institute funded by the Ontario Ministry of Health. The researchers focused on 1,134 patients aged 66 years and older in Ontario, who were prescribed oral linezolid for any duration from October 1, 2014, to January 1, 2021. Of these patients, 215 (19%) were taking antidepressants (103 patients were taking a selective serotonin reuptake inhibitor, 36 were taking a serotonin-norepinephrine reuptake inhibitor, 15 were taking a tricyclic antidepressant, and 7 were taking a norepinephrine and dopamine reuptake inhibitor; none were taking a monoamine oxidase inhibitor). The researchers specifically focused on clinically significant serotonin syndrome within 30 days of starting linezolid treatment that required an ambulatory care visit, emergency department visit, or hospitalization.

According to the analysis, serotonin syndrome occurred in fewer than 6 patients (<0.5%) in total.

Bai and colleagues matched 166 patients who were taking antidepressants with 166 patients who were not. “In this propensity score–matched cohort, the risk of serotonin syndrome was lower in the antidepressant group, with an adjusted risk difference of −1.2% (95% CI, −2.9% to 0.5%; P = .50),” the authors wrote. “Within this 95% CI, the worst-case scenario would be a 0.5% increase in the risk of serotonin syndrome due to antidepressants, which is equivalent to a number needed to harm of 200,” they wrote.

Bai and colleagues concluded, “These findings suggested that linezolid is likely safe for patients receiving antidepressants. Nevertheless, prescribers should remain vigilant for this potential drug interaction.”

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Monday, December 19, 2022

10-Item PANSS Appears Reliable for Measuring Schizophrenia Symptoms in Youth

A shortened version of the Positive and Negative Syndrome Scale (PANSS) appears to be a reliable tool for assessing psychosis symptoms in youth, according to a report in Journal of the American Academy of Child and Adolescent Psychiatry.

For the traditional PANSS, an interviewer rates adult patients on 30 measures of positive, negative, and associated cognitive and affective symptoms on a scale of 1 (absent) to 7 (extreme), wrote Robert L. Findling, M.D., M.B.A., of Virginia Commonwealth University and colleagues. With younger patients, the interviewer relies on interviews with both the patients as well as their primary caregivers.

“The [30-item] PANSS has a venerable tradition of use, but it is decades old, and was designed for use with adult patients,” Findling and colleagues continued. To create the shortened PANSS, the researchers selected two items from each of the five PANSS symptom domains: positive symptoms, negative symptoms, excited symptoms, cognitive symptoms, and depression/anxiety symptoms. The 10-item scale assessed delusions and unusual thoughts (positive symptoms), emotional withdrawal and apathy (negative symptoms), hostility and poor impulse control (excited symptoms), inattention and disorganized thinking (cognitive symptoms), and anxiety and guilt feelings (depression/anxiety symptoms).

Findling and colleagues tested the 10-item scale using data from an eight-week clinical trial that compared the safety and efficacy of several antipsychotics in 118 youth aged 9 to 19 years with schizophrenia or schizoaffective disorder. In that study, the participants were assessed with the 30-item PANSS every week. The researchers found that the 10-item scale matched the full 30-item scale almost 90% of the time and was accurate for both mild and severe symptom scores.

“The shorter version is likely to be more popular in clinical practice, given time and fiscal constraints, and more popular with families …,” Findling and colleagues concluded. “For pediatric trials and clinical assessment, using the optimized [shortened] PANSS will maintain treatment sensitivity and precision while reducing costs, shortening interviews, reducing burden, and improving score validity.”

To read more about this topic, see the Psychiatric Research and Clinical Practice article “Shortened Positive and Negative Symptom Scale as an Alternate Clinical Endpoint for Acute Schizophrenia Trials: Analysis from the US Food & Drug Administration.”

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Friday, December 16, 2022

Too Much Screen Time Associated With Increased Risk of OCD in Children

Excessive screen time watching videos and playing video games is associated with an increased risk of children developing obsessive-compulsive disorder (OCD), a study in the Journal of Adolescent Health suggests.

Jason M. Nagata, M.D., M.S.C., of the University of California, San Francisco, and colleagues analyzed data from 9,208 children who participated in the Adolescent Brain Cognitive Development Study. The participants were enrolled between 2016 and 2018, when they were between 9 and 10 years old, and 666 of the children had OCD at baseline. Participants answered questions about the typical number of hours per day they spent viewing TV shows or movies, watching videos, playing video games, texting, video chatting, or using social media. Parents of the participants were then asked two years later about participants’ OCD symptoms and diagnoses.

At baseline, youth on average reported 3.9 hours of screen time per day, with most of this time spent watching TV shows/movies, playing video games, and watching videos online. At follow-up two years later, 6.1% of the sample met diagnostic criteria for OCD, including 4.4% new cases of OCD.

The researchers found that each additional hour of total screen time was associated with a greater risk of OCD. Playing video games was most strongly associated with increased risk: After accounting for participants who had OCD at baseline, the researchers found that each additional hour spent on video games was associated with a 13% higher risk of developing OCD. Each additional hour spent watching videos was associated with 11% higher risk.

“[V]ideo game use could promote perfectionism where users may prioritize the need to attain a perfect score or exceed a previous best score,” Nagata and colleagues wrote. “Watching videos (such as on YouTube) could allow for compulsive viewing of homogenous content, which may be facilitated through algorithms or advertisements suggesting related content. Repeatedly watching the same or similar content could lead to overestimation of threats that could contribute to obsessions.”

The researchers concluded, “The findings should increase awareness around screen use and its possible role in OCD development. Videos and video games … offer focus points for future research and interventions to prevent OCD development in early adolescence.”

For related information, see the Psychiatric News AlertExcessive Screen Time in Childhood Linked to Binge-Eating Disorder.”

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Thursday, December 15, 2022

Mental Health Services May Reduce Reincarceration, Study Finds

Among adults with mental illness released from correctional centers, each month that passes after release without accessing mental health services is associated with a greater risk of reincarceration, according to a study published today in JAMA Network Open.

“Despite high rates of mental health needs, there is considerable evidence of low rates of treatment of mental disorders in correctional settings and upon release to the community, highlighting the urgency of scaling up interventions to meet these needs,” wrote Heather Palis, Ph.D., of the University of British Columbia and colleagues. “People who are incarcerated in provincial prisons in [British Columbia] have a reincarceration rate of approximately 50% in the 2 years following release. … [W]e expect this rate to be even higher for people with mental health diagnoses.”

Palis and colleagues used health and corrections data from the British Columbia Provincial Overdose Cohort, which contains a 20% random sample of the general population in British Columbia. The records were linked to British Columbia’s Client Roster, which includes health information. Participants were included if they had a complete record in the client roster between 2015 and 2018, had at least one release from a provincial correctional center during this period, and received a mental illness diagnosis in the year before release. Mental health service access was defined as visits to primary care offices, hospitalization, or emergency department visits. The authors also analyzed co-occurring substance use disorders (SUDs), defined as the presence of one hospitalization record or two outpatient records including an ICD-9 or ICD-10 code for SUD.

A total of 1,664 participants who were released from correctional centers 4,171 times during the study period were included in the study. Mental health services were associated with a reduced risk of reincarceration. For each additional month that passed between release and accessing mental health services, the risk of reincarceration increased by 4%. Among participants with SUDs, the reincarceration risk was lower when they accessed both SUD and other mental health services. Further, the authors found that outpatient emergency visits for mental health issues were associated with significantly higher risk of reincarceration compared with outpatient primary care visits for mental health services. “This emphasizes the pivotal role of regular contact with primary care services after release,” the authors wrote.

They concluded: “Scaling up of timely access to mental health services after release is critical. This must be done with attention to the service needs of people who have concurrent SUD and to people with the most severe mental disorder diagnoses, who face the highest risk of reincarceration.”

For related information, see the Psychiatric Services article “Prevalence of Mental Health Needs, Substance Use, and Co-occurring Disorders Among People Admitted to Prison.”

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Wednesday, December 14, 2022

COVID-19 May Increase the Risk of Endocarditis in People With Opioid, Cocaine Use Disorder

Exposure to COVID-19 appears to increase the risk of infective endocarditis in people with opioid use or cocaine use disorder, a report in Molecular Psychiatry has found. Infective endocarditis is a rare but often fatal inflammation of the heart valves.

“Drug-using populations, particularly those who use cocaine or opioids, have some of the highest risk for endocarditis, and here we show that having a COVID-19 diagnoses further increases this risk,” wrote corresponding author Nora D. Volkow, M.D., the director of the National Institute on Drug Abuse (NIDA), and colleagues.

Volkow and colleagues analyzed data from de-identified electronic health records (EHRs) of 109 million patients from 77 health care organizations across the United States from 2011 to 2022. The study population comprised 736,502 patients with a diagnosis of opioid use disorder, 379,623 patients with a diagnosis of cocaine use disorder, and 105,817,030 patients without a diagnosis of either condition.

The incidence rate of endocarditis (as measured by new cases per 1,000,000 person per day) among patients with opioid use disorder increased from 3.7 in 2011 to 30.1 in 2022. There was a plateau period between 2017 and 2020 followed by acceleration from 2021 to 2022. The incidence rate of endocarditis among patients with cocaine use disorder followed a similar trend as that of patients with opioid use disorder. The incidence rate of endocarditis among patients without either disorder did not increase significantly.

A clinical diagnosis of COVID-19 more than doubled the risk for new diagnosis of endocarditis in patients with either cocaine or opioid use disorder. Among these patients, the 180-day hospitalization risk following endocarditis was 67.5% in patients with COVID-19, compared with 58.7% in matched patients without COVID-19. The 180-day mortality risk following the new diagnosis of endocarditis was 9.2% in patients with COVID-19, compared with 8.0% in matched patients without COVID-19.

The authors noted that the use of contaminated syringes or injecting drugs in non-sterile environments may increase the entry of bacteria into the blood stream that then circulates throughout the various organs and can result in endocarditis.

“People with substance use disorder already face major impediments to proper health care due to lack of access and stigma,” Volkow said in a NIDA press release. “Proven techniques like syringe service programs, which help people avoid infection from re-used or shared injection equipment, can help prevent this often fatal and costly condition.”

For related information, see the Psychiatric News article “Most Patients Do Not Seek Follow-up Care After Non-fatal Opioid Overdose.”

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Tuesday, December 13, 2022

Pilot Study Suggests Repeat Ketamine Infusions Safe, Effective for Older Adults With Depression

Receiving biweekly ketamine infusions for one month may reduce symptoms of depression and improve cognition in older adults who have not experienced improvements when taking at least two different types of antidepressants, suggests a report in The American Journal of Geriatric Psychiatry. The pilot study also revealed that the repeated ketamine infusions were well-tolerated by adults aged 60 years and older.

Despite evidence that treatment-resistant depression is associated with poor long-term outcomes (including cognitive dysfunction and death) in older adults, treatment options for this population are limited, wrote Hanadi Ajam Oughli, M.D., of the University of California, Los Angeles, and colleagues. A previous study, described in The American Journal of Psychiatry, found that adults with treatment-resistant depression (mean age of 44 years) who received ketamine intravenously two or three times a week for four weeks experienced sustained improvements in depression symptoms.

For the pilot study, the researchers included 25 adults (mean age 71.5 years) with treatment-resistant depression from five U.S. sites. For the acute phase, the participants received ketamine IV (0.5 mg/kg of body weight) over 40 minutes twice weekly for four weeks. At the end of the acute phase, those who achieved Montgomery-Åsberg Depression Scale (MADRS) total score of less than 10 or at least a 30% reduction from baseline MADRS total score were invited to participate in a continuation phase. This phase consisted of an additional four weeks of one ketamine infusion per week.

The researchers monitored the participants’ dissociation and vital signs during the ketamine infusion sessions; they also assessed symptoms of craving and depression as well as cognitive performance at baseline, the acute phase, and the end of the continuation phase.

Of the 25 participants who started the study, 22 (88%) completed the acute phase of the trial, and 15 (60%) experienced 30% or greater reduction in MADRS and entered and completed the four-week continuation phase of the trial. The mean change in MADRS total score between baseline and the end of acute phase was a decrease of 9.4 points. For those who participated in the continuation phase, the mean change in MADRS total score between the start and end of the continuation phase was an increase of 3.5 points. At the end of the acute phase, 48% met the criteria for response (defined as 50% reduction in baseline MADRS total score) and 24% for remission (defined as a MADRS score of less than 10). At the end of the continuation phase, 47% met criteria for response and 27% for remission.

Twenty-three participants completed computerized cognitive assessments (NIH Toolbox Cognition Battery). During the acute phase, the participants experienced improvements in executive function; for those individuals who also participated in the continuation phase of the trial, the improvements in executive function were sustained for four weeks. Additionally, side effects were mostly limited to infusion-related transient hypertension, nausea, vomiting, headache, and dissociative symptoms (which peaked at about 40 minutes and resolved within 90 minutes after infusions).

“Taken together, these preliminary results support that IV ketamine is a promising treatment for [treatment-resistant depression] in older adults and is associated with improvement in [executive function], at least in the short term. This is important given the paucity of research and the limited, evidence-based treatment options for [treatment-resistant depression] in older adults.”

For related information, see the American Journal of Psychiatry article “A Double-Blind, Randomized, Placebo-Controlled, Dose-Frequency Study of Intravenous Ketamine in Patients With Treatment-Resistant Depression.”

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Monday, December 12, 2022

Study Questions Effectiveness of ACT Model Popular in Europe

Patients with severe mental illness who received care from a flexible assertive community treatment (ACT) team exhibited lower levels of personal and social functioning after one year compared with those who received standard ACT, according to a study in Psychiatric Services in Advance. Whereas ACT teams offer intensive support, including frequent home visits, to patients who have a hard time engaging in traditional mental health services, flexible ACT (FACT) teams adjust the intensity of the treatment. Such flexibility allows the FACT teams to take on higher caseloads.

“One of the main goals of the ACT model is to improve functioning with an approach that goes beyond medication management, such as supporting a patient’s social activities and helping with practical matters,” wrote Camilla Munch Nielsen, Ph.D., of Copenhagen University Hospital and colleagues. The researchers noted that FACT has replaced ACT in many European countries despite limited evidence for FACT’s effectiveness relative to ACT.

To compare outcomes in patients who received care from one of the two models, Nielsen and colleagues recruited patients who received care from nine ACT teams in the Copenhagen region from 2018 to 2019; during this period, six teams were reconfigured to the FACT model. The researchers evaluated 74 patients who were treated by a FACT team and 57 who were treated by an ACT team using the Personal and Social Performance (PSP) scale. The PSP measures functioning in four domains: social activities, relationships, self-care, and aggressive behaviors. Each patient received a score on a scale of 1 to 100 based on their verbal reports of their daily living during the assessment.

Thirty-eight FACT patients and 33 ACT patients were available at a one-year follow-up. After one year, the ACT patients’ functioning scores were about three points higher on average than the FACT patients, after adjusting for differences in baseline scores and substance use between the groups. Patients in both groups reported similar satisfaction and working alliance with their care teams.

“When we consider the results of this study together with the few previous studies on mental health care use, whether FACT is a beneficial alternative to ACT remains uncertain,” Nielsen and colleagues wrote.

For related information, see the Psychiatric Services article “Integrating Primary Care Into Assertive Community Treatment.”

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Friday, December 9, 2022

Increased Risk of Stroke Linked to Stress at Home, Work

Experiencing multiple stressful events or chronic stress at home or at work over the course of a year raises the risk of several types of stroke, a study published today in JAMA Network Open has found. However, the study also suggests that having a greater sense of control over the situations and experiences that affect one’s life—a greater locus of control—may help counter the impact of stress on stroke risk.

Catriona Reddin, M.B., of the University of Galway in Ireland and colleagues analyzed data from 26,812 participants in the INTERSTROKE study, an international case-control study of risk factors for stroke. Among the participants, 13,350 had been admitted to a hospital with a first ischemic or hemorrhagic acute stroke, and 13,462 had no history of stroke. The researchers measured stress in the preceding year using a standardized questionnaire that asked about home stress, work stress, financial stress, and stressful life events. They defined stress as feeling irritable or filled with anxiety or having trouble sleeping because of conditions at work or home. Participants who had strokes were instructed to answer the questions with respect to the time before their stroke.

The participants also rated, on a scale of 1 to 5, how much control they felt they had over what happens in life and at work. For perceived life control, participants were asked to rate their agreement with the statement, “I feel what happens in my life is often determined by factors beyond my control.” For perceived work control, they were asked to rate their agreement with the statement, “At work, I feel I have control over what happens in most situations.”

Participants who reported having experienced several periods of home stress or permanent home stress had 1.95 times the odds of having any stroke, 1.82 times the odds of having an ischemic stroke, and 2.55 times the odds of having intracerebral hemorrhage. Those who reported several periods of work stress or permanent work stress had 2.7 times the odds of having any stroke, 2.27 times the odds of having an ischemic stroke, and 5.2 times the odds of having cerebral hemorrhage. Having a higher locus of control at home was associated with a reduced odds of having any stroke, but having a higher locus of control at work did not appear to affect stroke risk.

The researchers noted several potential reasons for the association between stress and stroke.

“Acute stress may trigger an event by leading to activation of the sympathetic nervous system, causing vasoconstriction and plaque rupture in vulnerable individuals,” they wrote. “Chronic stress is hypothesized to cause dysregulation of the sympathetic system, endothelial dysfunction, and atherosclerosis.”

The researchers concluded, “Our findings … support the need to develop generalizable, effective, and feasible interventions to reduce psychosocial stressors.”

For related information, see the Psychiatric News article “Depression Increases Stroke Risk, Even After Symptoms Remit.”

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Thursday, December 8, 2022

Computer Program May Improve Driving by Teens With ADHD

Teen drivers with attention-deficit/hyperactivity disorder (ADHD) who complete a skills-training computer program may be less likely to take long glances away from the road and get into car accidents, according to a study in the New England Journal of Medicine.

“Teens with [ADHD] are twice as likely as neurotypical teen drivers to be in a collision,” wrote Jeffery Epstein, Ph.D., of Cincinnati Children’s Hospital Medical Center and colleagues. “When performing distracting tasks, teens take long glances (≥2 seconds) away from the roadway rather than repeated brief glances between the secondary task and the roadway, a behavior that increases the risk of motor vehicle collision.”

Epstein and colleagues recruited participants aged 16 to 19 with ADHD who had a valid driver’s license, spent at least three hours a week driving unsupervised, and had an average score on the Kaufman Brief Intelligence Test, 2nd edition. Participants were randomly assigned to either the intervention or control groups, both of which involved five 90-minute training sessions. In the intervention group, participants completed the Focused Concentration and Attention Learning (FOCAL+) program, a desktop-based software program that trains teens without ADHD to limit long glances away from the roadway. The authors enhanced the program to include simulator training that issued immediate auditory feedback when long glances occurred. Each training session also included one five-minute drive during which the authors used real-time eye tracking and onboard sensor data to identify when the teens took long glances away from the road. The control group participated in three units of the 2016 American Driver and Traffic Safety Education Association curriculum as well as training drives.

To measure the frequencies of long glances away from the roadway and variations in lane position, participants completed two 15-minute simulated drives at baseline and then at one month and six months after training. Further, a recording system was installed for one year following training in the vehicle that the teen drove most. The system measured long glances away from the roadway, as well as collisions or near collisions.

Seventy-six participants with ADHD were assigned to each group. During the 15-minute simulated driving evaluations, the mean number of long glances per drive was 21.5 in the intervention group and 23.1 in the control group at baseline. One month after training, participants in the intervention group had a mean 16.5 glances per drive, and then 15.7 long glances per drive at six months, compared with 28 and 27 long glances per drive, respectively, in the control group. The standard deviation in lane position, measured in feet, was 0.98 per drive at the one- and six-month follow up in the intervention group and 1.20 per drive for both follow-ups in the control group. Finally, a year after the training ended the rate of collisions or near collisions was 3.4% in the intervention group and 5.6% in the control group.

“Stimulant medication has been shown to improve real-world driving in teens with ADHD,” the authors wrote. “The pharmacologic effects of these medications last approximately 10 to 12 hours. Yet, teens drive and are susceptible to motor vehicle collisions during the late afternoon after school and during the evening, when the effects of stimulant medication are typically waning.”

For related information, see the Psychiatric News article “Medicated ADHD Patients Have Reduced Risk of Motor Vehicle Crashes.”

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Wednesday, December 7, 2022

Migraine in Young People Linked to Anxiety, Depressive Disorders, Study Shows

Children and adolescents with migraine have approximately twice the risk of anxiety or depression compared with youth without migraine, according to a report in the December JAMA Pediatrics.

“One in 10 children and adolescents experience migraine and, across the life span, it is the second most prevalent and disabling disease worldwide,” wrote Katherine Falla, M.D., of the University of Calgary and colleagues. “These results have critical implications for clinical practice, underscoring the need to screen all children and adolescents with migraine for anxiety and depression.”

The researchers searched the medical literature for case-control, cohort, and cross-sectional studies assessing the association between internalizing symptoms and/or disorders (such as anxiety and depression) and migraine in children and adolescents aged 18 years or younger. Eighty studies were included in the final analysis.

The researchers found that children with migraine had double the odds of having anxiety and depressive disorders compared with healthy controls. Moreover, in studies that pooled results for anxiety and depressive disorders, young people with migraine were more than four times as likely to have mixed anxiety and/or depressive disorders, according Falla and colleagues.

In an accompanying editorial, Jessica Hauser Chatterjee, M.D., Ph.D., and Heidi K. Blume, M.D., M.P.H., of the University of Washington School of Medicine noted that combination treatment with fluoxetine and cognitive-behavioral therapy (CBT) is one of the best approaches to the treatment of children with depressive disorders, and that CBT for migraine is one of the most successful treatments for youth with chronic migraine. They added that some youth with headache disorders may need treatment for other psychiatric disorders.

“The work by Falla and colleagues provides strong support for the expansion and increased availability [of] multifaceted and interdisciplinary approaches to migraine treatment,” they wrote.

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

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Live Meet-the-Candidate Town Halls End Tomorrow

Tomorrow marks the final day for APA’s live, virtual meet-the-candidate town halls, but recordings of the town halls held this week will soon be available. The Thursday town hall will feature candidates for resident-fellow member trustee-elect (elected by RFMs only). The town hall will begin at noon ET and run 30 to 60 minutes. Also, check out the bios and brief videos of all the candidates and read APA’s 2023 Election Guide to the Candidates. Voting begins Tuesday, January 3.



Tuesday, December 6, 2022

Limiting Consumption of Ultra-processed Foods May Help Slow Cognitive Decline, Study Suggests

People who consume more than 20% of their total daily calories in ultra-processed foods may experience faster cognitive decline than adults who consume fewer ultra-processed foods daily, a study published yesterday in JAMA Neurology suggests. Ultra-processed foods include cookies and cakes, diet and regular soda, processed meats, frozen meals, and more.

“Our findings are in line with previous studies linking consumption of [ultra-processed foods] and adverse health outcomes, such as the increased risk of overweight and obesity, metabolic syndrome, cancer, cardiovascular diseases, and all-cause mortality,” wrote Natalia Gomes Gonçalves, Ph.D., of the University of São Paulo Medical School in Brazil and colleagues.

The researchers analyzed data collected from participants in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil study). Public servants aged 35 to 74 years from six Brazilian cities were recruited for the study and followed up in three waves, approximately four years apart, from 2008 to 2017. Upon enrollment in ELSA-Brasil, these participants were asked about their food and drink consumption over the last 12 months using a validated Food Frequency Questionnaire. The researchers classified the participants’ consumption of foods and beverages into three categories, according to the extent of industrial processing:

  • Unprocessed or minimally processed foods (for example, fresh or frozen fruits and vegetables and grains) and processed culinary ingredients (for example, table sugar, oils, and salt)
  • Processed foods, which are manufactured using unprocessed or minimally processed foods (for example, canned fruits and smoked meat)
  • Ultra-processed foods, which are formulations of processed culinary ingredients with food additives not used in home preparations, such as flavors, colors, sweeteners, emulsifiers, and other substances

The ELSA-Brasil study participants received multiple cognitive assessments over the follow-up period. These tests included evaluating the participants’ immediate recall, late recall, word recognition, and semantic and phonemic verbal fluency.

Gomes Gonçalves and colleagues focused their analysis on 10,775 adults (mean age of 52 years, 53% White, and nearly 57% with at least a college degree). After a median follow-up of eight years, participants who reported consumption of ultra-processed foods of more than 19.9% of daily calories at baseline had a 28% faster rate of global cognitive decline compared with those who reported consumption of ultra-processed foods less than 19.9% of daily calories, Gomes Gonçalves and colleagues reported.

“Limiting [ultra-processed food] consumption, particularly in middle-aged adults, may be an efficient form to prevent cognitive decline,” Gomes Gonçalves and colleagues wrote. “Future studies investigating the mechanism by which [ultra-processed food] may lead to cognitive decline are needed, as well as confirmation of our findings in other longitudinal studies and randomized clinical trials.”

For related information, see the Psychiatric Services article “Nutrition and Exercise for Wellness and Recovery: A Randomized Controlled Trial of a Community-Based Health Intervention.”

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Meet-the-Candidate Town Halls: Daily Through December 8

Learn more about the candidates in APA’s 2023 election through live, virtual meet-the-candidate town halls this week. The Wednesday town hall will feature candidates for Area 5 Trustee (elected by Area 5 members only). The town halls will begin at noon ET and run 30 to 60 minutes. In the meantime, hear directly from the candidates by watching brief videos posted on APA’s website.




Monday, December 5, 2022

Buprenorphine Associated With Fewer Birth Risks Than Methadone During Pregnancy

Pregnant people with opioid use disorder who are treated with buprenorphine may experience a lower risk of neonatal complications (such as preterm birth) than those taking methadone, according to a study in the New England Journal of Medicine. The study did not reveal differences in maternal outcomes (such as caesarean section) between the two groups, however.

“The standard care for treating pregnant persons with opioid use disorder is opioid agonist therapy with buprenorphine or methadone, which is associated with improved adherence to prenatal care, lower incidence of preterm birth, reduced return to opioid use, and fewer instances of opioid overdose and death from opioid overdose,” wrote Elizabeth Suarez, Ph.D., M.P.H., of Brigham and Women’s Hospital and colleagues. (Suarez has since taken a position at Rutgers University).

To determine if there were differences in neonatal and maternal outcomes of people taking these medications during pregnancy, the researchers studied more than 2.5 million pregnancies recorded in a national Medicaid database between 2000 and 2018. This sample included 10,704 pregnant persons taking buprenorphine and 4,387 taking methadone during the first 19 weeks of pregnancy, as well as 11,272 taking buprenorphine and 5,056 taking methadone during the second half of pregnancy. Suarez and colleagues compared the two groups on a range of birth-related outcomes: neonatal abstinence syndrome, preterm birth, small birth size for gestational age, low birth weight, cesarean section, and severe maternal complications (for example, acute heart failure, delirium, or sepsis).

Overall, compared with pregnant persons taking methadone early in pregnancy, those taking buprenorphine had a 42% reduced risk of having a preterm birth, 28% reduced risk of an infant born a small birth size for gestational age, and 44% reduced risk of an infant born at low birth weight; these results were similar in persons exposed to buprenorphine or methadone during late pregnancy. Persons taking buprenorphine in the 30 days prior to the birth of the baby also had a 27% reduced risk of having an infant with neonatal abstinence syndrome. There were no statistical differences in caesarean section or severe maternal complication risk between the two groups. 

“Persons who received buprenorphine may have received more comprehensive care in an office-based care setting than persons who received methadone in an opioid treatment program, which could have resulted in the underdiagnosis of health conditions in persons who received methadone,” Suarez and colleagues wrote. However, when the researchers limited the study population to those assumed to have received high-quality care, the findings were only slightly different. This suggests that the setting in which patients received care was not a factor in buprenorphine’s benefits.

Though this study suggests that buprenorphine leads to more favorable pregnancy outcomes, “[a]ny opioid agonist therapy is recommended over untreated opioid use disorder during pregnancy, because untreated persons have greater incidence of adverse outcomes owing to withdrawal, return to opioid use, overdose, intravenous drug use, and inadequacy of prenatal care,” the authors concluded.

To read more on this topic, see the Psychiatric News article “Pregnant Women Face Hurdles Accessing Opioid Treatment.”

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Meet-the-Candidate Town Halls: Daily Through December 8

Learn more about the candidates in APA’s 2023 election through live, virtual meet-the-candidate town halls this week. The Tuesday town hall will feature the candidates for Area 2 Trustee (elected by Area 2 members only). The town halls will begin at noon ET and run 30 to 60 minutes. In the meantime, hear directly from the candidates by watching brief videos posted on APA’s website.





The content of Psychiatric News does not necessarily reflect the views of APA or the editors. Unless so stated, neither Psychiatric News nor APA guarantees, warrants, or endorses information or advertising in this newspaper. Clinical opinions are not peer reviewed and thus should be independently verified.