Check Out Psychiatric News’ Most Viewed Articles of 2023

Psychiatric News published more than 400 articles and 240 News Alerts in 2023. Below is a list of our 10 most popular articles of 2023:

Special Report: Bipolar Disorder II—Frequently Neglected, Misdiagnosed
Unlike its cousin, bipolar I disorder, which has been extensively studied and depicted in popular literature and on screen, bipolar II disorder is poorly understood, underdiagnosed, and insufficiently treated.

Special Report: Autism Spectrum Disorder and Inflexible Thinking—Affecting Patients Across the Lifespan
Inflexible thinking has important public health implications, as it not only affects an individual’s ability to adapt to a constantly changing world, but also contributes to workplace and relationship difficulties, increased risk for suicide, and even mass shootings.

Risk of Depression May Increase During First Two Years of Oral Contraceptive Use
Risk is greatest in women who began using oral contraceptives at or before the age of 20 years, then declines with time. How can psychiatrists help their patients weigh the risks and benefits of this effective yet easily reversed method of birth control?

Psychiatrists Win Important Gains in 2024 Fee Schedule
A decrease in overall payment for physicians will be offset for psychiatrists by an increase in reimbursement for psychiatrists providing psychotherapy as an add-on to E/M services.

FDA Clears Neurofeedback Intervention for PTSD
The device trains users to control key neural connections between the amygdala and frontal cortex to boost their emotional regulation and stress resilience.

Brain Scans May Offer Clues About Depression Remission
Many brain imaging studies have looked at key differences between the brains of people with or without depression. A study in the American Journal of Psychiatry examined how the brain changes when patients with depression get better.

Special Report: Evolving Controversies in the Treatment of Gender Dysphoric/Incongruent Minors
As gender-affirming treatment has become more common in this country, it is not surprising that controversies have arisen around providing such care to youth. This article examines the evolution of these controversies in the treatment of children and adolescents.

Memantine May Reduce Hair-Pulling, Skin Picking
Memantine targets glutamate receptors much like the antioxidant N-acetylcysteine, which has also shown some effectiveness in reducing these obsessive-compulsive behaviors.

FDA Approves Rexulti for Agitation Associated With Dementia Due to Alzheimer’s Disease
One expert called the approval a “positive step” for the treatment of agitation associated with dementia in Alzheimer’s but cautioned against using the drug as a panacea for all behavioral symptoms of dementia.

Telehealth Providers: Begin Planning Now for End of COVID-19 PHE
The DEA proposed two rules to allow limited flexibility around the prescribing of controlled substances, including buprenorphine, without an in-person visit after the public health emergency (PHE) ends.

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Living With Adults With Depressive Symptoms Linked to Lower Income, Quality of Life

Living with an adult with depressive symptoms is linked to substantially lower average yearly income and employment rates as well as reduced quality of life for adults who do not have depressive symptoms, a study in the Journal of Affective Disorders has found.

“These findings indicate that the impact of depressive symptoms may extend beyond the affected individuals, imposing a burden on other adults in their households,” wrote Paul Greenberg, M.S., M.A., of the Analysis Group, an economics consulting firm in Boston. “This further supports the value of adequate treatment to address depressive symptoms for adults and reduce the spillover effect to others in their households.”

Greenberg and colleagues analyzed data from The Medical Expenditure Panel Survey Household Component (MEPS-HC), which collects data on demographics, health conditions, health status, use of health care services, income, and employment for each person in a household. As part of MEPS-HC, adults also complete a self-administered questionnaire that contains the 2-item Patient Health Questionnaire. Data on quality of life were obtained from Short-Form 12 version 2 (SF-12v2), a survey which assesses mental and physical health. The researchers identified 1,699 adults without depressive symptoms living in a household with other adults who had depressive symptoms and 15,286 adults without depressive symptoms living in a household where no other adults had depressive symptoms between 2015 and 2019.

Adults without depressive symptoms who lived with adults with depressive symptoms earned $4,720 less in total annual income (representing 11.3% lower than the average income of $41,634 in MEPS), were less likely to be employed, and missed more workdays per year than their peers who lived with adults without depressive symptoms.

Adults without depressive symptoms who lived with adults with depressive symptoms also had a lower quality of life than their peers who lived with adults without depressive symptoms, as evidenced by mean scores that were 2.5 points lower on the mental component score and 2.1 points lower on the physical component score on the SF-12v2.

The “findings emphasize the need to ensure patients with depressive symptoms are identified and receive appropriate intervention, as improved management could address the increasing prevalence of depressive disorder and alleviate the burden associated with depressive symptoms on the individual themselves as well as on the members of their household,” the researchers wrote.

For related information, see the Psychiatric Services article “Incremental Health Care Burden of Treatment-Resistant Depression Among Commercial, Medicaid, and Medicare Payers.”

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Older Volunteers Delivering Loneliness Interventions Found to Be Less Lonely Themselves

A volunteer program that engages lonely older adults in delivering psychosocial interventions to other lonely older adults benefited the volunteers themselves by reducing their loneliness, stress, and depressive symptoms and increasing their social engagement, according to study in the American Journal of Geriatric Psychiatry.

The program could be a scalable solution to address the loneliness epidemic in this country, according to lead author Lisa Warner, Ph.D., of the Department of Psychology at MSB Medical School in Berlin and colleagues.

As part of the “Helping Alleviate Loneliness in Hong Kong Older Adults (HEAL-HOA)” trial, 185 adults aged 50 to 70 years old were randomized to work as volunteers delivering a manualized loneliness intervention by telephone to other older adults as part of a concurrent trial measuring the effect on recipients’ loneliness. A control group of 190 older adults participated in a psycho-education program and social gatherings but did not volunteer. Participants were recruited by the research staff through household visits and advertisements at public housing estates and community centers for older adults.

The primary outcome was loneliness as measured by the Chinese version of the 20-item Revised UCLA Loneliness Scale. Secondary outcomes were loneliness measured by the Chinese version of the De Long Gierveld Scale and measurements of social engagement, perceived social support, perceived stress, and symptoms of depression and anxiety.

Volunteers reported medium-sized reductions in their loneliness on the UCLA and De Long Gierveld scales compared with the control group. These effects remained even after controlling for age, gender, education, romantic cohabitation, and number of chronic illnesses. Moreover, the volunteer group reported increased engagement with their social network (small effect), decreased perceived stress (medium effect), and depressive symptoms after six months (small effect). There was a minimal effect on perceived social support and anxiety symptoms.

“Considering that volunteers engaged in only about half an hour of delivering telephone-based interventions per week for about 6 months, the effects on loneliness were substantial in our trial,” the authors wrote. “These positive effects may have been attributable to the combination of volunteering itself and the contents of the volunteering activity, consisting of receiving training and delivering structured loneliness interventions.”

They noted that future qualitative research might explore whether the effect of peer-to-peer counseling is related to the helpers’ learning how to cope better with their own problems.

For related information, see the Psychiatric News special report by former APA President Dilip Jeste, M.D., “Positive Psychiatry Shines Light on Patients’ Strengths, Wisdom.”

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Health Professionals Confident About Suicide Screening, Less So About Prevention Services

Most health professionals feel confident about screening for suicidality but less confident about performing more complex practices such as risk assessment and safety planning, a study in Psychiatric Services in Advance has found.

Celine Larkin, Ph.D., of the University of Massachusetts Chan Medical School and colleagues invited 5,559 clinicians in a large health care system to take a survey on suicide prevention practices and implementation, and only 1,224 responded. They included physicians, nurses, psychologists, social workers, residents, advanced practice providers, and medical assistants.

Participants were asked to rate their confidence in their ability to screen patients for suicidality, assess suicide risk severity, provide brief counseling to suicidal patients, help patients at risk create a personalized safety plan, and find referral resources. They also reported how many suicides they considered preventable; the proportion of all patients they personally screen for suicidal ideation; and the proportion of patients with suicidality whom they personally assess for risk severity, create a written personalized safety plan for, briefly counsel, and provide referrals to outpatient or community resources.

Overall, 65% of the participants reported that they were confident that they had the skills needed to screen patients for suicidality. However, fewer reported confidence in performing other suicide-related practices, as follows:

• Further assessment, 50%
• Providing referrals or resources, 43%
• Brief counseling, 38%
• Safety planning, 30%

Few participants reported personally delivering suicide-related services to all or most of their eligible patients, including 33% for screening, 36% for further assessment, 23% for brief counseling, 23% for providing referrals or resources, and 11% for safety planning. Behavioral health providers and health professionals who worked in emergency departments tended to have higher confidence in conducting a higher level of suicide-related practice.

Overall, 55% of participants endorsed the belief that most or all suicides were preventable, 49% agreed that universal screening for suicide would slow clinical care, and 19% believed that universal screening for suicide would result in increased psychiatric evaluations. Furthermore, 50% agreed that departmental leadership supported improvement in interventions for suicidal patients, and 45% felt that treatment of suicidal patients was a top priority in their department. In addition, 65% reported that they were using continuous quality improvement (CQI) methods in their work, and 53% reported that they had received formal performance improvement or CQI training.

“Our findings not only support the need for further training focused on attitudes and skills (ideally including live training and hands-on demonstration sessions) but also indicate the strong potential for CQI-type implementation strategies, such as small cyclical tests of change and audit-and-feedback strategies,” Larkin and colleagues concluded.

For related information, see the Psychiatric Services article “Suicide Risk Before Mental Health Treatment Initiation: Implications for Screening and Access to Care.”

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Experts Urge Caution in Prescribing Zuranolone for Postpartum Depression

Zuranolone (Zurzuvae, by Biogen) made medical news headlines when it was approved by the U.S. Food and Drug Administration (FDA) last August as the first oral treatment for postpartum depression. However, some experts have concerns about the drug’s pivotal trials that they feel should give health professionals pause in prescribing it.

“The FDA saw fit to approve zuranolone based on modest efficacy data in trials that compared it with substandard medical care,” wrote Vinay Prasad, M.D., M.P.H., of the University of California, San Francisco, and David Allely, B.S., of the Icahn School of Medicine at Mount Sinai in New York in JAMA.

The authors described two trials that the FDA reviewed when making its decision to approve zuranolone, the ROBIN study and the SKYLARK study, both of which had placebo control arms.

“The use of placebo control is inappropriate. Multiple guidelines endorse treatment of severe postpartum depression with SSRIs and psychotherapy. Yet, in ROBIN and SKYLARK, just 20% and 15% of women, respectively, were using antidepressants at baseline,” they wrote, adding that each participant should have been prescribed an SSRI and psychotherapy based on current standards of care. “The median length of time to response expected with these interventions does not justify withholding treatment from the control group. We are unable to assess whether the improvement in the treatment group would have been observed versus standard of care.”

They added that although the trials assessed the drug’s efficacy in people with severe postpartum depression, the FDA’s approval “does not qualify its indication for individuals with postpartum depression of this severity, instead granting a blanket approval for milder forms of postpartum depression—an indication that lacks evidence.”

The authors also noted that both trials suggested a large placebo effect, accounting for roughly 75% of the effect in both trials.

“Patients with postpartum depression in this study tended to get better, regardless of treatment,” the authors explained.

The authors had several other concerns, as follows:

• Misuse potential
• Impaired psychomotor functioning
• Lack of compatibility with breastfeeding
• Anticipated exorbitant cost, estimated to be $10,000 to $30,000 for the two-week course

“We suggest that the FDA require control groups that reflect standards of care to better inform and equip physicians with medications that might improve the health of patients, and we caution the current use of zuranolone,” Prasad and Allely concluded.

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Now in Psychiatric News

• More Than 1 in 4 U.S. Adults Plans to Make Mental Health a Priority in 2024
• Med Check: Opioid Overdose, Ketamine Side Effects, Schizophrenia
• Peer Support Specialists Have Something to Teach Psychiatrists

Patients at High Risk for Psychosis May Benefit From Step-Based Care

People who are at high risk of developing psychosis may benefit from a step-based care program that starts with low-intensity interventions before progressing to ones of greater intensity, according to a small study published in Psychiatric Services.

“Although comprehensive, cost-effective, and multicomponent treatment packages have been developed for individuals with psychotic disorders … treatment packages designed to address the complex needs of individuals at clinical high risk for psychosis are currently lacking,” wrote Sarah Hamilton, M.D., of Ohio State University and colleagues.

Hamilton and colleagues recruited people who were at clinical high risk for psychosis and enrolled in the Early Psychosis Intervention Center at Ohio State University for the study. Participants could participate in one or more of five intervention tracks, including psychotherapy, pharmacology, family support, peer or social support, and vocational and educational services. For most tracks, initial services were of low intensity and less specific to psychotic symptoms, such as psychoeducation that focused on anxiety or depression or the benefits of substance use reduction. Individuals who did not meet symptom response criteria after the initial intervention progressed to increasingly intense interventions more specific to symptoms of psychosis, such as metacognitive remediation therapy, which is designed to address the decline in cognitive functioning that accompanies psychotic disorders.

Participants were assessed weekly for positive symptoms and functional difficulties with the positive symptom items from the Structured Interview for Psychosis-Risk Syndrome (SIPS) and the Personal and Social Performance Scale (PSP), respectively. Participants were considered to have a symptomatic response if all positive symptom items on the SIPS were rated 2 or less (higher scores indicate greater symptom severity). A functional response was defined as a PSP score of 70 or more (with higher scores indicating better functioning), or a 5-point increase in the PSP from the baseline assessment score.

Thirty-eight participants attended step-based care clinical appointments for an average of 26 weeks and were regularly assessed for an average of 41 weeks total. Seven participants already met the criteria for symptomatic response at enrollment, and four individuals experienced onset of a psychotic disorder during the study period. Among the remaining 27 participants, two-thirds (67%) eventually met criteria for symptomatic response, with a median time to response of 11.1 weeks. These individuals continued to meet symptomatic response criteria for a median of 80% of the follow-up period.

Five participants already met the criteria for functional response at enrollment. Among the remaining 33 participants, 64% eventually met criteria for a functional response, with a median time to a response of 8.9 weeks. These individuals continued to meet functional response criteria for a median of 92% of the follow-up period.

“Although our results should be interpreted cautiously given that our study lacked a control group, our findings highlight the potential merits of step-based care for individuals at clinical high risk for psychosis,” the authors wrote. “[D]espite the additional challenges associated with delivering a personalized, multicomponent intervention package, our results suggest reasons for cautious optimism that such care may improve outcomes for individuals at clinical high risk for psychosis while minimizing exposure to interventions with greater risk or adverse effect profiles.”

For related information, see the Psychiatric News article “Predicting Psychosis: Field Moves From Assessment of Clinical Risk to Search for Biomarkers.”

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Tips for Doctors Working With Kids, Teens Using Mental Health Apps

Mobile apps for mental health and wellness have changed the way that people—particularly youth—track and care for their mental health. With more than 10,000 mental health–related apps on the market today, how can doctors best help youth navigate this rapidly expanding and evolving terrain?

In an article appearing in the Journal of the American Academy of Child & Adolescent Psychiatry, Stephen M. Schueller, Ph.D., of the University of California, Irvine, and colleagues recommend three actions that doctors can take to support youth using or interested in mental health apps:

1. Understand the content within mental health apps. “Although many mental health apps exist, only a few are widely used,” Schueller and colleagues write. “[C]linicians may find it helpful to learn the content of those apps that are reaching a significant youth audience.” The authors recommend that doctors spend 10 to 30 minutes exploring each popular app, reviewing resources that summarize information about mental health apps (see APA’s App Advisor), and asking young people about which apps they use and how they use them.

2. Explore motivation around the use of mental health apps. Once a person (young and old alike) has downloaded a mental health app, it can be difficult to stick with it, the authors note. Motivational interviewing techniques offer one strategy for helping youth to explore their reasons for using an app. “Clinicians can play an important role in helping youth decide whether to use a [mental health] app and how to get the most out of any [mental health] app they decide to use.”

3. Discuss potential risks of mental health apps and help youth mitigate them. There are risks to using mental health apps, just as there are risks to medications and other treatments. For example, some apps collect and store the user’s mental health information, which could become compromised in the event of a data breech; others may include content that can cause harm if applied inappropriately. “Clinicians can play an important role in understanding when, why, and how youth are engaging with apps,” the authors write. As a result, clinicians can help to determine whether the “apps are causing unintended harms, help youth understand key points within [these] apps, and encourage youth to apply app content to their own situations appropriately.”

Schueller and colleagues continue, “No [mental health] app will work for everyone, and each patient brings unique considerations into the use of a [mental health] app. Clinicians need to not only consider which [mental health] apps might be most relevant to a given young person, but how to assess their use of a [mental health] app once provided to guide future use.”

For related information, see the Psychiatric News article “Digital Mental Health Apps Need More Regulatory Oversight.”

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More Than 1 in 4 U.S. Adults Plans to Make Mental Health a Priority in 2024

Over 75% of U.S. adults plan to start 2024 with a New Year’s resolution—including 28% who are resolving to work on improving their mental health, according to APA’s latest Healthy Minds monthly poll. The poll was conducted online from December 2 to 4 among 2,202 adults.

Of those who want to work on improving their mental health, the most common steps they plan to take toward this goal include exercising more (67%) or meditation (49%). Other actions included seeing a therapist or psychiatrist (35% and 21%, respectively) and journaling (26%).

“Many see the new year as a time for a new chance, or to try something different, which is great,” APA President Petros Levounis, M.D., M.A., said in a news release. “At the same time, in mental health—just like physical health—maintenance and care matter. Preserve your healthy routines, maintain your relationships with loved ones, and take good care of yourself, as well as the people around you.”

Other mental health–related resolutions include focusing more on spirituality (40%), cutting back on social media (31%), and using a mental health app (21%). Additionally, 6% chose “forest bathing”—a still relatively unknown practice of immersing oneself in natural green spaces—as their mental health resolution.

Other popular resolutions identified by those polled included the following:

• Physical fitness (39%)
• Finances (34%
• Diet (26%)
• Social/relationships (22%)
• Traveling (21%)
• Hobbies/skill-based (18%)
• Organization/decluttering (15%)
• Professional/career (13%)
• Giving/volunteering (12%)

“Taking care of your mental health doesn’t need to be tied to a holiday—any of us can take any of these steps any time,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “That said, the change in year is a terrific excuse to try something new to care for your mental health.”

For related information, see the Psychiatric News article “Experts are Positive That Positive Psychiatry Works.”

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Psilocybin Group Therapy May Reduce Depression in People With Cancer

Psychedelic-assisted psychotherapy is typically provided in a private setting involving one patient and two therapists. A small study described today in Cancer suggests a single session of psilocybin-assisted therapy delivered in a group setting can significantly reduce depressive symptoms in patients with cancer for up to eight weeks with minimal side effects.

“Approximately 25% to 33% of patients with cancer meet criteria for clinically significant depressive symptoms, which are associated with lower treatment adherence, reduced quality of life, and higher rates of mortality,” wrote Manish Agrawal, M.D., CEO and Co-founder of Sunstone Therapeutics in Rockville, Md., and colleagues. Partial funding for this trial was provided by Compass Pathways, and some of the authors of the Cancer report hold Compass Pathways stock.

For the open-label study, the researchers recruited adults with cancer and major depression. Adults with depression with psychotic features and/or suicidal thoughts were excluded, as were those who were taking antidepressants, antipsychotics, and/or medical cannabis. Participants who had curable and noncurable cancer were included in the study.

A total of 30 participants (average age 56 years, predominantly women) were divided into three- or four-person groups. All groups received the following:

• One two-hour individual therapy session, where participants got to know their assigned therapist, were educated about what to expect with psilocybin therapy, and coping strategies.
• One two-hour session the day before psilocybin treatment. This included a 45-minute individual session with the therapist to set an intention and a 75-minute group psychoeducation component.
• One psilocybin session (lasting 6 to 7 hours), during which participants in each group simultaneously received 25 mg of psilocybin while in individual rooms with their assigned therapist. The participants were separated by other participants in their group by sliding doors without soundproofing.
• Two two-hour posttreatment integration sessions separated by one week. These sessions included a 45-minute individual component and a 75-minute group component.

Participants’ average score on the Montgomery‐Åsberg Depression Rating Scale (MADRS) at the start of the study was 25.9, indicating moderate depression. Three weeks after psilocybin treatment, average MADRS scores dropped by over 19 points in the group, and this improvement was maintained 8 weeks after psilocybin administration.

Half of the participants no longer met DSM-5 criteria for major depression by week 8. The patients also self-reported significant improvements in their anxiety symptoms following psilocybin-assisted therapy.

Agrawal and colleagues noted that this novel protocol did not result in any serious adverse events in the participants. The most common treatment-related side effects were nausea and headache, which were generally mild and are known side effects of psilocybin.

“This innovative framework offers increased scalability and dissemination of psilocybin treatment in real‐world settings and alleviates the cost and time burdens of using two therapists for one patient,” Agrawal and colleagues wrote.

“If group‐based approaches can improve treatment outcomes and save costs compared to individually delivered psychedelic‐assisted therapy, they will be an important innovation to make these treatments more affordable to ensure that as many patients as possible can benefit from their healing potential,” wrote Johannes Thrul, Ph.D., of the Johns Hopkins Bloomberg School of Public Health and colleagues in an accompanying editorial. However, the “potential for participants within a group to influence one another beneficially or detrimentally” should be considered an important limitation when examining these results, they added.

To read more on this topic, see the Psychiatric News article “Depression Improves Following Single Dose of Psilocybin.”

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Hypochondriasis Linked to Increased Risk of Death

People who have hypochondriasis (health anxiety disorder) may have an increased risk of dying by either natural or unnatural causes, including death by suicide, compared with people who do not have the disorder, a study in JAMA Psychiatry has found. According to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), people who have the disorder are preoccupied with thoughts that they have one or more serious and progressive physical disorders and repeatedly check for symptoms and seek reassurance from health professionals.

“[T]hese findings illustrate a paradox, whereby individuals with hypochondriasis have an increased risk of death despite their pervasive fears of illness and death,” wrote David Mataix-Cols, Ph.D., of the Karolinska Institutet in Stockholm and colleagues.

The researchers examined data from 4,129 people aged 6 years and older in the Swedish National Patient Register who received a diagnosis of hypochondriasis between January 1, 1997, and December 31, 2020, at the age of 6 years or older. The researchers matched those individuals with 41,290 demographically similar people without hypochondriasis. All individuals were followed until the date of death, emigration from Sweden, or the end of the study on December 31, 2020, whichever occurred first.

A total of 268 individuals with hypochondriasis and 1,761 individuals without hypochondriasis died of all causes during the follow-up. Those with hypochondriasis died at a mean age of 70 years, compared with a mean age of 75.1 years for those without the disorder.

Those with hypochondriasis had a 69% increased risk of dying of any cause, a 60% increased risk of dying of natural causes (for example, diseases of the circulatory, nervous, or respiratory systems), and a 143% increased risk of dying of unnatural causes compared with people without hypochondriasis. Those with hypochondriasis also had a 314% increased risk of dying by suicide, which was the most common cause of unnatural death. However, after the researchers adjusted for a history of depressive or anxiety disorders, suicide risk was no longer statistically significant.

“Clinicians should be aware that individuals with hypochondriasis are at risk of death by suicide, particularly if they have a lifetime history of depression and anxiety,” Mataix-Cols and colleagues wrote. “Dismissing these individuals’ somatic symptoms as imaginary may have dire consequences. More should be done to reduce stigma and improve detection, diagnosis, and appropriate integrated (i.e., psychiatric and somatic) care for these individuals.”

For related information, see The American Journal of Psychotherapy article “Psychodynamic Psychotherapy for Patients With Functional Somatic Disorders and the Road to Recovery.”

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Suicidal Symptoms May Worsen for Some Women Before, During Menses

Women who experience suicidal thoughts and behaviors may experience worsening symptoms in the days before and during menses, though the symptom changes vary significantly among individuals, according to a study published today in The American Journal of Psychiatry.

“Females (assigned female at birth) are three times more likely than individuals assigned male at birth to report suicidal ideation, suicidal planning, or a suicide attempt,” wrote Jaclyn Ross, Ph.D., of the University of Illinois at Chicago and colleagues. “Accumulating evidence shows that ovarian hormone fluctuations modulate imminent suicide risk for many females, resulting in increased likelihood of suicide attempts and deaths during the premenstrual and menstrual weeks.”

Ross and colleagues analyzed data provided by women aged 18 to 45 with 21- to 35-day menstrual cycles who were receiving outpatient mental health care and had experienced past-month suicidal ideation. For inclusion in the study, the women could not be pregnant or planning to become pregnant, nor could they be taking hormonal medications.

All participants completed daily electronic surveys through which they reported when menses began and psychiatric symptoms each menstrual cycle. The surveys asked the study participants to report suicidal thoughts and planning, as well as feelings of anxiety, depression, hopelessness, agitation, and more. The participants also provided urine samples, which allowed the authors to identify when ovulation occurred each cycle.

A total of 119 participants provided data covering two menstrual cycles. Findings included the following:

• Many participants experienced worsening psychiatric symptoms, suicidal ideation, and suicidal planning during the perimenstrual period (the days immediately before and after the onset of menses).
• Suicidal planning was more likely to occur during the perimenstrual period compared with other phases of the menstrual cycle.
• Depressive symptoms (depression, hopelessness, perceived burdensomeness, and anhedonia) were the most robust predictors of suicidal ideation and behaviors worsening during the perimenstrual period.
• Symptom changes in response to the menstrual cycle varied significantly across the study participants. The authors wrote that this finding underscores the importance of understanding individual differences in hormone sensitivity.

“These findings highlight the need for more intensive, longitudinal research on the mechanisms underlying and the prevention of suicidality across the cycle,” the authors wrote. “[I]ntervention efforts may benefit from strategies that specifically target depressive symptoms as they fluctuate across the cycle, given their powerful role in the cycle-suicidality relationship.”

For related information, see the Psychiatric News article “Depression After Hormonal Contraception Initiation Linked to PPD.”

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Study Highlights Need to Screen Young Children With Depression for Suicidal Behaviors

Children diagnosed with major depressive disorder between the ages of 3 and 6—known as preschool-onset MDD—are more likely than their peers to express suicidal thoughts and behaviors before the age of 13, a report in the Journal of the American Academy of Child and Adolescent Psychiatry suggests.

“While general [suicidal thoughts and behaviors] screening is not indicated for children under age 8, suicide assessment should be conducted if warning signs such as mood disturbances are present,” wrote Laura Hennefield, Ph.D., of the Washington University School of Medicine and colleagues. “Children with [preschool-onset] MDD would likely benefit from increased suicide screening, proactive safety planning, and early interventions.”

The study included 137 children aged 8 to 12 years who met the criteria for preschool-onset MDD and 53 children aged 8 to 12 with no history of depression.

The children with preschool-onset MDD and their caregivers had initially participated in a study testing the effectiveness of a parent-child psychotherapy for early childhood depression. As part of that study, caregivers completed multiple assessments about their children, such as the Kiddie Schedule for Affective Disorders and Schizophrenia-Early Childhood (K-SADS-EC). When the children were between 8 and 12 years, the researchers asked the caregivers to complete the K-SADS-Present and Lifetime (K-SADS-PL), which included questions on lifetime and current symptoms of depression as well as suicidal thoughts, behaviors, and attempts. The children also reported on their own lifetime and current symptoms. A child was considered to have suicidal thoughts and behaviors if such behaviors were reported by the caregiver or the child.

The researchers found that 67.9% of 8-to 12-year-old children who had preschool-onset MDD expressed suicidal thoughts and behaviors by preadolescence, including 26.3% over the prior month. In contrast, 22.6% of children without a history of depression endorsed suicidal thoughts and behaviors by preadolescence, including 3.8% over the prior month. The children with preschool-onset MDD were also significantly more likely to have made a suicide attempt by age 12 compared with peers without depression history.

Further analysis revealed that children with preschool-onset MDD who achieved remission following parent-child psychotherapy (defined as at least 50% reduction in symptom severity and loss of preschool-onset MDD diagnosis) were less likely to experience suicidal thoughts and behaviors after preschool.

“Studying those with or at risk for [suicidal thoughts and behaviors] early in development holds promise for identifying at-risk children for targeted preventative intervention to alter risk trajectories away from persistent or escalating [suicidal thoughts and behaviors],” the researchers said.

For related information, see the Psychiatric News article “Suicidal Thoughts Begin Early for Some Youth.”

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Psychiatric News Welcomes New Editor in Chief

Adrian Preda, M.D., a professor of clinical psychiatry and human behavior at the University of California, Irvine, School of Medicine, has been named editor in chief of Psychiatric News. Preda, who will officially start January 1, 2024, succeeds Jeffrey Borenstein, M.D., who has served as editor in chief since 2012.

Preda attended the Carol Davila University of Medicine and Pharmacy in Bucharest, Romania, and completed his residency at Yale University School of Medicine. He served as chief resident in psychiatry at Yale before taking on several roles with the VA North Texas Health Care System in Dallas, including medical director of mental health triage. He has been at the University of California, Irvine, School of Medicine since 2006 and has served in multiple positions at the institution, including director of residency training in psychiatry and vice chair of education in psychiatry and human behavior.

“Throughout my career, I have combined research, education, and clinical work, but I am now at the point at which I want to make an impact on the broader population, and this position with Psychiatric News will provide that opportunity,” Preda said in an interview.

“We’re thrilled to welcome Dr. Preda to the Psychiatric News team,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a news release. “In doing so, he will lead the primary and most trusted source of information covering developments in the field of psychiatry that impact clinical care and professional practice.”

An avid reader of Psychiatric News, Preda said he hopes to help the publication broaden its audience. “Psychiatric News can be a resource not just for psychiatrists, but for others who are interested in all aspects of mental health and well-being,” he said.

Borenstein will continue in his roles as president and CEO of the Brain & Behavior Research Foundation and host of the PBS series “Healthy Minds.”

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Youth With Autism More Likely to Experience Restraint in Hospital

Children and adolescents with autism spectrum disorder (ASD) are more than twice as likely as those without ASD to be restrained while hospitalized, according to a report published today in Pediatrics.

“Because people with ASD often have invisible disabilities or disabilities that are less frequently understood, they may get less support in health care settings,” wrote Mary Elizabeth Calabrese, D.O., M.P.H., and colleagues from Boston Children’s Hospital. “Work is needed to modify the hospital environment for children with ASD to reduce behavioral dysregulation that can lead to unnecessary and avoidable physical and pharmacologic restraint.”

Calabrese and colleagues examined retrospective medical data for all pediatric patients aged 5 to 21 years who were admitted to a pediatric inpatient unit between October 1, 2016, and October 1, 2021. Due to differences in protocols in psychiatric units and emergency departments, youth seen in psychiatric units or emergency departments were excluded from this analysis, the authors explained. They examined clinical orders for physical restraint (for example, cuffs or seclusion) and/or pharmacological restraint (for example, an antipsychotic or benzodiazepine injection) due to the patients’ violent or self-injurious behavior.

The final sample included 21,275 youth, including 1,187 (5.6%) youth with ASD. Of the 367 in the sample who experienced restraint, 88 (24%) had a diagnosis of ASD. Compared with youth without ASD, those with ASD were hospitalized longer, were more likely to have a comorbid psychiatric diagnosis, and were more likely to be admitted for a behavioral than a physical issue. After adjusting for these differences, youth with ASD were 2.3 times as likely to be restrained than youth without ASD.

This article was one of three published today in Pediatrics examining trends and disparities in the use of restraints in children’s hospitals. The second report indicates that Black children admitted to a hospital for a mental health crisis are more likely to receive pharmacologic restraint than children who were not Black. The third report shows that the rate of pharmacologic restraint has remained stable between 2016 and 2021, as slight decreases in the use of restraints for youth with ASD or anxiety were offset by increased restraint use for conditions like bipolar disorder and eating disorders.

“Now is the time to envision a path toward ending restraint use at children’s hospitals,” wrote Evan M. Dalton, M.D., M.S.H.P., of Texas Children’s Hospital in Houston and Stephanie K. Doupnik, M.D., M.S.H.P., of the Children’s Hospital of Philadelphia in a commentary.

To read more on this topic, see the Psychiatric News article “APA Resource Document Outlines Principles on Use of Seclusion, Restraint.”

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Skipping Breakfast, Pro-Inflammatory Diet Linked to Depressive Symptoms

Skipping breakfast and eating a diet high in foods associated with inflammation (for example, foods fried in oil) may raise the risk of depression, a study in the Journal of Affective Disorders has found.

Bo Li, Ph.D., of Jilin University in Changchun, China, and colleagues examined data from 21,865 adults who were participants in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018. During their participation in NHANES, the individuals completed two 24-hour dietary recalls where they reported what they ate and when. They also completed the Patient Health Questionnaire-9 (PHQ-9) as a measurement of symptoms of depression.

Li and colleagues assessed the participants’ diet via the dietary inflammatory index (DII). The DII calculates a score based on the amount of vitamins, minerals, nutrients, and substances in a person’s diet that either promote inflammation, such as saturated fat or alcohol, or help inhibit inflammation, such as fiber. For this analysis, Li and colleagues classified participants with a DII score of ≥0 as having a pro-inflammatory diet and those with a score <0 as having an anti-inflammatory diet.

Overall, 77.6% of participants reported breakfast in both 24-hour dietary recalls, 16.3% reported breakfast in only one recall, 6.1% did not report breakfast in either recall, and 7.9% had depressive symptoms with a PHQ-9 score of 10 or more. Participants with depressive symptoms were more likely to be female, be inactive in physical activity, and smoke. They were also more likely to have higher energy intake, have diabetes, have cardiovascular disease, and eat a pro-inflammatory diet.

Participants who ate a pro-inflammatory diet had 1.42 times the odds of having depressive symptoms compared with those who ate an anti-inflammatory diet. Compared with participants who reported eating breakfast on both dietary recalls, those who did not report breakfast in either recall had 1.54 the odds of having depressive symptoms. Furthermore, the researchers found that skipping breakfast was associated with eating a pro-inflammatory diet.

“Skipping breakfast may increase the risk of depression by raising DII. We recommend regular breakfast to lower DII and further reduce the risk of depression,” they wrote.

For related information, see the American Journal of Psychiatry article “Association Between Systemic Inflammation and Individual Symptoms of Depression: A Pooled Analysis of 15 Population-Based Cohort Studies.”

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Magnetic Seizure Therapy for Depression Found as Effective as ECT

Magnetic seizure therapy (MST) appears to be as effective as electroconvulsive therapy (ECT) at achieving lasting antidepressant effects in people with major depression and may be less disorienting. The findings were published yesterday in JAMA Psychiatry.

While ECT is highly effective for treating major depressive disorder, “it carries the risk of adverse neurocognitive effects,” wrote Zhi-De Deng, Ph.D., of the National Institute of Mental Health and colleagues. MST aims to match the efficacy of ECT while reducing the adverse effects, they continued.

Deng and colleagues conducted a trial of participants aged 18 to 90 years who were referred for ECT treatment. The participants had all experienced a major depressive episode and had a diagnosis of major depressive disorder or bipolar disorder. They had a baseline score of 18 or higher on the 24-item Hamilton Depression Rating Scale (HDRS-24). Participants were tapered off any antidepressant medications they were taking and assigned to receive either MST or right unilateral ultrabrief pulse ECT, after which they were followed for up to six months.

Participants in both groups received treatment three times per week until they achieved remission (defined as at least 60% reduction in HDRS-24 score and a total score of no more than 8), or until their HDRS-24 scores plateaued for at least three treatment sessions starting after treatment eight. If participants had less than a 25% decrease in HDRS-24 score by the eighth treatment, treatment was discontinued, and participants were given routine clinical care. Participants were considered to have completed treatment if they had received at least eight treatments or achieved remission prior to the eighth treatment.

Adverse effects were evaluated after each treatment session using the Columbia ECT Subjective Side Effects Schedule. The time it took participants to orient themselves following treatment was assessed after each session by having patients open their eyes on command and correctly answer personal identification questions, such as their name, age, and date of birth. Depression severity was measured with the HDRS-24 the morning of each treatment session, 24 to 72 hours after the last treatment session, twice per month for the first two months after treatment, and once per month thereafter.

Among 73 patients, 35 were randomized to MST and 38 to ECT. Both MST and ECT demonstrated clinically meaningful antidepressant effects, with participants in both groups starting with an average baseline HDRS-24 score of about 30, which then reduced to about 18 by the eighth treatment. The antidepressant benefit participants experienced at the end of treatment, as measured by the HDRS-24 score, was maintained at the two-month and six-month follow-ups. Additional findings included the following:

• 53 participants completed treatment, including 29 in the MST group and 24 in the ECT group.
• 45% of participants in the MST group and 42% of participants in the ECT group met remission criteria.
• The mean number of treatments needed to achieve remission was 9.0 in the MST group and 6.7 in the ECT group.
• On average, it took participants in the MST group a few minutes to orient themselves, compared with almost 20 minutes among participants in the ECT group.
• Five serious adverse events were reported, all in the ECT group, including three cases of worsening depression that resulted in hospitalization. In the MST group, four adverse events were reported such as nausea and vomiting after treatment.

“Our study is the first, to our knowledge, to demonstrate durability of antidepressant effects of MST that were comparable with those of ECT for up to 6 months,” the authors wrote. “[T]he faster time to orientation and improved autographical memory recall found with MST suggest that MST may provide substantial antidepressant benefits while maintaining a high level of cognitive safety.”

For related information, see the Psychiatric News article “Is Magnetic Seizure Therapy Ready to Round the Corner?”

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Psilocybin With Psychotherapy May Benefit Patients With Bipolar II Depression, Small Study Suggests

A single dose of the psychedelic psilocybin combined with psychotherapy appears to be safe and effective at reducing depression in people with treatment-resistant bipolar disorder II, according to a small study published today in JAMA Psychiatry. Bipolar II disorder is associated with difficult-to-treat depressive episodes but less severe manic episodes than those experienced by patients with bipolar I disorder.

“The findings support further study of psychedelics in the [bipolar II disorder] population,” wrote Scott Aaronson, M.D., of the Institute for Advanced Diagnostics and Treatment at Sheppard Pratt Health System and colleagues. “Individuals in this study displayed strong and persistent antidepressant effects, with no signal of worsening mood instability or increased suicidality.”

The open-label study included 15 patients (nine female, average age 37.8) with bipolar II disorder who had been experiencing an episode of depression lasting longer than three months. After withdrawal of antidepressants and mood-stabilizing medications for at least two weeks, all study participants received a single 25 mg dose of synthetic psilocybin. Therapists met with the patients for three sessions during pretreatment, during the 8-hour dosing day, and for three integration sessions posttreatment.

A study psychiatrist assessed the participants using the Montgomery-Åsberg Depression Rating Scale (MADRS), the Columbia Suicide Severity Rating Scale (CSSRS), and the Young Mania Rating Scale (YMRS) during follow-up visits at 1, 2, 3, 6, and 12 weeks.

The primary outcome measure for the study was a change in the Montgomery-Åsberg Depression Rating scale (MADRS) at three weeks posttreatment.

At week 3, all 15 patients had lower scores on the MADRS than at baseline (average reduction, 24 points). Twelve participants met the criteria for response (50% decrease in MADRS), and 11 met criterion for remission (MADRS score ≤10). At 12 weeks, 12 patients met both response and remission criteria. There were no significant adverse events related to the psilocybin dosing, and there was no significant change in scores on the safety measures for suicide or mania.

“The results of this trial are relevant for both efficacy and safety. However, the evidence for safety is far more compelling,” wrote David B. Yaden, Ph.D., of the Center for Psychedelic and Consciousness Research at Johns Hopkins University School of Medicine and colleagues in an accompanying editorial.

While the authors acknowledged the limitations of the small study, they noted that “[t]he favorable safety profile of this study strongly justifies a larger randomized clinical trial of psilocybin for bipolar II depression,” they wrote. “Bipolar disorders are associated with substantial suffering and dysfunction, and new treatments are needed.”

For related information, see the Psychiatric News article “Depression Improves Following Single Dose of Psilocybin.”

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Targeted Assessments May Help Identify Workers Experiencing Cognitive Impairment

“As the United States gears up for a likely presidential contest between an 81-year-old incumbent and a 78-year-old challenger, the dilemma of how to deal with the issue of older people in important positions who may be experiencing cognitive limitations is front and center in the public eye,” wrote psychiatrist and past APA President Paul Appelbaum, M.D., in a Law & Psychiatry column appearing today in Psychiatric Services.

According to 2022 data, nearly 58 million adults ages 65 and older live in the United States, accounting for about 17.3% of the nation’s population. This percentage is expected to keep growing.

“Encouraging workers to remain active beyond standard retirement ages will be important to satisfy demands for labor, especially in skilled positions,” noted Appelbaum, who is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and the director of the Division of Law, Ethics, and Psychiatry at Columbia University. But some may experience challenges with cognitive impairment while still in the workforce. What can employers do to prepare for the future?

He described two federal laws that prohibit discrimination based on age—the Age Discrimination in Employment Act (ADEA) and the Americans With Disabilities Act (ADA)—before noting that under federal law, employers are permitted to conduct target assessments of employees who show signs of impairment. “Applying that rule in a fashion that is fair to employees, and protective of the interests of employers and the public, is the difficult, but vital, task ahead.”

Appelbaum described how new approaches might include routine assessments of worker performance throughout an organization that do not single out older employees for more intensive scrutiny and clear standards for determining when evidence of impairment warrants targeted assessments.

“The prevalence of the most widespread form of neurocognitive disorder, Alzheimer’s disease, increases with age from 3% between 65 and 74 years of age to 17% between ages 74 and 84, jumping to 32% for people 85 years or older—hence the urgency of understanding the current parameters for how workplaces can and cannot address concerns about the mental functioning of older workers,” Appelbaum wrote.

For related information, see the Psychiatric News article “Tools for Countering Burnout Mirror Those for Aging Well as a Physician.”

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Youth Taking Antipsychotics Not at Increased Risk of Death

Physically healthy youth aged 5 to 17 years who begin taking antipsychotics for conditions that do not involve psychosis appear to be at no greater risk of death than those initiating other medications. This was one of several findings of a recent article in JAMA Psychiatry.

“Antipsychotic medications have potentially life-threatening cardiovascular, metabolic, respiratory, sedative, and other adverse effects in both children and adults, although many of these are infrequent,” wrote Wayne A. Ray, Ph.D., of Vanderbilt University School of Medicine and colleagues. “This finding suggests that antipsychotic medication–related fatalities are rare in healthy children without psychosis.”

Ray and colleagues used the Medicaid Analytic Extract, a national repository of data from the Medicaid and Children’s Health Insurance Program, to identify all individuals aged 5 to 24 without psychosis who initiated antipsychotic treatment between January 2004 and September 2013. Individuals diagnosed with a serious medical illness in the past year were excluded from the analysis. The researchers divided these patients into low- and high-dose antipsychotic groups, using 100 chlorpromazine mg daily or equivalent as the cutoff.

As a control group, the researchers identified similarly aged patients who began taking alternatives to antipsychotics for such conditions as attention-deficit/hyperactivity disorder, depression, or disruptive behaviors, including antidepressants or lithium.

A total of 2,067,507 children and young adults who filled nearly 22 million prescriptions (about 8.3 million antipsychotic prescriptions and 13.5 million control prescriptions) were included in the analysis.

Overall, the researchers found that patients taking low-dose antipsychotics were no more likely to die than those who took control medications; however, those who took high-dose antipsychotics were at a 37% increased risk of death compared with those who took the control medications.

When breaking down the data by age groups, Ray and colleagues found no increased risk of death among 5- to 17-year-olds taking high-dose antipsychotics. Eighteen- to 24-year-olds taking high-dose antipsychotics had a 68% increased risk of death. The heightened death risk in the high-dose group was significantly associated with drug overdoses and unintentional injuries. The researchers found no association between antipsychotics and suicide deaths or cardiovascular/metabolic deaths.

“[C]aution may be indicated when prescribing antipsychotic medications for young adults without psychosis who are receiving opioid treatment or who have substance use disorders,” Ray and colleagues wrote. “Additional research is needed, particularly for nonfatal overdoses, which are much more frequent than deaths in children and young adults.”

To read more about this topic, see the Psychiatric News article “Antipsychotic Use in Young Children Declining, but Concerning Trends Remain.”

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