Study Supports Use of Emotional Support, Service Dogs for Veterans With PTSD

Eighteen months after being paired with an emotional support or service dog, veterans with posttraumatic stress disorder (PTSD) continued to report improvements in overall functioning and quality of life, a report in Psychiatric Services in Advance has found.

While emotional support dogs can provide comfort to their handlers, service dogs for PTSD receive additional training in a variety of tasks specific to assisting individuals with PTSD (for example, turning on lights in a dark room and providing space between the individual and an approaching person), wrote Joan T. Richerson, M.S., D.V.M., of the VA Tennessee Valley Health Care System and colleagues. The researchers wanted to know whether veterans who were paired with service dogs for PTSD might experience greater therapeutic benefits than those paired with emotional support dogs.

Richerson and colleagues randomly assigned veterans who had been diagnosed with PTSD to receive either a service dog or emotional support dog. Emotional support dogs and service dogs were required to pass the American Kennel Club Canine Good Citizen and Assistance Dogs International Public Access tests. In addition, service dogs were taught to perform tasks specific to a handler’s PTSD (turn on lights in dark room; enter rooms and sweep the perimeter; bring objects; and stand in front or behind the handler, respectively, to provide space between the handler and a person approaching from front or back).

After an observation period during which the randomized participants were asked to complete a dog care course, 97 participants received a service dog, and 84 received an emotional support dog. Over 18 months, the researchers evaluated the study participants’ level of disability and health-related quality of life, using the World Health Organization Disability Assessment Scale II (WHODAS 2.0) and the Veterans RAND 12-Item Health Survey (VR-12 physical and mental scores). They also collected data on participants’ PTSD symptoms, health care use, and more.

Among the findings:

• WHODAS 2.0 scores fell in both groups from three months after pairing with the dogs to 18 months (indicating less disability).
• VR-12 mental scores in both groups increased from baseline to 18 months (indicating improvement in quality of life). There was no significant difference in VR-12 physical scores over time.
• PTSD Checklist for DSM-5 (PCL-5) scores in both groups fell over the course of the study (indicating improvement in PTSD symptoms).

“Some separation in [PCL-5] scores between the groups started to appear at 9 months, with scores for the service dog group decreasing more than those for the emotional support dog group,” the authors noted.

Receipt of a service dog compared with receipt of an emotional support dog did not significantly affect VA costs for any category of care or VA health care use, except for outpatient substance use disorder treatment, the authors continued.

“Future work should examine mechanisms by which a service or emotional support dog has an impact on patient functioning, such as by directly reducing PTSD symptoms (e.g., arousal or avoidance), indirectly reducing symptoms through improved treatment engagement (e.g., in psychotherapy) or adherence (e.g., to pharmacotherapy), or by enabling veterans to overcome challenging situations in the presence of such symptoms.”

For related information, see the Psychiatric Research & Clinical Practice article “A Qualitative Exploration of the Use of Service Dogs in Veterans with Post Traumatic Stress Disorder and Traumatic Brain Injury.”

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Biden to End Public Health Emergency Declaration in May

The COVID-19 public health emergency (PHE) will end on Thursday, May 11, the Biden Administration announced yesterday.

The administration’s decision to end the national emergency and PHE on May 11 will result in the end of multiple federal flexibilities affecting health care programs, including regulatory and statutory flexibilities provided by HHS and other Departments. This is a developing story; more information will be provided to APA members tomorrow.

Study Supports Repetitive TMS for Patients With Treatment-Resistant Depression

About 1 in 4 people with treatment-resistant depression may achieve remission with repetitive transcranial magnetic stimulation (rTMS), according to data collected from patients at five hospitals in France. The analysis, which was published in the Journal of Affective Disorders, also showed that patients with more severe symptoms at baseline experienced greater improvements following rTMS on average.

“To the best of our knowledge, this is the largest naturalistic study [of rTMS] with clinician-rated scales by … psychiatrists,” wrote Noomane Bouaziz, M.D., of EPS Ville Evrard in Neuilly-sur-Marne, France, and colleagues. “Our study encompasses a large variety of stimulation settings and comorbidities, reflecting usual clinical practice. Thus, this study is intended to guide psychiatrists in real-life practice, as a complement to [randomized, controlled trials] with strict inclusion criteria.”

Bouaziz and colleagues collected data from 435 adults who were treated with rTMS at one of five French University Hospitals between January 2015 and December 2020. The patients had a diagnosis of either unipolar or bipolar depression and had not responded to at least two trials of antidepressants. Many of these patients had psychiatric or other medical comorbidities; the only patients excluded from the study were those who had metallic implants, had nonstabilized epilepsy, and/or were pregnant. The rTMS protocols at the hospitals varied; the number of sessions ranged from 10 to 28 and the total delivered pulses per session ranged from 360 to 2,000.

The researchers compared patients’ Montgomery–Åsberg Depression Rating Scale (MADRS) scores at baseline with those following the completion of rTMS. Overall, MADRS scores decreased by about 9.5 points, which represented a 33% reduction from baseline levels. In addition, 22.8% of the patients achieved remission (defined as a MADRS score of 10 or less).

Bouaziz and colleagues next looked at factors that might influence a patient’s response to rTMS. They found that patients with more severe baseline depression had greater MADRS improvements following rTMS on average, whereas patients with milder depression were more likely to achieve remission. Patients who did not have psychiatric comorbidities and those who were not taking lithium showed greater symptom improvement than those who did meet these criteria; however, neither the presence of comorbidities nor use of lithium impacted remission rate.

To read more on this topic, see the Psychiatric News article “TMS Should Be Considered as First-Line Treatment for Moderate to Severe Major Depressive Disorder.”

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Substance Use Disorders Cost Employer Health Insurance $35 Billion in 2018

Substance use disorders (SUDs) cost employer-sponsored health insurance plans $35.3 billion in the United States in 2018, a study in JAMA Network Open has found. Alcohol use disorder was found to be the most costly at $10.2 billion a year, followed by opioid use disorder at $7.3 billion a year.

Mengyao Li, Ph.D., of the Centers for Disease Control and Prevention and colleagues examined data from Merative MarketScan 2018 Commercial Claims and Encounters Databases, which report expenditures for inpatient services, outpatient services, and outpatient medications from approximately 350 health insurance payers. The researchers compared the medical costs of 210,225 people who had an SUD diagnosis with those of 1,049,539 people who did not have an SUD diagnosis.

The mean total annual medical expenditure was roughly $26,000 per person with an SUD diagnosis, compared with roughly $10,400 per person without an SUD diagnosis. Additional analysis revealed that the annual attributable mean cost of any SUD diagnosis (including multiple SUD diagnoses) was roughly $15,640. Having an SUD diagnosis was associated with costs of roughly $6,500 for inpatient services, $8,600 for outpatient services, and $1,500 for outpatient medications.

The researchers wrote that their findings likely underestimated the actual medical costs that employers and their health insurance payers face because only 1% of the study population had an SUD diagnosis, compared with 11% of workers who self-reported an SUD in previous research that was conducted by the Substance Abuse and Mental Health Services Administration.

“Medical expenditures for SUDs represent the minimum direct cost that employers and health insurers face because not all people with SUDs have a diagnosis, and costs related to absenteeism, presenteeism, job retention, and mortality are not addressed,” Li and colleagues wrote.

Yet the researchers also noted that the $35.3 billion in medical costs associated with SUD diagnoses are a small fraction of the $1.1 trillion paid by private insurance in 2018 for personal health care expenditures.

They added that employers can take action by developing workplace-supported prevention, treatment, and recovery programs.

“The cost of strategies to support employees and their health insurance dependents to prevent and treat SUDs can be considered in terms of potentially offsetting the existing high medical cost of SUDs,” they wrote.

For addition reading, see the Psychiatric Services article “Cost Offsets of Treatment for Serious Mental Illness and Substance Use Disorder.”

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Fluvoxamine May Not Improve COVID-19 Outcomes

Fluvoxamine, a drug approved to treat obsessive-compulsive disorder, showed promise in some trials as a potentially inexpensive treatment for COVID-19. Yet a study published this month in JAMA found that the drug may be no more beneficial for patients with mild to moderate symptoms than a placebo.

Matthew McCarthy, M.D., of Weill Cornell Medicine and colleagues reported on the results of the ongoing Accelerating COVID-19 Therapeutic Interventions and Vaccines randomized clinical trial, which is testing several outpatient treatments for mild to moderate COVID-19. The participants were 30 years or older, had confirmed COVID-19 infections for 10 days or less, and were experiencing two or more COVID-19 symptoms for 7 days or less. Symptoms included fatigue, fever, cough, nausea, body aches, sore throat, and loss of sense of taste or smell.

Between August 6, 2021, and May 27, 2022, the participants were randomized to receive 50 mg of fluvoxamine twice daily for 10 days or a placebo. The participants completed assessments on the type and severity of their symptoms, any health care visit, and any other medications they started taking daily through the first 14 days. From days 15 to 28, the participants continued to report until they experienced three consecutive days without symptoms, which the authors defined as sustained recovery.

A total of 1,288 completed the trial, with 674 participants in the fluvoxamine group and 614 in the placebo group. The median age of the participants was 47 years, and 67% reported receiving at least two doses of the COVID-19 vaccine. The authors reported the following results:

• The median time to sustained recovery was 12 days in the fluvoxamine group and 13 days in the placebo group.
• 3.9% of the participants in the fluvoxamine group were hospitalized, had an urgent care visit, had an emergency department visit, or died through day 28 of the study compared with 3.8% of the participants in the placebo group.
• By day seven, 92.3% of the participants in the fluvoxamine group and 93.4% of the participants in the placebo group were not hospitalized and did not report any limitation of activities.
• Adverse events were uncommon in both groups.

The authors pointed to several potential reasons why their study found no therapeutic benefit to fluvoxamine compared with earlier studies. These reasons included the use of a lower dose of fluvoxamine, the timing of the trials (this trial took place during the Delta an Omicron variant surges, while other trials took place earlier in the pandemic), and differences in vaccination rates among the participants.

“In a way, the repeated study of fluvoxamine over the course of the COVID-19 pandemic brings up another issue—the need for continued study of authorized antivirals as the pandemic changes,” Adarsh Bhimraj, M.D., of Houston Methodist Hospital and Jason Gallagher, Pharm.D., of Temple University wrote in an accompanying commentary. “Drugs shown to be effective earlier in immune-naive populations and against more problematic SARS-CoV-2 variants require further study to define their role in the current landscape of COVID-19.”

For related information, see the Psychiatric News article “Antidepressants May Reduce Severity of COVID-19.”

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Buprenorphine Dispensing Rates to Youth With OUD Fell From 2015 to 2020

Despite the prevalence of adolescents and young adults with opioid use disorder (OUD), the proportion of youth aged 19 years or younger who received a prescription for buprenorphine fell by 45% between 2015 and 2020, according to a report published yesterday in Pediatrics. Over the same time, the proportion of adults aged 20 years and over who were dispensed buprenorphine increased by 47%.

Andrew Terranella, M.D., M.P.H., of the Centers for Disease Control and Prevention and colleagues noted that while just 22,000 youth aged 19 or younger received buprenorphine during the study period, an estimated 87,000 adolescents aged 12 to 17 and 227,000 young adults aged 18 to 25 have OUD. “[T]hese findings suggest that many youth who could benefit from [medications for OUD] are not receiving it,” they wrote.

The researchers analyzed data from the IQVIA National Prescription Audit New to Brand and Total Patient Tracker, which contains data on prescriptions dispensed by approximately 48,900 retail pharmacies, representing 92% of all prescriptions in the United States. They specifically focused on buprenorphine-dispensing trends in youth aged 19 or under from 2015 to 2020 and compared these dispensing trends with those of adults aged 20 or older. They also examined buprenorphine dispensing by prescriber specialty (for example, family medicine, general practice, and psychiatry).

The number of prescriptions written for youth aged 19 years or younger dropped from 68,857 in 2015 to 51,685 in 2020, a decrease of 25%.

Between 2015 and 2018, psychiatrists were the second highest prescribers of buprenorphine (prescribed 14% to 18% of prescriptions annually), trailing only family medicine physicians (prescribed 18% to 22%). The largest reductions in buprenorphine prescribing rates from 2015 to 2020 were by general practice physicians or physicians with an “unspecified specialty” and psychiatrists, with 55% and 63% reductions, respectively.

“Training more clinicians in addiction medicine and adolescent psychiatry could be important in expanding access to [medication for OUD] for adolescents, particularly for individuals with complex histories and comorbid psychiatric disorders,” Terranella and colleagues wrote. “Understanding barriers contributing to low prescribing rates by clinicians who treat youth can inform public health efforts to increase availability of [medication for OUD] in pediatric primary care settings as well as to improve linkage to care following OUD diagnosis and overdose events.”

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

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Many U.S. Medical Schools Fail to Offer 12 Weeks of Paid Parental Leave

Paid parental leave has numerous health benefits for both parents and infants, including a decrease in postpartum depression, a decrease in infant mortality, and improved parental-infant attachment. A study published Monday in JAMA Network Open suggests that many U.S. medical schools are failing to provide such leave to physicians.

“The American Academy of Pediatrics strongly supports 12 weeks of paid parental leave based on the evidence of parental and infant benefits with this duration of leave,” wrote Jessica Slostad, M.D., of Rush University Medical Center in Chicago and colleagues. “The lack of paid parental leave [is] associated with higher rates of physician burnout and work-life integration dissatisfaction and may further perpetuate sex, racial and ethnic, and socioeconomic disparities in academic medicine.”

Slostad and colleagues analyzed the parental leave policies for academic faculty in 87 of 90 medical schools that were ranked by US News & World Report from December 1, 2019, to May 31, 2020. For each medical school, the researchers recorded the total number of weeks of paid and unpaid parental leave, including any requirements to use vacation leave and/or sick leave, for birth, nonbirth, adoptive, and foster parents. The analysis revealed the following:

• 63 medical schools (72.4%) had some paid leave for birth mothers, but only 13 medical schools (14.9%) provided full pay for at least 12 weeks for the birth mother. The median duration of leave at full pay for birth mothers was 4 weeks.
• 37 medical schools (42.5%) did not provide birth mothers paid leave at full salary.
• 24 medical schools (27.6%) did not provide any paid leave for birth mothers and required that vacation, sick, and/or short-term disability leave be used to have any parental leave.

Leave policies were even more limited for nonbirth parents, as well as for adoptive and foster parents:

• For nonbirth parents, 11 medical schools (12.6%) offered at least 12 weeks of paid leave, 37 (42.5%) provided 1 to 11 weeks of paid leave, and 38 (43.7%) had no paid leave. The median duration of paid leave for nonbirth parents was 3 weeks.
• For adoptive parents, 12 medical schools (13.8%) offered 12 weeks of paid leave, 1 (1.1%) offered more than 12 weeks of adoption leave at full pay, 39 (44.8%) offered less than 12 weeks of paid leave, and 35 medical schools (40.2%) had no paid adoption leave. The median duration of paid leave for adoptive parents was 4 weeks.
• For foster parents, 6 medical schools (6.9%) offered 12 weeks of paid leave, while 65 schools (74.7%) offered no paid parental leave. The median duration of paid leave for foster parents was 0 weeks.

Slostad and colleagues concluded, “The definition of parental leave is expanding, and we call for 12 weeks of paid parental leave with policies that are clear and inclusive at the institutional, regional, and national level.”

In an accompanying editorial, Erika L. Rangel, M.D., M.S., of Massachusetts General Hospital described the need for a cultural shift in medicine: “Although legislation and policies for paid leave are important steps in the right direction, building a culture supportive of work-life integration in medicine requires not just a mandate, but a movement. … As a profession, a cultural movement in support of work-life integration must recognize that periods of additional expenditures are a long-term investment in the health, well-being, and future productivity of our workforce.”

For related information, see the Psychiatric News article “Paid Maternity Leave Improves Health, Mental Health for Both Mothers and Infants.”

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Metabolic Side Effects of Antipsychotics Vary, Meta-Analysis Finds

When it comes to the risk of metabolic side effects, not all antipsychotics are equal, suggests a meta-analysis published in World Psychiatry. The analysis revealed that patients with schizophrenia who took chlorpromazine or clozapine for more than 13 weeks experienced the most weight gain on average compared with those taking placebo.

Angelika Burschinski, M.D., of the Technical University of Munich and colleagues compiled data from 137 clinical trials that compared outcomes of patients who had schizophrenia, schizophreniform disorder, or schizoaffective disorder and took antipsychotics or placebo for more than 13 weeks. The combined sample included 35,007 participants who had taken 31 different antipsychotics (both oral and injectable) that are available in the United States and/or Europe. The researchers compared the effects of these medications on body weight as well as fasting glucose, cholesterol, and triglyceride levels.

The median age of the participants in the analysis was 39 years, and the median length of follow-up was 45 weeks. The researchers found that five antipsychotics contributed to significant average weight gain relative to placebo:

• chlorpromazine (5.13 kg, or over 11.3 lbs)
• clozapine (4.21 kg, or over 9.3 lbs)
• zotepine (3.87 kg, or 8.5 lbs)
• oral olanzapine (3.82 kg, or 8.4 lbs)
• long-acting injectable olanzapine (3.60 kg, or 7.9 lbs)

Seven other antipsychotics, including risperidone and quetiapine, were associated with average weight gains of 1 to 2 kg (2 to 4.5 lbs) over the study period.

The medications associated with the highest weight gain in participants were also associated with greater changes in glucose, cholesterol, and triglyceride levels. Olanzapine was associated with the greatest effects on glucose, total cholesterol, and LDL cholesterol; amisulpride (which led to an average weight gain of 1.43 kg, or over 3 lbs), was associated with the greatest effects on HDL cholesterol and triglycerides.

“[M]etabolic side effects of antipsychotics are likely to contribute to the average 14.5 years reduced lifespan of individuals with schizophrenia. Furthermore, weight gain is associated with decreased quality of life and treatment nonadherence, the latter resulting in poor treatment outcome and psychotic relapses,” Burschinski and colleagues wrote. “As antipsychotic drugs are often taken for long periods of time, our results represent more valuable clinical information on these health consequences than previous analyses based on short-term studies, which on average only lasted 6 weeks.”

To read more on this topic, see the Psychiatric News article “What Antipsychotic Dose Is Most Effective?”

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APA Releases Statement Following Shooting in Monterey Park

APA on Monday released a statement mourning the loss of life to gun violence in Monterey Park, Calif., on Saturday evening. “While the motive behind this horrifying act may never be clear, the [Asian American] community has endured violence and racism, particularly in the past few years. We stand in solidarity with this community,” the statement read.

Telehealth Options May Boost Number of Veterans Who Begin Treatment for Substance Use

Telehealth options may help increase the likelihood that veterans with substance use disorder (SUD) will initiate and stay in treatment, a study in the American Journal on Addictions has found. The study compared treatment initiation and retention among veterans with SUD who received telehealth referrals during the COVID-19 pandemic with that of veterans who were only referred for in-person treatment before the pandemic lockdowns began.

“Extending telehealth services as a treatment option may begin to address structural barriers to SUD care, particularly regarding the initiation in treatment among patients with SUD,” wrote Rebecca E. Sistad, Ph.D., of the U.S. Department of Veteran Affairs (VA) Boston Healthcare System and colleagues.

The researchers analyzed electronic health record data from 373 veterans between 21 and 87 years old who were referred to an outpatient alcohol and substance treatment clinic at a VA hospital. Among the veterans, 227 were referred to in-person treatment before the pandemic began and 146 were referred to telehealth treatment during the pandemic. Roughly 95% of the patients were male and roughly 87% of the patients were White.

The researchers found that approximately 58% of patients who received a referral for telehealth initiated SUD treatment, compared with just over 36% of those who received a referral for in-person treatment. After adjusting for differences in marital status, employment, and psychiatric disorder diagnoses between the groups, the researchers found that the odds of initiating treatment were 2.6 times greater when patients were referred for a telehealth appointment.

“Increasing the odds of attending just the first appointment is significant because patients were able to learn about services available and providers could link them to needed resources,” Sistad and colleagues wrote. “In addition to understanding and increasing awareness of treatment options, patients may also benefit from motivational interviewing and develop insight into their needs and strengths, to potentially increase motivation and promote treatment engagement.”

The researchers also examined the number of sessions the patients attended for four months after their first treatment session. Although the number of treatment sessions declined each month among both groups, they declined more among patients who had received in-person treatment. By the fourth month, the average number of sessions attended was significantly lower for patients who received in-person treatment compared with those who received telehealth treatment.

“Our findings add to the current literature by providing some evidence that offering the delivery of individual and group SUD treatment via telehealth may promote treatment retention and, potentially, a higher rate of attendance over time,” the researchers wrote.

For related information, see the Psychiatric News article “Telehealth Options for Treating Patients With SUD Expand.”

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Black, Native American/Alaska Native Patients Less Likely to Receive Follow-Up MH Care

Black and Native American/Alaska Native patients are less likely to attend follow-up outpatient mental health visits 30 days after discharge from hospital psychiatric units compared with White patients, according to a study published yesterday in Psychiatric Services.

“Patients who successfully transition to outpatient mental health care have a decreased risk for hospital readmission, violence, homelessness, and criminal justice involvement,” wrote Thomas Smith, M.D., of New York State Psychiatric Institute and colleagues. “However, critical disparities exist … Ethnoracially disadvantaged groups are more likely to live in communities with higher poverty levels, fewer health care providers, and greater transportation barriers that diminish access to care.”

To better understand the role of ethnoracial disparities in follow-up care after psychiatric hospitalization, Smith and colleagues analyzed data from 2012-2013 New York state Medicaid claims. The analysis included 17,488 patients who were under age 65; admitted to an inpatient psychiatric unit from 2012 to 2013 with a principal diagnosis of a mental illness; hospitalized for less than 60 days; discharged to the community; continuously enrolled in Medicaid for the 60 days after discharge; and enrolled in Medicaid before the inpatient admission. The authors looked at whether these patients attended an outpatient psychiatric service visit within seven or 30 days after their discharge. An outpatient visit was defined as a Medicaid claim for a visit at a licensed mental health outpatient setting or any outpatient service with a primary diagnosis of a mental disorder.

Further, the authors analyzed community, hospital, and patient characteristics that are believed to affect post-discharge mental health care. Some of these characteristics include rates of poverty in the community, the continuum of psychiatric services offered at the hospital, and the patient’s housing stability. They drew this data from the 2012-2013 American Hospital Association Annual Survey, the 2012-2013 Health Resources and Human Services Administration Area Resource File, and a 2012-2013 New York state managed behavioral health care organization discharge file.

Overall, 39.3% of the patients attended an outpatient mental health visit within seven days of discharge, and 60.1% of patients attended such visits within 30 days of discharge. Among Black patients, attendance was significantly lower compared with White patients, while the rate among Latinx patients did not differ significantly from that of White patients. Asian/Pacific Islander patients had the highest rate of 30-day follow-up attendance (71.9%), followed by White patients (64.1%), Latinx patients (62%), Native American/Alaska Native patients (56.2%), and Black patients (54.6%).

A community’s status as urban versus rural, as well as its poverty status, accounted for the greatest differences in follow-up attendance among the groups. Additional characteristics that were associated with lower follow-up rates included the following:

• Patients not participating in mental health care before admission.
• Patients not having an outpatient appointment scheduled during discharge planning.
• Patients being discharged from hospitals located in counties with high poverty levels or a low density of providers.
• Patients being discharged from hospitals that treat high proportions of patients with substance use disorder or who are homeless.

“Providers and policymakers need to consider important structural and cultural factors that underly social determinants of mental health and affect health care access and outcomes,” Smith and colleagues concluded.

For related information, see the Psychiatric Services article “Factors Associated With Discharge Planning Practices for Patients Receiving Inpatient Psychiatric Care.”

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Suicide Risk Higher for Some Patients Following Cancer Surgery

Some individuals who undergo surgery for cancer may be more likely to die by suicide than the general population, suggests a report in JAMA Oncology. The highest rates of death by suicide were among patients who underwent surgery for cancers of the head and neck, bladder, esophagus, and pancreas.

“Regular psychosocial distress screening of patients during preoperative evaluation and postoperative recovery and efforts to increase psychosocial support for these patients during postoperative recovery may represent possible strategies to reduce suicide risk among patients undergoing cancer operations,” wrote senior author Chi-Fu Jeffrey Yang, M.D., of Massachusetts General Hospital and colleagues.

Yang and colleagues analyzed data on cancer patients collected between 2000 and 2016 as part of the Surveillance, Epidemiology, and End Results (SEER) Program. The researchers compared the incidence of death by suicide among patients who underwent surgery for one of 15 solid-organ cancers in the United States with the incidence among the general population.

The study included 1,811,397 patients who underwent cancer surgery. During a median follow-up of 4.6 years, 1,494 of these patients (0.08%) died by suicide after surgery—a rate of death by suicide that was 1.29 times higher than the general population, when adjusted for age, sex, race, and calendar year of death. Among individual cancer types, 10 of the 15 assessed were associated with elevated suicide risk: brain, bladder, colon and rectum, esophagus, larynx, lung, oral cavity and pharynx, ovary, pancreas, and stomach.

The incidence of death by suicide was highest among patients who had undergone surgery for cancers of larynx (4.02 times higher than the general population), followed by cancers of the oral cavity and pharynx (2.43 times higher) and esophagus (2.25 times higher).

Approximately 3%, 21%, and 50% of deaths by suicide took place within the first month, first year, and first three years after surgery, respectively. Patients who were male, White, and divorced or single were at greatest risk of death by suicide.

“The findings of this study suggest that suicide is an important risk following cancer surgery and highlight the importance of improving access to support groups and implementing regular screening for distress during the postoperative period,” the authors wrote. “While screening for distress is recommended for all patients with cancer by major medical professional societies and is mandated by the American College of Surgeons Commission on Cancer, overall adherence to these recommendations has been shown to be low.”

For related information, see the Psychiatric News article “The Role of C-L Psychiatrists in Assessing Suicide.”

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Most U.S. Religious Leaders Endorse Medical Understanding of Depression, Survey Finds

By some estimates, up to 25% of people with mental illness in the United States seek help from religious leaders. What do these leaders believe about the cause and treatment of depression?

This was the question that Anna Holleman, Ph.D., and Mark Chaves, Ph.D., both of Duke University, set out to answer using the National Survey of Religious Leaders. They reported their findings in JAMA Psychiatry.

Holleman and Chaves focused specifically on the data obtained from the 890 primary leaders of religious congregations who predominantly completed the survey online between February 2019 and June 2020.

As part of the survey, respondents read a vignette describing a hypothetical congregant meeting the DSM-IV criteria for major depressive disorder.

“Respondents were asked how likely it is that this situation might be caused by chemical imbalance, genetic or inherited problem, traumatic experience, demon possession, lack of community or social support, lack of faith, and stressful circumstances in the congregant’s life,” the researchers wrote. Additionally, the respondents were “asked how likely they are to encourage this person to seek help from a mental health professional; take prescribed medication; and address the situation through prayer, scripture study, or other religious activity.” The respondents were asked about each cause and treatment separately, with the response options of not at all likely, a little bit likely, moderately likely, and very likely.

The top three causes of depression endorsed by clergy as moderately or very likely were as follows:

• Stressful circumstances (93%)
• Traumatic experiences (82%)
• Chemical imbalance (79%)

“Religious causes of depression were, by a large margin, the least endorsed by clergy,” Holleman and Chaves noted: 29% of those surveyed endorsed a lack of faith as a moderately or very likely cause of depression; 16% endorsed demon possession. “Even when clergy maintained that depression has a religious cause, they mainly combined that religious interpretation with a medical one.”

Most of the religious leaders indicated that they would be moderately or very likely to encourage a congregant with depression to seek help from a mental health professional (90%) and take prescribed medications (87%). Most leaders (84%) also said they would encourage the congregant to pray, study scripture, and participate in other religious activities.

“Religious leaders were much more likely to encourage a religious treatment for the depressive symptoms than they were to endorse a religious cause, but relatively few would encourage only a religious treatment,” the authors wrote. “These results suggest that medical professionals should view the vast majority of religious leaders as allies in identifying and properly treating depression.”

For related information, see the Psychiatric News article “Partnership Between Psychiatrists, Faith Leaders Untapped Key to Expanding Reach of MH Care.”

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Hospitalization With Infection Linked to Dementia Later in Life

People who are hospitalized with infection may have a greater risk of developing dementia later in life, a study in JAMA Network Open has found. The highest rates of dementia were found among people who had previously been hospitalized with respiratory, urinary tract, skin, blood and circulatory system, or hospital-acquired infections.

Ryan T. Demmer, Ph.D., M.P.H., of the University of Minnesota School of Public Health and colleagues analyzed data from 15,688 people who enrolled in the Atherosclerosis Risk in Communities (ARIC) study between 1987 and 1989. The participants had a mean age of 54.7 years at enrollment and were followed up a maximum of 32 years through 2019.

During the follow-up, 19% of the participants received a diagnosis of dementia. There were 23.6 diagnoses of dementia per 1,000 person-years in participants who had been hospitalized with infection, compared with 5.7 diagnoses of dementia per 1,000 person-years in participants who had not been hospitalized with infection. This represents a 70% increase in risk of developing dementia for participants who had been hospitalized with infection, the researchers wrote.

Although the study was not designed to tease out why infection appeared to increase dementia risk, the researchers noted several possible reasons.

“[B]lood and circulatory system infections could impact dementia risk because of the brain’s high vascularity, whereas urinary tract infections could be more likely to lead to sepsis or bacteremia,” they wrote. “In addition, there is substantial evidence that infections increase risk for vascular and metabolic illnesses known to be factors associated with increased risk of dementia, such as stroke, heart failure, coronary heart disease, and diabetes.”

Demmer and colleagues wrote that future research should consider whether noting a history of infections in dementia screening could improve identification of preclinical dementia.

“More importantly, our findings could inform approaches to mitigate or prevent dementias through accounting for the deleterious effects on cognitive and neurological health accrued throughout the lifetime due to infections and hospitalizations,” they concluded.

For more information, see the Psychiatric News article “COVID-19 Takes Cognitive Toll on Older Patients.”

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Ecopipam May Reduce Tics in Children With Tourette Syndrome

Youth with Tourette syndrome who take ecopipam (a selective dopamine 1 receptor antagonist) may experience a decrease in tics, suggests a study published yesterday in Pediatrics. The study was funded by Emalex Biosciences, which is developing ecopipam.

“Treatment decisions for [Tourette syndrome] require an assessment of disease severity and burden, comorbid conditions, and the concerns of patients and their caregivers regarding the cost, time, and side effects of treatments,” wrote Donald Gilbert, M.D., M.S., of Cincinnati Children’s Hospital Medical Center and colleagues. Most medications approved by the Food and Drug Administration for Tourette syndrome are antipsychotics, the authors noted, and “their use is limited by the risk of weight gain, metabolic changes, and drug-induced movement disorders.”

Gilbert and colleagues recruited participants aged 6 to 17 from 68 sites in the United States, Canada, Germany, France, and Poland between May 2019 and September 2021. All participants had Tourette syndrome and a minimum score of 20 on the Yale Global Tic Severity Score, Total Tic Score (YGTSS-TTS), on which a higher score indicates a more severe tic. Further, all participants experienced tics of sufficient severity to result in subjective discomfort, sustained social problems, emotional problems, and/or functional interference with daily activities.

Following a 28-day screening period and a baseline visit, participants were randomly assigned to receive either ecopipam or a matching placebo for a 4-week titration period followed by an 8-week treatment period. Ecopipam dosages were adjusted based on the participants’ weight, with doses ranging from 37.5 mg to 200 mg as a single nightly dose. At the end of the treatment period, participants were titrated off either ecopipam or the placebo at a rate of 25 mg per day. The authors assessed participants at weeks 4, 6, 8, and 12, then conducted follow-up visits at 7, 14, and 30 days after the participants’ last dose of medication.

A total of 153 participants were randomized to either the ecopipam group (n=76) or the placebo group (n=77). There was a statistically significant improvement in YGTSS-TTS scores among participants in the ecopipam group compared with those of participants in the placebo group. There was a 30% reduction from baseline to week 12 in YGTSS-TTS scores among participants in the ecopipam group, with the authors observing a significant benefit at the first evaluation (week 4), which then was sustained across all visits.

The majority of adverse experiences reported in both groups were mild to moderate during the study, with the most common including headaches, insomnia, fatigue, and somnolence. At week 12, mean body weight increased from baseline by about 4 pounds in the ecopipam group and over 5 pounds in the placebo group.

“Ecopipam may be a safe and effective treatment of [Tourette syndrome] with advantages over other currently approved therapeutic agents,” the authors concluded.

For related information, see the Psychiatric News article “‘Outbreak’ of Sudden Tics Among Teen Girls Has Surprising Global Similarity.”

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Cognitive Deficits in Early Childhood Linked to Later Psychotic Experiences

Children with a family history of schizophrenia who have early deficits in “set shifting”—the ability to fluidly move from one cognitive task to another—appear to be at increased risk for psychotic experiences in later childhood compared with children who have similar deficits but no family history of schizophrenia, according to a report in Schizophrenia Bulletin.

Psychotic experiences are subclinical hallucinations and delusions that may occur without a diagnosable psychotic disorder. “Psychotic experiences … are associated with an elevated risk of subsequent psychotic and nonpsychotic disorders,” wrote Christina Bruun Knudsen, M.A., and Nicoline Hemager, Ph.D., both of Aarhus University in Denmark and colleagues.

The researchers assessed neurocognition in 449 children aged 7 years who were participants in the Danish High Risk and Resilience Study—a prospective cohort study of children who have at least one biological parent with a schizophrenia spectrum diagnosis, bipolar disorder, or neither diagnosis. Neurocognitive assessments included tests of verbal and nonverbal intelligence, processing speed, sustained attention, verbal memory, visuospatial memory, working memory and set shifting.

The children were later assessed for psychotic experiences using a structured interview, first with the primary caregiver and then with the child at age 11. The interview inquired about five types of hallucinations and 13 types of delusions. If the children reported hallucinations and/or delusions, they were then asked additional questions, including the frequency and duration of these events.

Across all three groups, poor visuospatial memory and working memory “was associated with a modest, but significant, increased risk of psychotic experiences,” Knudsen, Hemager, and colleagues wrote. Children who had a family history of schizophrenia had an almost twofold increase in psychotic experiences during childhood despite similar neurocognitive performance on several domains compared with children who had a family history of bipolar disorder and children with no family history of either disorder. However, deficits in set shifting tests at age 7 among children with the family history of schizophrenia stood out as a particular risk for later psychotic experiences.

“Set-shifting or cognitive flexibility denotes the mental ability to appropriately and flexibly adjust one’s thinking and behavior in accordance with changes in the environment,” the authors wrote. “Whether such associations during childhood have implications for conversion to psychosis in adolescence and adulthood requires further research.”

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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COVID-19 Public Health Emergency Extended Again

The Department of Health and Human Services has renewed the public health emergency until April 11 due to the continued consequences of COVID-19. States will be given 60 days’ notice before termination of the public health emergency. The public health emergency was initially declared in January 2020, when the coronavirus pandemic began.

Inflation Worries Loomed Large for Americans in 2022, APA Poll Finds

Americans reported feeling anxious about many things in 2022, but one issue stood out above the rest: inflation.

This trend was brought to light by an analysis of six months of data collected by APA’s Healthy Minds Poll, which included a question each month from June through December on how anxious Americans felt about a list of current events. The polls were fielded online by Morning Consult to a group of more than 2,000 American adults.

“Americans are dealing with many stressors all at the same time,” APA President Rebecca W. Brendel, M.D., J.D., said in an APA news release. “Inflation directly affects people every day in every aspect of our lives, and there is little respite. It’s no surprise that it is causing so much stress as Americans struggle to make ends meet.”

When asked whether each of a series of eight current events made them somewhat or very anxious, respondents ranked these as their top issues:

• Inflation (ranged from a low of 79% to a high of 87%).
• Recession (ranged from 49% in June to 77% in July and continued at a high ranking).
• Gun violence (ranged from a low of 65% to a high of 70%).

Other issues about which respondents felt anxious included the following:

• Climate change (from 52% to 60% overall; Black and Hispanic Americans tended to report even higher levels of anxiety about climate change).
• Future of reproductive rights (from 48% to 56% overall; Black Americans tended to report even higher levels of anxiety over the future of reproductive rights).

Overall, anxiety about COVID-19 has been declining, from 54% of respondents reporting feeling anxious about the pandemic in August to 42% in December.

“Six months of polling on these current events has helped us understand and communicate the stress points that continuously impact Americans,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We hope that by acknowledging that these issues are causing anxiety, those that are impacted will know that they are not alone and that help is available.”

For more Psychiatric News coverage of the APA polls, see “More Americans Rate Their Mental Health Worse Compared With a Year Ago, Poll Finds” and “Nearly 1 in 3 Americans Anticipates More Stress Over Holidays This Year.”

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FDA Approves Second Monoclonal Antibody Medication for Alzheimer’s

The Food and Drug Administration (FDA) on Friday approved lecanemab for the treatment of Alzheimer’s disease. Lecanemab (brand name Leqembi) is the second monoclonal antibody approved for Alzheimer’s that targets a biological component of the disease. The approval of the other monoclonal antibody called aducanumab (Aduhelm) in 2021 was met with some controversy. Both medications attach to amyloid proteins in the brain and prevent the formation of amyloid plaques, which are associated with Alzheimer’s.

Lecanemab was approved under the FDA’s accelerated approval pathway, which expedites the approval of medications for life-threatening illnesses by allowing companies to use surrogate endpoints (in this case amyloid buildup) rather than wait potentially years before clinical benefits become evident. According to the drug label, lecanemab should be initiated in individuals with mild cognitive impairment or mild dementia.

“Alzheimer’s disease immeasurably incapacitates the lives of those who suffer from it and has devastating effects on their loved ones,” said Billy Dunn, M.D., director of the FDA Office of Neuroscience in a news release by the FDA. “This treatment option is the latest therapy to target and affect the underlying disease process of Alzheimer’s, instead of only treating the symptoms of the disease.”

Lecanemab’s efficacy was demonstrated in a phase 3 clinical trial of 1,795 participants whose results were recently published in the New England Journal of Medicine. Adults aged 50 to 90 with mild cognitive impairment or mild dementia and amyloid buildup (confirmed via a PET scan or cerebrospinal fluid testing) were randomly assigned to receive lecanemab (10 mg/kg) or placebo infusions every two weeks for 18 months.

After 18 months, the adults who received lecanemab showed significant reductions in amyloid buildup relative to those who received placebo, as well as slightly slower declines in cognitive performance. For example, average Clinical Dementia Rating–Sum of Boxes (CDR-SB) scores rose by 1.21 points in the lecanemab group compared with 1.66 points in the placebo group.

The participants who received lecanemab experienced a higher rate of adverse events compared with those who received placebo. Infusion-related side effects such as nausea or vomiting occurred in 26.4% of lecanemab participants compared with 7.4% of placebo participants. Additionally, amyloid-related imaging abnormalities (known as ARIAs)—which may indicate swelling or bleeding in the brain—occurred in 21.5% of lecanemab participants compared with 9.5% of placebo participants.

Kostas Lyketsos, M.D., the Elizabeth Plank Althouse Professor for Alzheimer’s Research at Johns Hopkins Medicine, said that the approval of lecanemab is a positive development, but far from a breakthrough given the modest cognitive benefits, side effects associated with the medication, and high cost ($26,500 for a year). However, he noted that the approval may lead Eisai and Biogen (developers of lecanemab) to design trials exploring whether the medication might prevent or slow cognitive impairment in adults with amyloid buildup but no other symptoms.

Additional coverage of the drug’s approval will appear in Psychiatric News.

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Past Incarceration Linked to Increased Mental Health Risk, Heavy Drinking in Older People

Past incarceration may raise the risk of cognitive impairment, mental health conditions, and heavy drinking in older people, a study published today in JAMA Network Open suggests.

Ilana R. Garcia-Grossman, M.D., of the University of California, San Francisco, and colleagues analyzed data from 13,462 community-dwelling adults aged 50 years or older who participated in the Health and Retirement Study (HRS) in 2012 or 2014. The HRS is a longitudinal survey of adults in which participants are asked about their economic, health, and psychosocial well-being. The participants were considered to have mental health conditions if they had been told by a physician that they have any emotional, nervous, or psychiatric problem. The participants were considered to have cognitive impairment if they had been told by a physician that they have Alzheimer disease, dementia, senility, or serious memory impairment. Garcia-Grossman and colleagues defined self-reported heavy alcohol use as drinking more than four alcoholic drinks daily.

Among the 13,462 participants, 946 (7.6%) reported having been incarcerated at some point in their lives. Those who had been incarcerated had a mean age of 62.4 years versus 66.7 years for those who had not been incarcerated and were more likely to be male, Black, or Latinx or in the lowest quartile of wealth (total assets and debts).

After adjusting for the participants’ age, sex, race and ethnicity, wealth, educational attainment, and uninsured status, the researchers found that those who had been incarcerated had an 80% higher risk of having cognitive impairment or a mental health condition and a 113% higher risk of heavy alcohol use than participants who had not been incarcerated. Participants who had been incarcerated also had a higher risk of having hearing impairment, chronic lung impairment, mobility impairment (for example, using a cane or walker), and impairment in activities of daily living (for example, difficulties taking medications and shopping for groceries).

“It is possible that people who experience incarceration have worse baseline health before they enter jail or prison that persists into older age following incarceration,” Garcia-Grossman and colleagues wrote. “Additionally, exposure to incarceration may exacerbate poor health outcomes through exposure to trauma and violence, acute and chronic stress from living in dehumanizing conditions, and/or variable access to healthy food, physical activity, and high-quality health care.”

The researchers added that it is also possible that incarceration has a negative impact on social determinants of health such as employment or housing.

“These findings suggest that attention to incarceration history may be valuable for understanding and mitigating health risks in older age,” the researchers concluded.

For related information, see the Psychiatric Services article “Mental Health in the Era of Mass Incarceration.”

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Physical Activity Found Effective for Reducing Depression Symptoms in Youth

Aerobic physical activity may be associated with reduced depressive symptoms in children and adolescents, especially among teens over age 13, according to a study published this week in JAMA Pediatrics.

“There is an urgent need to explore novel treatment approaches that can be safely, feasibly, and widely implemented in the daily routine of children and adolescents with depression,” wrote Francesco Recchia, M.Sc., of the University of Hong Kong and colleagues. “The findings of this systematic review and meta-analysis strengthen the role of physical activity for depressive symptom management and highlight the potential of structured physical education programs in primary and secondary schools for improving the mental health of children and adolescents.”

Recchia and colleagues analyzed randomized clinical trials published in PubMed, CINAHL, PsycINFO, EMBASE, and SPORTDiscus. The researchers specifically focused on studies that investigated the effects of interventions that involved aerobic physical activity on depressive symptoms in children and adolescents aged 18 years and younger. Aerobic physical activity was defined as “an activity in which the body’s large muscle groups move in a rhythmic manner for a sustained period of time.” The interventions lasted four or more weeks and could be implemented alone or alongside treatment as usual, an educational component, or participants’ current physical education routine. The studies also included a control condition in the form of no treatment, waiting list, or treatment as usual.

Twenty-one studies with a total of 2,441 participants were included in the meta-analysis. Physical activity interventions were associated with a reduction in depressive symptoms compared with the control condition. The interventions resulted in greater benefits among participants aged 13 years or older, and among those with a mental illness and/or depression diagnosis. There was no association between physical activity and depressive symptoms at follow-up in the four studies that analyzed this association. The authors suggested this may be due to the small number of studies that investigated follow-up outcomes.

Further, interventions that were shorter than 12 weeks and those that included three physical activity sessions a week had greater benefits on participants’ depressive symptoms compared with interventions of other frequencies and durations. The authors noted that this finding is reflected in the results of similar meta-analyses on the association between physical activity and depressive symptoms, “suggesting that increasing amounts of physical activity may not translate into greater reductions in depressive symptoms.” More research is needed, they continued, to establish the optimal timing of physical activity to manage depressive symptoms.

“Physical activity is remarkable medicine,” wrote Eduardo Bustamante, Ph.D., of the University of Illinois Chicago and colleagues in an accompanying commentary. “[T]he systematic review and meta-analysis by Recchia et al. is part of a potential watershed moment for the field. The evidence that physical activity is effective medicine for mental health is robust; now we need to find ways to get people to take it.”

For related information, see the Psychiatric News article “Physical Activity May Lower, Prevent Depression.”

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Youth Who Threaten Violence at School May Have Psychiatric, Learning Problems

Youth who make threats of violence against others at school often have a range of psychiatric and learning disorders, according to a report in the Journal of the American Academy of Child & Adolescent Psychiatry. Also, many of these youth report having been bullied, and more than half have a history of traumatic family events.

“Evaluations of youths who make threats need to go beyond simply assessing the threat itself and should include identifying underlying psychiatric problems,” wrote Deborah M. Weisbrot, M.D., of Stony Brook University Medical Center and colleagues. “Psychiatric evaluation of students who issue threats of any type can lead to revelations about psychiatric diagnoses and crucial treatment and educational recommendations.”

Weisbrot and colleagues reviewed the records of children and adolescents referred by school staff for threat assessment evaluations between 1998 and 2019 to the Stony Brook University Child and Adolescent Outpatient Clinic. The clinic serves over 19 school districts with youth from diverse socioeconomic backgrounds across eastern Long Island.

The researchers defined a “threat” as an expression of intent to do harm or act out violently against someone or something. Threats were categorized as being either verbal or nonverbal (such as violent drawings), as well as those that involved bringing a weapon to school.

The study sample included 157 youth aged 5 to 18 years (average age, 13 years); 51.6% were receiving special education services. Eighty percent of students had made a verbal threat, and 29.3% had brought a weapon to school. About 50% had a history of medication treatment, and 36.3%, psychotherapeutic intervention.

Each student received a psychiatric evaluation with a systematic, semistructured interview, which also included discussions with the student, school faculty, and the student’s guardian. Here are some of the findings:

• 89.8% reported a history of trauma, such as bullying, teasing, physical or sexual abuse, a traumatic family event (such as the death of a loved one), and/or severe parental discord and/or divorce.
• 26.8% reported severe teasing or bullying during the academic year when the threat was made.
• 66.9% were diagnosed with ADHD (the most common of the diagnoses among the youth). Other diagnoses included learning disorders in 28.7%, depressive disorders in 26.8%, oppositional defiant disorder in 24.2%, and anxiety disorders 22.9%. The most common comorbidities in the youth were ADHD plus learning disorder, oppositional defiant disorder, depression, or anxiety.
• 88.5% received recommendations for psychiatric medication, including stimulants (63.1%), antidepressants (26.1%), and antipsychotics/mood stabilizers (23.3%). 70.1% received recommendations for psychotherapy and medication.
• Students with a prior threat history or with paranoid symptoms were more than five times as likely to be recommended for a therapeutic school settings or psychiatric hospitalization.

“School-based threat assessment teams are essential to the evaluation of student threats. Close collaboration between the psychiatric clinician and the school-based threat assessment team and school administrators enhances effective threat assessment,” the authors wrote. “We found that even among those who made relatively minor threats, … there were often major underlying psychiatric disorders. Formal psychiatric evaluations of all students who issued threats were invaluable in discovering crucial treatable psychiatric conditions.”

For related information, see the Psychiatric News article “Threat Assessment Can Help Prevent School Violence, but Reliance on a ‘Profile’ Doesn’t Work.”

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