Moderated Online Postpartum Group May Help Moms With Postpartum Depression

Postpartum depression—which can disrupt the forming of bonds between a mother and child—is estimated to impact between 12% and 24% of women following the birth of a child. A study in Pediatrics now suggests that women with postpartum depression who participate in a parenting program via Facebook may experience more rapid symptom improvements than those who do not participate in such a program. However, participation in the parenting program via Facebook may not impact parenting stress or responsiveness.

“Our study is among the first to examine the effects of a parenting program administered through a social media platform,” wrote James P. Guevara, M.D., M.P.H., of Children’s Hospital of Philadelphia and colleagues. “Social media may be an important platform to provide parenting support for women with [postpartum depression] symptoms when in-person participation is difficult … .”

Guevara and colleagues recruited mothers over age 18 years who screened positive for minor to moderate depression symptoms on the Edinburgh Postnatal Depression Scale (EPDS=10-19). To be included in the study, mothers were also required to read and write in English and have access to a smartphone or tablet. Seventy-five women were randomized into one of two groups for the three-month study: One group was invited to participate in the Parenting With Depression secret Facebook group and an online cognitive-behavioral therapy (CBT) program called MoodGym; the other group was invited to participate in MoodGym only. Participants in both groups also received a list of community mental health resources.

The Parenting With Depression intervention consisted of eight weekly topics (for example, psychoeducation and parent-child interactions), released in three separate posts to the Facebook group over the course of the week. The posts included videos, narrated PowerPoint presentations, and written materials. Participants were encouraged to “friend” other group members and respond to their posts. A facilitator reviewed posts, commented on posts, and provided tips for group members.

Study participants were evaluated monthly using the EPDS. Additionally, at the start of the study and again three months later, the participants were assessed on their levels of stress, parent-child interactions, parenting self-esteem, and more. Women whose EPDS scores exceeded 20 or who reported suicidality were contacted by a psychologist to assess risk; those deemed to be at high risk were referred for further care and were excluded from further participation in the study.

Participants assigned to the Facebook group intervention experienced a more rapid decline of depressive symptoms than those assigned to online CBT only, with differences between the two groups emerging at one month. While both groups demonstrated what the authors termed “modest improvements in responsive parenting,” there was no difference between the two groups on this measure over time.

Guevara and colleagues noted that the data were collected during “the height of the COVID-19 pandemic,” which may have led to less engagement with the Facebook group intervention. “Only 9 (28%) of the intervention group participants viewed and posted comments to at least one-third of the weekly content,” they wrote. “[W]e found that women who engaged this much had greater improvements in responsive parenting than those with less engagement. This suggests that passively viewing content is not as helpful as engaging in the exercises and interacting with other participants and the study facilitator.

They concluded, “[G]reater attention to participant engagement and ensuring and accounting for mental health treatment are needed to improve parenting outcomes with social media-based parenting programs.”

For related information, see the Psychiatric News article “Women With Postpartum Depression May Benefit From One-Day Online Workshop.”

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APA Releases Revamped Practice Guideline on Eating Disorders

APA has released an updated practice guideline on how to assess and treat patients with eating disorders—the first full update since 2006. The fourth edition of APA’s Practice Guideline for the Treatment of Patients With Eating Disorders reflects numerous new research findings since 2006 as well as diagnostic changes following the publication of DSM-5 in 2013 and DSM-5-TR in 2022.

“Eating disorders often are unrecognized and untreated,” noted Catherine Crone, M.D., chair of the practice guideline writing group, in an APA press release. “This guideline and supplementary resources are intended to serve as a practical tool for clinicians to help with screening, diagnosis, and providing evidence-based treatment for eating disorders.”

The updated guideline includes 16 clinical recommendations or suggestions related to anorexia nervosa, bulimia nervosa, and binge-eating disorder, including:

• Screening for the presence of an eating disorder as part of an initial psychiatric evaluation.
• Conducting comprehensive patient evaluations, including laboratory tests such as electrocardiograms.
• Formulating patient-centered and culturally sensitive treatment plans.
• Setting individualized weight goals for patients with anorexia.
• Treating patients with anorexia, bulimia, or binge-eating disorders with eating disorder–focused psychotherapy.
• Including family-based therapy as part of a treatment plan for adolescents with anorexia or bulimia.

The guideline also includes information on how to of evaluate patients for avoidant/restrictive food intake disorder (ARFID), which was added to DSM-5; however, due to limited clinical data, there are no specific recommendations for how to treat patients with ARFID.

To provide additional assistance to health professionals, APA has developed supplemental materials, such as a clinician pocket guide and an online course designed to introduce learners to concepts in the new guideline. Soon to be released are a guide for patients/families and an interactive clinical decision support tool.

“Early identification and treatment of an eating disorder is critical for achieving positive long-term outcomes,” said Joel Yager, M.D., a professor emeritus of psychiatry at the University of Colorado School of Medicine and the chair of the writing group for the three previous editions of the eating disorders practice guideline. “We hope that this tool will help anyone make an informed diagnosis regardless of their previous experience with eating disorders.”

To read more on this topic, see the Psychiatric News article “Special Report: Youth With Eating Disorders—Time Is of the Essence in Achieving Remission.”

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Youth With Anxiety May Experience Worsening Symptoms After COVID-19

Youth with anxiety disorders who contract COVID-19 may experience worsening anxiety symptoms, suggests a small study reported in a letter in the Journal of the American Academy of Child & Adolescent Psychiatry.

Jeffrey R. Strawn, M.D., of the University of Cincinnati and colleagues analyzed data collected from a longitudinal study of adolescents aged 12 to 17 who had been diagnosed with primary anxiety disorders and were being treated with duloxetine or escitalopram. At the start of the study in December 2019, these youth participated in weekly follow-up visits, where they were evaluated using several measures, including the Generalized Anxiety Disorder-7 (GAD-7) and Clinical Global Impression-Severity (CGI-S) scales.

Strawn and colleagues focused their analysis on data obtained from 26 patients who were about 14 years old and had been evaluated weekly for 7 to 96 weeks. All patients met criteria for generalized anxiety disorder, 19% had separation anxiety disorder, 78% had social anxiety disorder, 30% had panic disorder, 26% had ADHD, and 37% had a history of a depressive disorder. All patients were treated with either duloxetine (30-120 mg/day) or escitalopram (5-20 mg/day) at the start of the study.

The researchers examined 1,308 weeks of data—including 1,019 patient-weeks from patients who did not contract COVID-19, 289 patient-weeks from patients with COVID-19 infection, and 139 patient-weeks post-COVID-19. All patients with COVID-19 were unvaccinated and experienced mild symptoms, the researchers noted.

The researchers found that post-COVID-19, patients’ anxiety symptoms were significantly worse on all GAD-7 subscales (including feelings of nervousness, irritability, and dread) and the CGI-S scale.

“Adolescents with more severe anxiety may experience greater or more severe long COVID symptoms or COVID-19–related worsening anxiety may potentiate long COVID symptoms,” Strawn and colleagues wrote. “Ultimately, understanding the neuropsychiatric effects of COVID-19 and long COVID … may inform novel treatments or optimization of existing interventions.”

For related information, see the Psychiatric News article “Psychological Stress May Not Be Only Route Of COVID-19’s Psychiatric Burden.”

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How Will End of PHE Impact You? Practice Management Helpline Wants to Know

The COVID-19 Public Health Emergency (PHE) will end on Thursday, May 11. APA wants to hear from you on how this change might affect your practice and your patients. Please email the Practice Management Helpline at practicemanagement@psych.org with a short description about how the requirement to have an in-person visit with a patient to prescribe controlled substances, the requirement to have a DEA license in any state in which you are prescribing controlled substances, and/or how the controlled substances shortages are affecting your practice. By sharing your story, we may use de-identified information in our advocacy efforts. Please let us know if you would be comfortable if we contacted you for more information.

Prazosin May Reduce Drinking in Some Individuals With AUD

Prazosin—a medication commonly used to treat high blood pressure—may also reduce drinking by adults with alcohol use disorder (AUD), according to a clinical trial involving active-duty military appearing in Alcohol: Clinical and Experimental Research. Adults with elevated heart rate or blood pressure seemed to benefit the most from this medication.

Murray Raskind, M.D., of the VA Puget Sound Health Care System and colleagues enrolled 102 active-duty soldiers (95% male) who were participating in a mandated Army outpatient alcohol treatment program. All participants had to be in good overall health, meet DSM-IV criteria for alcohol abuse or dependence, and be free of any psychotic or manic symptoms and any other substance use disorder except nicotine. The participants were randomized to receive 13 weeks of prazosin (titrated up to 20 mg daily) or placebo. For the first nine weeks, the participants were in the outpatient alcohol treatment program while also taking the medication; for the final four weeks, the participants received only the medication.

After nine weeks, the soldiers who were taking prazosin reported significantly less drinking from baseline than those who were taking placebo, quantified in standard drinking units (0.6 ounces of pure alcohol) per day. After 13 weeks, drinking levels remained lower in the prazosin group relative to placebo, though the difference was no longer statistically significant. There were also no significant differences in the number of drinking days or alcohol craving scores between the groups at 9 or 13 weeks.

Raskind and colleagues next analyzed the data by subgroups. They found that participants with comorbid AUD and posttraumatic stress disorder (n=48) who were taking prazosin reported statistically fewer cravings than those taking placebo after 13 weeks. Likewise, participants with an elevated standing heart rate (≥ 90 beats per minute) or systolic blood pressure (≥ 130 mmHg) in the prazosin group had statistically fewer drinks and fewer drinking days (both almost at zero) than those in the placebo group. The benefits of prazosin relative to placebo were more evident in these participants between weeks 9 and 13.

“[T]he greater clinical impact of prazosin in the last 4 weeks of the current trial that followed completion of formal alcohol treatment program participation suggests potential benefit of prazosin for alcohol relapse prevention,” Raskind and colleagues wrote. “These observations provide rationale for an extended-duration prospective relapse prevention [trial] of prazosin in … persons with AUD who have recently achieved abstinence but continue to experience alcohol withdrawal signs and symptoms and/or elevated cardiovascular parameters.”

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

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Memantine May Reduce Symptoms of Hair-Pulling, Skin-Picking Disorder

Patients with trichotillomania (also known as hair-pulling disorder) and/or excoriation (skin-picking) disorder may experience symptom improvements while taking the Alzheimer's medication memantine, a report published today in AJP in Advance suggests.

Trichotillomania and excoriation disorder are characterized by repetitive behaviors focused on the body and intrusive urges that are believed to be driven in part by the glutamate system. Memantine, which is approved by the FDA for moderate to severe Alzheimer’s disease, works by regulating the activity of glutamate.

To test the safety and effectiveness of memantine compared with placebo in patients with trichotillomania and/or excoriation disorder, Jon E. Grant, M.D., M.P.H., of the University of Chicago and colleagues recruited 100 adults (86 women, average age 31 years) with a current primary DSM-5 diagnosis of trichotillomania (n=53), excoriation disorder (n=43), or both (n=4). These participants were assigned to either memantine or placebo for eight weeks. Those in the memantine group were started on 10 mg/day; the dosage was increased to 20 mg/day at week two for the remaining six weeks.

Grant and colleagues evaluated the participants using the NIMH Trichotillomania Symptom Severity Scale—a 6-item, 20-point scale that assesses the frequency of pulling and/or picking, intensity of urges, subjective distress, and interference in daily activities—every two weeks for eight weeks. The researchers also used the Sheehan Disability Scale and Clinical Global Impressions (CGI) severity scale to evaluate the participants’ functioning and other symptoms, respectively.

At baseline, the participants’ average NIMH Trichotillomania Symptom Severity Scale score was 12. After two weeks, the participants in the memantine group experienced about a 4-point drop in their severity scores, compared with a less than 2-point decrease in severity scores the placebo group. Scores in the memantine group continued to gradually decline over the next six weeks, whereas the placebo group saw no further improvement.

At the end of the study, 60.5% of participants in the memantine group were “much or very much improved,” compared with 8.3% in the placebo group, based on the CGI scale. Six participants in the memantine group (10.9%) stopped pulling/picking completely by the end of the trial, whereas only one (2.2%) of the participants in the placebo group achieved complete symptom remission.

The authors noted that cognitive-behavioral therapy (CBT) has shown benefit for trichotillomania and skin-picking disorder and should be considered in conjunction with medication.

“Memantine constitutes a promising treatment option for trichotillomania and skin-picking disorder—conditions that have a relative paucity of evidence-based pharmacological intervention options,” Grant and colleagues concluded. “[W]hether some individuals would have responded to a higher dosage [of memantine] merits further evaluation.”

For related information, see The Journal of Neuropsychiatry and Clinical Neurosciences article “An fMRI Pilot Study of Cognitive Flexibility in Trichotillomania” and the Psychiatric News article “N-Acetylcysteine May Help Patients Resist Urge to Pick Skin.”

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FDA Advisory Panel Recommends Approval for Over-the-Counter Narcan

Last week the U.S. Food and Drug Administration (FDA) Nonprescription Drugs Advisory Committee and the Anesthetic and Analgesic Drug Products Advisory Committee voted unanimously, 19-0, to recommend that Narcan (naloxone HCl) 4 mg nasal spray be made available without a prescription, Emergent BioSolutions announced. The medication reverses an opioid overdose by blocking the effects of opioids.

The FDA is not bound by the committees’ guidance but will take their advice into consideration when it makes its decision on whether to make the drug available over the counter (OTC). If approved, Narcan would be the first OTC naloxone product. The FDA’s decision is expected by March 29.

The recommendation comes after Emergent presented an overview of its OTC development program, medical need, human factors study data, and seven years of postmarketing safety data.

“Bystanders are present at nearly half of fatal overdoses, yet naloxone is administered in only a small percentage of those cases,” said Joshua Lynch, D.O., E.M.T.-P., of the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, in the announcement. “The reality is accidental overdoses can happen to anyone, anywhere, at any time, and we can all do our part by being prepared to help like we would in any other emergency. With access to over-the-counter naloxone, we would have a critical opportunity to close this gap and reduce the number of opioid-related deaths.”

According to a report in STAT, while Narcan’s cost varies widely, a two-pack of 4 mg spray typically costs between $35 and $65.

The report also noted that although the committee’s vote was unanimous, the FDA’s scientific advisors and agency leaders criticized Emergent, noting that the company’s user-friendliness tests did not include time limits and included language that may have yielded misleadingly low rates of user error. Such errors included spraying naloxone into the air rather than into the nostril of the person who overdosed and failing to wait the recommended two to three minutes between doses if the person remains unresponsive. Some of the company’s study groups also failed to include significant numbers of limited-literacy participants. However, the panel felt that the urgent need for overdose treatment amid the current opioid crisis outweighed these criticisms.

In December, the FDA accepted for priority review a New Drug Application (NDA) for Harm Reduction Therapeutics Inc.’s OTC RiVive (3.0 mg intranasal naloxone) for the emergency treatment of opioid overdose. The company submitted the NDA after the FDA encouraged pharmaceutical companies to develop new nonprescription naloxone products. Harm Reduction Therapeutic Inc. said that it expects to learn the FDA’s decision on approval by the end of April.

For related information, see the Psychiatric News articles “Naloxone Prescription Fills Inch Upward, But Remain Low Overall” and “Naloxone Costs Rise for Uninsured Patients.”

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APA Announces Results of 2023 Election

At its meeting on February 16, APA’s Committee of Tellers approved the following results for APA’s 2023 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting on March 11 and 12.

President-elect
Ramaswamy Viswanathan, M.D., Dr.Med.Sc.

Secretary
Gabrielle L. Shapiro, M.D.

Minority/Underrepresented Representative Trustee
Kamalika Roy, M.D., M.C.R.

Area 2 Trustee
Kenneth B. Ashley, M.D.

Area 5 Trustee
Heather Hauck, M.D.

Resident-Fellow Member Trustee-Elect
Sarah El Halabi, M.D., M.S.

“I am honored that my colleagues in psychiatry have elected me to the APA presidency,” said Viswanathan in a news release. “I look forward to working together to further develop and expand our workforce and to keeping up our momentum on research and development of cutting-edge psychopharmacologic, neuro-interventional, and psychotherapeutic treatment and preventive approaches. We will also work together to advance physician wellness, reduce practice burdens, advocate for our patients and our profession, address inequities in health care, and promote appreciation of diversity and inclusion.”

“Congratulations to Dr. Viswanathan and the other candidates on their election,” said APA President Rebecca Brendel, M.D., J.D. “I look forward to working with him and all the newly elected APA leaders to advance psychiatric practice and APA’s leadership role in increasing access to care and improving the quality of mental health care.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., echoed those sentiments. “APA members and the profession of psychiatry will be well served by Dr. Viswanathan’s leadership and commitment. I want to congratulate Dr. Viswanathan and all the newly elected APA leaders.”

Viswanathan’s term as president-elect of APA will begin in May at the conclusion of the APA Annual Meeting, when current President-Elect Petros Levounis, M.D., M.A., begins his one-year term as president. The other winners will also take office at that time.

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VA, DoD Recommend Buprenorphine Over Full Agonist Opioids for Chronic Pain

In their most recent guideline on the use of opioids to manage chronic pain, the U.S. departments of Veterans Affairs (VA) and Defense (DoD) recommend against using full agonist opioids (for example, morphine) for patients who require daily pain management. Rather, the guideline, which was approved in May 2022, recommends using buprenorphine for patients who require long-term opioid therapy. The guideline was summarized in a report published this week in the Annals of Internal Medicine.

“Chronic pain is common in the United States and continues to burden individuals, families, and society,” wrote Friedhelm Sandbrink, M.D., a member of the VA/DoD Guideline Development Group, and colleagues. “The benefits that opioids can provide are small and are outweighed by the risks to the patient.”

The VA/DoD Guideline Development Group was assembled by the VA/DoD Evidence-Based Practice Work Group in December 2020 to update the clinical practice guideline for opioid therapy for chronic pain, which was last updated in 2017. The guideline is updated every five years or more frequently as new evidence emerges. The VA and DoD define chronic pain as persistent and recurrent pain lasting longer than 90 days, and opioid therapy is considered long term when it continues longer than three months.

Compared with the 2017 recommendation against initiation of long-term opioid therapy, the 2022 guideline makes a broader recommendation against using opioid therapy in general. This update “reflects the evidence that opioid therapy for any duration may be harmful,” Sandbrink and colleagues wrote. For those patients with chronic pain for whom long-term opioid therapy may be appropriate based on a clinical assessment, the 2022 guideline recommends using buprenorphine. This is due to buprenorphine’s lower risk for overdose and misuse compared with full agonist opioids, as well as buprenorphine’s superior safety profile, the authors noted. The 2022 guideline is consistent with the 2017 guideline in recommending that professionals use the lowest dose possible when prescribing an opioid. Further, the guideline recommends reevaluating patients at 30 days or less after initiating opioid therapy, followed by frequent follow-up visits when opioids are continued.

The updated guideline also makes several new recommendations for behavioral health assessments in all patients. It recommends screening for mental health conditions, history of traumatic brain injury, and psychological factors (such as pain catastrophizing) when considering long-term opioid therapy, as these conditions are associated with a higher risk for harm. In concurrence with the 2017 guideline, the 2022 guideline also recommends assessing patients for suicide risk and self-directed violence when initiating, continuing, changing, or discontinuing long-term opioid therapy.

“These recommendations are an important update in the changing and challenging landscape that clinicians and patients navigate to address chronic pain in the context of the worsening overdose epidemic,” wrote Chinazo Cunningham, M.D., M.S., and Joanna Starrels, M.D., M.S., of Albert Einstein College of Medicine in an accompanying editorial.

“[T]he most potentially transformative VA/DoD recommendation is to prescribe buprenorphine instead of full opioid agonists for patients who are receiving daily opioids for treatment of chronic pain,” Cunningham and Starrels continued. “This recommendation is exciting, but underdeveloped, and many questions about implementation remain.”

For related information, see the Psychiatric News article “CDC Issues New Opioid Prescribing Guideline.”

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Prolonged Grief Disorder Among Veterans Linked to Risk of Other Psychiatric Disorders, Suicide

As many as 7% of U.S. veterans were found to have a positive screen for prolonged grief disorder, reports a study in The American Journal of Geriatric Psychiatry. Veterans with prolonged grief disorder were more likely than those without the disorder to also have posttraumatic stress disorder (PTSD), major depressive disorder, and generalized anxiety disorder. They were also more likely to endorse suicidal thoughts and behaviors.

Prolonged grief disorder was approved by the APA Board of Trustees and Assembly for inclusion in DSM-5 in 2020. The disorder is characterized by a cluster of symptoms that persist more than a year after the death of a loved one and differ markedly from those that are part of the normal grieving process. The symptoms of prolonged grief disorder are also associated with poorer prognosis and greater functional impairment.

Peter J. Na, M.D., M.P.H., of VA Connecticut Healthcare System and colleagues analyzed data from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 2,441 U.S. veterans. Survey participants were asked, “Have you ever experienced a death of someone close?” Those who answered affirmatively were asked to think about the person who had been most difficult to lose and were assessed using the 5-item Brief Grief Questionnaire. Veterans were determined to have prolonged grief disorder if the loss was at least 12 months prior to taking the questionnaire and they scored 5 or greater. The participants were also evaluated for PTSD, major depression, generalized anxiety disorder, and suicidal thoughts or behaviors in the previous year.

Of the 2,441 study participants (average age 63 years, predominantly White and non-Hispanic), 2,339 (92.7%) reported the loss of someone close and 158 (7.3%) screened positive for prolonged grief disorder. Factors associated with an increased risk for the disorder were being female; Black; having served in the Marine Corps; having more adverse childhood experiences; losing someone to suicide, homicide, or COVID-19; and/or having a personal history of COVID-19 infection.

After the researchers adjusted for sociodemographic, military, and trauma variables, veterans with prolonged grief disorder were five to nine times more likely to screen positive for PTSD, major depressive disorder, and generalized anxiety disorder. After additional adjustment for current psychiatric and substance use disorders, veterans were two to three times more likely to endorse suicidal thoughts and behaviors.

“Further research is needed to replicate these findings, evaluate interrelationships between [prolonged grief disorder] and other psychiatric outcomes, and evaluate the efficacy of interventions targeting [prolonged grief disorder] in this population,” the authors wrote.

For related information, see the Psychiatric News article “Pandemic Takes Toll on Those Who Grieve.”

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Mental Health Found to Be Worsening Among U.S. High School Students

The latest results from the CDC’s Youth Risk Behavior Survey are in, and the data paint a concerning picture about the mental health of U.S. high school students, particularly among female students.

“Across almost all measures of substance use, experiences of violence, mental health, and suicidal thoughts and behaviors, female students are faring more poorly than male students,” noted the executive summary of The Youth Risk Behavior Survey Data Summary & Trends Report: 2011–2021.

The CDC conducts the Youth Risk Behavior Survey every two years among a nationally representative sample of U.S. public and private high school students. For the survey, students complete a nearly 100-item questionnaire during one class period. Among the findings of the surveillance data from fall 2021—the first collected since the start of the COVID-19 pandemic—were the following:

• 42% of students reported feeling persistently sad or hopeless in the past year. Nearly 60% of female students and nearly 70% of those who identified as LGBQ+* reported persistent sadness and hopelessness. 
• 22% of students reported having seriously considered attempting suicide during the past year. In 2021, 30% of females reported having such thoughts—a jump from 19% in 2011. In 2021, 14% of males reported having such thoughts compared with 13% in 2011.
• 10% of students attempted suicide at least once in the past year. The percentage of female students who attempted suicide increased from 10% in 2011 to 13% in 2021. The percentage of male students who attempted suicide increased from 6% in 2011 to 7% in 2021.

“[A]lthough Black students were less likely to report poor mental health and persistent feelings of sadness or hopelessness than some other groups of students, they were significantly more likely than Asian, Hispanic, and White students to have attempted suicide,” the executive summary noted.

The report also includes the following chapters and key survey findings:

• Sexual behavior: The proportion of high school students who engaged in sexual behaviors that increase their risks for HIV, STDs, and unintended pregnancy decreased from 2011 to 2021.
• Substance use: Overall substance use among high school students decreased from 2011 to 2021. However, the percentage of students who used electronic vapor products or misused prescription opioids has not changed in recent years.
• Experiencing violence: Although bullying at school decreased from 2011 to 2021, the percentage of students who missed school because of safety concerns and experienced sexual violence increased.
• New and emerging national data: The 2021 questionnaire included three new questions to assess adolescents’ environments with a focus on protective factors (for example, social connectedness) and social determinants of health (for example, unstable housing). Because these questions were included for the first time in 2021, no trend data are available.

“These data make it clear that young people in the U.S. are collectively experiencing a level of distress that calls on us to act,” the report stated. “Supporting schools in efforts to reverse these negative trends and ensure that youth have the support they need to be healthy and thrive will require partnership.”

For related information, see the Psychiatric News article “Surgeon General Calls for Action to Address Youth Mental Health Crisis” and APA Foundation’s Notice. Talk. Act. at School website.

*Because the 2021 national Youth Risk Behavior Survey did not have a question assessing gender identity, this report did not highlight data specifically on students who identify as transgender. Therefore, the T commonly used in the acronym LGBTQ+ is not included when referring to the data.

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Life Outlook Improves When Patients Work With Peers, Meta-Analysis Suggests

Patients with mental illness who receive services delivered by individuals with lived experience of mental illness (peer support services) may experience greater personal recovery (for example, life satisfaction and hopefulness) than those patients who do not receive peer support services, a meta-analysis in Psychiatric Services in Advance has found.

“The effect of peer support on personal recovery was most pronounced in peer support delivered as an add-on to mental health hospital treatment,” wrote Cecilie Høgh Egmose, M.Sc., of the University of Copenhagen in Denmark and colleagues. “However, the evidence for the efficacy of peer support provided independently of hospital settings and online is promising and requires more high-quality [randomized, controlled trials] and attention from policy makers and funders.”

Høgh Egmose and colleagues compiled data from 49 randomized, controlled trials testing the effectiveness of peer support interventions that were delivered by peers only or by both mental health professionals and peers. Peers included individuals in paid and volunteer positions.

The combined data included 12,477 patients with a range of conditions including schizophrenia, bipolar disorder, depression, anxiety, and eating disorders. The peer support programs were divided into four categories, including those led by as follows:

1. Peers working in hospital services (for example, recovery mentors delivered one-to-one peer support or group-based, peer-led self-management programs).
2. Peers working in nonhospital settings, such as a university research center or a residential program.
3. Peers working in established, paid service positions (for example, peers helped to facilitate conversations about requests for treatment, assertive community treatment, and occupational rehabilitation goals).
4. Peers working with online support groups.

Overall, peer support was associated with a small positive effect on personal recovery compared with control interventions such as placement on a waitlist or receipt of usual care. Peer support was also associated with a slight decrease in anxiety and seemed to have a positive impact on patients’ hope and self-advocacy.

“We found that peers employed and trained in supporting roles in the mental health hospital treatment service had a small positive effect on personal recovery, had a small-to-moderate positive effect on self-efficacy, and were associated with a small reduction in overall psychiatric symptoms,” Høgh Egmose and colleagues wrote. “Nevertheless, before we can recommend implementation of peer support in specific health care settings, co-created high quality trials measuring the effectiveness, including potential adverse effects, and the cost-effectiveness of the intervention are needed.”

To read more on this topic, see the Psychiatric News articles “Peer Support Specialists Can Play Important Role in Patients’ Lives” and “Peer Specialists Can Aid in Suicide Prevention.”

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Air Pollution Exposure May Be Linked to Late-Onset Depression

Long-term exposure to common levels of air pollution may be linked to an increased risk of depression after age 64, according to a study published today in JAMA Network Open.

“Although depression is less prevalent among older adults as compared with the younger population, there can be serious consequences, such as cognitive impairment, comorbid physical illness, and death,” wrote Xinye Qiu, Ph.D., of the Harvard T.H. Chan School of Public Health and colleagues. “Therefore, it is of crucial importance to study preventable risk factors for developing depression among older adults to reduce the associated health care burden.”

Qiu and colleagues conducted a longitudinal cohort study using data from all Medicare beneficiaries who were continuously enrolled in the Medicare Fee-for-Service program and Medicare Part A and Part B from 2000 to 2016. The researchers excluded any participants who received a depression diagnosis within five years of Medicare enrollment to reduce the occurrence of participants with preexisting depression. Depression was identified based on all available Medicare claims, including those from a hospital or skilled nursing facility. Finally, the authors looked at three air pollutants: fine particulate matter (measured in micrograms per cubic meter), nitrogen dioxide (measured in parts per billion), and ozone (measured in parts per billion). They used ZIP codes included in the Medicare data to track air pollution exposure for each year of the study period as well as the five years before to determine long-term exposure.

The final study sample included over 8.9 million Medicare beneficiaries (mean age of 73.7 years) and 1.5 million late-life depression diagnoses. All three air pollutants included in the study were associated with an increased risk of developing depression after 64 years of age. Each five-unit increase in long-term exposure to particulate matter, nitrogen dioxide, and ozone was associated with an adjusted percentage increase in depression risk of 0.91%, 0.61%, and 2.13%, respectively.

The authors found that older adults with comorbidities had a higher risk of developing late-life depression when exposed to elevated pollution, especially nitrogen dioxide, compared with those without comorbidities. Further, the authors found that socioeconomically disadvantaged participants (those who also qualified for Medicaid) had a higher risk of late-life depression when exposed to particulate matter or nitrogen dioxide.

“The study findings have implications for both environmental regulation and public health management,” the authors concluded. “We hope this study can inspire researchers to further consider possible environmental risk factors (such as air pollution and living environment) for the prevention of geriatric depression, to understand the disease better moving forward, and to improve the delivery of mental health care services among older adults.”

For related information, see the American Journal of Psychiatry article “Association Between Ambient Air Pollution and Daily Hospital Admissions for Depression in 75 Chinese Cities.”

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Psychiatrists Describe What Abortion Restriction Could Mean for People With Psychiatric Disorders

The Supreme Court decision in Dobbs v Jackson Women’s Health Organization to end the constitutional guarantee of a right to abortion will not only impact the 1 in 4 people in the United States who seek abortions—it’s likely to also impact psychiatric practice. So wrote psychiatrists Katherine Wisner, M.D., M.S., and Paul Appelbaum, M.D., in a Viewpoints article published yesterday in JAMA Psychiatry.

Wisner is the director of the Asher Center for the Study and Treatment of Depressive Disorders at Northwestern Feinberg School of Medicine. Appelbaum, a past APA president, is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and director of the Center for Law, Ethics, and Psychiatry at Columbia University.

“As psychiatrists, we have specific concerns about the impact of abortion restrictions on people with mental illness,” they wrote, noting that studies have found a higher prevalence of psychiatric disorders among people who have had abortions. “Vulnerable pregnant people will be subject to devastating levels of distress associated with denial of access to abortion, as in giving birth to the child of a rapist. … For patients without access to abortion services, attempts at self-injury to induce pregnancy loss will repeat the tragedies of the pre-Roe era.”

There are also long-term consequences for the babies born to people with psychiatric disorders who were compelled to continue unwanted pregnancies.

“In this immediate post-Dobbs period, states vary in the degree of restrictions with respect to the gestational timing limits, personnel who can perform abortions, requirement for pre-termination counseling, rules governing state or private insurance coverage, and exceptions for rape, incest, or congenital malformations,” Wisner and Appelbaum wrote. “Psychiatric disorders also are among conditions that may threaten the life and health of a pregnant person, yet some of the newer statutes appear to exclude mental illnesses as exceptions.”

They pointed to exclusion of mental illness from Oklahoma’s statutory definition of a “medical emergency justifying abortion” as a “a physical disorder, physical illness or physical injury including a life endangering physical condition caused by or arising from the pregnancy itself.” The authors noted that psychiatrists may again be called upon to authorize exceptions to abortions in states that have more lenient restrictions (as was sometimes the case prior to the Roe v. Wade decision).

“The prospect of psychiatrists again serving as gatekeepers is not appealing, given the pressures they will face to authorize exceptions,” the authors wrote. “However, the response cannot be the exclusion of all mentally ill pregnant people whose lives or health are endangered by denial of access to safe abortions. … At the very least, states legislating abortion restrictions must recognize the impact of undesired pregnancies on people with or at risk for mental disorders and create mechanisms to keep them safe.”

For related information, see the Psychiatric News articles “Experts Share Advice for Post-Roe World: ‘We Have to Be Proactive’” and “APA Responds to End of Roe v. Wade.”

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Biden Urges Bipartisan Efforts on Mental Health in State of the Union Address

In his State of the Union address last night, President Joe Biden pointed to numerous health policies, including improving mental health and addressing the opioid epidemic, that represent opportunities for members of both parties to work together.

APA applauded the inclusion of mental health in Biden’s address in a news release. “While the nation faces the opioid epidemic, an ongoing crisis in youth mental health, and barriers to access, mental health is truly an issue where bipartisan progress can and must be made,” APA’s statement reads.

During his address, Biden spoke about his four-part Unity Agenda, which focuses on tackling the mental health crisis, especially among youth; addressing the epidemic of opioid and other drug overdoses; ending cancer; and supporting veterans.

Biden outlined specific actions his administration will take in his Unity Agenda, including the following:

Supporting the health care workforce: This year, the Centers for Disease Control and Prevention (CDC) will launch a new campaign to provide mental health and resiliency resources for health care organizations on how to support their workforces.

Strengthening parity enforcement: The administration will propose new rules this spring to ensure insurers are not imposing inequitable barriers to care and that mental health professionals are being paid on par with other health professionals.

Investing in crisis services and 988: In the coming year, the Department of Health and Human Services (HHS) will improve the capacity of the recently launched 988 Lifeline by investing in the crisis care workforce, scaling mobile crisis services, and developing guidance on best practices in crisis response.

Expanding access to telehealth services: According to the Unity Agenda, HHS will triple resources dedicated to promoting interstate license reciprocity for delivering mental health services across state lines. The Department of Defense (DOD) will also expand the BRAVE program, a virtual behavioral health center providing services 24/7 to service members and their families located on federal installations across the globe.

Recruiting a more diverse mental health workforce: HHS will increase funding to expand the Minority Fellowship Program and recruit mental health professionals from Historically Black Colleges and Universities.

Fighting the opioid epidemic: The administration will expand access to proven treatments, including buprenorphine, for opioid use disorder; launch a national campaign to educate young people on the dangers of fentanyl and how naloxone saves lives; and ensure every jail and prison across the country can provide treatment for substance use disorders.

Supporting veterans and their families and reducing veteran suicide: The Department of Veterans Affairs (VA) will create new resources to improve suicide risk identification and increase counseling on the safe storage of firearms and lethal medications.

For related information, see the APA news release “APA Statement Ahead of Tonight’s 2023 State of the Union.”

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Excessive Crying, Irritability in Infancy Associated With Later Behavioral Problems

Infants who cry excessively (more than 3 hours at least 1 day/week) may be more likely to experience behavioral problems in childhood and adolescence than infants who cry less, suggests a report published yesterday in the Journal of the Academy of Child & Adolescent Psychiatry. Brain scans of these children at age 10 also revealed that the amygdala—a part of the brain involved with assessing threat and regulating emotional responses—was smaller in those who cried excessively and/or were irritable as infants.

“Most infants who cry excessively grow to be healthy, typically developing children, and it remains reasonable to remind parents of the good prognosis,” wrote Sara Sammallahti, Ph.D., of Erasmus MC Sophia Children’s Hospital in the Netherlands and colleagues. “Nonetheless, … our results suggest parent-reported excessive crying should not be simply shrugged off: it could reflect one of the earliest child markers of vulnerability to develop behavioral problems.”

The researchers analyzed data from the Generation R Study cohort, which included 4,751 children born in the Netherlands between 2002 and 2006. As part of the study, parents were asked to report if their three-month-old infants cried excessively by answering yes or no to the question “Has your child ever cried for more than 3 hours a day (24 hours) during the last week?” and/or if the baby was irritable, using the Mother and Baby Scales irritability scale. The parents were also asked to complete the Child Behavior Checklist (CBCL) when the children were 1.5, 3, 6, and 10 years. The CBCL measures internalizing problems (such as anxiety) and externalizing problems (such as aggression). At age 14, the youth completed the Youth Self-Report, which also measures internalizing and externalizing problems in adolescence. The children also underwent a structural brain MRI around the age of 10.

Children who cried excessively in infancy had higher parent-rated internalizing and externalizing problems throughout childhood compared with those who did not cry excessively in infancy; higher infant irritability was also associated with higher parent-rated internalizing and externalizing problems. Similarly, children who cried excessively and/or were more irritable as infants had smaller amygdala volume at 10 years.

“Excessive crying and irritability in infancy may reflect an early vulnerability to behavioral problems and be linked with neurobiological differences in the development of the amygdala,” Sammallahti and colleagues wrote.

They continued, “Neurobiological differences can manifest in crying behavior; however, behavior could also precede neurobiological differences: the experiences of irritable, excessively crying infants could impact structural amygdala development … [O]ur study suggests crying behavior and amygdala development are associated.”

For related information, see the Psychiatric News article “Irritability in Childhood May Point to Teens At High Risk for Suicide.”

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One Eating Disorder Found to Be More Heritable Than Others

Genetics play a strong role in the development of avoidant restrictive food intake disorder (ARFID), according to an analysis appearing in JAMA Psychiatry. The analysis suggests that ARFID is more heritable than other eating disorders.

“Unlike anorexia nervosa, dietary restriction in ARFID is not motivated by body image concerns or drive for thinness but rather based on sensory sensitivity to food qualities (e.g., texture, smell, taste), lack of interest in food/eating (ie, low appetite), and/or fear of aversive somatic consequences of food intake (e.g., choking, vomiting, allergic reactions), often in response to aversive eating experiences,” wrote Lisa Dinkler, Ph.D., of the Karolinska Institutet in Sweden and colleagues. “With an estimated prevalence of 1% to 5%, ARFID is at least as common as autism and potentially as common as attention-deficit/hyperactivity disorder (ADHD).”

Dinkler and colleagues used data from the Child and Adolescent Twin Study in Sweden, which aims to collect comprehensive psychiatric and developmental data on all twins born in Sweden since July 1, 1992.

The study population consisted of 33,902 children born between 1992 and 2010 (the twins were assessed at ages 9 or 12 depending on birth year). Overall, 682 children met the criteria for ARFID based on the DSM-5 definition of exhibiting avoidant/restrictive eating with clinically significant consequences that are not attributable to anorexia, bulimia, or a body image disturbance. The prevalence of ARFID was slightly higher in males (2.4%) than females (1.6%). Of this group, 67.2% experienced weight loss or failure to gain weight, 50.6% had problems with psychosocial functioning, 8.5% required supplements or tube feeding, and 0.6% had a nutritional deficiency.

Based on the prevalence of ARFID in identical and fraternal twins, Dinkler and colleagues estimated that ARFID risk was 79% due to heritable factors such as genetics or shared family environment. This rate was similar even after excluding children who had comorbid autism or another medical condition that could contribute to avoidant eating (for example, thyroid disorder). The 79% heritability is higher than what has been reported for anorexia (48% to 74%), bulimia (55% to 61%), and binge eating disorder (39% to 57%). The 79% heritability is on par with autism, schizophrenia, and ADHD, the authors noted.

“The high heritability of the ARFID phenotype provides strong support for future twin and molecular genetic studies of ARFID,” Dinkler and colleagues concluded.

To read more on this topic, see the Psychiatric News special report “Youth With Eating Disorders—Time Is of the Essence in Achieving Remission.”

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Maternal Immune System Deficiencies Linked to Risk of Mental Illness in Offspring

Rare deficiencies in the immune systems of mothers, called primary antibody immunodeficiencies (PIDs), may be associated with an increased risk of psychiatric disorders and suicidal behavior in their offspring, a study in JAMA Psychiatry has found. Primary antibody immunodeficiencies are associated with recurrent infections, allergies, and autoimmune diseases.

Josef Isung, M.D., Ph.D., of the Karolinska Institutet in Stockholm and colleagues analyzed data from Sweden’s National Patient Register for 4,294,169 people who lived in Sweden at any time between 1973 and 2013, among whom 7,270 had a mother or father with PIDs. They found that people with mothers who had PIDs had a 17% increased risk of psychiatric disorders and a 20% increased risk of suicidal behavior compared with people who did not have mothers with PIDs.

Increased risk varied among different types of psychiatric disorders as follows:

• 71% increased risk of bipolar disorders
• 49% increased risk of autism spectrum disorders
• 33% increased risk of obsessive-compulsive disorder
• 30% increased risk of attention-deficit/hyperactivity disorder
• 23% increased risk of major depressive disorder and other mood disorders

Furthermore, people whose mothers had both PIDs and autoimmune diseases had a 24% increased risk of psychiatric disorders and a 44% increased risk of suicidal behavior. People whose fathers had PIDs did not appear to have increased risk of psychiatric disorders or suicidal behavior.

“While our data cannot pinpoint a precise causal mechanism underlying the observed associations, the results add to the existing literature suggesting that the intrauterine immune environment may have implications for fetal neurodevelopment and that a compromised maternal immune system during pregnancy may be a risk factor for psychiatric disorders and suicidal behavior in their offspring in the long term,” Isung and colleagues wrote.

For related information, see the American Journal of Psychiatry article “Maternal Immune Activation and Neuropsychiatric Illness: A Translational Research Perspective.”

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Childhood Adversity May Account for Some Brain Differences Between White, Black Children

Black children are more likely to experience adverse life events than White children, and these disparities may contribute to differences between their brains, according to a study published yesterday in The American Journal of Psychiatry.

“What the data show is the overwhelming impact of structural racism on the developing brain, which is going to have big implications for these kids’ emotional health as they start to get older, especially if we don’t address the different aspects of structural inequities and racism,” Nathaniel Harnett, Ph.D., of McLean Hospital told Psychiatric News.

Harnett and colleagues used data from the Adolescent Brain and Cognitive Development (ABCD) Study released in March 2019, which included 9,382 participants aged 9 and 10. They gathered family demographic data through surveys that the participants’ parents completed. The surveys assessed both parent and child race/ethnicity; parental education and employment; parental hardship (such as not being able to afford rent); and total family income, among other variables.

The participants’ neighborhood disadvantage was assessed using the Area Deprivation Index, which uses 17 socioeconomic indicators—including poverty, housing, and employment—to characterize a given neighborhood. Family conflict was assessed using the Youth Family Environment Scale, and trauma history was assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children for DSM-5. The authors used structural MRI data to investigate the relationship between racial disparities in adversity exposure and differences in brain structure.

The authors found that White children’s parents were more likely to be employed, have higher educational attainment, and greater family income compared with Black children’s parents (88.1% of White parents made $35,000 a year or more versus 46.7% of Black parents). White children also experienced less family conflict, less material hardship, less neighborhood disadvantage, and fewer traumatic events compared with Black children.

Childhood adversity was associated with lower gray matter (nodes where information is processed) volume in the amygdala and several regions of the prefrontal cortex. White children showed greater gray matter volume compared with Black children in 10 brain regions. Black children showed lower gray matter volumes in the amygdala, the hippocampus, and several subregions of the prefrontal cortex compared with White children. These regions of the brain are key to regulating the emotional response to threat, Harnett explained, but he emphasized that, overall, these differences were small.

In an accompanying commentary, Deanna Barch, Ph.D., and Joan Luby, M.D., of the Washington University School of Medicine in St. Louis pointed to some of the additional adverse social determinants of health that were not examined in the study, such as a youth’s personal experience of racism. They wrote that some people have argued that the experience of racism is a form of trauma itself that can lead to posttraumatic stress disorder.

The study “is an important step towards understanding how [social determinants of health] impact brain development in youth as a potential pathway to risk for mental health challenges,” Barch and Luby wrote.

For a more coverage of this study, see the Psychiatric News article “Childhood Adversity Impacts Brain Development, Study Shows.”

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Biden Announces End of COVID Public Health Emergency in May

The Biden administration announced this week that the COVID-19 Public Health Emergency (PHE), first issued in March 2020, will end on May 11.

The PHE waived a host of restrictions on the use of telehealth to help patients receive services, including mental health services, without leaving their homes. With the end of the emergency, those waivers will be lifted, and several pre-pandemic regulations will be back in effect. These include the following:

• With very few exceptions, health care professionals registered with the Drug Enforcement Administration (DEA) will be required to have had an in-person visit with a patient in order to prescribe controlled substances.
• Health care professionals will be required to have a DEA registration in any state in which they are prescribing controlled substances.
• Health care professionals will be required to use HIPAA-compliant messaging software for telehealth; under the PHE, physicians and other health care professionals may use popular technology, such as Skype and FaceTime, to conduct telehealth sessions.

Importantly, some states and health care plans—recognizing that telehealth has now become a permanent feature of health care—may continue certain flexibilities and coverage; commercial and Medicaid payers may vary widely in their telehealth policies. APA members are urged to contact the APA Practice Management Helpline, their APA district branch, state medical board, or other trusted resource for information about the status of coverage for their patients.

Additionally, the Consolidated Appropriations Act of 2023 (HR 2617), the federal spending bill signed by President Joe Biden in late December, extends some telehealth flexibilities for physicians treating Medicare patients: Any in-person requirements for billing Medicare are suspended through at least the end of 2024. Audio-only visits are a permanently allowable telehealth modality in Medicare.

The PHE was set to expire on April 11, and Republicans in the House of Representatives had submitted two pieces of legislation calling for an immediate end to the emergency. In a statement from the White House Office of Management and Budget on Monday, the administration extended the date of the expiration to May 11 saying an immediate end to the PHE would “would create wide-ranging chaos and uncertainty throughout the health care system—for states, for hospitals and doctors’ offices, and, most importantly, for tens of millions of Americans.”

For more information, see “Comparison of Telehealth Provisions During the Public Health Emergency and After the Public Health Emergency” on the APA website. APA is now working on updating the site now that the end date of the PHE has been announced.

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