APA Responds to DEA’s Proposed Rules Regarding Telehealth, Buprenorphine

Today APA filed two letters with the U.S. Drug Enforcement Administration (DEA) in response to two proposed rules that if finalized would affect how health professionals implement telehealth services and prescribe certain controlled medications. The proposed rules, which were developed with the U.S. Department of Health and Human Services and in close coordination with the U.S. Department of Veterans Affairs and announced on February 24, would extend certain flexibilities in these areas after the COVID-19 public health emergency expires on May 11. Yet in several ways the proposed rules are more restrictive than what the public health emergency has allowed.

The first proposed rule (Docket No. DEA–407) would prohibit health professionals who offer telehealth services from prescribing Schedule II controlled substances such as methylphenidate (Ritalin), mixed amphetamine salts (Adderall, etc.), and opioid pain relievers (Vicodin, Oxycontin, etc.) and Schedule III-V narcotics other than buprenorphine without examining patients in person first. However, health professionals would be able to prescribe a 30-day supply for buprenorphine and non-narcotic Schedule III-V drugs such as benzodiazepines (Valium, Xanax, etc.) and prescription sleep aids (Ambien, etc.) without an in-person visit if the telemedicine appointment is for a legitimate medical purpose. Prescriptions for more than a 30-day supply would require an in-person visit.

In its response, APA recommended that the DEA balance common-sense safeguards for DEA enforcement without decreasing access to lifesaving treatment, stating that the requirement may cause the following three harms:

• It penalizes patients who face barriers to accessing care, such as inadequate or no health insurance and/or challenges with mobility and transportation.
• It may incentivize nonspecialist practitioners to treat complex conditions on their own rather than referring a patient to a specialist.
• It would create significant additional and unnecessary costs to the patient and the health care system by generating duplicative high-cost care rather than making appropriate use of community-based professionals.

The second proposed rule (Docket No. DEA–948) would expand the situations in which physicians may prescribe controlled substances through the internet for legitimate medical conditions even without an in-person evaluation as long as the medications have been approved for treatment of opioid use disorder (OUD) and the physician is able to conduct a patient evaluation. To date, buprenorphine is the only Schedule III-V medication approved by the U.S. Food and Drug Administration for this purpose. Nonetheless, this proposed rule would also create restrictions that were not in place during the public health emergency. Patients would either have to be examined in person by the physician within 30 days, have a referral from another practitioner, or the physician would have to examine the patient via telehealth while the patient is in the physical presence of another DEA-registered health professional.

In its response, APA recommended that the DEA remove the in-person requirements for the prescribing of buprenorphine for the treatment of OUD via telemedicine when clinically indicated.

“If the DEA does not permanently remove the in-person requirement for the prescribing of buprenorphine for the treatment of OUD via telemedicine, APA strongly encourages DEA to continue the waiver of the in-person requirement for the duration of the opioid [public health emergency],” APA wrote. “The flexibilities during the COVID-19 PHE have allowed practitioners to use clinical decision-making to determine when and how often to see a patient in-person, and we recommend that this flexibility continue.”

In both letters, APA also offered the following recommendations:

• Allowance for referring practitioners to not be registered with the DEA.
• Reduction in administrative requirements for referring and prescribing practitioners.
• Reduction in additional state-based registration requirements.
• Removal of clinical decision-making from regulation in these proposed rules.
• Clarification of key inconsistencies in the proposed rules.

The DEA provided a 30-day comment period for the proposed rules. Comments must be submitted or postmarked by 11:59 p.m. tonight. To submit a comment, visit https://www.regulations.gov/.

For related information, see the Psychiatric News article “Telehealth Providers: Begin Planning Now for End of COVID-19 PHE.”

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What’s Your Experience With Telepsychiatry? APA Wants to Know

APA is continuing to advocate for changes to improve the practice of psychiatry and we need to hear from you to better understand how you use telepsychiatry technologies. Unidentified aggregated data will be shared with the Centers for Medicare and Medicaid Services (CMS) as it promulgates rules that impact psychiatry.

TAKE SURVEY

FDA Approves Naloxone Nasal Spray for Over-the-Counter Sale

The U.S. Food and Drug Administration (FDA) yesterday approved Narcan (naloxone) 4 mg hydrochloride nasal spray for purchase without a prescription. Narcan rapidly reverses the effects of an opioid overdose.

“Naloxone is a critical tool in addressing opioid overdoses, and today’s approval underscores the extensive efforts the agency has undertaken to combat the overdose crisis,” Patrizia Cavazzoni, M.D., director of the FDA’s Center for Drug Evaluation and Research, said in an FDA news release.

The FDA’s action “paves the way” for Narcan to be sold in drugstores, supermarkets, convenience stores, gas stations, and online, according to the release. The medication will be available in retailers and online by the late summer, and it will still be available as a prescription in the meantime.

The over-the-counter (OTC) approval was granted to Emergent BioSolutions, Narcan’s manufacturer. In February, two FDA advisory committees recommended Narcan be made available without a prescription.

According to a news release from the company, the OTC product will have the same formulation, device design, and prescription strength as the original product.

Cavazzoni said in the FDA release that the agency is working with its federal partners to ensure continued access to naloxone during Narcan’s transition to OTC status. “Further, we will work with any sponsor seeking to market a nonprescription naloxone product, including through an Rx to OTC switch, and encourage manufacturers to contact the agency as early as possible to initiate discussions,” Cavazzoni added.

APA expressed its support of Narcan for OTC use in a letter to FDA Commissioner Robert M. Califf, M.D., in January, noting that naloxone nasal spray and autoinjector formulations are safe and effective. Further, APA encouraged the FDA to address supply chain issues; education related to opioid overdoses (such as through a package insert that describes the sign of an opioid overdose, outlines how to administer naloxone, and reminds the user to call emergency services); and cost.

“Cost barriers must be mitigated through payers’ coverage of OTC formulations of naloxone,” APA’s letter stated. “For example, Medicare does not pay for some forms of nicotine replacement therapy such as the patch, gum, or lozenges due to [these products] being OTC. APA encourages FDA to work with [the Centers for Medicare and Medicaid Services] and other payers to keep cost down for the most vulnerable populations.”

Finally, APA noted that prescribers should continue to write naloxone prescriptions to patients at risk, as insurers can continue to cover prescription naloxone.

Emergent BioSolutions’ news release did not state the price of OTC Narcan.

For related information, see the Psychiatric News Alert “FDA Advisory Panel Recommends Approval for Over-the-Counter Narcan.”

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Hospital Incentive Program Found to Increase Buprenorphine Prescriptions for Patients With OUD

Pennsylvania patients with opioid use disorder (OUD) were more likely to receive a prescription for buprenorphine within 30 days of a visit to the emergency department (ED) if they were seen at a hospital participating in the state’s Opioid Hospital Quality Improvement Program than those seen at a hospital that did not participate in this program. These findings are described in a recent report in JAMA Health Forum.

“With surging rates of opioid overdose deaths, ED encounters present a crucial opportunity to engage patients with OUD treatment,” wrote Keisha T. Solomon, Ph.D., of Howard University and colleagues. “The [Opioid Hospital Quality Improvement Program] may be a new policy approach to expanding access to evidence-based treatment for OUD across a diverse and large population of hospitals.”

In response to high opioid overdose death rates, the Pennsylvania Department of Human Services in 2019 implemented the Opioid Hospital Quality Improvement Program—a statewide program that provides financial incentives to any hospital in the state that agreed to implement changes to increase the number of OUD patients who transition from the ED to follow-up OUD treatment, including buprenorphine.

The researchers analyzed data on 17,428 adults (about 57% male) who were enrolled in Medicaid and were seen in an ED for an opioid-related cause (for example, opioid withdrawal or opioid overdose) between January 1, 2016, and December 31, 2020. The main outcome was patients’ receipt of buprenorphine within 30 days of their ED visit.

A total of 14,585 patients with OUD sought care at a hospital ED that was participating in the Opioid Hospital Quality Improvement Program; 2,843 patients sought care at a hospital ED that was not participating in the program. Prior to the Opioid Hospital Quality Improvement Program, the baseline rate for patients prescribed buprenorphine within 30 days of their ED visit for an opioid overdose was similar between hospitals that were and were not participating in the program (5.0% and 5.7%, respectively), Solomon and colleagues noted. However, the researchers found that patients who visited an ED at a hospital participating in the program in 2020 were 3.6 percentage points more likely to receive buprenorphine treatment within 30 days than patients treated at nonparticipating hospitals.

“State programs that use financial incentives to drive OUD treatment practice changes in hospitals may be effective in improving quality and care transitions,” Solomon and colleagues wrote. “Similar programs across the nation should be considered as part of a multifaceted approach to mitigating the opioid epidemic.”

For related information, see the Psychiatric News article “High-Dose Buprenorphine in the ED Effective for OUD.”

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Experts Call for Consistent Screening of Food Insecurity Among Adolescents

It is well established that adolescents experiencing food insecurity (inconsistent access to enough safe and affordable food to live an active, healthy life) are at greater risk of physical and mental problems. In a Viewpoint article published yesterday in JAMA Pediatrics, Kaitlyn Harper, Ph.D., M.Sc., M.A., of Johns Hopkins Bloomberg School of Public Health and Hilary Seligman, M.D., M.A.S., of the University of California, San Francisco (UCSF), describe the need to integrate an accurate and reliable screening tool to assess food insecurity into clinical settings.

“The Biden-Harris national strategic plan emphasizes the importance of reaching populations that have been inadequately served by existing food and nutrition security programs and policies,” they wrote. “Adolescents fall into this gap.”

Harper is a postdoctoral fellow at Hopkins whose research is focused on improving food and nutrition security for children and adolescents in the United States through federal programs. Seligman is a professor of medicine, epidemiology, and biostatistics at UCSF and an expert in food insecurity and its health implications across the life course.

In the article, Harper and Seligman described efforts to date to quantify adolescent food insecurity in the United States by surveying heads of households. The authors pointed out that these surveys likely underestimate the extent of the problem—as research shows caregivers’ responses and adolescents’ responses on food security rarely match.

Food insecurity during adolescence can lead to short- and long-term morbidity and early death, as well as increased risk of engaging in risky health behaviors. “Although it is difficult to disentangle trauma directly related to food insecurity from other trauma often experienced simultaneously, such as racial discrimination, unstable housing, and neighborhood violence, adolescents living in households with food insecurity have an increased risk of mental health disorders, including depression, anxiety, substance use or substance use disorder, and suicidality,” Harper and Seligman wrote. “The health ramifications of food insecurity among adolescents underscore the need for an accurate and reliable screening tool that may be widely used in clinical settings.”

They described several food security screens that have been tested on adolescents in research settings, including the nine-item Self-Administered Food Security Survey Module for Youth Ages 12 and Older and the two-item Hunger Vital Sign.

They concluded, “Screening adolescents for food insecurity can help providers understand the unique adolescent experience with accessing affordable and nutritious food. It can also serve as the first step toward referring high-risk patients to food security programs, including SNAP (Supplemental Nutrition Assistance Program) and the U.S. Department of Agriculture’s Produce Prescription Program. Finally, screening may create momentum for policies and programs that are uniquely tailored to the food security needs of adolescents.”

For related information, see the book The Social Determinants of Mental Health.

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Attention Bias Modification Treatment Found Effective for Social Anxiety Disorder

People with social anxiety disorder may benefit from an intervention that trains them to focus their attention on neutral facial expressions more than negative ones, according to a report in AJP in Advance. In a clinical trial, participants with social anxiety disorder who received 10 sessions of an attention bias modification treatment over 12 weeks experienced similar symptom improvements as those who received 12 weeks of escitalopram—a first-line treatment for the disorder.

“Social anxiety disorder involves chronic fear and avoidance of scrutiny,” wrote Gal Arad, M.A., of Tel Aviv University, Daniel S. Pine, M.D., of the National Institutes of Mental Health, and colleagues. “Patients with social anxiety, as compared to healthy peers, dwell longer on scowling facial expressions, a tendency implicated in the maintenance of the disorder.”

To test if shifting one’s attention from negative expressions to more neutral ones might reduce social anxiety symptoms, Arad, Pine, and colleagues recruited 105 adults (average age 31) seeking treatment for social anxiety. The participants were randomly assigned to one of three groups:

• One group received 12 weeks of gaze-contingent music reward therapy (GC-MRT).
• Another received 12 weeks of escitalopram (up to 20 mg/daily).
• The third group was placed on a waitlist for 12 weeks.

Participants in the GC-MRT group received one introductory session the first week, where they learned about how GC-MRT works. Beginning week 2 through week 5, the participants received 10, 20-minute GC-MRT sessions twice a week, as well as one session weeks 8 and 11. In each session, the participants were shown a set of neutral and scowling faces on a computer screen. When the participants fixated on a neutral face, music played (from a music track they chose); when they shifted focus to a threatening face, the music stopped.

The researchers assessed the study participants halfway through the trial and again at week 13 using the clinician-rated total severity score on the Liebowitz Social Anxiety Scale and the self-reported Social Phobia Inventory.

Relative to the participants on the waitlist, those in the GC-MRT and escitalopram groups showed lower symptom severity at the midtreatment and posttreatment assessments. For comparison, the waitlist group showed minimal improvements on either scale.

“GC-MRT presents low demands on patients, is short term, and requires minimally trained professionals, making it a viable treatment option,” Arad, Pine, and colleagues wrote.

For related information, see the American Journal of Psychiatry article “Harnessing the Power of Gaze Through Music.”

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Sleep Apnea Linked to Increased Risk of Suicide Attempts

People who are diagnosed with sleep apnea may have an increased risk of dying by suicide, a study in the Journal of Psychiatric Research has found. Sleep apnea is a potentially serious disorder in which breathing repeatedly stops and starts during sleep.

Che-Sheng Chu, M.D., of Kaohsiung Veterans General Hospital in Kaohsiung City, Taiwan, and colleagues examined data from the Taiwan National Health Insurance Research Database. The researchers selected 7,095 adults aged 20 years or older who had been diagnosed with sleep apnea between 1998 and 2010 and 28,380 adults without sleep apnea who were matched based on their age, sex, and comorbidities (such as depressive disorder, diabetes, and/or substance use disorders). They then examined suicide attempts that took place during the follow-up period, which ended December 31, 2011 (all participants were followed up to at least one year after receiving a diagnosis).

Adults with sleep apnea had 4.53 times the risk of carrying out a suicide attempt during the follow-up period compared with those who did not have sleep apnea, after the researchers accounted for demographic data, mental disorders, and physical comorbidities. When the researchers excluded adults with mental disorders, patients with sleep apnea had 4.23 times the risk of carrying out a suicide attempt compared with those who did not have sleep apnea.

During the follow-up period, adults who had sleep apnea also had 3.86 times the risk of repeated suicide attempts compared with those who did not have sleep apnea—a risk that remained about the same when the researchers excluded adults with mental disorders.

The researchers noted several potential reasons for the increased risk of suicide attempts among adults with sleep apnea. For example, studies suggest that people with sleep apnea are more prone to cognitive decline, and people with cognitive impairment have a higher risk of attempting suicide, they wrote. Numerous studies also point to the toll that waking up throughout the night can have on mental health.

“[A]wakening at night leads to a high risk of suicide attempts due to increased utilization of substances, reduced social support, feeling[s] of loneliness, and decreased frontal lobe function,” the researchers wrote. “From clinical and public health perspectives, routine and frequent screening for suicidal ideation is important for patients with sleep apnea. Further studies are necessary to elucidate the pathophysiology of sleep apnea and suicidality.”

For related information, see the American Journal of Psychiatry article “The Evolving Nexus of Sleep and Depression.”

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Ready to Shake Up Mental Health Care? Innovation Lab Is for You!

APA’s Psychiatry Innovation Lab nurtures early-stage ideas and ventures by investing in them with mentorship, education, and collaboration opportunities within the community of mental health innovators. Submit video pitches of ideas that aim to improve mental health care delivery and how psychiatrists diagnose, treat, and manage patients by next Friday, March 31. Four finalists will be selected to pitch their ideas to a panel of judges and audience members at APA’s 2023 Annual Meeting.

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Antipsychotic Polypharmacy at Higher Doses Does Not Increase Hospitalization Risk, Study Finds

Patients with schizophrenia appear to be at a lower risk of hospitalization for physical health issues when taking high doses of two or more antipsychotic medications concurrently (polypharmacy) than when taking just one antipsychotic medication (monotherapy) at the same dose, according to a study published yesterday in AJP in Advance.

“When patients were treated with high-dose antipsychotic monotherapy …, they had approximately a 20% higher risk of severe cardiovascular outcomes leading to hospitalization compared with periods when the same patients were treated with corresponding high-dose combination therapy,” wrote Heidi Taipale, Ph.D., of the University of Eastern Finland and colleagues.

The study included data collected from 61,889 patients diagnosed with schizophrenia who were alive on January 1, 1996, and had received inpatient care, as documented in Finland’s nationwide Hospital Discharge register. Taipale and colleagues tracked these patients up until December 31, 2017, or until they died, whichever occurred first. They specifically compared the patients’ nonpsychiatric and cardiovascular hospitalizations during periods when they were receiving antipsychotic polypharmacy versus monotherapy. The researchers also compared differences in outcomes according to antipsychotic exposure by further dividing the groups according to the following defined daily doses (DDDs): <0.4, 0.4 to <0.6, 0.6 to <0.9, 0.9 to <1.1, 1.1 to <1.4, 1.4 to <1.6, and ≥1.6. (A DDD of 1.0 reflects the average dose of a medication prescribed to an adult, according to the World Health Organization.)

Here are some of the findings they reported:

• About 46.4% of patients had used high-dose (≥1.6 DDDs/day) monotherapy and 52.6% had used high-dose polypharmacy.
• During the follow-up period (about 15 years), 45,013 patients experienced nonpsychiatric hospitalization and 13,893 experienced cardiovascular hospitalization.
• The risk of nonpsychiatric hospitalization was 13% lower when patients were taking high-dose antipsychotic polypharmacy compared with when taking high-dose monotherapy.
• The risk of cardiovascular hospitalization was 18% lower when patients were taking high-dose antipsychotic polypharmacy compared with when taking high-dose monotherapy.

“Our results on antipsychotic use in a large nationwide cohort over a long follow-up show that antipsychotic polypharmacy is associated with lower risk of hospitalizations for physical health issues than monotherapy in the maintenance treatment of schizophrenia when high total dosage is assessed,” the authors concluded. “The current recommendations of treatment guidelines categorically encouraging use of monotherapy instead of polypharmacy are not based on evidence and should take a more agnostic approach to this issue.”

For related information, see the Psychiatric News article “Two Studies Analyze Add-On Treatments for Schizophrenia.”

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Ready to Shake Up Mental Health Care? Innovation Lab Is for You!

APA’s Psychiatry Innovation Lab nurtures early-stage ideas and ventures by investing in them with mentorship, education, and collaboration opportunities within the community of mental health innovators. Submit video pitches of ideas that aim to improve mental health care delivery and how psychiatrists diagnose, treat, and manage patients by next Friday, March 31. Four finalists will be selected to pitch their ideas to a panel of judges and audience members at APA’s 2023 Annual Meeting.

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Parents May Underestimate Frequency of Mental Health Concerns Among College Students

College students are far more likely to report having experienced an eating disorder, depression, or suicidal ideation compared with what parents report knowing about their children’s experiences with mental illness, according to a UnitedHealthcare report published today.

“It may not be surprising that some students and parents have different perceptions of the college experience, but this report demonstrates the need to create environments for ongoing meaningful conversations with these emerging adults,” said Donald Tavakoli, M.D., national medical director for behavioral health with UnitedHealthcare, in a news release.

The 2022 College Student Behavioral Health Report was conducted by YouGov, an international Internet-based market research and data analytics firm. YouGov surveyed 1,034 participants, 506 of whom were current college students, and 528 of whom were the parents of college students. The participants completed online surveys from August 8 to 14, 2022. Most of the students surveyed (85%) reported being enrolled in a health insurance plan.

The survey revealed significant gaps in parents’ understanding of their children’s mental health concerns. For every 10 students who reported seeking help for themselves or a friend in the last year, only eight parents reported they knew their child sought help. The disconnects between students’ experiences and parents’ perception of their child’s mental health include the following:

• 41% of students reported experiencing depression, compared with 22% of parents reporting their child experienced depression.
• 13% of students reported experiencing suicidal ideation or intent, compared with 4% of parents reporting their child experienced suicidal ideation or intent.
• 11% of students reported experiencing an eating disorder, compared with 5% of parents reporting their child experienced an eating disorder.
• 6% of students reported experiencing a substance use disorder (SUD), compared with 4% of parents reporting their child experienced an SUD.

Further, students who did not seek help for their mental health concerns, but said they needed help, reported the following reasons:

• 40% said help was too expensive.
• 28% said it took too long to get an appointment.
• 25% said they did not know where to find mental health resources.
• 20% said they were concerned about their parents finding out.
• 14% said they were concerned about friends or classmates finding out.

Students who reported experiencing a mental health concern during the past year were twice as likely as those who did not to express doubts about graduating on time. Among those who experienced an SUD, 94% expressed doubts about graduating on time, and 88% of those who experienced suicidal ideation or intent expressed such doubts.

“We need to work with students to educate them on their options for mental and behavioral support,” Tavakoli said in the release. “Colleges, parents, health care providers, and health plans all can play a role in supporting navigation to appropriate care.”

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

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Breast Cancer in Women With Severe Mental Illness Often Undertreated, Review Suggests

Women with severe mental illness (SMI)—such as schizophrenia, bipolar disorder, or major depression—are less likely to receive recommended treatment for breast cancer than those without SMI, according to a report in Psycho-Oncology.

Prior studies suggest that death from breast cancer is higher among patients with preexisting SMI compared with those without mental illness. Such higher death rates may be the result of reduced access to early cancer screening; delays in seeking cancer care; and/or a lack of collaboration between psychiatrists, primary care physicians, and oncologists, wrote Steve Kisely, M.D., Ph.D., of the University of Queensland in Australia and colleagues.

Curious about the barriers that patients with SMI experience following a breast cancer diagnosis, the authors compiled and reviewed articles that reported data on whether an SMI diagnosis impacted the receipt of guideline-appropriate cancer treatment (for example, surgery, chemotherapy, radiotherapy, and/or adjuvant endocrine therapy) for adult female breast cancer patients.

Kisely and colleagues included 13 studies in the review, which included a total of 299,193 participants. Of these, four studies estimated the odds of receiving guideline-appropriate breast cancer treatment in people with schizophrenia and related psychotic disorders and/or mood disorders; these were included in a meta-analysis.

The pooled data from the four studies showed that patients with SMI were about 17% less likely to receive guideline-recommended cancer treatment than those without SMI. Kisely and colleagues also found “that patients with bipolar disorders, schizophrenia, and other psychotic disorders had a significantly higher risk of delays to starting cancer treatment of 2 months or more after breast cancer diagnosis, and they were less likely to initiate their adjuvant hormonal therapy within 1 year of their diagnosis.”

The authors concluded, “Our results suggest that greater action is needed to improve access to guideline-appropriate care for breast cancer outcomes of psychiatric patients. In the area of colorectal cancer, people with schizophrenia who received case management including education on screening and patient navigation had higher participation rates compared [with] controls who had treatment a usual. This approach might also be applied to breast cancer treatment including the use of navigators, in combination with collaborative care between general practitioners, oncology, and mental health services.”

For related information, see the Psychiatric Services article “Association Between the Maryland Medicaid Behavioral Health Home Program and Cancer Screening in People With Serious Mental Illness.” 

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Postoperative Delirium Associated With Accelerated Cognitive Decline, Study Finds

Older adults who develop delirium after a surgery may experience faster cognitive decline than those who do not develop post-surgery delirium, suggests a report in JAMA Internal Medicine. The findings are based on cognitive data collected up to six years after the participants’ elective surgeries.

“Delirium is recognized as a common and serious disorder and represents the most frequent postoperative complication in older adults,” Zachary J. Kunicki, Ph.D., M.S., M.P.H., of Brown University and colleagues wrote. “With growing recognition of the association of delirium with a higher risk for long-term cognitive decline and dementia, a better understanding of the association between these conditions is greatly needed.”

Kunicki and colleagues analyzed data from the Successful Aging after Elective Surgery (SAGES) cohort, which included 560 adults aged 70 years and older who showed no signs of dementia and were scheduled for an elective surgery. The SAGES participants received daily delirium assessments following surgery until discharge. The researchers then tracked the participants’ cognitive performance using a variety of tests (including tests of attention, memory, and language) 11 times for six years.

Of the 560 participants in the study, 134 (24%) developed delirium following surgery. On average, adults who did and did not develop postoperative delirium experienced similar cognitive trajectories: They had some noticeable cognitive decline in the first month following their surgery, followed by a month of small cognitive improvements, and then stable cognition or minimal decline for about 2.5 years. Between 2.5 years and 6 years, the participants experienced greater cognitive decline.

Across all time points, however, the adults who had postoperative delirium experienced greater cognitive declines than the adults who did not have postoperative delirium. After 72 months, general cognitive performance scores (an average of participants’ cognitive tests) dropped by an average of 5.79 points in the delirium group compared with 3.53 points in the no-delirium group. These findings suggest “delirium was associated with a 40% faster pace of cognitive decline compared with the comparison groups that provide estimates of normal cognitive aging,” the researchers wrote. “[I]t remains uncertain if delirium causes subsequent cognitive decline or if persons with preclinical brain disease are more likely to develop delirium.”

They continued, “While further study is needed, the current study’s results support … the potential importance of delirium prevention in older adults who are undergoing elective surgery.”

To read more about this topic, see the Psychiatric News article “Meta-Analysis Explores Delirium Medication Option.”

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1 in 5 Deaths by Suicide Related to Intimate Partner Problems

One in five deaths by suicide is related to problems with current or former intimate partners such as divorce, separation, romantic breakups, arguments, jealousy, conflicts, and intimate partner violence, a study in the American Journal of Preventive Medicine has found.

Ayana Stanley, Dr.P.H., of the Centers for Disease Control and Prevention Division of Violence Prevention and colleagues analyzed data from the National Violent Death Reporting System for 402,391 adults who died by suicide between 2003 and 2020. They compared the circumstances leading up to suicide deaths related to intimate partner problems with suicide deaths not related to intimate partner problems.

People whose suicide deaths were related to intimate partner problems compared with those who were not had greater odds of the following:

• 6.5 times the odds of having experienced interpersonal violence.
• 4.1 times the odds of having arguments with others such as family, friends, and associates.
• 2.7 times the odds of having a history of suicidal thoughts.
• 2.2 times the odds of interpersonal violence victimization.
• 2.1 times the odds of having a depressed mood.
• 2.0 times the odds of having financial problems.
• 2.0 times the odds of having problematic alcohol use.
• 1.6 times the odds of having recent legal problems.

Aside from problematic alcohol use, there was no significant difference between the two groups regarding problematic substance use.

“[T]he present study underlines the increased association of mental health problems among suicide decedents specifically experiencing [intimate partner problems] compared to those who did not. A partner relationship marked by interpersonal conflict and violence may contribute to or exacerbate mental health problems. Conversely, mental health problems may also contribute to difficulties experienced within an intimate partner relationship,” Stanley and colleagues wrote.

“Additionally, experiencing an acute adverse life event (like deciding to divorce or experiencing intimate partner violence) could contribute to an impulsive suicide attempt among individuals who did not previously have a suicide plan,” the researchers continued. “Thus, monitoring by clinicians, mental health providers, and the helpful connectedness of … family and friends of non-suicidal individuals encountering severe adverse life events is paramount.”

For related information, see the Psychiatric Research & Clinical Practice article “Recent Stressful Experiences and Suicide Risk: Implications for Suicide Prevention and Intervention in U.S. Army Soldiers.”

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Got an Idea? Submit a Video ‘Elevator Pitch’

The Psychiatry Innovation Lab is a platform to accelerate innovative ideas and ventures that aim to improve the delivery of mental health care. Those interested in participating are asked to submit a video pitch of their idea. These pitch videos, which should feature the problem, the proposal to solve the problem and business model, should be three to five minutes in length. All proposals are due by Friday, March 31. Finalists will present their ideas at the live showcase at APA’s Annual Meeting on Monday, May 22, at the Mental Health Innovation Zone in San Francisco. Awards will be given to the best ideas!

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Certain Patients With OUD Remain at Risk of Overdose After Entering Treatment

Patients who enrolled in a trial of medication treatment for opioid use disorder (OUD) who did not start or complete their assigned medication were at greater risk of experiencing an overdose than those who took their medication, according to a study published in The American Journal of Psychiatry.

“A substantial body of evidence has shown that treatment with medication for opioid use disorder (MOUD) can decrease both overdose risk and all-cause mortality among people with opioid use disorder,” wrote Laura Brandt, Ph.D., of City College of New York and colleagues. “The aim of this study was to estimate the risk of overdose events once a patient is diagnosed with OUD and engaged in MOUD treatment and to test whether the assignment to a medication (methadone, buprenorphine, extended-release naltrexone) influences this risk.”

Brandt and colleagues used data from three large MOUD clinical trials that included 2,199 adult participants with OUD:

• In the first study, participants received outpatient methadone or buprenorphine treatment for 24 weeks. Adverse events such as overdoses were reported weekly.
• For the second study, participants received counseling and buprenorphine for three to four weeks and were followed for an additional four to eight weeks. Those who did not maintain abstinence received buprenorphine treatment for 12 weeks followed by a four-week taper period. Adverse events were reported biweekly.
• Participants in the third study received outpatient buprenorphine or extended-release naltrexone over 24 weeks. Adverse events were reported weekly.

Fifty-seven overdose events occurred in the three studies, experienced by 51 participants. Fifteen overdoses occurred among 283 participants assigned to naltrexone (5.3%), eight among 529 participants assigned to methadone (1.51%), and 16 among 1,387 patients assigned to buprenorphine (1.15%). Nearly 28% of the participants assigned to naltrexone never started the medication, compared with only 2.2% of those assigned to buprenorphine and 1.7% of those assigned to methadone. Those who did not start naltrexone had an overdose rate of 8.9% compared with 3.9% among those who did start the medication.

Overall, the risk of experiencing an overdose was significantly higher among those who never started their assigned medication or who stopped their medication. Further, taking benzodiazepines at baseline was associated with an increased risk of an overdose among participants in all three medication groups.

“Patients should be educated about overdose risk, the protective effect of MOUD, and the danger of discontinuing medication,” the authors concluded. “Benzodiazepine use is also a signal of risk, and patients taking benzodiazepines should be evaluated and treated for mental health problems as part of an effort to wean them off benzodiazepines.”

For related information, see the Psychiatric Services article “Factors Associated With Initial Treatment Choice, Engagement, and Discontinuation for Patients With Opioid Use Disorder.”

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Got an Idea? Submit a Video ‘Elevator Pitch’

The Psychiatry Innovation Lab is a platform to accelerate innovative ideas and ventures that aim to improve the delivery of mental health care. Those interested in participating are asked to submit a video pitch of their idea. These pitch videos, which should feature the problem, the proposal to solve the problem and business model, should be three to five minutes in length. All proposals are due by Friday, March 31. Finalists will present their ideas at the live showcase at APA’s Annual Meeting on Monday, May 22, at the Mental Health Innovation Zone in San Francisco. Awards will be given to the best ideas!

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California Insurance Law Linked to Increase in Gender-Affirming Surgery

Individuals with gender dysphoria who lived in California were significantly more likely to undergo gender-affirming surgery following the 2013 implementation of a state law prohibiting insurance discrimination against gender-affirming care compared with those living in Arizona and Washington, where no such law exists. That was the finding from a study of 25,252 transgender and gender-diverse patients in California, Washington, and Arizona that was published yesterday in JAMA.

The increase appeared significant among patients with private insurance or Medicaid, but not patients paying out of pocket.

“The findings suggest that the legislation, which prohibited insurance denial of health care benefits based on patient sex, gender, gender identity, or gender expression, facilitated access to gender-affirming surgery among insured patients with a diagnosis of gender dysphoria,” wrote Anna Schoenbrunner, M.D., of The Ohio State University and colleagues.

The researchers compared the number of gender-affirming surgeries from January 1, 2005, to June 30, 2013 (prior to implementation of California’s Insurance Gender Nondiscrimination Act) and July 1, 2013, to December 31, 2019 (after implementation of the law), for 17,934 individuals with gender dysphoria in California and 7,328 individuals with gender dysphoria in Arizona and Washington.

In California, 2,715 admissions (15.1%) had at least one gender-affirming surgery within the study period. In Arizona and Washington, 203 (2.8%) patients underwent at least one gender-affirming surgery. Patients’ median age at time of surgery was 34 years in California and 39 years in Arizona and Washington; 51.2% identified as female, 46.2% as male, and 2.5% as unknown.

Before the implementation of the Insurance Gender Nondiscrimination Act, 66 California sites performed a median of one gender-affirming procedure per site; after implementation, 106 sites performed a median of two procedures per site. In both Arizona and Washington, the number of sites performing gender-affirming procedures dropped in the same period.

After the implementation of the California law, there was an increase of 5.7 surgeries per quarter in the state compared with 0.41 surgeries per quarter in Arizona and Washington. The law was associated with a 12.1% increase in the probability that a patient with gender dysphoria would receive gender-affirming surgery in California compared with Arizona and Washington.

“These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients,” the authors wrote.

For related information, see the Psychiatric News article “APA Joins Amicus Against Arkansas Law Banning Gender Affirming Therapy.”

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COVID-19 Stress During Pregnancy Associated With Worse Postpartum Outcomes

Experiencing high levels of stress during pregnancy is known to place mothers and their infants at risk of mental health problems. A report published today in JAMA Network Open highlights some of the impact that worries about COVID-19 may have had on the mental health of women and their offspring.

In a longitudinal study, Susanne Schweizer, Ph.D., of the University of Cambridge and colleagues found that “COVID-19–related stress was significantly associated with maternal postpartum distress, depression, and GAD [general anxiety disorder] as well as infant negative affectivity, even when controlling for COVID-19 risk reported during the pandemic.”

The results were based on data collected as part of the COVID-19 Risks Across the Lifespan, which included women from Australia, the United Kingdom, and the United States. A total of 318 women who reported being pregnant at the first assessment wave that took place between May 5 and September 30, 2020, and completed follow-up assessments between October 28, 2021, and April 24, 2022, were included in the analysis.

In addition to completing the 8-item Patient Health Questionnaire and the 7-item General Anxiety Disorder scale, the study participants completed the following assessments:

• The 9-item Pandemic Anxiety Scale, which asked participants about their level of agreement with such statements as “I’m worried that I will catch COVID-19.”
• The 10-item Postpartum Distress Measure, which asked participants about their level of agreement with such statements as “I have recurring thoughts about harm coming to my baby, my family, or myself.”
• The 37-item Infant Behavior Questionnaire, which assessed negative affectivity (for example, how teary the baby was at the end of an exciting day), positive affectivity (for example, how much the baby laughed), and more.

Antenatal COVID-19–related stress was significantly associated with depression, general anxiety disorder, and postpartum distress among mothers 8 to 22 months postpartum. Among infants, antenatal COVID-19–related stress was selectively associated with negative affectivity but not positive affectivity or orienting behaviors (for example, spending more than five minutes looking at pictures in books).

“These results echo the findings of others that antenatal stress is detrimental to the postpartum mental health of both mother and child,” Schweizer and colleagues wrote. “More specifically, our findings demonstrate the association of pandemic-related stress with these adverse outcomes, highlighting the need to prioritize mental health care as part of antenatal care guidelines during pandemics.”

For related information, see the Psychiatric News article “Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions.”

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Family Bereavement Program Offers Long-Term Protection Against Depression

Children who experience the death of a parent are known to be at an increased risk of depression and other internalizing problems later in life. A study in the Journal of the American Academy of Child & Adolescent Psychiatry has found that children who together with their families participated in a bereavement program within 2.5 years of the death were less likely to experience depression up to 15 years later.

“The findings from this study have implications for future research on the prevention of depression,” wrote Irwin Sandler, Ph.D., of Arizona State University and colleagues.

Sandler and colleagues enrolled 244 youth aged 8 to 16 who had experienced the death of a parent 3 to 30 months prior to the study and their caregivers for a randomized, controlled trial. A total of 156 families participated in 12 sessions of a family bereavement program or were mailed three age-appropriate books about dealing with grief (literature control).

The family bereavement program included separate group sessions for the children and their caregivers. The caregiver sessions focused on supporting grieving caregivers, strengthening positive parenting techniques such as active listening, and reducing children’s exposure to stressful life events. The youth sessions focused on strengthening positive coping and emotion regulation skills. The children and their caregivers then came together for two joint sessions, where they could together practice their learned skills.

Sandler and colleagues conducted follow-up interviews with the youth to assess grief, intrusive thoughts, internalizing symptoms, depression, and anxiety; these interviews were conducted immediately after the family bereavement or control program, 11 months later, 6 years later, and 15 years later. A total of 186 children (now adults) were still in the trial at the 15-year follow-up.

Between the 6- and 15-year follow-up, 13.46% of the adults who had participated in the family bereavement program as children met the criteria for depression (assessed with the World Health Organization’s World Mental Health Composite International Diagnostic Interview) compared with 28.05% of those in the literature group; 4.81% of the adults who participated in the family bereavement program as children had generalized anxiety disorder as adults compared with 12.20% in the literature group.

After adjusting for multiple variables, Sandler and colleagues calculated that youth who participated in the family bereavement program were 67% less likely to have depression 15 years later compared with youth who had not participated in the program. Youth who participated in the family bereavement program were also less likely to develop anxiety disorders as adults.

“It may [be] that the FBP [family bereavement program] reduces MDD [major depressive disorder] in part through its reduction of negative self-referential processing of the stressors involved in grappling with academic, career, and romantic developmental tasks of early adulthood,” Sandler and colleagues wrote. “Future research is needed to study how preventive interventions such as the FBP may reduce negative self-referential processing as a pathway to the prevention of MDD.”

To read more on this topic, see the American Journal of Psychiatry study “CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial.”

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Combined Motivational Interviewing, CBT Found to Increase Motivation in People With Schizophrenia

People with schizophrenia are known to experience motivational deficits (for example, defeatist beliefs and social withdrawal) that can hinder their ability to engage in social and occupational activities. A study published yesterday in The American Journal of Psychiatry found that patients who participated in weekly group therapy sessions that combined motivational interviewing and cognitive-behavioral therapy (CBT) for three months experienced greater improvements in motivation and pleasure than those who did not receive the combined therapy.

“While there have been advances in pharmacological interventions for positive symptoms, they have had a minimal impact on daily functional outcomes for those living with the illness,” wrote L. Felice Reddy, Ph.D., of the Department of Veterans Affairs (VA) VISN 22 Mental Illness Research, Education, and Clinical Center in Los Angeles. “Our results are encouraging for psychosocial interventions aiming to improve quality of life for people with schizophrenia and indicate specific directions for future clinical research.”

For the study, Reddy and colleagues recruited adults with schizophrenia from outpatient clinics at the VA Greater Los Angeles Healthcare System. To be included, patients had to be clinically stable (for example, no inpatient hospitalizations during the three months prior to enrollment) and have moderate to severe levels of motivational negative symptoms (defined as a score of 15 or greater out of 36 on the motivation and pleasure subscale of the Clinical Assessment Interview for Negative Symptoms).

A total of 79 patients with schizophrenia experiencing moderate to severe negative symptoms were randomly assigned to one of two groups who received 12, one-hour weekly group therapy sessions:

• One group received integrated motivational interviewing (MI) and CBT: These weekly sessions focused on building motivation for goals; establishing a commitment to change; and resolving ambivalence with CBT-based behavioral activation, problem solving, and cognitive restructuring exercises.
• The other group (control) received mindfulness-based stress reduction therapy: These weekly sessions incorporated short videos, didactics, and experiential practice.

The researchers used several scales to evaluate the participants’ clinical symptoms and functioning three times over the course of the study, which included 12 weeks of active treatment and 12 weeks of follow-up. They also evaluated the participants’ pupillary response, as a biological marker of motivated effort on a cognitive task.

While the MI-CBT group showed significant improvement in motivational negative symptoms after 12 weeks, the active control group did not, Reddy and colleagues reported. At follow-up, participants in the MI-CBT group continued to show improvements in motivation and pleasure from baseline; however, the differences between the MI-CBT and control groups were less than during the active treatment period. Similarly, the MI-CBT group showed an increase in average pupil dilation from baseline to 12 weeks, but the control group did not; however, this effect did not persist over the follow-up period. There were no significant differences between the groups in terms of functioning.

“Evidence for the efficacy of negative symptom interventions is growing, and our results provide additional support,” Reddy and colleagues wrote. “A critical direction for future research is to translate these gains to lasting improvements in daily functioning.”

For related information, see the Psychiatric Services articles “Treatment Implications of Situational Variability in Cognitive and Negative Symptoms of Schizophrenia” and “Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals With Schizophrenia.”

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Risk of Dementia May Be Reduced by Vitamin D Supplementation

Older adults who take vitamin D may be 40% less likely to develop dementia compared with those who do not, according to a study published in Alzheimer’s & Dementia.

“Vitamin D deficiency may be a modifiable risk factor [for dementia] and has been recognized as a widespread health problem, with a worldwide prevalence of up to 1 billion,” wrote Zahinoor Ismail, M.D., of the University of Calgary and colleagues. “Yet, the role of vitamin D supplementation as a potential intervention has been a subject of debate and remains in equipoise.”

Ismail and colleagues used 2005-2021 data from the National Alzheimer’s Coordinating Center (NACC), which includes data on cognitive functioning from participants in the Alzheimer’s Disease Research Center. NACC collects demographic and standardized clinical data annually. Participants who had either normal cognition or mild cognitive impairment at baseline were included in the study. They were then divided into two groups: the vitamin D–exposed group, those who were taking either calcium-vitamin D, cholecalciferol (vitamin D3), or ergocalciferol (vitamin D2) at baseline; and the non-exposed group, those who were not taking vitamin D supplements during the study period (or prior to a dementia diagnosis).

A total of 12,388 participants were included, with 4,637 in the vitamin D–exposed group and 7,751 in the non-exposed group. After five years, 83.6% of those exposed to vitamin D had not developed dementia, compared with 68.4% of those not exposed to vitamin D. After controlling for baseline age, sex, education, race, cognitive diagnosis, depression, and APOE ε4 status (a gene associated with an increased risk of Alzheimer’s), almost 75% of those who developed dementia over 10 years had no exposure to vitamin D prior to their diagnoses. These findings were consistent across all vitamin D formulations included in the study.

Additional findings included the following:

• Women taking vitamin D had lower rates of dementia compared with men taking vitamin D.
• Though mild cognitive impairment at baseline was associated with more dementia diagnoses after five years compared with normal cognition at baseline, exposure to vitamin D was associated with lower odds of developing dementia after five years among both those with mild cognitive impairment and normal cognition at baseline.
• Though a depression diagnosis was associated with a 35% greater incidence of dementia, the study did not identify any significant interaction between depression and vitamin D exposure.

“[O]ur findings implicate vitamin D as a potential agent for dementia prevention and provide additional support for its use in at-risk individuals,” the authors wrote. “Information on dosage of vitamin D supplementation as well as the baseline levels of vitamin D will be essential to further clarify the efficacy and refine the target population for vitamin D supplementation in preventing [Alzheimer’s] and dementia.”

For related information, see the Psychiatric News article “Study Finds Selenium, Vitamin E Do Not Prevent Dementia.”

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Entering Treatment After First Episode of Psychosis May Reduce Risk of Self-Harm

Young people who began treatment within 14 days of being diagnosed with first-episode psychosis (FEP) were less likely to deliberately harm themselves than those who did not initiate treatment, according to a report in Psychiatric Services. The findings were based on data collected from Ohio Medicaid claims for more than 6,300 youth with FEP.

“Given the high rates of suicide in this population, our findings suggest a great need for suicide-specific interventions for individuals in the early course of a psychotic disorder,” wrote Heather Wastler, Ph.D., an assistant professor of psychiatry at the Early Psychosis Intervention Center at Ohio State University Medical Center, and colleagues.

Wastler and colleagues focused their analysis on 6,349 adolescents and young adults aged 15 to 24 years who were enrolled in Ohio Medicaid and were diagnosed with FEP between June 30, 2010, and December 31, 2017. They compared deliberate self-harm among those who did and did not initiate treatment after being diagnosed with FEP and among those who engaged or did not engage in treatment after initiation. Treatment initiation was defined as an inpatient admission or at least one psychotherapy session (individual, family, or group), medication management visit, or partial hospitalization within 14 days of an FEP diagnosis. Treatment engagement was defined as at least two of the same forms of treatment within 90 days of treatment initiation.

A total of 4,419 (69.6%) of the youth initiated treatment within 14 days of their FEP diagnosis; 55% of these youth engaged in treatment during the 90-day period. The researchers tracked the outcomes of the youth up to 365 days from the end of the initiation or engagement period, with follow-up ending at the first deliberate self-harm claim, the end of Medicaid enrollment, death, or the end of the study period (December 31, 2017).

A total of 229 individuals deliberately harmed themselves during the follow-up period. Of the 4,419 youth who initiated treatment, 134 (3.0%) deliberately harmed themselves at least once; among the 1,930 youth who did not initiate treatment, 95 (4.9%) deliberately harmed themselves.

“Given the established relationship between positive symptoms and suicide-related outcomes, it’s possible that this initial contact reduces DSH [deliberate self-harm] through the stabilization of psychotic symptoms with antipsychotic medication,” Wastler told Psychiatric News. “Another potential explanation is that providers might deliver brief evidence-based interventions such as crisis response planning, safety planning, or lethal-means counseling during the first treatment contact.”

Among the 2,431 who continued treatment, 64 (2.6%) deliberately harmed themselves during the follow-up period compared with 42 (2.1%) of those who discontinued treatment.

Wastler said that more sessions may be needed to reduce deliberate self-harm. She also noted that other factors, such as the quality of care received or the patients’ motivation for treatment, may have influenced the findings.

For related information, see the Psychiatric News article “New Network Collects Real-Time Data to Improve Treatment of Early Psychosis.”

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Experts at AAGP Annual Meeting Offer Tips for Taking Older Patients’ Medication History

Psychiatrists who treat older patients should review their patients’ medications very carefully, particularly when they are seeing a patient for the first time after a referral from a hospital, speakers at the American Association for Geriatric Psychiatry (AAGP) 2023 Annual Meeting in New Orleans said yesterday.

“More than 60% of medication reconciliation errors occur during transitions of care, usually on hospital admission, but then they perpetuate down the line” with each transition, such as from general hospital to psychiatric hospital, or upon discharge to home or another facility, said Paula Lester, M.D., in a presentation titled “Medication Reconciliation: Paperwork Saves Lives.” She is an associate professor of medicine at New York University (NYU) Long Island School of Medicine. “This is even more true for psychiatric patients, especially geriatric psychiatric patients because they have more frequent and longer admissions, and they have more care transitions.”

Lester added that older patients with mental illness often end up being transferred from a general hospital to a psychiatric hospital or vice versa, and that the electronic health record systems may not integrate well with one another. Furthermore, hospitalists in other specialties may be unaware of possible interactions between psychiatric medications and the medications they prescribe, she added.

Mark Shen, Pharm.D., a clinical pharmacist in care transitions at NYU Langone Hospital–Long Island, advised that psychiatrists try to use two sources of information when taking a complete medication history, such as the patient, caregiver, other physicians involved in the patient’s care, or the discharging hospital.

“One source might not be fully correct, and the other source might not be fully correct. It’s up to you to match those two lists together and come up with a list that makes sense,” Shen said.

Shen also suggested asking open-ended questions when speaking with patients, such as the following:

• What medications, including prescription, over the counter, and supplements, do you take?
• What medications do you take each day?
• What medications do you take only sometimes? For what symptoms do you take these medications?
• What medications do you take that are not pills (for example, eye drops, creams, patches, long-acting injectables)?
• What time do you take the medications
• Do you have any issues with unintended effects?

If patients do not take a medication as prescribed, psychiatrists should ask them why, Lester said.

“Sometimes there are good reasons why, [such as] side effects or they’ve taken it before and had a bad experience so they’re afraid of taking it again,” Lester said.

For related information, see the Psychiatric News article “To Improve Safety in Older Patients, Consider Deprescribing.”

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