Age at Onset of Problem Drinking May be Poor Predictor of Outcomes, Study Finds

People who begin to experience problem drinking after the age of 60 can benefit from treatment and may have better mental functioning than those who develop problem drinking earlier in life, according to a study published this week in Alcohol: Clinical and Experimental Research.

“Age of onset of problem drinking, that is, the age at which a person first experiences problems in relation to their drinking, has long been regarded as an important criterion in distinguishing between types of drinkers and in determining longer-term prognosis,” wrote Jennifer Seddon, Ph.D., M.Sc., of Oxford Brookes University and colleagues.

Seddon and colleagues used data from the U.K.-based Drink Wise, Age Well program, which provides resources to people aged 50 and older who experience alcohol problems. Participants were grouped based on the age at which they first experienced problem drinking: early onset (younger than 25 years); mid onset (25 to 39 years), late onset (40 to 59 years), and very late onset (older than 60 years).

The authors assessed participants’ alcohol use using the Alcohol Use Disorders Identification Test (AUDIT); a score of 20 or greater indicates high levels of alcohol problems and possible dependence. Further, they assessed participants’ mental health status with the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, and the 14-item Warwick Edinburgh Mental Well-being Scale. Cognitive impairment was assessed with the Montreal Cognitive Assessment. Finally, the authors collected information from participants on the number of days they drank in the past month, the number of drinks consumed on a typical drinking day, and their experiences with previous alcohol treatment.

Among 780 participants, 85 (11%) first experienced problem drinking at age 60 years or older. Those who began problem drinking after age 60 had significantly lower AUDIT scores (19.41 compared with scores ranging from 22 to 25 in the other age groups). After controlling for the effects of age, the researchers found that the cognitive functioning of the very late onset group was not significantly different from that of the other groups; they also found that these participants had significantly lower levels of depression and significantly better mental health well-being. Additionally, the age at which participants developed problem drinking was not associated with treatment outcomes, such as treatment completion.

“The results of this study suggest that older adults can benefit from alcohol treatment irrespective of age of problem drinking onset, and age of onset of problem drinking may be a poor predictor of treatment outcome,” the authors wrote.

For related information, see the Psychiatric News article “Underage Drinking Declines, But Extreme Binge Drinking Rises.”

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Depression Associated With Hormonal Contraception Linked to Higher Risk of Postpartum Depression

Women who have a history of developing depression after initiating hormonal contraception may have a greater risk of developing postpartum depression, according to a study published yesterday in JAMA Psychiatry.

“[A] woman’s reproductive life span is a time of heightened vulnerability for depression,” and initiating hormonal contraception has also been associated with an increased risk of developing a depressive episode, wrote Søren Vinther Larsen, M.D., of Copenhagen University Hospital and colleagues. “This study provides evidence for the existence of a subgroup of women who are sensitive to hormonal transitions across the reproductive life span.”

Vinther Larsen and colleagues used health care data from Danish national registers and included all women born in Denmark after 1978 who delivered their first child between 1996 and 2017. Participants were excluded if they had a multiple birth or stillbirth; had never used hormonal contraception; or had a depressive episode before 1996 or within 12 months prior to delivery (as this could indicate an ongoing depression while entering pregnancy).

The researchers identified participants who, prior to giving birth, experienced a depressive episode within six months of starting hormonal contraception. Depressive episodes were defined as filling a prescription for an antidepressant or being diagnosed with depression. They then identified the participants who developed postpartum depression, which they defined as filling a prescription for an antidepressant or being diagnosed with depression within six months after childbirth.

The study included 188,648 first-time mothers, of whom 5,722 (3%) had a history of depression associated with hormonal contraception initiation and 18,431 (9.8%) had a history of depression that was not associated with hormonal contraception. Those with a history of depression associated with the use of hormonal contraception had a higher risk of developing postpartum depression than those whose past depressive episodes were not associated with hormonal contraception. Further, the risk of developing perinatal depression (including depressive episodes that occurred between the third trimester and six months postpartum) was also greater for participants who had a history of hormonal contraception–associated depression compared with those who did not.

“Importantly, the findings do not imply that [hormonal contraception] use leads to a higher risk of PPD [postpartum depression] but do indicate that a history of [hormonal contraception]–associated depression may unmask [postpartum depression] susceptibility, which may prove useful as a clinical tool in [postpartum depression] risk stratification,” the authors concluded.

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

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Prepare Now for End of Public Health Emergency, Telepsychiatry Experts Advise

In a webinar today, APA leaders in telepsychiatry urged psychiatrists to start working with their telepsychiatry patients now to prepare for the end of COVID-19 Public Health Emergency (PHE) on May 11.

Shaban Khan, M.D., director of child and adolescent telepsychiatry at NYU Langone and chair of the APA Committee on Telepsychiatry, and John Torous, M.D., director of the Digital Psychiatry Division at Beth Israel Deaconess Medical Center and chair of the APA Committee on Mental Health Information Technology, outlined what psychiatrists need to know about the status of telepsychiatry in terms of prescribing medications, licensing, HIPA-compliant modalities for telepsychiatry, and coverage and reimbursement.

“We know that the landscape of psychiatry has fundamentally changed with the rapid increase in telehealth modalities throughout the COVID-19 public health emergency,” said Khan. “Federal and state governments have some authority to maintain elements of these flexibilities, but cannot—or in some cases, choose not to—maintain them all. So, when the PHE ends on May 11, 2023, some flexibilities will remain on a permanent basis, some will phase out, and some remain uncertain.”

During the webinar, Khan shared one important new piece of information: The Centers for Medicare and Medicaid Services (CMS) will not reimburse for partial hospitalization services delivered in the patient’s residence beyond the PHE. Partial hospitalization services can be delivered only in hospitals and community mental health centers starting May 12.

Some PHE flexibilities were extended or made permanent under Medicare. These include the following:

• Audio-only telehealth services for mental health and substance use disorders will be reimbursed on a permanent basis.
• In-person visit requirements for mental health services have been deferred through the end of 2024.
• Restrictions on geographic originating sites (the location where a Medicare patient gets medical services through a telecommunications system) have been permanently removed, including patients’ homes.
• Psychiatrists will be reimbursed for telepsychiatry services at nonfacility rates through the end of 2023, but beginning on January 1, 2024, Medicare will revert to paying the lower facility rates.

Other Medicare policies will revert to their pre-PHE status. For instance, after May 11 psychiatrists cannot bill Medicare for services delivered in states in which they are not licensed (in fact, most states have already ended those licensure flexibilities). Additionally, psychiatrists must use HIPAA-compliant technology, although the government announced an extension on enforcing this for 90 days after the end of the PHE to August 9. “You can help your patients by starting now to adopt and teach them about HIPAA-compliant communications platforms,” Torous said.

Finally, virtual supervision of psychiatry residents treating Medicare beneficiaries is scheduled to end on May 11, though APA has asked CMS to reconsider this provision.

Still other policies, especially the details of prescribing controlled substances to telepsychiatry patients, are still to be determined. In February the Drug Enforcement Administration (DEA) proposed rules about how to maintain some telehealth prescribing flexibilities after the PHE. 

“APA submitted comments suggesting extensive revisions to these rules, but we will not know the final contents or timeline of the rules until the final rules are published in the Federal Register,” Torous said. “If not finalized, the rules will revert to pre-public health emergency rules.

“In addition, the current rules are vague on where you have to be to prescribe controlled substances, but it is safe to proceed under the assumption that you will continue to need a physical location in order to obtain a DEA registration in any given state and that you will need a DEA registration in order to prescribe in the state,” Torous said. “Like controlled substances prescribing, assume that you will need to be licensed where your patients are.”

Look to Psychiatric News for further updates and to the Telepsychiatry Toolkit, Telepsychiatry Blog, and COVID-19 and Telepsychiatry Frequently Asked Questions. Members may also register for a webinar in May titled “Telepsychiatry Reimbursement: Who Pays for What?”

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Suicidal Thoughts Linked to Sleep Problems in Patients With Early Psychosis

People with early psychosis (those who have had only a single episode of psychosis) who experience persistent sleep problems are nearly 14 times as likely to report suicidal ideation as those with early psychosis who do not experience sleep problems, according to a report in Schizophrenia Bulletin.

“[I]nsomnia may represent an important treatment target in psychosis,” wrote Brian J. Miller, M.D., Ph.D., of Augusta University and colleagues. Additionally, the “findings provide … evidence that formal assessment and treatment of insomnia and sleep disturbance is relevant to the clinical care of patients with early psychosis as a predictor of suicidal ideation and symptom severity.”

By some estimates, up to 50% of people with schizophrenia will experience insomnia over the course of their illness. Several studies have also pointed to associations between insomnia and more severe symptoms of schizophrenia. Miller and colleagues wanted to know if the same was true of people experiencing early psychosis.

The researchers analyzed data from 403 people who had participated in the Recovery After an Initial Schizophrenia Episode (RAISE) trial—a large-scale research initiative testing coordinated specialty care treatments for reducing symptoms and improving quality of life for patients with first-episode psychosis. The participants were aged 15 to 40 years; had been diagnosed with schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified; had experienced only one episode of psychosis; and had taken antipsychotics for no longer than six months.

Miller and colleagues were particularly interested in what the available data from the RAISE trial might reveal of the relationships between sleep problems, suicidal ideation, and psychopathology at baseline as well as at months 6, 12, 18, and 24. At each time point, participants were assessed for insomnia and suicidal ideation using the Calgary Depression Scale for Schizophrenia (questions included “Do you wake earlier in the morning than is normal for you?” and “Have you felt that life isn’t worth living?”). The participants were also evaluated using the Positive and Negative Syndrome Scale (PANSS).

Over the two-year period, the prevalence of sleep problems among RAISE participants ranged from 40% to 57%, and the prevalence of suicidal ideation ranged from 5% to 15%. Additional findings from the study included the following:

• Sleep problems were associated with significantly increased odds of suicidal ideation at baseline and 18 months.
• Sleep problems at any time point were associated with an over a threefold increased odds of suicidal ideation.
• Sleep problems were associated with higher PANSS total, positive, and general psychopathology scores at baseline and all follow-up visits.

The authors concluded, “Our findings provide additional evidence that formal assessment and treatment of insomnia and sleep disturbance is relevant to the clinical care of patients with early psychosis as a predictor of suicidal ideation and symptom severity. They also underscore the need for comprehensive suicide risk assessment in patients with early psychosis.”

For related information, see the American Journal of Psychiatry article “Sleep Abnormalities in Schizophrenia: State of the Art and Next Steps.”

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Brief Interpersonal Therapy May Reduce Prenatal Depression

Pregnant individuals experiencing elevated levels of depression may benefit more from weekly interpersonal therapy (IPT) sessions than those who receive mental health counseling and maternity social services. These findings were published in JAMA Psychiatry.

“Approximately 17% of pregnant individuals meet criteria for major depressive disorder (MDD) diagnosis, and up to 37% report elevated symptoms during pregnancy,” wrote Benjamin L. Hankin, Ph.D., of the University of Illinois at Urbana-Champaign and colleagues. IPT “focuses on psychoeducation and interpersonal skill building to decrease interpersonal conflict and increase interpersonal support and competence.”

Hankin and colleagues recruited 234 individuals aged 18 to 45 who were no more than 25 weeks’ pregnant from obstetrics clinics in the Denver metropolitan area from 2017 to 2021. All participants reported elevated depressive symptoms—defined by the authors as a score of ≥10 on the Edinburgh Postnatal Depression Scale (EPDS) screening tool; about 37% had a diagnosis of MDD as determined by the Structured Clinical Interview for DSM-5.

The study participants were randomized to receive eight, 50-minute sessions of MomCare (described by the authors as “a culturally relevant, collaborative care intervention that provides brief IPT”) or enhanced usual care. Participants in the MomCare group were taught about the link between feelings and interpersonal interactions, as well as strategies to resolve interpersonal conflicts contributing to depression symptoms. Enhanced usual care combined mental health counseling and maternity social services, including information on housing and essential items. The participants were assessed using the EPDS and 20-item Symptom Checklist (SCL-20) for depression at baseline and throughout the pregnancy.

Over the course of pregnancy, individuals receiving MomCare experienced greater drops in depression symptoms, as assessed both by the EPDS and the SCL-20. “The benefit of IPT resulted in significant improvement observed relatively quickly [6 to 11 weeks],” Hankin and colleagues noted. In addition, just 6.1% of mothers receiving MomCare had a MDD diagnosis following birth, compared with 26.1% of the enhanced usual care group.

“Given our robust findings showing substantial improvements in maternal depression during pregnancy, future research from the Care Project will follow the neonates from birth through childhood to test rigorously whether reducing depression during pregnancy affects the development of infants’ risk mechanisms for later emerging depression, anxiety, and other health problems,” the authors wrote.

To read more about this topic, see the Psychiatric News article “Mood Symptoms in Pregnant Women May Not Be Fully Resolved by SSRIs.”

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Nearly 6 in 10 Patients With Bipolar Disorder Do Not Fill All of Their Prescriptions

A majority of patients who are prescribed medications for bipolar disorder do not fill their prescriptions as often as they receive them, a study in the Journal of Affective Disorders has found.

Jonne Lintunen, M.D., Ph.D., of Niuvanniemi Hospital in Kuopio, Finland, and colleagues studied data from Finnish health and prescription registries for 33,131 adults who have bipolar disorder. The patients were diagnosed with bipolar disorder between 1987 and 2018, and the researchers followed dispensing rates of electronic prescriptions from 2015 to 2018. Among all patients, 61.8% had at least one prescription for a mood stabilizer, and 88.6% had at least one prescription for an antipsychotic medication.

Over the four-year follow-up, 59.1% of patients did not fill at least one of their prescriptions for a mood stabilizer or antipsychotic medication. Furthermore, 31% of patients did not fill their prescriptions for a mood stabilizer or antipsychotic medication at least 20% of the time. Among mood stabilizers, lithium had the lowest proportion of nondispensed medications, 11.3%, and valproic acid had the highest, 14.8%. Among antipsychotics that had at least 1,000 prescriptions, clozapine had the lowest proportion of nondispensed prescriptions, 9.0%, and asenapine had the highest, 31.4%. Paliperidone and haloperidol also had high proportions of nondispensed prescriptions, 24.3% and 23.2%, respectively.

Lintunen and colleagues offered a possible explanation for why patients might be more likely to fill their prescriptions for lithium or clozapine than some of the other medications studied.

“Both of these drugs require regular blood tests … ; patients may be more adherent to their medications when they meet health care workers regularly,” they wrote. “In addition, [these medications’] superior effectiveness may explain good adherence: lithium is the most effective mood stabilizer for bipolar disorder and it prevents both manic and depressive episodes. … Similarly, clozapine is known to be the most effective antipsychotic.”

The researchers also found that patients who were younger than 25 years, who were diagnosed with bipolar disorder within the previous three years, or who had four or more previous hospitalizations because of bipolar disorder had twice the odds of not filling at least one prescription for their bipolar medications over the four-year follow-up.

“The high proportion of non-adherent patients is alarming since non-adherence is a well-known risk factor for poor clinical outcomes in bipolar disorder. Therefore, more attention should be given to the reasons why patients choose not to use their medications,” the researchers wrote.

For related information, see the Psychiatric News article “Motivational Pharmacotherapy Can Improve Medication Adherence.”

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Tool Helps Predict Suicide Risk Among People With Serious Mental Illness

The Oxford Mental Illness and Suicide tool (OxMIS) can accurately predict those with serious mental illness (SMI) who are at greatest risk of suicide, according to a study published this week in Translational Psychiatry.

“With further research on feasibility and work considering how to link risk scores to interventions, OxMIS could assist mental health services in reducing suicide rates in people with SMI,” wrote Amir Sariaslan, Ph.D., of the University of Oxford and colleagues.

OxMIS, is a brief, scalable assessment tool that uses 17 risk factors to determine suicide risk, including:

• Sociodemographic traits (such as sex, age, and educational attainment).
• Antisocial and suicidal traits (such as previous violent crime and self-harm).
• Familial traits (such as parent history of substance use or suicide).
• Clinical traits (such as recent inpatient care and comorbid depression).

OxMIS was initially tested and validated in a cohort of more than 75,000 individuals diagnosed with SMI in Sweden. In this study, the researchers looked to validate the tool in a second, different sample of patients.

Sariaslan and colleagues used population-based data from Finland, including the Care Register for Health Care, to identify all individuals aged 15 to 65 who were diagnosed with an SMI between 1996 and 2017. The authors identified a cohort of 137,112 individuals who had over 5 million recorded episodes of schizophrenia spectrum disorder or bipolar disorder. They randomly selected one episode per person to be the index episode, as OxMIS is intended to be used at a single time point. The authors then used OxMIS to calculate each individual’s 12-month suicide risk. Finally, the authors used Finland’s Causes of Death Register to identify those participants who died by suicide during the follow-up period.

In the 12 months following the index episodes, 1,475 participants died by suicide (1.1%). OxMIS was able to discriminate suicide risk with an area under the curve of 0.70. This means that in 70% of the instances when the authors randomly selected two participants, one who died by suicide and one who did not, OxMIS gave the person who died by suicide a higher predictive suicide risk score, the authors noted.

Prognostic models and tools are inconsistently used in mental health care, in part because these tools are rarely tested on cohorts of patients outside of the populations in which they were developed, Sariaslan and colleagues wrote. “Such validation is a necessary step on the path to implementation alongside work on feasibility, acceptability, and clinical impact. In the suicide field, this is not different—few models have been externally validated despite their clinical use in some settings.”

For related information, see the Psychiatric Services article “Universal Suicide Screening Is Feasible and Necessary to Reduce Suicide.”

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ECT May Be Superior to Ketamine for Adults Experiencing Major Depressive Episode

Electroconvulsive therapy (ECT) may be more effective than ketamine at reducing symptoms of depression, suggests a meta-analysis in JAMA Psychiatry.

“Importantly, ECT was associated with significantly higher response and remission rates but not with significantly faster onset of either response or remission,” wrote Vikas Menon, M.D., of the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) in India and colleagues.

Menon and colleagues searched MEDLINE, ScienceDirect, and Google Scholar databases from inception until May 31, 2022, for articles describing randomized, controlled trials (RCTs) comparing ketamine and ECT in patients with major depressive episode (MDE). The researchers limited their search to articles written in English. Five RCTs, including a total of 278 patients, were included in the meta-analysis.

The primary outcome for the analysis was depression rating at one week posttreatment. Secondary outcomes were response and remission rates, number of treatment sessions taken to attain response and remission, and adverse effects.

“In the main analysis, posttreatment depression ratings showed a trend for lower scores with ECT compared with ketamine,” Menon and colleagues reported. When the researchers excluded three of the RCTs for what they described as “reasons related to questionable methods and reporting,” they found that “posttreatment depression ratings in the remaining RCTs were significantly lower with ECT than with ketamine.” They calculated that patients were about 43% more likely to achieve remission with ECT relative to ketamine.

There was little difference between ketamine and ECT groups when it came to posttreatment cognition scores. The pooled ketamine versus ECT data showed that those who had received ketamine had a lower risk of headache and musculoskeletal pain whereas those who had received ECT had a lower risk of dissociative symptoms. None of the studies included in the meta-analysis assessed rates of memory loss, which is one of the most problematic side effects of ECT.

The authors acknowledged other limitations of the meta-analysis, including the small number of eligible studies and the small sample sizes of these studies.

“[G]iven the possibility that patients with bipolar depression may not respond as well to ketamine as those with major depressive disorder, we believe that future RCTs of ECT vs. ketamine for patients with MDE should report outcomes separately for bipolar depression and major depressive disorder … so that future meta-analyses can pool outcomes separately for bipolar disorder and major depressive disorder.”

For related information, see the Psychiatric Services article “Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners.”

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Some Interpersonal Problems More Difficult to Treat in Teens With Depression, Small Study Finds

Teenagers with depression related to problems with “role transitions” (life changes that require a new role) may be less responsive to interpersonal psychotherapy than peers experiencing depression related to other interpersonal problems, a report in the American Journal of Psychotherapy suggests.

“[F]uture researchers and therapists might consider how IPT-A [interpersonal psychotherapy for adolescents] may need to be modified for individuals with the role transitions problem area to improve outcomes,” wrote Meredith Gunlick-Stoessel, Ph.D., of the University of Minnesota and colleagues. “For example, these adolescents may need additional IPT-A sessions or other types of coping strategies to augment IPT-A.”

IPT-A, adapted from interpersonal therapy for adults, aims to treat depression by addressing one of four problem areas: grief (difficulty coping with the death of a loved one); role disputes (disagreements between an adolescent and others about expectations of each other in a relationship); role transitions; and interpersonal deficits (social isolation and feelings of loneliness). The goal of IPT-A is to help adolescents learn the communication and interpersonal problem-solving skills needed to resolve the problem area most closely related to their depression.

The researchers looked at treatment outcomes for 40 adolescents (aged 12 to 17 years) who underwent 12 IPT-A sessions over 16 weeks. The youth were divided into four groups: 15 had problems with role disputes, 12 had problems with role transitions, 12 had problems with interpersonal deficits, and one had problems with grief. Because only one adolescent had a primary problem area of grief, that adolescent was not included in the analyses.

The adolescents were assessed for depression at baseline and at 16 weeks with a battery of tests, including the Beck Depression Inventory, the Beck Hopelessness Scale, and the Children’s Depression Rating Scale–Revised.

The results of the study suggested that the type of interpersonal problem area affected treatment outcomes. Adolescents in the role transitions group had more severe depression and social adjustment problems than those in the interpersonal deficits group and more severe social adjustment problems than those in the role disputes group.

Some other findings included the following:

• Adolescents in the role disputes group were significantly younger than adolescents in the interpersonal deficits and role transitions groups.
• Adolescents in the role disputes group also had significantly worse expectations for therapeutic alliance than did participants in the role transitions group.
• Adolescents in the interpersonal deficits group had higher attachment avoidance (for example, they reported more discomfort with interpersonal closeness and intimacy and greater hesitancy to rely on others for emotional support) at baseline than adolescents in the role transitions group.

The authors noted that role transitions may be more complicated for teens to navigate compared with the other problem areas, requiring them to adjust their expectations of people in the new situation, negotiate disagreements about those expectations, learn new interpersonal skills, and come to terms with the loss of how things used to be.

“This preliminary study provided information about characteristics of adolescents with depression receiving IPT-A for different problem areas and about the impact of problem areas on outcomes after 16 weeks of IPT-A. If these results are replicated, close attention to the therapeutic relationship for adolescents experiencing role disputes, and to the potential need to augment treatment for adolescents experiencing a role transition, may be helpful,” they concluded.

For related information, see the Psychiatric News article “IPT: From Humble Origins as ‘High Contact Therapy’ to International Adoptions.”

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New Care Models Can Support People Experiencing Mental Illness, Homelessness

“Of more than 580,000 individuals in the U.S. who experience homelessness on a single night, estimates suggest that more than half have a mental illness or substance use disorder and at least 1 in 5 have severe mental illness.” So wrote Katherine A. Koh, M.D., M.Sc., a member of the street team at the Boston Health Care for the Homeless Program and Massachusetts General Hospital, and Benjamin Land Gorman, B.S., a medical student at Harvard, in a Viewpoint article in JAMA.

“People experiencing homelessness with mental illness face alarming rates of incarceration, discrimination, chronic disease, suicide, and premature death. This is intolerable—and preventable,” they continued.

They described recent political momentum to invest in solutions to these challenges—including recent steps taken by politicians in California, New York, and Portland, Ore. While they acknowledged that “each proposal has prompted debate on ethical and practical grounds, this momentum provides an urgent opportunity to implement community-based care options, reimagine institutionalization, and finally build a functional continuum of care for those experiencing homelessness and mental illness.”

The authors pointed to several community-based services that have shown promise in reducing homelessness and improving outcomes for those with mental illness:

• Assertive Community Treatment connects individuals with intensive support through multidisciplinary teams.
• Housing First provides individuals with immediate housing to subsidized, supportive housing.
• Critical Time Intervention offers time-limited case management to individuals during transitions between hospitals, shelters, and/or jails and the community.

Though many individuals are likely to benefit from large-scale investment in the above programs, “short-term hospitalization can be necessary for the humane care of those for whom the above options have failed and suffering persists,” they continued. They recommended three principles to guide the creation of programs for individuals with severe mental illness:

• Prioritize community building over isolation and security in recognition that purpose, meaningful relationships, and nourishing environments are fundamental to recovery.
• Be attentive to the microculture of the facility by showing compassion, acknowledging trauma, and ensuring the needs of patients and staff are met.
• Partner across care settings to ensure continuity of care once the patient leaves the inpatient program. “The Homeless Outreach and Mobile Engagement program in Los Angeles, funded through California’s Mental Health Services Act, is a successful example of dedication to active partnership across care settings—including crisis care, inpatient hospitalization, and housing—to ensure continuity.”

The authors concluded, “If health care professionals, patient advocates, and policymakers seize the moment and fight for investment in innovative and evidence-informed strategies, we may witness the dawn of a new era.”

For related information, see the Psychiatric News Alert “Involuntarily Hospitalizing Homeless People With Serious Mental Illness May Backfire, Experts Caution.”

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Depression, Anxiety After Cardiac Arrest Linked to Long-Term Increased Risk of Death

Patients who are diagnosed with depression or anxiety within a year of experiencing cardiac arrest may have a higher risk of dying sooner than their peers who are not diagnosed with these mental illnesses, a study in JAMA Network Open has found.

Juncheol Lee, M.D., Ph.D., of Hanyang University in Seoul and colleagues examined data from the claims records of 2,373 adults (median age 53 years; 78.4% male) who were hospitalized after cardiac arrest between January 1, 2005, and December 31, 2015, and who survived for at least one year. The researchers excluded patients who had been diagnosed with depression or anxiety within three years before their cardiac arrest. The researchers compared the long-term survival rates (up to 14 years) among those diagnosed with depression or anxiety, diagnosed with only depression, diagnosed with only anxiety, and those without depression or anxiety.

Overall, 16.7% of the patients were diagnosed with depression or anxiety in the year after their cardiac arrest; 10.6% were diagnosed with depression, and 9.6% were diagnosed with anxiety. Patients who were diagnosed with either disorder had a 41% greater risk of dying during the follow-up period compared with their peers without such a diagnosis. Specifically, those who were diagnosed with depression had a 44% greater risk of death.

The researchers noted that physical changes that often develop in the wake of a cardiac arrest can disrupt patients’ lives and make it difficult to complete previously simple daily tasks without assistance.

“These realities and arduous transformations can cause extreme limitations and despondency. Such life changes can result in a decrease in health-related quality of life, which affects psychological distress,” Lee and colleagues wrote.

“Because the present study identified an association between psychological dysfunction and an increase in long-term mortality, we believe it provides evidence that psychological rehabilitation of patients with [out-of-hospital cardiac arrest] is crucial,” they concluded.

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Involuntarily Hospitalizing Homeless People With Serious Mental Illness May Backfire, Experts Caution

Two articles published yesterday in JAMA Psychiatry investigate the recent policy by New York City Mayor Eric Adams that expands efforts to hospitalize individuals with serious mental illness experiencing homelessness.

In November, Adams issued a directive to first responders, including police officers, paramedics, and outreach workers, instructing them to involuntarily transport individuals with mental illness who are experiencing homelessness to hospitals if they present a serious risk of harm to themselves or others. The directive also lowers the threshold of what is considered harm, instructing authorities to remove an individual from the streets or subway if he or she appears unable to “meet basic living needs, even when no recent dangerous acts have been observed.” Further, Adams outlined an 11-point legislative agenda that includes his top priorities to address at the state level and would add many of the initiatives included in his directive to the state code.

“One might say, here we go again,” wrote Michael Hogan, Ph.D., of Case Western Reserve University School of Medicine in his JAMA Psychiatry viewpoint. Hogan pointed out that past policies have similarly attempted to address the problem of people with mental illness experiencing homelessness, but the cycle continues.

Further, Adams’ policy pushes against current trends, Hogan wrote. The policy increases police intervention while significant work is being done in other areas to decriminalize people with mental illness, such as the implementation of the 988 National Suicide Prevention Lifeline. Additionally, he noted, there are benefits and drawbacks to increased hospitalization. While inpatient treatment will likely reduce symptoms for people with acute illness, involuntary hospitalization initiated by police can be traumatic and intrusive.

“A more substantial limitation of the proposal is the fact that access to ‘aftercare,’ principally stable housing and flexible treatment and support, is not ensured in the mayor’s plan,” Hogan wrote. “Without these, any value achieved through hospitalization is temporary, providing only time-limited clinical benefit.” A more effective approach is to provide access to housing—particularly permanent supported housing (which Hogan called “the gold standard for addressing homelessness”)—as well as continued, clinically competent, and engaging treatment.

In another JAMA Psychiatry viewpoint, Nick Kerman, Ph.D., of the Centre for Addiction and Mental Health in Toronto and colleagues wrote that Adams’ policy is an example of those policies that, in the absence of government investment, “lead people with mental illness experiencing homelessness to be moved ‘out of sight, out of mind.’”

“We believe that New York City’s policy approach is a violation of human rights, harms the personhood of people with mental illness experiencing homelessness, and that this policy will have deleterious effects on this population, mental health services, and evidence-based interventions for homelessness,” the authors continued.

Involuntary hospitalization in the absence of imminent risk threatens to further erode this population’s “self-determination in seeking health care and service engagement” and “heightens the power imbalance between people experiencing homelessness and those providing them with services,” they wrote. They point to several other negative impacts of the policy, including the following:

• It perpetuates structural stigma in assuming people with mental illness experiencing homelessness cannot care for themselves and need to be hospitalized for theirs and others’ safety.
• It overlooks why people with mental illness are living on the streets and not in shelters and does not address their concerns about safety in emergency shelters.
• It burdens mental health systems that become tasked with addressing the housing and shelter needs of those admitted to the hospital.

“Involuntary hospitalization and outpatient care, with appropriate safeguards and practices to ensure procedural justice, have an important role in mental health systems,” Kerman and colleagues concluded. “However, the New York City policy oversteps these important boundaries and is not the answer to homelessness among individuals with serious mental illness. Instead, it is the latest form of displacement-based approaches to unsheltered homelessness.”

For related information, see the Psychiatric News article “M.D.s Call for Community Resources Amid Plans to Force Homeless Into Care.”

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Sleep Problems in Late Childhood, Early Adolescence Linked to Psychiatric Symptoms

Children aged 9 to 13 who experience sleep problems may be more likely to experience internalizing symptoms (such as depression and anxiety) and/or externalizing symptoms (such as aggression and rule-breaking behaviors) than children who do not experience sleep problems, according to a report in JAMA Psychiatry.

“Our findings emphasize the need for early identification and treatment of sleep problems in childhood to ameliorate or potentially prevent mental health difficulties in early adolescence,” wrote Rebecca Cooper, M.P.O., and Vanessa Cropley, Ph.D., both of the University of Melbourne, and colleagues.

The researchers analyzed data collected from 10,313 participants whose caregivers completed the Sleep Disturbance Scale for Children (SDSC) as part of the Adolescent Brain Cognitive Development (ABCD) Study when the youth were between the ages of 9 and 11 years and again two years later. Using the SDSC, the caregivers were asked about the youth’s experiences over the prior six months with such sleep problems as sleepwalking, nightmares, night sweats, sleep breathing disorders, troubles falling and/or staying asleep, and more. The caregivers also completed the 113-item Child Behavior Checklist, which asked about any internalizing or externalizing symptoms displayed by the youth in the previous six months.

The children were then categorized into four sleep disturbance profiles at baseline and at two-year follow-up:

• Low disturbance (25.2% at baseline; 30.3% at follow-up).
• Sleep onset/maintenance problems (16.0% at baseline; 32.6% at follow-up).
• Moderate and nonspecific disturbance, or “mixed disturbance” (42.3% at baseline; 22.1% at follow-up).
• High disturbance (16.5% at baseline; 15.0% at follow-up).

Compared with youth in the low sleep disturbances group, those who reported greater sleep problems had a greater risk of both internalizing and externalizing symptoms at baseline and at the two-year follow-up than those in the low disturbance profile. For instance, those in the high disturbance profile were 1.44 times more likely to experience internalizing problems and 1.24 times more likely to have externalizing symptoms than children in the low disturbance profile.

“[T]he strongest associations were observed for somatic distress, with an approximate 60% increase in symptom severity between the low disturbance and high disturbance profiles,” Cooper and Cropley wrote. “Clinically, these findings underline the importance of routine assessment and management of both sleep and psychopathology symptoms in youth, with special emphasis on symptoms of somatic distress.”

They concluded, “Follow-up of individuals in each of the sleep profiles will elucidate the developmental trajectory of different sleep problems into mid and late adolescence and their prospective association with later mental health outcomes.”

For related information, see the Psychiatric News article “Studies Highlight Impact of Sleep on Mental Health of Youth.”

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Anniversary of Parent’s Death Linked to Increased Suicide Risk in Some Adult Children

The anniversary of a parent’s death appears to be associated with an increased risk of suicide among women, according to a report published today in JAMA Network Open.

“In this case-crossover study using Swedish national register data, we found evidence of an anniversary reaction among women, with an increased risk of suicide most consistently observed during the 2-day period following the anniversary of a parent’s death. Among men, we observed a reduced risk of suicide around the anniversary,” wrote Alessandra Grotta, Ph.D., of Stockholm University and colleagues.

Grotta and colleagues relied on linked data from 1990 to 2016 from multiple Swedish registers for the study. The researchers focused their analysis on adults aged 18 to 65 who had experienced the death of a parent and later died of suicide. With each adult in the study serving as his or her own control, the researchers compared the association between the anniversary of the parent’s death and suicide with the association between periods before or after the anniversary of the parent’s death and suicide.

The study included 7,694 individuals (2,255 of whom were women) who died by suicide. The median age at suicide was 55 years, and the median time between parental death and suicide was 7 years, the researchers noted.

“There was evidence of an anniversary reaction among women, with a 67% increase in the odds of suicide when exposed to the period from the anniversary to 2 days after the anniversary, compared with when not being exposed (odds ratio [OR], 1.67),” the researchers wrote. “The risk was particularly pronounced among maternally bereaved women (OR, 2.29) and women who were never married (OR, 2.08), although the latter was not statistically significant.”

Additionally, the authors found an increased risk of suicide from the day before up to the anniversary of a parent’s death for women who were aged 18 to 34 years (OR, 3.46) and those 50 to 65 years (OR, 2.53) when their parent died. Suicide risk for men was lower from the day before up to the anniversary (OR, 0.57).

“Although the loss of a parent during childhood has received attention in previous research, bereavement following the loss of a parent experienced during adulthood has been largely overlooked,” Grotta and colleagues wrote. “These findings suggest that families and social and health care professionals need to consider anniversary reactions in suicide prevention among adults who have lost a parent, especially bereaved women.”

For related information, see the Psychiatric Services article “Underutilization of Mental Health Services Among Bereaved Caregivers With Prolonged Grief Disorder.”

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Patients on Clozapine Found to Significantly Increase Use of Community-Based MH Programs

Individuals with schizophrenia who began treatment with clozapine significantly increased their use of community-based services and decreased their use of psychiatric inpatient services over the next six months, according to a report in Psychiatric Services in Advance.

“Entering community-based care is a major goal in the recovery and optimization of longitudinal outcomes of individuals with schizophrenia,” wrote Deepak Sarpal, M.D., of the University of Pittsburgh and colleagues. “Our results suggest that clozapine treatment shifts resources from costly inpatient care to services focused on community-based care and long-term recovery, regardless of the patient’s age, gender, or race.”

Sarpal and colleagues examined data from the Allegheny County Data Warehouse of Southwestern Pennsylvania, which includes information on the utilization of more than 20 Medicaid- and county-funded behavioral public benefit programs; these programs include treatment for mental substance use disorders, community services such as residential housing programs, and forensic services such as involuntary commitment. The researchers identified 163 adults (aged 18 to 65) with schizophrenia or schizoaffective disorder who received their first clozapine prescription between 2009 and 2016 and took the medication regularly for six months.

Among these individuals, only 20 required inpatient hospitalization over six months of treatment, compared with 92 who required hospitalization in the six months prior to starting clozapine. Meanwhile, 79 of the 163 adults made use of community-based services following clozapine initiation, compared with just 35 who used these services in the previous six months. The researchers found no significant differences in the use of outpatient psychiatric care or need for forensic services before or after clozapine initiation.

“From the standpoint of high-value care, we believe our findings support the expansion of efforts by Medicaid managed care organizations to promote clozapine utilization for optimal and efficient long-term care,” Sarpal and colleagues concluded.

To read more on this topic, see the Psychiatric News article “Real-World Data Show Patients With Schizophrenia Adhere Better to Clozapine and LAIs.”

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Prenatal Exposure to Lithium in Drinking Water Linked to Higher Risk of Autism Spectrum Disorder

Children born to mothers whose household tap water has higher levels of naturally occurring lithium may have a higher risk of being diagnosed with autism spectrum disorder, a study in JAMA Pediatrics has found.

Zeyan Liew, Ph.D., M.P.H., of Yale School of Public Health and colleagues analyzed data from 8,842 children in Denmark with autism spectrum disorder and 43,864 of their peers without the disorder. All of the children were born from 2000 through 2013 and were followed to 2016. The researchers measured the concentration of lithium in 151 Danish public waterworks and used the addresses where the mothers lived while pregnant to determine which water source supplied the household at the time. The researchers then divided the lithium concentrations in the water into quartiles (four equal parts) and determined prenatal lithium exposure for each quartile.

The researchers found that the risk of having children with an autism diagnosis rose in relation to the amount of lithium in the household tap water where the mothers lived while pregnant. Compared with mothers in the lowest quartile of exposure, those in the top quartile of exposure had 46% higher odds of having children with autism spectrum disorder. Mothers who had the second and third highest exposures during pregnancy had a 24% and 26% higher odds, respectively, of having children with autism spectrum disorder.

The researchers noted that lithium occurs naturally and is present in drinking water at low concentrations because of the weathering of minerals in the earth. They added that they did not have data on whether the mothers took lithium medications while pregnant, but that the prevalence of such use is usually lower than .1% and is unlikely to be associated with lithium in drinking water.

“[Our] observations call for additional epidemiological studies to examine lithium exposure related [autism spectrum disorder], as well as adverse fetal development, including studies that address dose response and gestational timing of exposures,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “Lithium Exposure During Pregnancy and the Postpartum Period: A Systematic Review and Meta-Analysis of Safety and Efficacy Outcomes.”

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Promoting Parental Mental Health, Access to Preschool May Reduce MH Inequities in Children

Promoting parental mental health and preschool attendance among socioeconomically disadvantaged children can reduce mental health problems, according to a study published this week in Pediatrics.

“Evidence suggests only 9% to 27% of children aged 4 to 13 years with mental health problems access mental health services, with barriers to access disproportionately impacting families experiencing socioeconomic disadvantage,” wrote Sharon Goldfeld, Ph.D., of the Centre for Community Child Health at the Murdoch Children’s Research Institute in Melbourne, Australia, and colleagues. “Reducing children’s mental health inequities will likely require a coordinated approach by stacking multiple complementary interventions across the various environments in which children grow and live over time.”

Goldfeld and colleagues drew on data from the Longitudinal Study of Australian Children, a nationally representative sample of 5,107 infants that began in May 2004. Information from parent interviews and/or self-report questionnaires was collected when the children were aged 0 to 1, 2 to 3, 4 to 5, 6 to 7, and 10 to 11 years. Family socioeconomic status was measured during the first year with self-reported annual income, highest education, and occupation level. Families were considered disadvantaged if they were among “the 25% least socioeconomically advantaged families” in the study.

When children were aged 4 to 5 years, each child’s primary caregiver reported on his or her own mental health using the Kessler Screening Scale, with higher scores indicating greater psychological distress. Parents who scored between 6 and 13 were classified as having low psychological distress, while those who scored 14 or above were classified as having high psychological distress. Parents were also asked whether their children attended preschool. Finally, children’s mental health problems were measured when they were aged 10 to 11 years using the parent-reported Strengths and Difficulties Questionnaire; children were considered to have “elevated mental health symptoms” if their total score was in the 80th to 100th percentile.

Over 21% of children aged 10 to 11 were found to have elevated mental health symptoms, the authors noted. Children who were disadvantaged had a higher prevalence of elevated mental health symptoms (about 33%) compared with their nondisadvantaged peers (about 19%). Nearly 15% of children aged 4 to 5 who were disadvantaged had a parent experiencing high psychological distress compared with nearly 9% of their peers who were not disadvantaged, and fewer disadvantaged children attended preschool (about 61% vs. 69%).

Goldfeld and colleagues next simulated hypothetical interventions related to parental mental health and preschool attendance to estimate the potential impact on the children’s mental health. The authors estimated that improving parental mental health and preschool attendance among children who are disadvantaged to the level of their peers who are not disadvantaged could reduce 6.5% and 0.3% of socioeconomic differences in their mental heath problems, respectively. However, even when the authors modeled improvement in parental mental health and preschool attendance, the children who were disadvantaged had a 10% higher prevalence of mental health symptoms compared with their nondisadvantaged peers.

“This highlights a critical point: these interventions alone are not sufficient, especially for those who are marginalized and socioeconomically disadvantaged,” wrote Jessica Young, M.D., Ph.D., and Rebecca Baum, M.D., of the University of North Carolina-Chapel Hill School of Medicine, in an accompanying commentary. “Maximum impact on child mental health inequities will likely require a multisectoral and sustained strategy, stacking diverse types of complementary interventions over childhood, including those addressing disadvantage itself (e.g., family income support), together with strategies such as improved parental support and preschool provision.”

For related information, see the Psychiatric News article “Treating Family Members Can Break Depression Cycle, Says Expert.”

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Psychiatrists Outline Ethical Considerations Related to Psychedelics

“As psychedelic therapies gain increasing prominence, it is vital that psychiatrists remain mindful of unique ethical and practical challenges surrounding their use in clinical settings,” wrote Gregory Barber, M.D., a psychiatrist in private practice in Bethesda, Md., and Charles Dike, M.D., M.P.H., chair of the APA Ethics Committee, in a review article appearing in Psychiatric Services in Advance. Dike is also an associate professor of psychiatry at Yale University School of Medicine.

Contemporary research on psychedelics for the treatment of mental illness is focused primarily on psilocybin, found in a type of mushroom, and MDMA, a synthetic amphetamine derivative in the subgroup of psychedelics called empathogens. Barber and Dike underscored several ethical issues that psychiatrists may face regarding psychedelic therapies in clinical practice:

• Research equipoise amid high enthusiasm for psychedelics: Psychedelic therapies are in a relatively early stage of research. Research equipoise requires that researchers and clinicians must not decide what is true before the science informs their decision.
• Informed consent: Distinctive features of psychedelic psychotherapies may require what some have called “enhanced consent.” The goal of “enhanced consent” is to ensure that patients have a thorough understanding of psychedelic therapies. “These principles of consent apply in current research settings but would also be relevant in general clinical practice if psychedelics were to be approved for broader use,” they wrote.
• Patient vulnerability: Psychedelic psychotherapy involves profound and acute changes in consciousness, and some unique risks and possible adverse effects, which place patients in a vulnerable position. “Psychedelics are not effective or desirable for everyone, and psychiatrists should attempt to identify patients who are particularly vulnerable to negative outcomes before suggesting that [they] undergo a psychedelic experience,” they wrote.
• Off-label use of psychedelics: “If psychedelics are approved for general psychiatric use, psychiatrists will likely encounter patients who seek psychedelic therapies,” they wrote. In that case, psychiatrists should be mindful that psychedelics should be prescribed only to treat diagnosable psychiatric disorders. Patients should be carefully screened for any underlying psychopathology. “If no clinical indication is found, psychiatrists should avoid prescribing psychedelics, just as they would any other medication.”
• Nonclinical uses of psychedelics: Psychiatrists may already be hearing from patients who are seeking their advice about the use of psychedelics outside clinical settings. Psychiatrists should be clear that although clinical trials are promising, these medications are still in the experimental stage. Such conversations may offer opportunities to educate patients on “the difference between psychedelic use in a clinical setting, where clear protocols are in place to ensure patient safety, and in a naturalistic setting [for example, for recreational use], where efficacy and safety are less assured,” they wrote.
• Equity and access: As research and clinical applications of psychedelics expand, efforts should be made to ensure that these interventions can be accessed by anyone who may benefit from them and are not reserved for a select few.

“As psychedelics become more prominent in psychiatry, psychiatrists should continue to emphasize their safe, effective, and ethical use,” Barber and Dike wrote.

For related information, see the Psychiatric News article “Psychedelics Legislation Gains Momentum.”

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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.

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