Wednesday, May 31, 2023

Heart Attack Linked to Faster Cognitive Decline Over Time, Study Suggests

Individuals who experience a myocardial infarction (heart attack) appear to have a faster cognitive decline over time than those who do not experience a myocardial infarction, according to a report published yesterday in JAMA Neurology.

The findings point to the importance of tracking the cognitive function of patients who have experienced a myocardial infarction and suggest that high-risk patients should be counseled on the potential cognitive ramifications of such an event, wrote lead author Michelle C. Johansen, M.D., Ph.D., of Johns Hopkins University and colleagues. “The findings also suggest that prevention of [myocardial infarction] may be a strategy to preserve brain health in older adults,” they added.

Johansen and colleagues analyzed data from six U.S. prospective cohort studies conducted from 1971 to 2019. The studies, which included repeated measures of cognition and blood pressure over time, included the Atherosclerosis Risk in Communities Study, Coronary Artery Risk Development in Young Adults Study, Cardiovascular Health Study, Framingham Offspring Study, Multi-Ethnic Study of Atherosclerosis, and the Northern Manhattan Study.

The sample included 30,465 individuals, average age 64, who had no history of myocardial infarction, dementia, or stroke at the time of their first cognitive assessment; 29% of the individuals were Black, 8% were Hispanic, 69% were White, and 56% were female. The individuals were followed for a median of 6.4 years, during which time 1,033 (3.4%) experienced one or more myocardial infarction events. The primary outcome measure was change in global cognition; secondary outcomes were changes in memory and executive function.

Overall, a myocardial infarction was not associated with immediate changes in global cognition, memory, or executive function. However, individuals with one or more myocardial infarction event demonstrated faster declines over the years after the myocardial infarction than those who did not have a myocardial infarction in all three measures of cognition: global cognition (−0.15 points per year), memory (−0.13 points per year), and executive function (−0.14 points per year). “[T]he decline in global cognition after … [myocardial infarction] was equivalent to 6 to 13 years of cognitive aging, representing an important public health problem,” Johansen and colleagues wrote.

They continued, “The lack of a significant cognitive change in the short term in the overall study population suggests that cognitive change is not secondary to acute illness or delirium but rather a sustained impairment in cognition.

In an accompanying editorial, Eric E. Smith, M.D., M.P.H., of the University of Calgary and Lisa C. Silbert, M.D., M.C.R., of Oregon Health and Science University, wrote, “Patients with history of [myocardial infarction] should be asked about cognitive symptoms periodically, with follow-up cognitive screening for patients in whom symptoms are endorsed by themselves or an informant. Referral to a cognitive specialist or neuropsychologist may be warranted in select cases.”

For related information see the Psychiatric News article, “Dementia Risk Higher in Patients With Atrial Fibrilation.”

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Tuesday, May 30, 2023

Cannabis Use Disorder Associated With Increased Risk of Bipolar Disorder, Depression

Cannabis use disorder appears to be independently associated with an increased risk of bipolar disorder and unipolar depression, according to a report in JAMA Psychiatry.

“Cannabis use is increasing worldwide and is suspected to be associated with increased risk of psychiatric disorders,” wrote Oskar Hougaard Jefsen, M.D., of Aarhus University Hospital–Psychiatry in Denmark and colleagues. To better understand the relationship between cannabis use and mood disorders, Jefsen and colleagues studied data collected in several Danish registries.

The study included individuals who were at least 16 years old and living in Denmark at some point between January 1, 1995, and December 31, 2021. All individuals included in the study were followed up until they were diagnosed with an affective disorder; they developed schizophrenia, died, or emigrated; or the end of data collection on May 3, 2022. In addition to identifying individuals who had received a diagnosis for cannabis use disorder, the researchers examined data on their sex, age, history of other psychiatric disorders, and more.

Of the 6,651,765 individuals who were included in the analysis, 60,696 received a diagnosis of cannabis use disorder during the follow-up period and 260,746 developed an affective disorder, Jefsen and colleagues reported.

After adjusting for a variety of factors, including a diagnosis of a psychiatric disorder prior to a cannabis use disorder diagnosis, the researchers found that those with cannabis use disorder had a higher risk of subsequent unipolar depression (HR, 1.72), including both psychotic and nonpsychotic subtypes (HR, 1.87 and 1.71, respectively). Similarly, cannabis use disorder was associated with a higher risk of both nonpsychotic bipolar disorder (HR, 2.79 for men and 2.50 for women) and psychotic bipolar disorder (HR, 4.04, both sexes combined).

“Although excess risks of unipolar depression and bipolar disorder were highest immediately after diagnosis of [cannabis use disorder], they remained significantly elevated up to 5 to 10 years after [cannabis use disorder],”Jefsen and colleagues wrote.

They continued, “Our findings lend support to the notion that cannabis use may represent an independent factor associated with unipolar depression and bipolar disorder. The risk of psychiatric disorders appears to be higher for schizophrenia than for affective disorders and higher for psychotic bipolar disorder than for nonpsychotic bipolar disorder, potentially pointing to a primarily psychotogenic effect of cannabis.”

For related information, see the Psychiatric News article “Study Links Long-Term Cannabis Use, Cognitive Deficits.”

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Friday, May 26, 2023

Ketamine Comparable to ECT for Patients With Refractory Depression Without Psychosis

Ketamine is about as effective as electroconvulsive therapy (ECT) at reducing depressive symptoms in patients with treatment-resistant depression, according to a study published this week in The New England Journal of Medicine. These findings were also discussed during a session on Wednesday at APA’s Annual Meeting in San Francisco.

For decades, physicians have recognized ECT as an effective and fast-acting treatment option for people with refractory depression, lead study investigator Amit Anand, M.D., of Brigham and Women’s Hospital in Boston, told Annual Meeting attendees during his presentation of the data.

However, as he and colleagues wrote in the NEJM paper, “ECT remains underused owing to limited availability, social stigma, and concerns regarding the adverse effect of cognitive impairment. … Ketamine is an attractive alternative for patients [with treatment-resistant depression] because it does not require general anesthesia and is not associated with clinically significant memory impairment.”

To compare these two treatments, Anand and colleagues recruited adults aged 21 to 75 who had been referred by their clinical providers for ECT. The participants met the criteria for a DSM-5 diagnosis for major depressive disorders without psychotic features. All participants were required to have a score greater than 20 on the 60-point Montgomery–Åsberg Depression Rating Scale (MADRS), indicating moderate to severe depression, and to have failed to respond to at least two adequate trials of antidepressant treatment.

A total of 403 patients from five clinical sites across the country were randomly assigned to three weeks of ECT (right unilateral ultrabrief) thrice weekly or ketamine (0.5 mg per kilogram of body weight over 40 minutes) twice weekly. For both treatments, clinicians could use their judgement to adjust the ECT electrode placement/ketamine dose or end treatment early. Participants were allowed to continue to take previously prescribed medications throughout the trial. The primary outcome was patient-reported treatment response, defined as at least a 50% decrease on the 16-item Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR).

“This trial was designed to be pragmatic and mimic what is going on in real-world clinics,” Anand said during his presentation. “The practitioners’ goal was to try and get the patients better as they normally would.” Anand added that the choice of the QIDS-SR as the main outcome reflected an approach to test which treatment patients thought was better.

After three weeks, 55.4% of participants in the ketamine group and 41.2% in ECT group reported a response to treatment, according to the QIDS-SR. Similarly, the clinician-rated MADRS scale suggested that 50.8% in the ketamine group responded to the treatment and 41.1% responded ECT. Ketamine was also associated with slightly higher remission rates on both the QIDS-SR and MADRS.

The participants receiving ECT reported greater problems with memory at the end of treatment compared with those who received ketamine, though by the one-month follow-up, there was little difference between the two groups. Among other side effects, ECT participants reported more musculoskeletal adverse effects, whereas ketamine participants reported more dissociation symptoms.

To read more on this topic, see the Psychiatric News article “Why Are Psychiatrists Hesitant to Refer Patients For Interventional Treatments?

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Thursday, May 25, 2023

Treating Chronic Pain Starts With Patient Education

According to the U.S. Centers for Disease Control and Prevention, more than 50 million adults in the United States experienced chronic pain (pain lasting three or more months) in 2021. Such pain is known to increase the risk of depression and anxiety. In a packed session yesterday at APA’s Annual Meeting in San Francisco, Xavier Jimenez, M.D., the director of psychiatry at Long Island Jewish Medical Center, offered pointers to psychiatrists on how best to talk with patients about their chronic pain and help them get on board with treatment.

Psychiatrists are typically “adept at psychopharmacology, and much of chronic pain management is applied psychopharmacology, including detoxification,” Jimenez explained to the audience. “We also have psychotherapeutic skills that are highly relevant in the [chronic pain] space.” For example, psychiatrists are well-positioned to help patients work through changing treatment goals, such as moving from pain relief to improved function.

Jimenez said that psychiatrists should try to determine how physical sensations and emotional reactions combine to create each patient’s subjective experience of pain. These emotional reactions are often a response not only to pain itself, but to the event that led to the pain such as an injury, accident, or surgery, he said. He invited psychiatrists to consider posttraumatic stress disorder (PTSD) as a model for better understanding patients with chronic pain.

“Think of your chronic pain patient who is very hypervigilant about their pain and avoiding different activities or things that activate the pain. They could also have hyperarousal to pain,” Jimenez said. “We see these features time and again in PTSD, and it has been shown in fMRI studies that patients with PTSD and patients with chronic pain but without PTSD have shared neural pathways.”

Educating patients about how chronic pain works can help build rapport and get them on board with approaching their pain from a psychiatric angle. For example, a discussion of central sensitization—an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity—can help patients understand why even a slight touch that would not bother most people is so painful to them.

“Once you open their eyes to the fact that there is more to pain processing than the knee, the back, the foot, and so on, then you can [create treatment] targets, which is where we get into our management strategies,” he said.

Jiminez encouraged psychiatrists to pay heed to signs of catastrophizing in their patients with chronic pain. “This could manifest as someone thinking that their body is falling apart, they’re always going to be disabled, they’re going to die, things of that nature. [Catastrophizing] has been shown in patients with chronic pain and is one of the poorest prognostic factors for a patient,” he said. “It’s an important [psychiatric] target to treat because if you don’t address it, the patient is going to continue to languish.”

Jiminez suggested that psychiatrists become familiar with the Pain Disability Index, which assesses whether patients are completely disabled, partially disabled, or not at all disabled by their pain across seven domains: “It’s a very important conversation starter. For example, you might see someone who is occupationally impaired but they’re not impaired at all on the other domains. That’s a bit of a red flag for malingering,” he said. “Or if you see somebody who’s only sexually impaired but everything else is fine, that may connote some complex relationship issues.”

The Adverse Childhood Experiences (ACEs) questionnaire can also help psychiatrists to gain a better understanding of their patients. “It can open up the conversation for patients to realize that some of the things that happened a long time ago might actually be connected to what’s happening now, and that trauma or adversity [they experienced] as a child or young adult could be catching up with them,” he said. He added that the ACEs questionnaire could lead to a conversation about central sensitization and other neural phenomena that can contribute to chronic pain.

“You can help them understand that there’s something neurobiological that you want to manipulate with your treatments to help them with their pain,” he said. “That is usually more effective than saying you’re going to try to help them with their depression because most people will say ‘Yeah, I’m depressed because I’m in pain.’ So let’s get past that and try to help them with the neurological underpinnings of their pain.”

Look for future coverage of APA’s 2023 Annual meeting in upcoming issues of Psychiatric News.

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Friday, May 19, 2023

Depression Associated With More Frequent Pain in People With Sickle Cell Disease, Study Finds

People with sickle cell disease and depression may experience more frequent pain episodes than those with the condition who do not have depression, suggests a report published yesterday in JAMA Network Open

Sickle cell disease is an inherited blood disorder, characterized by abnormal hemoglobin (a protein in red blood cells), which interferes with red blood cells’ ability to transport oxygen to tissues. Additionally, sickled red blood cells often clump together, blocking the flow of healthy, oxygenated blood, which can result in severe pain—most commonly in the chest, arms, and legs.  

“Although individuals with [sickle cell disease] experience a variety of complications, pain is a hallmark of the disease and often leads to increased health care utilization and hospitalizations, impacting overall quality of life,” wrote Kelly M. Harris, Ph.D., of the Washington University in St. Louis School of Medicine and colleagues. People with sickle cell disease also have higher rates of depression than those without the disease.  

“The pathways through which [sickle cell disease] affects opportunity and life outcomes are relatively clear, but the impact that these outcomes in turn have on [sickle cell disease] symptoms and symptom severity is less defined,” they continued. 

To understand the relationship between pain associated with sickle cell disease and mental health, educational attainment, and employment, Harris and colleagues examined patient registry and survey data collected by the U.S. Sickle Cell Disease Implementation Consortium.  

The authors focused their analysis on 2,264 participants (56% identified as female; 96% identified as Black) who were aged 15 to 45 years (mean age, 28 years). Characteristics of this group included the following:

  • 47% reported taking daily pain medication, and 49% reported taking hydroxyurea (a medication used to treat sickle cell disease).
  • 33% reported having been diagnosed with depression and/or had in their medical record at least one documented treatment for depression. 
  • 48% reported experiencing more than four pain episodes in the prior 12 months.
  • 78% reported their highest level of education as a high school diploma or lower.
  • 54% reported an annual family income of $25,000 or less, and 41% were unemployed.

Statistical analysis by Harris and colleagues revealed that depression was associated with increased pain frequency, but not pain severity; individuals who reported having been diagnosed with depression were about 1.5 times as likely to have four or more pain episodes in a year compared with those without depression. Among other factors tested, educational attainment and income were not associated with increased pain frequency or severity; however, being unemployed and/or identifying as female was associated with increased pain frequency and severity.

“The findings of this cross-sectional study suggest that pain interventions cannot ignore screening for depression and other mental health challenges among patients with [sickle cell disease],” the authors reported. “Without proper screening and assessments for depression, we might overestimate other factors and overlook key factors or outcomes in this population.”

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APA Annual Meeting Starts Tomorrow!

APA’s 2023 Annual Meeting will kick off tomorrow, May 20, in San Francisco. Plenary speakers include actress and political activist Ashley Judd and New York Times best-selling authors Heather McGhee and Beth Macy. Can’t travel to the meeting? You don’t have to miss a beat with livestreamed sessions available through the Virtual Annual Meeting. Download the Annual Meeting app to find daily reporting by Psychiatric News throughout the meeting.



Thursday, May 18, 2023

Study Identifies Maternal Risk Factors Associated With Behavioral Challenges in Youth

Developing an infection and/or smoking while pregnant are just two of several factors that a study in the Journal of the American Academy of Child & Adolescent Psychiatry suggests may put offspring at risk of emotional, cognitive, and behavioral dysregulation.

“Emotional, cognitive, and behavioral dysregulation in childhood is associated with impaired psychosocial functioning, poor school performance and with increased rates of psychiatric disorders, suicidality, and functional impairment in adulthood,” wrote Jean Frazier, M.D., of UMass Chan Medical School and colleagues.

Frazier and colleagues used data from the National Institutes of Health Environmental Influences on Child Health Outcomes (ECHO) research program. The seven-year research project includes 69 pediatric longitudinal cohorts and aims to investigate the effects of environmental exposures on child health. The ECHO data include information about mothers, including family history of psychiatric illnesses; tobacco use during pregnancy; pre-pregnancy body mass index; educational attainment; gestational diabetes diagnoses; and prenatal infections such as fever, flu, or sexually transmitted infections. Frazier and colleagues limited their analysis to include only ECHO studies in which researchers collected information about children aged 6 to 18 using the Child Behavior Checklist as well as mothers’ experience with prenatal infection. No studies with less than 10 children were included in the analysis.

The Child Behavior Checklist is a tool that is administered to parents and includes 120 questions about the child/adolescent’s behavior. Children are considered to meet the criteria for a dysregulation profile if their sum scores for three of the checklist’s subscales (attention, anxious/depressed, and aggression) is 180 or higher.

The authors analyzed data from 4,595 youth from 18 ECHO cohorts (25% of these youth were born preterm, or before 37 weeks gestation; 17% were born extremely preterm, or before 28 weeks gestation). Over 600 children (13.4%) met the criteria for a dysregulation profile. The frequency of dysregulation profiles was 11.5% for girls and 15.1% for boys. Additional findings include the following:

  • Youth with a dysregulation profile had higher odds of having a close relative (parent or sibling) with a psychiatric disorder than those without the dysregulation profile.
  • Youth with a mother who had less than a high school education had higher odds of having a dysregulation profile compared with those whose mothers had some college or above.
  • Compared with those without a dysregulation profile, youth with a dysregulation profile were more likely to be born to mothers considered overweight prior to pregnancy, more likely to be exposed to prenatal tobacco use, and more likely to be exposed to a prenatal infection.

“Social and educational interventions could possibly target the modifiable risk factors (e.g., maternal obesity, prenatal tobacco use, maternal education) and modify the developmental trajectories associated with the [dysregulation profile], particularly if there are multiple modifiable risk factors seen in an individual child,” the authors concluded. “Critically important to the overall management of these dysregulated youth is more fully understanding the drivers behind a child’s behavior and providing support and intervention in a sustained way.”

For related information, see the Psychiatric News article “Special Report: Stress and Distress During Pregnancy—How to Protect Both Mother and Child.”

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Wednesday, May 17, 2023

Most Americans Feeling Stressed About Inflation, Survey Shows

Inflation is causing a significant amount of stress for most Americans, especially women and people who are socioeconomically more vulnerable, a report in JAMA Network Open has found.

Cary Wu, Ph.D., of York University in Toronto and colleagues analyzed data from the Household Pulse Survey collected from September 2022 to February 2023 by the U.S. Census Bureau. They measured inflation stress using the survey question, “How stressful has the increase in prices in the last two months been for you?” The potential answers were “not at all stressful,” “a little stressful,” “moderately stressful,” and “very stressful.” Approximately 370,000 people participated in the survey.

Overall, 93.2% of the respondents reported that prices for goods and services had increased in the area where they live and shop in the last two months. Among these respondents, 47.3% reported that the price increases were very stressful, 28.2% reported that price increases were moderately stressful, 18.9% reported that price increases were a little stressful, and 5.6% reported that price increases were not at all stressful.

Women were 30% more likely to report feeling higher inflation stress than men. Compared with White respondents, Latinx and Black respondents were 65% and 25%, respectively, more likely to report higher inflation stress, whereas Asian respondents reported slightly lower inflation stress. However, when the researchers adjusted the results to account for socioeconomic status, higher socioeconomic status negated the differences between Black respondents and White respondents.

Individuals who were widowed, divorced, or separated were 54%, 57%, and 99%, respectively, more likely to report feeling higher inflation stress than married respondents. There was no statistical difference between married respondents and those who had never been married.

“In the time of high inflation, there is an urgent need for research and policy development to safeguard public health and prevent the worsening of health disparities,” Wu and colleagues wrote.

For related information, see “Inflation and a Recession Are Top Anxiety-Inducing Current Events Polled Since June.”

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Virtual Supervision of Residents Now Permitted Through December 31

The Centers for Medicare and Medicaid Services (CMS) is allowing virtual supervision of residents at least through December 31. Virtual supervision was expected to end on May 11, when the Public Health Emergency ended.

The decision to extend this flexibility appears to be the result of advocacy by APA and other medical education groups. In an April 13 letter to CMS, APA joined with the American Association of Directors of Psychiatric Residency Training and the American Association of Chairs of Departments of Psychiatry urging CMS to codify virtual supervision of residents on a permanent basis before the expiration of the COVID-19 PHE in May.

“Telehealth care by residents has been demonstrated throughout the PHE to be a safe and effective strategy for maintaining, and in many cases increasing, access to care,” the three groups wrote. “The teaching physician is ultimately responsible for the clinical outcomes of the care provided by residents. … Continuing virtual supervision for patients and residents after the end of the PHE ensures patients maintain access to effective care.”


Tuesday, May 16, 2023

Regular Internet Use May Lower Dementia Risk in Older Adults

Older adults who use the internet regularly have nearly half the risk of dementia as adults with limited internet use, according to a report in the Journal of the American Geriatrics Society. The study also suggested that the more years of regular internet use, the more pronounced the dementia benefits become.

“Our findings show evidence of a digital divide in the cognitive health of older-age adults,” wrote Gawon Cho, B.A., B.B.A., Rebecca Betensky, Ph.D., and Virginia Chang, M.D., Ph.D., of New York University. The benefits of regular internet use did not vary based on race/ethnicity, sex, educational attainment, or generation. “Therefore, we did not find evidence that the internet has exacerbated socioeconomic disparities in the burden of dementia.”

Cho and colleagues used data from the Health and Retirement Study (HRS), an ongoing biennial survey of community-dwelling adults aged 50 years and older. Since 2002, HRS participants have been asked the following yes/no survey question: “Do you regularly use the World Wide Web, or the Internet, for sending and receiving e-mail or for any other purpose, such as making purchases, searching for information, or making travel reservations?” Based on participants’ baseline response to this question, they were divided into two groups: regular internet users or nonregular internet users.

The analysis by Cho and colleagues included 18,154 adults aged 50 to 64 who did not have dementia at baseline and who responded to at least one survey between 2002 and 2016. Participants were then followed until they stopped completing the HRS survey or they completed the 2018 HRS survey (the median follow-up period was about 8 years).

Overall, about 65% of participants considered themselves regular internet users at baseline, and most of these adults continued to report regular use of the internet during subsequent surveys. The researchers found that adults who used the internet regularly at baseline had a 43% reduced risk of dementia during the follow-up period. The benefits seemed to be cumulative; that is, for every survey period in which a participant reported regular internet use, dementia risk dropped by about 20%.

“Since a person’s online engagement may include a wide range of activities, future research may identify different patterns of internet usage associated with the cognitively healthy lifespan while being mindful of the potential side effects of excessive usage,” Cho and colleagues concluded.

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Monday, May 15, 2023

Americans Feel Worried About Their Safety, APA Poll Finds

Seven in ten American adults reported that they felt anxious or extremely anxious about keeping themselves or their families safe, according to a recent APA Healthy Minds Poll.

While this is an improvement over the 80% of adults who expressed anxiety over their safety and that of their loved ones in 2020 (during the early days of the pandemic), the percentage reporting anxiety about keeping safe has increased since 2022.

Regarding specific areas of concern, 78% of adults surveyed said they were anxious about inflation, and 70% were anxious about the possibility of a recession. Anxiety about gun violence also stood out among the poll findings: 67% of those surveyed said they felt anxious about gun violence, including 42% who said they were “very anxious” about gun violence—an increase of 5% over the previous month.

“Ongoing stress about our basic needs can lead to other negative mental health effects,” said APA President Rebecca Brendel, M.D., J.D. “The impact of this stress means that psychiatrists will need to continue work with the communities they serve, the larger mental health field, and policymakers to ensure those who need care can access it.”

A sample 2,201 adults completed the online poll by Morning Consult between April 20 and 22. The data were weighted to approximate a target sample of adults based on gender, educational attainment, age, race, and region. The survey has a margin of error of +/- 3.1 percentage points.

Overall, 37% said they felt more anxious this year than at this time last year—a jump of 5%; 30% said they had talked about mental health issues with a mental health professional in the past few years—an increase of 4% from 2022.

The following are other findings from the poll:

  • 78% agreed that a person’s mental health has an impact on his or her physical health.
  • 78% agreed that untreated mental illness has a significant negative impact on families.
  • 64% agreed that untreated mental illness has a significant negative impact on the economy.

“The majority of the public understands something we’ve been saying for a long time: Your mental health is about your health,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “It’s contingent upon us as a field to continue to spread that message” along with the messages ”that those who are experiencing mental health concerns aren’t alone and that there are ways to receive help.”

More information about the poll can be found in the APA release “Americans Express Worry Over Personal Safety in Annual Anxiety and Mental Health Poll.”

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Friday, May 12, 2023

Congressional Briefing Emphasizes Actions Necessary to Address Substance Use Disorder Crisis

Smita Das, M.D., Ph.D., M.P.H. (pictured at left), chair of APA’s Council on Addiction Psychiatry, was among a panel of experts who spoke to members of Congress and their staffs on Wednesday about the addiction crisis in this country and what actions Congress can take to address it.

“As a psychiatrist who has dedicated my professional career to helping patients, I want to make clear that addiction is a chronic brain disorder, and it can be effectively treated,” Das said during the briefing, which was titled “A National Response to a Deadly Crisis: SUPPORT Full-Spectrum Addiction Care.”

Important steps have been taken to address the upward trend of opioid overdoses, as well as to reduce stigma of addiction, Das said. For example, the 2018 SUPPORT for Patients and Communities Act addressed many aspects of the opioid epidemic, including prevention, treatment, and recovery. But more needs to be done, Das continued. Additional investments can help to build a robust workforce trained to provide addiction care, reduce barriers to access, and expand integrated care, she said.

Reps. Annie Kuster (D-N.H.) and David Trone (D-Md.) also attended the briefing. Kuster and Trone, along with Brian Fitzpatrick (R-Pa.) and Lisa McClain (R-Mich.), are co-chairs of the Bipartisan Mental Health and Substance Use Disorder Task Force.

One of the task force’s goals is to educate members of the House to recognize that both mental and substance use disorders (SUDs) are medical conditions that can be successfully treated, Kuster said. “I feel that we have been successful [in this effort],” she said.

Das was joined on the panel by Brian Hurley, M.D., M.B.A., president of the American Society of Addiction Medicine’s Board of Directors; Natalie Kirilichin, M.D., M.P.H., representing the American College of Emergency Physicians; Kelly Dunn, Ph.D., M.B.A., M.S., representing the American Psychological Association; and Philip Rutherford, chief operating officer of Faces & Voices of Recovery, which advocates for people in recovery from SUDs.

The briefing focused on four themes:

  • Prioritize prevention, health, wellness, and equity: The speakers emphasized the importance of investments in policies and programs that address underlying structural and social determinants of addiction.
  • Establish universal access to addiction medications as standard of care: The presenters emphasized that there are effective medications available to treat SUDs, but a significant number of people with SUDs cannot access them. Creative solutions are needed to help the many people with SUDs who do not have access to specialists for in-person care, Das said.
  • Ensure appropriate coverage of, and reimbursement for, effective addiction care: Public and private payers should comprehensively cover and provide reimbursement for the entire continuum of SUD care, the presenters said. Das also emphasized the importance of mental health parity, noting that the Mental Health Parity and Addiction Equity Act was enacted in 2008, yet true parity has not been achieved.
  • Strengthen the addiction care workforce: There are not enough professionals in the country with the knowledge and training to treat people with SUDs, the presenters noted. Psychiatrists are uniquely positioned to treat those with SUDs, as well as their co-occurring psychiatric disorders, Das said. “However, the shortage of psychiatrists and physicians trained in addiction medicine, addiction psychiatry, or pain management has created a long-standing, acute treatment gap for those with or at risk for SUDs,” she said.

More needs to be done to close the SUD treatment gap, Das said. Solutions include increasing access, decreasing stigma, coordinating care, and working together to help patients and communities recover from the impact the crisis has had on the country. “We must treat substance use disorders as the chronic diseases that they are,” Das said.

For related information, see the Psychiatric News article “Congress Removes X-Waiver Requirement.”

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Thursday, May 11, 2023

FDA Approves Rexulti for Agitation Associated With Dementia Due to Alzheimer’s Disease

The U.S. Food and Drug Administration (FDA) yesterday approved the expanded use of Rexulti (brexpiprazole) for the treatment of agitation associated with dementia due to Alzheimer’s disease (AD).

“Agitation associated with dementia due to Alzheimer’s disease is a common neuropsychiatric symptom that is reported in approximately half of all patients with Alzheimer’s dementia,” wrote Otsuka Pharmaceutical Co. Ltd. and Lundbeck LLC, makers of the medication, in a press release. The symptoms cover “a large group of behaviors occurring in patients with Alzheimer’s disease, such as pacing, gesturing, profanity, shouting, shoving, and hitting.”

Brexpiprazole was first approved by the FDA in 2015, as an adjunctive therapy to antidepressants in adults with major depressive disorder and as a treatment for adults with schizophrenia. In 2021, the FDA expanded the use of the medication for the treatment of adolescents over the age of 13 with schizophrenia. Earlier this year, Otsuka and Lundbeck announced that the FDA would review the companies’ supplemental New Drug Application for brexpiprazole for the treatment of agitation associated with AD.

In a hearing last month, the FDA’s Psychopharmacologic Drugs Advisory Committee and the Peripheral and Central Nervous System Drugs Advisory Committee voted 9-1 in favor of the approval of brexpiprazole for the new indication, noting the data presented by Otsuka and Lundbeck suggested that the benefits of the medication outweighed the risks for patients with these symptoms.

A briefing document released prior to the April meeting describes some of these data, including several phase 3, 12-week, randomized, placebo-controlled studies. “Results from Studies 331-12-283 and 331-14-213 suggest that brexpiprazole exhibited a statistically significant treatment effect in the reduction of agitation over a 12-week treatment period, while also showing a similar safety profile relative to its use in adults with schizophrenia and major depressive disorder,” the document stated. “[B]rexpiprazole’s effect on mortality appears to be consistent with the known risk with other antipsychotics in elderly patients with dementia.”

According to the updated medication label, Rexulti is to be taken daily. The medication is not approved for the treatment of Alzheimer’s patients with dementia-related psychosis without agitation.

For related news, see the Psychiatric News article “Experts Discuss Challenges of Treating Neuropsychiatric Symptoms of Dementia.” 

Wednesday, May 10, 2023

DEA, SAMHSA Release Temporary Rule Extending Telemedicine Flexibilities

The U.S. Drug Enforcement Administration (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA) have issued a temporary rule that extends telemedicine flexibilities adopted during the COVID-19 Public Health Emergency (PHE). The temporary rule will go into effect tomorrow, May 11, when the COVID-19 PHE expires, and extends the full set of telemedicine flexibilities adopted during the COVID-19 PHE for six months (through November 11). Additional flexibilities will extend to established patients until November 11, 2024.

“Access to evidence-based treatment is a pillar of the HHS Overdose Prevention Strategy,” said Miriam E. Delphin-Rittmon, Ph.D., the Health and Human Services (HHS) assistant secretary for mental health and substance use and the leader of SAMHSA, in a press release issued by SAMHSA on Tuesday. “We strongly support policies that promote access to effective and safe treatment for opioid use disorder, including through telemedicine platforms, and ensuring continued access to necessary controlled medications past the COVID-PHE.”

This development is the latest in a story that began back in February, when the DEA announced two proposed rules (Docket No. DEA–407 and Docket No. DEA–948) for the prescribing of controlled medications via telemedicine. There was a 30-day public comment period for the proposed rules, which ended on March 31.

APA filed two letters with the DEA in response to the proposed rules during this time, recommending that the DEA “focus on balancing common-sense safeguards for DEA enforcement without decreasing access to lifesaving treatment” and consider ways to extend flexibilities made during the COVID-19 PHE. These comments were just two of the tens of thousands of comments that the agency received.

DEA Administrator Anne Milgram last week announced that the agency had received “a record 38,000 comments on its proposed telemedicine rules” and would delay releasing the two permanent rules that were set to go into effect when the COVID-19 PHE ends. “We take those [38,000] comments seriously and are considering them carefully,” Milgram said.

The SAMHSA release noted: “For any practitioner-patient telemedicine relationships that have been or will be established up to November 11, 2023, the full set of telemedicine flexibilities regarding prescription of controlled medications established during the COVID-19 PHE will be extended for one year—through November 11, 2024.”

“We recognize the importance of telemedicine in providing Americans with access to needed medications, and we have decided to extend the current flexibilities while we work to find a way forward to give Americans that access with appropriate safeguards,” Milgram said.

For related information, see the Psychiatric News article “APA Responds to DEA’s Proposed Rules Regarding Telehealth, Buprenorphine.”

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Tuesday, May 9, 2023

Zuranolone Found to Quickly Reduce Major Depression Symptoms in Phase 3 Trial

Adults with major depressive disorder may experience mood improvements within days of taking zuranolone (50 mg/day), a study in The American Journal of Psychiatry (AJP) suggests. Zuranolone is an oral, once-daily neuroactive steroid that acts on GABA-A receptors.

“[P]atients receiving zuranolone 50 mg/day demonstrated significantly greater improvements in depressive symptoms at day 15 compared with those receiving placebo,” wrote Anita H. Clayton, M.D., of the University of Virginia School of Medicine and colleagues. The study “supports the potential role for a 14-day therapy with oral zuranolone 50 mg/day in adults with MDD [major depressive disorder], with rapid improvements in depressive symptoms observed at the day 3 visit that were sustained through day 42, relatively high response and remission rates, and a favorable safety profile.”

The study was funded by Biogen Inc. and Sage Therapeutics Inc., who are working together on the development of zuranolone.

The phase 3 trial included patients who were between the ages of 18 and 64 years, had received a diagnosis of major depressive disorder (according to DSM-5 criteria), had been experiencing symptoms of depression for a least four weeks, and had a Hamilton Depression Rating Scale (HAM-D) score of at least 24 at screening and before they started taking the assigned study medication.

The researchers randomized the participants to take either 14 days of treatment with zuranolone 50 mg/day or placebo in the evening. Regardless of the participants’ assigned group at the start of the trial, they were permitted to take other antidepressants, provided they had been on a stable dose for at least 60 days before the study began and they agreed to continue taking the medication throughout the study period. The researchers evaluated the participants 10 times over the course of the 42-day trial using such assessments as the HAM-D, the Columbia–Suicide Severity Rating Scale, the Clinical Global Impressions severity score, and more.

A total of 534 patients (266 in the zuranolone group; 268 in the placebo group) were included in the final analysis. The patients in both groups (who were predominantly White and female) had experienced major depressive disorder for a mean of approximately 11 years.

Compared with patients who took placebo, those who took zuranolone demonstrated a statistically significant improvement in depressive symptoms at day 15. “Numerically greater improvements in depressive symptoms for zuranolone versus placebo were observed by day 3 (least squares mean change from baseline HAM-D score, −9.8 vs. −6.8), which were sustained at all visits throughout the treatment and follow-up periods of the study,” Clayton and colleagues wrote.

More than 60% of the patients who took zuranolone reported treatment-emergent adverse events compared with nearly 45% of the patients who took placebo. The most common adverse events (>5% frequency in any group) were somnolence (drowsiness), dizziness, headache, sedation, and diarrhea. Nine patients in the zuranolone group and four in the placebo group discontinued treatment due to treatment-emergent adverse events.

“[E]fficacy and safety results with zuranolone were similar regardless of whether patients were receiving a concomitant antidepressant therapy, suggesting that combination therapy may be a viable option for patients who are currently on an antidepressant therapy but would benefit from a therapy that may improve depressive symptoms with 2 days of treatment,” Clayton and colleagues wrote. “Overall, the study adds to the evidence suggesting that zuranolone constitutes a promising novel therapy for the treatment of MDD in adults.”

For related information, see the Psychiatric News Med Check summary “FDA Grants Zuranolone Priority Review for Major Depression and Postpartum Depression.”

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Monday, May 8, 2023

Early PET Scans Improve Confidence When Diagnosing Cognitive Problems

Adults who receive a positron emission tomography (PET) scan to measure brain amyloid levels shortly after seeing a doctor for cognitive problems are more likely to be confidently diagnosed within three months than those whose PET scans are delayed, suggests a study published today in JAMA Neurology.

“Amyloid deposition in the brain is one of the main hallmarks of Alzheimer disease (AD) and is considered one of the strongest risk factors of dementia,” wrote Daniele Altomare, Ph.D., of Geneva Memory Center in Switzerland and colleagues. “This evidence from [the Amyloid Imaging to Prevent Alzheimer’s Disease Diagnostic and Patient Management Study] of the clinical effect of amyloid PET in a European memory clinic population suggests that widespread implementation of this imaging technique may improve the timely diagnostic workup of patients under evaluation for cognitive decline.”

Altomare and colleagues enrolled 840 older adults (median age 71) from eight memory clinics across Europe in the study. The participants had varied stages of cognitive problems, ranging from subjective cognitive decline to mild cognitive impairment to dementia. The participants were then placed in one of three assessment groups:

  • Group 1 participants received an amyloid PET scan within one month of their baseline clinical visit.
  • Group 2 participants received an amyloid PET scan about eight months after their baseline visit.
  • Group 3 participants received a PET scan at the direction of the physician managing their care (free choice group).

The researchers then compared how many participants in groups 1 and 2 received a very high-confidence diagnosis of their condition (physician was 90% sure or better of being correct) at a follow-up visit three months after the baseline assessment. At three months, 40% (109 of 272) of participants in group 1 had a diagnosis with very high confidence compared with 11% (30 of 260) in group 2. This diagnostic improvement was seen in participants across all three cognitive stages (subjective cognitive decline, mild cognitive impairment, and dementia).

The researchers noted that given free choice, physicians frequently requested an amyloid PET early in the diagnostic evaluation. Almost 70% of participants in group 3 received a PET scan before the three-month follow-up visit, and 37% of group 3 participants received a diagnosis with very high confidence.

“A timely high-confidence diagnosis is critical to the efficacy of disease-modifying therapies, especially anti-amyloid drugs, whose efficacy might decrease with advancing disease progression,” the authors concluded.

To read more about this topic, see the Psychiatric News article “FDA Clears First In Vitro Assay to Improve Alzheimer’s Diagnosis.”

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Friday, May 5, 2023

Psychosis Induced by Substance Use Linked to Schizophrenia

More than a quarter of people who experience substance-induced psychosis are diagnosed with schizophrenia within six years, a study in The American Journal of Psychiatry has found.

Eline B. Rognli, Ph.D., of Oslo University Hospital and colleagues analyzed data from 3,187 patients in the Norwegian Patient Registry who were between the ages of 18 and 79 and had a diagnosis of substance-induced psychosis from 2010 to 2015. The patients had a mean age of 33.6 years, and 73.5% were men. Among the patients, 14.2% had alcohol-induced psychosis, 17.6% had cannabis-induced psychosis, 22.2% had amphetamine-induced psychosis, and 38.8% had psychosis induced by multiple substances. The patients were followed from the first diagnosis of substance-induced psychosis in the observation period until a diagnosis of schizophrenia spectrum disorder or bipolar disorder, death, migration, the month they turned 80, or the end of 2015, whichever came first.

Overall, 27.6% of the patients with substance-induced psychosis transitioned to schizophrenia within six years. Men had a higher rate of transitioning to schizophrenia than women: 28.6% among men compared with 24.8% among women. The transition rate was highest for the youngest patients: 32.7% for patients aged 18 to 25 years and 32.9% for patients aged 26 to 30 years. The transition rate was highest for cannabis-induced psychosis and lowest for alcohol-induced psychosis. Among those who transitioned to schizophrenia, 56.4% did so within a year of their diagnosis of substance-induced psychosis.

The researchers also examined the relationship between substance-induced psychosis and bipolar disorder. Overall, 4.5% of patients with substance-induced psychosis transitioned to bipolar disorder within six years. Women had a higher rate of transitioning to bipolar disorder than men: 7.1% among women compared with 3.5% among men. Among those who transitioned to bipolar disorder, 52.0% did so within a year of their diagnosis of substance-induced psychosis.

“Transition rates from substance-induced psychosis to schizophrenia spectrum disorder were six times higher than transition rates to bipolar disorder. … [O]ur findings indicate that substance-induced psychosis, particularly cannabis-induced psychosis, is a major risk factor for schizophrenia, and that younger age among men and repeated emergency admissions are associated with higher risk,” the researchers wrote. “This should inform and guide how … health services provide care for individuals with substance-induced psychosis.”

For related information, see The American Journal of Psychiatry article “Prediction of Onset of Substance-Induced Psychotic Disorder and Its Progression to Schizophrenia in a Swedish National Sample.”

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Thursday, May 4, 2023

DEA Delays Proposed Telehealth, Buprenorphine Rules

The U.S. Drug Enforcement Administration (DEA) has delayed finalizing two proposed rules that were set to go into effect after the COVID-19 public health emergency expires on May 11. The proposed rules, if finalized, would affect how health professionals implement telehealth services and prescribe certain controlled medications, including medications for treating attention-deficit/hyperactivity disorder and opioid use disorder (OUD). The DEA received 38,000 comments in response to the proposed rules, which were announced on February 24. Instead of finalizing the rules, the DEA, in concert with the U.S. Department of Health and Human Services (HHS), has submitted a draft temporary rule to the Office of Management and Budget titled “Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications.”

If finalized, the proposed rules would extend certain flexibilities for telehealth services after the COVID-19 public health emergency expires. Yet in several ways the proposed rules are more restrictive than what the public health emergency has allowed, thus garnering a backlash from stakeholders in public health. For example, 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.

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 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. However, patients would have to be examined in person by the physician within 30 days, have a referral from another practitioner, or be examined by the physician via telehealth while the patient is in the physical presence of another DEA-registered health professional.

APA is among the stakeholders who sent comments to the DEA about the proposed rules. In its two responses to the proposed rules, APA recommended that the DEA balance common-sense safeguards for DEA enforcement without decreasing access to lifesaving treatment and remove the in-person requirements for the prescribing of buprenorphine for the treatment of OUD via telemedicine when clinically indicated.

In a statement, DEA Administrator Anne Milgram said, “We take those [38,000] comments seriously and are considering them carefully. We recognize the importance of telemedicine in providing Americans with access to needed medications, and we have decided to extend the current flexibilities while we work to find a way forward to give Americans that access with appropriate safeguards.”

Milgram added that details about the draft temporary rule submitted to the Office of Management and Budget will become public after its full publication in the Federal Register.

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

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Wednesday, May 3, 2023

Black, Hispanic Veterans More Likely Than Whites to Have AUD Diagnosis Despite Similar Drinking

Black and Hispanic veterans are more likely to be given a diagnosis of alcohol use disorder (AUD) than White veterans despite similar levels of alcohol consumption, according to a report published today in AJP in Advance. The racial discrepancy in diagnosis was evident for both men and women but was greatest for Black men who in some cases had a greater than 100% chance of having a diagnosis of AUD than White male veterans.

“The absence of other factors to explain this discrepancy strongly suggests the presence of racial and ethnic biases in the diagnosis of AUD by VA practitioners,” wrote Rachel Vickers-Smith, Ph.D., of the Mental Illness Research, Education, and Clinical Center at Veterans Integrated Service Network 4 in Philadelphia and colleagues.

The researchers examined the association between levels of alcohol consumption and diagnoses of AUD among 700,012 veterans enrolled in the Million Veteran Program, a longitudinal cohort study that began enrolling veterans in 2011. The sample included 638,204 men (74% identified as White, 19% as Black, and 7% as Hispanic) and 61,808 women (62% identified as White, 30% as Black, and 8% as Hispanic).

Alcohol consumption was defined as an individual’s maximum score on the consumption subscale of the Alcohol Use Disorders Identification Test (AUDIT-C), a screen for unhealthy alcohol use. The AUDIT-C includes three questions:

  • How often do you have a drink containing alcohol?
  • How many standard drinks containing alcohol do you have on a typical day?
  • How often do you have six or more drinks on one occasion?

These responses are scored from 0 to 4 points and summed for a total AUDIT-C score of 0 to 12 points. (AUDIT-C scores ≥3 for women and ≥4 for men reflect unhealthy alcohol use.) A diagnosis of AUD was indicated by the presence of relevant ICD-9 or ICD-10 codes in the participants’ electronic health records.

Vickers-Smith and colleagues focused their analysis on the highest AUDIT-C recorded score (maximum AUDIT-C score) for each participant. Most veterans in the sample had AUDIT-C scores that indicated a low overall level of risk for harmful drinking.

At every maximum AUDIT-C score, White men were less likely than Black men to receive an AUD diagnosis; at maximum AUDIT-C scores of 1 to 10, Black men had 23% to 109% greater odds of an AUD diagnosis than White men. The greatest difference was at an AUDIT-C score of 4, where White men were approximately one-third as likely to have an AUD diagnosis as Black men. Although Hispanic men had a lower frequency of AUD diagnosis than Black men across all AUDIT-C scores, the frequency was generally higher than that among White men, with the greatest difference also at an AUDIT-C score of 4.

“The prevalence of disorders associated with persistent heavy drinking (e.g., alcoholic cirrhosis and hepatitis), whose diagnoses generally rely on objective measures (e.g., laboratory values and ultrasound findings), was similar across the three groups, which suggests that the greater likelihood of an AUD diagnosis among Black and Hispanic veterans was likely not due to different levels of alcohol consumption,” Vickers-Smith and colleagues wrote. “Black women were [also] more likely than Hispanic and White women to receive an AUD diagnosis, despite having a similar distribution of alcohol consumption and prevalence of alcohol-related disorders among the groups.”

For related information, see the Psychiatric News articles “Consult Cases Demonstrate Result of Implicit Racial Bias” and “Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR.”

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Tuesday, May 2, 2023

Dementia, Self-Harm Found to Be Linked in Older Adults

More than 60% of people with dementia who later harm themselves tend to do so within two years of their dementia diagnosis, suggests a study reported in Alzheimer’s & Dementia. The study also found that older adults who harm themselves, particularly men with no prior history of such behavior, may be at greater risk of a later dementia diagnosis than those who do not.

“Our results highlight the need for better mental health and behavioral supports soon after dementia diagnoses or self-harm in older people,” wrote Adrian R. Walker, Ph.D., of UNSW Sydney and colleagues.

Walker and colleagues relied on linked hospital data from New South Wales, Australia, to form two cohorts of people over the age of 40:

  • The dementia cohort: People without a history of self-harm who had a diagnosis of dementia between July 1, 2001, and December 31, 2014.
  • The self-harm cohort: People without a history of dementia who had a diagnosis of self-harm between January 1, 2005, and December 31, 2014.

The final datasets included 154,811 people in the dementia cohort, including 652 who had a later record of self-harm, and 28,972 people in the self-harm cohort, including 870 who had a later record of dementia. The researchers then analyzed the data to identify patient characteristics that might predict self-harm outcomes in the dementia cohort and dementia outcomes in the self-harm cohort.

The analysis revealed that “men, people around the age of 70, and people who have a complex psychiatric profile living with dementia are at the greatest risk of self-harm, and that this risk peaks within 24 months of the first hospital admission for dementia,” Walker and colleagues wrote. “Similarly, our findings from the self-harm cohort suggest that self-harm in older adults may be linked with an ensuing dementia diagnosis within 24 months.”

The authors concluded, “Poor mental health, dementia, and self-harm are substantially intertwined in older adults. Qualitative research with people with lived experience of dementia and self-harm may shed further light on the relationships among these factors.”

For related information, see The American Journal of Psychiatry article “Dementia Is More Than Memory Loss: Neuropsychiatric Symptoms of Dementia and Their Nonpharmacological and Pharmacological Management.”

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Monday, May 1, 2023

Depression Symptoms in Youth Worsened During COVID-19 Pandemic, Meta-Analysis Finds

A meta-analysis of more than 50 longitudinal studies of children and adolescents from 12 countries has confirmed what many had feared: Symptoms of depression in youth around the world increased during the COVID-19 pandemic. The findings were published today in JAMA Pediatrics.

“Our findings are in line with other mental health–related studies which report increases in eating disorders and emergency department visits for suicide attempts and ideation during the COVID-19 pandemic,” wrote Sheri Madigan, Ph.D., of the University of Calgary and colleagues. “The magnitude of this [depression] increase was more than what could be expected based on time trends and can therefore likely be attributed to the disruptions, restrictions, and stress imposed on children and adolescents and their families during the pandemic.”

Madigan and colleagues combined data from 53 longitudinal studies that compared pre-pandemic and pandemic symptoms of depression and/or anxiety in youth. Twenty-seven studies reported data from North America (51%), 13 (24%) from Europe, 10 (19%) from Asia, 2 (4%) from Australia, and 1 (2%) from Israel. The combined sample included data from over 40,000 children and adolescents.

The meta-analysis found strong evidence that depression rose in children and adolescents during the pandemic. Larger increases in depression symptoms were seen among females compared with males, adolescents compared with children, and youth from mid- and high- income families compared with those from low-income families. The meta-analysis also revealed that anxiety symptoms slightly increased in the children and adolescents during the pandemic.

“Our results, as well as those of many other scholars, sound a clarion call to policymakers that a response is needed to directly address the mental health crisis being experienced by children and adolescents,” Madigan and colleagues concluded. “The development and widespread availability of timely and evidence-based global mental health prevention and intervention efforts to address childhood mental illness are critical and urgently needed.”

To read more on this topic, see the Psychiatric Services article “A Marshall Plan for Children’s Mental Health After COVID-19.”

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