More Youth Drive Under the Influence of Cannabis Than Alcohol

Nearly a quarter of drivers between the ages of 16 and 20 years who have used cannabis in the past year have driven under the influence of the drug, a study in Addictive Behaviors has found. Overall, more people in this age group reported driving under the influence of cannabis than under the influence of alcohol.

Christopher P. Salas-Wright, Ph.D., M.S.W., M.A., of Boston College and colleagues examined data from 12,863 drivers aged 16 to 20 years who participated in the 2020 and 2021 National Survey on Drug Use and Health.

Overall, 6.27% of the participants reported driving under the influence of cannabis and 2.63% reported driving under the influence of alcohol in the past year; 1.83% reported both behaviors in the past year.

Among participants who reported past-year cannabis use, 24.46% reported driving under the influence of the drug in the past year as well. Among participants who reported past-year alcohol use, 6.1% reported driving under the influence of alcohol as well. Among participants who reported using both cannabis and alcohol in the past year, 8.41% reported driving under the influence of cannabis and alcohol in the past year as well.

White participants were more likely than Black and Latinx participants to report driving under the influence of cannabis. However, there were no differences among different racial groups in terms of driving under the influence of alcohol.

“These estimates translate to more than a million young people each year who are taking part in illegal behaviors that risk putting their lives and the lives of others in serious danger,” Salas-Wright and colleagues wrote. “In all, [the] findings make clear that [driving under the influence] is by no means limited to adults and underscore the importance of prevention efforts targeting teen and underaged cannabis and alcohol misuse and impaired driving.”

For related information, see the Psychiatric News article “Experts Clear the Smoke on Cannabis Use Disorder.”

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Urine Drug Screens as Part of OUD Treatment Can Be Successfully Managed Via Telehealth

Urine drug screening of people in treatment for opioid use disorder (OUD) is feasible and reliable via telehealth, according to a study published today in JAMA Health Forum.

“This cohort study’s findings … are consistent with the premise that long-standing and stringent requirements (e.g., requiring in-person visits, frequent drug testing) for being prescribed buprenorphine for OUD can be relaxed without jeopardizing the quality or safety of care for many patients,” wrote Arthur Robin Williams, M.D., M.B.E., of Columbia University and colleagues. Williams is also chief medical officer of Ophelia, a telehealth-based OUD treatment platform available in 14 states.

Williams and colleagues analyzed data from 3,395 adults (primarily in New York and Pennsylvania) who initiated buprenorphine treatment via Ophelia between January 1, 2021, and June 6, 2022. As part of Ophelia’s virtual care model, participants were periodically sent urine drug screening kits that they used off-screen during an appointment and then showed the results to a clinician. The protocol recommended that the first test occur one week after starting buprenorphine with periodic follow-ups as patients progressed from stabilization to maintenance treatment.

Overall, 81.9% of the patients completed a drug screen within the first 30 days of care. Among patients who remained in treatment for at least 90 days, 97.6% completed at least one drug screen. Patients under 30, racial and ethnic minority patients, patients living in urban areas, and cash-pay patients were less likely to complete a drug screen within 30 days.

By 180 days, the positivity rate for buprenorphine had risen to 98.4% from a baseline of 96.9%, while opioid positivity dropped to 3.3% from a baseline of 7.9%; positive tests for cocaine and benzodiazepines also dropped significantly from baseline rates.

“Although TBOT [telehealth-based opioid treatment] has demonstrated the potential to extend treatment access to underserved areas, our findings that early UDS completion varied across demographic subgroups suggests that further study of UDS in remote care settings is warranted,” the authors wrote. “It is … important for [telehealth] platforms to consider the complex interplay between clinical suitability for remote care and socioeconomic and digital barriers.”

To read more on this topic, see the Psychiatric News article “APA Responds to DEA’s Proposed Rules Regarding Telehealth, Buprenorphine.”

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Nominations Open for APA Components and Board of Trustees

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Dementia Results in Nearly 1.4 Million Emergency Visits Annually, Study Finds

Patients with Alzheimer’s disease and related dementias (ADRD) account for nearly 7% of all annual emergency department visits by individuals age 65 and older, according to a report published this week in JAMA Neurology.

“Emergency departments are often not the right place to manage these behaviors,” Lauren Gerlach, D.O., M.S., of the University of Michigan Medical School, said in a news release. “We really need to do better to support caregivers so there are options other than seeking emergency care.”

Gerlach and colleagues analyzed data on emergency department visits by adults aged 65 and older from the 2016-2019 National Hospital Ambulatory Medical Care Survey. The survey collects data from random samples of emergency department visits and includes information on patients’ dementia diagnoses. The primary reason for the visit was reported by the patient or a proxy.

Among more than 20.3 million annual visits to emergency departments by patients aged 65 and older, almost 1.4 million were by patients with Alzheimer’s or a related dementia. Additional findings include the following:

• Emergency department visits by patients with ADRD were more common among those who were 85 years or older, were female, and/or had medical comorbidities.
• The most common reasons for the visits by patients with ADRD included accidents (7.9%) and behavioral disturbances (7.4%), which were about twice as likely among this patient population than patients without ADRD.
• Common diagnoses included dementia with or without behavioral disturbances, symptoms involving cognitive function and awareness, and urinary tract infections.
• Patients with ADRD were more likely to undergo head computed tomography scans and/or urinalysis compared with patients without ADRD.
• Patients with ADRD were more likely to receive antipsychotics and less likely to receive opioids.

“Given the high rates of [emergency department] visits for behavioral disturbances, it is perhaps unsurprising that those with ADRD visits were twice as likely to receive antipsychotic agents,” the authors wrote. “Such use is concerning given the increased mortality risk associated with antipsychotic agents and potential for transition to long-term use.”

For related information, see the Psychiatric News Alert “Dementia, Self-Harm Found to Be Linked in Older Adults.”

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Postpartum Depression Pill Zuralonone Shows Promise in Women With Severe Symptoms

Women with severe postpartum depression may experience improvements within a few days of taking the oral medication zuranolone (a neuroactive steroid), suggests a report published today in The American Journal of Psychiatry. These improvements continued even after the women stopped the 14-day medication regimen.

The study was funded by Sage Therapeutics and Biogen, which are involved in the development of the medication.

Postpartum depression affects an estimated 17% of women worldwide, according to Kristina M. Deligiannidis, M.D., of Zucker Hillside Hospital and colleagues. This disorder can lead to multiple challenges for mothers and infants, including poor maternal-infant bonding, increased risk of infant behavioral problems, and suicidal ideation in mothers. “Current treatment options often include standard-of-care antidepressants; however, achieving response to treatment can take up to 12 weeks,” Deligiannidis and colleagues wrote. “Given the deleterious effects of untreated [postpartum depression], identification of rapid and effective treatment options is critical.”

Zuranolone is a rapid-acting medication in development for the treatment of postpartum depression; it has been granted priority review by the Food and Drug Administration. A previous trial found zuranolone at the 30 mg/day dose to be effective and generally well tolerated.

For the current phase 3 trial, 196 women aged 18 to 45 with severe postpartum depression were randomized to zuranolone (50 mg/day) or placebo pills for 14 days. To be included in the trial, the participants had to have a baseline score of at least 26 on the 17-item Hamilton Depression Rating Scale (HAM-D), experienced a major depressive episode with onset during the third trimester of pregnancy or up to four weeks after giving birth, and were within the postpartum period of 12 months or less. The researchers evaluated the participants using multiple assessments over the course of the 45-day trial, including the HAM-D total score, Clinical Global Impressions severity (CGI-S) score, Hamilton Anxiety Rating Scale (HAM-A), 9-item Patient Health Questionnaire (PHQ-9), and more.

“Patients receiving zuranolone demonstrated robust, clinically meaningful, and rapid improvements in depressive symptoms, as assessed by change from baseline HAM-D score, which were evident as early as day 3 and were maintained through day 45,” Deligiannidis and colleagues wrote. The women also showed improvements in anxiety and symptom severity from baseline to day 15.

The most common side effects reported by patients were somnolence, dizziness, sedation, and headache.

“Given the prevalence and substantial adverse maternal and infant outcomes associated with [postpartum depression], its appropriate management is essential,” Deligiannidis and colleagues wrote. “Therefore, if approved, zuranolone would be the first short-course, rapid-acting, oral treatment for patients with PPD.”

For related information, see the Psychiatric News article “Perinatal Treatment Requires Careful Risks, Benefit Consideration.”

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Levin to Step Down as CEO and Medical Director of APA in May 2024

APA CEO and Medical Director Saul Levin, M.D., M.P.A., has announced that he is resigning from the position effective May 31, 2024.

In a statement to the APA membership, the Board of Trustees wrote, “Dr. Levin started his tenure as APA CEO and Medical Director in July of 2013 and since then has led APA with vision and care. Under his leadership, APA has rebranded, moved its headquarters back into the District of Columbia, and purchased its office space. He oversaw the establishment of APA’s PsychPRO mental health registry and the build out of APA’s Communications, Government Relations, Policy, and Diversity and Health Equity teams.

“We will celebrate these and many other of his accomplishments at the 2024 APA Annual Meeting in New York. Dr. Levin plans to remain active in global psychiatry and to become more invested in the World Psychiatric Association.”

The Board has appointed a committee to lead the search for APA’s next CEO and Medical Director. Past APA President Maria Oquendo, M.D., has agreed to chair the committee; the committee members are Bob Batterson, M.D., Frank Brown, M.D., M.B.A., David Fassler, M.D., Tanuja Gandhi, M.D., Patrice Harris, M.D., M.A., and Steve Koh, M.D., M.P.H., M.B.A. APA has retained the national search firm of Heidrick & Struggles to work with the search committee and identify candidates who can continue to build upon the successes APA has achieved during Levin’s tenure.

“Saul Levin’s leadership of APA over the past decade has been transformative,” said APA President Petros Levounis, M.D., M.A., told Psychiatric News. “He has been both visionary and pragmatic, and he leaves our organization with solid achievements. We are saddened to see him go, but we know that we can look forward to working with him closely as he becomes more engaged with the World Psychiatric Association.”

In an email message to staff today, Levin noted that he began his affiliation with APA 37 years ago as an APA/APAF Leadership Fellow. “Working with this organization and with the amazing staff has been one of the most gratifying experiences of my professional life,” he said. “Together we have made a difference for our members and for their patients.”

The position description for CEO and Medical Director is posted here. Questions about the position and the search should be directed to APACEO@heidrick.com.

Depression Over Adulthood May Increase Risk of Dementia

Adults diagnosed with depression are more likely to be subsequently diagnosed with dementia, according to a study published today in JAMA Neurology.

“This association persisted when the time elapsed from the [date of depression diagnosis] was greater than 20 years and when depression was diagnosed in early, middle, or late life,” wrote Holly Elser, M.D., Ph.D., of the University of Pennsylvania and colleagues. “Our results therefore suggest that depression is not only an early symptom of dementia but also that depression is associated with an increase in dementia risk.”

The researchers used Danish health registers to identify adults diagnosed with depression between 1980 and 2017. Each person was matched with five adults of similar age and demographics who did not have a depression diagnosis. These people were then followed up until the occurrence of a dementia diagnosis, emigration, death, or the study cutoff date of December 31, 2018.

The final sample included 246,499 adults (average age, 50.8 years; 64.7% women) with depression and nearly 1.2 million adults who did not have depression. Two-thirds of the adults with depression were diagnosed before age 60. Among those with a depression diagnosis, 5.7% were subsequently diagnosed with dementia; in the comparison cohort, 3.2% were subsequently diagnosed with dementia.

In the overall group, the risk of a dementia diagnosis was 2.41 times higher in adults with depression compared with those without depression. When Elser and colleagues compared the risk of dementia according to the age at which the adults received their depression diagnosis, they found that the risk of dementia was slightly higher among adults diagnosed with depression between the ages of 18 and 44 years and 45 and 59 years than among adults diagnosed at 60 or older

“The increased risk of dementia associated with depression diagnosis raises the intriguing question of whether effective treatment of depression could modify dementia risk,” Elser and colleagues wrote. In their analysis, they found no difference in dementia risk between adults who started antidepressant therapy within six months of their depression diagnosis and those who did not. However, they noted “our analysis does not consider the duration or effectiveness of treatment, nor were we able to identify individuals who received behavioral therapy.”

For related information, see the Psychiatric News article “Brain Scans May Offer Clues About Depression Remission.”

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More Than One-Third of Bereaved May Have Prolonged Grief Disorder

More than one-third of people who are grieving meet the DSM-5 criteria for prolonged grief disorder, a study in the Journal of Affective Disorders has found. Yet the results suggest that most people who are bereaved feel that their grief is a normal response to loss regardless of how long they’ve been grieving.

“Although respondents’ views of the normalcy of their grief may be subject to bias, as in any other area of self-evaluation, it is useful to know how bereaved individuals themselves view their grief experiences,” wrote Kara Thieleman, Ph.D., of Arizona State University and colleagues. 

The researchers surveyed 1,137 bereaved adults using the Prolonged Grief-13-Revised scale (PG-13-R), which is used to identify patients who meet the DSM-5 criteria for prolonged grief disorder. The PG-13-R asks whether an individual has experienced bereavement, how many months it has been since the loss, and whether symptoms of grief have caused impairment in the individual’s functioning. For example, it asks “Do you feel yourself longing or yearning for the person who died?” Respondents were also asked to rate how normal of a response they believed each PG-13-R item to be. For example, they were asked “Do you feel it is normal for you to yearn for this person?” The average time since the loss was 10.6 years.

Overall, 34.3% of respondents met the criteria for a diagnosis of prolonged grief disorder, and 37.6% reported their grief impaired their functioning. When the researchers analyzed rates of prolonged grief disorder according to respondents’ relationship to the people who died, they found that bereaved parents had the highest rate of prolonged grief disorder at 41.6%, followed by bereaved spouses/partners at 33.7% and siblings at 29.4%. According to cause of death, those bereaved by overdose had the highest rate at 59.1%, followed by homicide/suicide at 46% and accidental causes at 36%. 

Nearly all respondents—98.1%—agreed that their overall emotional responses to their loss were normal and understandable, and fewer than 12% reported that a diagnosis of prolonged grief disorder would be helpful to them. Furthermore, 59.9% of those who lost a child, 63.6% of those who lost a spouse or partner, 42.5% of those who lost a parent, 33.3% of those who lost a sibling, 58.5% of those who lost a friend, and 51.9% of those who lost someone in another category reported that a diagnosis of prolonged grief disorder would be “very unhelpful.”

“In sum, differences in norms regarding the intensity, duration, and trajectory of grief among bereaved subgroups complicate the question of how to identify when grief may constitute a disorder,” Thieleman and colleagues wrote. “While more research is needed … it may be worthwhile to consider the context in which loss occurs when determining whether symptoms constitute normal grieving or potential disorder.”

For related information, see the Psychiatric News article “Assembly Approves New Diagnosis of Prolonged Grief Disorder for DSM-5-TR.”

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Study Suggests Few Disruptions in Treatment for OUD During the Pandemic

Disruptions in health care services during the COVID-19 pandemic did not significantly reduce the ability of adults to remain in treatment for opioid use disorder (OUD), suggests a report published this week in Psychiatric Services. The authors believe that access to telehealth services was partially responsible for the continuation of care during this period.

“Among a group of adults with commercial insurance or Medicare Advantage who had received opioid use disorder treatment before the COVID-19 pandemic, we observed minimal changes in outpatient and [medications for OUD] treatment utilization in the 2 years after pandemic onset,” wrote Kayla N. Tormohlen, Ph.D., M.P.H., of Johns Hopkins Bloomberg School of Public Health and colleagues. The authors noted it is unclear if the same applies to patients covered by Medicaid and patients without insurance.

The researchers analyzed deidentified administrative insurance claims for adults aged 18 or older who were covered by commercial insurance or Medicare Advantage from March 2018 to February 2022. To compare OUD treatment trends before the start of the pandemic with those in the years that followed, only patients who had an insurance claim indicating inpatient or outpatient treatment for OUD between March 2018 and February 2019 were included in the analysis. The final sample included 13,113 adults.

In March 2019, 10.6% of the patients had an OUD outpatient visit; by February 2022, 7.8% of the patients had an OUD outpatient visit—a decline of 2.8 percentage points, Tormohlen and colleagues reported. The proportion of patients receiving medication for OUD declined by 0.3 percentage points from March 2019 to February 2022.

Other findings included the following:

• Between March 2019 and February 2020, 98.6% of the patients who received outpatient opioid use disorder treatment obtained care via in-person settings only.
• Between March 2020 and February 2021, 46.0% of the patients received at least some opioid use disorder treatment via telehealth, 34.6% received a combination of telehealth and in-person care, and 11.4% received telehealth services only.
• Between March 2021 and February 2022, 34.9% of the patients received at least some outpatient care via telehealth, 23.4% received both telehealth and in-person care, and 11.5% received care via telehealth only.

“[T]he pandemic spurred widespread policy changes, including flexibility in the delivery of telehealth for opioid use disorder treatment, that may have enhanced treatment access,” they wrote. Even with these policy changes, however, the researchers noted that the “findings suggest that telehealth did not completely replace in-person services for opioid use disorder in either the first year of the COVID-19 pandemic or 2 years after its onset.”

They concluded, “Future research may examine how these policies affect receipt of care and explore how to optimally target in-person, telehealth, or a combination of treatment modalities to patients with opioid use disorder.”

For related information, see the Psychiatric News articles “Expanded Buprenorphine Prescribing Authority Gains Traction During Pandemic” and “Pandemic Creates Challenges, New Opportunities for Treating Patients With Substance Use Disorder.”

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Mood Disorders in Parents May Increase Risk of Anxiety Disorders in Offspring

Children who have a parent with a mood disorder appear to be at an elevated risk of a several anxiety disorders, suggests a report in the Journal of the American Academy of Child and Adolescent Psychiatry. The findings, which were based on a meta-analysis of 35 studies, suggest that children may be particularly at risk for panic disorder.

“Although we know that there is an overall increased risk for anxiety disorder in general among offspring of parents with mood disorders, little is understood about the risks of specific anxiety disorders and whether the risks differ between parental mood disorder subtypes,” wrote lead author En-Nien Tu, M.D., of the University of Oxford and colleagues.

To begin to answer these risks, Tu and colleagues sought out peer-reviewed studies that examined the risk of anxiety in the offspring of parents with mood disorders (at-risk group) and the offspring of parents who did not have these conditions (control group). The researchers identified 35 studies that fit their criteria that were published between 1994 and January 2023. Of these, 13 were cross-sectional studies, three were baseline data from cohort studies, and 19 were cohort follow-up studies. The majority of the studies included children under the age of 19 and most of the study participants were White and from high-income Western countries, the authors noted.

Anxiety disorders in the analysis included seasonal affective disorder (SAD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder, and agoraphobia.

Overall, 36.0% of children in the at-risk group experienced anxiety disorders during their lifetime, compared with 20.4% in the control group. Lifetime rates of anxiety disorders between the at-risk group vs. the control group were 20.4% vs. 10.0% for SAD, 14.5% vs. 7.16% for GAD, 15.6% vs 9.32% for social phobia, 20.2% vs. 12.1% for specific phobia, and 5.96% vs. 1.58% for panic disorder, and 4.17% vs. 4.40% for agoraphobia.

Compared with the control group, those who had parents with mood disorders were at 1.82 times higher risk of any anxiety disorder, except for agoraphobia; they also had more than a 3-fold greater risk of panic disorder compared with children who did not have a parent with a mood disorder.

When Tu and colleagues compared the offspring of parents with bipolar disorder with those of parents with unipolar depression, they found no significant difference between the risks of anxiety disorders across the offspring of parents with bipolar disorder versus unipolar depression.

The findings point to the importance of proactive prevention, early identification, and treatment strategies to reduce the risk of anxiety disorders in children of parents with mood disorders, the researchers noted. “An understanding of the mechanism underlying the increased rates of anxiety disorders in the offspring of parents with mood disorders may help identify important targets for intervention,” they wrote.

For related information, see the Psychiatric News Alert “One-Third of Teens Have Parent With Anxiety or Depression, Survey Suggests” and the Psychiatric News article “Childhood Anxiety Can Be Treated, the Challenge is to Recognize It.”

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Nominations Open for APA Components and Board of Trustees

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Donanemab Significantly Slows Progression of Alzheimer’s Disease, Study Finds

The drug donanemab significantly slowed the clinical progression of Alzheimer’s disease among patients with mild cognitive impairment or mild dementia, according to a study published yesterday in JAMA.

Donanemab is an antibody designed to target and remove beta-amyloid proteins that have clumped together to form plaques in the brain. It is manufactured by Eli Lilly and Company, which stated in a news release that it has submitted the drug for U.S. Food and Drug Administration (FDA) approval and expects regulatory action by the end of this year. Eli Lilly funded the study.

John Sims, M.D., of Eli Lilly and colleagues conducted a phase 3 randomized clinical trial including participants aged 60 to 85 years with early symptomatic Alzheimer’s disease who had amyloid and tau pathology (abnormal tau proteins and amyloid plaque are considered markers of Alzheimer’s). Participants were randomized to receive either donanemab (700 mg for the first three doses and 1,400 mg thereafter) or placebo, administered intravenously every four weeks for up to 72 weeks.

The study participants received MRIs at 4, 12, 24, 52, and 76 weeks to monitor amyloid plaque abnormalities, with additional MRIs scheduled at investigators’ discretion. (Amyloid-related imaging abnormalities—which can result in headache, confusion, as well as more severe symptoms—are associated with investigational interventions targeting amyloid proteins.)

Participants’ cognition and daily functioning were assessed using the integrated Alzheimer’s Disease Rating Scale (iADRS). They were also assessed using the Clinical Dementia Rating Scale, the Alzheimer’s Disease Assessment Scale, and the Alzheimer’s Disease Cooperative Study-Instrumental Activities of Daily Living scale.

Among 1,736 participants, 68.1% had low/medium tau pathology and 31.8% had high tau pathology (higher tau deposits in the brain are associated with greater memory and/or attention problems). When comparing iADRS measures between baseline and 76 weeks, Alzheimer’s disease progressed 22.3% more slowly in all participants receiving donanemab compared with the placebo group. In those with low/medium tau levels, the disease progressed 35.1% more slowly in participants receiving donanemab compared with the placebo group. Similarly, donanemab significantly slowed disease progression according to the three other scales the authors used in the study. At 76 weeks, disease progression with donanemab in the participants with low/medium tau was delayed by 4.36 months on the iADRS and 7.53 months on the Clinical Dementia Rating Scale.

The incidence of death was 1.9% in the donanemab group and 1.1% in the placebo group. Three participants with serious amyloid-related imaging abnormalities in the donanemab group died. Either amyloid-related imaging abnormalities or microhemorrhages occurred in 36.8% of participants receiving donanemab and 14.9% of those receiving the placebo.

“If approved by the FDA for the treatment of mild cognitive impairment and mild dementia due to Alzheimer’s disease, this will be the third disease-modifying medication available for the treatment of this devastating illness,” Rajesh Tampi, M.D., M.S., past president of the American Association for Geriatric Psychiatry, told Psychiatric News. “However, widespread use of this medication may remain elusive, due to the need for facilities that can conduct infusions and the monitoring of [amyloid-related imaging abnormalities] using MRI scans.”

Tampi also pointed out that equitable access to donanemab may be an issue. A high cost would make this drug unavailable for many patients with Alzheimer’s unless the Centers for Medicare and Medicaid Services and other payers covered the cost.

Other experts echoed Tampi’s points. The study found the greatest benefit in people with mild symptoms of Alzheimer’s, but minoritized groups are typically diagnosed at later stages, Jennifer Manly, Ph.D., of Columbia University Irving Medical Center and Kacie Deters, Ph.D., of the University of California, Los Angeles wrote in an accompanying commentary.

“Clinicians and the public will need to weigh the potential benefit of treatment (delay of progression of about 4 months on average) with the financial and quality-of-life costs of infusions, MRI monitoring, and risk of amyloid-related imaging abnormalities and brain volume loss,” Manly and Deters wrote.

For related information, see the Psychiatric News article “Aduhelm for Alzheimer’s: Questions Remain About Cost, Clinical Effectiveness.”

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Youth With Eating Disorders More Likely to Use Health Care Services

Children and adolescents who have eating disorders are more likely than those without eating disorders to use most mental health and non-mental health services, a study in the International Journal of Eating Disorders has found. The study also found that children and adolescents who have avoidant restrictive intake disorder (ARFID) use mental health and non-mental health services about the same as those youth with other eating disorders, with the exception of those who have anorexia nervosa.

“It is important to examine these patterns of utilization in order to identify specific needs and areas for system improvements for specific subgroups of patients with eating disorders,” wrote Jennifer Couturier, M.D., M.Sc., of McMaster University in Hamilton, Ontario, and colleagues. “[W]e wanted to examine differences between ARFID and the other subgroups, as we are not aware of any literature on health care utilization in the ARFID population.”

The researchers examined the health records of 1,449 patients aged 5 to 17 years who had eating disorders and compared them to the health records of 7,245 patients in the same age group in the general population who did not have eating disorders. The patients in the eating disorders group had been diagnosed within two years of their inclusion in the study and included 674 with anorexia nervosa, 230 with bulimia nervosa, 59 with binge-eating disorder, 171 with avoidant restrictive intake disorder, and 315 with other eating disorders. Outcomes included hospitalizations for mental health or non-mental problems and emergency department, psychiatry, general practitioner, and pediatrician visits.

The researchers found that the use of mental health services was higher in all of the subgroups of patients with eating disorders compared with patients in the general population. Likewise, the use of non-mental health care services was higher among patients in all of the subgroups compared with the general population except for general practitioner visits and emergency department visits, which were not significantly different from that of the general population.

Couturier and colleagues then compared the use of mental health and non-mental health services by patients who had ARFID with that of all the other patients who had eating disorders. Patients with ARFID appeared to use mental health and non-mental health care services about the same as patients with other eating disorders, except for those with anorexia nervosa. Compared with patients with ARFID, patients with anorexia nervosa had 1.62 higher odds of a mental health–related hospitalization, 1.76 times the rate of pediatrician visits for mental health, and 1.69 times the rate of psychiatry visits.

The researchers noted comments by authors of other studies to suggest that health professionals working outside of eating disorder programs may not have familiarity and experience diagnosing ARFID.

“These challenges suggest that more training and specialized services [need to] be developed for those with ARFID as [mental health and non-mental health service] utilization is similar to those with other eating disorders,” Couturier and colleagues concluded.

For related information, see the Psychiatric News Special Report “Youth With Eating Disorders—Time Is of the Essence in Achieving Remission” and “The American Psychiatric Association Practice Guideline For The Treatment Of Patients With Eating Disorders, Fourth Edition.”

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Don’t Miss Out on Free Webinars Coming This Week

APA and Morehouse School of Medicine African American Behavioral Health Center of Excellence have joined forces to create a series of webinars and training modules on addressing mental health disparities among Black Americans. Two webinars that are part of this educational series will take place this week:

• July 18, 3 p.m. ET: Black & Blue: The Intersection of Mental Health, Policing, and Race in A Crisis Response Psychiatrist Dionne Hart, M.D., will discuss the history of policing in the United States, innovative solutions to decrease the role of police in response to a mental health crisis, and more in this hour-long interactive webinar.
• July 19, 3 p.m. ET: Technology Acceptance and the Digital Divide Telepsychiatry can extend the reach of treatment to more patients, but “technology deserts” continue to exist. In this one-hour webinar, psychiatrist Iverson Bell, M.D., will describe remedies for overcoming technology deserts and more.

Online Emotion Regulation Therapy May Reduce Frequency of Self-Injury

Adolescents who engage in non-suicidal self-injury (deliberate harm to one’s body without suicidal intent) are known to be at risk of a variety of problems, including suicidal behaviors. A study published yesterday in JAMA Network Open suggests that adolescents diagnosed with non-suicidal self-injury (NSSI) who participate in an online emotion regulation therapy may be less likely to engage in such self-harm behaviors compared with those receiving usual care.

“There are very few empirically supported treatments for NSSI in adolescence. Dialectical behavior therapy is promising; however, it is a long and resource-demanding treatment that is not widely available,” wrote Johan Bjureberg, Ph.D., of the Karolinska Institutet in Stockholm and colleagues. “Briefer and more accessible treatments for NSSI are needed.”

To test whether a brief treatment delivered online might be able to help youth, Bjureberg and colleagues recruited adolescents aged 13 to 17 diagnosed with non-suicidal self-injury disorder (listed as a condition for further study in DSM-5) who did not have any immediate suicide risk. In total, 166 adolescents were randomly assigned to receive either 12 weeks of online emotion regulation therapy alongside usual care or usual care alone.

Usual care included weekly symptom assessments and supportive therapy sessions every two weeks. The online therapy included 11 educational modules for the adolescents and six modules for their parents. Emotion dysregulation is believed to in part drive NSSI behavior, and the modules aim to teach participants more adaptive ways of responding to their emotions. The participants also had online access to a therapist who encouraged engagement and answered questions.

NSSI frequency was both self-reported by the adolescents weekly and assessed by clinicians before and after treatment.

At the start of the study, the participants reported about 2.5 NSSI episodes per week. From pretreatment to one month post-treatment, the adolescents receiving the online therapy reported a 68% reduction in the number of NSSI episodes per week, whereas those in usual care alone reported no change. Similarly, at the one-month follow-up, the clinicians observed an 82% reduction in NSSI frequency for the online therapy group compared with a 47% reduction for those in usual care. The adolescents receiving the online therapy also reported greater improvements in their emotion regulation and overall functioning as well as fewer self-destructive behaviors compared with usual care at one-month and three-month follow-ups.

There was no difference in depression, anxiety, and stress symptoms between the two groups after the treatment, the researchers wrote. They noted that these findings are consistent with the online therapy’s emphasis on encouraging participants to accept internal experiences and control their behaviors while emotionally distressed, rather than trying to control the emotions themselves. “[T]argeting emotion regulation may not be sufficient for the treatment of anxiety and depression among adolescents,” they wrote.

To read more on this topic, see the Psychiatric News article “People Who Self-Injure Describe Behaviors as Addictive.”

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One-Third of Teens Have Parent With Anxiety or Depression, Survey Suggests

Parents and their teenage children report similar rates of anxiety and depression, according to a report published this week by Harvard Graduate School of Education’s Making Caring Common project. Further, almost 40% of teens report being worried about the mental health of at least one of their parents.

“There is a largely untold story about parent mental health in America,” the report’s lead author Richard Weissbourd, Ed.D., of the Harvard Graduate School of Education said in a news release. “Parents and teens’ mental health are deeply interwoven, and we need to do much more in this country to support parents and to promote their mental health. Parents and other primary caregivers also need the knowledge and resources to be able to support their teens’ mental health.”

Weissbourd and his colleagues conducted two surveys in December 2022. One survey was directed to teens (ages 14 to 17) and young adults (ages 18 to 25), while the other was directed to parents or caregivers. Respondents were recruited from NORC at the University of Chicago, a research organization with nationally representative panels of both adults and teens. The survey questions for teens and young adults asked the youth to identify up to two primary caregiver(s) and focused on issues such as their perceived stressors, relationships, view of their parents and schools, and their help-seeking strategies. Much of the caregiver survey directly matched the questions given to teens and young adults.

Respondents reported their anxiety and depression symptoms using the Generalized Anxiety Disorder-2 and Patient Health Questionnaire-2 measures, respectively. Respondents were considered to have anxiety or depression if they had scores of three or more, which is the score at which patients are typically screened for generalized anxiety disorder or major depressive disorder in clinical settings.

In total, 396 teens, 709 young adults, and 748 parents or caregivers responded to the survey, including 321 pairs of teens and their parents. (For the purposes of the report, the researchers categorized all female primary caregivers as “mothers” and all male primary caregivers as “fathers.”) The findings include the following:

• 18% of teens reported experiencing anxiety, as did 20% of mothers and 15% of fathers.
• 15% of teens reported experiencing depression, as did 16% of mothers and 10% of fathers.
• Teen girls reported higher rates of anxiety (24%) and depression (22%) compared with teen boys (12% and 8%, respectively).
• 40% of teens reported that they want their parents to “reach out more to ask how [they’re] really doing and to really listen.”
• Teens reporting depression and anxiety are much more likely to reach out to their friends (56%) than their parents (32%) for emotional support.
• Among the parent-teen pairs, a lack of awareness among the parents of the anxiety or depression that their teens experienced was strongly associated with depression and anxiety in both teens and parents. “The greater the misalignment, the greater the chances that both parents and teens reported these emotional challenges,” the authors wrote.

“The good news is that much is known about how to mitigate these emotional troubles in parents, how to guide parents in knowing and providing vital emotional support to their teens, how to reduce the harmful impact of parental depression and anxiety on teens, and how to head off damaging parent-teen dynamics,” the authors wrote. “But we need government agencies and community efforts at a much broader scale that support parents’ emotional health, connect parents to effective treatment, and equip them to promote their own and their children’s mental health.”

For related information, see the Psychiatric News article “Surgeon General Calls for Action to Address Youth Mental Health Crisis.” 

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Don’t Miss Out on Free Webinars Coming Next Week

APA and Morehouse School of Medicine African American Behavioral Health Center of Excellence have joined forces to create a series of webinars and training modules on addressing mental health disparities among Black Americans. Two webinars that are part of this educational series will take place next week:

• July 18, 3 p.m. ET: Black & Blue: The Intersection of Mental Health, Policing, and Race in A Crisis Response Psychiatrist Dionne Hart, M.D., will discuss the history of policing in the United States, innovative solutions to decrease the role of police in response to a mental health crisis, and more in this hour-long interactive webinar.
• July 19, 3 p.m. ET: Technology Acceptance and the Digital Divide Telepsychiatry can extend the reach of treatment to more patients, but “technology deserts” continue to exist. In this one-hour webinar, psychiatrist Iverson Bell, M.D., will describe remedies for overcoming technology deserts and more.

Psychiatric ‘Boarding’ Found More Likely During Pandemic for Youth With Public Insurance

Youth who were insured by Medicaid or other public programs and experienced a psychiatric emergency in Massachusetts during the COVID-19 pandemic were more likely to be held in the emergency department (“boarded”) than those who experienced such emergencies before the pandemic. Moreover, youth who were boarded during the pandemic were more likely to have readmissions to the emergency department within 30 days compared with prior to the pandemic. These findings were published in JAMA Network Open.

“Psychiatric boarding occurs when patients who accessed psychiatric emergency services … require treatment in an inpatient psychiatric unit … or community-based acute treatment … facility but experience administrative delays in their transfer and remain under clinical supervision in suboptimal care,” wrote Carolina Nicole Herrera, M.A., Rachel Oblath, Ph.D., and Alison Duncan, M.D., of Boston University.

Herrera and colleagues evaluated data from 7,625 encounters with publicly insured patients aged 4 to 20 years who were evaluated by a mobile crisis team between January 2018 and August 2021. Specifically, the researchers examined what happened after the initial evaluation by the mobile crisis teams—comparing such outcomes as the youth’s psychiatric boarding and repeat hospital visits—before the pandemic (January 2018 to March 2020) with what happened during the pandemic (March 2020 to August 2021). The authors considered the youth to have been psychiatrically boarded if they required 24-hour psychiatric care and an inpatient psychiatric unit or community-based acute treatment bed was unavailable within six hours of the disposition decision.

The average age of youth who were evaluated by the mobile crisis teams was 13.6 years; 48% identified as male; 36%, Black; 36%, Hispanic; and 91% spoke English. During the pandemic, the youth were twice as likely to be boarded in the emergency department as they were before the pandemic. These youth were also 64% less likely to be admitted to the hospital. Additionally, youth who were boarded during the pandemic had 2.2 times the rate of 30-day readmissions compared with those who were boarded before the pandemic.

In an accompanying editorial, Abigail Donovan, M.D., of Massachusetts General Hospital said the report paints a stark picture of psychiatric emergency services for youth insured by public programs during the pandemic: “[This] article is the first to demonstrate that compared with pre-pandemic, during the pandemic, publicly insured youths evaluated by a [mobile crisis team] who were boarding for a higher level of care were less likely ever to receive the treatment for which they were waiting,” she wrote. “Perhaps even more importantly, while youths were stable at the time of discharge, for some, this stability was short-lived … .”

Donovan concluded, “We must establish long-term plans for overhauling the mental health care system, implement immediate clinical innovations to prevent harm to vulnerable populations, and conduct additional research to delineate the current crisis further and evaluate future solutions. Only by taking these steps can we hope to repair our mental health care system before it collapses.”

For related information, see the Psychiatric News article “Congress Hears Testimony on Need for Robust MH Crisis Services.”

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Study Highlights Gaps in Insurance Acceptance Between Psychiatrists, Other Physicians

Between 2007 and 2016, psychiatrists who were accepting new patients participated in insurance networks at lower rates than physicians who were not psychiatrists. This was one of several conclusions of a report published yesterday in Psychiatric Services, which also revealed that the gap in insurance acceptance between psychiatrists and nonpsychiatrists was wider for Medicare and Medicaid than for private insurance.

“The reluctance of psychiatrists to participate in insurance networks substantially threatens mental health access, equity, and public health,” wrote Andrew D. Carlo, M.D., M.P.H., of Northwestern University Feinberg School of Medicine and colleagues. “Although our findings highlight this problem more clearly than have previous studies, our observations cannot directly inform an overarching strategy to mitigate the deleterious market forces that have led to the inequities and inadequacies in the contemporary U.S. mental health care delivery system.” 

Carlo and colleagues analyzed 10 years of data (January 2007 to December 2016) from the National Ambulatory Medical Care Survey (NAMCS), an annual survey that provides information about medical services in the United States collected from medical records. From these data, they calculated the differences between psychiatrists and other physicians in the sample. They next calculated the proportions of psychiatrists across all years and in two-year groupings between 2007 and 2016 who accepted Medicare, Medicaid, capitated private insurance, noncapitated private insurance, any private insurance, any public insurance, and any insurance. These calculations were repeated with nonpsychiatrists, and the results of the two groups were compared.

The unweighted sample included on average 4,725 physicians per two-year time group between 2007 and 2016; on average, 307 (7%) of these physicians were psychiatrists.

For all insurer groupings and periods, nonpsychiatrists accepted insurance at higher rates than psychiatrists, Carlo and colleagues reported. “Most notably, we found that, although all physicians working in solo practices and those in [metropolitan statistical areas] were less likely to accept insurance than their counterparts in group practices and outside of [metropolitan statistical areas], these trends were more pronounced among psychiatrists,” they wrote.

“Much has been written about the individual and contextual factors that underpin psychiatrists’ lack of insurance acceptance and disproportionate acceptance of self-pay patients, relative to nonpsychiatrists,” including “relatively low reimbursement rates for mental health services (often lower than rates for nonpsychiatrist physicians for the same service), comparatively arduous administrative burden due to a lack of insurance parity enforcement,” and more, the researchers wrote. “Our findings did not directly support any of these hypotheses or propose alternative explanations, but they have provided a higher-resolution description of the phenomenon, which may improve understanding of this problem.”

“Much has been written about the individual and contextual factors that underpin psychiatrists’ lack of insurance acceptance and disproportionate acceptance of self-pay patients, relative to nonpsychiatrists,” including “relatively low reimbursement rates for mental health services (often lower than rates for nonpsychiatrist physicians for the same service), comparatively arduous administrative burden due to a lack of insurance parity enforcement,” and more, the researchers wrote. “Our findings did not directly support any of these hypotheses or propose alternative explanations, but they have provided a higher-resolution description of the phenomenon, which may improve understanding of this problem.”

In an email to Psychiatric News, Carlo noted that “one of the challenges that people face in accessing psychiatric care is poor insurance network adequacy, leading to prohibitively high out-of-pocket costs for patients and their families.”

“Our findings suggest that much more needs to be done at various levels of the health care system to bring more psychiatrists and other mental health providers into public and private insurance networks,” he continued. “Possibilities include incentives for psychiatrists, enforcement of federal insurance parity laws, and other policy strategies. Psychiatrists can help facilitate change by advocating for enforcement of insurance parity laws and working with their local and regional societies/networks to identify strategies to improve network adequacy.”

For related information, see the Psychiatric News Alert “Survey Reveals Stark Difficulty in Obtaining Appointments With Child Psychiatrists” and the Psychiatric Services article “Patient Characteristics and Treatment Patterns Among Psychiatrists Who Do Not Accept Private Insurance.”

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APA members who have administrative experience, are passionate about disseminating news in the field of psychiatry, and are knowledgeable about print and digital communications are invited to apply. Watch a short video in which the current editor-in-chief discusses this influential and key position. The deadline for applications, which should include a vision statement and a curriculum vitae, is July 19, 2023.

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Less Than Two Hours of Exercise Weekly May Reduce Depression Risk in Adults 50 and Older

Just 100 minutes of moderate exercise weekly (for example, brisk walking) may help reduce the risk of depression in adults aged 50 years and older, suggests a report published today in JAMA Network Open. 

“The findings of this cohort study suggest that physical activity doses lower … than doses recommended in [WHO] guidelines for overall health … may protect against depressive symptoms and major depression among older adults,” wrote Eamon Laird, Ph.D., of the University of Limerick, Ireland, and colleagues. “We do not advocate for reduced activity levels in any population, but these findings suggest that even doses lower than recommended may protect mental health over time.”

Laird and colleagues used data from The Irish Longitudinal Study on Ageing, which collects demographic, health, and lifestyle information from community-dwelling adults who are at least 50 years old and live in Ireland. They examined data from 4,016 participants who had completed interviews and questionnaires between October 2009 and December 2018. Depression symptoms were assessed using the 8-item version of the Centre for Epidemiological Studies Depression (CES-D). Laird and colleagues converted participants’ responses on the Physical Activity Questionnaire into metabolic equivalent of task (MET) minutes per week. (One MET equals the amount of oxygen an average person uses while sitting for one minute. One minute of moderate activity equals about 4 METs.)

During the 10-year follow-up period, depression rates increased from a mean of 8.2% to 12.2%, Laird and colleagues reported. Compared with adults who reported low physical activity (<600 MET minutes per week), those who performed moderate activity (600 to 1,200 MET minutes per week) had a 7% lower rate of depressive symptoms and 42% lower odds of having major depression (defined as a CES-D score of ≥9 or a report of a major depressive episode). Adults who performed vigorous activity (1,200 to 2,400 MET minutes per week) had a 20% lower rate of depressive symptoms and 44% lower odds of major depression compared with the low physical activity group.

When taking a closer look at the low-activity group, Laird and colleagues found that performing at least 400 MET minutes per week could reduce the rate of depressive symptoms or major depression compared with adults who reported no physical activity.

Laird and colleagues also found that the depression benefits of low to moderate physical activity were more pronounced in adults with chronic diseases such as heart disease, cancer, or arthritis. “This was not surprising given that individuals without chronic conditions could already be engaged in salutary lifestyle practices, resulting in less likelihood of experiencing increased depressive symptoms and major depression compared with those with a chronic disease, and thus may require greater physical activity doses to elicit further protection,” they wrote.

To read more on this topic, see the Psychiatric News article “Exercise May Offset Genetic Risk for Depression.”

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Xylazine Present in Increasing Number of Fentanyl Overdose Deaths, CDC Finds

Overdose deaths involving illicitly manufactured fentanyl where the veterinary tranquilizer xylazine (“tranq”) was also detected jumped 276% from January 2019 through June 2022, a study in Morbidity and Mortality Weekly Report has found.

“It is important for overdose prevention and response messages to highlight the potential presence of xylazine in [illicitly manufactured fentanyl] products and emphasize the need for respiratory and cardiovascular support to address the sedative effects of xylazine,” Mbabazi Kariisa, Ph.D., of the Center for Disease Control and Prevention (CDC) and colleagues wrote.

The researchers analyzed data from the CDC’s State Unintentional Drug Overdose Reporting System to compare monthly deaths involving illicitly manufactured fentanyl with and without xylazine. A drug was considered involved or co-involved if it was listed as a cause of death on the death certificate or medical examiner or coroner report, versus only being detected in the body after death.

In 21 jurisdictions that included 20 states and the District of Columbia, the monthly proportion of deaths involving fentanyl with xylazine detected increased from 2.9% in January 2019 to 10.9% in June 2022. The number of cases where xylazine was co-involved rose from 12 to 188 over the same period. 

The researchers then expanded their analysis to include 32 jurisdictions spanning 31 states and the District of Columbia and narrowed the timeframe. They found that from January 2021 to June 2022, xylazine was detected in 9.0% deaths involving illicitly manufactured fentanyl and co-involved in 6.9%. The highest percentages and deaths involving fentanyl with xylazine detected were in Maryland, Connecticut, and Pennsylvania, at 27.7%, 26.4%, and 23.3%, respectively. Compared with deaths without xylazine, a higher percentage of deaths with xylazine had evidence of injection drug use, 28.6% versus 19.5%.

“Expanded postmortem and illicit drug product testing for xylazine is needed to clarify prevalence in drug supplies,” Kariisa and colleagues wrote. “[F]urther investigation of xylazine’s effects on humans is necessary to characterize morbidity and overdose risk.”

For related information, see the Psychiatric News article “Xylazine Increasingly Found in Overdose Deaths.” 

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APA members who have administrative experience, are passionate about disseminating news in the field of psychiatry, and are knowledgeable about print and digital communications are invited to apply. Watch a short video in which the current editor-in-chief discusses this influential and key position. The deadline for applications, which should include a vision statement and a curriculum vitae, is July 19, 2023.

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Stimulant Treatment in Youth Not Associated With Substance Use Later in Life

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) who are treated with stimulants do not have an increased risk of frequent alcohol, marijuana, cigarette, or other substance use later in life, according to a study published yesterday in JAMA Psychiatry.

“Childhood [ADHD] carries risk for elevated substance use and substance use disorder (SUD) by adulthood,” wrote Brook S.G. Molina, Ph.D., of the University of Pittsburgh and colleagues. Because stimulant medications decrease impulsivity in patients with ADHD, some researchers believe the medications decrease substance use in these patients, they continued. “However, early exposure to stimulants may cause neurobiological and behavioral sensitization to other drugs and thus increase the risk for harmful substance use.”

Molina and colleagues used data from the Multimodal Treatment Study of ADHD, a 14-month randomized clinical trial of medication and behavior therapy. Participants aged 7 to 9 years who were diagnosed with ADHD were randomly assigned to one of four treatment groups: medication management, multicomponent behavior therapy, a combination of the two, or referral to usual community care. Participants were assessed prior to randomization, at months three and nine, and at the end of treatment. They were then followed for 16 years and were assessed at years 2, 3, 6, 8, 10, 12, 14, and 16.

During the 12-, 14-, and 16-year follow-ups, the participants completed a questionnaire on their use of alcohol, marijuana, cigarettes, and several illicit and prescription drugs. Information on the participants’ stimulant treatment was collected via the Services for Children and Adolescents Parent Interview until the participants reached the age of 18 years; after age 18, the participants reported on their stimulant treatment.

A total of 579 participants were included in the analysis. Substance use increased steadily through adolescence and remained stable through early adulthood. After accounting for developmental trends in substance use through adolescence into early adulthood, there was no association between current or prior stimulant treatment and substance use. Further, there was no evidence that a longer duration of stimulant treatment was associated with less substance use in adulthood. However, while cumulative stimulant treatment was associated with increased heavy drinking, the authors noted that the effect size of this association was small.

The authors concluded that their study “failed to support any hypotheses of substance use protection or harm from stimulant treatment for ADHD.”

They continued: “Although these results contrast with recent conclusions of protection found in other data sets, across all studies the findings lend a measure of comfort in the consistent lack of evidence that stimulant treatment predisposes children with ADHD to later substance use.”

For related news, see the Psychiatric News article “Symptoms, Impaired Function of ADHD Often Persist Beyond Childhood.”

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Esketamine Found to Benefit Teens With Depression, Suicidal Thinking

Adolescents who are hospitalized for major depressive disorder (MDD) and suicidal thinking may see rapid improvements in symptoms within days of receiving esketamine infusions, suggests a report published Monday in the Journal of the American Academy of Child and Adolescent Psychiatry.

The small trial found that those who received three esketamine infusions over five days in addition to antidepressants or combination therapy experienced greater symptom improvements than those who received midazolam infusions (the control group) over five days. At the one-month follow-up, teens who received esketamine continued to show a greater response than those who received midazolam, the study found.

“Adolescents with MDD have a high risk of suicide, and recent studies have suggested that elevated rates of depression and suicide in adolescents have been identified during the COVID-19 pandemic,” wrote Yanling Zhou, Ph.D., of the Affiliated Brain Hospital of Guangzhou Medical University in China and colleagues. “Esketamine’s rapid-onset reduction of suicidal ideation might dramatically increase adolescent safety in emergencies.”

The trial included 54 hospitalized adolescents (48 were female) aged 13 to 18 who had moderate-to-severe depressive symptoms and had been experiencing suicidal ideation for more than three months. Moderate-to-severe depression was defined as a score of 17 or greater on the Hamilton Depression Rating Scale. Participants were considered to have suicidal ideation if they had a score of 1 or greater on the Columbia Suicide Severity Rating Scale (C-SSRS) ideation scale and a score of 2 or greater on the self-reported Beck Scale for Suicide Ideation. The participants were randomly assigned to receive three infusions of esketamine (0.25 mg/kg) or midazolam (0.045 mg/kg) over five days along with routine inpatient care and treatment.

The primary outcomes were scores on the Montgomery-Asberg Depression Rating Scale (MADRS) and the C-SSRS ideation and intensity scales. Participants were assessed at 24 hours after each infusion and at one, two, and four weeks after the final infusion.

Participants receiving esketamine had a significantly greater improvement from baseline to day 6 on the ideation and intensity scales of the C-SSRS than those receiving midazolam (-2.6 versus -1.7 for ideation and -10.6 versus -5.0 for intensity). They also showed greater improvement on the MADRS from baseline to day 6 (-15.3 versus -8.8).

Four weeks after the third infusion, 65% of participants who received esketamine experienced remission from suicidal ideation compared with 44% of participants who received midazolam.

“Larger studies are required to support esketamine’s clinical efficacy and assess its long-term [effects], such as cognitive impairment and risk of recreational use following acute treatment in adolescents,” Zhou and colleagues concluded.

For more information, see the Psychiatric News article “Esketamine, Antidepressant Combo Safe, More Effective Than Placebo.”

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