1 in 3 Adults Knows Someone Who May Be Struggling With Addiction, APA Poll Finds

More than 70% of American adults said they would know how to get help for their friend or family member who was struggling with an addiction, and 53% said they would reach out to a doctor for help, according to the latest findings from APA’s Healthy Minds Monthly Poll. The majority of those surveyed also said that if their loved one was dealing with addiction, they would initiate a conversation with them about addiction.

“It’s promising … that Americans show such openness to talking with loved ones who may have substance use disorders or behavioral addictions,” APA President Petros Levounis, M.D., M.A., said in a news release. The survey suggests that Americans are familiar with various methods of recovery, he continued.

The poll was conducted online by Morning Consult from August 12 to 13 among 2,201 adults. It had a margin of error of ±2 percentage points percentage points. Addiction was defined as a state of psychological or physical dependence (or both) on the use of alcohol or other drugs. The survey also noted that the term addiction sometimes applies to behavioral disorders, such as sexual, internet, or gambling addictions.

Thirty-six percent of respondents said they know someone who struggles with addiction. Further, adults aged 18 to 34 were twice as likely as adults aged 65 or older to say they know someone struggling with addiction (44% vs. 22%). Additional findings include the following:

• If a loved one was struggling with addiction, 73% of respondents said they would refer this person to recovery treatment; 74% said they would initiate a conversation about mental health or addiction.
• When asked to select which treatment they would most likely recommend to a loved one with addiction, 24% of respondents selected inpatient treatment and 23% selected support groups such as Alcoholics Anonymous; 19% of respondents had no opinion or did not know what treatment they would recommend to a loved one with addiction.
• Among the available responses on the survey, 65% of respondents considered recovery from a mental illness or addiction to be “Being able to function better in life,” while 38% said they consider recovery to be “Feeling better.”
• Only 7% of respondents said they did not think recovery from a mental illness or addiction is possible.

Overall, 8% of respondents said they would turn to social media for help for a loved one struggling with addiction. Among those aged 18 to 44, however, about 15% said they would reach out to social media.

“Reaching younger generations with credible, evidence-based information on social media, particularly about subjects like mental illness and addiction, is critical,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the release. “The trends in the poll absolutely support that organizations [such as APA] have a role to play in ensuring medically accurate information is available and widespread on these channels.”

For related information, see the Psychiatric News Alert “Respondents to APA Poll Express Confidence in Psychiatry as Innovative Field.”

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Federal Agency ‘Dead Set’ on Enforcing Parity, Seeks Psychiatrists’ Feedback on New Rules

The Employee Benefit Security Administration (EBSA) wants to hear from psychiatrists about recently proposed regulations to strengthen the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). The deadline to submit a formal comment on these proposed rules is Monday, October 2.

EBSA is part of the Department of Labor and is responsible for regulating 2.5 million employer-sponsored benefit plans providing health benefits to some 134 million people.

The new rules—proposed by the departments of Labor, Treasury, and Health and Human Services—are meant to close loopholes and add greater clarity to the law’s requirement. They were announced at an event at the White House on July 25 that brought together leaders of APA and other mental health and patient advocacy organizations.

“The idea behind parity is that if an insurer is going to impose a financial condition or a treatment limitation on a beneficiaries’ receipt of promised benefit, those requirements and limitations cannot be more restrictive for people with mental illness or substance use disorders than they are for people with general medical conditions,” Tim Hauser, deputy assistant secretary for program operations at EBSA, told Psychiatric News.

But the reality, as too many patients and their psychiatrists have learned, hasn’t lived up to the vision. Hauser outlined ways in which the proposed parity rules would make the law clearer and remove loopholes that insurers and health plans have used to dodge the law’s requirements.

• Inclusion of a statement of purpose: The statement of purpose is designed, Hauser said, to remind everyone of the purpose of parity: When insurance companies are determining treatment limitations on a beneficiaries’ receipt of promised benefit, they can be no more restrictive than those for general medical conditions.
• Clearer definitions of terms and concepts: For example, the proposed rules clarify the meaning of “restrictive” limitations on mental and substance use disorder benefits.
• Mandating collection of data on outcomes: Under the proposed rules, insurers and health plans would be expected to continually collect data on outcomes related to “non-quantifiable treatment limitations”—those treatment limitations that are not financial in nature but include such things as requiring prior insurance authorization for a particular treatment.
• Requiring a written analysis comparing limitations: Congress approved a law two years ago saying that the departments of Labor, Health and Human Services, and Treasury can request a written analysis comparing mental and substance use disorder treatment limitations and those for medical and surgical treatment. “Our proposed rule defines how that analysis should work, what information insurers need to be providing us, and makes clear what the consequences are for noncompliance,” Hauser said.

Hauser urged APA members and others to respond with comments on the proposed regulations by the October 2 deadline. The agency is particularly seeking feedback from psychiatrists on reliable metrics that might be used to compare treatment limitations, he said.

“The problem with access to treatment is a serious one,” he said. “Fifteen years into the parity law, we should not be dealing with these issues. We are dead set on fixing it.”

For a full report, see the Psychiatric News article “Federal Agency Declares It Is ‘Dead Set’ on Enforcing Parity.”

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Patients With Mental Illness May Not Receive Cancer Symptom Screening

Cancer patients with major mental illness are less likely to be screened for common cancer symptoms such as pain and fatigue than cancer patients without a major mental illness, suggests a report in Psycho-Oncology.

“There is evidence that patients with [major mental illness] are at a greater risk for delayed cancer diagnosis, experience unequal standards of care, and generally poorer disease outcomes due to a constellation of patient, provider, and health care system factors,” wrote Laura E. Davis, a Ph.D. student at McGill University; Alyson Mahar, Ph.D., of ICES in Toronto; and colleagues. Routine cancer symptom screening can help to identify the most severe symptoms experienced by patients and encourage discussion between patients and their doctors about how best to treat these symptoms, the authors continued.

For the study, Davis, Mahar, and colleagues relied on information collected in several databases to identify adults in Ontario who were diagnosed with cancer between January 1, 2007, and August 31, 2020. The researchers separated these patients into two groups: those with major mental illness (diagnosis of major depression, bipolar disorder, schizophrenia, and other psychotic illnesses five years before the cancer diagnosis) and those without major mental illness. They then tracked evidence of symptom assessments of these patients—from cancer diagnosis until death or end of study date (August 31, 2021), whichever occurred first. The researchers focused on two main outcomes: time to cancer symptom screening using the Edmonton Symptom Assessment System (ESAS-r) and time to severe symptom score.

The final cohort consisted of 4,049 patients with major mental illness seen in an inpatient setting, 9,775 patients with major mental illness seen in an outpatient setting, and 376,046 patients without a major mental illness diagnosis or use of mental health services in the five years to six months before cancer diagnosis.

Compared with those without a major mental illness, those with major mental illness were less likely to have an ESAS-r recorded, reported Davis, Mahar, and colleagues. They were also more likely to report a high symptom score across all nine ESAS-r symptoms.

“Notably, individuals with [a major mental illness] were more likely to report moderate-to-severe symptoms of nausea and pain, where well-defined management protocols exist,” the authors wrote. “This highlights the need for both improved access to symptom screening and management strategies for cancer patients with a pre-existing mental illness to provide appropriate support, optimize outcomes, and deliver equitable cancer care.”

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

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Antipsychotic Polypharmacy Increases Risk of Hypertension, Study Suggests

Individuals who take multiple antipsychotics to manage schizophrenia symptoms have three times the risk of developing hypertension relative to those taking one antipsychotic, according to a study published in Schizophrenia Bulletin. The risk of hypertension was greatest when the patients were taking multiple first-generation antipsychotics.

“[T]he risks of developing hypertension and its cardiovascular consequences over time need to be considered when making decisions on whether [antipsychotic polypharmacy] is justified,” wrote Emily Eyles, Ph.D., of the University of Bristol and colleagues. If antipsychotic polypharmacy is determined to be necessary, patients should receive regular blood pressure monitoring and potentially antihypertensive treatment to reduce cardiovascular risk, Eyles and colleagues continued.

The researchers compiled three study cohorts using data from the U.K. Clinical Practice Research Datalink, which includes de-identified patient records from over 700 primary care centers across the United Kingdom. The researchers identified adults with schizophrenia who received a new prescription for one or more antipsychotics between July 1, 1994, and August 30, 2018, and who had no history of diabetes (cohort 1), hypertension (cohort 2), or hyperlipidemia (cohort 3). Patients in each cohort were tracked for up to five years; until they received a diagnosis for diabetes, hypertension, or hyperlipidemia; they stopped taking antipsychotics; or they were no longer being seen by the practice.

In total, 1,663, 1,268, and 1,668 adults with schizophrenia were assessed for incidence of diabetes, hypertension, and hyperlipidemia, respectively. The average follow-up period was 14 months; during this time, 4.4% of the first cohort developed diabetes, 6.6% of the second cohort developed hypertension, and 3.8% of the third cohort developed hyperlipidemia.

Compared with adults taking one antipsychotic, those taking multiple antipsychotics had 3.16 times the risk of developing hypertension, even after adjusting for multiple variables including smoking, body mass index, psychiatric comorbidities, and total antipsychotic dose. There was no evidence of an association between antipsychotic polypharmacy and diabetes or hyperlipidemia.

To read more on this topic, see the Psychiatric News article “Study Finds Higher-Dose Antipsychotic Polypharmacy Does Not Increase Hospitalization.”

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Mental Health Service Use, Spending Jumped During Pandemic, Remain Elevated

Spending on mental health services among Americans with private health insurance has surged since the beginning of the COVID-19 pandemic, a research letter published today in JAMA Health Forum has found. The results suggest that spending on mental health services is continuing to rise even as the use of telehealth has plateaued.

Jonathan H. Cantor, Ph.D., of the RAND Corporation and colleagues examined data from 1,554,895 mental health service claims to ascertain trends in mental health services use and spending during three periods:

• Pre-pandemic, before the declaration of the public health emergency (January 1, 2019, to March 12, 2020).
• Acute phase of the pandemic, before vaccines were available (March 13, 2020, to December 17, 2020).
• Post-acute phase of the pandemic (December 18, 2020, to August 31, 2022).

The researchers found that during the acute phase, in-person visits decreased by 39.5% and telehealth visits increased roughly 1,019.3% (roughly tenfold) compared with the year prior. Jointly, this represented a 22.3% increase in overall service use. During the post-acute phase, telehealth visits stabilized at approximately 1,068.3% of pre-pandemic levels, whereas in-person visits increased 2.2% each month over the period. By August 2022, in-person visits reached 79.9% of pre-pandemic levels, and overall mental health service use was 38.8% higher than before the pandemic.

During the acute phase, per capita expenditures for mental health services were 29.5% higher compared with the year prior. During the post-acute phase, spending for telehealth services remained stable, and spending for in-person care decreased to pre-pandemic levels. However, the average spending rate on mental health services was $3,547,424 per 10,000 beneficiaries per month in the post-acute phase, compared with $2,308,247 during the pre-pandemic phase, a 53.7% increase.

“These findings suggest that telehealth utilization for mental health services remains persistent and elevated. If this increased utilization affects spending, insurers may begin rejecting the new status quo,” Cantor and colleagues wrote. “This concern is particularly relevant when considered against the backdrop of telehealth policies that expired alongside the national [public health emergency] declaration.”

For related information, see the Psychiatric News article “Expect a ‘Long Tail’ of Mental Health Effects From COVID-19.”

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Written Exposure Therapy May Be Viable Treatment for PTSD

Veterans with posttraumatic stress disorder (PTSD) who participated in written exposure therapy experienced similar improvements as those in a more intensive, prolonged exposure therapy, according to a study published this week in JAMA Psychiatry. Veterans in the written exposure therapy group were also less likely to drop out of the therapy.

While there are several evidence-based psychotherapies for PTSD, such as prolonged exposure therapy, these therapies can be time intensive and many patients drop out before completing them, wrote Denise Sloan, Ph.D., of the Veterans Affairs Boston Healthcare System and colleagues. “Written exposure therapy is emerging as an alternative, efficacious brief intervention for PTSD that requires less time and fewer resources,” the authors continued.

Sloan and colleagues recruited veterans who were seeking treatment for PTSD from three Veterans Affairs medical centers across the country. Participants were randomized to receive either weekly sessions of written exposure therapy or prolonged exposure therapy. The severity of their PTSD symptoms was assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), with 0 indicating no PTSD symptoms and 80 indicating severe symptoms. Assessments occurred before treatment and at 10, 20, and 30 weeks after the first treatment session. All therapists had doctorate degrees in clinical psychology.

Written exposure therapy treatment included five sessions in which individuals were instructed to write for 30 minutes about a specific traumatic experience. In the first three sessions, they focused on the details of the event and their feelings during it, while in the last two sessions they focused on how the event had affected their lives. At the end of each session, the therapist and patient briefly discussed the writing experience. During the first 60-minute session, the participants received information about PTSD symptoms and the rationale for treatment. Subsequent sessions were 45 minutes. Therapists were permitted to add up to two sessions to ensure participants received adequate exposure to the trauma memory before advancing to focusing on the event’s effect on their lives.

Prolonged exposure therapy consisted of eight to 15 90-minute sessions. Participants were asked to describe the details of the traumatic event, focusing on their most distressing traumatic memories. Between sessions, they were instructed to confront people, places, and situations that they had been avoiding and were related to their traumatic experiences.

A total of 178 veterans (about 75% men) were included in the study, and the mean CAPS-5 score was about 35 for both groups at baseline. By the 30-week assessment, CAPS-5 scores fell to about 26 for all participants, regardless of their treatment group. Those assigned to prolonged exposure therapy were significantly more likely to drop out prematurely (35.6%) compared with participants assigned to written exposure therapy (12.5%). In both groups, 60% of participants continued to meet PTSD diagnostic criteria at the final assessment.

“[Written exposure therapy] is poised to slide into place among those extensively studied and highly regarded treatments for PTSD,” wrote Charles Taylor, Ph.D., and Murray Stein, M.D., M.P.H., of the University of California, San Diego, in an accompanying commentary. “Yet, work can be done to determine who is best suited to [written exposure therapy] and to identify an optimal dose (or dose range). But even at this juncture a case could be made for starting the least burdensome treatment ([written exposure therapy]) and progressing to more intensive treatments.”

For related information, see the Psychiatric News article “Virtual Exposure Therapy Found Effective for PTSD.”

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Youth in Foster Care More Likely Than Peers to Be Prescribed Multiple Psychiatric Medications

Youth in the foster care system are more likely to be prescribed two or more psychiatric medications than other youth covered by Medicaid, according to a report published this week in JAMA Pediatrics.

“High rates of psychotropic prescription are concerning because of the limited safety and efficacy data for individuals younger than 18 years,” wrote Sarah Lieff, Ph.D., M.P.H., of Mathematica and colleagues at the U.S. Department of Health and Human Services. Mathematica is a research and data analytics consulting firm.

The researchers analyzed data from the 2019 Centers for Medicare & Medicaid Services’ Transformed Medicaid Statistical Information System Analytic Files, which contained information on Medicaid Children’s Health Insurance Program (CHIP) beneficiaries aged 3 to 17 years from all 50 U.S. states as well as Washington, D.C., Puerto Rico, and the U.S. Virgin Islands. To be included in the analysis, the youth had to have been covered by Medicaid for at least six consecutive months in the year.

The final study sample included 719,908 youth in foster care and 31,473,608 youth covered by Medicaid who were not in foster care. The researchers compared the rates of psychotropic medication and psychotropic polypharmacy (defined as prescription of two or more classes of psychiatric medications) between these two groups of youth, as well as diagnoses of mental health conditions.

Among youth in the foster care group, 26.25% had been prescribed a psychotropic medication and 13.27% were prescribed two or more psychotropic medications compared with 9.06% and 3.11%, respectively, among other Medicaid-enrolled youth.

The most common class of psychotropic medication prescribed to youth in the foster care group was stimulants (15.95%), followed by antidepressants (9.88%), and antipsychotics (7.87%). The most common medications prescribed to the other Medicaid-enrolled youth were stimulants (4.41%), antidepressants (2.75%), and antipsychotics (1.74%).

In the foster care group, 42.85% had a diagnosed mental health condition compared with 13.53% in the other group. Trauma or stressor-related disorder, attention-deficit/hyperactivity disorder, and behavior or conduct disorder were the most common mental health diagnoses in the foster care group.

“Given safety concerns and uncertainties about these medications’ long-term effects on brain development and metabolic adverse effects, judicious prescribing of psychotropic medications for child welfare–involved children remains a policy challenge,” Lieff and colleagues wrote. “Guidance on safe prescribing and oversight of psychotropic medication use in the child welfare system has been issued at the federal level; however, implementation at the state level varies and may benefit from further policy initiatives.”

For related information, see the Psychiatric News article “Antipsychotic Use in Children Declining, But Concerning Trends Remain.”

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Treatment for Type 2 Diabetes May Reduce Depressive Symptoms in Some Adults

Glucagon-like peptide-1 (GLP-1) receptor agonists—a common treatment for type 2 diabetes—may also help to reduce depressive symptoms in adults, suggests a meta-analysis published in The American Journal of Geriatric Psychiatry.

People with diabetes are known to be at greater risk of depression than those without the disease, wrote co-author Lixin Guo, M.D., of the Chinese Academy of Medical Sciences and colleagues. Though GLP-1 is a hormone produced in the gut that is released in response to food, GLP receptors are also present in the brain. Animal studies have suggested that activation of these receptors may produce antidepressant effects.

To examine the relationship between GLP-1 receptor agonists and depressive symptoms, Guo and colleagues searched electronic literature databases for studies that measured depressive symptoms in adults before and after administration of GLP-1 receptor agonists or a control treatment. They searched Cochrane Library, PubMed, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, among others.

Guo and colleagues narrowed in on six studies for the meta-analysis, including 2,071 participants (average age: 58 years). All but one of these studies included patients with type 2 diabetes (the other included patients with moderate Parkinson’s disease) who were given either GLP-1 receptor agonists (exenatide or liraglutide) or the control treatment (placebo, insulin, or glimepiride). Each study lasted between 24 and 60 weeks.

“The data from the overall meta-analysis showed that the change from baseline in depression rating scale scores decreased significantly when patients received GLP 1 [receptor agonists] compared to control treatments,” the authors reported. They found similar results when limiting their analysis to only the five studies that included patients with diabetes.

“Although our results suggest an antidepressant effect of GLP-1 [receptor agonists], the exact mechanism underlying this effect remains unclear,” they concluded. “Further [randomized, controlled trials] need to be performed with large samples … to verify the antidepressant activity of GLP-1 [receptor agonists], and should take the follow-up time, primary diagnosis of participants, depression rating scales, the agents and dosage of GLP-1RAs, and control conditions into consideration.”

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SSRIs May Increase Risks Associated With Anti-Amyloid Alzheimer's Medications

Doctors should be careful about prescribing anti-amyloid medications to patients with Alzheimer’s disease who are taking antidepressants, caution the authors of a letter published in Alzheimer’s & Dementia.

Despite the recent buzz around the U.S. Food and Drug Administration’s approval of multiple anti-amyloid medications for the treatment of Alzheimer’s disease, it is well known that these drugs come with some risks, including internal swelling and bleeding in the brain. Several selective serotonin reuptake inhibitors (SSRIs) also increase the risk of internal bleeding, and as depression is common among people with dementia, it is possible that patients eligible for anti-amyloid therapy will be taking SSRIs.

“Drugs with the highest degree of serotonin reuptake inhibition, such as fluoxetine, sertraline, and paroxetine, are frequently associated with increased bleeding and modifications of hemostasis markers that require special attention in the era of the anti-amyloid drugs,” wrote Beatriz Pozuelo Moyano, M.D., of Lausanne University Hospital in Switzerland and colleagues.

In addition to evaluating patients eligible for anti-amyloid therapy for prior history of microhemorrhages, physicians may benefit from considering the following questions:

• What type of antidepressant is the patient taking? Tricyclic antidepressants, serotonin antagonist and reuptake inhibitors (such as trazodone), or some of the norepinephrine reuptake inhibitors (such as atomoxetine or bupropion) are associated with a lower risk of hemorrhage than SSRIs.
• How long has the patient has been taking antidepressants? The risk of intracerebral hemorrhage is greatest during the first 30 days a patient is taking SSRIs.
• Could the patient be switched to a nonpharmacological intervention? Treating patients with behavioral and psychological symptoms of dementia with nonpharmacological interventions is always preferred.

“[W]e estimate that in patients eligible for anti-amyloid drugs, the indication for antidepressant treatment and its dose should be periodically reevaluated as the antiplatelet effect in antidepressants is dose dependent,” Moyano and colleagues wrote.

To read more on this topic, see the Psychiatric News article “FDA Approves Second Antibody Therapy for Alzheimer’s.”

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More Than Three-Fourths of Adolescents Who Vape Have Tried to Quit

Most adolescents who vape have tried to quit at least once, a study in Addictive Behaviors has found. The study also revealed which vaping cessation methods that adolescents are interested in trying.

Emily Jones, M.D., of Boston University and colleagues analyzed the responses of 185 adolescents aged 14 to 19 years who completed online questionnaires about vaping. All participants had vaped at least 10 times in their lives prior to completing the questionnaire, 159 participants currently vaped, and 26 participants were former vapers. Current vaping was defined as vaping at least once a day in the last 30 days, and previous vaping was defined as not having vaped in the last 30 days.

Overall, 81.3% of the participants reported at least one prior attempt to quit vaping. Among those who tried to quit, 78.4% tried to quit unassisted (“cold turkey”), 51.9% reported following “advice from a friend,” 21.1% tried nicotine replacement products, 17.3% tried a text-message program, and 15.7% tried using social media.

Jones and colleagues wrote that it was “surprising” that more adolescents had not turned to social media to try to quit, given the ubiquity of social media and how often adolescents engage with it.

“It is possible that teens may not perceive social media as a way to obtain health advice, or that some of the anti-vaping public health messages on social media do not resonate with teens,” the researchers wrote. They added that the popularity of quitting cold turkey could reflect the lack of knowledge, interest, trust, or paucity of programs available to adolescents to help them quit vaping.

The participants were interested in using a variety of methods for quitting vaping in the future, as follows:

• 71.6% were interested in quitting cold turkey
• 67% were interested in taking advice from a friend
• 44% were interested in using nicotine replacement products
• 34.6% were interested in using mobile apps
• 30.8% were interested in using a text-messaging program
• 28.8% were interested in taking medication
• 22.8% were interested in using social media
• 16.2% were interested in using phone counseling
• 13.5% were interested in participating in school-based programs

The researchers also found that greater perceived harm of vaping was significantly associated with motivation to quit vaping, while greater perceived risk of addiction and higher socioeconomic status were significantly associated with ever use of nicotine replacement to quit vaping.

“Together with our data on the correlates of use, these findings can serve as a first step for researchers to develop effective vaping cessation programs targeted to adolescents,” the researchers wrote.

For related information see the Psychiatric News Special Report “Vaping—A Call to Action for Psychiatrists.”

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Suicidal Behavior in Patients With MDD Associated With Death of Any Cause

Individuals with major depressive disorder (MDD) who exhibit suicidal behavior have 2.6 times the risk of dying from any cause compared with people with MDD who do not, according to a study published this week in JAMA Psychiatry.

“[MDD] is an important risk factor of suicidal behavior, but the added burden of suicidal behavior and MDD on the patient and societal level, including all-cause mortality, is not well studied,” wrote Johan Lundberg, M.D, Ph.D., of the Karolinska Institutet in Stockholm and colleagues. “Also, the contribution of various prognostic factors for suicidal behavior has not been quantified in larger samples.”

Lundberg and colleagues used data from the Stockholm MDD Cohort, which includes all patients diagnosed with MDD in any health care setting in the Stockholm region. The data included diagnoses, history of suicidal behaviors, days worked in the past month, and overall health care utilization such as number of outpatient physician visits and inpatient bed days per month. Further, the data included the date of death but not the cause of death.

The researchers identified all diagnosed MDD episodes among people aged 18 and older between 2012 and 2017, excluding those individuals with a history of psychosis, bipolar disorder, or dementia. Individuals whose depressive episode included suicidal behavior were matched with up to five individuals who had MDD without suicidal behavior of similar age, sex, year of MDD diagnosis, and sociodemographic status.

The study sample included 145,577 people who experienced a total of 158,169 MDD episodes, 1.4% of which included records of suicidal behavior; the average time from MDD diagnosis to the first record of suicidal behavior was less than six months. The rate of death by any cause was 2.5 per 100 person-years at risk for people whose episode included suicidal behavior and 1.0 per 100 person-years at risk for episodes without suicidal behavior. Suicidal behavior during a depressive episode was also associated with higher utilization of health care resources and days of work lost.

The individuals who experienced suicidal behaviors were younger and more prone to psychiatric comorbid conditions, such as personality disorders, substance use, and anxiety at the start of their episodes compared with those who did not experience suicidal behavior during an episode. The authors noted that the incidence of somatic disorders like heart disease or diabetes was not increased in individuals with suicidal behavior, “indicating that unnatural causes, such as accidents and suicides, may have been the main contributors to the increased mortality.”

They concluded: “Our results also indicate that patients at risk for suicidal behavior can be identified at an early stage to allow for enhanced monitoring and optimized treatment with the goal of preventing suicidal behavior and reducing mortality.”

For related information, see the Psychiatric News article “Special Report: Management of Major Depression—Yesterday, Today, and Tomorrow.”

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Respondents to APA Poll Express Confidence in Psychiatry as Innovative Field

Nearly three-quarters of respondents to an APA survey released this week said that they believe psychiatry is an innovative field that helps people with mental and substance use disorders. In addition, half of the respondents said they would consider brain imaging or genetic testing if it was recommended by a physician.

The survey asked respondents a series of questions about their awareness of a variety of innovative mental health tests and treatments—brain imaging, genetic testing, ketamine, psychedelic drugs, and deep brain stimulation—as well as about emerging technologies such as artificial intelligence (AI), chatbots, and virtual reality. Respondents were also queried about current events, stress, and anxiety.

Overall awareness of some of the latest tests and treatments for mental or substance use disorders is generally low: 40% of respondents said they had seen, read, or heard “some” or “a lot” about brain imaging (the remainder said they had seen, read, or heard not much or nothing at all). Thirty-nine percent said they knew about genetic testing, and the same percentage said they had seen, read, or heard about psychedelic drugs as they relate to treatment.

A total of 33% said they knew about ketamine as a treatment for depression, and smaller percentages said they knew about deep brain stimulation, transcranial magnetic stimulation, or biomarkers to predict medication effectiveness or the development of mental health conditions.

However, 72% said they agreed with the statement: “Psychiatry is an innovative field, and new diagnostic tools and treatments are being developed that will help people’s mental health.” And 51% and 49% said they would consider brain imaging or genetic testing, respectively, if it was recommended by a medical professional. Further, 46% said they would consider biomarkers to predict the likelihood of developing a mental illness, and 42% said they would consider use of virtual reality technology to treat a mental illness.

Respondents appeared to be divided about the use of AI in mental health diagnosis or treatment: 39% said they are somewhat or very comfortable with it, while 41% said they are uncomfortable. Younger adults are twice as likely as older adults to say they are comfortable with AI.

Meanwhile, the survey showed that people continue to be anxious about inflation, gun violence, and the economy. After a summer of record heat, concerns about climate change have increased. Here are some findings:

• A little more than three-quarters (76%) said they are anxious about inflation, down three percentage points from June; 68% said they are worried about a possible recession.
• 69% said they are somewhat or very anxious about gun violence, up a percentage point from June.
• 61% said they are somewhat or very anxious about climate change, up 5 percentage points from June.

The August Healthy Minds Monthly Poll was conducted by Morning Consult between August 1 and August 3 among a sample of 2,203 adults.

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Substance-Induced Psychosis Linked to Increased Risk of Suicide Attempt

Experiencing substance-induced psychosis may raise the risk of suicide attempt, a study in Addiction has found. Substance-induced psychosis, also known as substance-induced psychotic disorder, is a form of psychosis brought on by using or withdrawing from alcohol or other substances and usually dissipates within a month of stopping substance use.

Carsten Hjorthøj, Ph.D., M.Sc., of the Copenhagen Research Center for Mental Health and the University of Copenhagen and colleagues analyzed data from 5,806,700 people aged 13 years or older who lived in Denmark from January 1, 1995, to August 10, 2017. The researchers followed the individuals until the individuals had a suicide attempt, had a first psychotic disorder (except for first substance-induced psychosis), died, or emigrated, whichever came first. None of the individuals had a suicide attempt prior to the study.

Overall, 8,900 (78.8% males) individuals were diagnosed with a substance-induced psychosis, and of those, 740 had a suicide attempt during follow-up. In general, people who had experienced substance-induced psychosis had 13.4 times the risk of having a suicide attempt than the general population. After the researchers adjusted for other psychiatric diagnoses, the risk of suicide attempt in people who had experienced substance-induced psychosis was 3.5 times that of the general population.

Within 20 years, approximately 15% of individuals with a substance-induced psychosis had a suicide attempt.

Compared with the general population, people who had experienced substance-induced psychosis from opioids, alcohol, sedatives, and cocaine had 26.4, 17.7, 17.2, and 15.6 times the risk of a suicide attempt, respectively. People who had experienced substance-induced psychosis from either cannabis or hallucinogens had 8.9 times the risk.

“Our findings underscore a need for attention towards people with a history of substance-induced psychosis regarding suicidal behavior, including better follow-up,” the researchers wrote. “The study implies the need of follow-up guidelines for people with a substance-induced psychosis as well as evidence regarding interventions to reduce this excess risk of subsequent suicide attempt.”

For related information, see the American Journal of Psychiatry article “Transition From Substance-Induced Psychosis to Schizophrenia Spectrum Disorder or Bipolar Disorder.”

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FDA Targeted Ban on Flavored E-Cigarettes Did Not Significantly Reduce Youth Use

In January 2020, the Food and Drug Administration (FDA) began stepping up enforcement against the sale of most sweet-flavored e-cigarette cartridges as part of an effort to reduce e-cigarette use among youth. A study published today in JAMA Network Open suggests that this targeted enforcement was not associated with a significant decline in e-cigarette use among youth.

Karin Kasza, Ph.D., of Roswell Park Comprehensive Cancer Center in Buffalo, N.Y., and colleagues wrote that the FDA’s limited action “left open an avenue through which youth continued use of flavored e-cigarettes through using devices not covered by the enforcement guidance.”

Kasza and colleagues analyzed data from the Population Assessment of Tobacco and Health (PATH) Study for 2019 and 2021. This is a nationally representative longitudinal study of tobacco use among youth that tracks transitions in e-cigarette use, flavor/device combination used, brand used, nicotine use, and frequency of use. The analysis included responses from 9,088 youth aged 12 to 17 years in 2019 who also participated in 2021 when they were up to age 20.

Among youth aged 12 to 17 who used sweet-flavored e-cigarette cartridges in 2019, 51.5% continued to use e-cigarettes in 2021; this was similar to the 47.6% continuation rate among youth who used other e-cigarette flavors or devices (such as disposable e-cigarettes) in 2019. Eighty four percent of youth who used sweet-flavored cartridges in 2019 switched to another e-cigarette combination, with the use of sweet-flavored disposable e-cigarettes rising significantly between 2019 and 2021.

“Multiple sources identified that the disposable e-cigarette market, which contains inexpensive flavored products that appeal to youth, began proliferating in late Spring 2019,” Kasza and colleagues wrote. “Restrictions and enforcement efforts that only cover a subset of products do not appear to be associated with preventing youth flavored e-cigarette use.”

To read more on this topic, see this month’s Psychiatric News special report, “Vaping—A Call to Action for Psychiatrists.”

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Lithium May Reduce Psychiatric Hospitalizations in People With Bipolar, Major Depressive Disorder

Taking lithium may significantly reduce the risk of psychiatric hospitalization for people who have major depressive disorder or bipolar disorder, a study in the Journal of Affective Disorders has found.

Maurizio Pompili, M.D, Ph.D., of Sapienza University in Rome and colleagues analyzed data from the health records of 260 adult patients who had either major depressive disorder or bipolar disorder and had been admitted to the psychiatric unit of Sant’Andrea University Hospital in Rome between February 2019 and August 2020. The researchers compared the patients’ psychiatric hospitalization rates for the 12 months before they started taking lithium with their hospitalization rates during the first 12 months of taking lithium.

In the 12 months before taking lithium, 40.4% of the patients were hospitalized, whereas only 11.2% of patients were hospitalized while taking the drug. This represents a 3.62-fold reduction in hospitalization during lithium treatment. The risk of hospitalization did not differ significantly between patients with major depressive disorder and patients with bipolar disorder either before or during treatment with lithium, suggesting that taking lithium similarly benefitted both groups of patients.

Pompili and colleagues wrote that this finding was “unexpected,” as other studies have suggested that lithium is more effective in patients with bipolar disorder than those with major depressive disorder.

The risk of hospitalization also did not differ significantly between patients who took only lithium and patients who also took other psychotropic medications, with the exception of patients who also took antipsychotics: Patients who took an antipsychotic along with lithium had 21.1 times the odds of being hospitalized than those who did not take an antipsychotic.

“An association of co-treatment with an antipsychotic plus lithium among patients who required hospitalization probably represents greater illness severity,” the researchers wrote.

For related information, see the Psychiatric News article “Antipsychotics Increasingly Prescribed for Bipolar Disorder.”

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Cancer Survivors Commonly Engage in Risky Drinking, Study Suggests

Alcohol consumption and risky drinking behaviors are prevalent among both cancer survivors and patients who have received cancer treatment within the past year, according to a study published today in JAMA Network Open.

“Alcohol consumption, which is ubiquitous in the U.S. and causally linked with multiple types of cancer … is also associated with adverse health outcomes among individuals with a diagnosis of cancer, including higher risks of recurrence or onset of new primary cancers as well as death,” wrote Mengyao Shi, M.B.B.S., M.P.H., of Washington University in St Louis School of Medicine and colleagues. “In addition, alcohol is associated with worsened treatment outcomes, such as decreased effectiveness and increased risk of complications.”

Shi and colleagues identified cancer survivors among the 142,100 participants enrolled in the National Institutes of Health’s All of Us Research Program. The program collects data using survey responses and electronic health record data. The participants self-reported cancer diagnoses; age at cancer diagnosis; and current treatment status, including if they were currently receiving treatment for cancer. Further, the authors used linked electronic health record data to identify participants who underwent cancer treatment anytime in the year leading up to the survey.

As part of the All of Us Research surveys, participants were asked about their alcohol consumption. Those who had had at least one drink in their lifetime but reported not having any alcohol in the past year were considered former drinkers, and those who had at least one alcoholic drink in the past year were considered current drinkers. Participants were characterized as participating in risky drinking behaviors if they exceeded moderate drinking levels (consumed more than two drinks on a typical drinking day), engaged in binge drinking (drank six or more drinks on one occasion), or if they engaged in hazardous drinking (had scores of three or higher for women or four or higher for men on the Alcohol Use Disorders Identification Test-Consumption).

Of 15,199 participants included in the study, 77.7% were current drinkers. Additional findings include the following:

• Among current drinkers, 13% exceeded moderate drinking, 23.8% reported binge drinking, and 38.3% engaged in hazardous drinking.
• Participants who were men, younger than age 65, of Hispanic ethnicity, or who received a cancer diagnosis before age 18 were more likely to exceed moderate drinking.
• Among 76.4% of participants who received cancer treatment in the past year and were current drinkers, 12.1% exceeded moderate drinking; 23.4% engaged in binge drinking; and 38.4% engaged in hazardous drinking.

“Taken together, our findings point to the immediate and unmet need to intervene on the behalf of individuals with risky drinking behaviors in oncologic care settings,” Shi and colleagues wrote. “Given that drinking is deeply ingrained in societal norms and rituals, and considering the limited awareness of how alcohol consumption is associated with cancer outcomes, it is imperative to provide support to patients who are identified as alcohol users and offer them guidance.”

For related information, see the Psychiatric News article “NIAAA Director Hopeful About Growing Awareness of Risks, Harms of Alcohol.”

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Patients Found Less Likely to Cancel Telepsychiatry Visits, Study Shows

Patients with depression who scheduled an appointment to see a psychiatrist between July 2020 and October 2022 were less likely to miss or cancel the appointment if it was virtual compared with in person, according to a report published today in Psychiatric Services.

“Appointment completion was higher for telepsychiatry than for in-person care among all patient characteristics studied,” wrote Catherine K. Ettman, Ph.D., of Johns Hopkins Bloomberg School of Public Health and colleagues. The findings “suggest that telepsychiatry is associated with improved efficiency and continuity of care.”

The researchers examined electronic health records for 12,894 patients aged 10 or older with a diagnosis of depression who scheduled 586,266 psychiatric outpatient appointments at Johns Hopkins Medicine between November 2017 and October 2022. They compared the number of in-person and telepsychiatry appointments that patients completed, cancelled, or failed to show up to before the pandemic with these outcomes of in-person and telepsychiatry appointments scheduled from July 2020 to October 2022. (The researchers did not analyze the appointment trends between March 2020 and June 2020 due to the fall in overall appointment completion rates caused by the pandemic.)

Prior to the pandemic, the number of patients who scheduled and completed in-person appointments vastly outnumbered those who scheduled and completed telepsychiatry appointments. Between July 2020 and October 2022, however, telehealth appointments outnumbered the in-person appointments. During this period, 13.3% of telepsychiatry appointments were canceled compared with 18% of in-person appointments.

Overall, telepsychiatry appointments were 1.30 times more likely to be completed than in-person appointments. Moreover, the likelihood that a telepsychiatry appointment would be completed relative to an in-person appointment increased steadily between July 2020 and October 2022. Ettman and colleagues noted that the increased likelihood of completion of telepsychiatry appointments remained regardless of the patient’s age, gender, race, insurance, or employment status.

“[H]ealth systems may wish to maintain telepsychiatry to optimize delivery of care and to improve patient outcomes,” Ettman and colleagues wrote.

However, they noted that telehealth may not be accessible to all patients and may exacerbate existing disparities. For instance, they found that patients who were younger, female, White, employed, or had higher socioeconomic status or private insurance were significantly more likely to schedule telepsychiatry appointments compared with in-person appointments after the pandemic’s onset.

“These findings merit future study,” they wrote. “Additional research on patient preferences, potential disparities in access to care, and efforts to reduce barriers to telehealth is warranted.”

For related information, see the Psychiatric News article “After the Pandemic: What Will the ‘New Normal’ Be in Psychiatry?”

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Out-of-Pocket Costs May Serve as Barrier to Buprenorphine, Studies Suggest

Treating people with opioid use disorder (OUD) with buprenorphine is known to reduce opioid use, drug overdoses, and hospital visits, but the medication is underused. Two reports published yesterday—one appearing in JAMA Internal Medicine and another in JAMA Pediatrics—suggest that out-of-pocket costs for buprenorphine may be partly to blame for keeping the drug out of reach for adults and youth with OUD who have private health insurance.

As described in JAMA Internal Medicine, Ashley A. Leech, Ph.D., M.S., of Vanderbilt University School of Medicine and colleagues used the MarketScan Commercial Claims Database to track patients aged 18 to 64 years who initiated buprenorphine between April 1, 2013, and December 31, 2020. They wanted to understand the association between out-of-pocket costs for patients’ initial buprenorphine prescription (index fill) and buprenorphine discontinuation within one year.

Between 2013 and 2020, 40,035 commercially insured patients (median age, 34 years) began taking buprenorphine for OUD. “Only 22% of patients continuously used buprenorphine during the follow-up period, and 6% switched to naltrexone,” Leech and colleagues reported. They found that the higher the daily out-of-pocket costs for the patients, the higher the risk of medication discontinuation.

“Policies addressing patient-level hurdles within the OUD cascade of care may prevent lasting impact on adverse health outcomes associated with OUD,” Leech and colleagues wrote.

In the JAMA Pediatrics report, Andrew Terranella, M.D., M.P.H., of the CDC’s Division of Overdose Prevention and colleagues described how they studied IQVIA Longitudinal Prescription Data (which tracks the majority of U.S. prescriptions) to determine out-of-pocket costs for buprenorphine dispensed to youth aged 12 to 19 years between 2015 and 2020. Daily out-of-pocket costs were calculated across prescriptions and adjusted to 2020 dollars using the Consumer Price Index, the researchers noted.

“Mean daily [out-of-pocket] costs for buprenorphine declined between 2015 and 2020, with an increasing percentage of prescriptions paid by Medicaid. Nonetheless, mean daily [out-of-pocket] costs were approximately 24 times higher with commercial payers and 119 times higher for self-pay than for Medicaid in 2020,” Terranella and colleagues wrote. “The largest disparities by region, urban or rural status, and age were in the South, rural counties, and among younger adolescents.”

Leech and colleagues concluded, “The Patient Protection and Affordable Care Act’s preventive drug list mandates private insurance plans [to] cover recommended preventive services without patient cost-sharing. Adding OUD medications to this list could alleviate lasting consequences of the opioid crisis.”

For related information, see the Psychiatric Services article “Early Discontinuation of Buprenorphine Therapy for Opioid Use Disorder Among Privately Insured Adults.”

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FDA Approves First Oral Medication for Postpartum Depression

The U.S. Food and Drug Administration (FDA) on Friday approved Zurzuvae (zuranolone), the first oral medication for the treatment of postpartum depression in adults. Zuranolone acts on similar receptors in the brain as the intravenous medication brexanolone, which was the first postpartum depression medication to receive FDA approval in 2019.

“As a perinatal psychiatrist, I see the devastating impact [postpartum depression] has on mothers, particularly on the important mother-infant bond and long-term child development,” Kristina Deligiannidis, M.D., principal investigator of the Zurzuvae clinical program, said in a press release issued by Sage Therapeutics. Zuranolone and brexanolone are both manufactured by Sage Therapeutics.

“[W]ith Zurzuvae, we now have an oral treatment option that can provide rapid improvements in depressive symptoms in as early as three days for women with [postpartum depression],” continued Deligiannidis, who is also a professor at the Institute of Behavioral Science at the Feinstein Institutes for Medical Research in Manhasset, N.Y., and director of Women’s Behavioral Health at Zucker Hillside Hospital.

The efficacy of Zurzuvae was demonstrated in two randomized, double-blind, placebo-controlled trials—one of which was reported July 26 in The American Journal of Psychiatry. As described in the AJP report, 196 women aged 18 to 45 with severe postpartum depression were assigned to take either zuranolone (50 mg) or placebo pills daily for 14 days. Those in the zuranolone group experienced significantly greater improvements in their depressive symptoms than those taking placebo pills, and the improvements were maintained one month after the last zuranolone dose. Similar outcomes were reported in the other trial, where women with postpartum depression also received another formulation of zuranaolone (equivalent to 40 mg of Zurzuvae) or placebo for 14 days.

The recommended dose for Zurzuvae is 50 mg daily for 14 days. The medication is to be taken in the evening with a fat-containing food.

“This approval could be a game changer for psychiatry,” Jennifer Payne, M.D., vice-chair for research and a professor of psychiatry and neurobehavioral science at the University of Virginia School of Medicine, told Psychiatric News. Payne, who is an expert in women’s mood disorders, has consulted for Sage in the past but was not involved in the clinical development of zuranolone. “Not only does zuranolone continue the field’s paradigm shift toward rapid-acting depression treatment, but patients only need to take this medication for two weeks and not the rest of their lives.”

Sage predicted in the company press release that Zurzuvae will be available later this year, following the scheduling of the medication as a controlled substance by the U.S. Drug Enforcement Administration.

To read more on this topic, see the Psychiatric News article “Oral Medication Shows Promise for Postpartum Depression” and The American Journal of Psychiatry article “Zuranolone for the Treatment of Postpartum Depression.”

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Suicide Most Common Cause of Death in People With Schizophrenia, Study Finds

Suicide is the most common cause of death in patients who have schizophrenia spectrum disorders, a study in Schizophrenia Bulletin has found.

Marie Stefanie Kejser Starzer, M.D., of Copenhagen University Hospital and colleagues analyzed data from the OPUS I study, a randomized controlled trial of 578 patients experiencing their first episode of psychosis. Patients enrolled in the study between January 1, 1998, and December 31, 2000. When the patients enrolled, they were between 18 and 45 years old; had received first-time treatment for a diagnosis of schizophrenia, schizotypal disorder, delusional disorder, acute or transient psychosis, schizoaffective disorder, or nonspecific nonorganic psychosis; and had not received antipsychotic medication for more than 12 weeks. They were randomized to receive treatment as usual or a specialized early intervention that consisted of two years of assertive community treatment (including family involvement, social skills training, and psychoeducation) by a multidisciplinary team. Patients were then assessed multiple times over a 20-year period.

By the end of 2021, 14.2% of the patients had died. Of those, 48.6% died of external causes (for example, suicide or accidents) and 51.4% died of medical conditions and diseases. The most common cause of death was suicide, accounting for 27.8% of deaths; followed by accidents at 13.9%; unspecified medical abnormalities at 11.1%; and cardiovascular disease and cancer, both at 8.3%.

Death due to external causes, mostly suicide, occurred at a steady rate throughout the study, whether the patients had received treatment as usual or the specialized early intervention. Starzer and colleagues wrote that this indicates a need for continuous suicide-prevention efforts for people with schizophrenia.

“Early intervention services alone cannot address this issue, as the risk [was] present long after [the specialized early intervention] ended,” they wrote. “Perhaps more regular screening for suicide risk in aging patients with schizophrenia could help prevent some of these late suicides.”

Patients with a history of substance use had a higher risk of both all-cause mortality and death from medical conditions and diseases. 

“This underlines the importance of proper treatment of comorbid substance use at any time after patients are diagnosed,” the researchers wrote. They noted that the treatment of mental illness and the treatment of substance use are often managed by separate entities. “Lack of integrated treatment could be leading to suboptimal care for dual-diagnosis patients, and a more multidimensional and non-categorical treatment approach is needed.”

For related information, see the Psychiatric News article “COVID-19 Greatly Increases Mortality Risk for Schizophrenia Patients, Research Shows.”

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