Emergency Department Visits for Substance Use Linked to Schizophrenia Spectrum Disorders

Emergency department visits for substance use may be associated with an increased risk of developing a schizophrenia spectrum disorder, a study in JAMA Psychiatry has found. People who were seen in the emergency department for cannabis-induced psychosis had the highest risk of transitioning to a schizophrenia spectrum disorder within three years.

Daniel T. Myran, M.D., M.P.H., of the Ottawa Hospital Research Institute in Ontario and colleagues examined data from more than 9.8 million Ontaria residents aged 14 to 65 years between January 2008 and March 2022. Only those eligible for the province’s health coverage and without a history of a psychotic disorder were included.

Within three years, approximately 408,000 individuals had an emergency department visit for substance use; about 14,000 of the visits were for substance-induced psychosis. Compared with the general population, individuals with substance-induced psychosis had 163 times the risk of transitioning to a schizophrenia spectrum disorder. Individuals with an emergency department visit for substance use without psychosis had 9.8 times the risk of transitioning.

Other findings from the study include the following:

• Those seen for cannabis use and psychosis had 241.6 times the risk of transitioning to schizophrenia spectrum disorder compared with the general population.
• Those who did not have psychosis but were seen for amphetamine use, polysubstance use, and cannabis use had 28.4, 18.7, and 14.3 times the risk, respectively, of transitioning to a schizophrenia spectrum disorder compared with the general population.
• For all substance use visits, younger age and male sex were associated with a higher risk of transition to schizophrenia spectrum disorder compared with older age and female sex.

“Our findings … highlight the need for targeted secondary prevention providing early intervention and reducing substance use in the highest-risk groups, which may delay or prevent transition to schizophrenia spectrum disorders,” the researchers wrote. “Several prognostic factors, including cannabis use, younger age, and male sex, were associated with greater risk of transition, with clinical and policy implications.”

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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Only 20% of Patients With Postpartum Depression, Anxiety Symptoms Receive Diagnosis, Study Finds

The probability of receiving a postpartum mood or anxiety disorder diagnosis is three times higher for White patients with symptoms than for Black patients with symptoms, according to a study published yesterday in Psychiatric Services. In addition, regardless of race, only 1 in 5 women received a diagnosis.

“Despite their high prevalence and disease burden, [postpartum mood and anxiety disorders] often remain underdiagnosed,” wrote Stephanie V. Hall, Ph.D., M.P.H., of the University of Michigan, Ann Arbor, and colleagues. “Low diagnosis rates contribute to even lower treatment rates and exacerbate poor outcomes. Untreated [postpartum mood and anxiety disorders] are associated with worse maternal and infant health outcomes.”

Hall and colleagues linked Medicaid claims data in Michigan with results from the Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS), an ongoing representative survey of childbearing people conducted at two to six months after childbirth. All participants gave birth between 2012 and 2015 and were continuously enrolled in Medicaid from nine months before delivery through three months after delivery.

Participants self-reported their postpartum mood and anxiety disorder symptoms using an adapted version of the two-item Patient Health Questionnaire. The questions asked how often the participants had little interest or pleasure in doing things since their babies were born and how often they felt down, depressed, or hopeless. Participants were considered to have screened positive for postpartum mood and anxiety disorder symptoms if they responded “often” or “always” to either question.

A total of 2,781 participants were included in the study, 542 (19.5%) of whom screened positive for postpartum mood or anxiety disorder symptoms. More White participants received a diagnosis for postpartum mood and anxiety disorder compared with Black participants (23.8% vs. 8.9%) in the weighted sample. No covariates were significantly associated with having a diagnosis among White participants. Among Black participants, however, more comorbid conditions (such as diabetes or hypertension) and life stressors were significantly associated with receiving a diagnosis for postpartum mood and anxiety disorder.

“Measuring the factors associated with underdiagnosis is a first step in improving [postpartum mood and anxiety disorder] detection and treatment,” the authors wrote. “Implementing culturally sensitive care, including strategies such as using nonstigmatizing language to describe mental health, ensuring that providers reflect patients’ identities, and fostering patient-provider relationships, may mitigate underdiagnosis.”

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

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Study Reveals Genetic Links Between Schizophrenia and Risk Factors for Cardiovascular Disease

As a group, people with schizophrenia appear to be genetically predisposed to start smoking and to smoke more cigarettes per day, according to a genomic analysis that examined the relationship between schizophrenia and several risk factors for cardiovascular disease. The findings were published today in The American Journal of Psychiatry.

“Schizophrenia is associated with a two- to threefold greater risk of [cardiovascular disease] compared with risk in the general population, contributing to a 10- to 20-year reduced life expectancy,” wrote Linn Rødevand, Ph.D., of the Norwegian Center for Mental Disorders Research at the University of Oslo and colleagues. While some of this risk is believed to be the result of lifestyle factors (for example, smoking) and limited access to health care, research also suggests that the genetic makeup of some individuals with schizophrenia may increase risk of cardiovascular disease.

To understand the genetic overlap between schizophrenia and risk factors for cardiovascular disease, Rødevand and colleagues analyzed data from genomic-wide association studies (GWAS). GWAS is a research approach used to identify genomic variants that are associated—either positively or negatively—with a risk for a disease or a particular trait.

Results for schizophrenia were retrieved from the Psychiatric Genomics Consortium, consisting of 53,386 patients with schizophrenia and 77,258 control participants of European descent. GWAS data on risk factors for cardiovascular disease included millions of people and looked at such factors as smoking initiation, number of cigarettes smoked per day, body mass index (BMI), type 2 diabetes, blood pressure, and more.

In addition to risk for smoking and number of cigarettes smoked per day, genetic overlap was found between schizophrenia and other risk factors, such as BMI. However, people with schizophrenia were found to be genetically predisposed to lower BMI on average—despite obesity being more common in individuals with schizophrenia compared with those in the general population. This strongly suggests the influence of environmental factors, including the effects of antipsychotic drugs and socioeconomic challenges that contribute to unhealthy lifestyles, on the prevalence of obesity among patients with schizophrenia.

“Studies with larger GWASs will uncover more of the genetic architecture of schizophrenia and may reveal differences in genetic liability to [cardiovascular disease] across subsets of patients,” the researchers wrote. “Such findings could provide clinically useful discoveries that pave the way for risk stratification and more tailored interventions.”

For related information, see the Psychiatric News article “Psychiatrists Can Do More to Help Patients Quit Smoking.”

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Chemical Found in Plastics May Be Linked to Postpartum Depression

Pregnant women who have high levels of chemicals known as phthalates in their urine may have a higher risk of developing postpartum depression, according to a study published in JAMA Psychiatry. Phthalates are used in plastics and personal care products, and they have been identified as chemicals that interfere with normal hormonal actions.

“[T]he withdrawal of estrogen and progesterone after delivery is hypothesized to act as a biological trigger for some forms of [postpartum depression],” wrote Melanie Jacobson, Ph.D., M.P.H., of the NYU Grossman School of Medicine and colleagues. External factors that affect hormones, such as exposure to endocrine-disrupting chemicals, are plausible contributors to postpartum depression, the authors continued, but they have not been sufficiently examined.

Jacobson and colleagues used data from five of the cohorts in the National Institutes of Health’s Environmental Influences on Child Health Outcomes (ECHO) research program from 2006 to 2020. ECHO’s goal is to investigate how prenatal and early life environmental exposures impact child health and development. ECHO studies have taken place across the United States and Puerto Rico. The authors included all pregnant women in the ECHO cohorts for whom data on urinary chemical concentrations from at least one time point in pregnancy were available. The urine samples were analyzed for concentrations of synthetic environmental chemicals found in plastics, including phenols (bisphenol and triclosan), phthalate metabolite, paraben, triclosan, and triclocarban.

Participants also completed postnatal depression assessments between two weeks and 12 months after delivery. For four ECHO cohorts, participants completed the Edinburgh Postnatal Depression Scale, while one cohort completed the Epidemiologic Studies Depression Scale. To make the scores from the two scales comparable, the authors converted patients’ scores to the Patient-Reported Measurement Information System (PROMIS) depression scale.

Among the 2,174 participants included in the study, 349 (16.1%) met the threshold for postpartum depression on the PROMIS scale. These participants were more likely to be Hispanic, from the ECHO cohort in Puerto Rico, have lower education, and have substantially higher prenatal depression scores. Nearly all participants had detectable levels of several phthalate metabolites in their urine samples. The authors did not identify a significant association between environmental chemicals and postpartum depression; however, in further analyses, they found that higher levels of phthalate metabolite concentrations were associated with an increased risk of postpartum depression.

“Given the ubiquitous nature of phthalates in the environment, future studies are needed to confirm these observations,” the authors concluded. “This work underscores the importance of considering pregnancy a critical window of exposure to exogenous agents for maternal health outcomes after delivery, including psychiatric conditions.”

For related information, see the Psychiatric News article “Special Report: Women’s Reproductive Mental Health—A Clinical Framework.”

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Patients Using Benzodiazepines Found at Low Risk of Long-Term Use, Unsafe Doses

Most people who received prescriptions for benzodiazepines and related drugs were not long-term users and did not escalate to higher-than-recommended doses, according to a large population-based longitudinal study in AJP in Advance.

Benzodiazepine receptor agonists (BZRAs), which include benzodiazepines and the so-called “Z-drugs” (zopiclone, eszopiclone, zaleplon, and zolpidem), are the most commonly used drugs for treating insomnia and anxiety. However, because people may build up a tolerance to the drugs and can abuse them, many countries have sought to restrict their prescription. In 2020, the Food and Drug Administration updated the boxed warning on all BZRAs to explicitly “address the serious risks of abuse, addiction, physical dependence, and withdrawal reactions.”

“Although our findings do not refute the possibility that long-term use might have been higher without restriction, our results suggest that rigorously focusing on reducing long-term use of BZRAs may be outdated and should be replaced with an increased focus on selecting the appropriate treatment for each patient,” wrote Thomas Wolff Rosenqvist, M.D., of the Center for Clinical Research and Prevention at Bispebjerg and Frederiksberg Hospitals in Denmark and colleagues.

Using data from the Danish Civil Registration System, the researchers identified 950,767 individuals who initiated hypnotic benzodiazepines, anxiolytic benzodiazepines, or Z-drugs, respectively, between January 1, 2000, and December 31, 2020. The primary outcomes were long-term use, defined as use of BZRAs for more than one year and more than seven years. Researchers also looked at dose escalation for all users who had an uninterrupted period of BZRA use of at least three years from treatment initiation. 

Among the entire cohort, 46% had only a single purchase of a BZRA, and 22% had more than five purchases. For individuals with more than one purchase, the median treatment duration was 273 days.

The overall risk of use for more than one year was 15%, and the risk of use for more than seven years was 3%. The proportion of long-term users was highest among individuals who initiated treatment with Z-drugs (17.8%) and lower for users of anxiolytic and hypnotic benzodiazepines (13.1% and 9.8%, respectively).

Among the 5% of users who had at least three years of continuous use, there was no indication of dose escalation, and the median dose remained stable. However, 7% (N=3,545) of users escalated to doses above the recommended level. Psychiatric comorbidity, especially substance use disorder, was associated with higher risk of long-term use and dose escalation.

The researchers concluded, “We suggest that guidelines be updated to prioritize absolute and relative contraindications, rather than enforcing an outright ban” on BZRAs.

For related information see the Psychiatric News article “Estimates of Adult Benzodiazepine Use Double.”

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CMS Extends Comment Deadline on Proposed Parity Rules

The Centers for Medicare and Medicaid Services (CMS) has extended the deadline to October 17 for public comments on proposed rules updating regulations regarding the Mental Health Parity and Addiction Equity Act (MHPAE). The proposed rules will close loopholes in MHPAEA that insurance companies use to deny care for mental and substance use disorders.

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Hepatitis C Linked to Cognitive Impairment in Older Adults

Older adults who have hepatitis C may have a higher risk of developing cognitive impairment, a study in the American Journal of Geriatric Psychiatry has found.

Fu-Hsiung Su, M.D., Ph.D., of Fu Jen Catholic University in New Taipei City, Taiwan, and colleagues examined data from 23,781 participants aged 60 years or older whose information was available in the Taiwan Biobank in 2012. Among the participants, 912 had cognitive impairment as measured by the Taiwanese version of the Mini-Mental State Examination (MMSE). Participants received blood tests for hepatitis B and C as well as genetic testing.

The researchers found the following:

• Participants who had hepatitis C had 1.38 times the odds of having cognitive impairment compared with those without hepatitis C.
• Participants with hepatitis C but without hepatitis B had 1.52 times the odds of having cognitive impairment compared with participants without either type of hepatitis.
• Participants who had hepatitis B had 1.14 times the odds of having cognitive impairment compared with those without hepatitis B.
• Participants with hepatitis B but without hepatitis C had 1.21 times the odds of having cognitive impairment compared with participants without either type of hepatitis.

The researchers offered possible explanations for the more pronounced increase in risk among participants who had hepatitis C, noting that hepatitis C infection has been associated with disturbances in neurotransmitters and that hepatitis C can cross the blood-brain barrier and have toxic effects on brain cells.

The results also suggest that risk may be even higher in people with hepatitis C who also have a variation of the gene that provides instructions for making apolipoprotein E (APOE). The researchers noted that this variant, called APOE epsilon 4, has been shown in prior research to raise the risk of cognitive decline in people with hepatitis C. (APOE ε4 is also known to increase the risk for Alzheimer’s disease and is associated with an earlier age of disease onset in certain populations.)

“We suggest that individuals 60 years or older with chronic [hepatitis C] infection should undergo routine assessment of cognitive function by using rapid screening instruments, such as the MMSE,” they wrote. “Additional clinical and neuropsychological examinations may be indicated for individuals with abnormal MMSE scores.”

For related information, see the Psychiatric Services article “Integrating Hepatitis C Virus Treatment Programs Within Community Mental Health.”

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Higher Buprenorphine Dose May Improve Treatment Retention for Opioid Use Disorder

Patients who received a higher daily dose of buprenorphine (24 mg) were significantly more likely to remain in treatment over six months compared with those who received a lower dose (16 mg), according to a study published this week in JAMA Network Open.

“The U.S. Food and Drug Administration recommends a target dose of 16 mg for buprenorphine maintenance treatment, with an upper limit of 24 mg,” wrote Laura Chambers, Ph.D., M.P.H., of Brown University and colleagues. The authors noted that this recommendation was established prior to the emergence of fentanyl in the illicit drug supply. “Some physicians have suggested that the current daily maintenance target dose of buprenorphine (16 mg) may be inadequate to control withdrawal and cravings in patients who used fentanyl and that a higher daily dose may better suppress withdrawal and cravings.”

Chambers and colleagues conducted a retrospective study using data from the Rhode Island Prescription Drug Monitoring Program. They included patients who initiated buprenorphine treatment for opioid use disorder for the first time between October 2016 and September 2020. Each patient was followed for 180 days after initiation. The authors categorized patients as having discontinued treatment if they had a gap in treatment of more than 27 days based on prescription fill dates and days’ supply. To account for slight variations in prescribing, the authors categorized patients who received daily doses in the 14-18 mg range in the 16 mg group, and patients who received doses in the 22-26 mg range in the 24 mg group.

A total of 6,499 patients were included in the study, 57% of whom were 25 to 44 years old and 61% of whom were male. The initial daily dose for most patients was 8 mg (21%) or 16 mg (50%), and only 10% were initially prescribed a 24 mg dose. In total, 58% of patients discontinued buprenorphine treatment within 180 days. Of those who received 16 mg, 59% discontinued treatment compared with 53% of those prescribed 24 mg—a statistically significant difference, according to Chambers and colleagues.

“Effective treatment can save lives, but our proven treatments for opioid use disorders must evolve to match the challenges posed by the fentanyl crisis,” National Institute on Drug Abuse (NIDA) Director Nora Volkow, M.D., said in a news release. NIDA funded the study by Chambers and colleagues. “If science continues to demonstrate that a higher dosage of buprenorphine increases treatment retention, we must re-evaluate clinical guidelines to optimize treatment and help people achieve recovery.”

The authors noted that future research should examine outcomes for patients who are prescribed doses higher than 24 mg, “as it is uncertain where the ceiling is on the treatment effect in the era of fentanyl.”

For related information, see the Psychiatric News article “VA, DoD Recommend Buprenorphine for Chronic Pain.”

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Dialectical Behavior Therapy May Reduce Suicide Attempts in Youth With Bipolar Disorder

Young people with bipolar spectrum disorder who received dialectical behavior therapy (DBT) had significantly fewer suicide attempts compared with young people who received standard psychotherapy, according to a report in JAMA Psychiatry. DBT is an evidence-based treatment that focuses on emotional regulation, and one of its uses is for suicidal behavior.

“Up to 50% of youth with bipolar spectrum disorder attempt suicide,” wrote Tina Goldstein, Ph.D., of the University of Pittsburgh and colleagues. For up to 60% of individuals, their first suicide attempt is lethal, and for those who survive, the risk of death increases with each successive attempt. “Thus, the capacity to predict first attempt among youth with BP and provide a potentially preventive intervention like DBT offers a compelling future direction.”

Adolescents aged 12 to 18 years diagnosed with bipolar spectrum disorder were recruited from a specialty outpatient psychiatric clinic at the University of Pittsburgh Medical Center between November 2014 and September 2019. Forty-seven were randomized to receive 37 sessions of DBT over one year, and 53 were randomized to receive standard psychotherapy (for example, sessions focused on cognitive strategies and behavioral approaches). All youth received medication from study psychiatrists according to a treatment algorithm. By the study’s end, 28 youth had withdrawn from the study, and eight were lost to follow-up.

Primary outcomes included suicide attempts over one year and mood symptoms and episodes of depression and hypomania/mania. Suicide attempts were assessed using the Columbia Suicide Severity Rating Scale and the ALIFE Self-Injurious/Suicidal Behavior Scale. The researchers also assessed emotional regulation using the self-reported Difficulties With Emotion Regulation Scale. Over the year-long study, youth who had received DBT reported significantly fewer suicide attempts compared with those who had received standard psychotherapy. “[S]uicide attempts declined to a greater extent over time among those receiving DBT compared with those receiving [standard] psychotherapy, particularly among participants with a recent and/or lifetime history of suicide attempt,” the authors noted.

While the groups displayed similar improvements in symptoms of depression and episodes of hypomania and mania, those who received DBT experienced greater improvement in emotional regulation. Improvement in emotional regulation was associated with decreased suicide risk, particularly among those with high baseline emotion dysregulation.

The authors concluded: “Adolescents with bipolar disorder at elevated risk of suicidal behavior and those exhibiting high emotion dysregulation stand to benefit most from DBT’s effects on decreasing suicide attempt risk through enhancing emotion regulation.”

For related information, see the Psychiatric News article “We Must Continue Screening Youth for Suicide Risk.”

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Palliative Care Said to Help Patients With Serious Mental Illness

Researchers have long known that people with serious mental illnesses (SMI) tend to die at younger ages than those who do not have these conditions—likely due to their higher risk of chronic illnesses that tend to be more severe and diagnosed later in life. A recent article in JAMA Psychiatry examines why these patients may have been overlooked for palliative care and a few simple steps that psychiatrists can take to help connect patients to end of life care when needed.

“A distinguishing feature of palliative care in SMI is that unlike patients with fatal illnesses, such as cancer or heart disease, patients with SMI must cope with 2 distinct issues: lifelong SMI treatments and management of fatal medical conditions,” wrote Kwok Ying Chan, M.D., of the Palliative Medical Unit at Grantham Hospital in Hong Kong and colleagues. Additionally, “This population faces disparities at the patient, health care professional, and system levels, which are worsened by the prevalent stigma associated with major mental illness. The ensuing fragmentation impedes care integration and raises the likelihood of poor health outcomes.”

By learning more about general and specialized palliative care, including those with whom to collaborate on palliative care needs for patients, psychiatrists can help patients with SMI overcome barriers to this care, Chan and colleagues wrote. Some psychiatrists, such as those in consultation-liaison psychiatry and geriatric psychiatry, receive some training in palliative care as part of fellowship programs, they added.

“Understanding good palliative care practices is not the same as coping with common ailments,” they wrote. “As with many serious medical conditions, the best course of action for a patient with SMI should be determined in addition to the most effective disease-specific treatment. Close collaboration between psychiatrists and palliative care professionals can gradually improve patients’ quality of life.”

For related information, see the Psychiatric Services article “Future Care Planning: Concerns of Elderly Parents Caring for a Person With Serious Mental Illness.”

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MDMA-Assisted Therapy for PTSD Shows Promise for Patients of Diverse Backgrounds

Several sessions of MDMA-assisted therapy led to improvements in a diverse population of adults with moderate to severe posttraumatic stress disorder (PTSD), according to a report in Nature Medicine.

“In a historic first, to our knowledge, for psychedelic treatment studies, participants who identified as ethnically or racially diverse encompassed approximately half of the study sample,” wrote Jennifer Mitchell, Ph.D., of the University of California, San Fransico, and colleagues. “A substantial proportion of participants displayed comorbid features associated with high treatment resistance, such as major depression, multiple sources of trauma (including childhood and combat trauma), and dissociative subtype PTSD.”

Mitchell and colleagues enrolled 104 adults 18 years and older with moderate to severe PTSD—defined as a score of at least 28 on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). The participants, recruited from 13 sites across the United States and Israel, included 28 individuals who identified as Hispanic/Latino and 35 individuals who identified as American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, or multiple races.

Before starting therapy, all participants received three, 90-minute therapy sessions to prepare them for the study. The participants were then randomized to receive MDMA combined with therapy or placebo combined with therapy. They completed three eight-hour dosing sessions conducted by a two-person therapy team, spaced about one month apart. During these therapy sessions, 53 participants took the assigned MDMA pill and 51 took a placebo pill.

At baseline, the average CAPS-5 score among the participants was 39. At 18 weeks (about six to eight weeks after the third dosing session), CAPS-5 scores fell by 23.7 points in the MDMA group compared with 14.8 points in the placebo group. Further, 71.2% of those in the MDMA group no longer met DSM-5 criteria for PTSD after 18 weeks, compared with 47.6% of those in the placebo group. The participants in the MDMA group also showed reductions in functional impairment, as measured by changes from baseline on the Sheehan Disability Scale.

“These findings represent the culmination of over two decades of research, and, together with MAPP1 [a previous phase 3 trial], indicate that further consideration of this treatment in individuals with moderate to severe PTSD is warranted,” Mitchell and colleagues concluded.

To read more on this topic, see the Psychiatric News article “Australia Legalizes Psychedelics for Use in Depression, PTSD Therapy.”

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Cyberbullying Linked to Eating Disorder Symptoms in Youth

Youth who are cyberbullied or cyberbully others may be more likely to report disordered eating behaviors than those who are not involved with such bullying, a study in the International Journal of Eating Disorders has found.

Jason M. Nagata, M.D., M.Sc., of the University of California, San Francisco, and colleagues analyzed data from 10,258 participants in the Adolescent Brain Cognitive Development (ABCD) study, who were about 12 years old. As part of the ABCD study, the adolescents completed a self-reported questionnaire to capture lifetime cyberbullying (victimization and perpetration) using a modified version of the Cyberbullying Scale. They also completed the Kiddie Schedule for Affective Disorders and Schizophrenia, which categorizes child and adolescent mental health concerns, including eating disorder symptoms.

Overall, 9.5% of the adolescents had been cyberbullied, and 1.1% had cyberbullied others. The prevalence of eating disorder symptoms varied between 1.5% and 7.5%.

Adolescents who had been cyberbullied had roughly twice the rate of weight-related concerns as those who had not. These concerns included worrying about weight gain (prevalence ratio [PR] 2.41), feeling their self-worth was tied to their weight (PR 2.08), engaging in inappropriate compensatory behavior to prevent weight gain (for example, throwing up or overexercising; PR 1.95), binge eating (PR 1.95), and feeling distress with binge-eating (PR 2.64).

Adolescents who perpetrated cyberbullying had even higher rates of most of these concerns compared with those who had not perpetrated cyberbullying, including worrying about weight gain (PR 3.52), feeling their self-worth tied to their weight (PR 5.59), binge eating (PR 2.36), and feeling distress with binge eating (PR 2.84). However, there was no significant difference between those who perpetrated cyberbullying and those who did not with respect to engaging in inappropriate compensatory behavior to prevent weight gain.

Nagata and colleagues wrote that their findings have significant implications for public policy, public health, and clinical practice.

“In particular, our study supports the use of strategies to teach early adolescents methods to navigate negative appearance-related online comments,” they wrote. “Furthermore, adolescents who have experienced cyberbullying could benefit from eating disorder prevention programs to minimize the risk of eating disorder development.”

For related information, see the Psychiatric News article “Youth Online Behavior Offers Clues to Suicidality.”

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Study Explores Factors Driving Health Care Use Among Those Involved With Criminal Legal System

It is well-known that people with mental health and substance use disorders are more likely to interact with the criminal legal system than those without these disorders. A report in Psychiatric Services now suggests mental health disorders may be a stronger factor than substance use disorders in these individuals seeking health services.

“[O]ur findings suggest that interventions that address a broad range of behavioral health needs for individuals with mental illness will be important to reduce acute health care use among those with criminal legal involvement,” wrote Harini Shah, Laura Hawks, M.D., M.P.H., and colleagues at the Medical College of Wisconsin.

Shah, Hawks, and colleagues analyzed data from the annual National Survey on Drug Use and Health (NSDUH), collected between 2015 and 2019. They identified 9,039 community-dwelling adults 18 years and over who indicated they had been arrested, on probation, and/or on parole/supervised release in the past year. They then examined the relationship between mental illness, substance use disorder, or both and the adults’ use of health care services. Health care services encompassed emergency department visits, outpatient medical visits, and inpatient hospital stays.

Compared with individuals with neither disorder, those with mental illness had an average of 1.46 times as many outpatient visits, 1.43 times as many emergency department visits, and 2.14 times as many days spent in inpatient care. Individuals with comorbid mental illness and substance use disorder had 1.62 times as many emergency department visits and 4.16 times as many inpatient days as those with neither disorder. Individuals with only substance use disorder had 1.23 times as many emergency department visits relative to individuals with neither mental health nor substance use disorders.

The authors noted all the calculations factored in social and demographic variables such as race, age, employment status, and income, suggesting that these traits have very little influence on the link between mental illness and health care utilization.

“The observed increases in [emergency department] and inpatient utilization among those with mental illness suggest opportunities for enhancing access to ambulatory care, improving care coordination, and increasing available resources,” the authors wrote.

To read more on this topic, see the Psychiatric News article “Community MH Must Include Care for Incarcerated Individuals, Released Prisoners.”

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APA Urges Expanded Telemedicine Prescribing Rules in DEA Listening Session

Telemedicine prescribing has expanded access to psychiatric medications—including controlled substances such as buprenorphine, which are crucial to fighting the opioid epidemic. So said psychiatrist Shabana Khan, M.D., yesterday during a public meeting hosted by the Drug Enforcement Agency (DEA) about its proposed regulations on prescribing controlled substances via telemedicine. Khan, who was invited to speak at the meeting on behalf of APA, is director of child and adolescent telepsychiatry at NYU Langone Health, an assistant professor of child and adolescent psychiatry at NYU Grossman School of Medicine, and chair of the APA Committee on Telepsychiatry.

The proposed rules would curtail telemedicine prescribing flexibilities extended to physicians during the COVID-19 Public Health Emergency, for instance by requiring an in-person visit for the prescribing of controlled substances. “Rather than a mandatory blanket requirement [for an in-person visit], the need for an in-person examination of a patient really should be left to the clinical discretion of a practitioner who has the knowledge, skills, and experience to make that decision,” Khan said. “Reducing flexibility in modalities of care increases inequity, forcing practitioners to cherry-pick patients that have the ability to travel to in-person care.”

She added also that telemedicine has not been shown to increase diversion of controlled substances.

The DEA sponsored the listening session, which began yesterday and continued today, after receiving more than 38,000 public comments in response to the proposed rules, the largest response to rule making in the agency’s history. The proposals appear as two separate rules in the Federal Register (“Telemedicine Prescribing of Controlled Substances When the Practitioner and the Patient Have not Had a Prior In-Person Medical Evaluation” and “Expansion of Induction of Buprenorphine Via Telemedicine Encounter”).

APA responded to the proposed rules in two March 31 letters to DEA. “Our recommendations focus on balancing common-sense safeguards for DEA enforcement of legitimate controlled substance prescribing without decreasing access to lifesaving treatments,” Khan said. She emphasized that existing standards and regulations provide a high level of oversight and accountability of prescribing practices.

Khan noted that a special registration for telemedicine prescribing, which the agency is considering, could allow practitioners to affirm their adherence to safe prescribing.

Finally, Khan urged the agency to formulate new rules quickly. “Practices and clinicians are already scheduling several months out for appointments,” she said. “If DEA waits to issue updated rules much longer, patient care will have to be rearranged and may be disrupted. Our recommendations reflect a shared commitment across mental health services to providing evidence-based, high-quality, and equitable care that uses every tool in our toolbox to address the opioid and mental health crises in our country.”

For related information, see the Psychiatric News article “APA Advocacy With Regulatory Agencies Has Been Crucial for Telepsychiatry.”

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Surgical Intervention for Irregular Heartbeat Found to Reduce Depression, Anxiety

An estimated 1 in 3 patients with atrial fibrillation, or irregular heartbeat, is affected by symptoms of depression and anxiety. A report appearing today in JAMA suggests that patients treated with catheter ablation—a minimally invasive treatment for atrial fibrillation—experienced greater reductions in symptoms of depression and anxiety than those patients treated with antiarrhythmic medications.

“This study highlights the negative impact of [atrial fibrillation] on patients’ mental health,” wrote Ahmed M. Al-Kaisey, M.B.Ch.B., of Royal Melbourne Hospital in Australia and colleagues. “[C]atheter ablation resulted in significant and sustained improvements in markers of psychological distress, further focusing attention on the importance of mental health assessment in patients with symptomatic [atrial fibrillation].”

The REMEDIAL (Randomized Evaluation of the Impact of Catheter Ablation on Psychological Distress in Atrial Fibrillation) study involved patients aged 18 to 80 who sought care for symptoms of atrial fibrillation between June 2018 and March 2021. Fifty-two of these patients were randomized to receive catheter ablation, and 48 received medication for their heart condition. The researchers assessed the participants using questionnaires at study enrollment and periodically throughout the 12-month study. These questionnaires included the Hospital Anxiety and Depression Scale (HADS) and the 36-item Short Form Health Survey (SF-36).

The mean combined HADS score for all participants at baseline was 12.72, and severe psychological distress (combined HADS score >15) was present in 31 of 96 participants (32%).

During 12 months of follow-up, 23 of 49 participants (47%) in the ablation group had documented atrial fibrillation compared with 45 of 47 (96%) in the medication group. A greater percentage of patients in the ablation group showed reductions in psychological distress over time, with 14.2% continuing to report severe psychological distress at six months and 10.2% reporting symptoms of psychological distress at 12 months. The percentage of patients in the medication group reported severe psychological distress was 34% at six months and 31.9% at 12 months.

Compared with the medication group, the ablation group had significantly lower mean anxiety HADS scores at 6 and 12 months as well as significantly lower mean depression HADS scores at 3 months, 6, and 12 months. Ablation was also associated with significantly lower symptoms of atrial fibrillation compared with medication therapy at 3, 6, and 12 months.

“The REMEDIAL trial sheds light on the question of what evidence-based [atrial fibrillation] treatment strategy to pursue from a patient-centered perspective,” wrote Julia Lurz, M.D., of Leipzig University and Karl-Heinz Ladwig, M.D., Ph.D., of the Technical University München in Germany in an accompanying editorial. “[A]ttentive clinical acumen is important to establish individually tailored treatment strategies. It is desirable for physicians to increase awareness of frequently concomitant depression, stress, and anxiety in patients with [atrial fibrillation]; to implement screening and assessment; and to initiate comprehensive and collaborative care.”

For related information, see the Psychiatric News article “Depression, Anxiety After Cardiac Arrest Linked to Long-Term Increased Risk of Death.”

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Psychiatric News Remembers 9/11

On the 22nd anniversary of the terror attacks on 9/11, Psychiatric News remembers the thousands of people who perished in New York City, Arlington, Va., and Shanksville, Pa., as well as their families and friends whose lives were forever changed. Psychiatric News also recognizes the psychiatrists and other mental health professionals in New York and elsewhere who offered crisis counseling to survivors, relatives, friends, employers, first responders, and schools affected by the tragic events.

The articles that follow are some of the earliest reports filed by Psychiatric News following the attacks.

• “Psychiatrists Rush to Aid of World Trade Center Victims”
• “Psychiatry Answers Call After Terrorist Attacks”
• “APA Provides MH Expertise In Wake of Terrorist Attacks”
• “D.C. Psychiatrists Gear Up For Long-Term Response”
• “Training Near Ground Zero”
• “Lessons Amid Tragedy”

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Inflammation From Infection Linked to Increased Risk of Dementia

Inflammation has long been associated with increased risk of Alzheimer’s disease and other types of dementia. Now a study in JAMA Network Open suggests that the increased risk may be tied specifically to inflammation from infection more than general systemic inflammation such as that caused by autoimmune disorders.

Janet Janbek, Ph.D., of Copenhagen University Hospital–Rigshospitalet and colleagues examined data amassed between 1978 and 2018 from nearly 1.5 million adults in Danish national population registries. The individuals were born from 1928 to 1953, were alive and living in Denmark on January 1, 1978, and were included in the study upon their 65th birthday. None of the individuals had a record of diagnosed dementia upon enrollment.

The researchers defined exposure as inpatient, outpatient, or emergency hospital contacts with a primary or secondary discharge diagnosis of an infection or autoimmune disease beginning at age 50.

During the study period, 45% of the individuals had infections and 9% had autoimmune diseases. Five percent developed dementia after age 65.

The researchers found that over the study period, dementia occurred about 1.5 times as often in people who had infections than in people without infections. Furthermore, the more infections people had, the higher the rate of dementia. In contrast, dementia occurred in people who had autoimmune diseases at about the same rate (1.04 times) as people without autoimmune diseases; being diagnosed with multiple autoimmune diseases did not appear to increase the rate of dementia.

“Our data and the observational nature of our study do not directly support or refute any proposed mechanism, nor can we make firm conclusions about the role of inflammation in dementia on the basis of our findings,” the researchers wrote. However, the findings “may point toward a role for infection-specific processes rather than general systemic inflammation.”

For related information, see the Psychiatric News article “History of Severe Infection Linked to Substance-Induced Psychosis.”

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Antidepressants Found Effective for Depressed Patients With Other Medical Disorders

Many people with medical conditions such as heart disease and cancer also experience symptoms of depression. A report published yesterday in JAMA Psychiatry suggests antidepressants are as safe and effective for people with comorbid depression as those with depression only.

“It is important to screen for and manage comorbid depression in patients with medical diseases, and clinicians should choose treatments based on patient preferences and the antidepressant’s risk-benefit ratio,” wrote Ole Köhler-Forsberg, M.D., Ph.D., D.M.Sc., of Aarhus University Hospital-Psychiatry in Denmark.

The researchers identified 176 systematic reviews published before March 31, 2003, that included patients who had been diagnosed with a medical disorder and randomized to receive antidepressants or placebo for comorbid depression. Most of the systematic reviews involved patients with neurological (n = 79), cardiological (n = 18), and oncological (n = 20) diseases.

Köhler-Forsberg and colleagues narrowed in on 52 meta-analyses involving 27 medical diseases. They examined antidepressant efficacy as well as reports of patients discontinuing their antidepressants, including for adverse effects.

While patients assigned to antidepressants generally showed greater improvements in depression symptoms compared with those taking placebo, these improvements varied according to the comorbid medical condition examined. The researchers also found that patients assigned to antidepressants were more likely to discontinue taking the medication than those taking placebo.

Köhler-Forsberg and colleagues wrote that their analysis suggests the efficacy of antidepressants (relative to placebo) in patients with depression and comorbid medical diseases is comparable to their efficacy in people with depression alone.

“Future large, high-quality [trials] should include head-to-head comparisons between antidepressants to expand the knowledge on potential differences in efficacy and safety between antidepressants for depression comorbid with medical diseases and to allow more specific treatment recommendations for distinct medical diseases,” Köhler-Forsberg and colleagues concluded.

For related information, see the Psychiatric News article “Antidepressants May Lower Heart Attack Risk in Diabetes.”

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Eye Tracking May Aid Diagnosis of Autism in Young Children, Study Suggests

An eye-tracking device that measures social-visual engagement (how children look and learn from their surrounding social environment) may help to predict autism in children at risk for the disorder, according to a report in JAMA.

“Most parents of children with autism report having had concerns before the second birthday, yet the median age of U.S. autism diagnosis is 4 to 5 years,” wrote Warren Jones, Ph.D., of the Marcus Autism Center in Atlanta and colleagues. Objective biomarker tests could help reduce diagnostic delays and connect young people with services earlier.

For the study, Jones and colleagues recruited 475 children aged 16 to 30 months old who were enrolled at six U.S. autism specialty centers between April 2018 and May 2019. The cohort included a broad spectrum of children with autism—both with and without co-occurring intellectual and developmental delays—as well as many children without autism who nonetheless had significant speech-language and other developmental disabilities.

All participants were evaluated by autism experts who relied on such standardized assessments as the Autism Diagnostic Observation Schedule, Second Edition; the Mullen Scales of Early Learning; and DSM-5 criteria. In addition, clinical site staff used an automated device to track the children’s eye movement as they watched short videos of social interaction (for example, children playing together). Those performing the eye-tracking tests and clinical assessments were blind to each other’s results.

Eye-tracking of social-visual engagement was highly sensitive, successfully identifying children who were diagnosed with autism by clinical assessment in 71% of cases. The technique was also highly specific, correctly identifying those children who would not be diagnosed with autism in nearly 81% percent of cases. The eye-tracking test results correlated with clinical assessments of the child’s level of autism-related behaviors and verbal and cognitive abilities.

In an accompanying editorial, Geraldine Dawson, Ph.D., of the Duke University Center for Autism and Brain Development said the study “represents a significant step forward toward developing more objective tools for early diagnosis of autism.” She added, “Another possible future application of the findings … is the use of eye tracking to identify infants younger than 1 year who have a higher likelihood of a later autism diagnosis.”

Dawson said that demonstrating that an eye-tracking test improves diagnostic certainty would require following children whose diagnosis was uncertain to determine whether the test improves prediction of a later definitive autism diagnosis. “Future studies will need to assess how feasible, acceptable, reliable, and efficient the eye-tracking test is when used by clinicians as an aid in autism diagnosis in practice,” she wrote.

For related information, see the Psychiatric News article “Visual Diagnostics Become More Accessible.”

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Patients Seeking Mental Health Care Want More Say in In-Person, Virtual Appointments

Nearly 1 in 3 adults receiving mental health treatment who were surveyed earlier this year said they don’t have much choice when it comes to whether they see their clinician in person or via telehealth. In part, this was because those surveyed reported that they did not see clinicians who offered both in-person and telehealth visits.

These were a few of the key takeaways from a report published this afternoon in Health Affairs.

“Although preferences regarding modality varied, with some preferring in-person care and others preferring telehealth for different types of behavioral health visits, the majority of interview participants wanted to have the choice,” wrote Jessica Sousa, M.S.W., M.P.H., of the RAND Corporation and colleagues.

The researchers conducted a nationally representative survey of 2,071 U.S. adults (average age 49 years, 74% White) in early 2023, including 571 who used behavioral health services in the prior year. They also completed in-depth interviews with 26 people with bipolar disorder or depression during this time. The participants were asked whether their clinicians were offering both in-person and telehealth visits for medication or individual therapy and how decisions about whether they saw the clinician in person or virtually were decided.

Recipients of individual therapy were about twice as likely to have telehealth visits (80%) as in-person visits (42%) during the prior year, the researchers found. Those seen for medication visits were about equally likely to receive telehealth visits (54%) as in-person visits (58%). About 24% of those seeking therapy said that the provider decided whether they were seen in person or via telehealth; for those seeking medication appointments, about 35% said the provider decided.

The respondents whose clinicians offered both in-person and telehealth appointments were also asked to rate their level of agreement with statements such as “When deciding whether visits would be in person or by telehealth, my provider considered my preference” and “Most of the time, I was able to get the type of visit (telehealth versus in-person) that I preferred.”

Nearly 55% of the survey respondents agreed that their clinician considered their visit preference when deciding whether to see the patient in person or by telehealth; 68% agreed that they got the type of visit they preferred most of the time.

“Expanding telehealth is a laudable goal, given that it often is more convenient, increases access to care, and is effective for treating many behavioral health conditions. However, telehealth alone might not be sufficient,” Sousa and colleagues wrote. “For telehealth to achieve its potential to increase overall access to high-quality, patient-centered care, it is important to implement it in a manner that expands, rather than contracts, behavioral health access and options for patients.”

For related information, see the Psychiatric News article “The Hybrid Model: New Normal or Unstable Transition Phase?”

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Counterfeit Pills Increasingly Involved in U.S. Overdose Deaths

The percentage of overdose deaths involving counterfeit pills in the United States more than doubled between late 2019 and late 2021, according to findings published today in the CDC’s Morbidity and Mortality Weekly Report. The percentage of overdose deaths involving counterfeit pills more than tripled in western states in the country.

“Drug overdose deaths are at historically high levels in the United States, with a preliminary estimate of more than 105,000 deaths in 2022,” wrote Julie O’Donnell, Ph.D., of the National Center for Injury Prevention and Control and colleagues. “Counterfeit pills can expose new populations to highly potent drugs such as IMFs [illicitly manufactured fentanyls] and illicit benzodiazepines, and persons using pills might not be aware of their contents.”

O’Donnell and colleagues relied on data submitted to the CDC’s State Unintentional Drug Overdose Reporting System to examine trends in overdose deaths with evidence of counterfeit pill use. This system contains information submitted by jurisdictions throughout the country about drug overdose deaths from death certificates, postmortem toxicology reports, and more.

The authors calculated quarterly percentages of overdose deaths with evidence of counterfeit pill use from July 2019 to December 2021 based on information provided by officials from 29 states and the District of Columbia. The authors also examined information about the demographics of the people who died by overdose, the circumstances of the death, and the drugs involved.

From July 2019 to December 2021, 106,293 overdose deaths occurred among the 30 jurisdictions with complete data. Between July-September 2019 and October-December 2021, the overall quarterly percentage of overdose deaths involving counterfeit pills increased from 2.0% to 4.7%, according to O’Donnell and colleagues. The authors noted that the trend was “driven by an increase from 4.7% to 14.7% in western jurisdictions. Percentages remained below 4% in all other regions.”

Compared with people who died of drug overdose that did not appear to involve counterfeit pills, people who died of drug overdose involving counterfeit pills tended to be younger and Hispanic and have a history of prescription drug misuse.

“The highest percentages of deaths with evidence of counterfeit oxycodone use (both alone and with counterfeit alprazolam) were in western jurisdictions, whereas nearly one half of deaths with evidence of counterfeit alprazolam use only were in southern jurisdictions. This finding suggests that exposure to different types of counterfeit pills and drugs might vary by region,” O’Donnell and colleagues wrote. “Prevention and education materials that incorporate local drug seizure data and information about regional drug markets might be particularly effective at highlighting relevant counterfeit pill types and reducing deaths.”

For related information, see the Psychiatric News articles “Severe Grief Tied to Experiencing, Witnessing Overdose” and “Xylazine Present in Increasing Number of Fentanyl Overdose Deaths, CDC Finds.”

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Last Call! Nominations for APA Trustee Positions Due Today!

APA’s success hinges on the expertise, knowledge, and input of its members. Help shape the future of APA and the profession of psychiatry by nominating yourself or a colleague for one of the open positions on APA’s Board of Trustees by Friday, September 1.

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