Rise in Virtual Visits Linked to More After-Hours EHR Work

As virtual visits for health care expanded rapidly in response to the COVID-19 pandemic, the amount of time physicians spent using electronic health records (EHRs) outside of clinic hours also crept up. The findings, which were published yesterday in JAMA Internal Medicine, suggest that physicians offering telemedicine visits may need more time to complete EHR documentation.

“[A]lthough telemedicine may offer a convenient option for patients, it exhibits a dramatic dose-response association with EHR time that exacerbates EHR burden for physicians,” A. Jay Holmgren, Ph.D., M.H.I., of the University of California, San Francisco, and colleagues wrote. Previous studies have shown that physicians who spend more time working on EHRs outside of work are more likely to report burnout, the authors noted.

Holmgren and colleagues analyzed EHR data from physicians providing outpatient care at UCSF Health one year before the COVID-19 pandemic (August 2018-September 2019) and after the onset of the pandemic (August 2020-September 2021). The study sample included 1,052 physicians observed over 115 weeks.

From before the COVID-19 pandemic to after its onset, telemedicine use increased from 3.1% to 49.3%, the authors reported. The amount of time that physicians spent working in EHRs during scheduled hours increased from 4.53 hours to 5.46 hours (per eight hours of patient care) during this time. Other key findings from the report include the following:

• Time spent working in EHRs outside of scheduled hours increased from 4.29 hours to 5.34 hours.
• Time spent on clinical documentation (for example, writing clinical notes) during and outside of scheduled hours increased from 6.35 hours to 8.18 hours.
• The average number of weekly patient portal messages received by physicians increased from 16.76 to 30.33, and messages sent to patients increased from 13.82 to 29.83.

“Critically, the amount time spent on EHR work among the physicians in this study underscores the importance of reducing burden: for every 8 [patient scheduled hours], physicians were spending 5 or more hours outside [patient scheduled hours] working in the EHR,” Holmgren and colleagues wrote. “Health systems should consider the burden of EHR time for physicians who deliver care via telemedicine when considering scheduling, number of patients under care (i.e., panel size), and productivity expectations.”

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

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Older Adults With ADHD May Be More Sensitive to Vascular Damage in the Brain

Older adults with attention-deficit/hyperactivity disorder (ADHD) may be particularly vulnerable to the harmful effects of vascular damage, according to a report published today in The American Journal of Geriatric Psychiatry.

The small study revealed that while older adults with ADHD had less vascular damage in their brains than a matched group of older adults without ADHD, the impact of vascular damage on memory or executive function was greater in adults with ADHD than those without.

The findings suggest “ADHD lowers the threshold for experiencing the harmful effects of late-life brain pathology, and that older adults with ADHD are more sensitive to smaller degrees of cellular brain change,” wrote Brandy L. Callahan, Ph.D., of the University of Calgary and colleagues.

The study included 39 older adults (average age 63) with ADHD from a neurology clinic and 50 age- and gender-matched adults without ADHD. Both groups included participants with and without cognitive impairment. All participants were given a comprehensive neuropsychological assessment and underwent an MRI to identify white matter hyperintensities (WMHs), lesions which indicate nerve fibers damaged by vascular events such as inflammation or hemorrhages. Studies have suggested that WMHs are associated with cognitive problems.

Overall, the adults with ADHD and matched controls had similar performance scores on their neuropsychological tests, though adults with ADHD had slower processing speeds. Yet, the average volume of WMHs was significantly lower in the adults with ADHD compared with adults without ADHD (1,774 mm3 vs. 3,800 mm3).

Adults with ADHD who had higher WMH levels had significantly lower scores on tasks related to short-term verbal memory, short-term visual memory, long-term verbal memory, processing speed, and executive functioning than those with lower WMH levels. Adults without ADHD with higher levels of WMH also had lower cognitive scores, but the rate of decline was less pronounced.

“Given the results of the present study, it will be important to conduct additional work to determine the extent to which stimulant medication use in older adults with ADHD impacts vascular health,” Callahan and colleagues continued, noting that these medications increase heart rate and blood pressure. “[D]ecreases in cerebral small vessel integrity will likely have compounded effects on cognition in this population.”

To read more on this topic, see the Psychiatric News article “Symptoms, Impaired Function of ADHD Often Persist Beyond Childhood.”

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Reducing Burnout in VA Therapists: Study Points to Role of Institutional Support

Burnout is widespread among U.S. health care workers. Just this week, the Centers for Disease Control and Prevention (CDC) released a report that showed nearly 50% of health workers feel burned out.

Yesterday, Psychiatric Services published an article that suggests that when therapists feel institutional support for the evidence-based treatments they provide, they report less burnout and greater job satisfaction.

The rates of burnout among those who practice psychotherapy at the Veterans Health Administration (VHA)—including psychologists, social workers, and licensed professional mental health counselors—are particularly high, wrote Rebecca K. Sripada, Ph.D., of the U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System.

Sripada and colleagues analyzed data from the VHA’s national 2018 Mental Health Provider Survey, which asked those surveyed to rate their level of burnout and job satisfaction on a scale of 1 to 5. Other questions asked the respondents to rate difficulties they had scheduling evidence-based psychotherapy, establishing goals and ending psychotherapy, and more. Respondents who were nurses, psychiatrists, and clinical pharmacists were excluded from the analysis.

Of the 5,341 respondents included in the study, 2,146 (40.2%) respondents reported burnout, and 3,582 (67.1%) reported job satisfaction. The following factors were significantly associated with decreased likelihood of burnout and increased therapist satisfaction:

• Less difficulty scheduling evidence-based psychotherapy
• Sufficient telehealth resources
• Less difficulty establishing goals
• Less difficulty ending psychotherapy
• Reasonable workload

“These findings suggest that institutional support for evidence-based practices is robustly associated with job satisfaction and reduced burnout among therapists,” Sripada and colleagues concluded. “Expanding support for therapists to provide these services may accrue benefits to therapists, as well as to patients and health care systems.”

For related information, see the Psychiatric News article “Overdose Death Risk Elevated in Many Health Workers.”

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Should Psychiatrists Advocate Banning Screens From Kids’ Bedrooms?

Numerous studies have established a strong link between evening screen time and poor sleep quality. Yet should that association result in guidance from a child and adolescent psychiatrist, urging families to institute blanket bans on screens in bedrooms? That question was debated yesterday at this year’s American Academy of Child and Adolescent Psychiatry’s (AACAP) annual meeting in New York City by members of AACAP’s Media Committee.

At the start of the debate, Paul Weigle, M.D., the session’s chair, took a poll of the room, asking if attendees thought child and adolescent psychiatrists should advocate banning screens from bedrooms. Fifty-four percent of participants agreed, while 25% disagreed, and 21% were unsure.

Argelinda Baroni, M.D., Lauren Hale, M.D., and Dale Peeples, M.D., argued in favor of banning screens from bedrooms. Some of their reasons included the following:

• Screens in bedrooms contribute to poor sleep; they outlined the numerous consequences of poor sleep and the importance of sufficient, restorative sleep as fundamental to optimal functioning of the human body, especially the developing mind.
• Screens and social media apps are addictive.
• Unrestricted access to screens in the middle of the night is unhealthy.

While the ban proponents acknowledged that screen time in some capacity can have benefits for youth, they emphasized that those benefits can also be achieved in the living room, without disrupting sleep. “As your doctor, I can honestly tell you that you will feel better, sleep better, and have better concentration if you keep electronics out of your bedroom,” Peeples said.

On the opposite side of the debate were Gino Mortillaro, M.D., Ray Pan, M.D., and Michael Tsappis, M.D. They acknowledged the negative impact that screens have on sleep, but argued that bans are rarely ever followed. Other points of opposition included the following:

• Blanket bans have the potential to compromise the alliance between the psychiatrist and the youth, as well as the parents and the youth.
• Parents need to have a supportive alliance with their children. Banning screens from the bedroom reduces the opportunity for parents to have conversations with their youth.
• Banning screens also reduces opportunities for the youth to learn how to regulate themselves as they enter adulthood.

Further, they argued that banning screens reinforces a negative emphasis on real, but also imagined, effects of screens, without allowing room to acknowledge the numerous benefits provided by screen access. “Screens are increasingly relied upon for everyday activities, especially by young people,” Tsappis said.

In the rebuttal phase of the debate, Baroni noted that science is on the side of the ban proponents. Hale argued that encouraging moderation and limit setting are one in the same. If youth put their phones away an hour before bed, they may sleep 20 minutes more, which is just enough to reduce the risk of car crashes and improve grades, Hale argued.

On the opposition side, Pan pointed out that when treating substance use disorders, the literature encourages a harm reduction approach rather than an absolute ban. “The idea of making a black-and-white ban really runs the risk of us being hammers and only seeing nails,” Mortillaro said.

The lively debate also drew numerous audience questions from AACAP members, who shared their thoughts and experiences in their own practices. By the end of the debate, Weigle took another poll to determine if either side had swayed more audience members. The result was almost a total reversal of the original poll: By the end, 55% were against advocating for bans on screens in bedrooms, while 35% were in favor of such bans, and about 10% were unsure.

The AACAP meeting will run through Saturday, October 28. Look for additional meeting coverage in Psychiatric News.

For related information, see the Psychiatric News article “Sleep Problems in Late Childhood, Early Adolescence Linked to Psychiatric Symptoms.”

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Over 60% of Youth Who Vape Cannabis Report Psychological Distress

Youth who reported experiencing severe psychological distress were more likely to vape cannabis in the previous month than those who did not report psychological distress, according to a report in the American Journal of Preventive Medicine.

“Some adolescents may use cannabis to regulate distress, and adolescence is an important developmental period for intervention as adolescents who use cannabis as a coping mechanism may go on to develop problematic use,” wrote lead author Delvon T. Mattingly, Ph.D., of the University of Kentucky and colleagues.

The researchers looked at the association between cannabis vaping and psychological distress among 22,202 youth aged 11 to 18 years using data from the 2022 National Youth Tobacco Survey. Students surveyed were categorized as having normal, mild, moderate, and severe psychological distress, based on their responses to the Patient Health Questionnaire-4 (PHQ-4).

A total of 1,629 youth (about 7.6% of those surveyed) reported having vaped cannabis in the previous 30 days. The breakdown of psychological distress in this group was as follows:

• 22.9% reported severe psychological distress.
• 17.5% reported moderate psychological distress.
• 22.3% reported mild psychological distress.

Of those surveyed who had not vaped cannabis in the past 30 days, 11.4% reported severe psychological distress, 13.0% reported moderate psychological distress, and 20.5% reported mild psychological distress.

Adolescents who experienced severe psychological distress were 1.46 times more likely to have vaped cannabis in the previous 30 days, compared with those who experienced no psychological distress. Those with moderate or mild psychological distress were 1.22 times and 1.16 times more likely to have vaped cannabis, respectively. Being older (16 to 18), receiving poor grades, nicotine vaping, blunt use (for example, smoking cannabis in cigars, cigarillos, or little cigars), and more were associated with higher odds of cannabis vaping.

In addition to screening adolescents experiencing psychological distress so that they can receive the help they need, the authors emphasized that “screening and identifying adolescents with less severe distress and intervening could prevent problematic cannabis use.”

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

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Childhood Neglect May Alter Pleasure Experience Later in Life

Young adults who experienced neglect as children may have more difficulty feeling pleasure than those who were abused, a study in Depression & Anxiety suggests.

“[Childhood trauma] exerts a lasting impact on cognition, emotion, and behavior in adulthood,” wrote Xiongzhao Zhu, Ph.D., of Central South University and colleagues. “Children who have experienced neglect may receive less attention and care from caregivers, resulting in less frequency of receiving feedback related to rewards and thus affecting reward learning.”

Anhedonia—the inability to feel pleasure or engage in enjoyable activities—is a common symptom in a variety of psychiatric illnesses, including major depressive disorder (MDD) and obsessive-compulsive disorder (OCD). Anhedonia may also point to those most likely to develop mental illness, the researchers noted.

To examine the relationship between anhedonia and childhood trauma, Zhu and colleagues recruited patients with MDD and OCD from a psychology clinic at a Second Xiangya Hospital in China as well as university students from four universities in China.

The participants completed the Childhood Trauma Questionnaire, which assesses neglect (emotional and physical) and abuse (emotional, physical, and sexual), as well as multiple assessments that measured various aspects of anhedonia. The final sample (average age 22 years) included 305 patients with MDD, 152 patients with OCD, and 2,110 university students.

Zhu and colleagues reported the following:

• Childhood trauma was reported by 69.8% of the MDD patients, 65.8% of the OCD patients, and 33.6% of the university students.
• Neglect was reported by 62.6% of the MDD patients, 55.3% of the OCD patients, and 30.0% of the university students; abuse was reported by 38.7% of the MDD group, 32.9% of the OCD group, and 9.00% of university students.
• Anhedonia subtypes, including physical anhedonia and social anhedonia, were reported by 72.5% to 82.5% of patients with MDD, 47.4% to 65.7% of patients with OCD, and 15.3% to 19.8% of the university students.
• Childhood neglect, not abuse, was associated with anticipatory and state anhedonia in OCD patients and anticipatory, consummatory, physical, and state anhedonia in MDD patients and university students.

“Regarding the more specific forms of [childhood trauma], emotional neglect had the strongest association with most aspects of anhedonia,” Zhu and colleagues wrote. “These findings highlight the role of neglect … in influencing anhedonia, which may provide insights into the mechanisms by which [childhood trauma] leads to psychopathology and suggest the importance of early interventions for families in such circumstances.”

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Study Compares Clinical Outcomes of Older Adults Prescribed 10 Common Antidepressants

Older adults with depression may be least likely to discontinue or switch treatment when prescribed sertraline for the first time compared with other antidepressants, suggests a report in The American Journal of Psychiatry. The study compared one-year outcomes in 93,000 Danish residents with depression who for the first time filled a prescription for one of 10 antidepressants. The research was funded in part by the Health Research Foundation of the Central Denmark Region.

“Although clinical trials are considered the gold standard in drug effectiveness research, their experimental conditions often do not represent complex, real-world settings, primarily because of the exclusion of vulnerable populations such as older adults and individuals with comorbid conditions,” wrote Kazi Ishtiak-Ahmed, Ph.D., of Denmark’s Aarhus University Hospital and colleagues. “Therefore, real-world data are essential and complementary to those clinical trials, particularly for older patients.”

Using Danish national registers, the researchers identified adults aged 65 or older who filled a prescription for one of 10 most frequently prescribed antidepressants at a community pharmacy for the first time between 2006 and 2017. Adults who were initially prescribed more than one antidepressant and/or received their first prescription in an inpatient hospital were excluded.

The final sample included 93,833 older Danish adults (average age, 78 years) who initiated one of the following:

• Selective serotonin reuptake inhibitors citalopram, escitalopram, fluoxetine, paroxetine, or sertraline
• Serotonin-norepinephrine reuptake inhibitors duloxetine or venlafaxine
• Tricyclic antidepressant amitriptyline
• Atypical antidepressants mianserin or mirtazapine

The researchers tracked the patients’ outcomes for one year following their first fill of the antidepressant prescription. These outcomes included the following:

• Discontinuation, augmentation, and/or switching of an antidepressant
• Psychiatric outpatient, inpatient, and/or emergency visits
• Suicide attempt and/or self-harm
• Fall-related injuries
• Cardiovascular events
• All-cause mortality

The researchers compared the patients’ outcomes from each antidepressant group against those in the sertraline group (sertraline is recommended as the only first-choice treatment for depression in the current Danish guidelines).

Compared with sertraline, most of the other nine antidepressants were associated with a significantly higher risk of adverse outcomes, with venlafaxine, mirtazapine, and escitalopram having higher numbers of adverse clinical outcomes. Citalopram was associated with less risk of medication augmentation and psychiatric emergency or inpatient visits than sertraline, while amitriptyline was associated with fewer fall-related injuries and less risk of any psychiatric visit.

“Overall, our results align with the existing Danish guidelines recommending sertraline as the first choice for the pharmacological treatment of depression in older adults and highlight the importance of careful selection of antidepressant treatment in the initial pharmacological treatment of depression in older patients,” Ishtiak-Ahmed and colleagues concluded.

To read more on this topic, see the Psychiatric News article “Add-On Aripiprazole May Benefit Older Adults With Refractory Depression.”

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Mental Illness, Substance Use Disorder Linked to Stroke

Having a history of mental illness or substance use disorder (SUD) may be linked to an increased risk of stroke, a study in the Journal of Psychiatric Research has found.

Yann Le Strat, M.D., of Louis Mourier Hospital, in Colombes, France, and colleagues examined data from 36,309 participants aged 18 years and older in the National Epidemiologic Survey on Alcohol and Related Conditions-III.

As part of the survey, participants were asked whether during the last 12 months, they had experienced a stroke, and then whether this diagnosis was confirmed by a doctor or other health professionals. The researchers assessed past 12-month mental health and substance use disorders via the National Institute on Alcohol Abuse and Alcoholism’s Alcohol Use Disorder and Associated Disabilities Interview Schedule 5, which uses DSM-5 criteria.

Overall, 297 participants reported having had a stroke in the past 12 months. These participants had 1.59 times the odds of reporting at least one mental disorder or SUD during the past 12 months compared with those who did not have stroke. Those with a recent history of stroke also had more than twice the odds of reporting any mood disorder (such as major depressive disorder) and any anxiety disorder (such as generalized anxiety, panic disorder, social phobia, and agoraphobia). They also had more than twice the odds of reporting opioid use disorder.

Participants who reported having had a stroke in the past 12 months had higher odds of reporting cancer, metabolic conditions, cardiovascular disease, liver disease, digestive disease, sexual disease, lung problems, anemia, traumatic brain injury, and/or nerve disease. Overall, participants who reported having had a stroke in the past 12 months reported having a lower quality of life compared with the control group.

“The debilitating effects of combined mental and neurological disorders make it crucial for health care professionals treating individuals with stroke to screen for a range of physical conditions and mental disorders,” Le Strat and colleagues wrote.

For related information, see The Journal of Neuropsychiatry and Clinical Neurosciences articles “Factors Associated With Anxiety After Hemorrhagic Stroke” and “Poststroke Depression: An Update.”

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Latinx Youth With MH Problems May Have Greater Cardiometabolic Risks in Later Adolescence

Latinx middle schoolers who experience internalizing symptoms such as anxiety or depression have a greater risk of developing sleep problems, being overweight or obese, and engaging in sedentary behavior by the time they reach high school, according to a study published in the Journal of Adolescent Health.

“Irrefutable evidence identifies mental health as an important correlate of health behaviors and physical health outcomes underlying cardiometabolic risk,” wrote Kathleen Roche, M.S.W., Ph.D., of the Milken Institute School of Public Health at George Washington University and colleagues. “Public health concerns regarding increased cardiometabolic risks are elevated for the large and growing Latinx population.”

Roche and colleagues used data from the Pathways to Health/Caminos al Bienestar, an ongoing longitudinal study of Latinx adolescents and mothers. The researchers focused on middle school students enrolled in a suburban Atlanta school district during the 2017-2018 school year. The participants completed online surveys at baseline, then once every six months over four years. The surveys included a 29-item measure assessing the participants’ internalizing symptoms, including anxiety, depression, social withdrawal, and somatic symptoms (such as headache and stomachache) over the past six months.

The surveys also assessed participants’ sedentary behavior (total number of hours spent sitting during a weekday) and frequency of vigorous physical activity. The surveys included the 16-item version of the Food Habits Scale to determine whether the participants ate a healthy diet, and sleep problems were assessed using the 13-item Pittsburgh Sleep Quality Index. Participants reported their height and weight, from which the authors calculated their BMI. Finally, participants also reported if they had been diagnosed with diabetes, prediabetes, or high blood pressure.

At baseline, the 547 participants were, on average, 13 years old. The authors found that, even after adjusting for covariates, internalizing symptoms at baseline were associated with more sedentary behavior, more sleep problems, higher risk of being overweight or obesity, less vigorous physical activity, and a less healthy diet four years later. Further, being overweight or obese was associated with greater risk of diabetes or hypertension, and healthy diets were associated with increased odds of engaging in more vigorous physical activity.

“Importantly, the pathways linking early adolescent mental health to later health behaviors and physical health outcomes held even when adjusting for the co-occurrence of outcome variables and for internalizing symptoms during middle and late adolescence,” the authors wrote. “Our findings point to early adolescence as a critical developmental period for shaping later health behaviors and physical health outcomes.”

The authors also called for culturally informed studies on the links between mental and physical health so that intervention efforts can be targeted at the growing population of U.S. Latinx adolescents.

For related information, see the Psychiatric News article “Psychiatrists Call for Action After CDC Data Reveal Worsening of Youth Mental Health Crisis.”

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State MH Reporting Requirements Vary for Firearm Background Checks

States vary widely in the reporting of mental health data to the federal system known as NICS that conducts background checks on people who want to own a firearm, a study appearing in JAMA Internal Medicine has found.

“Firearm access by individuals with mental illness is associated with increased risk of suicide or homicide,” wrote Deirdre Brown, J.D., Ph.D., of Seattle University School of Law and colleagues. “Although NICS [National Instant Criminal Background Check System] is intended to be a nationwide database, the substantial variability in reporting requirements across states suggests that the intended purpose of the NICS is hampered,” they wrote.

Brown and colleagues used the Thomson Reuters Westlaw database to identify and collect data on each state’s laws regarding mental health reporting requirements between February and April 2022. They analyzed data on whether the states required reporting to NICS, how many requirements the states imposed, and the type of mental health and/or substance use–related events that were required to be reported.

State laws were inconsistent as to whether data were provided to NICS: 39 states required reporting, five permitted reporting, three required reporting to a state agency but were silent about reporting to NICS, and three states had no reporting laws.

Moreover, the number and type of mental illness or substance use–related varied from state to state:

• 16 states required reports of individuals being adjudicated incompetent to manage affairs or having a guardian appointment, and 24 states required reports of being incompetent to stand trial.
• 40 states required reporting of individuals who were involuntary committed to hospitalization, 23 states required reports of individuals being found not guilty by reason of insanity, and 18 states required reporting of individuals receiving involuntary outpatient treatment.
• 13 states required reporting of individuals who have received treatment for a substance use disorder, five states required reports of individuals voluntarily hospitalized, and one state required reports of individuals who voluntarily seek outpatient treatment.

Brown and colleagues cited a 2016 report that showed that preventing the purchase of firearms increased exponentially in states with increased requirements to report mental health to NICS. They said NICS’ reliability and utility would improve with national standards.

“A more robust approach is needed to ensure that critical information about individuals with mental health risks is accurately shared with the NICS,” they wrote. “It is imperative to identify consistent reporting strategies to prevent those in crisis from accessing firearms.”

For related information, see the Psychiatric News article “Multiple Barriers Inhibit Civilian Use of Red Flag Laws, Study Shows.”

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Don’t Shut Down Conversations When Youth Present With ‘Trending’ Disorders, Psychiatrist Says

Youth increasingly rely on social media to diagnose themselves with a variety of psychiatric illnesses—a trend that has been met with more than a few raised eyebrows.

In a short article in the Journal of the American Academy of Child & Adolescent Psychiatry, child and adolescent psychiatrist David C. Rettew, M.D., described how he works with youth with so-called “trending presentations” and cautions against the dangers of oversimplifying such cases. 

• Ask patients direct questions about whether they have a specific diagnosis in mind, as well as the research that led them to this conclusion: “[I]t is common for my new patients to get a little sheepish when disclosing the source of their investigations, as most commonly the ideas come from social media platforms such as YouTube or TikTok rather than the medical textbooks that used to make medical students wonder about being stricken with lots of exotic ailments,” he described.
• Reject the tendency to dismiss or deny the patient’s narrative “because it does not fit our current scientific or political perspective”: “Science has shown us repeatedly that virtually everything when it comes to mental functioning—from common personality traits to psychopathology to gender typical behavior—comes from a complicated mash-up of mutually interacting genetic and environmental factors. These environmental contributors include things such as peers and media influences, and their presence in the mix should not immediately disqualify someone’s history as undeserving.”
• The more complicated a clinical situation appears, the more important it is to stick to the basics: Establish good rapport with the patient, be thorough, validate while maintaining some skepticism, and give yourself time to conceptualize, he said. “[I]n so doing, we may find that those supposed trending presentations are an accurate description of symptoms that have been long experienced and suppressed by the individual until they are living in an environment supportive enough for their expression. … Or maybe we find out that, indeed, someone really has been heavily influenced by what they have heard from a peer or seen on a social media video as part of developmentally appropriate needs to feel connected socially and developmentally appropriate introspection at this age about their identity,” he wrote.

Rettew concluded, “Rigid and oversimplistic thinking often fails us and our patients by closing conversations before they ever truly open. The pathways through which our patients find their way to our office are incredibly rich and diverse. We lump them into convenient boxes at our peril, virtually begging our patients to reveal to us the deficiencies of our mental shortcuts.”

Rettew works for Lane County Behavioral Health in Eugene, Ore.

For more on this topic, see the Psychiatric News article “‘Outbreak’ of Sudden Tics Among Teen Girls Has Surprising Global Similarity.”

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Narcissistic Traits May Predict Patients’ Response to CBT for Depression

The presence of narcissistic traits may predict how well a patient responds to cognitive-behavioral therapy (CBT) for depression, according to a study published in The Lancet Psychiatry.

“In the past decade of personality and personality disorder research, narcissism has emerged as a dimensional construct that is present both in individuals who are mentally healthy and in psychiatric clinical populations,” wrote Maike Richter, M.Sc., Simon Mota, Ph.D., of the University of Münster in Germany and colleagues. “Clinical practice shows that narcissistic traits below the threshold for narcissistic personality disorder are common, can lead to interpersonal problems, and might negatively affect psychiatric symptomatology, such as depression severity, treatment adherence, and outcome.”

Richter, Mota, and colleagues investigated the impact of narcissism on depressive symptoms before and after treatment in two large samples of adults aged 18 and older. One included both psychiatric inpatients and patients receiving outpatient psychotherapy at the University Hospital Münster who were treated with CBT. The second included inpatients treated with psychoanalytic interactional therapy (PIT) at the Asklepios Clinic, a psychiatric hospital in Tiefenbrunn, Germany. PIT is a psychodynamic treatment specially designed for patients with severe personality disorders. Before and after treatment, patients completed the Narcissistic Admiration and Rivalry Questionnaire-short version. The six-item measure evaluates two facets of grandiose narcissism: admiration (I am a very special person and this gives me a lot of strength) and rivalry (I desire my rivals to fail). The sum of all items on the questionnaire measured core narcissism.

CBT inpatient treatment included one 50-minute, one-on-one therapy session per week with a clinical psychologist or psychiatrist. Outpatient CBT treatments consisted of one 50-minute, one-on-one therapy session per week with a clinical psychologist trainee. Patients in the CBT group completed the Beck Depression Inventory-Revised, a 21-item questionnaire that measures depression severity. Patients in the PIT group received one or two 25-minute, one-on-one sessions per week with a clinical psychologist or psychiatrist. These patients self-reported depression symptoms by completing the Patient Health Questionnaire-9.

A total of 2,371 patients were included, with 1,569 in the CBT group and 802 in the PIT group. The mean treatment duration was 300 days in the CBT group and 67 days in the PIT group. Findings included the following:

• Core narcissism did not predict depression severity before treatment in either group.
• Narcissistic rivalry was associated with higher depressive symptoms at baseline, while narcissistic admiration was associated with lower depressive symptoms.
• In the CBT group, patients with core narcissism and narcissistic rivalry had poorer treatment responses, while narcissistic admiration showed no effect.
• In the outpatient CBT group, the therapeutic alliance mediated 31% of the total effect of narcissistic rivalry on depression severity after treatment.
• Narcissistic traits were not associated with the treatment outcome in the PIT group.

“In the end, perhaps it will not be treatment packages (CBT vs. psychodynamic therapy) that determine how best to treat patients with narcissistic traits and depression, but rather individual treatment components, wrote Jan Philipp Klein, Dr.Med., of the University of Lübeck and colleagues in an accompanying commentary. “Until further evidence is available, therapists should consider that in the treatment of patients with narcissistic traits, a particular emphasis on building a strong therapeutic alliance might improve outcomes.”

For related information, see the Psychiatric News articles “Narcissism and Its Discontents” and “Love Pathology in Narcissistic Patients Can Be Treated Effectively.”

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Deadline Tomorrow: Submit Comments on Proposed Rules to Strengthen Parity Law

The Employee Benefit Security Administration, along with the Treasury Department and the Department of Health and Human Services, recently proposed new rules to strengthen the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) by closing loopholes and adding greater clarity to the law’s requirement. The deadline to submit comments on these proposed rules is tomorrow, October 17.

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Mental Health Services Conference Kicks Off With Presidential Session on Addiction

Understanding of the causes of substance use disorder (SUD) and behavioral addictions has come a long way since the 1980s, when addiction was recognized as a biopsychosocial illness, said APA President Petros Levounis M.D., M.A., yesterday in the opening session of APA’s Mental Health Services Conference. His presentation included a historical perspective of addiction and a discussion of a newer, more modern neurobiological framework that describes how addiction changes the circuitry of the brain.

Levounis described SUD and behavioral addictions as a complex interplay between psychological forces and neurobiological forces. He said that whereas it was once thought that individuals use substances to get high, escape, or self-medicate underlying, untreated psychiatric disorders like depression and anxiety, the psychological reasons for substance use are more nuanced and complex, such as using substances to enhance academic, athletic, or sexual performance.

Repeated substance use or repeated behaviors can also set the stage for SUD, Levounis said.

“We learned that lesson from the opioid epidemic, where the majority of people who got addicted to prescription opioids back in the late 1990s and early 2000s were [people who were injured], went to their doctors, and were prescribed massive amounts of opioids,” Levounis said. “So it’s use of the drug that increases vulnerability and can lead to addiction.”

He described how modern concepts of the neurobiology of addiction have evolved to focus on the “war” between pleasure-reward pathways in the brain that have been hijacked by substance use and the frontal lobes, which are responsible for rational thinking.

“The next time you have [a patient with SUD] in front of you, visualize in your head how strong are their hijacked pleasure-reward pathways versus how strong are their frontal lobes,” he said. “If the pleasure-reward pathways [are stronger], the person will relapse. If the frontal lobes are stronger, the person will be in recovery.”

Levounis also discussed the “anti-reward” pathways in the brain. He explained that when these pathways are activated, they produce irritability, annoyance, misery, restlessness, and pain.

“What happens is that the addiction morphs from primarily pleasure and reward to a desperate attempt to avoid pain,” he said.

Levounis described another component of the neurobiology of addiction, interoception, which is the process by which the mind senses internal signals from the body such as hunger or a rapid heartbeat. These signals can also include cravings, such as when people who smoke crave a cigarette. Levounis described research wherein people who smoked cigarettes and had a stroke that affected the parts of the brain responsible for interoception no longer felt the urge to smoke.

For related information, see the Psychiatric News article “APA President Traces How Understanding of Addiction Evolved.”

The Mental Health Services Conference will run through Saturday, October 14. Look to upcoming issues of Psychiatric News for coverage of the meeting.

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LSD Use Rising Among Adults, Especially Those With Depression

There are signs that U.S. adults are increasingly using lysergic acid diethylamide (LSD). A report in JAMA Psychiatry now suggests that between 2008 and 2019 a disproportionate percentage of young adults with depression reported past-year LSD use.

“Although LSD use may prove beneficial for some individuals, there can also be adverse consequences, particularly in medically unsupervised settings,” wrote Claire A. Walsh, M.A., and Deborah S. Hasin, Ph.D., of the New York State Psychiatric Institute and colleagues. “[U]nderstanding trends in the association between LSD use and depression in unsupervised, nonmedical settings has become an important public health issue.”

Walsh and colleagues analyzed responses of 478,492 adults aged 18 years or older who completed the annual National Survey on Drug Use and Health between 2008 and 2019. The overall number of adults who reported past-year LSD use increased significantly during this time, from 0.2% in 2008 to 0.9% in 2019. Overall, the prevalence of past-year LSD use increased significantly among adults with or without depression regardless of the participants’ race/ethnicity, age, sex, education, and more.

Among adults who reported past-year depression, the prevalence of past-year LSD use rose from 0.5% in 2008 to 1.8% in 2019. Among adults ages 18 to 25 with depression, the prevalence of past-year LSD use rose from 1.6% in 2008 to 4.9% in 2019.

“Disproportionate increases in LSD use among those with depression occurred in parallel with increases in the prevalence of major depression in the past decade, with diagnoses of past-year depression among U.S. adults increasing from 13.7 million in 2005 to 17.5 million in 2018,” the authors wrote. “If the rates of depression continue to increase in tandem with popular media and research reports presenting psychedelics as beneficial, the number of individuals who use LSD in the context of major depression will likely continue to increase.”

To read more about this topic, see the Psychiatric News article “Experts Offer Tips on Talking With Patients About Psychedelics.”

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APA Issues Statement on Terrorist Attacks in Israel

Today APA issued a statement about the events that are occurring in Israel and the Gaza strip.

“Innocent civilians should never have to endure the violence and chaos that happened last weekend. APA sends our support to all those affected in Israel and around the world. We mourn those who were lost and call for the immediate return of all hostages to their families. The scale of this terrorist act and the harm it is causing is unfathomable,” the statement said.

“Antisemitism and all forms of prejudice and hatred are unacceptable, and we stand with the Jewish people, now and as always. The brutalities of Hamas must end. It is our firm hope that one day we can see peace between the Israelis and Palestinians and an end to the violence in the Middle East.”

APA has also made available resources for individuals whose mental health may be impacted by these events.

For related information, see the Psychiatric Services article “Naturalistic Study of Posttraumatic Stress Disorder Among Israeli Civilians Exposed to Wartime Attacks.”

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ADHD Diagnoses, Prescription Stimulants Rise in Patients With OUD

Diagnoses of attention-deficit/hyperactivity disorder (ADHD) among patients with opioid use disorder (OUD) tripled between 2007 and 2017, a study in Psychiatric Services has found. At the same time, the prevalence of ADHD pharmacotherapy increased by 22% for patients with co-occurring ADHD and OUD.

Tae Woo Park, M.D., M.Sc., of the University of Pittsburgh and colleagues conducted two separate analyses of claims data from commercially insured patients between the ages of 13 and 64 years.

In the first analysis, the researchers studied data from 387,980 patients with OUD to estimate the prevalence of ADHD diagnoses and pharmacotherapy. They found that the proportion of patients with OUD and ADHD grew from 4.6% in 2007 to 15.1% in 2017. Among patients with both OUD and ADHD, the rate of those receiving medication for ADHD increased from 42.6% to 51.8%.

In the second analysis, the researchers studied data from 158,591 patients who received medications for OUD to examine the characteristics of those who received concurrent stimulant medication and those who did not. The researchers found that 10.5% of the patients in this analysis received concurrent prescription medications. Those who received concurrent stimulant medications tended to be younger, female, and diagnosed as having one or more psychiatric conditions compared with those who did not receive stimulants. Patients who had been diagnosed with other substance use disorders were less likely to receive a concurrent stimulant medication, the authors found.

The researchers noted that although ADHD diagnoses and treatments have grown steadily worldwide, particularly among adults, increases in ADHD diagnoses appear to have grown faster among patients with OUD than in the general population over the same period.

“Increased recognition of the role of ADHD in developing opioid use disorder and other substance use disorders has likely resulted in this rise in [ADHD] diagnoses,” Park and colleagues wrote. “Conversely, opioid use disorder may exacerbate ADHD symptoms over time and cause greater functional impairment, leading to an increased rate of ADHD diagnoses among patients with opioid use disorder compared with the general population.”

The researchers encouraged health professionals to exercise caution when prescribing stimulants for patients with ADHD who are taking medications for OUD.

“Given the potential for increased overdose risk and the potential risks for diversion and misuse associated with stimulant medications, clinicians managing ADHD symptoms of patients receiving [medication for OUD] should carefully weigh the risks and benefits of stimulant treatment on a per-patient basis,” they wrote.

For related information, see the American Journal of Psychiatry article “Personalizing the Treatment of Substance Use Disorders.”

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DEA, HHS Extend Telemedicine Flexibilities Through 2024

The Drug Enforcement Administration (DEA) and the Department of Health and Human Services (HHS) today announced the extension of COVID-19 telemedicine flexibilities for prescription of controlled medications through December 31, 2024. These telemedicine flexibilities authorize qualified health professionals to prescribe schedule II-V controlled medications via audio-video telemedicine encounters, including III-V narcotic-controlled medications approved by the Food and Drug Administration for the treatment of opioid use disorder via audio-only telemedicine encounters.

Earlier this year, the DEA proposed regulations that would curtail telemedicine prescribing flexibilities extended to qualified health professionals during the COVID-19 Public Health Emergency, for instance by requiring an in-person visit for the prescribing of controlled substances. (The proposals appeared 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 filed two letters in response to these proposed rules in March, urging that the DEA balance common-sense safeguards for DEA enforcement without decreasing access to lifesaving treatment.

The DEA received more than 38,000 comments on the proposed telemedicine rules and last month held two days of public listening sessions related to those rules. Psychiatrist Shabana Khan, M.D., chair of the APA Committee on Telepsychiatry, spoke on behalf of APA at the public meeting.

“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 during the meeting. “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 also added that telemedicine has not been shown to increase diversion of controlled substances.

The DEA homepage announcing the extension of the COVID-19 telemedicine flexibilities states: “We continue to carefully consider the input received and are working to promulgate a final set of telemedicine regulations by the fall of 2024, giving patients and medical practitioners time to plan for, and adapt to, the new rules once issued.”

For related news, see the Psychiatric News articles “APA Urges DEA to Expand Telemedicine Prescribing” and “APA Responds to DEA’s Proposed Rules Regarding Telehealth, Buprenorphine.”

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More Children, Adolescents With Type 1 Diabetes Receiving Psychotropic Medication, Study Finds

Children and adolescents with type 1 diabetes are at an elevated risk for psychiatric disorders, but treatment with psychotropic medications can cause adverse effects in this patient population. A new study has found that the prevalence of youth receiving these medications increased dramatically in Sweden from 2006 to 2019. The findings were published this week in JAMA Network Open.

“Various antipsychotics, mood stabilizers, and antidepressants have been associated with detrimental metabolic outcomes, including weight gain, hyperlipidemia, and insulin resistance,” wrote Shengxin Liu, M.Sc., and Tyra Lagerberg, Ph.D., of the Karolinska Institutet in Sweden and colleagues. “For children and adolescents with [type 1 diabetes], who already face an increased risk of metabolic complications and gastrointestinal symptoms, these adverse effects may exacerbate their health outcomes.”

Liu, Lagerberg, and colleagues used national Swedish registries to obtain data on all children (birth to 11 years) and adolescents (aged 12 to 17) who resided in Sweden at some point from 2006 to 2019. The National Patient Register provided information on patients diagnosed with type 1 diabetes and psychiatric disorders (such as depression, psychotic disorders, or personality disorders). The Prescribed Drug Register provided information on the medications dispensed to the youth. The authors specifically focused their analysis on first- and second-generation antipsychotics, antidepressants, anxiolytics, hypnotics, mood stabilizers, and medication for attention-deficit/hyperactivity disorder (ADHD).

Among 3.7 million children and adolescents, 13,200 had type 1 diabetes, 1,866 (14.1%) of whom were dispensed psychotropic medications during the study period. Other findings included the following:

• The prevalence of children with type 1 diabetes receiving psychotropic medications increased from 0.85% in 2006 to 3.84% in 2019.
• The prevalence of adolescents with type 1 diabetes receiving psychotropic medications increased from 2.72% in 2006 to 13.54% in 2019.
• Youth with type 1 diabetes consistently received psychotropic medications more than their peers without type 1 diabetes.
• The most commonly dispensed medications included hypnotics, ADHD medications, anxiolytics, and antidepressants.
• Psychiatric care was the primary source for prescriptions for psychotropic medications for youth with type 1 diabetes.
• Up to 50.1% of treatments with psychotropic medications lasted more than a year.

“The findings from our study emphasize the importance of integrating pediatric diabetes care and mental health professionals when managing children and adolescents with [type 1 diabetes],” the authors wrote. “This collaborative effort is essential not only for the early detection and screening of patients’ psychological needs but also for the diligent monitoring of psychotropic medication usage and patient outcomes.”

For related information, see the Psychiatric Services article “Adherence to Recommended Metabolic Monitoring of Children and Adolescents Taking Second-Generation Antipsychotics.”

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Study Examines Racial/Ethnic Disparities in Diagnosis of Psychotic Disorders

It is well known that Black patients are more likely to be diagnosed with a psychotic disorder than White patients—with potential explanations ranging from clinical bias to disparities in access to health care. A study of the health records of nearly 6 million members of Kaiser Permanente over a 10-year period has reaffirmed this disparity between Black and White patients for both affective and nonaffective psychotic disorders, while also identifying differences in psychotic disorder diagnoses for other racial and ethnic groups. The findings were published today in The American Journal of Psychiatry.

“This study of treated incidence cannot address whether disparities in diagnosis reflect true differences in the risk of psychotic disorder, noncausal factors—such as misdiagnosis and differential treatment access and utilization—or a combination of the two,” wrote Winston Chung, M.D., of Kaiser Permanente Northern California and colleagues.

Chung and colleagues examined electronic health records of patients who received care through Kaiser Permanente Northern California (KPNC)—a large, integrated health care delivery system that provides comprehensive medical care to more than 4 million individuals. The researchers focused specifically on those who received care between January 2009 and December 2019 and were enrolled with KPNC for at least one continuous year. The researchers identified psychotic disorder diagnoses from both inpatient and outpatient visits.

During the study period, 5,994,758 members received care; of this group, 13,303 individuals were diagnosed with a nonaffective psychotic disorder (for example, schizophrenia) and 5,888 were diagnosed with an affective psychotic disorder (for example, bipolar disorder with psychosis symptoms).

Compared with White patients, Black patients were 1.73 times as likely to receive a diagnosis of nonaffective psychosis and 1.43 times as likely to receive a diagnosis of affective psychosis after factoring in variables such as age, sex, marital status, and employment status. The risk of nonaffective psychosis was also elevated in individuals who identified as American Indian or Alaskan Native (1.67 times) compared with those who identified as White. Other findings included the following:

• Asian patients were 0.84 times as likely to receive a diagnosis of affective psychosis and 0.78 times as likely to receive a diagnosis of nonaffective psychosis as White patients.
• Hispanic patients were 0.85 times as likely to receive a diagnosis for nonaffective psychosis compared with White patients.
• Native Hawaiian or other Pacific Islander patients were 0.67 times as likely to receive a diagnosis of affective psychosis compared with White patients.
• A diagnosis of any psychotic disorder was associated with an increased risk of adverse health outcomes, including suicide, stroke, diabetes, and premature death.

“Our findings ... add to the evidence base for higher risk of psychosis diagnosis among Black participants in the United States. Although drivers of this risk are likely multifactorial, consistently elevated rates of psychosis among Black populations across the United States and Europe highlight the importance of social factors shared across settings, including racism and other forms of social disadvantage,” Chung and colleagues wrote. “Future research should consider the extent to which amelioration of such social forces might reduce the excess burden of psychosis among disproportionately impacted individuals.”

To read more on this topic, see the Psychiatric News article “Review Examines How Racism May Increase Psychosis Risk.”

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